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Admission Date: [2149-6-30] Discharge Date: [2149-7-14] Date of Birth: [2082-6-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Transferred from outside hospital for further care of pontine hemorrhage Major Surgical or Invasive Procedure: Dobhoff placed under flouroscopy GJ tube placed by general surgery History of Present Illness: The pt is a 67 year-old right-handed man with a PMH of HTN, HLD and EtoH who was transferred from an OSH. This history is compiled from his sister. Reportedly the patient had a fall 2 weeks ago for unclear reasons. It was not associated with LOC or trauma but since then he has had several falls. He has not been at baseline and has been falling and stumbling. None of these falls has been associated with trauma or LOC. He has also seemed more confused, especially in the last few days. His sister called his PCP who suggested he decreased his BP meds. She tried this without effect and decided to b bring him to [Hospital1 2519] today. At the OSH his work-up included a head CT which showed a pontine bleed as well as bilateral BG atrophy and encephalomalacia. His screening labs were otherwise remarkable for a Platelet count of 251 and an INR of 1.12. His sodium was 131, K was 3.0 and the Co2 was 91. His glucose was also elevated at 174 and his troponin was 0.03. His ECG showed SR with a normal axis and no ST changes. ROS: Unable to obtain Past Medical History: HTN HLD EtOH abuse Social History: History of alcohol and tobacco abuse Family History: Noncontributory Physical Exam: Vitals - Tm 98.4, Tc 96.8, BP 136/68 (range 124-176), P 82 (range 74-94) R 18, 96% on 2L NC Gen - in bed, somnulent, arousable to light touch HEENT - ATNC, PERRLA watery eyes, EOMI, L facial droop, supple neck, no JVD, no LAD CV - distant HS, RRR, no m,r,g Lungs - CTA B from front Abd - soft, NT, ND, no HSM, normoactive BS Ext - R hand in mitt, no edema, palp pulses Neuro - L leg and arm stiff to movement Psych - unable to assess Pertinent Results: CTA chest ([2149-7-13]): No evidence of pulmonary embolus. Study otherwise relatively unchanged from the previous CT of the chest dated [2149-7-9]. Chest portable ([2149-7-13]): In comparison with the study of [7-11], there is no evidence of acute focal pneumonia. The Dobbhoff tube has been removed. Calcification of the hemidiaphragmatic pleura on the right is again seen, consistent with asbestos-related disease. Bilateral lower extremity dopplers ([2149-7-10]): No evidence of deep vein thrombosis of the right or left lower extremity. CT head w/o contrast ([2149-7-9]): 1. Persistent area of subacute/chronic hemorrhage within the pons, likely representing expected evolution. No definite acute hemorrhage. MRI is recommended again for further evaluation. 2. Persistent ventricular prominence, which as stated before may represent central atrophy versus communicating hydrocephalus and clinical correlation is advised. TTE ([2149-7-1]): The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). 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 pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No valvular pathology or pathologic flow identified. CT C-spine w/o contrast ([2149-6-30]): No acute subluxation or fracture of the cervical spine. Multilevel degenerative change. [2149-7-14] 06:00AM BLOOD WBC-7.4 RBC-3.31* Hgb-10.9* Hct-30.2* MCV-91 MCH-33.0* MCHC-36.2* RDW-13.7 Plt Ct-341 [2149-7-9] 09:10PM BLOOD Neuts-81.6* Lymphs-11.1* Monos-6.1 Eos-0.2 Baso-1.0 [2149-7-14] 06:00AM BLOOD Glucose-129* UreaN-11 Creat-1.0 Na-136 K-3.2* Cl-99 HCO3-21* AnGap-19 [2149-7-9] 09:10PM BLOOD ALT-34 AST-49* LD(LDH)-253* CK(CPK)-281* AlkPhos-89 TotBili-0.6 [2149-7-14] 06:00AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.9 Cholest-102 [2149-7-1] 01:30AM BLOOD %HbA1c-7.6* [2149-7-1] 01:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2149-7-14] 06:00AM BLOOD Triglyc-101 HDL-37 CHOL/HD-2.8 LDLcalc-45 Brief Hospital Course: 67 yo M h/o HTN, ETOH abuse admitted for subacute pontine hemorrhage [6-30], did well with rehab until [7-6] when found to be aspirating. Fever of unknown source on [7-9], but afebrile x48 hrs so broad spectrum ABX d/c'd [7-12]. Mental status altered but suspect at new baseline. Hospital course was as follows: Pt admitted to ICU initially. HCT c/w subacute pontine hemorrhage. MI ruled out with cardiac enxzymes x3 and ECHO completed. Pt transferred to [Wardname 3709] on [2149-7-1]. CIWA protocol initiated and thiamine and folate started. Pt was stable. Speech and swallow advance diet initially then patient was made NPO secondary to aspiration risk. Pt ordered for MRI/A Brain with contrast was ordered to evaluate for hemorrhage. Pt was returned to the floor 2-3 times secondary to inability to cooperate and or sit still even with Ativan. MRI/A was setup on an outpatient basis. Rehab placement with PT/OT was pending. Pt was hypertensive so home metoprolol was started on [2149-7-2] at 12.5mg [Hospital1 ] and zocor was started. Metoprolol switched to Amlodipine 5mg PO daily and nystatin started for suspected thrush [2149-7-6]. On [2149-7-7], patient was made NPO secondary to aspiration risk. Tube feeds recs were Probalance 45cc/hr continuous with 75cc free water flushes. On [2149-7-7], Duboff attempted without success secondary to malformed nose from prior trauma then GI consulted for PEG placement. LLL pneumonia suspected, IV Cipro started. GI rec general surgery placement of gtube because an aspiration risk during the procedure. General surgery accepted. On [2149-7-9], pt became febrile 103 in the OR and tachcardic to 80-100. Pt completed a septic work-up on the floor (bcx, Ucx, a prior CT chest was completed the day prior). Vanco, Fluconazole, and Flagyl started for aspiration pneumonia. Pt was tranferred to Medicine. NPO, afebrile and at baseline level of mentation. On medicine floor, other active issues were as follows: 1. Hypoxia - Currently satting 96% on 2L. Source of hypoxia is unknown. No focal consolidation on chest radiograph. No evidence of pulmonary embolism by CT scan. Smoking history and history of COPD is unknown. No crackles heard on anterior auscultation. History of asbestos exposure with changes seen on CT, but unlikely to be source of acute hypoxia. ?relation to pontine hemorrhage, although patient with normal respiratory rate. No clear source was seen. Continued to wean patient. 2. Stroke - No changes seen. Poor mental status with limited responsiveness. Makes eye contact. Question if this is patient's new baseline. Cause unknown - hypertension vs. cavernous aneurysm. Goal was to control blood pressure with goal of 140-180. Continued PT and OT. 3. Fevers - Afebrile x96 hours. Antibiotics d/c'd on [7-12]. No new intervention was taken. 4. Hypertension - Blood pressure elevated this morning to systolic BP 180. Continue HCTZ 12.5mg PO daily via PEG tube. Increased ACE inhibitor to 6.25mg PO TID daily via PEG tube. 5. Nutrition - s/p PEG tube placement [7-12]. Spoke to nutrition, which recommended continuing Probalance regimen. Patient should have repeat swallow study in [3-8] days. 6. Hypokalemia - Persistent, 3.2 this morning. Cause unknown. Renal function is fine at this time. Continued to replete as needed. 7. EtOH abuse - CIWA d/c'd early in admission [1-4] no signs of withdrawal. Continued folic acid and thiamine supplementation. Medications on Admission: Amlodipine 5mg po daily Simvastatin dosage unknown Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H (every 4 hours) for 14 days: Last dose on [2149-7-16]. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Fever, Pain. 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Pontine Hemorrhage Hypokalemia Hypomagnesia Poor PO intake with aspiration risk Fever, now resolved Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for a stroke. You were set to get long term rehabilitation, but your course was complicated by a fever, high blood pressure and some troubles breathing. We are unsure why you developed fevers, but we treated you with antibiotics for several days. Your medication regimen has changed. Please look at your medication regimen closely. Please ensure to follow up with your physicians as listed below. Please return to the hospital for any chest pain, shortness of breath, new weakness or immobility of limbs, or any other concerns. Followup Instructions: F/U with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 39752] Mian in [1-5] weeks. Phone:[Telephone/Fax (1) ] F/U with [First Name8 (NamePattern2) ] [Name8 (MD) 162], MD (Neuro) Phone:[Telephone/Fax (1) 44] Date/Time:[2149-8-18] 3:00pm Patient should have repeat speech evaluation in [3-8] days. Completed by:[2149-7-14]	[ "5070", "2767", "4019", "2724", "42789" ]
Admission Date: [2170-5-8] Discharge Date: [2170-5-17] Date of Birth: [2093-7-30] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4691] Chief Complaint: Polytrauma - found down likely after fall from ladder Major Surgical or Invasive Procedure: Intubation ([2170-5-10]) Left paravertebral catheter placed ([2170-5-11]) Left chest tube placed ([2170-5-11]) History of Present Illness: 76 yo male with hx of dementia, CAD, recent falls transferred from an OSH after sustaining an unwitnessed fall on [Location (un) 7453]. Patient was found down in the garden and does not recall event. At OSH, patient was found to have a SDH and SAH as well as multiple rib fx. Patient was transferred to [Hospital1 18] for further management. Upon arrival here, patient was pan scanned and seen by neurosurgery. He was loaded with keppra. His TLS spine was cleared but his c-spine is still in a collar. Patient also has significant EtOH hx per report, though EtOH negative here. Per further discussion with the family it seemed as though there was a ladder nearby and he may have fallen and then tried to walk home before collapsing. His toxicology screen on admission was negative. INJURIES: Sm L PTX and apical HTX L medial rib fxs [12-17] L prox rib fxs [1-14] at trans proc artic L tentorial and inf sagittal sinus SDH L fronto-parietal SAH L clavicular fx close to scapula Mildly displaced fracture of inferior left scapula Past Medical History: PMH: CAD, MI, infrarenal AAA (5x4.6cm), congenital single R kidney, h/o past falls PSH: Cardiac stents Social History: Lives in [Hospital3 4298] with his girlfriend [Name (NI) ]. [Name2 (NI) ] a daughter and three grandchildren. History of heavy EtOH and tobacco. Family History: Non-contributory Physical Exam: (on admission) Gen: C-spine collar,lethargic but easily arousable, cooperative with exam HEENT: few abrasians Neck: Hard Collar Lungs: Decreased breath sounds on the left with occ. Wheeze Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic but arousable Orientation: Oriented to self only, spells first and last name, confused to place, time, president Pertinent Results: CT head ([2170-5-8]): Left tentorial and parafalcine subdural hemorrhage and left frontal and parietal subarachnoid hemorrhage. Punctate amount of intraventricular hemorrhage within the left occipital [Doctor Last Name 534]. CT cspine ([2170-5-8]): No acute fracture or malalignment; no significant canal stenosis. CT torso ([2170-5-8]): Small left hemopneumothorax with extensive left-sided rib fractures including segmental fractures of ribs two through six, as well as rib eight. Mildly displaced fracture of the inferior body of the left scapula. Comminuted left distal clavicular fracture. 4.8 x 4.6 cm infrarenal aortic aneurysm. Mild pulmonary edema with bibasilar atelectasis. CT head ([2170-5-9]): Partial interval resorption and/or redistribution of left frontal lobe subarachnoid hemorrhage. Tiny layering hemorrhage within the occipital horns of the lateral ventricles is new on the right and increased on the left. New right frontal lobe hyperdensity could be represent redistributed SAH or a small focus of parenchymal hemorrhage at the grey-white matter junction, perhaps secondary to diffuse axonal ("shear") injury. SDH overlying the left leaflet of the tentorium cerebelli is unchanged, while parafalcine SDH is decreased. CT head ([2170-5-11]): No new acute intracranial hemorrhage or major vascular territory infarction. Interval redistribution/resorption of subarachnoid and subdural hemorrhage. Probable minimal increase in blood products within the occipital [Doctor Last Name 534] of the left lateral ventricle. Possible shear injury involving the posterior corpus callosum. Consider MRI for further evaluation as clinically indicated. MRI head ([2170-5-12]): Subarachnoid and subdural blood products identified as on the prior CT. Signal changes in the splenium of corpus callosum, left frontal lobe as well as susceptibility abnormalities along the [Doctor Last Name 352]-white matter junction are suggestive of diffuse axonal injury. No territorial infarcts are seen. CXR ([2170-5-17]): ET tube is in standard placement, no less than 7 cm from the carina, although it is at the level of the lower margin of the clavicles. Pulmonary edema superimposed on residual abnormalities in both lungs due to ARDS and multifocal pneumonia has improved slightly since earlier today. Small right pleural effusion is likely. Heart size is top normal and mediastinal veins are still distended. No pneumothorax. Nasogastric tube passes into the stomach and out of view. Brief Hospital Course: [5-9]: The patient was admitted to the Trauma ICU from the ED. He was initially maintained on an oxygen facemask. Neurosurgey was consulted for his SAH and SDH and felt reimaging the next day was appropriate and surgical intervention was not intubated at that time. His head CT was repeated and showed just redistribution of blood. [5-10]: Epidural placement was attempt for discomfort and difficulty breathing but the patient was unable to tolerate procedure. His respiratory status worsened with desaturations despite 100% O2 facemask and he was ultimately intubated for airway protection. [5-11]: A left sided paravertebral catheter was placed to help with pain control given desaturations on CPAP ventilator mode. His post-placement CXR demonstrated worsening of his previously seen left sided pneumothorax and a left sided chest tube was placed with 300cc of old blood out and improvement in his pneumothorax. [5-12]: A repeat head CT was obtained given change in mental status which was unrevealing, and neurology was consulted. A head MRI was obtained which demonstrated moderate [Doctor First Name ]. The patient was minimally responsive at that time and mental status failed to significantly improve throughout the rest of his hospitalization. Sputum cultures were sent which demonstrated H.influenza and moderate streptococcus pneumonia, and he was started on levaquin. He continued to spike fevers and was changed to vanco and zosyn. Free water flushes were added for hypernatremia. [5-13]: A family meeting was held and the patient was made DNR with no further escalation in care. He respiratory status continued to decline with inability to tolerate CPAP and thick secretions. [5-14]: Propofol was added for dysynchrony on the ventilator - sedatives had previously been held for concern for depressed mental status. Discussions were made to hold a family meeting on Thursday [5-17]. [5-15]: His paravertebral catheter was dc'ed and fentanyl and oxycodone were added. His chest tube was dc'ed. His tube feeds were held for high residuals. [5-16]: His respiratory status continued to worsen despite diuresis. He continued to be unable to tolerate tube feeds. [5-17]: A family meeting was held with the patient's daughter, grandchildren and girlfriend. The decision was made to make the patient CMO with terminal extubation. The patient expired shortly thereafter. Medications on Admission: Asa 325mg po Prozac 80 Neurontin 900 tid Clonazepam 1 tid Risperidone 0.25 [Hospital1 ] Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Death Discharge Condition: Death Discharge Instructions: Death Followup Instructions: Death	[ "486", "5180", "2760", "41401", "V4581" ]
Admission Date: [2134-11-20] Discharge Date: Date of Birth: [2072-3-5] Sex: F Service: [Company 191] CHIEF COMPLAINT: Shortness of breath HISTORY OF PRESENT ILLNESS: 62-year-old African-American female with a history of diabetes, rheumatoid arthritis, hypertension, and Stage IV non-small cell lung carcinoma, who breath. The patient had been doing well until she had sudden onset of shortness of breath at rest that was unresponsive to her bronchodilator metered dose inhalers. The patient called EMS, where she was noted to be tachypneic and tachycardic as well as hypoxic, with oxygen saturation approximately 82% on [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] Emergency Department. In the Emergency Department, she had electrocardiogram demonstrating new right heart strain, and CT angiogram was performed, demonstrating evidence of bilateral pulmonary emboli. The patient was started on heparin, and echocardiogram was performed at the bedside, demonstrating right ventricular dilatation and paroxysmal subtotal wall motion. The patient was then transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Stage IV non-small cell lung carcinoma, diagnosed in [2134-8-8]. The patient had right upper lobe mass with right-sided pleural effusions, for which she underwent pleuroscopy and pleurodesis. She has been on gemcitabine/cisplatin chemotherapy three times, last on [2134-11-19]. Also has metastases to the contralateral lung as well as to the left adrenal gland. 2. Diabetes mellitus Type 2 3. Rheumatoid arthritis 4. Obesity 5. Asthma 6. Hypercholesterolemia 7. History of tobacco use ALLERGIES: No known drug allergies. MEDICATIONS: 1. Cozaar 100 mg by mouth once daily 2. Folate 2 mg by mouth once daily 3. Lipitor 10 mg by mouth once daily 4. Glyburide 10 mg by mouth once daily 5. Naproxen as needed 6. Methotrexate 2.5 mg four times per week 7. Serevent 8. Albuterol 9. Azmacort 10. Actos SOCIAL HISTORY: The patient is a 20 pack year smoker, but quit 16 years ago. No history of drug or alcohol use. FAMILY HISTORY: Significant for two brothers with [Name2 (NI) 499] cancer. PHYSICAL EXAMINATION: Vital signs: Heart rate 120 to 145, blood pressure 152/62, oxygen saturation 100% on 100% non-rebreather, respiratory rate 26 to 40. General: Morbidly obese African-American female, lying in bed, tachypneic. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light and accommodation, extraocular movements intact, no lymphadenopathy, no jugular venous distention. Cardiovascular: Tachycardic but regular. Lungs: Dullness to percussion at the right base, and decreased breath sounds. Abdomen: Soft, nontender, nondistended, positive bowel sounds, no masses. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis pulses bilaterally. Alert and oriented x 3. LABORATORY DATA: CT of the head was negative for bleed or metastases. CT angiogram showed bilateral pulmonary emboli. Electrocardiogram was sinus tachycardia, normal axis, new S1 Q3, intraventricular conduction delay with right bundle morphology. Chest x-ray with right basilar opacity consistent with right pleural effusion. HOSPITAL COURSE: 1. Pulmonary embolism: The patient had a right internal jugular placed and was started on heparin. The patient developed right neck hematoma and bleed on heparin. She consequently had thrombocytopenia (plt to 30k). The patient's heparin was discontinued. This occurred at a supratherapeutic level of heparin. Also noted to have stranding in the superior mediastinum, consistent with mediastinal hemorrhage. The patient underwent lower extremity Dopplers to find the source of the clot. She had small thrombus in the proximal left superficial femoral vein, as well as more occlusive thrombus in the popliteal vein on the left. The patient then underwent inferior vena cava filter placement with Trap-Ease type filter. The patient remained clinically stable and improved her oxygenation as well as her tachypnea. The patient was then transferred to the regular hospital floor. Heparin was continued to be held secondary to bleeding and thrombocytopenia risk. Heparin-induced thrombocytopenia antibody was negative. 2. Anemia: The patient suffered bleed on heparin at supratherapeutic level. Hematocrit decreased to 22. The patient was transfused four units of packed red blood cells with increase of hematocrit to 26. The patient had right neck hematoma as well as mediastinal bleed. There was some bruising over the left flank, consistent with retroperitoneal hematoma, although PT was not performed to validate this. The patient's hematocrit then rose on its own. No further blood transfusions were required. 3. Thrombocytopenia: The patient's platelet count on admission was 164. This decreased to a nadir of 33 on hospital day number five. It was unclear if this was due to heparin or to the chemotherapy the patient had received several days earlier. Heparin-induced antibody was negative, as well as other medications such as TPI were stopped. The patient's platelets gradually increased and are increasing at the time of this dictation. 4. Hypotension: The patient initially was hypotensive, probably secondary to her pulmonary embolism. The patient's blood pressure slowly increased during time. The patient was started on metoprolol 12.5 mg by mouth twice a day, with close attention to her blood pressure. 5. Diabetes mellitus: The patient was discontinued on her oral antihyperglycemics, and she was followed with a regular insulin sliding scale. She remained in fair control on this regimen. 6. Code: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1968], the patient's primary care physician, [Name10 (NameIs) 28822] the patient's code status with her and her family. The patient decided to become Do Not Resuscitate/Do Not Intubate. 7. Non-small cell lung carcinoma: The patient had been receiving outpatient chemotherapy. Secondary to her acute illness and her thrombocytopenia, these were not performed in-house. Consideration may be given to this in the future. A discharge summary addendum will be performed by the next intern. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 26586] Dictated By:[Name8 (MD) 104195] MEDQUIST36 D: [2134-11-28] 00:45 T: [2134-11-28] 01:40 JOB#: [Job Number ]	[ "5119", "2875", "2851" ]
Admission Date: [2114-10-3] Discharge Date: [2114-10-13] Date of Birth: [2077-7-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2186] Chief Complaint: fever, nausea, abdominal pain Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: 37 yo F w/o significant [Hospital 63245] transferred from OSH for management of pyelonephritis, bilateral pleural effusions, ascites. . Pt originally admitted to OSH on [2114-9-30] after presenting w/CC of vomiting, malaise, fever and back pain X4d, and Hx of recent UTI (treated in [Month (only) 216] w/unknown Abx as outpt). At the time, T 102, had upper abd tenderness, bilateral CVA tenderness, WBC [Numeric Identifier ], (+) Ua, CT abd confirmed severe Rt pyelonephritis with no other abnormalities. Pt started on Levoflox 500 IV q24h and Rocephin 2 gr IV q24h. Pt became afebrile within 36 h. Ux (+) for E.coli sensitive to ceftiaxone, resistant to levoflox. Levoflox D/Ced on [10-2] and replaced with gentamycin. On [10-3], pt afebrile w/WBC down to 8100, however c/o HA/ abd and flank pain and SOB. O2 sat 92-97% on RA. Vomited and became bradycardic (42, then up to the 50s). ECG sinus brady. On Lovenox 60 mg sc. Repeat CT of the abdomen showed new bilateral pleural effusions R>L, ascites and "generalized inflammation of the liver". Rt kidney looks improved compared to [9-30]. Sent to [Hospital1 18] for further management. Past Medical History: Hospitalized only for vaginal delivery X2. Recent UTI in [Month (only) 216]. No surgeries. LMP: [2114-9-27]. Social History: moved from [Country 4194] in [4-10], works in housecleaning, not married, 2 children in [Country 4194]; currently sexually active with 1 male partner ("rare" unprotected sex); No STDs Family History: NC Physical Exam: Tc 101.1 HR 48 BP 110/70 RR 16 O2sat 95% RA general- sitting up in bed, ill-appearing, no respiratory distress HEENT- sclerae anicteric, dry MM Neck- HOB 45deg: JVD to mandible Pulm- poor inspiratory effort, poor air movement, no audible wheezes Heart- bradycardic, regular, no m/r/g Abd- distended but soft, hypoactive bowel sounds, + tenderness to mild palpation of RUQ/epigastrium, + peritoneal signs, + guarding Ext- no peripheral edema, +2 PT pulses b/l Neuro- CN III-XII intact, strength exam limited by poor effort Pertinent Results: [2114-10-3] 08:35PM PT-13.7* PTT-34.8 INR(PT)-1.3 [2114-10-3] 08:35PM WBC-7.4 RBC-3.12* HGB-9.8* HCT-29.3* MCV-94 MCH-31.5 MCHC-33.5 RDW-13.1 [2114-10-3] 08:35PM ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-165 ALK PHOS-130* AMYLASE-27 TOT BILI-0.3 [2114-10-3] 08:35PM GLUCOSE-89 UREA N-8 CREAT-0.8 SODIUM-140 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-20* ANION GAP-16 [2114-10-3] 08:35PM CALCIUM-7.9* PHOSPHATE-3.0 MAGNESIUM-1.8 . Hepatitis B Surface Antigen NEGATIVE Hepatitis B Core Antibody, IgM NEGATIVE Hepatitis A Virus IgM Antibody NEGATIVE Hepatitis C Virus Antibody NEGATIVE [Doctor First Name ] negative . ESR 64* Parst S NEGATIVE . CT abd/pelv (OSH, [9-30]): R sided pyelonephritis, "generalized inflammation of the liver" . RUQ US: normal gallbladder, no gallstones, CBD 5mm, small calcification in R lobe of the liver likely representing granuloma, normal portal vein, no intrahepatic biliary ductal dilatation, small pleural effusion . [2114-10-5], CT HEAD WITHOUT CONTRAST: No intracranial mass effect, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct is apparent. The density values of the brain parenchyma are normal. The surrounding soft tissue and osseous structures are unremarkable. . [2114-10-5], CT ABDOMEN WITH IV CONTRAST: There are bilateral pleural effusions with atelectatic changes. There are no nodules visualized. The liver is enlarged and heterogeneous, which could be consistent with hepatitis. The gallbladder contains high attenuation material within the lumen consistent with sludge, but is not distended and there is no evidence of stones. There is a moderate amount of abdominal ascites. The pancreas, adrenal glands, spleen, left kidney, stomach, and abdominal loops of small and large bowel are within normal limits. The right kidney is enlarged and there are mottled wedge shaped areas of hypodensity. This appearance is suggestive of infarct versus pyelonephritis. The appendix is visualized and there are no signs of acute appendicitis. There is no free air and no pathologic mesenteric or retroperitoneal lymphadenopathy. . CT PELVIS WITH CONTRAST: The bladder, uterus, rectum, and sigmoid colon are within normal limits. There is a moderate amount of fluid surrounding the uterus, but no evidence for tubo-ovarian abscess. There is no pathologic mesenteric or inguinal lymph adenopathy. . BONE WINDOWS: No lytic or sclerotic foci are visualized. . TTE [10-8]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is top normal. There is a very small likely loculated pericardial effusion around the right atrium (?small pericardial cyst).. . MICRO: [2114-10-6] 9:41 am urine/serology FINAL REPORT [2114-10-7] Legionella Urinary Antigen (Final [2114-10-7]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgG AB (Final [2114-10-8]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS EBNA IgG AB (Final [2114-10-8]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgM AB (Final [2114-10-8]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. TOXOPLASMA IgG ANTIBODY (Final [2114-10-9]): NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final [2114-10-9]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. CMV IgG ANTIBODY (Final [2114-10-9]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 60 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [2114-10-9]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [2114-10-5]): Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [2114-10-5]): Negative for Neisseria Gonorrhoeae by PCR. LYME SEROLOGY (Final [2114-10-8]): NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. Reference Range: No antibody detected. RAPID PLASMA REAGIN TEST (Final [2114-10-8]): NONREACTIVE. Reference Range: Non-Reactive. Brief Hospital Course: A/P: 37yo F with pyelonephritis, ascites, and pleural effusions. . 1) Pyelonephritis: > 100K colonies of E. coli grew on urine culture from OSH ([Hospital6 18346]), which was sensitive to ceftriaxone, resistant to levoflox and cipro. Patient was initially treated with ceftriaxone here but due to development of serositis (pleural eff, ascites), without rash or arthralgias, which was thought to be possibly secondary to ceftriaxone. Because of this possibilty, she was changed to aztreonam per infectious disease recommendations. Another more plausible etiology of her serositis may have been due to inlfammatory response to overwhelming infectious process. The patient's symptoms of abdominal pain and dyspnea improved dramatically after 2 days of being on Aztreonam. A repeat abdominal and pelvis CT revealed wedge-shaped densities in R kidney: radiologically consistent with infarct vs. pyelonephritis, and not indicative of abscess or necrosis. Blood cultures have had no growth to date here or at OSH. Repeat urine cultures here showed no growth of organisms. WBC count improved throughout her stay and back to normal range prior to discharge. She completed a complete 14d course of IV antibiotics prior to discharge. It was felt, with assistance of an allergist, that this patient should not receive ceftriaxone in the future but can take other cephalosporins and other beta-lactam antibiotics. . 2) RUQ pain: Unclear what the cause was but felt to be most likely all secondary to her severe pyelonephritis. CT showed a heterogeneously enlarged liver with some small amt of ascites but LFTs were in normal range. Gallbladder with sludge but no stones. Hepatitis panel for Hep A, B and C were negative. Given Fitz-[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] syndrome was on differential diagnosis a pelvic exam was performed which was negative for cervical motion tenderness, a normal bimanual exam, and cultures for Chlamydia/gonorrhea were negative. No tubo-ovarian abscess was seen on CT scan. . Additional serologies were sent for more rare causes of hepatitis. Given her living environment ([Hospital1 6687] and [Country 4194]), she was at risk for tick-borne illnesses as well as tropical diseases. Serologies for Lyme, Ehrlichia, babesiosis were negative. Her smear (thick and thin) showed no parasites basically ruling out malaria. In addition, her EBV IgM, CMV IgM, and Toxo. serologies were negative. . 3) Neck pain: Patient complained of severe neck pain and stiffness. An LP was performed on Hospital Day 2 to eval for meningitis. CT Head showed no gross abnormality. Her CSF had 1 WBC, 7 RBCs, glucose and protein wnl, bacterial culture with no growth, viral culture no growth to date. Her neck pain improved throughout her stay especially with use of NSAIDs. . 4) Sinus bradycardia: Patient had profound sinus bradycardia initially during her first 5-6 days of hospitalization with heart rates in 20-40s. She maintained adequate blood pressures despite this heart rate. Her EKG consistently revealed a sinus rhythm with normal intervals. Given her bradycardia, abdominal pain and infectious condition, typhoid fever or other enteric fever were entertained as possible diagnoses. In addition, her bradycardia and relative normotensive state was concerning for possible increase intracranial pressure. Her CT head was unremarkable and blood cx never grew an organism likely ruling out these possible etiologies. In addition, an echocardiogram was obtained to evaluate for myocarditis, cardiomyopathy, or evidence of valvular vegetations. Her echo was basically normal with normal valves, normal EF, etc. Thus, her bradycardia remains a mystery and her heart rate improved to rates in 60s-70s prior to discharge. ? If bradycardia was due to increased vagal response from nausea and pain (? with normal BP). . 5) Dyspnea: Patient complained of inability to take deep breaths and shortness of breath during her first several days in the hospital. Her dyspnea was attributed to her bilateral pleural effusions and likely resulting pleurisy. Her symptoms improved and her oxygenation was never a significant issue. She was ambulating well without evidence of effusions or hypoxia prior to discharge home. . Medications on Admission: None at home (ceftriaxone 2g q24h, gent 80 mg [Hospital1 ], promethazine, ambien, ibuprofen, vicodin on transfer) Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: 1. Pyelonephritis 2. Serositis 3. Reaction to ceftriaxone Discharge Condition: Stable, afebrile, no pain Discharge Instructions: If you experience any fevers, chills, shortness of breath, back pain, abdominal pain; please call your doctor or go to ER. You should not take the antibiotic ceftriaxone again. Followup Instructions: Please make an appt with your primary doctor in 2 weeks. Completed by:[2114-10-13]	[ "5119", "42789" ]
Admission Date: [2160-6-4] Discharge Date: [2160-6-7] Date of Birth: [2106-10-4] Sex: M Service: ORTHOPAEDICS Allergies: Indocin / Enalapril / Claritin / Lipitor / Pravachol Attending:[First Name3 (LF) 64] Chief Complaint: Left hip pain/arthritis Major Surgical or Invasive Procedure: [2160-6-4] - Left total hip arthroplasty History of Present Illness: Mr. [Known lastname ] is a 53 year old man with left hip dysplasia and arthritis that has failed non-operative treatment. He presents for a left hip arthroplasty. Past Medical History: dysplasia, hypertension, heart murmur, asthma, LBP, headache, GERD, s/p appendectomy Social History: n/c Family History: n/c Physical Exam: At the time of discharge: AVSS NAD wound c/d/i without erythema [Last Name (un) 938]/FHL/TA/GS intact SILT distally Brief Hospital Course: The patient was admitted on [2160-6-4] and, later that day, was taken to the operating room by Dr. [Last Name (STitle) ] for a left total hip arthroplasty without complication. Please see operative report for details. Postoperatively the patient was transferred from the PACU to the SICU for postoperative hypoxia secondary to sleep apnea and analgesic effects. The patient was placed on CPAP and monitored carefully; he was transferred to the floor on POD1. The patient was initially treated with a PCA followed by PO pain medications on POD#1. The patient received IV antibiotics for 24 hours postoperatively, as well as lovenox for DVT prophylaxis starting on the morning of POD#1. The drain was removed without incident on POD#1. The Foley catheter was removed without incident. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was stable, and the patient's pain was adequately controlled on a PO regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to home with services or rehabilitation in a stable condition. The patient's weight-bearing status was weight bearing as tolerated with posterior precautions. Medications on Admission: albuterol, diovan 320, HCTZ 25, wellbutrin 100, lovastatin 40, atenolol 50 Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Enoxaparin 40 mg/0.4 mL Syringe Sig: [2-15] syringe Subcutaneous once a day for 3 weeks. Disp:18 syringe Refills:0 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 14. Outpatient Physical Therapy Routine total hip protocol WBAT with posterior precautions 15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:80 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Left hip pain/arthritis Discharge Condition: Stable Discharge Instructions: experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by a visiting nurse at 3 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 4 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg twice daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by VNA in 3 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at 3 weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative leg with posterior precautions; no active knee extensions. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Routine total hip protocol WBAT with posterior precautions Treatments Frequency: Lovenox injections. Wound checks. VNA to remove staples at 2 weeks. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1953], [MD Number(3) 1240]:[Telephone/Fax (1) 1228] Date/Time:[2160-7-4] 11:20 Provider: [First Name11 (Name Pattern1) 2482] [Last Name (NamePattern4) 10466], [MD Number(3) 1240]:[Telephone/Fax (1) 250] Date/Time:[2160-7-4] 12:00 Provider: [First Name11 (Name Pattern1) 198] [Last Name (NamePattern4) 199], M.D. Date/Time:[2160-9-2] 3:20	[ "4019", "49390", "53081" ]
Admission Date: [2105-6-15] Discharge Date: [2105-6-23] Date of Birth: [2049-4-29] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: left cranial defect Major Surgical or Invasive Procedure: [2105-6-15] Left cranioplasty [2105-6-15] Left craniotomy evacuation of epidural hematoma History of Present Illness: This is a 50 year old man with a history of HTN, polysubstance abuse (cocaine, heroin, alcohol), hepC presented recently to [Hospital 487] Hospital with headache and ?fall to head. We saw him [2105-2-19]. AT THAT TIME GCS on arrival was 11 and patient found to have Right sided hemiplegia. NCHCT done at that time revealed large L basal ganglia bleed with minimal midline shift. Pt found to deteriorate from there with subsequent intubation on propofol. We took him to the OR [2-19] for a L hemicraniectomy for decompression. He resides at rehab right now and has much improved since. Past Medical History: - polysubstance abuse - HTN - Hep C - HIV, CD4 510 in [2105-5-18] - IVC filter - ICH, s/p hemicraniectomy [2105-2-19] - Laparotomy [2-/2105] for acute abdomen during G tube placement - Syphilis 20 years ago - Latent TB 10 years ago, treated with INH for one year Social History: From OMR: He is originally from [State 3908], he moved to Mass in [2102] after being inmate x 15 years in [State 3908]. He was living in shelters until his ICH and since then has been at [Hospital3 ]. [Last Name (un) ] history of substance abuse including Heroin, cocaine, opioids, alcohol, and intermittent tobacco smoking. Family History: From OMR: No history of neoplastic/infectious diseases Physical Exam: On Admission: AF VSS normocephalic, R indentation from flap removal HEENT: no LNN Pupils: PERL Neck: Supple. Lungs: no SOB, CTA bilaterally. Cardiac: RRR Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: cooperates well with exam. Orientation: x 3 (aphasic)? Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2-->1 on R and 3-->2 on left. Visual fields not assessed V, VI: intact doll's eyes VII: IX, X: Palatal elevation symmetrical. Motor: dense central R hemiparesis Sensation: perceives pain and LT on the R; left nl Reflexes: B T Br Pa Ac Right 3+ -------------> Left 2+ -------------> Toes upgoing on right Clonus 5 B on R Coordination: n/a At discharge: awake, alert, oriented x [1-23]. Speaks in short phases. Follows simple commands. Pupils asymmetric, L > R, both reactive. Right hemiparesis. Moves left spontaneously. Pertinent Results: [2105-6-15] Ct head - Status post left cranioplasty with large left extraaxial hematoma with pneumocephalus. This results in partial effacement of the left lateral and third ventricles, and 8 mm rightward shift of normally midline structures. [6-15] CT head - Interval evacuation of left extraaxial hematoma, which is now largely replaced with air and a small amount of residual fluid. Persistent mass effect with 8 mm rightward shift of normally midline structures. Effacement of the third and left lateral ventricles, without evidence of right lateral ventricle entrapment. [6-16] CT head: IMPRESSION: 1. Very slight decrease in the amount of postoperative pneumocephalus and mass effect. 2. Small amount of stable residual subdural blood products in the surgical bed. 3. No evidence of new hemorrhage. [2105-6-16] NCHCT: IMPRESSION: 1. No change in the appearance of the intracranial postoperative pneumocephalus and small amount of left subdural blood products. Stable intracranial mass effect. 2. Increase in the amount of fluid in the subgaleal space overlying the left cranioplasty with a decrease in the amount of subcutaneous emphysema. Brief Hospital Course: Patient was admitted to Neurosurgery on [2105-6-15] and underwent the above stated procedure. Please review dictated operative report for details. Patient was extubated without incident and transferred to PACU then floor in stable condition. Patient developed increasing subgaleal swelling and increasing headaches. A repeat Ct head showed a large left Epidural hematoma. He was take emergently back to the OR for a craniotomy and evacuation of EDH. he tolerated this procedure well. He remained intubated and transferred to SICU. He was extubated without incident on [6-16]. He was then transferred to the floor in stable condition. CT head done on [6-16] showed pneumocephalus and 100% oxygen was intiated. He became for confused with a tense craniotomy site in the afternoon. CT head was without much changes, no acute hemorrhage. He was started on both Dilantin and levetiracetam. He was more alert and oriented on [6-17] and he was transfered to the SDU. SQH was started. He was transferred out of the SDU on [6-18] and was ready for discharge, awaiting guardianship [Name2 (NI) 92579]. On [6-19] he was tolerating his tube feeds at goal. Patient was febrile overnight on [6-19] to 102. An infectious work-up was sent including CBC, urine cultures, blood cultures, and CXR. CBC revealed a WBC of 13.3. Blood cultures, urine cultures, and CXR were negative. A medicine consult was obtained. On [6-21], his WBC was elevated, CBC with diff was sent. Urine culture showed E.coli and he was started on IV ceftriaxone to complete 10-day course (first day [2105-6-21], last day [2105-6-30]). He was screened for rehab and accepted pending approval of his HCP. On [6-22], his HCP was [Name (NI) 653] and agreed to his placement. He will be discharged to rehab on [6-23]. =============================== TRANSITION OF CARE: -Patient has a chronic microcytic anemia documented throughout hospitalization; HCT stable between 24-28. -Pt needs to complete 10-day course of ceftriaxone for resistant UTI. If cannot receive IV ceftriaxone at rehab, should switch to PO cefpodoxime (last day [2105-6-30]). Medications on Admission: 1. Amlodipine 10 mg PO DAILY hold for sbp <100 2. Baclofen 5 mg PO BID Hold for change in mental status, sedation 3. Bisacodyl 10 mg PO DAILY:PRN constipation 4. Calcium Carbonate 750 mg PO TID 5. Citalopram 20 mg PO DAILY 6. Cyclobenzaprine 5 mg PO TID:PRN Muscle spasm Hold for sedation, RR <10, change in mental status 7. Docusate Sodium 100 mg PO BID 8. HydrALAzine 50 mg PO BID hold for sbp <100 9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob, wheeze 10. Lisinopril 40 mg PO DAILY hold for sbp <100 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 20 mg PO BID 13. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain hold for sedation, RR <10, change in mental status 14. Sucralfate 1 gm PO QID 15. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing 2. Amlodipine 10 mg PO DAILY 3. Baclofen 5 mg PO Q12H 4. Bisacodyl 10 mg PO DAILY 5. Citalopram 20 mg PO DAILY 6. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm 7. Docusate Sodium 100 mg PO BID 8. LeVETiracetam 500 mg PO BID 9. Lisinopril 40 mg PO DAILY 10. Metoclopramide 10 mg PO TID 11. Multivitamins 1 TAB PO DAILY 12. Phenytoin (Suspension) 100 mg PO Q8H 13. Sucralfate 1 gm PO QID 14. Senna 1 TAB PO BID 15. HydrALAzine 50 mg PO BID 16. Heparin 5000 UNIT SC TID 17. Calcium Carbonate 750 mg PO TID 18. Famotidine 20 mg PO BID 19. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 20. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: left cranial defect left epidural hematoma cerebral edema mental status change Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? Have a caretaker check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound was closed with staples. You must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? You have been prescribed Keppra (Levetiracetam) and Dilantin (Phenytoin) for anti-seizure medicine, please take it as prescribed and follow up with laboratory blood drawing for phenytoin level in one week. This can be drawn at your extended care facility or your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [6-30] days(from your date of surgery) for removal of your staples and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ], to be seen in [3-27] weeks. ??????You will need a CT scan of the brain without contrast.	[ "5990", "4019" ]
Admission Date: [2111-12-11] Discharge Date: [2111-12-15] Date of Birth: [2073-10-3] Sex: F Service: MEDICINE Allergies: Elavil Attending:[Doctor Last Name 10493] Chief Complaint: Diabetic ketoacidosis Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known firstname 32248] is a 38 yo F with PMH of DM Type I sent from [Hospital1 ] group home for altered mental status and found to be in diabetic ketoacidosis. She reports having increased sweets in diet recently and not trying to control her FSG until it was too late. She reports FSG in the 500s and says she developed nausea and vomiting in this context. She stopped taking insulin as no longer eating. Her sister was concerned for altered mental status after speaking to her on the phone, and patient reportedly speaking gibberish when found. . On arrival to the ED FSG was greater than assay, T 97.3 HR 84 BP 138/77 RR 35 100%RA. Femoral line placed and insulin drip started at 7 units per hour; also given 3L NS IV and calcium gluconate for her hyperkalemia. She was given a dose of vancomycin and zosyn due to concern for infection given a WBC of 25.9. CXR and head CT unremarkable. Per ED nurse report, patient had drop in blood pressure to 70's while in the CT scanner in setting of recent 4mg IV morphine which resolved with aggressive IV hydration. Transferred to MICU. . On arrival to the ICU she was awake and alert, oriented to person only. Denied any pain although she did endorse recent vomiting. Past Medical History: DM Type 1 - poorly controlled with h/o neuropathy, DKA S/p L BKA [2111-8-18] H/o ARDS secondary to sepsis PVD Depression Chronic anemia Dyslipidemia CHF Social History: Lives in apartment with 16-year-old daughter. Denies EtOH use currently although reports occasional use in past. [4-7] cigarettes a day on and off for 10 years. Denies h/o illicit drug use besides marijuana although admitted to cocaine use after being found to have urine positive for cocaine. Family History: Father with Type 2 DM Physical Exam: VS: T 95.7 BP 101/49 HR 82 RR 13 100% RA Gen: resting comfortably, oriented to person only, responds to questions, awake, no apparent distress, slightly slurred speech HEENT: NC, AT, pupils 3mm equal but minimally reactive to light, +thrush in mouth Neck: supple, no LAD CV: RRR, no appreciable murmur Lungs: CTAB Abd: soft, NT ND BS + EXT: right femoral line in place, s/p L BKA, small 2cm x3cm area of skin breakdown on anterior aspect of left stump slight amount of purulent drainage but no surrounding erythema, warmth or induration, patient denies pain. Right foot without any skin breakdown. Pertinent Results: Admission labs: [2111-12-11] 04:45PM BLOOD WBC-25.9# RBC-2.95 Hgb-9.6* Hct-30.8* MCV-104# MCH-32.6# MCHC-31.2 RDW-18.3* Plt Ct-878* [2111-12-11] 04:45PM BLOOD PT-13.4 PTT-97.7* INR(PT)-1.1 [2111-12-11] 04:45PM BLOOD Glucose-1131* UreaN-82* Creat-4.2# Na-123 K-7.6* Cl-85* HCO3-LESS THAN [2111-12-11] 04:45PM BLOOD Albumin-4.3 Calcium-10.3* Phos-11.8# Mg-3.1 [2111-12-12] 04:11AM BLOOD %HbA1c-12.0* Discharge labs: [2111-12-14] 07:25AM BLOOD WBC-9.2 RBC-3.29* Hgb-10.4* Hct-29.7* MCV-90 MCH-31.6 MCHC-35.0 RDW-17.3* Plt Ct-462* [2111-12-14] 07:25AM BLOOD Glucose-241* UreaN-16 Creat-1.0 Na-133 K-4.6 Cl-101 HCO3-23 AnGap-14 Cardiac markers [2111-12-11] 04:45PM BLOOD CK(CPK)-134 [2111-12-11] 10:32PM BLOOD CK(CPK)-208* [2111-12-11] 11:57PM BLOOD CK(CPK)-229* [2111-12-12] 05:04AM BLOOD CK(CPK)-301* [2111-12-13] 04:23PM BLOOD CK(CPK)-105 [2111-12-11] 04:45PM BLOOD CK-MB-9 [2111-12-11] 10:32PM BLOOD CK-MB-13 [2111-12-11] 11:57PM BLOOD CK-MB-14 [2111-12-12] 05:04AM BLOOD CK-MB-16 [2111-12-13] 04:23PM BLOOD CK-MB-5 [2111-12-11] 04:45PM BLOOD cTropnT-0.43* [2111-12-11] 10:32PM BLOOD cTropnT-0.51* [2111-12-11] 11:57PM BLOOD cTropnT-0.60* [2111-12-12] 05:04AM BLOOD cTropnT-1.02* [2111-12-13] 04:23PM BLOOD cTropnT-0.77* Elevated LFTs [2111-12-13] 08:49AM BLOOD ALT-53* AST-68* LD(LDH)-306* AlkPhos-757* Amylase-441* TotBili-0.4 [2111-12-12] 02:43AM BLOOD GGT-1212* [2111-12-11] 08:49PM BLOOD Lipase-588* [2111-12-12] 02:43AM BLOOD Lipase-299* G [2111-12-13] 08:49AM BLOOD Lipase-217* [2111-12-11] 08:49PM BLOOD Amylase-1028* [2111-12-12] 02:43AM BLOOD Amylase-1030* [2111-12-13] 08:49AM BLOOD Amylase-441* Hep panel pending Micro: [2111-12-11] 05:25PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.019 [2111-12-11] 05:25PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-1000 Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2111-12-11] 05:25PM URINE RBC-0-2 WBC-[4-8] Bacteri-FEW Yeast-MANY Epi-0-2 [2111-12-11] Urine Cx: YEAST >100,000 ORGANISMS/ML [2111-12-11] Blood Cx: Pending, no growth to date x 2 Altered mental status: [2111-12-11] 05:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG [2111-12-11] 04:45PM BLOOD ASA-6 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Imaging [2111-12-11] CXR: No acute cardiopulmonary process [2111-12-11] Head CT: No evidence of acute intracranial hemorrhage, mass lesion or major territorial infarct. [8-/2111] ECHO: Normal cavity sizes with global biventricular hypokinesis c/w diffuse process (toxin, metabolic, infiltrative process, etc. - cannot fully exclude multivessel CAD, but less likely). LVEF 35%, Mild mitral regurgitation Brief Hospital Course: 38 yo F with DMI, PVD s/p recent BKA presenting with diabetic ketoacidosis. # Diabetic Ketoacidosis: DKA [3-7] poor glycemic control and insulin noncompliance, supported by HbA1c of 12. Pt reports diabetes was bettercontrolled as a child but has found it difficult to control since starting to manage it on her own. [Month (only) 116] also have contribution from chemical pancreatitis or cocaine. Patient transferred to MICU on insulin drip with appropriate glycemic response, closing of anion gap, and improved mental status. Lytes repleted aggressively. Transferred to floor when stable. Insulin regimen changed to NPH 75/25 15 U qAM, 20 U qHS with sliding scale, to be adjusted as needed. Pt discharged home with services, including diabetes teaching. Pt scheduled to follow up with [Last Name (un) ] diabetes educator [First Name5 (NamePattern1) 16883] [Last Name (NamePattern1) 32249] on [2111-12-24], already scheduled to see Dr. [Last Name (STitle) 978] on [2112-1-20]. Follow up also scheduled with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 1007] on [2111-12-22]. # Leukocytosis: Initially concerning for possible infection but did resolve off antibiotics. Pt remained afebrile. Urine culture grew only yeast, not treated as patient asymptomatic. Blood cultures x 2 pending with no growth to date at time of discharge. # Acute Renal Failure: Likely secondary to volume depletion in setting of DKA, resolved at time of transfer to floor. Of note, lasix held secondary to acute renal failure. Would recheck Cr at time of follow-up. # Altered Mental Status: Resolved, likely [3-7] DKA and metabolic derangements. Psych recommended limiting use of narcotics, benzos and anticholinergic meds to avoid exacerbation of possible residual delirium. Also recommended haldol or cogentin prn for agitation, which pt did not require. Pt [Name (NI) ] x 3 on transfer to floor. Psych recommended restarting klonopin to anxiety, continued to hold lorazepam at time of discharge. # Depression: Psych evaluated patient who was very closed off during her admission as she did not want to repeat her story to another stranger. Psych was able to determine that she did not need inpatient treatment. Pt open to the idea of being followed by a psychiatrist at [Hospital1 18], provided with contact into to schedule outpatient appointment. # Hypertension: Medication initially held as blood pressures running lower. However, these were added back tolerated. Pt on home doses of clonidine and metoprolol on discharge. Lasix continued to be held in context of acute renal failure, and pt remained euvolemic. Pt to discuss with PCP when to restart Lasix. # Elevated LFTs: Unclear etiology, also elevated in past per OMR. GGT also elevated, suggesting a hepatic etiology. However, pt without abdominal pain or tenderness. Hepatitis serologies pending on discharge, would pursue outpatient work-up by PCP. # Elevated Troponin: Pt asymptomatic and hemodynamically stable. Likely elevated secondary to demand ischemia in the setting of severe DKA and dehydration, although given h/o DM1 and vascular disease as well as recent cocaine use, ACS was also a possibility. However, ruled out by normal EKG and serial cardiac markers. Pt continued on ASA and restarted on metoprolol prior to discharge. Would follow up as outpatient. # Pancreatitis: Asymptomatic but elevated amylase and lipase. Pt asymptomatic with benign exam. # Anemia: Pt noted to have chronic anemia. Hct remained at baseline during admission, pt hemodynamically stable on discharge. Would recommend further work-up as outpatient. # Wound care: Pt noted to have small area of breakdown at her left BKA site. Pt reports recent fall. Small shallow ulcer noted with clean borders. Pt received wound care during her admission. Discharged with home services including PT. # Substance abuse: Urine tox screen positive for cocaine. Pt unlikely to benefit from detox or counseling at this time as she currently denies any history of illicit drug use. Pt to follow up with a psychiatrist. Medications on Admission: Ambien 10 mg qhs ASA 81 mg daily Calcium 500 mg daily Clonazepam 1 mg qhs Clonidine 0.1 mg [Hospital1 ] Furosemide 20 mg daily Gabapentin 300 mg TID Humalog Humulin R Vicodin 5/500 q4 hours prn pain Dilaudid 1-2 mg q4hours prn Lantus 15 units before breakfast Lorazepam 0.5 mg q12 hours prn anxiety Toprol 200 mg daily Omeprazole 20 mg daily Vitamin D Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:30 Tablet, Chewable(s) Refills:2 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 6. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 9. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ergocalciferol (Vitamin D2) Oral 11. Insulin NPH & Regular Human 100 unit/mL (75-25) Suspension Fifteen (15) u Subcutaneous qAM, Twenty (20) u Subcutaneous qHS. Adjust as directed. Disp:2 Vials Refills:2 12. Insulin Lispro 100 unit/mL Solution Sig: As directed Subcutaneous As directed: Sliding scale as directed. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary - Diabetic Ketoacidosis - Non ST elevation MI - Chemical pancreatitis (asymptomatic) - Acute renal failure (resolved) Secondary - Diabetes Type I - S/p left BKA - Peripheral neuropathy - Hypertension - Dyslipidemia - Depression - Chronic anemia Discharge Condition: Stable Discharge Instructions: You were admitted for altered mental status due to diabetic ketoacidosis. Your mental status returned to baseline as your glucose level was corrected. It is very important that you take your insulin as directed and watch your diet. Your kidney function worsened initially but is now improved. It appears there was some injury to your heart; it is important that you continue taking baby aspirin. Of note, your labs showed anemia and elevated liver and pancreatic enzymes, although you did not have any symptoms. Please follow up with your PCP regarding all of these issues. The following medications were changed: Insulin dose changed to NPH 75/25 2x/day Lasix held; please discuss with your PCP when to restart it. Lorazepam stopped; please discuss with your psychiatrist whether you should restart it. Please continue to take all of your other medications as prescribed. Please call your doctor or come to the emergency room if you develop chest pain, shortness of breath, confusion, dizziness. Please also call your doctor if you are having difficulty controlling your sugars. Followup Instructions: You are scheduled to follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 1007] on Tuesday, [2111-12-22] @ 3:30pm. Please call [Telephone/Fax (1) 10492] if you have any questions. You will need to have your labs checked to make sure they are improving. You also have an appointment with [Doctor First Name 16883] [Doctor First Name 32249], the diabetes educator at [Last Name (un) ], on Thursday, [2111-12-24] @ 9 am. Please call [Telephone/Fax (1) 2384] if you have any questions. Lastly, you are scheduled to see your [Last Name (un) ] doctor, Dr. [Last Name (STitle) 978], on [2112-1-20] at 3:30 pm. We recommend making an appointment to see a psychiatrist for follow-up to help you adjust your medications. You can schedule an appointment by calling [Telephone/Fax (1) 1387]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10491] MD, [MD Number(3) 10495]	[ "5849", "41071", "2761", "4280", "V5867", "4019", "2859", "2724", "2767" ]
Admission Date: [2119-4-27] Discharge Date: [2119-5-24] Date of Birth: [2119-4-27] Sex: M Service: NEONATOLOGY HISTORY: Baby [Name (NI) ] [Known lastname ] is a former 32 and [6-26] week male admitted to the Neonatal Intensive Care Unit for management of prematurity. The infant was born to a 33 year old gravida III, para II-III, O positive antibody negative, GBS unknown, hepatitis B surface antigen negative, RPR nonreactive woman. Reportedly uncomplicated antepartum course until 31 and one half weeks when admitted with pre-PROM. Received Magnesium Sulfate, Betamethasone, Ampicillin and Erythromycin. She remained afebrile. The decision was made to induce on the day prior to delivery because of decelerations. A cesarean section was performed for nonreassuring fetal heart tracing. Maternal temperature maximum 99.2. Apgar eight at one minute and nine at five minutes. PHYSICAL EXAMINATION: On admission, examination was remarkable for well appearing preterm infant in no distress with vital signs that were stable, pink color, normal facies, soft, anterior fontanelle, intact palate, no grunting, flaring, retracting, clear breath sounds, no murmur, present femoral pulses, flat, soft, nontender abdomen without hepatosplenomegaly, normal phallus, testes and scrotum normal perfusion, stable hips, normal tone and activity for gestational age. Birth weight 2040, greater than 75th percentile. Discharge weight , greater than 50th percentile. Admission length 42.5 centimeters, 25th to 50th percentile, discharge length 47.0 centimeters, 50th percentile. Admission head circumference 32.25, greater than 75th percentile, discharge head circumference 33.5, greater than 50th percentile. HOSPITAL COURSE: 1. Respiratory - The baby remained in room air without any respiratory distress. The infant showed an occasional episode of apnea and bradycardia. At the time of discharge, he is free of apnea, bradycardia and desaturations for five days. He did not require any methylxanthine treatment. 2. Cardiovascular - No murmur. No issues. The baby did not require any pressors. 3. Fluid, electrolytes and nutrition - Parameters as stated above. The baby initially had peripheral intravenous started at maintenance intravenous fluids of 80 cc/kg. Dextrostix stable at greater than 60. Enteral feedings were introduced on the first night of life and advanced slowly. The baby did demonstrate some aspirates thought to be secondary to slowed motility from maternal magnesium sulfate. Ultimately, feedings were advanced slowly without incident to PE-20 by date of life seven. Calories were increased to 24 calories per ounce. He currently is eating Enfamil-24 with iron ad lib a minimum of 130 cc/kg. He is exceeding this minimum all p.o. without issue. The baby is voiding and stooling. Last set of electrolytes on [2119-5-3], sodium 141, potassium 5.8, chloride 108, bicarbonate 23. 4. Gastrointestinal - Peak bilirubin on day of life three was 10.8/0.4. The baby responded to phototherapy which was discontinued on day of life six. He had a rebound bilirubin of 6.8/0.3. 5. Hematology - The baby did not require any blood products during this admission. Admission hematocrit was 48.9. 6. Infectious disease - The infant had a blood culture and a complete blood count sent on admission with a white blood cell count of 12.0, 20 polys, 0 bands, platelet count 270,000 and hematocrit 48.9. He was started on a 48 hour course of Ampicillin and Gentamicin. At 48 hours, cultures were negative and the baby was clinically well and antibiotics were discontinued. He has had no further issues with infection. 7. Neurology - The baby is appropriate for gestational age. A head ultrasound was not indicated based on gestational age of greater than 32 weeks. The baby is appropriate for gestational age. 8. Audiology - Hearing screen was performed with automated auditory brain stem response. The patient passed the screening. 9. Ophthalmology - Examination not indicated based on gestational age. 10. Psychosocial - The parents have been visiting frequently and look forward to [Known lastname ] transitioning home with his siblings. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home with family. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], telephone [Telephone/Fax (1) 54555], fax [Telephone/Fax (1) 54556]. CARE RECOMMENDATIONS: 1. Continue ad lib feedings of Enfamil-24 with iron. 2. Medications - None at the time of discharge. 3. Car seat position screening - pending at the time of this dictation. 4. State Newborn Screens have been sent per routine and results are pending. 5. Immunizations received - Hepatitis B vaccine [2119-5-10]. IMMUNIZATIONS RECOMMENDED: Synergis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks. 2. Born between 32 and 35 weeks with two of three of the following: a. DayCare during RSV season. b. A smoker in the household, neuromuscular disease, airway abnormalities or a school age sibling. c. With chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age, for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW-UP APPOINTMENT: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2119-5-25], at 11:20 a.m. DISCHARGE DIAGNOSES: 1. Former 32 and [6-26] week nondysmorphic male. 2. Status post rule out sepsis with antibiotics. 3. Status post apnea and bradycardia of prematurity. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Last Name (NamePattern1) 36251] MEDQUIST36 D: [2119-5-23] 16:38 T: [2119-5-23] 17:57 JOB#: [Job Number 54557]	[ "V290", "V053" ]
Admission Date: [2160-5-31] Discharge Date: [2160-6-7] Date of Birth: [2088-9-8] Sex: F Service: MEDICINE Allergies: Betalactams / Ceftriaxone Attending:[First Name3 (LF) 4232] Chief Complaint: altered mental status hypertensive emergency Major Surgical or Invasive Procedure: right internal jugular central venous line placement-[2160-5-31] History of Present Illness: Pt is a 71yoW resident at [Hospital3 1186], presenting with change in mental status. On day prior to pres pt became increasingly lethargic, c/o mild abdominal pain. Labs were checked and pt was noted to have leukocytosis. She was started on flagyl and IV fluids empirically for c. difficile colitis given recent history. She became increasingly lethargic there and today BP was elevated at 240/110. Nitropaste was applied and patient was transferred to [Hospital1 18] ED. . In the [Hospital1 18] ED head CT was significant for acute occipital bleed 9mm x 7mm. She was seen by the neurology and neurosurgery services. The neurology service found her exam to be non focal and felt that her encephalopathy was not related to the bleed. They recommended blood pressure control, repeat CT head in 24 hours, and MRI head once pt could remain still. . She was afebrile in the ED but was given Vancomycin, Ceftriaxone, and Acyclovir out of initial concern for meningitis. Once CT finding of bleed, and renal function showing slight worsening, it was felt that meningitis unlikely to be cause of encephalopathy and so no LP was performed. She received 1L NS in ED. . ROS: Answers no - no CP, SOB, Abd pain Past Medical History: HTN DM CKD -stage iv, recently primary nephrologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] has been discussing starting HD Hyperparathyroidism Anemia Glaucoma - legally blind Depression - on remeron hypothyroidism MGUS CAD - nl dobutamine echo in [2158] - cath in [2148] with LAD disease Social History: Ms. [Known lastname ] is a widowed mother of 12 children aged 37-50. She has more than 50 grandchildren. She currently lives at [Location 1188] house. Before that she lived with her [Location ] [Name (NI) 38329] [Name (NI) ] and [Name (NI) 97278] two children. She received home health care 5 times per week and also had a visiting nurse. [First Name (Titles) ] [Last Name (Titles) ] [Name (NI) 97279] [Name (NI) ] takes care of Ms. [Known lastname ] finances, and she seems to trust her. Patient and daughter at bedside state that her living situation has certainly contributed to her depressed state and that she should not return there. According to Ms. [Known lastname ], her daughter [Name (NI) 6744] [Known lastname ] [Name (NI) ] is her health care proxy. She has never smoked, does not drink alcohol, and has not used drugs Family History: non-contributory Physical Exam: On admission: 98 138/80 80 RR 14 98%RA Quiet, no unprompted speaking Pupils sluggish but reactive and symmetric OP clear, adentulous, dry mucous membranes No JVD No TM No carotid bruits RRR nl s1s2 no mrg Lungs with decreased bs b/l, clear Abd soft nt nd nabs Rectal with good tone, guaiac negative v soft brown/green stool Ext w/o edema, wwp Neuro: AA, answers when asked name "[Known firstname 2155]", all other questions answers yes/no only, CN 3-12 intact (blind), MAE but not cooperating with strength exam, babinski downgoing, follows simple commands . Pertinent Results: Studies: [2160-5-31] CXR: no acute cardiopulmonary process . . [2160-5-31]: CT abdomen/pelvis: IMPRESSION: 1. Intermediate density material in left colon, sigmoid, and rectum, which, in the absence of oral contrast administration reflects high density material such as calcium or even hemorrhage. No bowel wall thickening or other findings to suggest ischemia. 2. Soft tissue lesion seen in the rectum. Clinical correlation is recommended. 3. Left hip destruction with fluid in the joint space as seen on previous examinations. 4. Multiple renal cysts which are incompletely characterized on this examination, however, they are similar to the exam of [2160-3-5]. . [2160-5-31] CT head: IMPRESSION: 1. Acute hemorrhage within the left occipital lobe. No evidence of mass effect. 2. Unchanged appearance of infarct of the left occipital lobe and unchanged appearance of small vessel disease. Final Attending comment: The above mentioned left sided acute bleed is in the temporal lobe, a tiny right anterior thalamic acute hemorrhage is also seen.Findings are likely due to hypertension. . 4/1507 CT head repeat: IMPRESSION: Interval decrease in size of small left posterior temporal/occipital lobe intraparenchymal hemorrhage. Stable right anterior thalamic tiny hyperdensity. No new lesions identified. . [2160-6-1] EEG: IMPRESSION: This is an abnormal EEG due to the slow and disorganized background and the bursts of generalized slowing. This suggests a mild encephalopathy, which may be seen with infections, toxic metabolic abnormalities or medication effect. No epileptiform features were noted. . . Labs: Admission: WBC-8.0# RBC-4.08* Hgb-12.6# Hct-36.0 MCV-88 MCH-30.8 MCHC-34.9 RDW-15.3 Plt Ct-245 Neuts-73.3* Lymphs-22.9 Monos-3.5 Eos-0.1 Baso-0.2 PT-12.2 PTT-26.4 INR(PT)-1.0 Glucose-99 UreaN-58* Creat-3.9* Na-139 K-5.2* Cl-106 HCO3-23 AnGap-15 ALT-19 AST-28 AlkPhos-62 Amylase-133* TotBili-0.5 Lipase-43 Albumin-4.3 Calcium-12.7* Phos-5.3* Mg-3.2* freeCa-1.59* . Lactate-1.9 . [2160-6-1] 01:20AM BLOOD CK(CPK)-24* [2160-6-1] 07:55AM BLOOD CK(CPK)-24* [2160-6-1] 01:20AM BLOOD CK-MB-3 cTropnT-0.10* [2160-6-1] 07:55AM BLOOD CK-MB-NotDone cTropnT-0.08* . TSH-0.94 PTH-206* Blood Osmolal-311* . SPEP-ABNORMAL B IgG-2075* IgA-209 IgM-43 . BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Discharge labs: WBC-5.5 RBC-3.11* Hgb-9.1* Hct-28.1* MCV-90 MCH-29.4 MCHC-32.5 RDW-15.2 Plt Ct-189 . Glucose-101 UreaN-34* Creat-3.3* Na-142 K-4.0 Cl-115* HCO3-21* Calcium-9.9 Phos-4.4 Mg-2.1 . . [2160-5-31] 05:50PM [2160-6-1] 01:28AM BLOOD . . MICRO:. . [2160-6-1] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-negative [2160-5-31] Blood cultures x2 sets negative [2160-5-31] URINE URINE CULTURE-negative Brief Hospital Course: Ms. [Known lastname ] is a 71 year old female with who presented to the ED from rehab with a change in mental status in setting of hypertensive emergency, intracranial bleed, acute on chronic renal insufficiency, hypercalcemia. She was admitted to the MICU for inital care to control her blood pressure and monitor her mental status. She was then transferred to the medical floor once her blood pressure was better controlled. Her hospital course is described below by problem. . ### Change in mental status: Multifactorial including hypertensive encephalopathy, mild worsening of renal failure, possible c. difficile colitis, intracranial bleed, and hypercalcemia. Her mental status returned to baseline with treatment of hypercalcemia and hypertension. (see below). She was then transferred from the MICU to the regular medical floor. . ### Occipital intracranial hemorrhage: A 9mm ICH was seen on her original CT head on presentation to the ED. Two consults were obtained, neurology and neurosurg, both teams felt there was no indication for surgery as the bleed was very small. Her SBP goal was 130-160 given the bleed. A subsequent CT of the head showed a slightly smaller area of bleed suggesting resolution. . ### Hypertension: Her systolic blood pressure was initially 240. She was started on a labetolol drip initally, and then transitioned to oral agents including metoprolol, isosorbide moninitrate, clonidine and hydralazine. The doses were titrated upwards to achieve optimal control. Upon discharge her blood pressure was within the 130-160 range. The doses can be confirmed on her medication list. . ### Acute Renal Failure: On presentation, she had only slightly decreased GFR from baseline, and her urine lytes were consistent with a pre-renal picture. Renal was consulted and felt that her initial presentation was unlikely purely uremic encephalopathy. There was no indication for urgent hemodyalisis. Her Cr returned to baseline at discharge (~3.3) and she was making adequate urine. She was treated with sevelamer (no calcium acetate given her hypercalcemia) to control her phosphate levels. She was started on sodium bicarb given her acidosis which was thought to be attributed to her chronic renal insufficiency. She has a follow up appointment with Dr. [Last Name (STitle) ], her outpatient nephrologist, in [2160-6-17]. . ### Hypercalcemia: Her hypercalcemia was likely secondary to tertiary hyperparathyroidism compounded by her renal insufficiency (her PTH was elevated in the 200's). An SPEP was sent which was positive for monoclonal antibodies consistent with her history of MGUS. She was treated with IVF (NS) and furosemide and her calcium returned to [Location 213] range. She was also given cinacalcet. . ### Anemia: likely secondary to her chronic renal failure. She was on aranesp as an outpatient was treated with epogen while an inpatient. She was also continued on her iron supplementation. Her HCT was stable at baseline in the low 30's. . ### Possible C difficile colitis: She had a recent history of C. diff and was complaining of abdminal pain at the rehab center. They empirically started her on metronidazole and it was continued in house. The final date of treatment should be [2160-6-14] for a total 14 day course. . ### Diabetes: Uncontrolled insulin dependent diabetes. She was continued on an insulin sliding scale and her blood sugars were fairly well controlled in house. . ### Depression: Her mirtazapine was originally held but was then restarted after she was out of the MICU and on the medicine wards. . ### Hypothyroidism: Continued on levothyroxine 50mcg daily . ### FEN: She had a speech and swallow consult which showed she did not aspirate despite her lack of teeth. She should continue to eat a cardiac/diabetic diet and have sugar free shake supplements with meals (TID). TO DO: please have labs checked on Monday [2160-6-9] including CBC, sodium, potassium, chloride, bicarb, BUN, Cr, calcium, magnesium, phosphorous, glucose. Medications on Admission: MVI Levothyroxine isosorbide Rememeron Metoprolol Clonidine Aranesp insulin Flagyl - started past few days Discharge Medications: 1. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days: Last day of treatment is [2160-6-14]. 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Aranesp Injection 17. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding scale Subcutaneous ASDIR (AS DIRECTED). 18. Outpatient Lab Work please have labs checked on Monday [2160-6-9] including CBC, sodium, potassium, chloride, bicarb, BUN, Cr, calcium, magnesium, phosphorous, glucose. 19. finger sticks Please check finger sticks for blood glucose before meals and at bedtime. Use insulin sliding scale for correction. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Primary diagnosis: hypertensive emergency intracranial hemorrhage -small in the occipital lobe chronic renal insufficiency Hypercalcemia . Secondary diagnosis: anemia diabetes type 2 CAD hypothyroidism Hyperparathyroidism Glaucoma - legally blind Depression MGUS Discharge Condition: stable. normotensive. Discharge Instructions: You were admitted with an altered mental status and were found to have very high blood pressure and a very small bleed in your brain. You were admitted to the medical intensive care unit and were given medicines to help your blood pressure. . Your blood pressure medicine doses have been changed. Please see the medication list for the new medications and doses. . You should have your blood pressure checked at least once a day to ensure it is below 160/90. If it is higher, please contact your physician. . You are being treated for C.diff infection empirically. The last day of treatment is [2160-6-14]. Please continue to take metronidazole antibiotic as prescribed until then. . Please have labs checked on Monday [2160-6-9] including CBC, sodium, potassium, chloride, bicarb, BUN, Cr, calcium, magnesium, phosphorous, glucose. . Please call your PCP or go to the emergency room if you have fevers >101, chills, shortness of breath, chest pain, altered mental status, or any other symptoms which are concerning to you. Followup Instructions: You should follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ]. We were unable to make an appointment for you since it is the weekend. Please call [Telephone/Fax (1) 608] to schedule an appointment. You will need to have your creatinine and other labs drawn early next week. . The following appointments were in the computer and are listed below as a reminder for you: . Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2540], RN Phone:[Telephone/Fax (1) 435] Date/Time:[2160-6-18] 9:30 . Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 252], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2160-7-1] 11:15 . Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. Phone:[Telephone/Fax (1) 435] Date/Time:[2160-7-17] 10:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 4236] Completed by:[2160-6-8]	[ "5849", "311", "2449", "25000" ]
Admission Date: [2194-8-5] Discharge Date: [2194-8-14] Date of Birth: [2128-8-7] Sex: F Service: CARDIOTHORACIC Allergies: Keflex Attending:[First Name3 (LF) 281] Chief Complaint: Tracheobronchomalacia with severe COPD admit for increasing shortness of breath, possible Y-stent placement. Major Surgical or Invasive Procedure: [2194-8-9] Bronchoscopy, with therapeutic aspiration. [2194-8-7] Rigid bronchoscopy, Y stent placement. [2194-7-30] Flexible bronchoscopy History of Present Illness: The patient is a 65-year-old woman with multiple medical problems including COPD on home O2 and tracheobronchomalacia who presents today for progressive dyspnea over the last year. The patient was evaluated in [2193-5-24] by Dr. [Last Name (STitle) ] and had bronchoscopy, which demonstrated significant tracheobronchomalacia. She underwent Y-stent placement in [Month (only) ] [2192]. The stent was in place for approximately two weeks before it was removed due to increased coughing and mucous production. The patient could not tolerate the stent. The patient followed up on [2194-8-5] for reevaluation given that her shortness of breath has increased from baseline, her mobility is fairly significantly limited now. Her previous use of home O2 has now increased to 24 hours a day, 3 liters nasal cannula. She uses CPAP at night. She is referred by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for evaluation for possible re-stenting versus other surgical procedures. Past Medical History: CAD, s/p CABG, with LAD and LCx stenting CHF, diastolic dysfunction Chronic reactive airway disease, no prior h/o emergent intubation Chronic renal insufficiency (baseline Cr low-1s): erythropoietin deficiency AFib GERD Gout Obstructive sleep apnea HTN Hyperlipidemia Hypothyroidism Depression Obesity Discoid lupus (inactive) s/p MVR with St. Jude valve ([2188]), on coumadin s/p L parietal CVA ([2186]), no residual neurologic deficits h/o bladder CA h/o colonic polyps h/o diverticulosis s/p cholecystectomy, t&a, tubal ligation, C-section, vocal cord polyp excision Social History: 15 yr hx tobacco, 1pk every 3d, quit [2186] Occasional EtOH Disability Lives alone, just moved to new home without stairs Divorced, one daughter [Name (NI) ] IVDU Family History: Cardiomyopathy AFib Valvular heart disease Older sister - RA [Name (NI) ] sister - COPD ([Name2 (NI) 1818]), GERD Physical Exam: general: Obese white female in NAD wearing 4 liters of oxygen continuously HEENT: unremarkable Cor: RRR S1, S2 w/ mech mitral valve Chest: Course breath sounds that clear w/ coughing. occas wheezes. Abd: large, round, soft, NT, +BS Extrem: no edema Neuro: intact Pertinent Results: Video swallow [2194-8-12]: Pt appears safe from oropharyngeal standpoint for return to a PO diet of regular solids and thin liquids. She does not require chin tuck maneuver at this time. She tolerates whole pills with thin liquids. Pt may wish to have assistance with set up for meals/cutting meats, etc, but does not require 1:1 supervision with meals for swallow safety. Maintain standard aspiration precautions. Please reconsult if there are further concerns for aspiration or other oropharyngeal dysphagia. This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of 6, WFL. RECOMMENDATIONS: 1. PO diet: regular solids, thin liquids 2. PO meds whole with thin liquids 3. Assist with meal set up as needed. Pt may require assistance with cutting foods, etc. Does not require 1:1 supervision with meals. 4. Maintain standard aspiration precautions. 5. Consider further w/u of coughing during meals not associated with aspiration and/or c/o GERD to level of pharynx during today's evaluation. In addition, pt has c/o food getting "stuck" at the level of the sternum, even prior to admit. 6. Reconsult if there are further concerns for aspiration or other oropharyngeal dysphagia. CXR [2194-8-11]: REASON FOR EXAMINATION: Followup of a patient with known tracheobronchomalacia and right lower lung pneumonia. Portable AP chest radiograph was compared to [2194-8-10]. The cardiomegaly with bulging of the pulmonary trunk is stable. There is no change in the position of the mitral valve. There is no appreciable change in the right lower lobe and left perihilar opacities as well. There is no increase in pleural effusion. There is no pneumothorax. ECHO: [2194-8-12] Conclusions There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The transmitral gradient is normal for this prosthesis. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Symmetric LVH with normal global systolic function. A focal wall motion abnormality cannot be excluded. Mitral valve prosthesis with at least mild mitral regurgitation and normal gradients. Compared with the prior study (images reviewed) of [2192-3-28], the findings are similar. The pulmonary artery systolic pressures were not estimated on the prior study. Brief Hospital Course: The patient was admitted on [8-5] to the Interventional Pulmonology service for treatment of her increasing shortness of breath due to COPD and evaluation for possible placement of a Y-stent for tracheobroncialmalacia. On [8-7], she had a Y-stent placed by Dr. [Last Name (STitle) ] and therapeutic aspiration. She experienced acute exacerbation of her COPD after placement of her Y-stent and was admitted to the ICU. Steroids started, on a 14 day taper down to baseline of 5mg PO daily. Admitted to floor from ICU for ongoing pulmonary care. Pt w/ repeated episode of diarrhea- C-diff toxin neg. Bowel regimen tapered. BAL grew out MRSA that was sensitive to Bactrim. Vancomycin d/c'd. Will complete a 2 week course of Bacrtim on [2194-8-23]. Pt's coumadin was resumed at lower dose than home regimen as she is on bactrim which will elevate her INR. [8-9] therapeutic bronchoscopy; mid-trachea proximal end of silicone Y-stent minimal granulation tissue, extensive amount of mucus secretions in Y-stent successfully suctioned through the bronchoscope, distal end of the stent bilaterally with minimal amount of granulation tissue. [8-12] passed video swallow: [Last Name (un) 1815] reg diet w/ thin liquids and meds whole w/o difficulty. Pt had loose stool x 3days and C-diff toxin A+B were negative x3. Pt was placed on lactose free diet and imodium. The patient is on maximal medical therapy for COPD with inhalers as well as prednisone. Recommendation would be to continue her medications as prescribed at this time. She remians on CPAP at night for sleep apnea Medications on Admission: aspirin 81', Bumex 4qam, 3qpm, L-thyroxine 0.05', Prilosec 20'', KCl 40'', Lexapro 20', Effexor 150', allopurinol 100'', Lipitor 80', clonidine 0.1'', Singulair 10', Spiriva, verapamil SR 240', Coumadin 5 mg/5 mg/7.5 mg alternating, Colace''', prednisone 5 mg daily)albuterol nebulizer b.i.d., iron 325', Advair 500/50'', colchicine 0.6'', Klonopin 0.5'', fiber laxative, Flexeril prn - bipap, she believes the settings are 17/10. Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 5. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO 8PM (). 6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO QAM (once a day (in the morning)). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 2.5/3 mg/ml Inhalation Q4H (every 4 hours) as needed for wheezes. 15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 20. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 22. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO BID (2 times a day). 23. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Five (5) ML Miscellaneous TID (3 times a day). 24. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO QHS (once a day (at bedtime)). 25. Ipratropium Bromide 0.02 % Solution Sig: Three (3) ML Inhalation Q6H (every 6 hours) as needed. 26. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [12-25] Puffs Inhalation Q6H (every 6 hours) as needed. 27. coumadin coumadin dose daily based on INR- Last INR 3.4 on [2194-8-14] Given 1 mg today [2194-8-14] Goal 2.5-3.5 Home coumadin dose 5mg alter w/ 7.5mg 28. prednisone prednisone 50mg starting [2194-8-14] then decrease by 10mg every 2 days until at maintenance dose of 5mg. 29. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO qid prn. Discharge Disposition: Extended Care Facility: [Hospital6 ] Hospital [Hospital1 189] Discharge Diagnosis: Tracheobronchomalacia with severe chronic obstructive pulmonary disease. Atrial fibrillation, CAD s/p CABG and stent CHF (diastolic dysfunction), reactive airway disease CRI (~1.2), pulm nodules, L parietal CVA '[86], h/o bladder ca, diverticulosis, GERD, gout, OSA, HTN, hypercholesterol, hypothyroid, depression, obesity, ? discoid lupus PSH: MVR (mechanical valve [2188]), CABG, appendectomy, cholecystecomy, BL tubal ligation, c-sxn, vocal cord polyp excision Discharge Condition: Decondition Discharge Instructions: Call Dr.[Name (NI) 14680] office [Telephone/Fax (1) 10084] if experience: -Fever, increased shortness of breath, cough, increased sputum production, difficulty swallowing, or nausea/vomiting. Prednisone taper 50 mg x 3 days (day one [2194-8-14]), 40 mg x 3 days, 30 mg x 3 days, 20 mg x 3 days, 10 mg x 3 days then 5 mg daily. Check INR daily until stable therapeutic. Follow INR daily until INR stabilized between 2.5-3.5 Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] as directed Follow-up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 42167] [Telephone/Fax (1) 54195] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 286] Completed by:[2194-8-18]	[ "32723", "4280", "5859", "V5861", "42731", "2449", "311", "40390" ]
Admission Date: [2195-11-27] Discharge Date: [2196-2-10] Date of Birth: [2131-8-13] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 695] Chief Complaint: Hepatocellular carcinoma and Hepatitis C virus. Major Surgical or Invasive Procedure: [2195-11-27]: Extended right hepatic lobectomy,intraoperative ultrasound, lysis of adhesions. [2195-12-1]: Exploratory laparotomy, portal vein thrombectomy. [2195-12-26]: Orthotopic deceased donor liver transplant (brain dead donor) piggyback, portal vein-to- portal vein anastomosis, common bile duct-to-common bile duct anastomosis with no T-tube, infrarenal iliac artery conduit to the common hepatic artery of the donor, and portal vein thrombectomy. [2196-1-2]: Exploratory laparotomy, drainage of subphrenic abscess, liver biopsy and Vicryl mesh closure of intra-abdominal wall. tracheostomy abdominal washout abdominal closure with mesh peritoneal drain placement tunnelled HD line placement nasointesintal feeding tube placement Past Medical History: Hepatitis C (relapsed after pegylated Interferon and Ribavirin) Cirrhosis Prostate cancer Depression Overactive bladder Insomnia cholecystectomy ([2169]) Social History: The patient works full time in the IT division of [Last Name (un) 9997] Market. He is single. He is a former polydrug abuser, mostly narcotics. He has not used alcohol or drugs in 29 years. Family History: NC Physical Exam: POst OP Liver resection: VS: 98.0, 90, 108/62, 18, 98% General: Pain managed with intermittent IV morphine, in NAD Card: RRR, no M/R/G Lungs: CTA bilaterally Abd: Incision dressing C/D/I, abdomen appropriately tender, 1 JP drain in place Extr: no C/C/E Pertinent Results: At time of initial surgery: [2195-11-27] WBC-10.5# RBC-4.67 Hgb-15.0 Hct-43.9 MCV-94 MCH-32.2* MCHC-34.2 RDW-15.1 Plt Ct-163 PT-18.5* PTT-38.6* INR(PT)-1.7* Glucose-140* UreaN-9 Creat-0.5 Na-136 K-4.2 Cl-105 HCO3-25 AnGap-10 ALT-75* AST-152* AlkPhos-119 TotBili-3.8* Calcium-8.6 Phos-3.2 Mg-2.2 At time of Liver transplant: [2195-12-25] WBC-18.6* RBC-3.15* Hgb-10.5* Hct-29.3* MCV-93 MCH-33.4* MCHC-35.9* RDW-20.0* Plt Ct-53* PT-24.9* PTT-54.1* INR(PT)-2.4* Fibrino-266 Glucose-135* UreaN-35* Creat-1.8* Na-135 K-4.1 Cl-102 HCO3-23 AnGap-14 ALT-20 AST-56* AlkPhos-91 Amylase-126* TotBili-36.0* Albumin-3.1* Calcium-9.0 Phos-3.0 Mg-2.1 HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE [2196-1-22] TSH-13* T4-3.0* At Time of Discharge: [2196-2-10] WBC-4.1 RBC-3.07* Hgb-9.2* Hct-27.9* MCV-91 MCH-30.0 MCHC-32.9 RDW-17.8* Plt Ct-134* PT-19.7* PTT-28.4 INR(PT)-1.8* Glucose-140* UreaN-79* Creat-2.8* Na-139 K-4.4 Cl-100 HCO3-30 AnGap-13 ALT-29 AST-22 AlkPhos-239* TotBili-1.3 Albumin-2.4* Calcium-8.2* Phos-3.9 Mg-2.0 [2196-2-9] tacroFK-9.5 Brief Hospital Course: On [2195-11-27], he underwent extended right hepatic lobectomy,lysis of adhesions and intraoperative ultrasound for hepatocellular carcinoma and Hepatitis C virus. Surgeon was Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]. Operative findings included extensive intra-abdominal adhesions from his prior cholecystectomy. He had increased venous collaterals but not obvious portal hypertension. The liver was large and cirrhotic with large regenerative nodules. There was a mass lesion in segment VIII extending and pushing into segment [Doctor First Name ] with involvement of the peripheral branches of the middle hepatic vein but the proximal right hepatic vein was clear. There were no other lesions in the remainder of the liver demonstrated by intraoperative ultrasound. Please refer to operative report for further details. Initially, he did well, but was also having decreased urine output. A liver doppler ultrasound was performed showing patent flow in the left portal vein, left hepatic vein, and left hepatic artery. Main portal vein was unable to be visualized and af luid collection adjacent to the surgical margin was noted. On POD 3 he was noted to have worsening encephalopathy and repeat liver doppler ultrasound was done showing new ascites. There was no flow within the main portal vein, though apparently forward flow was seen in the left portal vein. As the findings were concerning for portal vein thrombosis versus slow flow a CT was obtained showing thrombosis of the left portal vein and main portal vein, extending to the confluence of the SMV, portal vein, and splenic vein. The splenic vein was occluded to approximately its mid segment. The common and left hepatic arteries were patent. The left hepatic vein appeared patent. The IVC was patent. Hypoattenuation was noted in segment V/VIII. Given these findings, he was taken back to the OR by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for exploratory laparotomy, portal vein thrombectomy. Due to difficult anatomy, the thrombectomy could not be done, and an attempt was made by interventional radiology with TPA. He had a portal venogram suggestive of acute expansile thrombus within the main portal vein. Narrowing was seen at the junction of the main and left portal veins. A 5 French catheter was placed. On [12-2], focal contrast extravasation from the right portal vein stump into the region of the JP drain was seen. Successful exclusion of the right portal vein stump with placement of covered stents in the main and left portal vein was done with no further extravasation, however there was still persistent thrombus in the main and left portal veins after mechanical thrombectomy (Angioget). Attempt was made at another thrombectomy with TPA and on [12-3] there was interval improvement, but still some thrombus in the stent and the main portal vein. Heparin drip was initiated and the patient was placed on empiric Ceftriaxone. Also due to his worsening mental status he was intubated. He was started on TPN for nutrition support. Micafungin was started for moderate growth of yeast from a sputum specimen on [12-7]. Platelats dropped as low as 57 on [12-6], a HIT panel was sent which returned as positive. Serotonin release assay was sent and reported as borderline positive. The heparin was stopped and he was started on bivalarudin. WBC was elevated around POD 8 ([12-5]), although he remained afebrile. He was pan-cultured. All cultures remained negative except PD fluid was positive for VRE. LFTs were notable for progressive increase of total bilirubin, worsening jaundice and worsening mental staus consistent with hepatic failure. Lactulose and Rifaximin were started. He remained intubated. Overall, liver function continued to worsen and progressed to hepatorenal syndrome necessitating CVVHD. It was determined at this time that he should undergo liver transplant evaluation. He had all serologies and baseline exams completed. He was listed for liver transplant. On [2195-12-25], a donor liver was available. The patient underwent Orthotopic deceased donor liver transplant (brain dead donor)non- ABO compatible liver transplant. Plasmaphereis was performed prior to OR. Procedure consisted of piggyback, portal vein-to- portal vein anastomosis, common bile duct-to-common bile duct anastomosis with no T-tube, infrarenal iliac artery conduit to the common hepatic artery of the donor, and portal vein thrombectomy for portal vein/superior mesenteric vein/splenic vein thrombosis. This was a PLease see the operative report for full surgical detail, however it should be noted that the patient received 8000 mL of crystalloid, 69 units of fresh frozen plasma, 79 units of packed red cells, 12 units of platelets, 12 units of cryo, and took 7 liters of CCVH. He was left with an open abdomen, was transferrred back to the SICU intubated. On [12-28] he was brought back to the OR for Abdominal washout, Tru-Cut biopsy of the liver, reclosure of Silastic abdominal closure. He was unable to be closed and then on [2196-1-2] he was taken once again to the OR with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for exploratory laparotomy, drainage of subphrenic abscess, liver biopsy and Vicryl mesh closure which was attached to the fascia for closure of the intra-abdominal wall. Liver biopsy results from [12-28] showed Zone three hepatocyte apoptosis/necrosis with focal drop-out, consistent with preservation/reperfusion injury. Mild to moderate, predominantly zone three cholestasis, with focal feathery degeneration of hepatocytes and rare bile plug formation. No acute rejection was seen. White count noted to once again be 21.5 (it had normalized previously) and blood cultures from [1-1] came back positive for VRE. Because of the previous peritoneal fluid VRE positive cultures the patient had been on daptomycin, had remained on the micafungin for the sputum yeast and had additionally been on Zosyn. Blood cultures were checked daily and did not clear until [1-16]. During that interval the Dapto was changed to Linezolid. He received 19 days of linezolid and then per ID recommendations he was switched to Tigecycline because on [1-13] he underwent a technically successful aspiration/drainage of a complex intraperitoneal fluid collection. 10 French [Last Name (un) 2823] catheter was placed and left to bag gravity drainage. Cultures showed sparse growth of enterococcus. On [1-9] he had drainage of a non-infected pleural effusion. Given prolonged intubation, he underwent trache placement on [1-11] by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. He had been on CVVH throughout while intubated. LFTs were notable for persistent bilirubin elevation. GI was consulted and performed an ERCP on [1-8]. Cholangiogram revealed a tight curve/loop in the mid common bile duct, with possible evidence of a subtle stricture just above this curve with mild upstream biliary dilation, An 8cm by 10Fr biliary stent was placed across the mid-CBD. The bilirubin was 21.9 at the time of the ERCP. Over the remainder of the hospital course and towards the end of the hospitalization the bilirubin decreased to normal value of 1.4 and all other LFTs were WNL. A repeat ERCP was scheduled for [3-2]. Coumadin was started on [1-19] for h/o portal vein thrombus/HIT+ and adjusted daily. In early [Month (only) 1096] it was determined he would be stable enough for intermittent HD. A post pyloric feeding tube was in place and he has been receiving tube feeds. The patient had multiple speech and swallow evaluations including video swallow that demonstrated aspiration. He remained NPO with meds given as suspesions via the feeding tube. He was on strict aspiration precautions. He was not to even attempt swallowing pills. Intensive speech therapy was recommended for rehab. Trache was gradually transitioned to trache collar. Mental status improved. With this improvement, the trache was decannulated which he tolerated. Of note, with improved mental status, he was very anxious. Psychiatry evaluated and recommended risperdal. This was started and proved to decreased anxiety. Psychiatry continued to follow and recommended starting remeron. This was started on [1-22]. Mood and sleep improved. The patient was finally stable enough to be transferred to the regular surgical floor on [1-24]. He has been evaluated throughout by PT noting severe deconditioning/weakness. PT recommended rehab. OT evaluated and worked with him also making recommendations for rehab. The patient has had a VAC to the abdominal wound since the mesh was placed. The mesh was eventually removed at the bedside during a debridement, and the VAC is still in place with a white sponge to the underlying structures. The wound is slowly closing although healing has been very slow. Wound measures 22cm x 9cm x 2cm. Vac change consists of white sponge first on top of bowel then black sponge changed every 72 hours. On [1-22] thyroid function tests were sent (TSH 13, T4 3.0) , he was found to be hypothyroid and was started on Levoxyl. TSH decreased to 8.8 on [2-6]. Intermittent HD was performed and on [1-28] had successful uncomplicated placement of a 15.5 French x 23 cm tip-to-cuff tunneled hemodialysis catheter via right internal jugular venous access with the tip of the catheter terminating in the right atrium ready for use. No heparin was used during HD for line flushes (HIT +). The xray done at the time of the line placement was concerning for increased bilateral pleural effusions. There was concern for aspiration. And the patient seemed increasing confused. The patient had a head CT which showed no evidence of acute intracranial pathological process. He was transferred back to the SICU for two days, but cleared and came back to the surgical floor. ID followed throughout and recommended a 4-week course of therapy, which changed to tigecycline, from the day of the first negative blood culture for VRE ([1-16]) and an indefinite course of fluconazole given his many anastomoses and high likelihood of recurrence. Multiple c diffs were sent (all negative) for multiple loose stools. The cellcept has been changed several times due to its potential GI effects and is now 250 QID. Imodium was started twice daily. Prograf levels have been followed throughout with dosing based on levels. He is currently on a prednisone taper per transplant clinic guidelines. Patient remains on coumadin therapy. Medications on Admission: Enablex 7.5', Mirtazapine 45 qhs, Nadolol 20', Risperidone 0.5' Zolpidem 20', Mag Ox 400' Discharge Medications: 1. white petrolatum-mineral oil 56.8-42.5 % Ointment [Month/Day (4) ]: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Month/Day (4) ]: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 3. valganciclovir 50 mg/mL Recon Soln [Month/Day (4) ]: Four [Age over 90 1230]y (450) mg PO 2X/WEEK (MO,TH). 4. insulin regular human 100 unit/mL Solution [Age over 90 ]: per sliding scale Injection four times a day. 5. risperidone 1 mg/mL Solution [Age over 90 ]: 0.5 mg PO BID (2 times a day). 6. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [Age over 90 ]: Ten (10) ML PO DAILY (Daily). 7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 8. fluconazole 40 mg/mL Suspension for Reconstitution [Last Name (STitle) ]: Two Hundred (200) mg PO Q24H (every 24 hours). 9. ipratropium bromide 0.02 % Solution [Last Name (STitle) ]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. miconazole nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical PRN (as needed) as needed for irritation. 11. acetaminophen 650 mg/20.3 mL Solution [Last Name (STitle) ]: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours) as needed for pain: 2 gram maximum daily. 12. metoprolol tartrate 25 mg Tablet [Age over 90 ]: 0.5 Tablet PO BID (2 times a day): Via tube. 13. mycophenolate mofetil 200 mg/mL Suspension for Reconstitution [Age over 90 ]: Two [Age over 90 1230]y (250) mg PO QID (4 times a day). 14. tigecycline 50 mg Recon Soln [Age over 90 ]: Fifty (50) Recon Soln Intravenous Q12H (every 12 hours) for 7 doses: Through [2-13]. 15. methylprednisolone sodium succ 40 mg Recon Soln [Month (only) ]: Ten (10) mg Injection Q24H (every 24 hours): Please decrease to 8 mg daily on Friday [2-12]. Follow transplant clinic taper. 16. levothyroxine 200 mcg Recon Soln [Month/Day (4) ]: Fifty (50) mcg Injection DAILY (Daily). 17. Outpatient Lab Work Stat labs every Monday and Thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin, PT/INR fax to [Telephone/Fax (1) 697] attn: transplant rn coordinator 18. loperamide 1 mg/5 mL Liquid [Telephone/Fax (1) ]: Two (2) mg PO twice a day: 8 AM and 2 PM . 19. Outpatient Lab Work TROUGH PROGRAF:every Monday and Thursday starting [2196-2-11], Tacrolimus; Trough Tacro to be drawn at [Hospital1 ] and dropped off at [Hospital1 18] [Hospital Ward Name 516] Lab [Location (un) ], [Hospital Ward Name 332] 304 before 9 AM to be run same day. 20. warfarin 1 mg Tablet [Hospital Ward Name ]: Three (3) Tablet PO once a day: Check PT/INR Monday and Thursday. Goal INR [3-18]. 21. tacrolimus 5 mg Capsule [Month/Day (3) ]: Five (5) mg PO BID (2 times a day): Give as suspension via tube. Discharge Disposition: Extended Care Facility: [Hospital 1263] Hospital Transitional Care Unit - [Location (un) 686] Discharge Diagnosis: HCC s/p right trisegmentectomy with postop liver failure malnutrition, severe HRS HIT+ Portal vein thrombus s/p ABO incompatible liver transplant ATN Hypothyroid traumatic foley insertion VRE, peritoneal fluid 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: The Transplant Office [Telephone/Fax (1) 673] should be called if the patient develops fevers, chills, nausea, vomiting, increased diarrhea, jaundice, inability to take medications, increased abdominal pain/bloating, wound edges appear red or wound drainage increases or smells foul, malfunction of tube feeding, confusion or increased urine output. The patient has a tunneled dialysis line and should receive hemodialysis three times a week Blood will be drawn twice weekly on Monday and Thursday with results faxed to the transplant clinic at [Telephone/Fax (1) 697]: CBC, Chem 10, AST, ALT, T Bili, Alk Phos, Albumin, PT, INR TROUGH PROGRAF:every Monday and Thursday starting [2196-2-11], Tacrolimus; Trough Tacro to be drawn at [Hospital1 ] and dropped off at [Hospital1 18] [Hospital Ward Name 516] Lab [Location (un) ], [Hospital Ward Name 332] 305 before 9 AM to be run same day. ALL MEDICATIONS MUST BE GIVEN CRUSHED OR AS SUSPENSIONS via Dobhoff. Patient is to be kept completely NPO until can pass swallow evaluation after completing speech therapy. Please contact [Name (NI) ] [Last Name (NamePattern1) 7474] [Name (NI) 9999] at [Telephone/Fax (1) 673] with any questions. No medication changes are to be made without prior discussion with the transplant clinic Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2196-2-17] 2:00 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10000], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2196-2-25] 11:30 [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2196-2-25] 1:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2196-2-10]	[ "51881", "5845", "0389", "99592", "78552", "2762", "496" ]
Admission Date: [2144-5-11] Discharge Date: [2144-5-15] Date of Birth: [2101-3-4] Sex: M Service: SURGERY Allergies: flu vaccine [2143]-[2144](18 yr +) / Penicillins Attending:[First Name3 (LF) 371] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 110371] is a 43 year-old male with a history of afib, Hep C, DM, COPD, chronic low back pain presenting with abdominal pain that started yesterday afternoon. The pain had sudden onset, diffuse, crampy in nature, without radiation and not associated with activity or PO intake. He reports two days of constipation, normal of [1-13] bowel movements per day is normal for him. He continues to have flatus and reports no nausea, vomiting or diarrhea. He presented to [Hospital 5503] Hospital this evening with persistent pain and underwent a CT scan which per report showed focal segment of colon with multiple diverticula, wall thickening and surrounding inflammatory change with scattered free intraperitoneal air and trace free fluid along the left pelvis. He denies fevers, chills, chest pain, or shortness-of-breath. Past Medical History: afib not anticoagulated, hep C (type F) dx 10 years ago, chronic low back pain, asthma, DM, COPD Past Surgical History: R knee surgery for torn ACL [2134] Social History: EtOH use: Denies Tobacco use: 3ppd Previous smoker: 3ppd x 20 years Recreational drugs (marijuana, heroin, crack pills or other): Denies Marital status:Lives in [Location (un) 5503]. Unemployed but previously employed as a Fisherman. Family History: Noncontributory Physical Exam: On admission: Vitals: Weight: 350lbs 97.2 104 164/92 16 97% 2LNC GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Morbidly obese, soft, TTP LLQ and RUQ, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No LE edema, LE warm and well perfused On discharge: VS: 98.4 84 134/76 18 98% on 1L NC GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Diminished at bases ABD: Obese, soft, slightly tender to LLQ but improved significantly. No rebound or gaurding. No palpable masses. EXTR: No edema, warm and well perfused Pertinent Results: On admission: 140 \| 101 \| 22 / ---------------- 107 3.3 \| 30 \| 0.7 \ \ 15.4 / 18.1 ------ 180 / 48.6 \ CT A/P [2144-5-11]: 1. Sigmoid diverticulitis with air and fluid surrounding the sigmoid colon with small left pelvic fluid collection. Extensive free intraperitoneal and retroperitoneal air with air tracking into a fat-containing umbilical hernia. 2. Asymmetric ground glass opacity at the right lung base, which may represent infection or aspiration. 3. Aortic valve calcification, of indeterminate hemodynamic significance. Left ventricular hypertrophy. CHEST PORT. LINE PLACEMENT [2144-5-11]: 1. Right PICC line with the tip in the right atrium. Recommend pulling back 2-3 cm. 2. Mild pulmonary edema. On discharge: [2144-5-15] 04:51AM BLOOD WBC-11.8* RBC-5.20 Hgb-15.5 Hct-48.2 MCV-93 MCH-29.8 MCHC-32.1 RDW-14.0 Plt Ct-223 [2144-5-15] 04:51AM BLOOD Glucose-138* UreaN-7 Creat-0.6 Na-140 K-3.3 Cl-100 HCO3-33* AnGap-10 [2144-5-15] 04:51AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.5* Brief Hospital Course: Mr. [Known lastname 110371] was admitted on [2144-5-11] to the trauma SICU for close observation given his diagnosis of perforated diverticulitis and free air seen on CT scan. He did not have evidence of peritoneal signs on exam and was only moderately tender. He was kept NPO and aggressively resuscitated. He was also started on IV cipro/flagyl. His heart rate in the ICU was poorly controlled in the setting of atrial fibrillation. This improved with diltiazem and on HD 2 he was restarted on his home doses of sotalol and digoxin. Overall he did well in the ICU with improved abdominal exam so was transferred to the floor on [5-12]. On the floor he was monitored on telemetery and he remained in atrial fibrillation with rate well controlled. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. His oxygen saturation decreased to the 80's on room air but was in the mid to high 90's on minimal supplemental O2 via nasal cannula. Pulmonary toilet and incentive spirometry were encouraged and he was started on nebulizer treatments. A chest x-ray on [5-12] showed significant improvement with only minimal residual signs of CHF. I&O's were monitored and he was voiding adequate amounts of urine. He was started on SC heparin for DVT prophylaxis. His blood glucose was monitored and he required very minimal coverage with insulin sliding scale, with his blood sugars remaining in the 100's throughout his hospital stay. His abdominal exams were monitored serially and improved over the the 3 days that he was on the floor. His tenderness had decreased significantly and his WBC count trended downward from its peak at 18.1 on admission to 11.8 at discharge on [5-15]. He had a large bowel movement on [5-14] and his diet was slowly advanced over 24 hours to regular which he tolerated without increased abdominal pain or nausea. He was continued on the cipro/flagyl and discharged to rehab on [5-15] to complete a total 2 week course. Follow up was scheduled in [Hospital 2536] clinic prior to discharge. Medications on Admission: Medications: Dabigatran 150mg daily (not taking), digoxin 0.25mg daily, diltiazem 120mg daily, furosemide 40mg daily (not taking), gabapentin 900mg QID, ipratropium/albuterol prn, lisinopril/HCTZ (20/12.5) daily, nicotine patch 21mg Q24H, pantoprazole 40mg daily (not taking), prednisone 40mg daily (not taking), sotalol 160mg [Hospital1 ], nitroglycerin 0.4mg prn Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 2. sotalol 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QID (4 times a day). 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: One Hundred (100) mL Intravenous Q8H (every 8 hours) for 11 days: Last day [2144-5-25]. 9. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Two Hundred (200) mL Intravenous Q12H (every 12 hours) for 11 days: Last day [2144-5-25]. 10. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three (3) ML Intravenous Q8H (every 8 hours) as needed for line flush. 11. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 12. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital - [Location (un) 5503] Discharge Diagnosis: Perforated diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with perforated diverticulitis. You were placed on bowel rest and given IV antibiotics. Your pain has improved and you have been advanced to a regular diet. You are now being discharged to rehab to complete a 2 week course of IV antibiotics and continue your recovery from your hospitalization. Please follow up in the Acute Care Surgery clinic at the appointment listed below. You should also follow up with your primary care provider after leaving the rehab facility. Followup Instructions: Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2144-6-2] at 2:30 PM With: ACUTE CARE CLINIC/Dr. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2144-5-15]	[ "42731", "25000", "4019", "3051" ]
Admission Date: [2149-5-20] Discharge Date: [2149-6-1] Date of Birth: [2087-3-25] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 330] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: HD line placement and removal History of Present Illness: 62-year-old woman with a history of alcohol abuse, chronic alcoholic pancreatitis, and COPD who was transferred to [Hospital1 18] on [5-20] from [Hospital 1562] Hospital for worsening alcoholic hepatitis. Was transferred to [Hospital1 1562] from etoh detox the previous week for lethargy and dark stools, which had evidently been ongoing for several weeks. At the OSH, was found to have a bilirubin of 3 on admission, AST of 199, ALT of 60, alk phos of 308, GGT of 1611, plts of 68,000. sodium of 117, creatinine of 1.1, and hct of 11.3. Exam was significant for encephalopathy, distended abdomen, and heme positive dark stools. Patient was treated with octreotide, PPI [Hospital1 ], lactulose, lasix, rocephin (for presumed, not confirmed SBP) and prednisolone in context of alcoholic hepatitis. EGD was never performed as patient was deemed too unstable. Patient continued to decline clinically and labs were concerning for HRS; as such, she was transferred to [Hospital1 18] for further work-up. . Since transfer to [Hospital1 18] her Cr has rapidly worsened from 1.6 to 6.9 despite midodrine, octreotide and albumin. Her renal failure has been attributed to HRS. She was started on vancomycin and zosyn for presumed HAP started on [5-24]. Vancomycin was stopped on [5-25] but vanco level has been therapeutic since that time given worsening renal function. Temp HD line was placed [5-30]. Plan was to initiate HD today, but patient was hypotensive with an SBP in the 70s while at HD just prior to starting HD, so she was transferred to the ICU for closer monitoring and consideration of CVVH initiation. Prior to arrival, she received 200 ccs of NS with improved SBP to the 90s. . In the ICU, patient is sedated. She states that she is at [Hospital 61] to pick up her husband. She states the year is [2140]. She is unable to provide any additional history. . Review of sytems: Patieht unable to provide. Past Medical History: --Alcohol abuse (large tumblers of wine throughout the day, as per daughters) --COPD --S/p nephrectomy for benign renal nodules --Chronic alcoholic pancreatitis Social History: Patient lives with her husband near [Hospital3 ]. Her husband drinks as well. She has 2 daughters, aged 38 and 40, one of whom ([Doctor First Name ] [Telephone/Fax (1) 85430]) is her healthcare proxy. Ms. [Known lastname 85431] used to work for [Company 85432] as a quality inspector specialist but was laid off in [Month (only) 958] of this year, and as a result, has started drinking during the day. Patient states she drinks 3-4 glasses of wine/day, but her daughters say she drinks much more. Denies smoking or illicit drug use. Family History: Not obtained during initial interview. Physical Exam: ADMISSION PHYSICAL EXAM: T: 96.5, BP: 145/80, HR: 73, SPO2: 92% on 4L GENERAL: Jaundiced, mumbling, no acute distress HEENT: PEARLA, mucous membranes dry CHEST: Crackles at lower bases bilaterally CARDIAC: Regular rate and rhythm; no murmurs, rubs, or gallops ABDOMEN: Obese, +BS, soft, non-tender, no appreciable fluid wave EXTREMITIES: Positive peripheral pulses, 1+ edema bilaterally SKIN: Warm, dry, and jaundiced Pertinent Results: [2149-5-20] 07:20PM PT-17.7* PTT-38.1* INR(PT)-1.6* [2149-5-20] 07:20PM PLT COUNT-165 [2149-5-20] 07:20PM NEUTS-84.3* LYMPHS-8.5* MONOS-2.8 EOS-3.6 BASOS-0.9 [2149-5-20] 07:20PM WBC-12.8* RBC-2.94* HGB-10.2* HCT-32.4* MCV-110* MCH-34.8* MCHC-31.5 RDW-17.6* [2149-5-20] 07:20PM ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-2.2* MAGNESIUM-2.3 [2149-5-20] 07:20PM LIPASE-40 [2149-5-20] 07:20PM ALT(SGPT)-71* AST(SGOT)-138* LD(LDH)-387* ALK PHOS-154* AMYLASE-17 TOT BILI-13.8* [2149-5-20] 07:20PM GLUCOSE-233* UREA N-38* CREAT-1.4* SODIUM-144 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-22 ANION GAP-16 [2149-5-20] 09:14PM URINE GRANULAR-0-2 HYALINE-[5-22]* [2149-5-20] 09:14PM URINE RBC->50 WBC-[11-1]* BACTERIA-NONE YEAST-RARE EPI-0-2 [2149-5-20] 09:14PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR [2149-5-20] 09:14PM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.010 [2149-5-20] 09:14PM URINE HOURS-RANDOM UREA N-379 CREAT-55 SODIUM-65 POTASSIUM-32 CHLORIDE-114 CXR [5-29]: 1. Ill-defined opacities bilaterally at the lung bases, improved since [2148-5-23], similar to [2149-5-27], possibly from aspiration. 2. Bibasilar opacities, likely atelectasis at the lung bases. 3. Small left pleural effusion. 4. Stable mild cardiomegaly. . RUQ u/s [2149-5-22]: Patchy echogenic hepatic echotexture and reversed flow in the portal veins and splenic vein suggesting the presence of a splenorenal shunt. The findings are consistent with cirrhosis and portal hypertension. Brief Hospital Course: This is a 62-year-old woman with a pmhx. of alcohol abuse, chronic pancreatitis, and COPD who presented from [Hospital 1562] Hospital with worsening alcoholic hepatitis and likely hepato-renal syndrome. The [Hospital 228] hospital course was complicated by hepatic encephalopathy and progressive renal failure with signficant uremia along with a hospital acquired pneumonia. The patient's renal function continued to decline despite treatment for hepato-renal syndrome. A temporary HD line was placed in her right IJ and, on [5-31], the patient went to HD where her SBPs declined to the 80s with acute worsening of her mental status. She was transferred to the MICU. Shortly after arriving to the MICU, the patient's HCP (daughter, [Name (NI) ]) met with the MICU and hepatology physicians and expressed a wish for her mother to be comfortable without escalation of care and a focus on comfort. The patient was made CMO. Her medications were discontinued aside from morphine and zydis. Her HD line was removed. Medications on Admission: On Transfer # Lidocaine 5% Patch 1 PTCH TD DAILY # Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB # Midodrine 10 mg PO TID # Miconazole Powder 2% 1 Appl TP QID:PRN irritation # Fluconazole 200 mg IV Q24H day 1 = [5-25] # Multivitamins 1 TAB PO/NG DAILY # Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [Hospital1 ] # Octreotide Acetate 200 mcg SC Q8H # FoLIC Acid 1 mg PO/NG DAILY # Ondansetron 4 mg IV Q8H:PRN nausea # Pantoprazole 40 mg PO Q12H # Heparin 5000 UNIT SC TID # Piperacillin-Tazobactam 4.5 g IV Q8H # Insulin SC (per Insulin Flowsheet) # Rifaximin 550 mg PO/NG [Hospital1 ] # Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB/wheeze # Lactulose 15 mL PO/NG TID # Thiamine 100 mg PO/NG DAILY Discharge Medications: 1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO TID (3 times a day) as needed for agitation: as per hospice protocol. Disp:45 Tablet, Rapid Dissolve(s) Refills:0 2. Hospital Bed Sig: One (1) bed once. Disp:1 bed Refills:0 3. Oxygen Please provide patient with 2L continuous oxygen for use while under hospice care. 4. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q2H (every 2 hours) as needed for pain, shortness of breath: as per hospice protocol. Disp:500 cc Refills:0 Discharge Disposition: Home With Service Facility: Hospice and Palliative Care Discharge Diagnosis: Liver Failure Renal Failure Hospital Acquired Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital with liver failure and developed kidney failure while in the hospital. This is all related to your liver losing its ability to function. Given the severity of your illnessand your wishes to maximize the quality of your life at this time, your care was transitioned to focus on comfort and you were sent home with medications that will help with your breathing, pain and agitation. You and your family will be supported in managing these symptoms by a visiting hospice nurse in your home. You should contact this agency when you or your family have questions or concerns about how to manage your symptoms while at home. Followup Instructions: Please contact your [Name (NI) 269]/hospice agency for questions regarding symptom management.	[ "486", "5849", "496", "25000" ]
Admission Date: [2168-8-26] Discharge Date: [2168-9-2] Service: MEDICINE Allergies: Penicillins / Percocet / Heparin Agents Attending:[First Name3 (LF) 106] Chief Complaint: SOB Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: Ms. [Known lastname 6940] is an 86 year old female with diastolic CHF, afib, CAD, [Known lastname 1192] MS/MR, s/p bioprosthetic AVR ([2162]) and h/o CVA who presents with shortness of breath on transfer from [Location (un) 5871]/OSH. . Patient was doing okay at home, 24hr home O2 3-4L, until this morning when her daughter thought she was more short of breath and tachypneic. Per daughter, patient had a high "salty" diet on Sunday, but otherwise denies medication changes, fevers, chills, nausea, vomiting, dysuria, cough, chest pain and palpitations at home. She has stable lower extremity edema, which does not seem to have worsened as well as orthopnea. She also has constipation alleviated with lactulose regularly 3-4times weekly. She endorses compliance with her medications, including lasix, metoprolol, diltiazam and aspirin. She has not had any recent changes in her medications. . She went to [Hospital 5871] hospital and found to have bilateral rales with diminished breath sounds. An ABG was 7.5/44/60/33 and she was desated to 70s% on RA. Labs notable for hct of 30, WBC 11.6. A CXR showed pulmonary edema with large R sided pleural effusion. She got 80mg iv lasix, 120mg of dilt po and placed on BIPAP briefly and transferred her to [Hospital1 18]. She was transferred on NRB. . At [Hospital1 18], her VS were T97.3 HR90 BP99/49 RR24 95% NRB. She was unable to be weaned off NRB, desating to 80s. She has put out ~600cc of urine. An ECG was notable for afib hr 98bpm, unchanged from baseline. . Her VS on transfer are: BP 106/74, HR 94, RR 22, 97-98% NRB. Full code for now. Daughter is with her. . Of note, patient was recently admitted in [2168-7-7] for CHF exacerbation. She had a TTE on that admission that showed [Year (4 digits) 1192] MS/MR/TR, severe pulm artery systolic hypertension, EF 65%. She was found to have a pleural effusion that was tapped and showed transudative fluid, culture/cytology negative. She was diuresed with lasix and her symptoms improved. TIA in 10/[2168]. No other CVA or TIA. . On review of systems, s/he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: CAD -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: -Successful LAD/D1 bifurcation PTCA in [2152] -Rotational atherectomy of the first diagonal branch [2153] -PACING/ICD: None Others: - AF on coumadin -Bovine aortic valve relacement in [2162], complicated by brief episode of atrial fibrillation. Has been on coumadin in the past but not currently. -Right carotid endarterectomy in [2158] -Peripheral vascular disease -Fall with left hip fracture in [2163]. ORIF left intertrochanteric femur fracture -Vertebral compression fracture, T8, [2164] -Bilateral osteoarthritis of the knees -Constipation -Status post bilateral cataract extraction -Diverticulosis Social History: Lives in [Hospital1 6930] with daughter [Name (NI) 2411], currently at [Hospital 100] Rehab after hospitalization at [Hospital1 ] [Location (un) 620]. Walks with a cane, good social support, non smoker, rare alcohol use. Denies any other illicit drug use. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 102/55 85 15 97% NRB, 6L GENERAL: petite elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP wnl. 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: +scoliosis and kyphosis. Resp were unlabored, no accessory muscle use. decreased breath sounds b/l, bibasilar rales extending up mid lung fields ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 3+ pitting edema b/l extending to knees SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: [2168-8-25] 11:44PM BLOOD WBC-8.2 RBC-4.10* Hgb-11.0* Hct-33.7* MCV-82 MCH-27.0 MCHC-32.8 RDW-17.5* Plt Ct-307 [2168-8-27] 06:05AM BLOOD WBC-6.4 RBC-3.88* Hgb-10.2* Hct-32.3* MCV-83 MCH-26.2* MCHC-31.5 RDW-17.3* Plt Ct-298 [2168-8-28] 05:03AM BLOOD WBC-6.9 RBC-4.17* Hgb-11.0* Hct-34.6* MCV-83 MCH-26.5* MCHC-32.0 RDW-17.5* Plt Ct-297 [2168-8-25] 11:44PM BLOOD Neuts-86.4* Lymphs-8.8* Monos-4.3 Eos-0.3 Baso-0.3 [2168-8-25] 11:44PM BLOOD PT-26.8* PTT-34.8 INR(PT)-2.6* [2168-8-27] 06:05AM BLOOD PT-28.5* INR(PT)-2.8* [2168-8-28] 09:41AM BLOOD PT-29.7* PTT-36.1* INR(PT)-2.9* [2168-8-25] 11:44PM BLOOD Glucose-130* UreaN-23* Creat-0.7 Na-132* K-4.0 Cl-90* HCO3-31 AnGap-15 [2168-8-26] 02:59PM BLOOD Creat-0.7 Na-138 K-3.1* Cl-93* [2168-8-27] 12:49AM BLOOD Na-138 K-3.7 Cl-94* [2168-8-27] 06:05AM BLOOD Glucose-112* UreaN-22* Creat-0.8 Na-139 K-3.2* Cl-90* HCO3-41* AnGap-11 [2168-8-27] 06:32PM BLOOD UreaN-30* Creat-0.9 Na-136 K-5.2* Cl-90* HCO3-36* AnGap-15 [2168-8-28] 05:03AM BLOOD Glucose-122* UreaN-32* Creat-0.9 Na-138 K-3.9 Cl-89* HCO3-40* AnGap-13 [2168-8-25] 11:44PM BLOOD proBNP-5178* [2168-8-25] 11:44PM BLOOD cTropnT-<0.01 [2168-8-27] 06:05AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.2 [2168-8-28] 05:03AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1 . MICRO [2168-8-26] 12:21 am URINE Site: CATHETER FINAL REPORT [2168-8-28] URINE CULTURE (Final [2168-8-28]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . Chest xray portable AP [8-25] CHEST, AP SEMI-UPRIGHT: There has been interval reaccumulation of a large right pleural effusion, with silhouetting of the right heart border and hemidiaphragm. A [Month/Year (2) 1192] loculated effusion persists along the lateral left hemithorax. Left lower lobe atelectasis is unchanged. [Month/Year (2) ] cardiomegaly, vascular congestion, and pulmonary edema have slightly increased. CABG changes are present. There is continued tortuosity and calcification of the aorta. IMPRESSION: 1. Recurrent large right pleural effusion and loculated [Month/Year (2) 1192] left effusion. 2. [Month/Year (2) ] congestive heart failure. Brief Hospital Course: 86yo elderly female w hx of CAD, ARV, mod-severe MS [First Name (Titles) ] [Last Name (Titles) ] HTN on ECHO [7-/2168] managed on 24hr Home O2 3-4 liters, chronic afib on coumadin, and vasculopathy transferred from OSH for management acute SOB x 2 days found to have [Year (4 digits) ] edema and recurrent pleural effusion. . Pt made CMO for untreatable valve disease, afib, and pulmonary htn. Her SOB worsened gradually during her admission and she was made CMO by family on [9-2]. Palliative care was consulted. She was started on IV morphine drip titrated for comfort. She passed on [9-2] afternoon with family at bedside and pastoral care. . . . # SOB: Chronic complaint, currently on home o2 since [10/2167], acutely worsening in last 2 days. P/w rales and chest xray findings suggestive of [Year (4 digits) ] edema and recurrent pleural effusion. Diagnosis most likely heart failure [2-9] valvulopathy with contribution from chronic afib. Pt also with evidence of [Month/Day (2) ] htn on recent TTE and is on home O2. Other less likely etiologies include MI, infection, pna but no chest pain, biomarkers negative, leukocytosis negative, afebrile. Therapeutic approach was aggressive diuresis in setting of volume overload and dCHF. Thoracentesis was felt to be too invasive at this time given recurrence of symptoms. She was continued on O2 therapy and weaned from NRB to face shovel to NC. Home o2 3-4L via NC (ultimate goal). She was diuresed with IV lasix pushes and metolazone, and monitored for urine output. She was started on IV lasix drip on [8-30] due to inadequate clinical improvement on IV pushes. She was continued on home meds metoprolol and diltiazem for rate control. Her SOB improved only minimally with diuresis and thoracentesis was attempted on [8-31] to palliate her symptoms and improve her oxygenation status. We attempted to wean from shovel but patient continued to desat to low 80s with tachycardia to 130s w exertion, eating. . # Afib: Pt denies palpitations, although SOB likely exacerbated by her chronic afib. Maintained on coumadin anticoagulation therapy for arrhythmia which was continued as an inpatient. Given her TIA in [10/2168], her CHAD2 score= 5, it is believed that pt is high risk for stroke. She was continued on metoprolol and diltiazem for rate control. Per PCP, [Name10 (NameIs) ] has been anticoagulated since [2168-8-15] and was not candidate for cardioversion given <4 wks therapeutic level on coumadin. . # CAD: s/p atherectomy [2153], single vessel disease w diffuse atherosclerosis. Currently on statin, asa therapy. EKG at baseline. Continued on statin, asa therapy as inpatient. Cardiac biomarkers were negative on admission and there was no need to trend CE's given no EKG changes, and pt lack of chest pain. . # UTI: Pt found to have asymptomatic UTI from ED culture - ecoli. Started on Ciprofloxacin po renally dosed x 14days. . # Valve disease: h/o of AVR and known MS/MR noted to be mod-severe on last TTE 7/[2168]. Valvulopathy likely contributing to her symptoms of SOB and DOe. There was no need to repeat ECHO given recent documentation. Dr. [Last Name (STitle) ] reviewed her ECHO findings and confirmed her non-candidacy for valvuloplasty given MR [First Name (Titles) ] [Last Name (Titles) 6941], and per report not a surgical candidate for valve replacement as well. . #Constipation: managed on lactulose at home 3-4x weekly. She was maintained on bowel regimen. Medications on Admission: Acetaminophen 650 mg PO/NG Q6H:PRN pain Aspirin 81 mg PO/NG DAILY Morphine Sulfate 1-2 mg IV Q6H:PRN sob Bisacodyl 10 mg PR HS:PRN constipation Omeprazole 20 mg PO DAILY Calcium Carbonate 500 mg PO/NG TID Ciprofloxacin HCl 500 mg PO/NG Q12H uti, tx 2wk course start [Date range (1) 6942] Senna 1 TAB PO/NG [Hospital1 ]:PRN constipation Diltiazem Extended-Release 300 mg PO DAILY Simvastatin 20 mg PO/NG DAILY Docusate Sodium 100 mg PO BID Simethicone 40-80 mg PO/NG QID:PRN bloat, abd pain Furosemide 20 mg/hr IV DRIP INFUSION Lactulose 30 mL PO/NG Q8H:PRN Constipation Vitamin D 1000 UNIT PO/NG DAILY Metoprolol Tartrate 12.5 mg PO/NG TID Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased	[ "51881", "5119", "5990", "4280", "42731", "4019", "2724", "4168", "41401", "V4582", "V5861" ]
Admission Date: [2178-11-12] Discharge Date: [2178-11-25] Date of Birth: [2095-4-30] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2777] Chief Complaint: psoas abcess wrapping around aorta with penetrating ulcer growing unknown AFB organism, epidural abcess L3-L5 with effacement and osteomyelitis / discitis at L4, L5 level Major Surgical or Invasive Procedure: [2178-11-13]: s/p Right-sided axillobifemoral bypass graft; Extensive aortic debridement with ligation of the infrarenal aorta and bilateral common iliac arteries; Extensive retroperitoneal debridement; Lumbar disk debridement by Dr. [Last Name (STitle) 1352]; Drain placement. History of Present Illness: 83 F who presents for admission for psoas abcess wrapping around aorta with penetrating ulcer growing unknown AFB organism, epidural abcess L3-L5 with effacement and osteomyelitis / discitis at L4, L5 level. The patient states that she acquired the infection after a right lower extremity VNUS procedure in [State 8842]. At that time, she developed shingles and was treated with acyclovir. Upon her return home to [Location (un) 3844], she fell a couple of times believed to be due to her spinal stenosis. However, she began to use her walker more frequently, progressing to the inability to get out of bed. In mid [Month (only) 205] she went to local ER. There on examination they felt that she had an anuersym on exam. They shipped her out to [University/College ] for further work-up. No sugical interventions were peformed. She did have multiple FNA of psoas abcess peri aortic wall fluid and epidural abcess L3-L5. She states that a lesion on her Right wrist was biopsied. She states her biopsies and FNA were negative. She was treated with moxifloxacin and Vancomycin for six weeks. Four days after her discharge, she developed groin pain, fever to 102, and hypotension. She was transferred back to DHMC and treated empirically for sepsis given her hypotension. Treated aggressively with volume. Antibiotics were changed to daptomycin, monofloxacin. Got one dose of ceftazidime. She stabalized quickly. Blood cultures remained negative. The hypotension was also thought to be secondary to narcotics. Pt also experienced ATN. On DC her creatinine was trending down. Pt had repeat MRI of psoas abcess after ATN improved, showed no change in size. Vascular and NS recommended no surgical intervention. ID recommended a workup for TB, pt did have a history of positive PPD with no treatment. This workup remains negative. (Quantiferon gold assay was negativ, 3 induced sputum cx's negative). Pt also had repeat FNA, originally cx's were negative. They eventually grew out AFB not consistant with TB or MAC. Her antibiotics then were switched to Imipenem, Rifaximin for an additional 2 weeks [7-21] - [8-8], Clarithromycin for life time. Pt was still experiencing hypotension at this time, Vascular recommended repeat scan which showed increase size of the psoas abcess and worsening of the discitis. Upon discharge pt seemed to be improving rapidly and was nearly independent in early [Month (only) 359]. However, a few weeks prior to her presentations, she began experiencing back pain, increasing weakness, and fevers. Workup included a CT scan that showed and enlarging paraaortic abscess. Her PCP referred her for 2nd opinion with Dr. [Last Name (STitle) ] at [Hospital1 18]. He reviewed her records and instructed her to come in for admission and emergent surgery on [11-13]. Past Medical History: VASCULAR HISTORY: AAA, : New. Carotid Endarectomy, : L CEA. PAST MEDICAL HISTORY: Rheumatoid Nodule, MGUS, Angular Chelitis, Dermatomyositis, Thrombocytosis, Pulmonary Hypertension, Spinal Stenosis, Depression, Osteoporosis, Ectopic pregnancy with perotinitis, Rheumatoid arthritis, [Last Name (un) 39070] Hunt Syndrome with Left sided Bells Palsy PAST SURGICAL HISTORY: L CEA, B/L knee replacements, C section, R carpal tunnel release, VNUS RLE Social History: Remote Smoker Drinks Rarely Lives Independently at Retirement Community Family History: Son deceased of testicular Cancer Physical Exam: Vital Signs: Temp: 98 RR: 18 Pulse: 73 BP: 133/46 96%RA Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit, abnormal: Facial Palsy Left. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, Guarding or rebound, No hepatosplenomegally, No hernia, abnormal: Palpabel Mass umbilical region. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE/LLE 1+ edema, Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. Ulnar: P. Brachial: P. LUE Radial: P. Ulnar: P. Brachial: P. RLE Femoral: P. Popiteal: P. DP: D. PT: D. LLE Femoral: P. Popiteal: P. DP: D. PT: D. Pertinent Results: [2178-11-25] 05:22AM BLOOD WBC-6.7 RBC-3.44* Hgb-10.5* Hct-31.7* MCV-92 MCH-30.5 MCHC-33.0 RDW-14.2 Plt Ct-196 [2178-11-24] 06:09AM BLOOD WBC-5.4 RBC-3.46* Hgb-10.4* Hct-30.7* MCV-89 MCH-30.2 MCHC-34.0 RDW-14.2 Plt Ct-175 [2178-11-12] 11:03AM BLOOD WBC-7.6 RBC-3.92* Hgb-11.4* Hct-35.8* MCV-91 MCH-29.0 MCHC-31.8 RDW-13.7 Plt Ct-386 [2178-11-18] 10:10AM BLOOD Neuts-83.3* Lymphs-10.0* Monos-4.1 Eos-2.5 Baso-0.2 [2178-11-18] 10:10AM BLOOD Neuts-83.3* Lymphs-10.0* Monos-4.1 Eos-2.5 Baso-0.2 [2178-11-13] 07:00PM BLOOD Neuts-91.6* Lymphs-5.8* Monos-2.3 Eos-0.1 Baso-0.2 [2178-11-25] 05:22AM BLOOD Plt Ct-196 [2178-11-23] 05:00AM BLOOD PT-11.7 PTT-24.3 INR(PT)-1.0 [2178-11-12] 11:03AM BLOOD PT-12.7 PTT-24.2 INR(PT)-1.1 [2178-11-25] 05:22AM BLOOD Glucose-130* UreaN-22* Creat-0.6 Na-135 K-4.1 Cl-101 HCO3-27 AnGap-11 [2178-11-12] 11:03AM BLOOD Albumin-4.2 Calcium-10.0 Phos-3.2 Mg-2.4 Iron-22* Time Taken Not Noted Log-In Date/Time: [2178-11-13] 10:05 pm SWAB AORTIC ABS R/O ACTINOMYCES. GRAM STAIN (Final [2178-11-13]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2178-11-20]): NO GROWTH. ANAEROBIC CULTURE (Final [2178-11-21]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. ACID FAST CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [2178-11-15]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. [2178-11-13] 3:50 pm TISSUE R/O ACTINOMYCES. AORTIC TISS. GRAM STAIN (Final [2178-11-13]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2178-11-20]): NO GROWTH. ANAEROBIC CULTURE (Final [2178-11-21]): NO GROWTH. POTASSIUM HYDROXIDE PREPARATION (Final [2178-11-16]): NO FUNGAL ELEMENTS SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [2178-11-15]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. Time Taken Not Noted Log-In Date/Time: [2178-11-13] 9:58 pm ABSCESS AORTIC ABSCESS. R/O ACTINOMYCES. GRAM STAIN (Final [2178-11-13]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2178-11-20]): NO GROWTH. ANAEROBIC CULTURE (Final [2178-11-21]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [2178-11-15]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2178-11-16]): NO FUNGAL ELEMENTS SEEN. [2178-11-13] 5:00 pm TISSUE SOURCE IS SPINAL BONE. R/O ACTINOMYCES. GRAM STAIN (Final [2178-11-13]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2178-11-20]): NO GROWTH. ANAEROBIC CULTURE (Final [2178-11-21]): NO GROWTH. ACID FAST SMEAR (Final [2178-11-15]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2178-11-16]): NO FUNGAL ELEMENTS SEEN. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. [2178-11-12] 3:45 pm BLOOD CULTURE FINAL REPORT [2178-11-18] Blood Culture, Routine (Final [2178-11-18]): NO GROWTH. Brief Hospital Course: Pt presented to the hospital on [2178-11-12] with psoas abscess wrapping around aorta with penetrating ulcer growing unknown AFB organism (mycobacterium chlonae), epidural abscess L3-L5 with effacement and osteomyelitis/discitis at L4, L5 level. She agreed to have surgery. Preoperatively an ID consult was obtained. Pre-operatively, she was consented. A CXR, EKG, UA, CBC, Electrolytes, type and screen were obtained. On [2178-11-13] she was taken to the operating room for right axillary artery to bilateral femoral artery bypass with PTFE, resection and debridement of infrarenal aorta, debridement of L4/L5 discs. Postoperatively, she was transferred to the CVICU intubated for close monitoring overnight. She was placed on TB/respiratory precautions for +PPD. [Date range (1) 93377]: Extubated, ID following Amikacin 850mg, Linezolid continued. Non productive cough, sputum cx pending. C/O severe pain, pain consult initiated. [11-16] pain consult obtained for acute on chronic pain- long standing spinal stenosis with long term narcotic and antidepressant use) now with spinal debridement. Home med lyrica restarted, Oxycodone and Dilaudid increased. JP bulb intact, draining moderate mounts. [12-6] + edema, lasix started. [Date range (1) 52935] Ortho/spine- Dr. [Last Name (STitle) ] following. Cleared patient for activities from spine perspective. Off TB precautions per ID. VSS. On clears/advancing as tolerated, positive flatus. Physical therapy initiated. ID closely following, awaiting final cultures. [11-19] PICC line placed in IR for long term ABX. Nutrition consulted. Calorie counts initiated. VSS. [11-20] Geriatrics consulted. Nutritional labs obtained and supplements provided/encouraged. TPN initiated for poor po intake. Geriatrics recs- 6 small meals, boost supplements and aggressive bowel regime. No Dobbhoff, no tube feeds. [Date range (1) 69262] VSS. No events. Poor po intake, continued regular diet and TPN. Pain controlled on current regime. JP drain discontinued on [11-25]. ID continues to follow cultures. Will have weekly labs at rehab. Follow up apptmoints scheduled for ortho, ID and Dr. [Last Name (STitle) ]. Medications on Admission: acyclovir [Zovirax] - 5 % Cream clarithromycin - 500 mg Tablet"' folic acid - 1 mg Tablet' metoprolol tartrate - 25 mg Tablet" naproxen - 250 mg Tablet oxycodone - 10 mg Tablet pregabalin [Lyrica] - 50 mg Capsule"' risedronate [Actonel] - 35 mg Tablet venlafaxine - 75 mg Capsule, Sust. Release 24 hr' aspirin - 81 mg Tablet, Delayed Release (E.C.) calcium carb-mag oxide-vit D3 [Calcium Magnesium + D] - 400 mg-167 mg-133 unit Tablet docusate sodium - 100 mg Capsule ergocalciferol (vitamin D2) [Vitamin D] - 400 unit Capsule multivitamin psyllium [Metamucil] - 0.52 gram Capsule vit A,C & E-lutein-minerals [I-Vite] - 1,000 unit-[Unit Number ] mg-60 unit-[Unit Number ] mg-55 mcg-2 mg-2 mg Tablet Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000 Injection TID (3 times a day). 5. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 13. amikacin 250 mg/mL Solution Sig: 850mg Injection Q24H (every 24 hours): Management by Dr. [Last Name (STitle) 9461]/ID [Telephone/Fax (1) 457], fax [Telephone/Fax (1) 1419]. Last through at 1500 at [Hospital1 18] [2178-11-25]. 14. Regular Insulin sliding scale Fingerstick QACHSInsulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: 1. Mycotic contained rupture with infection of the infrarenal aorta. 2. Psoas abscess. 3. Diskitis L4-5. 4. Osteomyelitis of L4 and L5. 5. Spondylolisthesis of L4 on 5. 6. Severe lumbar stenosis. 7. Peripheral Vascular Disease 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: 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: [Name10 (NameIs) 1412] [Name Initial (NameIs) ] [Name12 (NameIs) 1413], M.D. Date/Time:[2178-12-3] 1:30 Infectious DIsease. [Hospital Ward Name ] LMOB Basement [Telephone/Fax (1) 457] Provider: [Name10 (NameIs) ] [Name11 (NameIs) 9462] [2179-1-6] 10:00a Infectious Disease. [Hospital Ward Name ] LMOB Basement [Telephone/Fax (1) 457] Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2178-12-17] 9:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2178-12-17] 11:30 Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1352] (ortho/spine) [Telephone/Fax (1) 3736]. [2178-12-14] 1040am. Office- [Hospital Ward Name 23] [Location (un) ], [Hospital Ward Name ] Completed by:[2178-11-25]	[ "4168", "311" ]
Admission Date: [2105-10-23] Discharge Date: [2105-10-24] Date of Birth: [2039-3-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5893] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr [Known lastname 19017] is a 66 y/o M with a PMHx of stage 4 COPD (FEV1 0.44L (18%)) on 4L home o2 with numerous hospitalizations for COPD exacerbations and intubation, who presents with SOB and CP which was different than baseline. He describes the CP as left stabbing subcostal pain with point location. The pain has been going on intermittently for 3 weeks but has become worse. His SOB lasts all the time while his CP is intermittent and lasts a few seconds. He denied n/v/f/c/d/c. He reports weening his prednisone down at home and currently was on 30mg daily. . In the ED, his initial VS were initially BP 130/p, HR 112, RR 33 O2sat 96% on NRB. He was given Combivent neb, SoluMedrol 125 x1, ASA 162mg, Levaquin 750mg IV x1 (he refused), Nitro SL x1, and Percocet x1. His EKG was unchanged but showed low voltage. A quick bedside ultrasound showed no pericardial effusion in the ED. He was weened off the NRB to nasal cannula at 5L with sats around 95%. He had a CXR and CTA chest. Past Medical History: # COPD on 4 L O2 at home w/ BiPAP qhs - s/p multiple admissions and intubations for flares - [3-/2105]: FEV1 0.56(23%)and FEV1/FVC 40% # h/o chronic indwelling urethral catheter - has been out for >1 yr - has a h/o VRE UTI # hx of MRSA # CAD s/p NSTEMI ([2101]) - [4-9] with NL cath - TTE with preserved biventricular function in [2103] - uses ntg ~1x/week # Steroid induced hyperglycemia # Hypertension # Hyperlipidemia # Chronic low back pain L1-2 laminectomy from accident at work # Left shoulder pain for several months # Cataracts bilaterally - s/p surgery for both # GERD # BPH Social History: Retired [Company ] mechanic. Exposed to a lot of spray paint. Married with six children. Lives at home in [Location (un) 686] with wife and step-son. His step-son is "trouble" with a history of drug use, possible drug dealing and brings guns in the house. Pt does not feel safe at home. Minimally active at baseline, walks to kitchen and bathroom, but spends most of day in bed.. Substances: 20 p-y smoking, quit 25 years ago. Occassional EtOH. Quit marijuana 3 years ago. Denies IVDA. Family History: Mother w/ asthma, Alzheimer's disease. Father w/ [Name2 (NI) 499] cancer. Physical Exam: T: 97.3 BP: 118/67 P: 102 RR: 22 O2 sats: 93% on 4L NC Gen: lying in bed, NAD HEENT: teeth missing, PERRL, MMM Neck: no JVD appreciated, well healed scar from prior trach CV: tachycardic RR, very distant heart sounds, no murmur appreciated Resp: tachypnic, bilateral wheezing Abd: +BS, soft, NTND Ext: DP 2+ symmetric, muscle atrophy Neuro: alert and oriented to person, place and date Pertinent Results: Imaging: CTA CHEST W&W/O C&RECONS, NON-CORONARY [2105-10-23] 4:17 AM IMPRESSION: 1. No evidence of pulmonary embolism, aortic dissection, or pneumonia. 2. Stable likely post inflammation/aspiration bronchiectasis within the lower lobes. . CHEST (PORTABLE AP) [2105-10-23] 2:52 AM IMPRESSION: 1. No acute cardiopulmonary process. 2. Evidence of emphysema, bronchiectasis, and pulmonary hypertension. 3. No significant change since [2105-10-10]. . Micro Data: None . Labs: [2105-10-23] 02:50AM BLOOD WBC-18.8* RBC-4.39* Hgb-12.4* Hct-37.2* MCV-85 MCH-28.3 MCHC-33.4 RDW-15.2 Plt Ct-343 [2105-10-23] 10:16AM BLOOD WBC-13.3* RBC-4.18* Hgb-11.7* Hct-35.0* MCV-84 MCH-28.1 MCHC-33.5 RDW-15.0 Plt Ct-273 [2105-10-23] 10:16AM BLOOD Glucose-128* UreaN-18 Creat-0.7 Na-137 K-4.4 Cl-98 HCO3-33* AnGap-10 [2105-10-23] 02:50AM BLOOD CK(CPK)-41 Amylase-162* [2105-10-23] 10:16AM BLOOD CK(CPK)-31* [2105-10-23] 04:45PM BLOOD CK(CPK)-34* [2105-10-23] 02:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2105-10-23] 10:16AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2105-10-23] 04:45PM BLOOD CK-MB-NotDone cTropnT-<0.01 Brief Hospital Course: 66 yo M with PMH of COPD with FEV1 0.44L (18%) on 4L home o2, CAD s/p NSTEMI in [2101], HTN, chronic back pain who presents with SOB and chest pain and likely COPD exacerbation. . # COPD: he presented with SOB which is likely his COPD exacerbation. His CXR and CTA chest showed no signs of consolidation. He is currently doing well on nasal cannula. He still has bilateral wheezing. No obvious signs of infection. Antibiotics aside from his home Bactrim were not needed. Patient to continue on home steroids and inhalers, and oxygen. Patient also to continue on BIPAP at night [12-9] with 4L oxygen. Patient will need interval PFTs done as an outpatient. . # leukocytosis: Likely steroid induced. No signs of infection at this time. . # tachycardia: Thought to be related to nebulizer treatments as he does not appear dry on exam. Monitored on tele without event. . # chest pain: Ruled out for MI. Thought to be costochondritis and given NSAIDs. . # CAD s/p NSTEMI in past: He noted chest pain on admission which has since resolved. Cardiac enzymes were negative and continued on home ASA, statin, CCB. Patient not currently on an ACE. . # steroid induced hyperglycemia: monitor FS and use humalog SC . # chronic pain: back and shoulder pain. Continued percocet. . . After discussion with the staff and the medical team, all were in agreement that the patient was a suitable candidate for discharge. Medications on Admission: Advair 250/50 [Hospital1 ] Ativan 0.5mg qhs prn Prednisone 30mg qDaily Albuterol prn Bactrim DS qMWF Verapamil XL 120 qdaily Calcium carbonate 500 tid Vit D3 400 [Hospital1 ] ASA 81mg Senna/Colace pantoprazole 40 qdaily Zoloft 50 qdaily Flomax 5 qdaily atorvastatin 10 qdaily Lactulose Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 9. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Disp:30 Tablet(s) Refills:2 12. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 18. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: COPD Exacerbation . Secondary Diagnoses: # Severe COPD on 4 L O2 at home w/ BiPAP qhs - s/p multiple admissions and intubations for flares - [9-/2105]: FEV1 0.44(18%)and FEV1/FVC 32% # h/o chronic indwelling urethral catheter - has been out for >1 yr - has a h/o VRE UTI # hx of MRSA # CAD s/p NSTEMI ([2101]) - [4-9] with NL cath - TTE with preserved biventricular function in [2103] - uses ntg ~1x/week # Steroid induced hyperglycemia # Hypertension # Hyperlipidemia # Chronic low back pain L1-2 laminectomy from accident at work # Left shoulder pain for several months # Cataracts bilaterally - s/p surgery for both # GERD # BPH # Hx of resistant Pseduomonas PNA infxn Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You were admitted with shortness of breath and chest pain. You were found not to have a clot in your lungs and also your breathing resolved spontaneously. . 1. PLease take all medication as prescribed. 2. Please make all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. Followup Instructions: Provider: [Name10 (NameIs) 13368] [Last Name (NamePattern4) 13369], MD Phone:[Telephone/Fax (1) 1091] Date/Time:[2105-12-2] 2:00 Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2105-12-3] 10:10 Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2105-12-3] 10:30 Completed by:[2105-10-24]	[ "2724", "4019", "41401", "53081" ]
Admission Date: [2106-2-5] Discharge Date: [2106-2-11] Date of Birth: [2037-6-2] Sex: F Service: CARDIOTHORACIC Allergies: Effexor Attending:[First Name3 (LF) 5790] Chief Complaint: cough and dyspnea Major Surgical or Invasive Procedure: [2106-2-5]: Right thoracotomy and tracheoplasty with mesh, right main stem bronchus/bronchus intermedius bronchoplasty with mesh, left main stem bronchus bronchoplasty with mesh, bronchoscopy with bronchoalveolar lavage. History of Present Illness: Ms. [Known lastname 96986] is a 68-year-old woman who has had significant dyspnea. She underwent a bronchoscopy which revealed diffuse and severe tracheobronchomalacia with the preponderance of disease at the distal trachea and main bilateral bronchi. She underwent a stent trial and had significant alleviation of her dyspnea and an improved overall quality of life and activity level. She was brought in for tracheoplasty. Past Medical History: Hypertension hypothyroid COPD TBM depression elevated cholesterol osteoarthritis GERD Obstructive sleep apnea Past surgical history: Bilateral Knee replacements Oophorectomy on left tonsillectomy rotator cuff repair Social History: Lives with partner. Ex [Name2 (NI) 1818], quit: 23 years ago; used to smoke 2.5 to 3 packs per day. Denies drugs, ETOH, Family History: Mother: hypothyroid and stroke Father: [Name (NI) 2481] Physical Exam: Discharge vital signs: T 96.6 P 79 reg HR 110/60 RR 18 O2 sats 95% on 4L NC Discharge Physical Exam: Gen: Pleasant in NAD Lungs: clear t/o, at times rhonchorus t/o clearing with cough right thoracotomy healing without redness, purulence or drainage CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND Ext: warm without edema Pertinent Results: [2106-2-9] 07:55AM BLOOD WBC-8.9 RBC-3.93* Hgb-11.6* Hct-35.1* MCV-89 MCH-29.5 MCHC-33.0 RDW-14.4 Plt Ct-333 [2106-2-9] 07:55AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-143 K-4.1 Cl-105 HCO3-29 AnGap-13 [2106-2-9] 07:55AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.5 CXR [2106-2-9]: IMPRESSION: Appearance is similar to prior study with mild basal atelectasis on the left and small right effusion in addition to mild increased interstitial markings peripherally in the right lung and at the left lower zone, which may reflect underlying interstitial disease, possibly with mild superimposed edema. Brief Hospital Course: Ms. [Known lastname 96986] was taken to the operating room by Dr. [Last Name (STitle) ] on [2106-2-5] for right thoractomy and tracheoplasty with mesh, right main stem bronchus/bronchus intermedius bronchoplasty with mesh, left main stem bronchus bronchoplasty with mesh, and bronchoscopy with bronchoalveolar lavage, for her tracheobronchomalacia. The patient was extubated in the OR, and transfered to the PACU for recovery then to the SICU for further management that evening. The patient had epidural with bupivicaine and dilaudid for pain management. The patient was transferred to the floor in stable condition on [2106-2-7] (POD 2). The following is a systems review of her hospital course. Neurologic: The patient had a bupivicaine and dilaudid PCA which was effective in pain control. Acute pain service managed this until it was discontinued on POD 3. The patient was transitioned to tylenol, ibuprofen, oxycodone, and lidocaine which was effective. She is also on home gabapentin. She remained neurologically intact. Of note she admits to former narcotic addiction, therefore care will be made to assist in titrating off oxycodone after the immediate postoperative period. Pulmonary: The patient was brought out of the OR with a right [Doctor Last Name ] chest tube which was removed on POD 1 without pneumothorax on postpull film. Aggressive pulmonary toilet was instituted with around the clock mucolytics, nebulizers, and incentive spirometry. The patient was kept on her home inhalers, and home bipap. She also remained on oxygen via nasal canula 4L during the day. At night she used her home bipap. Pulmonary was consulted and followed alongside. The patient had desaturations during the night on bipap therefore her nightly oxygen was increased to >92% with 6L. Two doses of lasix were given POD 3 and 4 for pulmonary congestion and to diurese after the initial fluid given postoperatively. CXR's were followed. CV: The patient remained hemodynamically stable throughout her stay in NSR. Abd: The patient was advanced to a regular diet which she tolerated. Stool softeners were given. The patient passed gas and was close to having a bowel movement on date of discharge. GU: A foley was kept during the epidural and dc'd POD 3 with good urinary response thereafter. ID: The patient remained afebrile with CBC trends followed. There were no infectious processes during the stay. Prophylaxis: Heparin was given for DVT prophylaxis. Dispo: PT evaluated the patient on POD 4 and deemed the patient would benefit from a short stay in rehab, which the patient would also like. The patient was ambulating with PT, tolerating a regular diet with pain controlled on an oral regimine. Her oxygen on 4L nasal cannula was 95%. The patient was deemed stable for transfer to rehab on [2106-2-11]. Medications on Admission: ADVAIR DISKUS - 250-50 mcg/Dose Disk with Device - 1 (One) puff inhaled twice a day ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every 4-6 hours as needed for shortness of breath/wheezing CABERGOLINE - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth three times a week FLUTICASONE - (Prescribed by Other Provider) - 50 mcg Spray, Suspension - 2 sprays(s) nares twice a day GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule - [3-4] Capsule(s) by mouth twice a day 600 mg in am, 900 mg in pm LEVOTHYROXINE - (Prescribed by Other Provider) - 137 mcg Tablet - 1 (One) Tablet(s) by mouth once a day OMEPRAZOLE - (Prescribed by Other Provider; Dose adjustment - no new Rx) (Not Taking as Prescribed: pending GI study) - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day PRAVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily RANITIDINE HCL - (Not Taking as Prescribed: pending GI study) - 300 mg Capsule - 1 Capsule(s) by mouth daily SERTRALINE [ZOLOFT] - 100 mg Tablet - 1 (One) Tablet(s) by mouth twice a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 tablet inhaled daily TOLTERODINE [DETROL LA] - 4 mg Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth once a day TRIAMTERENE-HYDROCHLOROTHIAZID - 37.5-25 mg Capsule - 1 (One) Capsule(s) by mouth once a day ZAFIRLUKAST [ACCOLATE] - 20 mg Tablet - 1 (One) Tablet(s) by mouth twice a day ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) - Dosage uncertain ASCORBIC ACID [VITAMIN C] - (OTC) - 500 mg Tablet - one tablet by mouth once a day CALCIUM - (Prescribed by Other Provider; OTC) - Dosage uncertain DHA-EPA-POLICOSANOL-B6-B12-FA - (OTC) - 200 mg-300 mg-10 mg-250 mcg-250 mcg-6.25 mg Capsule - 1 (One) Capsule(s) by mouth once a day FERROUS SULFATE [IRON (FERROUS SULFATE)] - (OTC) - 325 mg (65 mg Elemental Iron) Tablet - 1 (One) Tablet(s) by mouth twice a day GUAIFENESIN [MUCINEX] - 1,200 mg Tab, Multiphasic Release 12 hr - 1 Tab(s) by mouth twice a day To continue while stent in place MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day S-ADENOSYLMETHIONINE [[Male First Name (un) ]-E] - (OTC) - 400 mg Tablet - 1 (One) Tablet(s) by mouth once a day VITAMIN E - (OTC) - 400 unit Capsule - 1 (One) Capsule(s) by mouth once a day Discharge Medications: 1. cabergoline 0.5 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) spray Nasal twice a day. 4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QPM (once a day (in the evening)). 6. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. sertraline 100 mg Tablet Sig: One (1) Tablet PO twice a day. 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO once a day. 13. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 14. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for thick secretions. 17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place x 12 hours during the day and take off at night. 18. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 19. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 20. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 21. acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML Miscellaneous Q6H (every 6 hours). 22. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours): give with mucomyst. 23. zafirlukast 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 24. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 25. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day: may want to hold if constipated during the first couple weeks following surgery. 26. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 11496] Discharge Diagnosis: Tracheobronchomalacia HTN Hypothyroid COPDdepression elevated cholesterol osteoarthritis GERD obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Call Dr. [Last Name (STitle) ] if you have: -Fevers greater than 101.5 -chills -sweats -shakes -shortness of breath -worsening cough Call if right incision opens, become increasingly red, swollen or drains. Call for uncontrolled surgical pain. Take stool softeners while on narcotics. Do not drive while on narcotics for pain. You may shower but do not tub bath for 6 weeks. Followup Instructions: Provider: [Name10 (NameIs) 1532] [Last Name (NamePattern4) 8786], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2106-3-2] 10:30 [Hospital1 18] [Hospital Ward Name ] [Location (un) 453] [Hospital1 ] 116. Get a chest xray 30 minutes prior to your appointment on [Location (un) ] clinical center radiology department. Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2106-3-2] 11:15 Completed by:[2106-2-11]	[ "496", "4168", "32723", "4019", "2449", "53081", "311", "2720" ]
Unit No: [Numeric Identifier 76948] Admission Date: [2190-1-16] Discharge Date: [2190-1-21] Date of Birth: [2190-1-16] Sex: M Service: NB SERVICE: [Location (un) 13248] Newborn Service. HISTORY: This is an infant boy, born at 39 and 6/7 weeks gestational age to a 28-year-old, G1 P0 mother, with a birth weight of 9 pounds 0 ounces (4080 gm). Prenatal laboratory studies were hepatitis B surface antigen negative, RPR nonreactive antibody negative, rubella immune and B positive [Location (un) ] type. MATERNAL HISTORY: Notable for a diagnosis of endometrial tuberculosis made while the mother was living in [Name (NI) 11150]. The diagnosis was reportedly made from a positive PCR test on an endometrial biopsy which was obtained during a workup in [Country 11150] for maternal infertility. As per the infectious disease notes, the mother underwent approximately three months of a four-drug regime for MTB, which was not fully completed due to transaminitis during pregnancy. In addition, the maternal history was notable for gestational diabetes and maternal alpha thalassemia trait. The baby was delivered on [2190-1-16] at 1417 hours via a C-section for a failed induction with Apgars of 9 and 9. The mother was GBS positive, but received a full course of intrapartum antibiotics, and there were no other sepsis risk factors present. PHYSICAL EXAMINATION ON ADMISSION: The baby's birth weight was 9 pounds 0 ounces (4080 gm). Length was 20 inches. Head circumference was 36 cm. The baby was [Name2 (NI) 3584] and well appearing. There are two nevi present on the back, both approximately 0.5 cm in diameter. However, one containing two areas of central irregular hyperpigmentation. The anterior fontanelle was open and flat. There was a red reflex present in both eyes. The palate was intact. The lungs were clear to auscultation. On admission, the patient had a 1/6 systolic murmur, heard best at the left upper sternal border with 2+ femoral pulses. The abdominal examination was benign with positive bowel sounds and no hepatosplenomegaly or masses. The baby's right testicle had descended, but the left testicle was undescended. Anus was normally placed. There were no spinal defects. The hips were stable and symmetric. The baby's tone was good with positive Moro, grasp and suck reflexes. SUMMARY OF HOSPITAL COURSE: 1. RESPIRATORY: The baby remained stable on room air throughout his admission. 2. CARDIOVASCULAR: As noted above, the baby was noted to have a soft 1/6 systolic murmur on day of life 0. This murmur consisted throughout the admission, and by day four, it was noted to be a grade [2-24] murmur. At that time, a cardiac evaluation was initiated with a chest x- ray, 12-lead EKG, pre and post-ductal sacs, and four- extremity [Month/Day (4) ] pressure measurements, all of which were within normal, based on the initial review by the NICU attending. As of the date of this dictation, the final read of the EKG by [Hospital3 1810] Cardiology is pending. It was thought by both the NICU attending and the newborn service pediatrician that the murmurs were consistent with a likely muscular VSD. No echocardiogram was performed inpatient. However, we recommend that the baby be followed as an outpatient by cardiology to insure that the murmur resolves. 3. NGI: The baby was initially monitored for hypoglycemia, in light of the maternal history of insulin-dependent diabetes mellitus and the baby's slight LGA status. Thereafter, the baby took good p.o. of breast milk with some supplementation with Good Start 20k calorie formula. At the time of discharge, the discharge weight is 3995g. 4. INFECTIOUS DISEASE: The mother was [Name (NI) 76949], but received a full-course of intrapartum antibiotics and no other sepsis risk factors were present. Therefore, the baby did not undergo a sepsis evaluation. With regard to the maternal diagnosis of MTB, status post approximately three months of a four-drug regime, infectious disease was consulted. As per their note, the risk of congenital transmission of TB to the infant is considered quite low, given the fact that the mother had already received several months of treatment and is asymptomatic, especially since her own diagnosis was never culture-confirmed. Nevertheless, based on the recommendations of infectious disease, three gastric aspirates for mycobacterial stain and culture were sent from the baby, and are pending w/ no growth to date, as of the date of discharge. Infectious disease has advised us that there is no need for TB precautions, such as airborne precautions for the baby, and that standard universal precautions with glove wearing during examination of the baby are sufficient. The plan is for the baby to be followed up with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 50148], at [Hospital3 1810] ID in the next two weeks. An appointment has been scheduled for them, as noted below. 5. HEMATOLOGY: The baby was noted to have a somewhat elevated bilirubin at 15.4 at approximately 60 hours of life and was treated with phototherapy for approximately 14 hours with excellent response. A rebound bilirubin off of lights was 12.4 on [2190-1-20]. Maternal [Year (4 digits) ] type is B positive. The baby's [Year (4 digits) ] type is B negative and Coombs negative. 6. GENITOURINARY: The patient has left cryptorchidism. It is recommended that the baby be followed up with urology in the next six months, in the event that the left testis does not descend. 7. DERMATOLOGY: In light of the one nevus with the irregular hyperpigmentation, it is recommended that the baby be followed up as an outpatient by dermatology. CONDITION ON DISCHARGE: Condition at discharge is good. DISCHARGE DISPOSITION: Discharge disposition is to home. PRIMARY PEDIATRICIAN: The name of the primary pediatrician is Dr.[Doctor Last Name 7517], [Hospital 1426] Pediatrics (of whom Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], has given verbal sign out). CARE/RECOMMENDATIONS: A. Continue p.o. ad lib of breast milk and Good Start 20K calorie formula. B. No medications. C. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 International Units (provider is [Name Initial (PRE) ] multivitamin preparation) daily until 12 months corrected age. D. State newborn screening was sent on [2190-1-19]. E. The hepatitis B vaccine administered on [2190-1-19]. F. The baby passed his [Name (NI) 72589] hearing screen bilaterally. G. Follow up appointments: It is recommended that the baby follow up with his primary care pediatrician within one day after discharge. An appointment has been scheduled with [Hospital3 1810] infectious disease with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 50148], on [2190-2-2] at 12 noon. They are located at [Hospital1 61634], on the fifth floor in the clinic that is labeled the "Adolescent's" clinic. It is further recommended that the baby be followed up as an outpatient with cardiology and dermatology. Lastly, in the event that the baby's left testis remains undescended at six months of life, it is recommended that the baby follow up with outpatient urology for treatment of cryptorchidism. DISCHARGE DIAGNOSES: 1. Term LGA (large for gestational age) infant boy. 2. Maternal endometrial tuberculosis with the baby's gastric aspirates pending as of discharge. 3. Indirect hyperbilirubinemia, status post phototherapy/resolved. 4. Cardiac evaluation for persistent murmur, thought likely a VSD, with recommended cardiology follow up. 5. Nevus with irregular hyperpigmentation with recommended dermatology follow up. 6. Left cryptorchidism with recommended follow up with urology if testis remains undescended. [First Name8 (NamePattern2) 73452] [Last Name (NamePattern1) ]. [Name8 (MD) ], MD [MD Number(2) 73453] Dictated By:[Last Name (NamePattern1) 72910] MEDQUIST36 D: [2190-1-20] 21:34:05 T: [2190-1-21] 00:10:58 Job#: [Job Number 76950] cc:[Last Name (NamePattern1) ] [Name6 (MD) ] [Last Name (NamePattern4) 76951], MD [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 76952], MD	[ "V053" ]
Admission Date: [2137-4-1] Discharge Date: [2137-4-5] Date of Birth: [2055-8-13] Sex: M Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 2972] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 81 year old man with a history of prostate cancer metastatic to bone, evidence of RV failure on echo in [5-26], CAD s/p CABG who was brought in by his family for increasing somnolence. Admitted to the MICU for hypotension. Was breifly on levophed for hypotension and started on vanc cefepime empirically for ?sepsis. Now being transferred to medicine floor for further mx. The pt was discharged from rehab two days ago, was at rehab since discharge from [Hospital1 18] on [2137-3-1] for somnolence where he was found to have a UTI and C.diff infection, per his family at the time of his discharge from rehab he was at his baseline mental status (AAOx3, able to recall the days events). Last night his family notes that he was increasingly somnolent, and this morning he was sleeping more often but arousable and complained of fatigue. His family also noted that he had worsening erythema and edema of his left lower extremity. His family also noted that he had been having significant amounts of diarrhea (7 BM's per day) while at rehab, most recently treated with loperamide and since returning home has improved, with no bowel movements today. In the ED, initial VS were: 100.1, 100, 117/49, 16, on 100% 10L. He initially was somnolent, only responding to deny pain, cough, dyspena and dysuria. In the ER was noted to be somnolent initially, his mental status improved with IV fluids however when he spiked a temp to 100.9 his blood pressure dropped to 77/48, mentating well at that time. He was given 1LNS and his SBP improved to the 90's, however his blood pressure dropped again to 82/40, so he was given a second liter and started on levophed. He had a LLE ultrasound that was negative for DVT, RUQ US which showed a 6mm CBD, no cholecystitis, a CT head with no acute process and a CXR with no evidence of pneumonia. He was given vancomycin for presumed cellulitis and empiric cefepime for the hypotension. His labs were notable for a lactate of 1.4, troponin of 0.02, CK of 367, MB of 2, AST of 41, AP of 206. VS on transfer: 99.6 ??????F (37.6 ??????C), 91, 16, 108/49, 96% on RA. On arrival to the MICU, VS were 98.5, 90, 101/63, 18, 94% on RA. He currently is awake, alert and oriented x 3, denies any pain, chest pain, shortness of breath, n/v/d, abdominal pain, he also says that the swelling in his left leg is significantly improved from prior. His only current complaint is that he is thirsty. Currently Review of systems: (+) Per HPI and for chronic diarrhea (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Metastatic Prostate Cancer - CABG x 4 vessels [2120]. - Hypertension. - Hyperlipidemia. - E. coli urosepsis in [2135-5-17]. - One fall with subsequent wrist fracture. - Right heart failure (EF 65%). - [2135-9-21] underwent T9 to L1 fusion with vertebrectomy T11. Past Oncologic History: Prostate cancer diagnosed in [2117]. S/p radical prostatectomy. XRT to pelvis approx one and a half years after prostatectomy for rising PSA. In [2123], started hormones for metastatic prostate cancer. In [2130-11-16], started on KHAD trial of Ketoconozole, Hydrocortisone, and Dutasteride as he became hormone refractory. Was on Sutent Trial temporarily from [Date range (1) 31896]. Was on diethylstilbesterol from approx [2131] to [2134-1-5]. Has also been maintained on Lupron/Pamidronate. Last dose of Lupron was [2134-1-5] at dose of 22.5 mg. He is status post Clinical Trial #08-359 taxotere every 3 weeks plus atrasentan vs placebo and prednisone daily. He was unable to tolerate this regimen secondary to toxicity. He received Taxotere every 3-4wks & lupron every 3mos. He finished cycle 15 of Taxotere on [2135-7-25]. He was then on leupropride every 12 weeks, which began on [2135-7-5]. He is s/p Clinical Trial #08-359 taxotere every 3 weeks plus atrasentan vs placebo and prednisone daily. He was unable to tolerate this regimine secondary to toxicity. He was changed to taxotere alone, off protocol he recieved 16cycles. He was followed and started on DES/coumadin after his insurance denied coverage for another therapy - [2136-10-9] taxotere/lupron C1 - [2136-11-6] C2 taxotere - [2136-11-27] C3 taxotere - [2136-12-18] C4 taxotere - [2137-1-8] C5 Taxotere, briefly discontinued secondary to declining PSA and LE edema - [2137-2-12] C6 Taxotere followed by Neulasta [2137-2-13] Social History: - Retired construction worker. Lives at home with his son. - Tobacco: None. - etOH: Former social drinker, last use 35 yo ago. - Illicits: None. Family History: Brother with prostate cancer. Physical Exam: ADMISSION VS: 98.5, 90, 101/63, 18, 94% 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, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE: VS: TC 97.9 BP 146/70 HR 98 RR 18 98% RA General: Alert, oriented X 3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Mild stasis changes. Neuro: CNII-XII intact Pertinent Results: ADMISSION LABS [2137-3-31] 08:10PM BLOOD WBC-8.2 RBC-3.08* Hgb-8.7* Hct-28.4* MCV-92 MCH-28.2 MCHC-30.6* RDW-18.2* Plt Ct-206 [2137-3-31] 08:10PM BLOOD Neuts-73.2* Lymphs-19.5 Monos-6.7 Eos-0.4 Baso-0.2 [2137-3-31] 09:07PM BLOOD PT-13.8* PTT-28.9 INR(PT)-1.3* [2137-3-31] 08:10PM BLOOD Glucose-128* UreaN-23* Creat-1.1 Na-136 K-4.3 Cl-102 HCO3-26 AnGap-12 [2137-3-31] 08:10PM BLOOD CK-MB-2 [2137-3-31] 08:10PM BLOOD cTropnT-0.02* [2137-4-1] 02:51AM BLOOD CK-MB-2 cTropnT-0.01 [2137-4-1] 07:52PM BLOOD CK-MB-1 cTropnT-<0.01 [2137-4-1] 02:51AM BLOOD Albumin-2.6* Calcium-7.7* Phos-3.2 Mg-1.7 [2137-3-31] 08:26PM BLOOD Lactate-1.4 [2137-4-1] 11:53AM BLOOD Lactate-1.3 [2137-4-1] 02:51AM URINE Mucous-RARE [2137-4-1] 02:51AM URINE RBC-<1 WBC-<1 Bacteri-MOD Yeast-NONE Epi-<1 [2137-4-1] 02:51AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2137-4-1] 02:51AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 DISCHARGE LABS [2137-4-5] 05:20AM BLOOD WBC-5.0 RBC-2.76* Hgb-7.8* Hct-25.4* MCV-92 MCH-28.2 MCHC-30.6* RDW-18.0* Plt Ct-211 [2137-4-5] 05:20AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-136 K-3.8 Cl-104 HCO3-23 AnGap-13 [2137-4-5] 05:20AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.1 STUDIES: CT HEAD [2137-3-31]: CT OF THE BRAIN: There is no evidence of acute intracranial hemorrhage, discrete masses, mass effect or shift of normally midline structures. The ventricles and sulci appear slightly prominent, consistent with age-related involutional changes. Minimal periventricular and subcortical white matter changes appear consistent with sequelae of chronic small vessel ischemic disease. [Doctor Last Name ]-white matter differentiation is preserved. There is atherosclerotic calcification of the bilateral vertebral arteries, left greater than right. Bilateral mastoid air cells are clear. Visualized paranasal sinuses are unremarkable. Rounded metallic density seen in the soft tissue infraorbitally on the right. IMPRESSION: No acute intracranial process. ABD U/S [2137-3-31]: IMPRESSION: 1. No evidence of acute cholecystitis. 2. Right lobe hepatic cyst unchanged from CT of [2136-8-23]. LENIS [2137-3-31]: IMPRESSION: No evidence of DVT in left lower extremity ECHO [2137-4-1]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The right ventricular cavity is mildly dilated with borderline normal free wall function. There is abnormal septal motion/position. 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 structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Dilated right ventricle with borderline normal free wall function. Moderate tricuspid regurgitation with moderate-severe pulmonary artery systolic hypertension. Preserved left ventricular regional and global systolic function. Mild mitral and aortic regurgitation. Compared with the prior study dated [2135-5-27] (images reviewed), pulmonary artery systolic pressure is worse. The right ventricle is better seen on the current study and is similarly dilated with borderline systolic function. Other findings are similar. CXR [2137-4-2]: Recent mild pulmonary edema has improved, and nearly resolved in the left lung. Greater opacification at the base of both lungs particularly the right is an indication of decreasing aeration either by virtue of atelectasis or Pneumonia. Small right pleural effusion is probably unchanged since [3-31], and noncontributory. Heart size and mediastinal contours are normal. Right subclavian infusion port ends in the right atrium. No pneumothorax. MICRO: C.DIFF: TEST NOT PERFORMED AS STOOL FORMED URINE CULTUREL NO GROWTH BLOOD CULTURES x 2: NO GROWTH TO DATE Brief Hospital Course: HOSPITAL COURSE: Mr. [Known lastname ] is an 81 y/o M with a history of metastatic prostate cancer, recent hospitalization for a UTI and C.diff infection who presented from home with increasing somnolence and improved with empiric broad spectrum antibiotics. Was found to have a pneumonia and possible recurrence of his c diff colitis. Discharged back to rehab in a safe condition. #) Hypotension: The patient's hypotension resolved in the context of fluid resuscitation, antibiotics, and time. He has not had any localizing symptoms other than perhaps some tachypnea and a subjective sense of dyspnea in concert with increasing perihilar consolidation. We initially started him on IV Vancomycin and cefepime for presumed cellulitis because of the eryhtema in his legs but that was later judged to be venous insufficincy. He was noted to have an opacity in his RLL which was read as pneumonia vs atelectasis. However, at time of discharge, given that he had been on room air for his stay on the floor, and had no other sign of recurrent infection, was transitioned to PO levofloxacin and will complete an 8 day course at rehab. He was also noted to have some watery diarrhea on and off and therefore was started on PO vancomycin for a total 14 day course for possible recurrence of his c. diff. He was dc-ed to rehab in a stable condition. #) Metastatic Prostate Cancer: Pt has completed cycle 6 of docetaxel on [2137-3-4] and radiation therapy for a spinal met as well. We increased his home dose of oxycodone prn. Per his oncologist, dr [Last Name (STitle) ], unlikely to get any furhter chemo for his cancer. #) CAD s/p CABG: stable. We held atenolol but restarted it on dc. Aspirin and simvastatin were continued. #) GERD: we continued home omeprazole TRANSITIONAL ISSUES: PT WILL NEED 4 MORE DAYS OF LEVO AND 10 OF PO VANCOMYCIN. HOSPICE OPTION WAS DISCUSSED BY PCP AND MEDICAL TEAM AND THE PT [Name (NI) ] BE AMENABLE TO IT. THIS MUST BE CONTINUED AT REHAB. Medications on Admission: 1. atenolol 50 mg DAILY 2. folic acid 1 mg DAILY 3. furosemide 20 mg DAILY 4. gabapentin 300 mg Q12H 5. nitroglycerin 0.4 mg as needed for chest pain 6. omeprazole 20 mg DAILY 7. oxycodone 5 mg Q6H as needed for pain. 8. prednisone 5 mg DAILY 9. simvastatin 40 mg 0.5 Tablet QHS 10. aspirin 81 mg DAILY 11. ferrous sulfate One Tablet DAILY 12. ondansetron 4 mg every eight hours as needed for nausea. Discharge Medications: 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours. 5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: as directed Sublingual every 3 minutes upto 3 times as needed for chest pain. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO at bedtime. 11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:4 Tablet(s) Refills:0 12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. 14. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) 3075] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for Living Discharge Diagnosis: PRIMARY DIAGNOSES: 1. Pneumonia 2. Recurrent C. Diff Colitis SECONDARY DIAGNOSES: 1. Metastatic Prostate Cancer 2. Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [Known lastname ], It was a pleasure taking care of you at the [Hospital1 18]. You were admitted with confusion and low blood pressures which was likely thought to be due to an infection in your lungs. You improved with antibiotics and are now being discharged with antibiotics to treat your lung infection as well as your belly infection. You were discharged to your nursing home for continued care. MEDICATIONS STARTED: 1. Levofloxacin: please take this for 4 more days (until [2137-4-9]), once a day by mouth in the morning for your pneumonia. 2. Vancomycin: please take for 10 more (until [2137-4-15]) days via mouth four times a day for your diarrheal illness Followup Instructions: Department: ADULT MEDICINE When: WEDNESDAY [2137-5-1] at 10:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8471], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site We are working on a follow up appointment with your primary care provider [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for your hospitalization. You need to be seen within 1 week of discharge. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call the office at [Telephone/Fax (1) 1144]. We are working on a follow up appointment for your hospitalization with in Hematology/Oncology with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. You need to be seen within 1 week of discharge. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call the office at [Telephone/Fax (1) 10784].	[ "0389", "486", "2724", "53081", "4019", "V4581" ]
Admission Date: [2107-3-10] Discharge Date: [2107-3-12] Date of Birth: [2055-2-22] Sex: M Service: OTOLARYNGOLOGY Allergies: Hayfever Attending:[Known firstname 12657] Chief Complaint: L acoustic neuroma Major Surgical or Invasive Procedure: Transcochlear translabyrinthine resection of left acoustic neuroma with facial nerve monitoring and abdominal fat obliteration. History of Present Illness: 51-year-old man with no significant past medical history who complains of sensation of dizziness, lightheadedness for the past five months. The patient denies any vertigo. He says the lightheadedness comes on and off most of the days. He sometimes has to grab on things because he feels as if he is going to pass out. He denies any sweating or tachycardia before this event. He has no headaches. Those events last for about one to two minutes and resolve spontaneously. They are not worse when he stands up and he does not relate any triggers. Past Medical History: L hearing loss, dizziness Social History: The patient is married. He has three children. He has his own business. He quit smoking 25 years ago (he smoked for 10 years). He drinks four to five glasses of wine per week and several cups of coffee per day. Family History: His family is very healthy. No neurologic condition in the family Physical Exam: AVSS NAD L ear dressing C/D/I CTAB RRR Abd: soft NT ND, incision C/D/I Ext: WWP Neuro: CN II-XII grossly intact with exception of L CN VIII AAOx3 Pertinent Results: MR [2107-1-6]: There is an enhancing soft tissue lesion involving the left internal auditory canal, measuring 1.3 cm in long axis and 0.3 cm in short axis. The lesion extends from the cochlear aperture to the porus acousticus, and is consistent with a vestibular schwannoma. There is no evidence of an abnormal enhancing mass on the study from [2098], and this finding is new since that time. Additionally, there is evidence of enhancement within the cochlea itself. The right internal auditory canal is patent, without evidence of an abnormal soft tissue mass. The visualized brain demonstrates normal signal intensity and appearance. The ventricles, sulci and cisterns are age appropriate. No additional area of abnormal enhancement is identified. There is no mass effect or midline shift. There is no extra-axial fluid collection. There is no decreased diffusion to indicate an acute infarct. The flow voids of the major vessels are present. The visualized paranasal sinuses and left mastoid air cells are clear. There is some small amount of fluid in the right mastoid air cells. The orbits and soft tissues are intact. [2107-3-11] 02:18AM BLOOD WBC-10.3# RBC-3.91* Hgb-12.1* Hct-36.2* MCV-93 MCH-31.1 MCHC-33.5 RDW-12.7 Plt Ct-273 [2107-3-11] 02:18AM BLOOD Glucose-130* UreaN-11 Creat-0.9 Na-139 K-4.1 Cl-104 HCO3-29 AnGap-10 Brief Hospital Course: 52M admitted for L acoustic neuroma, POD 2 s/p translabyrinthine, transcochlear resection. Admitted to TSICU for q1h neuro checks. Never developed any facial nerve or other neurologic deficits. His diet was advanced as tolerated to regular which was well-tolerated. Pt. complaining of some dizziness post-operatively, which has improved. He is ambulating without assistance. At time of discharge pain well controlled with oral pain medications, pt. not experiencing major dizziness, patient ambulating without difficulty, pt. voiding without difficulty. Medications on Admission: Viagra prn, Claritin prn, ASA 81 Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: left acoustic neuroma Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Leave left ear dressing in place until your follow-up appointment. [Name8 (MD) ] MD [First Name (Titles) ] [Last Name (Titles) ] greater than 101.5, increased pain not controlled with pain medication, new-onset dizziness, increased redness or drainage from abdominal wound, bleeding or saturated ear dressing, new onset facial weakness, trouble with speech or swallowing. Cover abdominal wound with dry gauze as nescessary. You may shower. Keep head dry. Pat dry abdominal wound after showing. Followup Instructions: Call Dr.[Name (NI) 37129] office for follow-up appointment [Telephone/Fax (1) 29891].	[ "V1582" ]
Admission Date: [2148-9-14] Discharge Date: [2148-9-26] Date of Birth: [2092-10-28] Sex: M Service: MEDICINE Allergies: Acyclovir Attending:[First Name3 (LF) 465] Chief Complaint: . Fevers, Line infection . Major Surgical or Invasive Procedure: . Exchange of tunneled femoral HD catheter in IR placement of midline . History of Present Illness: . Mr. [Known lastname ] is a 55 year old man with a history of ESRD on HD, DMII, HCV who presented to [Hospital1 18] from home complaining of "not feeling right". He reported that a few days prior to admission he felt unwell. He had nausea and one episode of vomiting. He mentioned some of his symptoms at [Hospital1 2286] but it is not clear if anything such as blood cultures were done at that time. He continued to feel poorly so on the morning of admission he was sent in from HD to the ED for evaluation. He also noted that he began feeling lower back pain which was new. +fevers/chills. Pt also denied SOB. . In the ED his temp was noted to be 101.4, with SBP's in the 70's. Peripheral dopamine was started as the patient refused a CVL. 3L NS was administered. . Past Medical History: . 1. Type 2 diabetes times 16 years. 2. End stage renal disease secondary to diabetes, currently on hemodialysis. L femoral tunnelled catheter. 3. Hepatitis C. 4. History of deep venous thrombosis and superior vena cava thrombosis 5. Hypertension. 6. Congestive heart failure with ejection fraction of 40 percent in [2145-8-27]. In [5-30], LVEF 55%, impaired relaxation, [1-29]+ MR. 7. History of zoster. 8. Aortic calcifications. 9. Elevated homocysteine. . Social History: . Quit IVDU (heroin) 11 years ago. Tob: 10-20cigs/day x 40years. No current EtOH use. Lives alone, at home in [Location (un) 686]. Not employed. . Family History: pt refused to relay history Physical Exam: . VS: Tm 101.4 Tc 96 BP 102/63 HR 76 RR 25 Sat (100% on 2L in ED) Gen: Man in no apparent distress, somewhat uncooperative HEENT: OP clear, MM, PERRL, sclerae anicteric Neck: Scars from R IJ tunneled cath, CV: nl s1/s2, no m/r/g Pul: Crackles in bilateral lower lung fields Abd: Soft, NT, ND, +BS Back: No midline tenderness Ext: L femore tunneled cath, no purulence or tenderness Neuro: A&Ox3 . Pertinent Results: . [2148-9-14] 06:40PM CORTISOL-26.3* [2148-9-14] 05:54PM GLUCOSE-117* UREA N-15 CREAT-4.7* SODIUM-138 POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-22 ANION GAP-18 [2148-9-14] 05:54PM LD(LDH)-175 [2148-9-14] 05:54PM CALCIUM-8.5 PHOSPHATE-2.6* MAGNESIUM-1.2* [2148-9-14] 05:54PM CORTISOL-24.1* [2148-9-14] 05:54PM WBC-15.9# RBC-4.20 HGB-12.4* HCT-37.0* MCV-88 MCH-29.6 MCHC-33.7 RDW-15.5 [2148-9-14] 05:54PM PLT SMR-LOW PLT COUNT-84* [2148-9-14] 01:00PM PT-33.3* PTT-150* INR(PT)-3.6* [2148-9-14] 10:47AM LACTATE-3.3* [2148-9-26] Vanco 15.1 [2148-9-14] blood cx STAPHYLOCOCCUS, COAGULASE NEGATIVE . [9-22] CXR: FINDINGS: Comparison is made to previous study from [2148-9-17]. There is a catheter projecting over the mid abdomen likely into the IVC. Clinical correlation is recommended. There is a very large right-sided pleural effusion, which is partially loculated along the right lateral chest wall, which is unchanged from the prior study. The right side down decubitus view demonstrates some layering of the fluid; however, a LEFT side down decubitus view would be best for evaluation of the pleural fluid. The left lung field is clear. There are no signs for overt pulmonary edema. There is cardiomegaly. Overall, the findings are stable. . [9-22] AXR: FINDINGS: Catheter is seen projecting over the mid abdomen in the IVC/right atrium, likely [Month/Year (2) 2286] catheter. There is a large right pleural effusion. There is no free air under the diaphragm. Intraluminal jejunal contrast from previous study is noted. Note is made vascular calcifications. No dilated bowel loops are identified. Stool and air is present within the colon. IMPRESSION: 1) No obstruction. 2) Large right pleural effusion. . ECHO, [2148-9-18]: LVEF 50-55%. The left atrium is mildly dilated. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [2148-8-21], mitral regurgitation is now more prominent and estimated pulmonary artery systolic pressure is now higher. As noted in the prior report would consider diagnosis of amyloid versus hypertensive heart disease. No vegetation identified but cannot exclude. . Tunneled Catheter Placement, [2148-9-17]: Status post successful placement of tunneled hemodialysis catheter via the left transfemoral approach. Extensive venous disease in the infrarenal inferior vena cava, left common iliac and left external iliac veins. There is no apparent venous inflow from the right iliac system. This will likely preclude any further de [Last Name (un) 11083] placement of transfemoral approach lines or catheters. This patient may be served with placement of a stent within the narrowed segment of the infrarenal inferior vena cava and or left common and external iliac veins. Status post venous angioplasty in the infrarenal abdominal aorta and left external iliac artery. Removed catheter tip sent for microbiology. . Chest xray, [2148-9-17]: Right-sided pleural thickening and subpleural atelectasis are chronic since at least [2147-12-28]. Since [9-14], a large right pleural effusion has reaccumulated. Atelectasis at the base of the left lung is unchanged. There is no interstitial pulmonary edema. Heart size top normal. . EKG, [2148-9-14]: Sinus rhythm; Indeterminate axis; Intraventricular conduction delay; Possible anterior infarct - age undetermined; Generalized low QRS voltages; Since previous tracing of [2148-1-16], no significant change . MRI Spine, [2148-9-14]: Limited study secondary to motion. No evidence of discitis or osteomyelitis on this non-enhanced study. Question of elongation of intra-articular region at L5 level could be to spondylolysis. . EGD: Esophagus: Mucosa: Esophagitis with ulceration and no bleeding was seen in the lower third of the esophagus . Protruding Lesions A single nodule with some supoerficial erosion was seen in the gastroesophageal junction. Not biopsied because of elevated INR. Other Whitish exudate was seen in the esophagus Stomach: Other Small thickened fold was seen with some erythema in the body of the stomach Duodenum: Other A small thickened fold vs nodule was seen in the duodenal bulb. Impression: Esophagitis in the lower third of the esophagus Nodule in the gastroesophageal junction A small thickened fold vs nodule was seen in the duodenal bulb. Small thickened fold was seen with some erythema in the body of the stomach Whitish exudate was seen in the esophagus Otherwise normal EGD to second part of the duodenum Recommendations: PPI Repeat EGD with biopsy of the esophageal nodule when INR is lower Follow Hct Brief Hospital Course: . This is a 55 year old man with a history of ESRD on HD, DMII, HCV admitted to the MICU after tunneled fem line infection and hypotension requiring pressors in the unit. Blood cxs revealed [4-30] Coag Neg Staph with antibiotics were narrowed to Vancomycin QHD. . Brief MICU Course: the patient was started on broad spectrum IV antibiotics, Vanc and Gent for presumed HD femoral line infection. The patient had a low blood pressure at baseline, however dopamine was required for hypotension (80s/60s). A Cortisol stim test was performed to evaluate for adrenal insufficiency and the patient did not respond appropriately. A five day course of Hydrocortisone TID was started for adrenal insufficiency. The patient's Coumadin was supratherapeutic upon admission and was held given the need for changing HD catheter. Dopamine was weaned off. Gent was stopped when [4-30] blood cxs grew Coag neg Staph. Vancomycin was continued. Mr. [Known lastname ] will be maintained on a 4 wk course from the day the infected [Known lastname 2286] catheter was pulled ([2148-9-17]). The cathether was pulled and exchanged on [9-17]. He was given 4 unit FFP prior to the procedure to reverse his INR. He was transferred to the general medicine [Hospital1 ] after his hypotension resolved and his pressors were weaned. . 1. Sepsis/Line Infection: The most likely source for his sepsis was the HD cath (prior to this admission, last changed 1 yr ago). Blood cultures from [Date range (1) 79555] have been negative. No further cultures were drawn. The patient was treated with vancomycin 1g during HD dosed if the vanco level was <15. The patient will remain on the Vanco for a 4 week course. This was communicated to the patient's outpatient hemodialysis center as they would be dosing his vancomycin as an outpatient. . 2. Vomiting/esophageal nodule/ulceration: Towards the end of his hospitalization, the patient had nausea and vomiting intermittently. He often experienced this at home. He also complained of burning in his epigastrium. His protonix was changed to [Hospital1 ] with some improvement in his symptoms. Reglan was changed to QID with meals and before bedtime. A KUB showed no abdominal pathology. The patient remained afebrile. Amylase was elevated but his lipase was WNL. The DDx included diabetic gastroparesis vs. PUD vs mesenteric ischemia. Given the absence of abdominal pain and a neg FOBT, mesenteric ischemia was low on the differential. The epigastric burning and tenderness made PUD a possible cause. As the patient's Hct had dropped from 35 to 29, an EGD was scheduled to R/O PUD. The patient had a previous EGD which showed Barrets esophagus. The current EGD showed esophagitis and a nodule in the GE junction. The plan was to biopsy the nodule when the INR was lowered. GI recommended that this be done within six weeks. The patient was advised to have the biopsy done this admission and the risks of delaying the procedure were explained to him. Because he had had an extensive hospitalization, he declined and preferred to be readmitted for reversal of his INR in about 4 weeks. An appointment for re-admission for the procedure was made for [10-28]. As the patient had no vomiting in > 72 hrs and was tolerating PO, it was thought that he was ready for discharge. A gastric emptying study should be scheduled as an outpatient. . 3. Worsening effusion/consolidation on chest xray: The patient has had a persistent R sided effusion for years which has been tapped multiple times, showing transudative fluid. In [2145] a pulmonary consult was obtained which recommended no further taps and no pleurodesis. They recommended managing his effusions with volume removal via [Year (4 digits) 2286]. The most recent CXR showed a worsened loculated effusion. He had last been tapped in [12-31]. The fluid was both loculated and transudative. As the patient was felt to be only minimally symptomatic with occasional SOB, it was decided that tapping the fluid would be of minimal utility and was not done. . 4. Amyloidosis on echo: Cardiology was consulted and no biopsy was recommended. Per the patient's nephrologist (and PCP) this issue will being worked up as an outpatient with outpatient MRI. This is likely a result of his CKD. . 5. Endocrine: a) DM II: The patient had his BS tested qid. The patient was continued on his home RISS. The patient was not on any long acting insulin at home. The sliding scale was adjusted down secondary to episodes of hypoglycemia and decreased PO intake from vomiting. . 6. Possible Adrenal insufficiency: As the patient did not respond appropriately to the [Last Name (un) 104] stim test, he was started on hydrocortisone TID x 5 days. The patient's blood pressure remained stable in the 90's upon cessation of the hydrocortisone. . 7. h/o DVT: The patient is on Coumadin for DVT. He had a subtherapeutic INR secondary to holding coumadin for replacement of the femoral line. He was restarted on coumadin 4 mg Qhs as this was his home dose and was bridged with a heparin gtt. The patient again became supratherapuetic on 4mg Qhs. Upon discharge, the patient was advised to hold his coumadin for two nights and then have his INR checked at [Last Name (un) 2286] on the third day. The patient's outpatient [Last Name (un) 2286] center was informed of the need for his nephrologist to redose his coumadin based on his INR at his next [Last Name (un) 2286] appointment. They were also informed that they were to dose his vancomycin 1g with [Last Name (un) 2286] if the vanco level was < 15. . 8. FEN: Patient was maintained on a renal diet. His phosphate binders were held while his phosphate was low. . 9. PPX: heparin/Coumadin, continue PPI. . Code: Full . Access: He has a femoral line that has been replaced. Due to very poor peripheral access, a midline was placed for his EGD and peripheral access. This was left in at discharge inadvertently, but was noted by the hemodialysis staff several days later. His PCP [Last Name (NamePattern4) ]. [First Name (STitle) 805] was informed that the intention was to remove this access while he is an outpatient. Peripheral access will need to be readdressed on readmission for EGD. . . Medications on Admission: . Vitamin B1 100mg po qd Protonix 20mg po qd Insulin Reg 5u PRN Forsenol 1000mg po tid Tums 1gm TID w/ meals Sensipar 30mg po qd Fluoxetine 10mg 4x/wk on non-HD days . Discharge Medications: 1. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO 4X/WEEK ([Doctor First Name ],MO,WE,FR): Give on non-HD days. 2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous QHD for 9 days: Please check vancomycin trough and give dose at hemodialysis if trough < 15. Started on [2148-9-17] and needs 4 weeks of treatment (complete [2148-10-15]). 4. Tums 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO three times a day: Take three times per day with meals. 5. Vitamin B-1 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. Insulin Please resume your outpatient insulin regimen, Regular Insulin 5 units PRN hyperglycemia (high blood sugar). 7. Forsenol Please continue your outpatient regimen of Forsenol (phosphate binder). Forsenol 1000 mg PO TID. 8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). Disp:60 Tablet(s) Refills:2 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 10. coumadin Please do not take coumadin on thursday and friday evening [9-26] and [9-27]. Your nephrologist will tell you how much coumadin to take on saturday during [Month/Day (4) 2286] Discharge Disposition: Home Discharge Diagnosis: . Line sepsis, femoral catheter exchange . Discharge Condition: . Good . Discharge Instructions: . 1- Please attend all follow-up appointments as listed below. . 2- Please take all medications as prescribed. . 3- Please call your doctor if you experience fevers, chills, nausea or vomiting. Also please call your doctor if you experience bleeding, redness, warmth at the site of your new femoral line or back pain. . Please do not take your coumadin thursday or friday evening. Your INR will be sent to Dr. [First Name (STitle) 805] by the [First Name (STitle) 2286] staff on saturday and he will re-dose your coumadin. . You will need to return to the hospital for a biopsy of the esophagus. You will be notified when the scheduled appointment is. Followup Instructions: . You will restart your outpatient [First Name (STitle) 2286] treatments on Saturday per your usual routine. They are expecting you on Saturday at your usual time. You will be seen by one of your renal doctors at [Name5 (PTitle) 2286] and [Name5 (PTitle) ] have your INR checked at that time and your coumadin dosed. . Please follow up with your PCP [Name9 (PRE) ],[First Name3 (LF) 251] [Name Initial (PRE) ]. [Telephone/Fax (1) 3637]. . [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] Completed by:[2148-10-1]	[ "4280", "40391", "4240", "V5861", "V5867" ]
Admission Date: [2105-12-1] Discharge Date: [2105-12-11] Date of Birth: [2042-7-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Fevers Major Surgical or Invasive Procedure: PICC line placed Left subclavian triple lumen catheter and right arterial line On transfer from OSH, patient had right chest tube in place History of Present Illness: 63 yo M with HTN, hyperlipidemia, and newly diagnosed multiple myeloma, presents on transfer from [Hospital6 ] with persistent fevers. Patient was admitted to OSH on [2105-11-22] with chief complaint of SOB and right knee pain. On further evaluation patient was found to have a complicated right empyema and right knee septic arthritis growing a pansensitive strep pneumo. Antibiotic treament was intiated with ceftriaxone and a right chest tube ([11-23]) was placed by thoracic surgery and right knee was washed out with polyethylene liner exchange ([11-24]). In addition, patient was found to have cecal dilation on [11-28] and illeus, NG tube was placed to continuous suction, and the patient was started on erythromycin. The patient was persistently febrile since admission and his central line was exchanged on [11-30], sputum recultured with MRSA, and patient started on vancomycin. Patient was transferred to [Hospital1 18] on [12-1] at the request of his family for further evaluation for his persistent fevers. Past Medical History: HTN Hyperlipidemia Multiple Myeloma right TKR Social History: Divorced, with 2 children. No smoking, occasional alcohol, no drug use. Lives in [Location 32775]. Family History: non-contributory Physical Exam: VS: Temp:101.4 BP: 120/67 HR:88 RR:12 O2sat 99% on FiO2 50% Vent: AC 550/12/5/50% GEN: intubated and sedated HEENT: PERRL, pupils pinpoint, anicteric, MMD, op without lesions NECK: supple, no supraclavicular or cervical lymphadenopathy, no carotid bruits, no thyromegaly or thyroid nodules, could not assess JVP 2/2 body habitus RESP: Decreased BS L>R, with scattered inspiratory crackles CV: HS distant, RR, S1 and S2 wnl, no M/R/G appreciated ABD: distended, no BS appreciated, soft, nt, no masses, unable to assess for hepatosplenomegaly EXT: no c/c/e, warm, good pulses, hands b/l with mottled color SKIN: no rashes/no jaundice NEURO: limited [1-30] sedation, face symmetrical, no withdrawal to pain MSK: Right knee - incision c/d/i, no joint erythema, swelling or effusions Pertinent Results: [2105-12-1] 07:45PM BLOOD WBC-9.9 RBC-2.91* Hgb-9.3* Hct-28.9* MCV-99* MCH-32.1* MCHC-32.4 RDW-14.8 Plt Ct-319 Neuts-84.6* Lymphs-10.9* Monos-2.9 Eos-1.3 Baso-0.2 PT-14.9* PTT-37.2* INR(PT)-1.3* Glucose-127* UreaN-22* Creat-1.0 Na-140 K-4.2 Cl-113* HCO3-23 AnGap-8 ALT-22 AST-38 AlkPhos-59 TotBili-0.5 Lipase-142* Calcium-7.2* Phos-3.5 Mg-2.6 TotProt-9.2* Albumin-1.7* Globuln-7.5* Calcium-7.6* Phos-4.3 Mg-2.6 Iron-14* calTIBC-107* VitB12-1272* Folate-17.3 Ferritn-GREATER TH TRF-82* Triglyc-226* [2105-12-6] TSH-2.2 [2105-12-2] CRP-GREATER TH [2105-12-2] PEP-ABNORMAL B IgG-6435* IgA-92 IgM-25* IFE-MONOCLONAL [2105-12-4] Vanco-12.2 [2105-12-7] Vanco-24.9* [2105-12-1] Lactate-1.1 [2105-12-1] Type-ART Temp-37.8 pO2-102 pCO2-34* pH-7.46* calTCO2-25 Base XS-0 Intubat-INTUBATED [2105-12-2] ESR-125* KNEE (2 VIEWS) RIGHT PORT [2105-12-2] 5:30 PM Frontal and lateral projections of right knee, with no comparison on PACS, show total right knee replacement prosthesis in near anatomic alignment, and no hardware complications. The suprapatellar effusion is moderate. Osteophytes are present in the patella. Calcifications within the distal quadriceps tendon. Multiple surgical clips are present. IMPRESSION: Right total knee replacement with no complications. [2105-12-2] CT SINUS FINDINGS: No prior studies of the head are available for comparison. There is an endotracheal tube in place as well as an orogastric tube. There is minimal mucosal thickening of the right frontoethmoidal recess. There is moderate mucosal thickening of the left sphenoid air cell and minimal mucosal thickening of the right sphenoid air cell. Minimal mucosal thickening with small polypoid lesions is seen within the maxillary sinuses bilaterally. The right OMU is widely patent. The left OMU is somewhat narrowed but still patent. There is bilateral [Doctor Last Name 13856] bullosa. Nasal septum is deviated to the right with a right-sided nasal septal spur. The cribriform plates are essentially symmetric. There are no areas of bony destruction. The visualized mastoid air cells are clear. No suspicious bony abnormalities are seen. The visualized orbits are normal. The visualized intracranial structures are grossly normal. Fluid is seen within the nasopharynx. IMPRESSION: Mucosal changes of the paranasal sinuses as described above in the setting of orogastric and endotracheal tubes. No areas of bony destruction. [2105-12-2] CT CHEST WITH CONTRAST [2105-12-2]: IMPRESSION: 1) Circumferential complex right pleural disease likely due to organizing phase of empyema. No large loculated collections. 2) Bibasilar consolidation likely due to provided history of pneumonia. High attenuation focus within left basilar consolidation may be due to aspirated barium if the patient has received oral contrast at the outside hospital. 3) Small left pleural effusion and trace ascites. 4) Slight overdistention of endotracheal tube cuff. 5) Distended loops of bowel within the imaged portion of the upper abdomen on scout image incompletely evaluated. Consider dedicated abdominal radiograph if warranted clinically. 6) Incompletely imaged distended gallbladder. MRI OF THE TOTAL SPINE HISTORY: 63-year-old man with strep pneumonia, septic arthritis, and empyema who is persistently febrile; assess for epidural abscess. MR OF THE CERVICAL SPINE: TECHNIQUE: Sagittal pre-gado T1, post-gado T1 with and without fat sat, T2, STIR; axial T2-weighted images of the cervical spine were obtained as part of the total spine protocol. FINDINGS: No comparisons are available. There is enhancement and T2 hyperintensity of the retropharyngeal/prevertebral soft tissues extending from the skull base to the C3 level which is concerning for cellulitis/phlegmon. No discrete fluid collections are identified concerning for abscesses. There is minimal T2 hyperintensity and enhancement of the right side of the C2 vertebral body but without destructive changes of the adjacent endplates or signal abnormalities of the C2/3 disc. There is possible T1 hyperintensity in this region on the pre-gado images. These findings likely represent a hemangioma. The remainder of the visualized bone marrow signal is normal with no loss of vertebral body heights. At C3/4, there are degenerative changes of the right uncovertebral and facet joints causing mild right foraminal stenosis. At C4/5, there are degenerative changes of the right facet and uncovertebral joints as well as thickening of the ligamentum flavum which is causing moderate right foraminal stenosis. At C5/6, there is a disc osteophyte complex eccentric to the right and thickening of the ligamentum flavum, the combination of which is causing mild canal stenosis but no foraminal stenoses. No paraspinal soft tissue abnormalities are seen. MR OF THE THORACIC SPINE: TECHNIQUE: Sagittal pre-gado T1, post-gado T1 with and without fat sat, T2, STIR; axial T2-weighted images of the thoracic spine were obtained as part of a total spine protocol. FINDINGS: No comparisons are available. The alignment of the thoracic spine is normal. The visualized bone marrow signal is normal with no loss of vertebral body heights or intervertebral disc space heights. Spinal canal is widely patent. At T2/3, T5/6, T6/7, T8/9, and T9/10, there are small disc protrusions which are not contacting the ventral cord. Partially imaged is an azygos lobe of the right lung. There are also loculated fluid collections within the right pleural space and consolidation of the right lower lobe with apparent bronchiectasis. There is a right-sided chest tube in place. [2105-12-2] MR OF THE LUMBAR SPINE: IMPRESSION: 1. Edema and enhancement of the retropharyngeal/prevertebral soft tissues extending from the skull base to the C3 level without discrete fluid collections consistent with cellulitis/phlegmon. No abscesses. 2. No evidence of spondylodiscitis or epidural abscesses. 3. Degenerative changes of the cervical spine causing mild canal stenosis at the C5/6 level. 4. Degenerative changes of the lumbar spine causing mild canal stenosis at the L4/5 level. 5. Loculated fluid collections within the right pleural space with a chest tube in place. There is also consolidation in the right lower lobe with apparent bronchiectasis. [2105-12-2] LENIs IMPRESSION: No evidence of DVT. [2105-12-2] ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes and global systolic function. [2105-12-3] CT HEAD IMPRESSION: No acute intracranial process. Brief Hospital Course: STREPTOCOCCAL EMPYEMA: Patient had chest tube placement and infusion of TPA with successful drainage. SEPTIC PROSTHETIC KNEE: The patient was taken to the OR at [Hospital1 34] for washout polyethylene liner exchange. . MRSA VAP: Secondary to endotracheal intubation, successfully treated. . RETROPHARYNGEAL COLLECTION NOS: The initial imaging studies were concerning for a retropharyngeal collection, but after repeat imaging and ENT consultation this was not felt to be present. . DELIRIUM: Multifactorial including infection and hospitalization, slowly improving with suppotive care and minimizing the use of centrally acting medications. . SVT NOS: The patient had several episodes of SVT, but he remained in sinus for the remainder of the hospitalization. This was likely due to BB withdrawal and acute illness . ANEMIA: Secondary to blood loss from surgery and malignancy (Ferritin > 1000) . MULTIPLE MYELOMA: Diagnosed just prior to admission and he has had no treatment to date. He was treated with IVIG on [12-4], and will be due for a second in early [2105-12-29]. His work-up has been completed at OSH and his treatment will be managed by his primary oncologist: [First Name8 (NamePattern2) ] [Name8 (MD) 4223], MD, [Location (un) ], [Hospital1 ],[Numeric Identifier 10727] [Telephone/Fax (1) 10728]. . ACUTE RENAL FAILURE: Resolved. . DYSPHAGIA: Still on pureed and thin liquids with supervision. This should continue to improve. . HYPERTENSION: Well controlled, HCTZ stopped, Toprol started for SVT and can be titrated up if there is the blood pressure is not well controlled. . HYPERLIPIDEMIA: Stable, continue statin. . DIABETES MELLITUS TYPE II: FSBS well controlled on Lantus and ISS . LINES: Right antecubital PICC line inserted [2105-12-4] . DVT PROPHYLAXIS: Lovenox . DISPOSITION: Being screened for rehabilitation, medically stable to go. Medications on Admission: Home: lisinopril 20mg daily lipitor 20mg daily Prilosec 30mg daily ASA 81 mg daily HCTZ 25mg daily . On Transfer: Albuterol neb Q4H prn Ipratropium neb Q4H prn Morphine 4mg Q30min prn pain Lorazepam 2mg Q1H prn pain Acetaminophen 650mg Q4h prn dilaudid 1mg Q20mins prn Atorvastatin 20mg daily ASA 81 mg dialy Heparin SC TID Combivent 10 puffs Q4hours Insulin SS Metoprolol 2.5mg IV Q6 hours Metoprolol 5mg IV Q6 hours erythromycin 250mg Q8 hours pantoprazole 40mg daily Ceftriazone 2gm Q12 hours Vancomycin 1gm Q12 hours Dexmedethomidine 800mcg Fentanyl gtt TPN Albumin 25% TID Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day). 4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours): LAST DOSE [2105-12-22]. 12. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection [Month (only) ] GIVE 0.5-1.0 MG IV Q 2 HOURS PRN AGITATION (). 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 15. Insulin Glargine and SS Give Lantus 5 units HS and Humalog per sliding scale 16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-30] Sprays Nasal QID (4 times a day) as needed. 17. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 18. Lisinopril WOULD RESTART THIS MEDICATION AT REHABILITATION IF TOLERATED BY BLOOD PRESSURE (was on 20 mg/day Discharge Disposition: Extended Care Facility: [Location (un) ] center Discharge Diagnosis: RIGHT STREPTOCOCCAL PNEUMONIAE EMPYEMA STREPTOCOCCAL PNEUMONIAE SEPTIC PROSTHETIC KNEE INFECTION MRSA VENTILATOR ASSOCIATED PNEUMONIA DELIRIUM NOS SVT NOS ANEMIA - BLOOD LOSS AND MALIGNANCY MULTIPLE MYELOMA ACUTE RENAL FAILURE DYSPHAGIA HYPERTENSION HYPERLIPIDEMIA DIABETES MELLITUS TYPE II Discharge Condition: Stable Followup Instructions: Call for appointment with orthopedic surgeon: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 548] [Last Name (NamePattern1) 439], [Location (un) 86], [Telephone/Fax (1) 75347] Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7443], MD URGENT CARE ID Phone:[Telephone/Fax (1) 457] Date/Time:[2105-12-18] 1:30 Call Dr. [Last Name (STitle) 20090],[First Name3 (LF) 177] S [Telephone/Fax (1) 7164] for a follow-up appointment	[ "5849", "42789", "4019", "2724", "25000" ]
Admission Date: [2190-2-23] Discharge Date: [2190-2-26] Date of Birth: [2108-5-28] Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim / E-Mycin / Flagyl / Pepcid Attending:[First Name3 (LF) 2387] Chief Complaint: Stroke during cardiac catheterization Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Ms. [Known lastname 111600] is an 81 year old female with severe AS who presents after a catheterization. She was getting an outpatient work-up for AS repair with a right and left heart cath. However, the vascular access was difficult in the procedure and she has a residual groin hematoma. Also, directly post-procedure course was complicated by right grip strength decreased and right finger-to-nose decreased. She also had a change in her affect post-procedure. . In the post-cath recovery room, neurology service evaluated the patient and agreed that she had focal neuro deficits. She underwent a CT head which showed concern for aneurysm vs tortuous vessel vs hypodensity in the the right MCA territory. Her symptoms improved. At time of cath a HCT was drawn and was 22. Repeated it remained stable at 22. A CT abdomen was done for concern of RP bleed and the wet read was negative for bleed. . On arrival to the floor, patient was having mild abdominal discomfort, denied CP, SOB, orthopnea, though she continued to be fatigued. . Cardiac review of systems is notable for absence of chest pain, positive for recent dyspnea on exertion, ankle edema, negative for paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: Critical aortic stenosis [Location (un) 109] 0.7cm2, peak/mean 128/58 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: AS -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Hysterectomy [2135] Dyslipidemia GERD Bladder CA s/p surgical removal [2165] Dysphagia Neuropathy Anemia CCY [2137] Hernia [2175] Back surgery [2183] Cataract removal Social History: Lives at home, son lives at home with her. Retired from sewing business. Tobacco: never. ETOH: denies. Drug use: denies. Family History: Mom passed away age 59 from heart problems. [Name (NI) ] passed away age 74 from PNA. Sister passed away age 79 had a history of valve surgery but died from leukemia. Brother passed away age 50 from cancer. Brother alive age 84 had a valve replacement one year ago. Physical Exam: ADMISSION EXAM: VS: T=97.5 BP=117/50 HR=70 RR=13 O2 sat= 96% GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate. General fatigue. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Normal rate, regular rhythm, [1-26] crescendo decrescendo murmur loudest at the upper sternal borders. LUNGS: Scoliosis and kyphosis. Resp were unlabored, no accessory muscle use. CTAB with basilar crackles, no wheezes or rhonchi. ABDOMEN: Soft, NTND. Palpable pelvic kidney in right lower quadrant. No HSM or tenderness. Ileostomy. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Small right groin hematoma at cath site SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. DISCHARGE EXAM: VS: 98.2 113/62 75 96%RA +100cc x24hrs GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: MMM CARDIAC: [1-26] crescendo-decrescendo murmur best at USB with +S2 LUNGS: Scoliosis and kyphosis. Resp were unlabored, no accessory muscle use. CTAB with basilar crackles, no wheezes or rhonchi. ABDOMEN: Soft, NTND. Palpable pelvic kidney in right lower quadrant. No HSM or tenderness. ostomy bag draining clear yellow urine EXTREMITIES: No c/c/e. No femoral bruits. Small right groin hematoma at cath site SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: CN II-XII intact. No dysarthria. Str [3-27] b/l UE. Str with poor effort LE b/l, but equal. Pertinent Results: [2190-2-23] 04:17PM BLOOD WBC-4.5# RBC-3.12# Hgb-6.6# Hct-22.9# MCV-73# MCH-21.1* MCHC-28.7# RDW-17.4 Plt Ct-357 [2190-2-23] 11:00AM BLOOD PT-11.4 INR(PT)-1.1 [2190-2-24] 06:00AM BLOOD Glucose-85 UreaN-18 Creat-0.8 Na-146* K-3.3 Cl-111* HCO3-24 AnGap-14 [2190-2-24] 06:00AM BLOOD Cholest-139 [2190-2-24] 06:00AM BLOOD Triglyc-71 HDL-72 CHOL/HD-1.9 LDLcalc-53 LDLmeas-62 [2190-2-23] 03:18PM BLOOD Type-ART O2 Flow-2 pO2-134* pCO2-38 pH-7.47* calTCO2-28 Base XS-4 Comment-NC 2 LIT [2190-2-25] 07:45AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1 [2190-2-25] 07:45AM BLOOD WBC-9.0 RBC-3.82* Hgb-8.3* Hct-27.9* MCV-73* MCH-21.6* MCHC-29.6* RDW-17.4* Plt Ct-323 [2190-2-25] 07:45AM BLOOD Glucose-90 UreaN-16 Creat-0.6 Na-145 K-4.1 Cl-113* HCO3-24 AnGap-12 [2-23] Cath: HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.47 m2 HEMOGLOBIN: 9.5 gms % FICK PRESSURES RIGHT ATRIUM {a/v/m} 7/4/4 RIGHT VENTRICLE {s/ed} 31/9 PULMONARY ARTERY {s/d/m} 20/11/15 PULMONARY WEDGE {a/v/m} 18/19/14 LEFT VENTRICLE {s/ed} 171/14 AORTA {s/d/m} 120/56/83 CARDIAC OUTPUT HEART RATE {beats/min} 84 RHYTHM SINUS O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 49 CARD. OP/IND FICK {l/mn/m2} 3.8/2.6 RESISTANCES SYSTEMIC VASC. RESISTANCE 1663 PULMONARY VASC. RESISTANCE 21 Total time (Lidocaine to test complete) = 1 hour 8 minutes. Arterial time = 59 minutes. Fluoro time = 18.6 minutes. Effective Equivalent Dose Index (mGy) = 1066 mGy. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 106 ml COMMENTS: 1. Selective coronary angiography in this right-dominant system demonstrated no significant disease. The LMCA had mild disease. The LAD had a 40-50% lesion in its mid portion. The LCx had mild disease. The RAC had mild disease. 2. Resting hemodynamics revealed normal right- and left-sided filling pressures, with an RVEDP of 9 mm Hg and a PCWP of 14 mm Hg. There was no pulmonary arterial hypertension, with a PASP of 20 mm Hg. The cardiac index was preserved at 2.6 L/min/m2. There was a 51 mm Hg gradient across the aortic valve. 3. Critical aortic stenosis, with a calculated valve area of 0.47 cm2. FINAL DIAGNOSIS: 1. No hemodynamically significant coronary artery disease. 2. Critical aortic stenosis. [2-23] CTA Head: 1. CTA demonstrates no gross evidence of infarct or hemorrhage. Note is made that the MRI performed a few hours later demonstrates an acute infarction in the territory of the posterior division of the right MCA which was too early to be seen on this current CT exam. 2. Diffuse atherosclerotic disease without evidence of significant stenosis or occlusion. 3. Heterogeneous thyroid gland. Ultrasound is suggested if clinically warranted. 4. Questionable 2.8 mm infundibilum/aneurysm at the left M1-M2 junction. 5. Possible right upper lobe infiltrate and thickening of the bilateral interlobular septa which may represent pulmonary congestion. Chest CT is suggested if clinically warranted. [2-24] CAROTID U/S A mild amount of heterogeneous plaque was seen in the bilateral internal carotid arteries. On the right side, peak systolic velocities were 73 cm/sec for the proximal internal carotid artery, 87 cm/sec for the mid internal carotid artery and 97 cm/sec for the distal internal carotid artery. Peak systolic velocities in the common carotid artery were 50 cm/sec and 73 cm/sec in the right external carotid artery. The right ICA/CCA ratio was 1.9. On the left side, peak systolic velocities were 55 cm/sec for the proximal ICA, 69 cm/sec for the mid ICA, 58 cm/sec for the distal ICA. A peak systolic velocity of 68 cm/sec was seen in the left CCA and a peak systolic velocity of 53 cm/sec was seen in the left ECA. The left ICA/CCA ratio was 1.0. Both vertebral arteries presented antegrade flow. COMPARISON: Findings are concordant with what was seen in the carotid CTA obtained on [2190-2-23]. IMPRESSION: Less than 40% stenosis of the bilateral internal carotid arteries, in their cervical portion. [2-24] MR HEAD Acute infarct in the posterior division right middle cerebral artery with findings indicative of slow or collateral flow through the right middle cerebral artery sylvian branches. Mild brain atrophy is seen. No midline shift or hydrocephalus. [2-23] CT ABDOMEN 1. No evidence of retroperitoneal or intra-abdominal hemorrhage. 2. Small amount of soft tissue density surrounding the right femoral access site which may represent a small amount of hemorrhage (less than 1 cm). 3. Stable intrahepatic duct dilation from previous CTs. Cause is not identified on this CT. 4. Ileal conduit with bilateral moderate hydronephrosis. 5. Multiple wedge compression fractures of the lumbar spine, stable since [2185]. . Discharge labs: [2190-2-26*] 07:25AM BLOOD WBC-7.4 RBC-4.07 Hgb-9.0* Hct-30.8* MCV-76* MCH-22.2* MCHC-29.3* RDW-17.9* Plt Ct-366 [2190-2-23] 06:15PM BLOOD Neuts-77.8* Lymphs-16.1* Monos-4.5 Eos-1.0 Baso-0.6 [2190-2-26] 07:25AM BLOOD PT-11.8 PTT-29.3 INR(PT)-1.1 [2190-2-26] 07:25AM BLOOD Glucose-95 UreaN-21* Creat-0.8 Na-144 K-4.4 Cl-110* HCO3-25 AnGap-13 [2190-2-26] 07:25AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.2 [2190-2-24] 06:00AM BLOOD Triglyc-71 HDL-72 CHOL/HD-1.9 LDLcalc-53 LDLmeas-62 Brief Hospital Course: 81 year old admitted for evaluation of critical AS, with post cath complication of left hemianopia and left hypesthesia as well as hematoma at cath site. . # Transient Ischemic Attack: Directly post-cath course was complicated by right grip strength decreased and right finger-to-nose decreased. She also had a change in her affect post-procedure. She was brought to the PACU and evaluated by neurology who noted these deficits, with quick improvement. She underwent a CT head which showed possible hypodensity in MCA territory. She was transferred to the CCU where her symptoms were noted to be almost entirely resolved. An MRI of the head was performed showing acute infarct in the posterior division right middle cerebral artery with findings indicative of slow or collateral flow through the right middle cerebral artery sylvian branches. Her blood pressure was maintained greater than 120 for perfusion. No TPA was indicated. Aspirin was continued. No significant carotid stenosis was noted on ultrasound. She was evaluated by PT who recommended rehab and she was discharged. . # Critical AS: Patient found to have a valve area of 0.5 at cath with symptoms of DOE progressing. She is currently being managed as an outpatient. Lasix was held given her euvolemia. . Transitional issues: -Check electrolytes and renal function Monday [3-1] and adjust potassium, lasix as indicated -Physical therapy Medications on Admission: Folic acid 1mg daily Lasix 40mg [Hospital1 ] K-dur 40mg daily Omeprazole 20mg daily Simvastatin 20mg daily Ambien 10mg QHS Iron 650mg daily MVI daily Tylenol PRN ASA 81mg daily Lactulose 15ml PRN Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 7. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 8. multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO once a day. 10. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) ml PO once a day as needed for constipation. 11. Outpatient Lab Work Please check chemistry panel including BUN/Cr on Monday [3-1] Discharge Disposition: Extended Care Facility: [Hospital1 ] Nursing & Therapy Center - [Location 1268] ([Location (un) 86] Center for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Stroke Aortic Stenosis 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: Ms. [Known lastname 111600], You were admitted to the Cardiac ICU because you had a stroke after your cardiac catheterization. This resolved spontaneously and was felt to be related to clots from your cath. . We have made several changes to your medications, which will be relayed to the rehab facility. You should make sure to go over your medications with them carefully at the time of discharge. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] W. Location: [Hospital ] MEDICAL ASSOCIATES Address: [Location (un) ], [Street Address(1) 4323],[Numeric Identifier 4325] Phone: [Telephone/Fax (1) 5457] Appt: [3-4] at 1:30pm Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Doctor Last Name ] BLDG, [Apartment Address(1) 17383] Address: [Last Name (NamePattern1) 8541], [Location (un) ],[Numeric Identifier 8542] Phone: [Telephone/Fax (1) 7960] Appt: [3-10] at 2:30pm Department: NEUROLOGY When: TUESDAY [2190-3-23] at 4:00 PM With: DRS. [Name5 (PTitle) ] & HAUSSEN [Telephone/Fax (1) 1694] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SURGERY When: WEDNESDAY [2190-4-7] at 2:00 PM With: [Name6 (MD) ] [Name8 (MD) 6144], MD [Telephone/Fax (1) 170] Building: LM [Hospital Unit Name ] [Location (un) 551] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "4241", "41401", "2720", "53081" ]
Admission Date: [2130-3-21] Discharge Date: [2130-4-11] Date of Birth: [2092-6-7] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins Attending:[First Name3 (LF) 689] Chief Complaint: liver hematoma, acute anemia Major Surgical or Invasive Procedure: Bronchoscopy x 2 Thoracentesis Mechanical Ventilation Intubation History of Present Illness: Mr. [Known lastname ] is a 37-year-old male with past medical history significant for mental retardation, seizure disorder, prior DVTs/PEs on chronic warfarin, ileus, chronic aspiration with several aspiration realted PNAs in the past who was admitted to [Hospital6 33] from his group home on [3-13] with lethargy and fevers. Per OSH report, patient had clean urine and blood cultures but CXR remarkable for a LLL PNA so he was placed on Levaquin (patient allergic to cephalosporins/PCN) and required intubation for 5 days due to respiratory distress and hypoxia. He was extubated on [3-19] but has required high flow facemask at 70-80% to maintain oxygen saturations above 90%. He was reintubated on [3-21] and had a CT torso that revealed large intraparenchymal and subcapsular liver hematoma that is felt with likely active extravasation of IV contrast. On [3-21] he was also noted to have hct drop from 31-->20. He was subsequently transferred to the surgical ICU on [3-22]. He underwent an hepatic angiogram by IR but was found not to have active bleeding thus not embolized. He has been managed conservately and has been hemodynamically stable. His hospital course has been complicated by presumed VAP and bilateral pleural effusions that have been thought to contribute to his inability to wean from the vent. Of note he has had a bronch on [3-23], BAL with no growth and thoracentesis on [3-27] with 750cc removed. He has been on vancomycin, aztreonam, tobramycin and metronidazole for presumed VAP started on [3-22]. . Review of systems: (+) Per HPI (-) Unable to provide Past Medical History: -mental retardation -seizure disorder -prior DVTs/bilateral PEs (per OSH records, idiopathic and unclear cause, patient does not have an IVC and he is on home Warfarin) -GERD -UTI with sepsis in [2129-4-1] -spastic quadraparesis / cortical blindness -h/o meningitis in childhood -urolithiasis -chronic constipation Social History: Patient lives in group home. Mother and 2 sisters very involved with his care. From the [Hospital3 ] area. No history of any tobacco, ETOH or illicit drug use. Family History: noncontributory Physical Exam: General: pale skin, intubated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles at left base, rhonchi anteriorly, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender to palpation , non-distended, bowel sounds present GU: foley in place Ext: cool, well perfused, 2+ pulses, no clubbing, cyanosis or edema On discharge, afebrile, breathing comfortably with good saturations on room air, abdomen soft, non-distended, non-tender Pertinent Results: Admission labs [2130-3-21]: WBC-19.7* RBC-3.26* Hgb-10.3* Hct-28.9* MCV-89 MCH-31.7 MCHC-35.6* RDW-16.7* Plt Ct-137* Neuts-93* Bands-1 Lymphs-1* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 PT-16.1* PTT-31.2 INR(PT)-1.4* Glucose-93 UreaN-8 Creat-0.7 Na-150* K-3.2* Cl-110* HCO3-28 AnGap-15 ALT-1057* AST-2387* LD(LDH)-1864* AlkPhos-145* TotBili-3.0* Albumin-3.7 Calcium-8.9 Phos-2.7 Mg-2.0 Type-[Last Name (un) ] pO2-107* pCO2-36 pH-7.46* calTCO2-26 Base XS-1 Comment-GREEN TOP Lactate-1.7 Hypercoagulability workup: [2130-3-31] 02:22PM BLOOD Lupus Anticoag-POS [2130-3-31] 02:22PM BLOOD ProtCAg-26* ProtSFn-51 [2130-3-31] 02:22PM BLOOD ACA IgG-PND ACA IgM-PND [2130-3-21] 08:42PM BLOOD ALPHA-FETOPROTEIN (AFP) AND AFP-L3- low [2130-3-31] 02:22PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND [2130-3-31] 02:22PM BLOOD ANTITHROMBIN ANTIGEN-85% (normal) [2130-3-31] 02:22PM BLOOD FACTOR V LEIDEN-Negative Discharge labs [2130-4-11]: [2130-4-11] 06:35AM BLOOD WBC-15.5* RBC-3.62* Hgb-11.6* Hct-37.7* MCV-104* MCH-32.1* MCHC-30.8* RDW-21.1* Plt Ct-428 [2130-4-11] 06:35AM BLOOD Glucose-128 UreaN-12 Creat-0.5 Na-143 K-3.7 Cl-110 HCO3-21 [2130-4-11] 06:35AM BLOOD Calcium-8.5 Phos-1.7 Mg-2.0 Microbiology: [3-21] MRSA screen negative [3-21] Blood cultures negative [3-21] Urine culture negative [3-22] VRE swab negative [3-22] Sputum culture GRAM STAIN (Final [2130-3-22]): [9-25] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. RESPIRATORY CULTURE (Final [2130-3-24]): SPARSE GROWTH Commensal Respiratory Flora. [3-23] C diff negative [3-27] Thoracentesis GRAM STAIN (Final [2130-3-27]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2130-3-30]): NO GROWTH. ANAEROBIC CULTURE (Final [2130-4-2]): NO GROWTH. [3-28] Bronchial washings: GRAM STAIN (Final [2130-3-28]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2130-3-30]): Commensal Respiratory Flora Absent. YEAST. 10,000-100,000 ORGANISMS/ML.. [3-29] Blood cultures negative [3-31] Monospot negative [3-31] CMV IgG ANTIBODY (Final [2130-3-31]): EQUIVOCAL FOR CMV IgG ANTIBODY BY EIA. 4 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [2130-3-31]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. Greatly elevated serum protein with IgG levels >[2119] mg/dl may cause interference with CMV IgM results. CMV viral load non-detectable [4-1] Blood cultures negative [4-2] BAL GRAM STAIN (Final [2130-4-2]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2130-4-4]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. [4-2] Urine culture: yeast [4-3] Blood culture negative Imaging: [3-21] EKG: Sinus tachycardia. Early precordial QRS transition. Modest ST-T wave changes with what may be borderline short QTc interval. Findings are non-specific. No previous tracing available for comparison. [3-21] CXR: The tip of the endotracheal tube lies approximately 2.5 cm above the carina. Nasogastric tube extends well into the stomach. Left IJ catheter extends to about the junction of the brachiocephalic vein and superior vena cava. Cardiac silhouette is within normal limits. There is hazy opacification in the right hemithorax, consistent with layering effusion. Some indistinctness of pulmonary vessels could reflect elevated pulmonary venous pressure. Mild bibasilar atelectasis. Right subclavian catheter tip is difficult to see, though it probably lies within the distal SVC. [3-21] Liver/Abdomen angiogram: Selective arteriograms of the proper hepatic artery and two secondary hepatic arterial branches demonstrating marked vasoconstriction and displacement of vessels secondary to a large subcapsular hematoma with no angiographic evidence of active extravasation. Therefore, no embolization was performed. [3-23] CT Abdomen/Pelvis: 1. Large intraparenchymal and subcapsular hematoma within the right lobe of the liver. In the absence of trauma, and a normal appearance to the liver parenchyma on exam one week prior, the etiology of this bleed is uncertain. Multiphasic imaging demonstrates areas of active bleeding in the more inferior aspect of the subcapsular component of the right lobe of the liver as described. The left lobe of the liver appears unremarkable. 2. Small-to-moderate amount of intermediate-density material within the abdomen and pelvis consistent with hemorrhagic fluid. 3. Small bilateral pleural effusions, right greater than left with adjacent compressive atelectasis. 4. Rectal wall thickening and perirectal fat stranding may result from chronic disimpaction. Circumferential fatty thickening in the colonic wall may reflect chronic inflammatory changes. 5. Bilateral hip dysplasia. Abnormal configuration of thoracolumbar vertebral bodies may represent disuse. Osteopenia. [3-22] LENIs: No evidence of DVT in either lower extremity. [3-23] TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. 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. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No diastolic dysfunction, pulmonary hypertension or pathologic valvular disease. [3-27] CTA Torso: 1. No change in the large, previously seen intraparenchymal and subcapsular hepatic hematoma. There is no evidence of active extravasation. An underlying mass within the parenchymal hematoma cannot be excluded. 2. Moderate-sized bilateral pleural effusions with neighboring compressive atelectasis of the right and left lower lobes. An underlying infection within these regions cannot be excluded. 3. No evidence of pulmonary embolism. [3-30] Feeding tube conversion: Successful conversion of a G tube to a GJ tube, 22 French; the tube is ready for use. [3-31] Echo: Positive bubble study. Right-to-left shunt across the interatrial septum is seen at rest during bubble study. [4-2] LENIs: No DVT in bilateral lower extremity. [4-3] CT Abdomen/pelvis: 1. Stable size of large right hepatic intraparenchymal and subcapsular hematomas. 2. Foci of subcutaneous gas anterior to the lateral margin of the left rectus muscle. The findings are of unclear etiology. Differential diagnosis would include iatrogenic causes perhaps related to manipulation of the patient's PEG tube or other procedures and correlation for these recommended. In the absence of these, this finding can be seen in necrotizing fasciitis, although there are not necessarily other CT findings to suggest this diagnosis; however, clinical correlation in this region is recommended. 3. Marked dilation of the rectosigmoid. 4. Stable bilateral pleural effusions and compressive atelectasis. 5. Mild thickening of the distal esophagus. Correlation for esophagitis recommended. [4-6] CTA Chest: 1. No acute central or segmental pulmonary embolism. No acute aortic pathology. 2. Persistent moderate simple pleural effusions with moderate bibasilar atelectases. 3. Grossly unchanged right intraparenchymal and subcapsular hepatic hematomas, incompletely evaluated in the current study. [4-7] CXR: In comparison with the study of [4-5], there is little overall change. Continued bilateral layering effusions with bibasilar atelectasis. Prominence of mediastinal veins most likely represents the supine positioning. Dilatation of the mid portion of the trachea is again seen, reflecting either preexisting tracheomalacia or recent intubation and cough overinflation. Brief Hospital Course: This is a 37 year old male with mental retardation, seizure disorder, h/o PE/DVTs, PNA complicated by hypoxic respiratory failure requiring intubation, and liver hematoma. # Hypoxic respiratory failure: Hypoxic respiratory failure felt to be multifactorial in etiology, including aspiration pna compounded by bilateral pleural effusions, VAP, volume overload and ASD. He had a thoracentesis on the surgical service on [3-27] with 750 cc fluid removal and bronch on [3-23] and mini BAL on [3-28]. All cultures were negative. He was given an empiric course of vancomycin, aztreonam, tobramycin and metronidazole started on the SICU service for an 8 day course for presumed VAP. He was diuresed daily to lasix 1 L net negative and was extubated on [4-4]. An ECHO in work up for shunt revealed ASD and was felt to have been playing a role in his hypoxemia. He also had several CTAs throughout his hospitalization that were negative for PE. At time of discharge, he remained on room air with sats in the mid-upper 90s%. # Fever: Patient was febrile and spiking high grade temps with leukocytosis on broad spectrum antibiotics while in the intensive care unit. Infectious disease was consulted and extensive culture data were negative. His fever was felt to be likely due to his hematoma and possibly drug fever given multiple abx. He self-defervsced and was afebrile for days prior to discharge. He continued to have a leukocytosis without signs of infection. His workup included search for DVT/PE which were negative. If patient develops fever or diarrhea, c diff should be considered given his recent antibiotic exposure but he did not have diarrhea while in the hospital and had a negative c diff earlier in the admission. # Hepatic hematoma: He was found to have a hepatic hematoma on admisson but remained hemodynamically stable. Patient received two units of pRBCs to support his blood count. He was conservatively managed and angiogram did not show any active bleeding requiring embolization. Per discussion with family, no aggressive interventions including drains/hepatectomy were persued. As mentioned, he was hemodynamically stable throughout hospital stay. # History of PE: Anticoagulation with warfarin was held in setting of hematoma. Hypercoaguable work up revealed lupus anticoagulant with all other tests normal except beta2 glycoprotein which is still pending. Discussed possibility for IVC filter but given ASD/hypercoaguable state, this was not felt to be a good long term solution. He had several CTAs negative for PE. He was discharged on twice daily heparin subq shots and should not restart warfarin anticoagulation for at least two weeks. He has a follow-up appointment with his PCP scheduled to discuss this hospitalization and determine anticoagulation goals. # Anemia: Patient was anemic throughout his hospital stay. This was likely due to blood loss from his hepatic hematoma and poor nutrition evidenced by low prealbumin on admission. His MCV was elevated after switching from depakote to valproic acid syrup as below. Folate and B12 levels were pending at time of discharge. # Seizure disorder: He was continued on phenobarbitol and depakote initially but whole depakote pills were found in his stools prompting concern about absorption. He was changed to valproic acid syrup and had a therapeutic level prior to discharge. He was continued on phenobarbitol. Patient has an appointment to establish care with an epilepsy specialist at [Hospital1 18] later this month. # FEN: Due to chronic aspiration, his chronic G-tube was converted to GJ tube on [3-30]. He was seen by nutrition for tube feeding recommendations to maximize his nutritional status. DNR/DNI per discussion with HCP, mother. Medications on Admission: -PO warfarin / per INR level -Depakote ( 625mg qam, 500mg daily at 2pm, 875mg qpm) -Phenobarbitol 90mg qdaily -Omeprazole 20mg qdaily -Colace 100mg [Hospital1 ] -Miralax qdaily -Milk of magnesia -tap water enema -atenolol 12.5mg daily -baclofen 10mg TID Discharge Medications: 1. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) milliliter Injection [Hospital1 ] (2 times a day): Inject 1 mL sub-cutaneous twice daily. Disp:5 10 mL vials Refills:2 3. Phenobarbital 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup Sig: Ten (10) milliliters PO qAM (morning). Disp:2 bottles Refills:2 5. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup Sig: Ten (10) milliliters PO qPM (evening). 6. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup Sig: Fifteen (15) milliliters PO qHS (bedtime). 7. Baclofen 10 mg Tablet Sig: One (1) Tablet PO three times a day. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Bowel regimen Please continue previous bowel regimen with milk of magnesia, daily tap water enemas and daily miralax. 10. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) milliliters PO BID (2 times a day). 11. Syringe with Needle (Disp) 1 mL 25 X 1 Syringe Sig: One (1) syringe Miscellaneous twice a day: Please use 1 syringe for each 1mL sub-cutaneous heparin shot. Disp:100 syringes Refills:2 Discharge Disposition: Home with Service Facility: Southeastern residential Services Discharge Diagnosis: Primary: Hepatic hematoma Pneumonia Secondary: Seizure disorder Discharge Condition: Non-verbal, requiring total care Discharge Instructions: You were admitted to the hospital for lethargy and fevers. You were in the intensive care unit for close monitoring. Your hospital course was complicated by severe pnuemonia requiring a breathing tube to support your breathing and you were found to have bleeding in your liver. You improved with antibiotics and were taken off of your warfarin blood thinners to allow your liver bleed to heal. Please follow-up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] and see a neurologist regarding your seizure medications. The following changes were made to your medications: 1. Stopped dekapote as you were not completely digesting it. 2. Started valproic acid syrup to control your seizures. 3. Stopped warfarin as you had a liver bleed. 4. Started heparin shots twice daily to prevent blood clots. Followup Instructions: Please follow-up with your PCP to discuss your anti-coagulation for your prior PE. You have an appointment scheduled on [4-21] at 1pm at Dr.[Initials (NamePattern4) 27811] [Last Name (NamePattern4) ] office. You have an appointment to establish care with a seizure specialist at [Hospital1 18]: Department: NEUROLOGY When: MONDAY [2130-4-24] at 8:30 AM With: DR. [First Name (STitle) ] & DR. [First Name (STitle) ] [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "51881", "5070", "53081" ]
Admission Date: [2120-2-19] Discharge Date: [2120-2-28] Date of Birth: [2082-6-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4765] Chief Complaint: DOE, chest pressure Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 35 year-old man who has a h/o palpitations/SVT for over 10 years s/p ablation of two left sided accessory pathways in [2117-9-20] who now presents with SVT with chest pressure and SOB. . Per Dr.[Name (NI) 1565] last OMR note in [4-19], "these were documented to be a long RP tachycardia, which turned out to be in a left-sided accessory pathway. (From [2117-1-6] to [2117-1-28] the pt underwent a Pt Activated [Name (NI) 99007] Recorder that made note of episodes of Afib that occurred right after runs of rapid SVT with brief conversion to sinus. Prominent ST depressions were noted during these episodes also. The majority of the episodes were a long RP tachycardia that occasionally degenerated into atrial fibrillation.) He underwent a mapping and ablation of his pathway in [2117-9-13], localized to two locations on the left side of the mitral annulus. These were ablated. For the following seven months, he was free of symptoms whatsoever. He then began to develop a recurrence of palpitations, however, these were distinctly different than his supraventricular tachycardia. They were less intense and shorter in duration. In retrospect, he felt a similar feeling after some of his more typical SVT episodes prior to his ablation. Further monitoring ([4-19]) found that he is having runs of paroxysmal atrial fibrillation. He occasionally has a narrow complex tachycardia preceding this, which looks like an atrial tachycardia, perhaps the pulmonary vein etiology. In general, he is doing quite well with these and only has enduring periods of heightened stress. When relaxed, he seems to be very quiescent from any arrhythmia standpoint." . Pt. had been in his usual state of health until last night before admission when he couldn't sleep, feeling subjectively hot and cold. He developed chest pressure when lying on left chest starting roughly around MN. He also notes DOE, feeling winded when climbing one flight of stairs. He took atenolol 50 mg PRN (he takes PRN); however, symptoms persisted until he saw his PCP [Last Name (NamePattern4) ] 6PM, who noted SVT with rate of 170, and sent him to ED. Possible triggers recently include several stressors in his life, URI symptoms (earache), recent etOH on Saturday, 2 cups of coffee daily chronically. . In ED, had unsuccessful cardioversion attempted with ibutilide, successfully converted with 200J without complication. CXR showed mild pulmonary edema. EP consulted and recommended atenolol 50 mg qd and observation. During obs, his HR increased to 150s with oxygen sats in 90-93% on room air. This rhythm was noted to be aflutter. He received propafenone 600 mg X1 and was cardioverted again (200J) to sinus rhythm. His CXR is suggestive of mild pulmonary edema and resting sats 92% on 8L NC. Per EP, he will continue propafenone 150mg q8hours and possible ablation in am. . In CCU, he reports feeling slightly better. he is still c/o mild left chest pressure only when he leans on L side. +mild SOB with talking. No sensation of palpitattions, LHD, dizzyness. he does feel very tired as he has not slept in 48 hrs. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: SVT PAF Right inguinal hernia at age of 1 Social History: Patient is married and works as a sales engineer. Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Family History: Father: hx premature atrial fibrillation Mother: MVP Physical Exam: VS: T 99 , BP 131/95 , HR 104, RR 18, O2 92% on 5LNC Gen: WDWN young male in mild resp distress. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. MM dry. Neck: Supple with JVP at 10 cm (under jaw) CV: tachycardic, regular, normal S1, S2. No S4, no S3. No murmurs Chest: No chest wall deformities, scoliosis or kyphosis. Scarce crackles L>R 1/3 up bilaterally Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; 2+ DP Pertinent Results: TRANSESOPHAGEAL ECHOCARDIOGRAM: 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 or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 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. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. IMPRESSION: No thrombus, masses, or vegetations identified. No PFO/ASD. Mild mitral regurgitation. . . TRANSTHORACIC ECHOCARDIOGRAM The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . . MRI/MRI HEAD AND NECK 1. Acute infarct of the medial right posterior temporal and occipital lobes. Small acute infarct of the right thalamus. 2. Acute thromboembolism of the P2 segment of the right posterior cerebral artery. 3. Normal MRA of the neck. . . CT ANGIOGRAM OF THE CHEST 1. No evidence of pulmonary embolism or pulmonary edema. 2. Bilateral pleural effusions with associated atelectasis. 3. Patchy areas of airspace disease involving both upper lobes suspicious for pneumonia. 4. The tip of the endotracheal tube is seen at the superior edge of the clavicles. Brief Hospital Course: The following issues were dealt with on this admission: . # Rhythm: On the evening of [2-20] the patient went into rapid atrial flutter with a rate in the 150's. He did not respond to a diltiazem drip, so he was started on procainamide following cardioversion, and then propafenone. He continued to have tachyarrhythmias on this regimen, and was started on amiodarone and esmolol drips on [11-25]. He did quite well on this regimen, and converted to sinus rhythm, with intermittent bouts of atrial fibrillation that were not sustained. He was transitioned to a po regimen of amiodarone and metoprolol on [2-25], which he tolerated well. . # Pump: Patient presented with signs and symptoms of pulmonary edema, confirmed on CXR and CT, which was thought to be secondary to a tachycardia-induced cardiomyopathy in the setting of his arrhythmia. An echocardiogram was ordered, and was wnl, and this was followed up with a cardiac MR (read pending on discharge). The edema was severe enough to require a brief period of intubation electively on [2-20]. The patient was extubated without any complications on the morning of [2-22]. . # CVA: Patient was found to have an acute right posterior cerebral infarction on CT head. MRI following showed an acute thromboembolism of the P2 segment of the right posterior cerebral artery, and acute infarction of the medial posterior temporal and occipital lobes, and a small acute infarct of the right thalamus. A TEE was negative for thrombus or ASD/PFO. Neurology was consulted, and recommeded anticoagulation with warfarin, with a heparin bridge to an INR of 2.5, and lipitor. He was discharged with follow up in coumadin clinic. . # PNA: The patient was found to have sputum cultures postive staph aureus, pan-sensitive, and resistant to penicillin. He was initially managed with vancomycin, and was transitioned to po dicloxacillin once his sensitivities confirmed the absence of MRSA. Medications on Admission: Atenolol Discharge Medications: 1. Warfarin 2.5 mg Tablet Sig: As directed by your coumadin clinic at Dr.[Name (NI) 99008] office Tablet PO once a day: Until your follow up with Dr. [Last Name (STitle) ], continue to take 5mg each day, which is two 2.5mg tablets. Disp:60 Tablet(s) Refills:2 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 3. Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 3 days. Disp:12 Capsule(s) Refills:0 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:60 Tablet(s) Refills:2 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation Stroke Discharge Condition: Stable Discharge Instructions: You were admitted because you had an irregular heart rhythm. We controlled this with intravenous medications, and eventually transitioned you to oral medications called metoprolol and amiodarone. We will be discharging you with a monitor for your heart rhythm. This will be followed up by Dr. [Last Name (STitle) 2357]. . You also suffered a stroke during this admission, which required us to thin your blood with an IV medication called heparin. We transitioned you to an oral blood thinner called coumadin. You are also on a cholesterol drug called lipitor for stroke prevention. . You will need to follow up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] to monitor your coumadin. When you are on coumadin, we closely monitor a level in your blood called your INR, which measures how thin your blood is. This will be more frequent initially. Please see below for your follow up information. . You also need to follow up with Dr. [Last Name (STitle) 2357] for management of your abnormal heart rhythm. Please see below for follow up information. . . Please take all of your medications as indicated below. . . If you experience any concerning symptoms, please return to the emergency department. Followup Instructions: 1. Dr.[Name (NI) 99008] office will be in touch regarding follow-up for your coumadin 2. Dr.[Name (NI) 7719] nurse practitioner will contact you regarding follow up for your rhythm.	[ "42731", "42789", "4280", "2724", "V1582" ]
Admission Date: [2174-3-12] Discharge Date: [2174-3-29] Date of Birth: [2132-1-13] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: Pedesatrian vs. Car Major Surgical or Invasive Procedure: L Craniectomy for evacuation of SDH PEG Tube placement History of Present Illness: 42 year old male s/p ped vs vehicle this evening at approimately 2100. intoxicated with alcohol. Struck at approx 30MPH, unknown LOC. Transferred to OSH, reported GCS of 15 upon arrival. Head CT demonstrated reported L 8mm SDH. Transferred via ambulance to [Hospital1 18], and in transport, patient began to decompensate and was difficult to arouse. Upon arrival to [Hospital1 18] he was noted to have a non reactive L pupil and spontaneuos movement of RUE only. Patient intubated. NSurg was stat paged to evaluated. Upon my arrival patient intubated without sedation. No movement of extremities witnessed. Exam as follows: Past Medical History: Alcohol intoxication Hypertension Social History: Unknown Family History: Unknown Physical Exam: PHYSICAL EXAM: O: T: BP: 142/78 HR:70 R: 24 O2Sats:99 Gen: No obvious trauma. intubated HEENT: NC, AT Pupils: R pupil 2 and MR, L pupil blown. EOMs n/a Extrem: Warm and well-perfused. Neuro: Mental status: intubated Cranial Nerves: I: Not tested II: R pupil 2 MR, L pupil fixed and dilated III, IV, VI: N/A V, VII: N/A VIII: N/A IX, X: no gag reflex [Doctor First Name 81]: N/A XII: N/A Motor: No movement of extremities to nox stimuli Toes upgoing bilaterally On discharge: arousable to voice, oriented to self, right side full, PERRL, left facial, left grip [3-19] o/w plegic on left side. withdraws to pain LUE and LLE Pertinent Results: ADMISSION LABS: [2174-3-12] 12:38AM WBC-11.0 RBC-4.78 HGB-15.4 HCT-44.0 MCV-92 MCH-32.2* MCHC-35.0 RDW-12.5 [2174-3-12] 12:38AM PT-11.8 PTT-20.2* INR(PT)-1.0 [2174-3-12] 12:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2174-3-12] 12:38AM GLUCOSE-162* UREA N-7 CREAT-0.6 SODIUM-134 POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-21* ANION GAP-21* IMAGING: CT Head [3-12]: Large left subdural and parafalcine subdural hematoma with approximately 1.7 cm rightward shift of midline structures. Compression of the left lateral ventricle with some dilation of right lateral ventricle could indicate obstruction. Mass effect on the brainstem and partial effacement of the suprasellar cistern. CT Head [3-12]: Status post left craniectomy with evacuation of subdural hemorrhage. Rightward shift of midline structures now measures 5 mm, previously 17 mm. Small amount of hemorrhage along the left convexity remains. Stable parafalcine subdural hemorrhage. No evidence of new hemorrhage. CTA Head [3-12]: Atherosclerotic plaquing and stenosis in bilateral carotid bulb and proximal ICA. No evidence of dissection. MRI Head [3-13]: IMPRESSION: Post-operative changes with stable left extra-axial collection at the craniotomy site. Degree of midline shift to the right is unchanged. Foci of restricted diffusion in the left frontal lobe which could be related to the presence of blood products or may be post-traumatic/ischemic . MRI C/T-Spine [3-13]: Likely chronic compression fractures at T7-T8. No ligamentous injury [3-18] CT Head: IMPRESSION: 1. In comparison to [2174-3-13] MR, there is interval increase in fluid collection at the left craniectomy site, which may represent a pseudomeningocele. 2. Left frontal hypodensities likely evolving contusions not well visualized on prior exams. 3. Stable appearance of subdural hematoma layering along the left side of falx cerebri, without evidence of shift of normally midline structures. [3-18] EEG: This is an abnormal routine EEG due to the presence of a slow background which reached a maximum of 7 Hz. It is also abnormal due to the presence of generalized delta frequency slowing throughout much of the recording. There were no clear epileptiform discharges or electrographic seizures noted. [3-20] R UE duplex: There is complete thrombosis of the left axillary, brachial and basilic veins. The left IJ, subclavian and cephalic veins are patent. [3-21] Head CT: IMPRESSION: 1. No evidence of new abnormalities. 2. Stable fluid collection at the left craniectomy site with evolving blood products, which may represent a pseudomeningocele. 3. Stable left frontal subcortical hypodensities, likely nonhemorrhagic contusions. Decreased left parafalcine subdural hematoma. 4. Small superficial left frontal parafalcine hemorrhagic focus could represent diffuse axonal injury or subarachnoid blood. 5. Stable small right subdural hygroma. Brief Hospital Course: The patient was taken emergently to the operating room for a L craniectomy and evacuation of the SDH. He tolerated the procedure well and transferred to the ICU in critical but stable condition. His post operative Head CT demonstrated good decompression and evacuation. His left pupil was immediately reactive post op, and he remained intubated. He was noted to have a 10 point drop in his sodium from pre to post op. For this, 3% HTS was initiated at 30cc/hour. His sodium was slowly corrected to the normal range. On [3-12], the patient underwent an MRI of his Head and Neck. His head CT was negative for infarct, and the C-Spine was negative for ligamentous injury. He was placed on [Initials (NamePattern4) ] [Last Name (NamePattern4) ] DT prophylaxis, and he was quite tremulous. On [3-13] Neurology was consulted to help with management of his seizure risk and DTs. They recommended the patient be placed on Dilantin and kept at a level near 20. Because he continued to have tremors and withdrawal activity, he was placed on an ativan drip on [3-14]. On [3-15] he was much stronger on his R side than the previous day and spontaneously moving the L side. On [3-16] he continued on the ativan drip and the TSICU began to transition him to valium. He was also febrile to 102.6 and was pancultured. A bronchoscopy was performed as well. On [3-17] His hemoglobin was 7 and he received a unit of PRBC's with good results, his ativan drip was discontinued and he was solely on PO Valium. He remained intubated and the ICU was attempting to extubate him which was unsuccessful as he continued to be somnolent. On [3-18] his exam was slightly improved and a head CT was obtained to assess for interval change which was stable. On [3-19] the patient was neurologically stable but again febrile. He was pancultured again and noted to have gram + cocci in his sputum. Neuro checks were liberalized to Q4hrs. An EEG was obtained to rule out seizures. On [3-20] the patient continued on propofol and clonidine for withdrawal/agitation. Dilantin was discontinued. It was recommended to the ICU that trach/Peg planning was initiated. On [3-21] he was extubated. He continued on tube feeds in hopes that he would be able to take PO. He was started on a heparin gtt for a left upper extremity DVT (basilic, brachial & axillary). A head CT was obtained after the patient was therapeutic and was stable. On [3-22] the patient remained lethargic, but neurologically stable. It was decided to proceed with peg planning. He was cleared for transfer to the step down unit and he continued on a heparin gtt with goal of a PTT of 60-80. On the morning of [3-23] he was at goal for his heparin gtt and continued to await PEG placement. He also followed commands with his RUE He went for his PEG tube placement on [3-24]; his heparin gtt was stopped for this procedure. He tolerated it well, and tube feeds and heparin drip were restarted on [3-25]. He was transferred to the floor. On [3-26] he was started on tubefeeds and per nutrition rec's it was replete with fiber at goal of 90cc/hr. He was started at 30cc/hr and it was increased 30cc q8 to goal. He tolerated this well. On [3-27] he was therapeutic on his heparin gtt and he was started on Coumadin with goal INR 2.0 to 3.0. His clinical exam was improved and he was verbal and interacting well. On [3-28] he passed speech and swallow for thin liquids and regular solids with supervision. On [3-29] he was screened for rehab and accepted a bed at [Hospital 38] rehab. Medications on Admission: Atenolol Discharge Medications: 1. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing, congestion. 13. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 15. warfarin 5 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) for 1 doses. 16. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 17. 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. 18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 19. Metoprolol Tartrate 10 mg IV Q4H:PRN htn sbp over 140 Hold for HR <60 or SBP <100 20. HydrALAzine 20 mg IV Q6H:PRN HTN, SBP over 140 hold for HR over 120 or SBP less than 120 21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 22. HYDROmorphone (Dilaudid) 0.125-0.25 mg IV Q3H:PRN pain 23. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: L SDH Cerebral Edema Encephalopathy Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you are being discharged on Coumadin. Have your INR checked at rehab with goal of 2.0 to 3.0 for your INR ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ] , to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[2174-3-29]	[ "51881", "2761", "4019" ]
Admission Date: [2104-9-8] Discharge Date: [2104-9-28] Date of Birth: Sex: Service: CHIEF COMPLAINT: This is a [Age over 90 ] year old female with a chief complaint of headache since noon time, acute onset during lunch. HISTORY OF PRESENT ILLNESS: This is a [Age over 90 ] year old white female who presented to the emergency room earlier on the evening of admission with a history of having been found down by her laundry at approximately 6:00 p.m. this evening with confusion and question of mental status changes. The family had found her down. Upon EMS transport and arrival at [Hospital1 1444], she was able to relate the story of the relatively acute onset of a headache which developed while having lunch on the day of admission. She complained of persistent headache with mild associated nausea, but no vomiting. She was last seen in early to mid-afternoon and then was found down at 6:00 p.m. CT scan in the emergency room showed a large amount of subarachnoid hemorrhage. PAST MEDICAL HISTORY: CVA in [2094]. History of long standing left bundle branch block. She denied history of seizure disorder. PAST SURGICAL HISTORY: Noncontributory. MEDICATIONS: Included vitamin E, vitamin C, aspirin one per day. ALLERGIES: She had no known allergies. SOCIAL HISTORY: Included the fact that she lived alone. Was an elderly patient in [Hospital3 ] and supportive environment with supportive family. She was a nonsmoker with a negative alcohol history. PHYSICAL EXAMINATION: Vital signs were 95.2, 181/93, 95, 18, 96% saturation. Neuro exam showed her to be awake, alert and oriented times one, she knew her name. She did not recognize the place or the day or date. Head was normocephalic, atraumatic. Neck was supple with full range of motion. No meningismus was present. Left pupil was 2.5 mm and nonreactive post surgical. Right was 1.25 mm and nonreactive post surgical. Extraocular movements intact. Visual fields were full to confrontation grossly. Smile was equal. Tongue was midline. She had dry mucous membranes. Face was symmetric with V1 through 3 intact. Cranial nerves II-XII were also grossly intact. On mental status she was slightly confused, thought she was at [Hospital3 43992] in [Location (un) 3146] and that it was, indeed, [2104-8-21]. She offered a mildly inconsistent history regarding the onset of her symptoms, but she repeated test phrases well and followed all simple one and two step commands. She faltered on three step commands two out of three times. She was moving all extremities throughout a full range of motion. Strength was [5-25] in all major muscle groups of bilateral upper and lower extremities equally. Sensory exam was intact to light touch. Plantar responses were mute bilaterally or mildly downgoing bilaterally. There was no ankle clonus. Deep tendon reflexes were 1+ throughout. Gait and Romberg were not tested. Finger to nose was slow, but without any dysmetric movements. General physical exam including chest, heart, abdomen, extremities and skin was essentially unremarkable. LABORATORY DATA: At the time of admission white count was 16.7, hematocrit 41.4, platelets 287. Chem-7 was within normal limits. Coags were within normal limits. CPK was 123, troponin less than 0.3, CKMB 6. Head CT at that time showed diffuse subarachnoid hemorrhage. A CT angiogram was done at that time urgently and found a large, bilobular, 15 mm tall by 11 mm wide, right, anterior, communicating artery aneurysm with a narrow neck. The above findings were discussed by phone with Dr. [Last Name (STitle) ], the attending neurovascular neurosurgeon. He came to the emergency room and patient was quickly taken to the angiogram suite that evening for possible coil embolization in the next few hours following admission. HOSPITAL COURSE: The patient was, indeed, taken to angiography and underwent angiogram and coiling of the aneurysm. Patient tolerated the procedure well. Initial post-angiogram and post-coiling course was unremarkable. She was noted to be moving all extremities spontaneously. Pupils were 3.5 on the left surgical, right 1.5 trace reactive, but surgical. However, there was no other movement to painful stimulus in the lower extremities. She was, therefore, taken for an urgent noncontrast CT scan which showed good position of the coils. On the following day she was noted to be more awake and moving all extremities. Pupils were unchanged. She was following all commands. At 6:00 p.m. on [9-11] patient was awake and alert in the ICU and an extra-ventricular drain was placed by Dr. [Last Name (STitle) 35957], chief neurosurgery resident, under sterile conditions. Patient tolerated the procedure well. Opening pressure transduced at 19 and the ventricular drain was set at 10 cm above the tragus. On the 23rd she was noted to be moving extremities, but not following commands. Therefore, she was taken to the angiogram suite for urgent diagnostic angiogram to rule out spasm. Angiogram showed a small amount of spasm and papaverine was injected at that time. On the 24th she was noted to be more awake and again moving all extremities and following some simple commands. On the 25th she was awake and attentive to the examiner, was trying to mouth words, moved all extremities purposefully, but did not follow commands. Patient remained stable in this condition. On the 27th she became hypertensive and sedation was increased and patient was subsequently placed back on full ventilatory support. She became nonresponsive at that time and after discussion with the family, patient was changed to DNR status. On the 29th patient remained on ventilatory support, but was noted to be attentive to examiner mildly, grimacing to pain and localizing right arm to pain and withdrawing legs briskly. Patient remained DNR at that time. For the remainder of the patient's postoperative hospitalization, her neurologic examination essentially remained unchanged. After several days of this, the family made a decision to withdraw care due to the gravity of patient's serious neurologic condition. Patient was subsequently changed to comfort measures only on the afternoon of [9-27] and she died peacefully on the morning of [9-28] and was pronounced at 4:07 a.m. on the 8th. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. Dictated By:[Name8 (MD) 22907] MEDQUIST36 D: [2105-1-1] 10:21 T: [2105-1-4] 19:31 JOB#: [Job Number 43993]	[ "9971", "4280" ]
Admission Date: [2164-8-21] Discharge Date: [2164-8-28] Date of Birth: [2083-5-13] Sex: F Service: MEDICINE Allergies: Zocor Attending:[First Name3 (LF) 2782] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy History of Present Illness: The patient is an 81 year old female with CAD, hypertension, DM2, and prior colectomy for diverticular disease who was transferred from [Hospital3 10310] after presenting with weakness and crampy abdominal pain. Patient went to beach on Sunday and starting feeling unwell after returning home with crampy epigastric and RUQ abdominal pain. Nausea with several episodes of vomiting. No diarrhea or blood in stool. She had subjective fever and chills, but did not check her temperature. No dysuria, no increased urinary frequency. No CP/SOB/cough. She stayed at a relative's home and continued to feel unwell, eventually presenting to the OSH ED on Monday. . In the OSH ED, her initial vitals were T 103.1, HR 112, BP 128/58, RR 28, and SpO2 95% on RA. Labs were notable for WBC 9.6 with 14% bands, creatinine 1.0, and Troponin 0.42. UA was positive with many WBCs and bacteria, no squamous epithelial cells. EKG showed ST depressions in V4-V6. RUQ ultrasound at the OSH showed evidence of sludge and [Doctor Last Name 5691] in gallbladder, moderate wall thickening, and pericholecystic fluid. She was given Ceftriaxone 1000 mg and Flagyl 500 mg. She was transferred to [Hospital1 18] for further management. . In the ED, initial vitals were: T 98.7, HR 109, BP 110/54, RR 20, and SpO2 97% on RA. RUQ US was repeated and showed a small 8 mm cystic structure in the body of the pancreas communicating with the duct, slightly distended gallbladder and mild focal gallbladder wall edema, without ductal dilatation. U/A was remarkable for likely UTI with significant epithelial cells, glucose and ketones. WBC notable for a bandemia of 3% (WBC 10.9) and anemia with Hct of 31.9. BUN/Cr elevated (1.2) and glucose 382 with significant transaminitis and obstructive pattern. Of note, initial EKG showed ST depressions in V4-V6 with troponin leak to 0.49, improving to 0.33 on repeat with resolution of ST depressions. ERCP was notified and will see today. She was started on Zosyn for coverage of biliary infection and suspected UTI and given a total of 4L IVF. Her BPs were labile, dropping as low as 80s/40s, prompting admission to the ICU. . In the ICU, she continued to have epigatric and RUQ abdominal pain, but improved from admission. She denied any current fevers, chills, chest pain, SOB, or nausea. She denied any lightheadedness or dizziness. She continued to have malaise and subjective generalized weakness, but was mentating well. . Review of systems: (+) Per HPI. Subjective fevers and chills at home. Slight cough today nonproductive of sputum. (-) Denies recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea, or congestion. Denies shortness of breath or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: # Hypertension # Hypercholesterolemia # CAD s/p CABG x5 ([2151]) # Diabetes Mellitus # Diverticulitis -- Colectomy and pouch [2148], Colostomy for diverticular disease -- Takedown in [2148] # Chronic back pain # Atrial Fibrillation -- patient unaware of diagnosis # Pterygium removal -- bilateral Social History: # Tobacco: denies # Alcohol: denies # Illicits: denies Family History: Multiple family members with CAD. Husband recently deceased. Son recently died from lung cancer at age 57. Physical Exam: ADMITTING PHYSICAL EXAM: Vitals: T 98.0, BP 131/49, HR 72, RR 18, SpO2 100% on 2L NC General: Alert, oriented, no acute distress HEENT: Sclera with some injection, post-op changes from bilateral pterygium removal, dry mucous membranes, oropharynx clear, dentures Neck: supple, JVP not elevated, no LAD Lungs: Few crackles at right base but otherwise clear CV: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops. Abdomen: Well healed midline abdominal incision. Bowel sounds present. Soft, tender to palpation in RUQ. Mildly distended. No rebound tenderness or guarding. No organomegaly. GU: Foley catheter in place with somewhat dark urine Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis or edema. Pertinent Results: ADMISSION LABS: [2164-8-21] 12:30AM URINE RBC-7* WBC->182* BACTERIA-MANY YEAST-NONE EPI-10 TRANS EPI-<1 [2164-8-21] 12:30AM URINE BLOOD-SM NITRITE-POS PROTEIN-30 GLUCOSE-1000 KETONE-40 BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-MOD [2164-8-21] 12:30AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.019 [2164-8-21] 12:30AM PT-15.6* PTT-23.4 INR(PT)-1.4* [2164-8-21] 12:30AM PLT COUNT-179 [2164-8-21] 12:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2164-8-21] 12:30AM NEUTS-91* BANDS-3 LYMPHS-4* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2164-8-21] 12:30AM WBC-10.9# RBC-3.95# HGB-11.3# HCT-31.9# MCV-81 MCH-28.5 MCHC-35.3* RDW-13.7 [2164-8-21] 12:30AM ALBUMIN-3.4* [2164-8-21] 12:30AM CK-MB-7 [2164-8-21] 12:30AM cTropnT-0.49* [2164-8-21] 12:30AM LIPASE-12 [2164-8-21] 12:30AM ALT(SGPT)-296* AST(SGOT)-259* ALK PHOS-147* TOT BILI-5.5* DIR BILI-4.5* INDIR BIL-1.0 [2164-8-21] 12:30AM GLUCOSE-382* UREA N-22* CREAT-1.2* SODIUM-134 POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-23 ANION GAP-17 [2164-8-21] 04:52AM cTropnT-0.33* Brief Hospital Course: 81 year old female with CAD, hypertension, DM2, and prior colectomy for diverticular disease who was transferred from [Hospital3 10310] after presenting with weakness and crampy abdominal pain with RUQ US showing evidence of cholecystitis and an obstructive pattern on her LFTs.She had labile blood pressure in the ED with SBP intermittently down to the 80s. She was given a total of 4L IV fluids, with improvement in her BP. Shee was admitted to the ICU from the ED. # Cholecystitis / Cholangitis: -S/P ERCP with sphincterotomy [2164-8-21] -treated with Unasyn until [8-26], chanced to PO Cipro and Flagyl then -LFTs improved and she tolerated food -Will need cholecystectomy in approximately 3 months (post cardiac cath, see below) -Will need EUS for incidental cyst of pancreas seen on ERCP with Dr. [Last Name (STitle) ] in 4 weeks #Acute blood loss anemia: -Her Hct dropped from 31.0 to 25.3 following the ERCP, and she was transfused 1 unit PRBCs on [2164-8-22] with an appropriate increase in her Hct #Acute MI, Type II (NSTEMI) -EKG in the ED initially showed ST depressions in V4-6, which resolved when she became normotensive. She did not have any symptoms consistent with anginal equivalent. She has know CAD (S/P CAB in [2151]) and multiple risk factors (DM, HTN, hyperlipidemia). -Toponin peaked at 0.49 on [8-21] -Stress MIBI off beta blockers on [8-24] was positive: a moderate, partially reversible perfusion defect in the mid-anterior and mid-anterolateral walls with corresponding mild hypokinesis, and a drop in EF from 55% to 45% with stress (compared to at rest/baseline) -Cardiology followed pt and recommended a) maximizing medical management, b)outpatient cardiology evaluation, followed by c)cardiac cath as an outpatient -Medical management: beta blocker (dose increased until limited by HR; lisinopril; ASA. Reportedly allergic to statins. #DM II, uncontrolled with complications -on glipizide 10 mg [Hospital1 ] at home. Hemoglobin A1c = 8.6, suggesting needs better control -initially on ISS, when switched to home regimen FSBS was in the 200-300 range. -we added Metformin 850mg and she can f/u with pcp regarding glucose control, she is on janumet at home this should be held if she is just on metformin (she should call pcp if glucose >200) #Fever -On [8-26] pt developed a low-grade fever. Workup, which included CDiff toxin assay, CXR, UA, urine culture, blood cultures, and lower extremity noninvasives showed no DVT, no UTI, and slight LLL pulmonary infiltrate but no clinical signs of pneumonia and an improving wbc. although she had low grade fever on [8-27], she was afebrile on the day of discharge and looked clinically well...given that she will be completing a course of cipro/flagyl no other abx were started for the cxr findings. cdiff neg. she should have close follow up with her Pcp if she develops higher fever, cough, dyspnea --recommend outpatient repeat cxr in [3-9] weeks to document resolution of infiltrate Medications on Admission: Aspirin 81 mg PO daily Simvastatin 60 PO QHS Atenolol 12.5 mg PO BID Lisinopril 20 mg PO daily Glipizide 10 mg PO BID Janumet (Sitagliptin/Metformin 50/100 mg) PO BID Vit D [2153] units PO daily Discharge Medications: 1. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 3. metoprolol succinate 50 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 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours) for 10 days. Disp:20 Tablet(s) Refills:0 8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 10. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Cholangitis Cholecystitis Acute myocardial infarction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for obstruction of your bile ducts from stones, and infection of the gallbladder and the bile ducts. This was treated with antibiotics and a procedure called an ERCP. You will need to complete the antibiotics at home. A fluid collection near the pancreas was also found and Dr. [Last Name (STitle) ] would like to see you in four weeks to perform an endoscopic ultrasound (EUS) in order to better characterize that fluid collection. You also had a heart attack during this hospitalization. You had a positive nuclear stress test (MIBI) which showed that you may be at risk for another heart attack in the future. We restarted medications which can help protect you against another heart attack and Cardiology (Dr. [Last Name (STitle) ] would like to see you in his office on [2164-9-7]. At that appointment he will talk to you about a cardiac catheterization. Before you see him, please avoid doing strenuous activity like lifting heavy objects (more that [6-12] punds) or climbing stairs. You can (and should) walk and do other household activities normally. Call a doctor immediately if you feel unwell in any way, especially if you develop chest, neck, arm, or jaw pain, shortness of breath, nausea or vomiting. Your diabetes also needs to be better controlled please measure your blood sugar before each meal amd at bedtime and enter these values with the time and date in a log and bring that to your primary care doctor. Call your primary care doctor if you fingerstick blood glucose is less than 60 or more than 350. Your xray showed a small possible pneumonia in the L lung you should have a repeat xray in the next 2-4 weeks with your PCP. [Name10 (NameIs) ] your doctor if you have shortness of breath, high fever, cough You will need to have your gallbladder removed surgically in approximately 3 months, after you are cleared by your Cardilogist to have this procedure. You can have this done at your local hospital or make an appointment with one of our general surgeons if you wish to have it performed at the [Hospital 61]. Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [2164-9-7] at 10:20 AM With: [Name6 (MD) ] [Name8 (MD) 163], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: ZILBER,DMITRIY A. Location: [Hospital3 ]-[Hospital1 420] Address: [Doctor Last Name ], [Hospital1 420],[Numeric Identifier 15489] Phone: [0-0-] Appointment: Monday [2164-9-10] 9:00am Department: DIGESTIVE DISEASE CENTER When: FRIDAY [2164-9-21] at 12:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2839], MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 1951] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: FRIDAY [2164-9-21] at 12:00 PM	[ "0389", "41071", "5849", "2851", "5990", "99592", "V4581", "4019", "42731", "2720" ]
Admission Date: [2155-12-16] Discharge Date: [2155-12-24] Date of Birth: [2079-8-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 678] Chief Complaint: Fever, altered mental status Major Surgical or Invasive Procedure: Dialysis History of Present Illness: This is a 76 year-old man with a history of DM II, CAD/CHF (EF 45%) and HD dependent ESRD who presents to the ED from dialysis with fever, gait instablitiy, and altered mental status. Pt was in dialysis today when he was noted to be more confused than his baseline. He was also noted to have difficulty ambulating with ? leg/knee pain. In ED, VS were 101.8 (rectal), HR 11, BP 208/93, RR 22 O2 sat 97%. He was a+o x1. Pt appeared confused but was protecting airway, following commands. He denied abd pain, tenderness. Urinary catheter was noted to have pus. The patient was given Given 1 L IVF, 2g ceftriaxone, 1g vancomycin. CT head was obtained and was negative for acute bleed. EKG was without change compared to previous. CXR preliminary read showed volume overload. UA was postive for >1000 WBC. Of note, the patient was admitted in [3-/2155] with a similar presentation of altered mental status and fever to 101 without source. Upon transfer to the ICU, the patient had no complaints. He was oriented x2. He reported feeling well. He denies any recent illness was well as abdominal pain, chest pain, shortness of breath, cough, urinary frequency, lightheadedness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Diabetes type 2. # End-stage renal disease, on hemodialysis. # CHF with EF of 45-55%. # Hypertension. # Status post nodular cavitating lung disease with positive rheumatoid factor. Followed by Dr. [Last Name (STitle) 575] in [2151]. # MRSA bacteremia in [2149-6-7]. # CAD. # COPD. # Secondary hyperparathyroidism Social History: The patient is married to a retired nurse ([Location (un) ]). He has six children. Family History: non-contributory Physical Exam: Vitals: T:98.8 BP:171/76 HR:94 RR:18 O2Sat: 96% on RA GEN: thin, elderly man, no acute distress HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear NECK: JVP 7cm, no bruits, no CAD, trachea midline COR: RRR, normal S1 S2, 2-3/6 SEM at LUSB PULM: Lungs with bilateral rales up to [2-9] lower lung fields. ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: radial pulses +2, RUE with forearm fistula +thrill. diminished pedal pulses. Trace pedal edema bilaterally. No joint swelling, tenderness. NEURO: alert, oriented x1 (to person, place, not year). Unable to name president. CN II ?????? XII grossly intact. Moves all 4 extremities. Responds to commands, answers questions appropriately. Strength 4/5 in upper and lower extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. LE with chronic venous statsis changes. Pertinent Results: [2155-12-16] 01:35PM BLOOD WBC-8.1 RBC-3.93* Hgb-11.6* Hct-35.7* MCV-91 MCH-29.5 MCHC-32.5 RDW-14.0 Plt Ct-381 [2155-12-19] 05:40AM BLOOD WBC-8.9 RBC-3.54* Hgb-10.4* Hct-32.3* MCV-91 MCH-29.4 MCHC-32.2 RDW-13.8 Plt Ct-321 [2155-12-17] 03:15PM BLOOD Glucose-152* UreaN-19 Creat-5.8# Na-137 K-5.3 Cl-95* HCO3-31 AnGap-16 [2155-12-19] 05:40AM BLOOD Glucose-164* UreaN-17 Creat-4.9# Na-141 K-4.0 Cl-98 HCO3-34 AnGap-13 [2155-12-16] 01:35PM BLOOD ALT-18 AST-73* AlkPhos-97 TotBili-0.4 [2155-12-18] 06:49PM BLOOD CK-MB-2 cTropnT-0.35* [2155-12-19] 05:40AM BLOOD CK-MB-3 cTropnT-0.33* [2155-12-16] 01:43PM BLOOD Glucose-148* Lactate-3.6* Na-143 K-5.2 Cl-92* calHCO3-33* [12-16] CT head There is no hemorrhage, hydrocephalus, shift of normally midline structure, or evidence of major vascular territorial infarct. The [Doctor Last Name 352]-white matter differentiation is preserved. Hypodensities in the periventricular and subcortical white matter reflect chronic microvascular ischemic change. Note is made of a prominent cleft vs. old left cerebellar infarct, unchanged. Incidental note is made of a cavum septum pellucidum et [Last Name (LF) 26095], [First Name3 (LF) ] anatomic variant. The visualized paranasal sinuses and mastoid air cells remain normally aerated. The cavernous carotids are calcified. IMPRESSION: No hemorrhage. [12-16] CXR IMPRESSION: Patchy bilateral airspace opacities, which is likely related to fluid overload. Infection is not excluded. Repeat radiography following appropriate diuresis is recommended to assess underlying infection. [12-17] CXR There is no interval change in perihilar vascular indistinct and extensive patchy opacities involving the entire lungs. This may represent volume overload although widespread infection in appropriate clinical setting cannot be excluded. The absence of pleural effusion somehow questions the diagnosis of pulmonary edema favoring infection but cannot absolutely exclude it. Cardiomegaly is present. Mediastinum is unremarkable. [12-18] Renal US IMPRESSION: 1. No evidence of renal obstruction. Equivocal non-obstructing tiny stones in the lower pole of the left kidney. 2. Abnormal appearance of the bladder, with thickened, irregular wall. Further evaluation with CT or MRI is recommended. 3. Bilateral atrophic kidneys may relate to prior infections or chronic medical renal disease. [12-18] CT pelvis IMPRESSION: 1. Bladder wall thickening is difficult to evaluate as the bladder is collapsed due to Foley catheter. If this is of clinical concern, repeat ultrasound after clamping of Foley catheter is recommended. 2. Enlarged gallbladder, but given asymptomatic nature, and lack likely due to fasting state. 3. Atrophic kidneys, as in the prior studies. 4. Bilateral atelectasis, but airspace opacification (aspiration, early infectious consolidation) cannot be excluded. [2155-12-20] 06:55AM BLOOD WBC-9.3 RBC-3.29* Hgb-9.6* Hct-29.8* MCV-91 MCH-29.2 MCHC-32.2 RDW-14.6 Plt Ct-349 [2155-12-21] 07:00AM BLOOD WBC-9.1 RBC-3.34* Hgb-9.7* Hct-30.2* MCV-91 MCH-29.2 MCHC-32.2 RDW-14.5 Plt Ct-337 [2155-12-22] 05:00AM BLOOD WBC-7.8 RBC-4.07* Hgb-12.0* Hct-37.1* MCV-91 MCH-29.4 MCHC-32.3 RDW-13.9 Plt Ct-356 [2155-12-23] 05:40AM BLOOD WBC-8.5 RBC-3.76* Hgb-10.9* Hct-33.3* MCV-89 MCH-28.9 MCHC-32.7 RDW-14.2 Plt Ct-376 [2155-12-19] 05:40AM BLOOD Glucose-164* UreaN-17 Creat-4.9# Na-141 K-4.0 Cl-98 HCO3-34 AnGap-13 [2155-12-20] 06:55AM BLOOD Glucose-64* UreaN-24* Creat-6.5# Na-136 K-4.4 Cl-95 HCO3-30 AnGap-15 [2155-12-21] 07:00AM BLOOD Glucose-60* UreaN-16 Creat-4.9# Na-136 K-4.2 Cl-94 HCO3-31 AnGap-15 [2155-12-22] 05:00AM BLOOD Glucose-82 UreaN-27* Creat-6.4# Na-133 K-4.8 Cl-92 HCO3-28 AnGap-18 [2155-12-23] 05:40AM BLOOD Glucose-88 UreaN-36* Creat-8.1# Na-135 K-4.8 Cl-92 HCO3-29 AnGap-19 [2155-12-18] 06:49PM BLOOD CK-MB-2 cTropnT-0.35* [2155-12-19] 05:40AM BLOOD CK-MB-3 cTropnT-0.33* [2155-12-19] 05:40AM BLOOD Triglyc-112 HDL-28 CHOL/HD-3.6 LDLcalc-52 [2155-12-16] 2:45 pm URINE CATHETER. FINAL REPORT [2155-12-18] URINE CULTURE (Final [2155-12-18]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Blood cultures x2 [12-16] negative Blood cultures x2 [12-20], [12-23] NGTD MRSA screen [12-17] positive Brief Hospital Course: 76 year-old gentleman with a history of Type 2 diabetes, Chronic Kidney disease, Congestive heart failure who presents with fever, altered mental status, pyuria and pulmonary congestion. . 1. Fever: Urinalysis showing pyuria with >1000 WBC. Patient was afebrile during admission, without dysuria or suprapubic tenderness. He was initially started on Ciprofloxacin, however on hospital day 2 Urine culture showed E.coli resistant to Ciprofloxacin. Patient was started on Ceftriaxone on [12-18]. Nephrology was consulted, who continued him on his dialysis regimen. They recommended a renal US to rule out obstruction, which was negative for obstruction but showed an abnormal appearing bladder. CT pelvis confirms a thickened bladder wall, though no obstruction. Patient continued to have fevers, so Vancomycin was added on [12-20]. Chest x-ray showed Left lower lobe consolidation. Vancomycin was discontinued on [12-23], as it was thought unlikely that patient had MRSA pneumonia. Culture data was negative. Blood cultures were all NGTD. Please continue Cefpodoxime for 8 days, for a total of 2 weeks treatment for UTI and pneumonia. Of note, patient at baseline gets febrile during/after dialysis. This is attributed to a reaction to one of the dialysis catheters. As an outpatient this is treated with Tylenol and Benadryl. No need for readmission unless fevers persist over 12 hours after dialysis, or patient has other focal symptoms. 2. Systolic congestive heart failure: Increased vascular congestion on chest x-ray. Patient has a history of CHF with EF last documented at 45% ([3-15]). No oxygen requirement and trace peripheral edema on exam. No concern for acute change in cardiac function. Patient was not diuresed, as he appeared euvolemic during hospitalization. 3. Altered mental Status: Patient initially presented with confusion, however this resolved on admission. There was no evidence of CNS injury on CT and symptoms most likely delerium in the setting of UTI. With prolonged stay in the hospital, patient continued to be A+Ox2, though more confused overall. This was attributed to hospital associated delirium. He was more confused during and after dialysis, which according to his wife occurs at baseline. . 4. Chronic kidney disease: Gets Dialysis T Th Sa. Patient was evaluated by nephrology, and received dialysis. Appeared euvolemic on exam. . 5. Type 2 diabetes: Well controlled throughout hospitalization. Home regimen was held, and sugars were controlled with sliding scale insulin only. Please continue outpatient regimen of glipizide. Medications on Admission: Amlodipine 5 mg Daily Glipizide 5 mg [Hospital1 ] Metoprolol Tartrate 50 mg Tablet [Hospital1 ] Ranitidine HCl [Zantac] 150 mg Tablet qhd Cinacalcet 90 mg DAILY. Aspirin Child 81 mg (chewable) QD Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day for 4 doses. Disp:4 Tablet(s) Refills:0 6. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day. 7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 12. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO qHemodialysis for 8 days. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital Discharge Diagnosis: Primary diagnosis: 1. Urinary tract infection 2. Left lower lobe pneumonia 3. Chronic kidney disease 4. Chronic systolic heart failure Secondary diagnosis 1. Type 2 diabetes 2. Hypertension Discharge Condition: Alert and oriented x2. Patient gets febrile and weak after dialysis, but back to baseline within 6-12 hours thereafter. Discharge Instructions: You were admitted with fevers and changes in your thinking. You were found to have a urinary tract infection. We treated you with antibiotics. You received dialysis. You had a CT scan of your pelvis that showed no obstruction in your kidneys, though you have a thickened bladder wall. You had some changes on your EKG, that are concerning for your heart. You will need a stress test as an outpatient. Your chest x-ray showed a Left sided pneumonia. The antibiotics for your urinary infection will also treat your pneumonia. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet If you develop pain with urination, blood in your urine, fevers, chills, chest pain, or shortness of breath, please see your doctor or go to the emergency room. Followup Instructions: You have an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216] on the [Location (un) ] of [Company 191] on [12-26] Friday at 3:30pm. The clinic number is [Telephone/Fax (1) 1300] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 684] Completed by:[2155-12-24]	[ "5990", "486", "40391", "4280", "25000", "41401", "496" ]
Admission Date: [2142-10-11] Discharge Date: [2142-10-12] Date of Birth: [2084-9-7] Sex: F Service: MEDICINE Allergies: Tramadol / Abacavir Attending:[First Name3 (LF) 2763] Chief Complaint: Hypertension Major Surgical or Invasive Procedure: HD History of Present Illness: 58 y/o anuric HD dependent female with HIV on HAART (last CD4 94), CKD stage V on HD ([1-10] HTN, dialyzed MWF via L CVL), RUE AVG (ligation and subsequent excision ([2142-9-15]), HCV with liver biopsy [3-/2137] (grade II inflammation) who p/w RUQ pain and vomiting starting at 4 pm today after HD. . Of note, pt recently admitted from [Date range (1) 100888] on surgery service for right arm arteriovenous graft infection. She underwent excision right arteriovenous graft. GPC bacteremia on blood cultures [2142-9-13]. Graft cultures speciated as enterobacter. She completed vancomycin for 2 weeks at [Year (4 digits) 2286], and ciprofloxacin PO daily for 2 weeks. . Pt reports RUQ pain, intermittent, +chills. Denies fevers. No diarrhea, constipation, cough/cold sx. Reports vomiting, non-bloody. No HA, visual changes. Reports she missed her BP pills yesterday and today due to nausea/vomiting. Of note, pt does not make urine. . In ED, initial VS - initial VS were: 8, 98.6, 53, 226/101, 18, 100%. EKG showing sinus brady 48, NA, Qtc 461. Lactate wnl. Alk phos slightly above baseline. RUQ US showing stones, no cholycystitis. CXR showing no acute process. Transplant surgery notified, and they are aware and recommend MICU admission. CT A/P negative for acute process. Overall, "no SBO. Distal colonic wall thickening is more likely related to underdistension than colitis, but clinical correlation recommended. Polycystic kidneys. High density streaks in peritoneum unchanged since [2137], could be related to a barium spill. CT head showed no acute proces. . Pt started to develop worsening SOB, and there was a ? of mild pulmonary edema. SBP was 240s at this time. Nitro gtt started at 0.2 mcg. . Vitals on transfer - BP 215/117, HR 72, RR 18, 100% 2L NC. Access - 20G, HD line, R EJ. . On arrival to the MICU, mental status is alert. . Review of systems: (+) Per HPI. (+) HA (-) Denies fever, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea, constipation, changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: HIV on HAART CKD stage V on HD ([1-10] HTN) RUE AVG, ligated [2142-6-15] Hep C: Liver biopsy [3-/2137] showed focal mild-to-moderate portal chronic inflammation with focal periportal extension (grade II). HTN Diverticulosis High-grade adenomatous polyp Social History: no current IV drug use, no current etoh or smoking Family History: non-contributory Physical Exam: Vitals: 97.6, 222/120, 72, 18, 100 RA General: Alert, but somewhat sleepy, oriented, mild distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1, prominent S2, grade III holodystolic murmur heard best at LSB Lungs: mild crackles at bases, no wheezes, rales, ronchi Abdomen: soft, minimally tender RUQ, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 1+ 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 Pertinent Results: Labs on Admission: [2142-10-11] 12:35AM BLOOD WBC-3.5* RBC-3.99* Hgb-11.9* Hct-39.0 MCV-98 MCH-29.9 MCHC-30.5* RDW-17.3* Plt Ct-148* [2142-10-11] 12:35AM BLOOD Neuts-66.3 Lymphs-26.5 Monos-4.9 Eos-1.4 Baso-0.9 [2142-10-11] 12:35AM BLOOD Plt Ct-148* [2142-10-11] 01:41PM BLOOD WBC-3.2* Lymph-25 Abs [Last Name (un) ]-800 CD3%-56 Abs CD3-449* CD4%-25 Abs CD4-200* CD8%-31 Abs CD8-246 CD4/CD8-0.8* [2142-10-11] 12:35AM BLOOD Glucose-110* UreaN-27* Creat-5.9* Na-137 K-4.2 Cl-93* HCO3-29 AnGap-19 [2142-10-11] 12:35AM BLOOD ALT-18 AST-39 CK(CPK)-52 AlkPhos-490* TotBili-0.7 [2142-10-11] 12:35AM BLOOD Lipase-39 [2142-10-11] 12:35AM BLOOD CK-MB-2 cTropnT-0.02* [2142-10-11] 12:35AM BLOOD Calcium-10.3 Phos-3.9 Mg-2.1 [2142-10-11] 01:41PM BLOOD PTH-2913* [2142-10-11] 12:48AM BLOOD Lactate-1.8 . Labs on Discharge: [2142-10-12] 03:29AM BLOOD WBC-3.3* RBC-3.63* Hgb-10.7* Hct-34.7* MCV-96 MCH-29.6 MCHC-30.9* RDW-17.1* Plt Ct-137* [2142-10-12] 03:29AM BLOOD Neuts-56 Bands-0 Lymphs-40 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2142-10-12] 03:29AM BLOOD Plt Ct-137* [2142-10-12] 03:29AM BLOOD Glucose-87 UreaN-41* Creat-8.1# Na-136 K-4.3 Cl-94 HCO3-30 AnGap-16 [2142-10-12] 03:29AM BLOOD ALT-20 AST-34 LD(LDH)-174 AlkPhos-415* TotBili-1.1 [2142-10-11] 01:41PM BLOOD GGT-62* [2142-10-12] 03:29AM BLOOD Albumin-4.2 Calcium-10.0 Phos-4.8* Mg-2.0 [2142-10-11] 01:41PM BLOOD PTH-2913* . CT head without contrast [10-11]: IMPRESSION: 1. No acute intracranial process. 2. Opacification of the left mastoid air cells may be due to inflammatory or infectious process. . CT abd/pelvis without contrast: IMPRESSION: 1. No evidence of bowel obstruction, diverticulitis or renal stones. 2. Left and sigmoid colonic wall thickening with mild stranding along the medial wall of the descending colon is most likely undersitension and chronic abnormality rather than mild colitis, though clinical correlation is needed. 3. Polycystic kidneys with some new intermediate density lesions and some increased in size and a septated left cystic lesion. Outpatient MRI is recommended in no more than 6 months to assess further. 4. Cholelithiasis without CT evidence of cholecystitis. 5. 4 mm right middle lobe nodule needs no follow- up if patient is low risk for malignancy. 12 month f/u chest CT if patient is high risk for a malignancy. . CXR PA and lateral: IMPRESSION: Vascular engorgement and early pulmonary edema, due to volume overload, and/or cardiac insufficiency. . Liver/gallbladder US [2142-10-11]: IMPRESSION: Cholelithiasis without evidence of cholecystitis. Polycystic kidneys are partially imaged and not completely evaluated, though no overtly concerning lesion is seen in their visualized portions. Brief Hospital Course: 58 y/o anuric HD dependent female with HIV on HAART, HCV, CKD stage V on HD, RUE AVG ligation and subsequent excision ([2142-9-15]), who p/w RUQ pain, nausea, and vomiting, and is admitted to MICU for hypertensive emergency. . # HTN emergency: pt presented with SBP in 230s and evidence of vascular engorgement and early pulmonary edema with volume overload, classifying her HTN as HTN emergency. Head CT was wnl. No EKG evidence of strain or ischemia was seen. Etiology of elevated BP was likely related to nausea/vomiting/missing BP pills at home, along with pain. Baseline SBP 140-160 per review of clinic notes. Of note, mental status was alert. She was started on nitro gtt with goal SBP 180 but was d/ced in the PM after normalization of her pressures. We continued home lisinopril and home metoprolol. Pain control was achieved with IV morphine. Patient tolerated HD performed in the ICU and was discharged after overnight stay. . # RUQ pain: RUQ US showed cholelithiasis without cholecystitis. CT A/P showed no SBO. Distal colonic wall thickening is more likely related to underdistension than colitis. No fever or jaundice, or evidence for cholecystitis. Elevated alk phos may suggest infiltrative disease. Recommend repeating outpatient LFTs and w/u with possible MRCP if alk phos remains elevated. Consider outpt cholecystectomy for biliary colic, now resolved. . # CKD stage V on HD ([1-10] HTN): gets dialyzed on MWF. Renal team performed UF on hospital day 1, and HD on Friday (hospital day 2). Continued sevelamer, nephrocaps. Of note, patient's PTH returned as 2913. Pt will start IV zemplar at HD for ? secondary vs. tertiary hyperparathyroidism. . # HIV: on HAART. Last CD4 94 (22%) and VL 71 copies/ml. We continued atazanavir, raltegravir, ritonavir, lamivudine. On discharge, CD4 count pending. Pt may require bactrim ppx depending on CD4 count. Pt was set up with ID appt on discharge. . # HCV: liver biopsy [3-/2137] showed focal mild-to-moderate portal chronic inflammation with focal periportal extension (grade II). . # Hx of right arm arteriovenous graft infection/excision right arteriovenous graft: GPC bacteremia on blood cultures [2142-9-13]. Graft cultures speciated as enterobacter. She completed vancomycin for 2 weeks at [Year (4 digits) 2286], and ciprofloxacin PO daily for 2 weeks. No signs of infection locally or systemically. Bcx pending on d/c. . # 4 mm right middle lobe nodule: per radiology, needs no follow-up if patient is low risk for malignancy. 12 month f/u chest CT if patient is high risk for a malignancy. Communicated above with oupt PCP. . # Transitional issues: - follow up CD4 count, and start bactrim prophylaxis depending on result. - Started IV zemplar at HD (Dr [Last Name (STitle) 7473] [Name (STitle) 82414]) given high PTH values (2913). - 4 mm RML nodule, which requires repeat evaluation and possible CT if high risk for malignancy - ID appt re: HIV care as outpt Medications on Admission: 1. sevelamer carbonate 800 mg Tablet [Name (STitle) ]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. B complex-vitamin C-folic acid 1 mg Capsule [Name (STitle) ]: One (1) Cap PO DAILY (Daily). 3. atazanavir 150 mg Capsule [Name (STitle) ]: Two (2) Capsule PO DAILY (Daily). 4. raltegravir 400 mg Tablet [Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 5. ritonavir 100 mg Capsule [Name (STitle) ]: One (1) Capsule PO DAILY (Daily). 6. lamivudine 10 mg/mL Solution [Name (STitle) ]: 25 mg PO DAILY (Daily). 7. docusate sodium 100 mg Capsule [Name (STitle) ]: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet [Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. lactulose 10 gram/15 mL Syrup [Name (STitle) ]: Fifteen (15) ML PO DAILY (Daily) as needed for constipation. 10. polyethylene glycol 3350 17 gram/dose Powder [Name (STitle) ]: One (1) PO DAILY (Daily). 11. heparin (porcine) 1,000 unit/mL Solution [Name (STitle) ]: One (1) Injection PRN (as needed) as needed for line flush. 12. aspirin 81 mg Tablet, Chewable [Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 13. acetaminophen 325 mg Tablet [Name (STitle) ]: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 14. lisinopril 20 mg Tablet [Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 15. metoprolol succinate 100 mg Tablet Extended Release 24 hr [Name (STitle) ]: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 16. oxycodone 5 mg Tablet [Name (STitle) ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Medications: 1. sevelamer carbonate 800 mg Tablet [Name (STitle) ]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. B complex-vitamin C-folic acid 1 mg Capsule [Name (STitle) ]: One (1) Cap PO DAILY (Daily). 3. atazanavir 150 mg Capsule [Name (STitle) ]: Two (2) Capsule PO DAILY (Daily). 4. raltegravir 400 mg Tablet [Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 5. ritonavir 100 mg Capsule [Name (STitle) ]: One (1) Capsule PO DAILY (Daily). 6. lamivudine 10 mg/mL Solution [Name (STitle) ]: Twenty Five (25) mg PO DAILY (Daily). 7. senna 8.6 mg Tablet [Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. docusate sodium 100 mg Capsule [Name (STitle) ]: One (1) Capsule PO BID (2 times a day). 9. lactulose 10 gram/15 mL Syrup [Name (STitle) ]: Fifteen (15) ML PO DAILY (Daily) as needed for constipation. 10. polyethylene glycol 3350 17 gram/dose Powder [Name (STitle) ]: One (1) packet PO DAILY (Daily). 11. aspirin 81 mg Tablet, Delayed Release (E.C.) [Name (STitle) ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. lisinopril 20 mg Tablet [Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 13. metoprolol succinate 100 mg Tablet Extended Release 24 hr [Name (STitle) ]: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 14. oxycodone 5 mg Capsule [Name (STitle) ]: [12-10] Capsules PO every four (4) hours as needed for pain. 15. zemplar qhd Discharge Disposition: Home Discharge Diagnosis: PRIMARY: - hypertensive emergency . SECONDARY: - end stage renal disease, on HD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you in the hospital. You were admitted to the intensive care unit due to very high blood pressures, likely a result of nausea/vomiting, inability to take your home pills, and a shortened [Known lastname 2286] session the day before. . While you were here, we controlled your blood pressure with IV medications. Your blood pressure responded nicely. You are being discharged on your home blood pressure regimen of metoprolol and lisinopril. . While you were here, we also checked some blood tests related to your kidneys. Your PTH levels were high and the kidney team will add a new IV medication called zemplar with your [Known lastname 2286]. . MEDICATION CHANGES - addition of IV zemplar with [Known lastname 2286] . No other changes were made to your medications. Please follow-up with your outpatient appointments below. Please seek medical attention for any concerns. Followup Instructions: Appointments: 1) Department: [Hospital3 249] When: THURSDAY [2142-10-18] at 3:50 PM With: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 275] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] linical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . 2) Department: INFECTIOUS DISEASE When: TUESDAY [2142-10-30] at 10:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4593], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] Completed by:[2142-10-12]	[ "40391" ]
Admission Date: [2136-7-16] Discharge Date: [2136-7-30] Date of Birth: [2066-3-12] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 473] Chief Complaint: peri-hepatic fluid collection Major Surgical or Invasive Procedure: [2136-7-17] - CT-guided drainage of a gallbladder fossa collection with percutaneous drain placement. History of Present Illness: This is a 70-year old male with history of unresectable pancreatic cancer s/p ex-lap, open cholecystectomy and retroperitoneal lymph node biopsies on [2136-6-28], discharged on [7-9] with a post-op course complicated by gram negative bacteremia and delirium. He was transferred from [Hospital 1474] Hospital with 5 days of abdominal pain, nausea and vomiting. He has been having less frequent bowel movements (last was 3 days ago) and reported not passing flatus for the past 2 days. He denied any fevers or chills. KUB was without evidence bowel obstruction. Past Medical History: PMH: COPD, on home oxygen 2L continuously; Anxiety; Depression; OSA; Hx of ARF; DMII, HTN, CAD s/p PTCA [35] yrs BU, ?seizures vs. syncope PSH: open appendectomy, tonsillectomy, bilateral carotid stents Social History: Patient retired (used to work for oxygen device company) and lives with his mother in [Name (NI) 7740]. Has 5 children. Previously smoked 3-4 packs/day x 45 years gradually decreasing for past 8 years, now 0.75 pack per day. Patient states he quit alcohol 30 years ago. Prior crack/cocaine x 2 yrs. Quit a few yrs ago. Family History: Mother CABG [14], alive 95. Father died at of pancreatic cancer at age 72. Physical Exam: PHYSICAL EXAM (on admission): Vitals: T 98.9 HR 86 BP 163/91 RR 16 SO2 96% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, mildly distended, mildly tender to palpation on RUQ and periumbilical area, no rebound or guarding DRE: normal tone, no gross or occult blood. Guaiac neg. Ext: No LE edema, LE warm and well perfused Pertinent Results: [2136-7-16] 03:15PM BLOOD WBC-26.0# RBC-4.05 Hgb-12.3* Hct-39.7# MCV-98 MCH-30.4 MCHC-31.0 RDW-17.0 Plt Ct-637# [2136-7-16] 03:15PM BLOOD Neuts-88.4 Lymphs-8.9* Monos-2.2 Eos-0.3 Baso-0.2 [2136-7-16] 03:15PM BLOOD PT-14.7* PTT-21.7* INR(PT)-1.3* [2136-7-16] 03:15PM BLOOD Glucose-116* UreaN-12 Creat-0.8 Na-144 K-3.6 Cl-101 HCO3-31 AnGap-16 [2136-7-16] 03:15PM BLOOD ALT-65* AST-103* AlkPhos-958* TotBili-1.1 [2136-7-17] 04:25AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.2* [2136-7-18] 06:30AM BLOOD Vanco-21.7* [2136-7-16] 03:32PM BLOOD Lactate-1.6 [2136-7-16] CT ABD & PELVIS WITH CONTRAST - In the right lobe of the liver, there is a rim enhancing collection measuring 4.0 x 5.6 cm that contains foci of air, concerning for abscess. Increased ascites compared to the prior exam. Increased intrahepatic biliary duct and pancreatic duct dilation, likely secondary to known pancreatic mass. [2136-7-17] CT GUIDED NEEDLE PLACTMENT - Technically successful CT-guided aspiration drainage of a gallbladder fossa collection. 8 French [Last Name (un) 2823] catheter placed. 30 cc of purulent material were aspirated to bag and gravity. 1 cc was sent for microbiology specimen. No immediate complications. Brief Hospital Course: NEURO/PAIN: The patient was maintained on IV pain medication on admission and transitioned to PO narcotic medication with adequate pain control on HOD#X once oral intake was tolerated. The patient remained neurologically intact and without change from baseline during their stay. His home dosing of benzodiazepines was continued without evidence of delirium or mental status change. The patient remained alert and oriented to person, location and place. CARDIOVASCULAR: The patient remained hemodynamically stable. The patient was maintained on IV anti-hypertensive medication, with transition to their oral home anti-hypertensives on HOD#[3-15]. Their vitals signs were closely monitored. The patient's home anti-hypertensive medications were resumed on HOD#3. Unfortunately, the patient developed ventricular tachycardia prior to ERCP in the setting of hypokalemia and hypomagnesemia. He required amiodarone boluses and synchronized cardioversion to revert to sinus rhythm. He was transferred to the ICU for monitoring. Patient treated with esmolol drip overnight and remained in sinus rhythm throughout. Esmolol drip stopped and patient placed back on home metoprolol. He tolerated this well and cardiology agreed with this management. He was transfered out of the ICU and did well on oral metoprolol up to discharge without any hemodynamic instability. RESPIRATORY: The patient had no episodes of desaturation or pulmonary concerns. The patient denied cough or respiratory symptoms. Pulse oximetry was monitored closely and the patient maintained adequate oxygenation. GASTROINTESTINAL: The patient was NPO on admission and on HOD#2 experienced significant abdominal distention and episodic emesis requiring nasogastric tube placement. The NGT was discontinued on HOD#3 and was replaced on HOD#6 when complained of increasing abdominal discomfort and epigastric bloating. The second NGT placement resulted in 2.5L of bilious return. He was eventually showing improvement, the NGT was removed and clear liquids were tolerated. He did receive 2-days of supplemental TPN, but this was discontinued and the patient was again allowed to maintain a regular diet, as tolerated. The patient underwent a CT of the abdomen and pelvis on admission that showed a right lobe of the liver rim enhancing collection measuring 4.0 x 5.6 cm that contained foci of air, concerning for abscess. There was increased ascites compared to the prior exam and increased intrahepatic biliary duct and pancreatic duct dilation, likely secondary to known pancreatic mass. He underwent CT-guided aspiration and drainage of a gallbladder fossa collection on HOD#2 with placement of an 8-French [Last Name (un) 2823] catheter, and 30 cc of purulent material were aspirated to bag and gravity. 1-cc was sent for microbiology specimen. The culture returned mixed bacterial flora and he was started on Vancomycin and Zosyn IV on admission. He was continued on these antibiotics until PO intake was established, at which time the patient was transitioned to oral Augmentin. IV antibiotics were resumed when his ICU transfer was instated, and a 10-day course was completed. The drainage catheter was removed prior to discharge. Patient underwent ERCP with placement of mental biliary stent. The duodenal was not obstructed as previously thought and no stents were placed. Oncology and palliative consults were obtained. He was discharged with heme/oncology and palliative care follow-up regarding possible chemotherapy and hospice services. GENITOURINARY: The patient's urine output was closely monitored in the immediate post-operative period. A Foley catheter was placed on admission to monitor urine output and was removed on HOD#2, at which time the patient was able to successfully void without issue. The patient's intake and output was closely monitored for urine output > 30 mL per hour output. The patient's creatinine was stable. HEME: The patient's hematocrit was stable and trended closely. He did have a single episode of bloody bowel movement which resolved without issue; and serial hematocrits were stable. The patient remained hemodynamically stable and did not require transfusion. The patient's coagulation profile remained normal. The patient had no evidence of bleeding. ID: The patient was admitted with a WBC of 26.0 which trended down following drainage and IV antibiotic treatment. The patient underwent a CT of the abdomen and pelvis on admission that showed a right lobe of the liver rim enhancing collection measuring 4.0 x 5.6 cm that contained foci of air, concerning for abscess. There was increased ascites compared to the prior exam and increased intrahepatic biliary duct and pancreatic duct dilation, likely secondary to known pancreatic mass. He underwent CT-guided aspiration and drainage of a gallbladder fossa collection on HOD#2 with placement of an 8-French [Last Name (un) 2823] catheter, and 30 cc of purulent material were aspirated to bag and gravity. 1-cc was sent for microbiology specimen. The culture returned mixed bacterial flora and he was started on Vancomycin and Zosyn IV on admission. He was continued on these antibiotics until PO intake was established, at which time the patient was transitioned to oral Augmentin. However, he was restarted on IV antibiotics when transfered to the ICU and these were completed during his hospitalization. The drainage catheter was kept in place on discharge. Blood and urine cultures were unrevealing. He remained afebrile on admission, despite the above collection. ENDOCRINE: The patient's blood glucose was closely monitored with Q6 hour glucose checks. Blood glucose levels greater than 120 mg/dL were addressed with an insulin sliding scale. PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ TID for DVT/PE prophylaxis and encouraged to ambulate immediately once cleared by physical therapy. The patient also had sequential compression boot devices in place during immobilization to promote circulation. GI prophylaxis was sustained with Protonix/Famotidine when necessary. The patient was encouraged to utilize incentive spirometry, ambulate early and was discharged in stable condition with follow-up with hospice and heme/oncology appointments. He will have VNA nursing services and PT support as a bridge to hospice care. Medications on Admission: albuterol 5 mg/mL neb prn, alprazolam 1 mg'''', plavix 75 mg', effexor 75 mg' QOD, finasteride 5 mg', fluticasone-salmeterol 250/50 mcg', glipizide 2.5 mg'', ipatroprium-albuterol 18/103 mcg'', lisinopril 10 mg', metoprolol 100 mg', percocet 5/325 mg QID prn, promethazine 6.25 mg/5 mL' 0.5 (One half) teaspoon daily, aspirin 325 mg', docusate 100 mg', flaxseed oil, magnesium oxide 400 mg'', omega-3 FAs 1000 mg'', Lidocaine 5 % Topical Cream as needed Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation DAILY (Daily). 2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 7. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO QOD (). 9. morphine 10 mg/5 mL Solution Sig: [6-19] mL PO Q4H (every 4 hours). Disp:300 mL Refills:0 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 11. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety, agitation, signs of withdrawal. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: peri-hepatic abscess/fluid collection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to Dr.[Name (NI) 9886] surgical service for evaluation and management of your peri-hepatic fluid collection. You are now being discharged home. Please follow these instructions to aid in your recovery: Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. General Discharge Instructions: * Please resume all regular home medications, unless specifically advised not to take a particular medication. * Please take any new medications as prescribed. * Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. * Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. * Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. * Please also follow-up with your primary care physician. Followup Instructions: You will be contact[Name (NI) ] by Hospice of [Name (NI) 86] & Greater [Hospital1 1474] regarding Hospice options. There number is [Telephone/Fax (1) 39156] - please contact them this week regarding follow-up with them. You will be contact[Name (NI) ] by the outpatient hematology/oncology service regarding a follow-up appointment; if you don't hear from them in [2-12] days, please call their office at ([Telephone/Fax (1) 63419]. Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2136-8-17] 11:40 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2136-8-17] 12:00 Provider: [Name10 (NameIs) ] [Name8 (MD) 611], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2136-8-17] 12:00	[ "25000", "41401", "4019", "496", "32723", "V4582" ]
Admission Date: [2109-12-17] Discharge Date: [2109-12-25] Date of Birth: [2046-9-18] Sex: F Service: O-MED CHIEF COMPLAINT: Shortness of breath, cough, and fatigue. HISTORY OF PRESENT ILLNESS: This is a 63-year-old woman with extensive small cell lung carcinoma with metastases to [Last Name (LF) 500], [First Name3 (LF) ], and liver. She was treated with cisplatin and etoposide and radiation therapy to the chest for metastases to the thoracic spine in [2107]. A cerebellar metastasis was resected in [2108] with whole brain radiation therapy. A few months ago, she was noted to have metastases to the left pelvis which was also treated with radiation therapy. More recently, she was discovered to have metastases to the liver which have also been treated a total of five cycles of chemotherapy with her last dose administered on [2109-12-12] (five days prior to admission). The patient was doing well on the day after her last chemotherapy except for left shoulder pain which was relieved with the application of Bengay. The following day, three days prior to admission, the patient developed a cough with yellow sputum production, and felt very weak, and slept the entire day. Since that time, her cough has continued, and she has been feeling progressively short of breath. The shortness of breath is worsened with exertion and describes pleuritic chest pain. The chest pain is only present with coughing and not associated with nausea, vomiting, or diaphoresis. She has been having subjective fevers at home, but no chills or night sweats. Both her husband and her son have been sick recently with an upper respiratory infection. She denies hemoptysis of dysphagia, but she has been using her inhaler more frequently over the last three days. She was scheduled to receive her flu shot this week. REVIEW OF SYSTEMS: On review of systems, the patient reports decreased oral intake over the last three days prior to admission with a bowel of soup and some Boost as her only oral intake during this time period. She had one episode of urinary incontinence yesterday evening, but she has not had any problem since. She denies bowel incontinence or abdominal pain. No recent blurred vision, focal weakness or numbness, or difficulty with ambulation. The patient was admitted directly from the Clinic for evaluation of shortness of breath. PAST MEDICAL HISTORY: 1. Small cell lung carcinoma diagnosed in [2107-11-30], and status post radiation therapy and chemotherapy. 2. Metastases to T11, status post radiation therapy and chemotherapy. 3. Metastases to cerebellum, status post resection and whole brain radiation therapy. 4. Metastases to the left pelvis, status post radiation therapy. 5. Metastases to the liver, status post chemotherapy times five cycles. 6. Chronic obstructive pulmonary disease. 7. Gastroesophageal reflux disease. 8. History of pulmonary embolism in [2109-3-29] at [Hospital ] Hospital. 9. History of supraventricular tachycardia. 10. Laminectomy in [2092]. 11. Tonsillectomy in [2068]. 12. History of hypertension. 13. History of diverticula. 14. Question of transient ischemic attack in [2106]. 15. Umbilical hernia. SOCIAL HISTORY: The patient has a greater than 30-pack-year smoking history. She denies current alcohol use. She formerly worked as a part-time truck driver for the Town of [Location (un) 932], but she has been retired for the last two years. FAMILY HISTORY: Family history medical history revealed her family history is strongly positive for rheumatic heart disease. Her mother died at the age of 53 of heart failure, and brother also with rheumatic heart disease and died in his 40s. Her father is 88 and is status post coronary artery bypass graft in [2105]. She has no other siblings. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: (Outpatient medications included) 1. Lasix 20 mg p.o. q.o.d. 2. Elavil 25 mg p.o. q.h.s. 3. Coumadin 4 mg p.o. q.d. 4. Effexor 75 mg p.o. q.d. 5. Diltiazem-ER 100 mg p.o. q.d. 6. Ranitidine 150 mg p.o. b.i.d. 7. Lipitor 30 mg p.o. q.d. 8. Theophylline 200 mg p.o. q.d. 9. Singulair 10 mg p.o. q.d. 10. Flovent 44 mcg 2 puffs b.i.d. 11. Combivent as needed. 12. Senna one tablet p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on admission to the floor revealed temperature was 100.7, blood pressure was 100/52, heart rate was 112, respiratory rate was 24 to 26, oxygen saturation was 93% on 2 liters. In general, the patient was tachypneic, but she was sitting upright in bed and appeared slightly uncomfortable. Head, eyes, ears, nose, and throat examination revealed the oropharynx was clear. Mucous membranes were dry. Jugular venous pulsation was not elevated. Her neck was supple with a large well-healed surgical scar on the left posterior neck. Her sclerae were anicteric. On chest examination, she had diffuse coarse breath sounds bilaterally with a prolonged expiratory phase and left basilar rales. Cardiovascular examination revealed she was tachycardic, normal first heart sound and second heart sound. No murmurs, rubs, or gallops were appreciated. Her abdomen was soft, nontender, and nondistended with normal active bowel sounds. No hepatosplenomegaly was noted. Extremity examination revealed good capillary refill with no lower extremity edema. On neurologic examination, she was alert and oriented times three. Motor was [6-2] in the upper extremities and lower extremities. Sensation was intact to light touch in the bilateral lower extremities. She had reproducible back pain to palpation in the left scapular area. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory values on admission revealed white blood cell count was 1.2, hemoglobin was 10.5, hematocrit was 30.8, and platelets were 190. The differential on the white blood cell count revealed 20% neutrophils, 30% bands, 22% lymphocytes, and 26% monocytes. Her chemistry panel revealed sodium was 131, potassium was 6.2 (with a recheck of 3.3), chloride was 93, bicarbonate was 25, blood urea nitrogen was 25, creatinine was 0.9, and blood glucose was 105. Absolute neutrophil count was 250. PT was 14.9, PTT was 29.3, INR was 1.5. LDH was 795, total bilirubin was 0.9, AST was 54, ALT was 17, alkaline phosphatase was 142. Calcium was 9, phosphorous was 3.2, magnesium was 2. PERTINENT RADIOLOGY/IMAGING: During hospitalization, a chest x-ray on admission showed post radiation changes in the left perihilar region with hazy areas of increased opacity in the lower lobe (the right greater than the left, possibly indicating pneumonia; however, unable to access to motion artifact. A [Month/Day (1) 500] scan on [2109-12-24] revealed no new metastases with improvement in known metastases in the left pelvis and T11. Magnetic resonance imaging of the head on [2109-12-23] revealed no evidence of new metastases. Stable postoperative changes in the left cerebellar hemisphere, air/fluid levels in maxillary sinus, and stable right parafalcine hemangioma. An transthoracic echocardiogram on [2109-12-20] revealed an ejection fraction of 60% to 65%, 1+ aortic regurgitation, trivial mitral regurgitation, mild pulmonary artery systolic hypertension. No effusions. Electrocardiogram on admission revealed sinus tachycardia and early R wave progression. No ST-T wave changes compared to electrocardiogram dated [2109-1-21]. IMPRESSION: This is a 63-year-old female with small cell lung cancer with multiple sites of metastases presenting with shortness of breath, cough, and fatigue times three days. HOSPITAL COURSE: 1. PULMONARY SYSTEM: The patient was admitted for dyspnea, cough, and fever which was thought secondary to community-acquired pneumonia versus viral infection. On hospital day two, she was noted to have progressive worsening of respiratory distress, and an arterial blood gas was performed which showed a pH of 7.22, a PCO2 of 61, and a PO2 of 354, and a bicarbonate of 26. Due to her progressive worsening of respiratory symptoms and a mixed respiratory and metabolic acidosis, she was transferred to the Intensive Care Unit. While in the Intensive Care Unit, she was stabilized on noninvasive ventilation and frequent nebulizers. She did not require intubation. She was started on steroids for a chronic obstructive pulmonary disease flare, and her dyspnea improved significantly. There was some concern for a pulmonary embolism given her history of pleuritic chest pain and hypercoagulable state, given her cancer, and she was restarted on heparin as her INR on admission was subtherapeutic. After stabilization in the Intensive Care Unit, she was transferred back to the floor where she was continued on albuterol and Atrovent nebulizers; eventually spacing to q.8h. Additionally, she was continued on Flovent and Singulair as well as starting Serevent during this admission. She was sent home on a prednisone taper as well. Of note, her chest x-rays consistently showed an elevated left hemidiaphragm which appeared chronic in nature and was likely secondary to radiation-induced changes. 2. ONCOLOGY: The patient has a history of small cell lung carcinoma with metastases to the brain, [Year (4 digits) 500], and liver; status post multiple rounds of radiation therapy and resections. Her liver metastases appeared to be improving with chemotherapy, and her last cycle was on [2109-12-12] (five days prior to admission). While in house, she had an evaluation of progression of cancer with a magnetic resonance imaging of the head which showed no new metastatic disease and a [Year (4 digits) 500] scan which showed no new metastases as well as improvement in known metastases in T11 and left pelvis when compared to a [Year (4 digits) 500] scan dated [2109-6-14]. She was to follow up with Dr. [Last Name (STitle) 3274] for further chemotherapy regimens. 3. INFECTIOUS DISEASE: On presentation, the patient had subjective fevers at home with a low-grade temperature and 100.7 on admission. Her admission laboratories were notable for a bandemia of 30%, and an absolute neutrophil count of 250. As such, she was treated for a febrile neutropenia given her recent chemotherapy. She was started on cefepime 2 g q.8h. for empiric coverage. As her presenting symptoms appeared consistent with community-acquired pneumonia, azithromycin was added. She had repeat blood cultures which were all negative for growth, and a urinalysis which was unremarkable. While in the Intensive Care Unit, she had a sputum culture which grew out yeast and was thought to be oropharyngeal in origin given her inhaled steroid use. A viral culture was also performed and was negative for organisms. While in the Intensive Care Unit, her antibiotics were switched from cefepime and azithromycin to Levaquin, vancomycin, and Flagyl; and eventually narrowed the spectrum to Levaquin as possible sources of infection were excluded. She was continued on a 7-day course of Levaquin for pneumonia in the setting of a chronic obstructive pulmonary disease flare. The Levaquin was discontinued just prior to discharge. She was also started on Nystatin swish-and-swallow for yeast noted on sputum culture. 4. CARDIOVASCULAR SYSTEM: The patient with a history of supraventricular tachycardia, but no known coronary artery disease. She had pleuritic chest pain during her hospitalization which was related only to coughing. Her electrocardiogram was without changes. She was tachycardic for the first half of her admission which resolved with fluid rehydration. A transthoracic echocardiogram was performed on [2109-12-20] for evaluation of congestive heart failure given her symptoms of acute shortness of breath and diffuse rales on examination. The echocardiogram showed no evidence of congestive heart failure with an ejection fraction of 65%, and no significant valvular abnormalities. Her diltiazem was titrated up as her blood pressure would allow, and she was back on her outpatient regimen of diltiazem-XL 180 mg p.o. q.d. by the time of discharge. 5. RENAL SYSTEM: The patient had a normal creatinine of 1 at the time of admission which bumped up to 1.7 while in the Intensive Care Unit. A fractional excretion of sodium was performed on several occasions, and she was found to be less than 0.1%; indicating a volume depletion. She was aggressively fluid rehydrated, and her creatinine fell to 1.4. The etiology of her bump in creatinine was unknown; however, it was temporally related to two doses of intravenous Lasix. There were no episodes of hypotension to explain acute tubular necrosis. Urine eosinophils were drawn to rule out acute interstitial nephritis, and were initially found to be negative. However, a repeat sample (which was sent six hours later) showed moderately positive. It was unknown how to interpret the test, as the patient did not have any other symptoms of acute interstitial nephritis and seemed to be improving with fluid rehydration. Antibiotics were discontinued, as she had finished a 7-day course, in case they were implicated in her acute jump in her creatinine. It was thought that she may need an outpatient referral to the [Hospital 10701] Clinic if her creatinine remains consistently elevated. 6. HEMATOLOGY: The patient with a history of pulmonary embolism in [2109-3-29] which was probably secondary to hypercoagulable state given her neoplasm. Her Coumadin was subtherapeutic on admission at 1.7, and she was started on heparin in the Intensive Care Unit for possible pulmonary embolism. Her Coumadin dose was increased, and her INR bumped to 9. She was given one dose of vitamin K, and her Coumadin normalized with 36 hours. Her INR remained stable around 2 for the remainder of her hospitalization. The patient's admission hematocrit was read around baseline of 30; however, her hematocrit fell to 26, and she was given 2 units of packed red blood cells with an appropriate response. There was no clear source of bleeding, and it was felt that her anemia was secondary to chemotherapy. The patient also had a drop in platelets from 190 on admission to approximately 60 while in the Intensive Care Unit; which was also thought secondary to chemotherapy versus heparin-induced thrombocytopenia. A heparin-induced thrombocytopenia antibody was negative. It was not clear of the etiology of the acute thrombocytopenia; however, Levaquin has rarely been associated, and therefore was discontinued once completing a 7-day course. At the time of discharge, her platelets had rebounded to 81. 7. FLUIDS/ELECTROLYTES/NUTRITION/GASTROINTESTINAL: The patient has known metastases to liver which showed some improvement by recent chemotherapy. Her liver function tests were within the normal range during this hospitalization. Her initial presentation included a history of poor oral intake for which she was aggressively rehydrated with intravenous fluids. By the time of discharge, she had been taking adequate oral intake for approximately 24 hours without difficulties. 8. NEUROLOGIC SYSTEM: The patient has a history of metastases to the cerebellum; status post resection and radiation therapy. He also has known metastases to the thoracic spine. She has recent complaints of left shoulder and back pain which was concerning for recurrence. There were no focal deficits on examination, and a repeat magnetic resonance imaging on [2109-12-23] showed no new disease. On numerous occasions during the hospitalization, the patient had some episodes of urinary incontinence; however, she felt this was related to her lack of mobility and inability to make it to the commode in time. She had no episodes of bowel incontinence, and there was no focal deficits on lower extremity neurologic examination. Therefore, it was felt unnecessary to a further workup for spinal cord disease at this time. 9. ENDOCRINE SYSTEM: The patient was monitored on q.i.d. fingersticks secondary to high-dose steroids for a chronic obstructive pulmonary disease flare and was found on several occasions to have blood sugars in the 50s. She was completely asymptomatic at this time, and repeat fingersticks revealed glucoses of around 70. It was felt that her hypoglycemia was secondary to insulin given from the sliding-scale in combination with acute renal failure with the insulin remaining in the bloodstream longer than normal. CONDITION AT DISCHARGE: Condition on discharge was stable and improved. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease exacerbation. 2. Febrile neutropenia. 3. Acute renal failure. 4. History of small cell lung cancer with metastases. 5. Hypertension. 6. Thrombocytopenia. 7. Dehydration. MEDICATIONS ON DISCHARGE: 1. Diltiazem-XL 180 mg p.o. q.d. 2. Multivitamin one tablet p.o. q.d. 3. Coumadin 4 mg p.o. q.h.s. 4. Albuterol and Atrovent nebulizers q.8h. standing and q.4h. as needed with weaning down as needed. 5. Singulair 10 mg p.o. q.d. 6. Serevent 2 puffs b.i.d. 7. Flovent 2 puffs b.i.d. 8. Lipitor 30 mg p.o. q.d. 9. Prednisone taper. 10. Magnesium oxide 40 mg p.o. b.i.d. 11. Effexor 75 mg p.o. q.d. 12. Ranitidine 150 mg p.o. b.i.d. 13. Senna one tablet p.o. q.d. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [Last Name (STitle) 3274] on [2110-1-7] as previously scheduled. 2. The patient was sent home with [First Name (Titles) 407] [Last Name (Titles) 11807] and instructions on using new nebulizer machine. She did not require home oxygen at this time as her oxygen saturations remained 95% to 98% on room air at the time of discharge. MARK [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 3282] Dictated By:[Last Name (NamePattern1) 6240] MEDQUIST36 D: [2109-12-25] 15:19 T: [2109-12-30] 11:06 JOB#: [Job Number 102000]	[ "486", "5849", "2875" ]
Admission Date: [2136-8-6] Discharge Date: [2136-8-10] Date of Birth: [2069-6-14] Sex: M Service: CARDIOTHORACIC SURGERY HI[Last Name (STitle) 2710]OF PRESENT ILLNESS: The patient is a 67-year-old male, with known aortic insufficiency, who has been followed with serial echoes over the years. He recently developed increased chest tightness with exertion, and had palpitations and a presyncopal episode. He then underwent stress test which was found to be positive. After the positive stress test, he was then referred for cardiac catheterization, where he was found to have a dilated aortic root with severe aortic insufficiency, and stenosis of his right coronary artery, and an ejection fraction of 45%. He was then referred to Dr. [Last Name (Prefixes) 2545] for aortic valve replacement and coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Bilateral effusion of ankles. 3. Status post GI bleed secondary to NSAID use where he did have positive ulcer confirmed by EGD. ALLERGIES: NSAIDs or [Doctor Last Name ] II inhibitors, although he is able to tolerate a baby aspirin without any complications. MEDICATIONS ON ADMISSION: 1. Univasc 90 mg po qd. 2. Lipitor 40 mg po qd. 3. Aspirin 81 mg po qd. 4. Multivitamin qd. FAMILY HISTORY: Significant for a brother with coronary artery disease, having had a myocardial infarction at the age of 63, and his father also expired as a result of myocardial infarction. SOCIAL HISTORY: He is retired and lives with his wife. [Name (NI) ] does not nor has not ever smoked. He drinks a glass of wine a day. REVIEW OF SYSTEMS: Significant for him wearing glasses. He has no dysphagia. He does exhibit shortness of breath with exertion. He has experienced palpitations and chest tightness. He has had GI bleed with a negative colonoscopy, but positive EGD which showed an ulcer. He does have gait problems as a result of his ankle effusion. He has had no CVAs or TIAs. PHYSICAL EXAM: He was a well-appearing male in no apparent distress, looking younger than his stated age. His vital signs included a heart rate of 64, blood pressure 156/48 on the right, and 147/50 on the left. His skin was intact with no signs of rashes or infections. HEENT - PERRL, anicteric sclerae, and EOMI. His neck was supple with no JVD, no thyromegaly. His chest was clear to auscultation bilaterally with no wheezing, rales or rhonchi. His heart had a regular rate and rhythm with a III/VI systolic ejection murmur. His abdomen was soft, nontender, nondistended with positive bowel sounds and no masses. His extremities were warm and well-perfused with no clubbing, cyanosis or edema, and shows no varicosities. His neuro exam showed him to have [4-6] bilateral lower extremity strength, and his cranial nerves II through XII were grossly intact. His pulses showed him to have 2+ bilateral pulses in the femoral arteries, dorsalis pedis arteries, posterior tibialis arteries, and radial arteries. He does not show any signs of carotid bruit. His EKG on admission showed a sinus rhythm with a 1?????? AV block and PR interval of 308. His chest x-ray showed no acute disease. HOSPITAL COURSE: On day of admission, [2136-8-6], he underwent aortic valve replacement with a #27 mm pericardial CE valve and coronary artery bypass grafting x 1 with a saphenous vein graft to the PDA. The surgery was performed by Dr. [First Name (STitle) ] [Last Name (Prefixes) ] with Dr. [Last Name (STitle) 14968] and [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], NP as assistants. The surgery was performed under general endotracheal anesthesia with cardiopulmonary bypass time of 103 minutes, and a crossclamp time of 87 minutes. The patient tolerated the procedure well and was transferred to the Surgical Recovery Unit with two atrial and two ventricular pacing wires, two mediastinal and one left pleural chest tube, AV-paced at 90 beats per minute, on a propofol drip. He, in the overnight period, maintained a mean arterial pressure of 65 with a CVP of 12, PAD of 15. In the overnight period, he did well. He was extubated without difficulty and remained hemodynamically stable with a cardiac output 7.78 and a cardiac index of 3.65. He did have his chest tubes discontinued on the first postoperative day without difficulty. He had his Swan removed, and he was transferred to the Surgical Floor on this day. On postoperative day #2, he began working more with physical therapy, and cardiac rehab was initiated. He did have a chest x-ray which showed no sign of pneumothorax and a very small bilateral effusion. On postoperative day #3, he had his pacing wires DC'd without incident and continued with cardiac rehab. His hospital course was uneventful, and it was felt, on postoperative day #4, that he would be ready to be discharged to home. DISCHARGE EXAM: Showed his vital signs to be stable, with a temp of 99.2, heart rate 84, blood pressure 120/80. His lungs were clear to auscultation bilaterally. His heart regular rate and rhythm. His abdomen was soft, nontender, nondistended with positive bowel sounds. His extremities showed no clubbing, cyanosis or edema. His wounds were healing well, and his sternum was stable. DISCHARGE LABS: Include a white count of 8.9, hematocrit 26.5%, platelet count 137,000, sodium 138, potassium 3.9, chloride 103, bicarb 29, BUN 17, creatinine 0.8, blood glucose 108. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg po qd. 2. Lipitor 40 mg po qd. 3. Lopressor 25 mg po bid. 4. Lasix 40 mg po qd x 5 days. 5. Potassium Chloride 20 mEq po qd x 5 days. 6. Percocet 1-2 tabs po q 4 h prn pain. DISCHARGE DIAGNOSES: 1. Status post aortic valve replacement with a #27 CE valve and coronary artery bypass grafting x 1 on [2136-8-6]. 2. Status post bilateral effusion of ankles. 3. Hypercholesterolemia. 4. Gastrointestinal bleed due to nonsteroidal anti-inflammatory drugs with positive ulcer by esophagogastroduodenoscopy. FO[Last Name (STitle) ]P PLANS: 1. Follow-up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], in 1 week. 2. Follow with his cardiologist, Dr. [Last Name (STitle) 20222], in 2 weeks. 3. Follow with Dr. [Last Name (Prefixes) ] in 4 weeks. DISCHARGE INSTRUCTIONS: He should follow a cardiac diet. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 31272] MEDQUIST36 D: [2136-8-10] 11:22 T: [2136-8-10] 10:23 JOB#: [Job Number 52325]	[ "4241", "9971", "41401", "2720" ]
Admission Date: [2190-12-16] Discharge Date: [2191-2-18] Date of Birth: [2142-11-26] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 48-year-old male with a known history of endocarditis who was recently discharged from [Hospital1 18] on [2190-12-2] on ampicillin and gentamicin for an enterococcal bacteremia. He represented to the hospital on [2190-12-16] with a 101.3 temperature with ibuprofen use. PAST MEDICAL HISTORY: Hepatitis C virus x12 years with interferon treatment. GERD. Enterococcal bacteremia and endocarditis. Mitral regurgitation with torn mitral chordae. History of IV drug use with [2190-11-27] being the last stated use. Congestive heart failure. Anemia. MEDICATIONS ON ADMISSION: 1. Ampicillin 2 grams IV q.8h. 2. Gentamicin 80 mg IV q.8h. 3. Lasix 20 mg once a day. 4. Ferrous sulfate 325 mg once a day. 5. Ibuprofen 400 mg p.o. 3x a day. 6. Colace. 7. Nicoderm patch TD 21 mg once a day. 8. Seroquel 12.5 mg twice a day with an additional 25 mg dose every evening. 9. Multivitamins and vitamin E. SOCIAL HISTORY: Patient is a current smoker with a 20-pack- year history and admitted to remote IV cocaine use, remote alcohol abuse, and he is a resident of a facility for rehabilitation. He was admitted to the hospital on [2190-12-16] for evaluation of his fever on double IV antibiotics. Admission labs were a white count of 11.1, hematocrit 29, platelet count 438,000. Sodium 140, K 4.5, chloride 104, bicarbonate 27, BUN 14, creatinine 1.2 with a blood sugar of 119. Peak and trough gentamicin studies were done. Additional blood cultures were done. Patient had a long preoperative course. Over the course of the approximately 8 weeks prior to his surgery, he completed a 56-day course of ampicillin IV and a 56-day course of gentamicin IV. He had minor complications from this which included an episode of acute renal failure with his creatinine trending up to 2.1 and then back down again before prior to surgery. His blood cultures did show enterococcus which was treated with double antibiotic therapy. He also developed vertebral osteomyelitis during his hospital stay, which was diagnosed by MRI and evaluated by neurosurgery which recommended only antibiotic therapy and no need to biopsy or pursue at this time. He was followed daily by the infectious disease service as well as by cardiology service and was maintained for CHF with originally Lasix and ACE inhibitor. Over the course of his stay, preoperatively he also developed a right lower extremity peroneal vein DVT for which he was initially heparinized and then placed on Coumadin at therapeutic doses for coverage of the DVT. PICC line was also placed during that 8 weeks stay. Prior to surgery, ultimately the patient also had a cardiac catheterization on [2191-1-28] which showed clean coronary arteries, severe mitral regurgitation, severe tricuspid regurgitation, and severe pulmonary hypertension. Over the course of this stay, it was also discovered the patient required dental extractions. He was seen by the OMFS service. He was then transitioned from Coumadin to Lovenox and then ultimately as the INR dropped down to IV Heparin in preparation for 4 teeth extraction which took place on [2-11]. In addition, during that time period, he did complete his 8 weeks course of antibiotics. After his extractions, he went back on Coumadin. On[2-10], 4 days prior to surgery, he had a repeat TEE which showed severe MR, mild-to-moderate TR, and no abscess present in his heart. The patient was finally cleared for surgery. A repeat MRI was done in late [Month (only) 404] which showed essentially no change in the vertebral osteomyelitis. But with the official radiology [Location (un) 1131] that clinical findings often precede MR findings which lag behind. Dr. [Last Name (Prefixes) ] accepted evaluation and when the patient had approximately 14 days of negative blood cultures, he agreed to do the mitral valve prolapse. The patient had been off all antibiotics approximately 10 days at that time. Laboratory studies the day prior to operation were as follows: Sodium 137, K 4.6, chloride 104, bicarbonate 26, BUN 24, creatinine 1.3 with a blood sugar of 110, anion gap 12. White count 7.4, hematocrit 35.0, platelet count 256,000. PT 12.8, PTT 79.4 on Heparin drip with an INR of 1.0. [Last Name (STitle) 2708]was then officially cleared for surgery, and on [2191-2-14], the patient underwent mitral valve prolapse with a 29-mm porcine mitral valve by Dr. [Last Name (Prefixes) 411]. He was transferred to cardiothoracic ICU in stable condition. On postoperative day 1, patient had been extubated, had a respiratory rate of 19, saturating 96% on nasal cannula. Postoperatively, white count was 10.8, hematocrit 31, platelet count 156,000. INR 1.0, creatinine 1.3, K 4.8. His exam was unremarkable. He began Lopressor beta-blockade and Lasix diuresis again. Patient was transferred out to the floor that afternoon. He was seen again by cardiology postoperatively and case management to help him set up his living situation postoperatively. He had also been followed repeatedly by social work services preoperatively about 2 months before surgery. On postoperative day 2, his creatinine remained stable at 1.3. His white count rose slightly to 13.6. He was sleepy, but appropriate and with a nonfocal neurological exam. He had some nausea and vomiting early that morning. He continued on perioperative vancomycin. His Foley was removed. His pacing wires were removed. He started Heparin for his DVT after his pacing wires were removed later that day. ID was again reconsulted for clarification of postop antibiotics. White count was rechecked the following morning with a plan to panculture the patient if patient developed any fever. However, the patient had a temperature of only 98.9 that morning. Patient was seen and evaluated by physical therapy and began to work on ambulation with support from PT and the nurses. On postoperative day 3, patient had already ambulated to level 3. Was on Heparin at 800 units an hour. Received his first dose of Coumadin 5 mg later that evening. His Lasix was switched over to p.o. He was encouraged to increase his activity level with a plan to discharge him to his outside living situation in approximately the next 1-2 days. Central venous line was removed. Pacing wires had already been removed. Heart was regular rate and rhythm with a grade 2/6 systolic ejection murmur. Sternum was stable. Incision was clean, dry, and intact. He had a nonfocal neurologic exam, and his lungs were clear bilaterally. His weight was below his preoperative weight by 1.3 kilograms. Re[Last Name (STitle) 60120]reening was completed on postoperative day 4. The day of discharge, he did a level 4. His blood pressure was 111/76, in sinus rhythm at 87 with a respiratory rate of 20, saturating 97% on room air. He continued on his Heparin and received his Coumadin to get him therapeutic. From his dose the night prior, he continued with his beta-blockade with metoprolol 25 mg p.o. b.i.d. His exam was unremarkable. The patient did have a bowel movement. He was ready for discharge home and was progressing very well. He had been receiving Heparin and Coumadin for his DVT prior to surgery. But the nurse practitioner spoke with a primary care group, Dr. [Last Name (STitle) 1270] who felt the patient did not need to be anticoagulated. Surveillance blood cultures were drawn and the patient was given instructions to followup with ID in [12-26] weeks, with Dr. [Last Name (Prefixes) ] in 4 weeks for his postop surgical visit and with Dr. [Last Name (STitle) 1270] in [1-27] weeks postdischarge. Labs prior to discharge showed a white count of 8.7, hematocrit 29.1, platelet count 254,000. Creatinine 1.2. Coumadin was discontinued. DISCHARGE DIAGNOSES: Status post mitral valve replacement with 29-mm porcine mitral valve. Hepatitis C x12 years. Intravenous drug abuse. Vertebral osteomyelitis. Enterococcus bacteremia with endocarditis. Mitral regurgitation with torn mitral chordae. Congestive heart failure. Anemia. Right lower extremity deep venous thrombosis. Status post 4 dental extractions. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. once daily x7 days. 2. Ferrous sulfate 325 mg p.o. once a day for 1 month. 3. Quetiapine fumarate 12.5 mg p.o. twice a day. 4. Nicotine 21 mg 24-hour patch apply 1 patch transdermally daily. 5. Metoprolol 50 mg p.o. twice a day. 6. Potassium chloride 20 mEq p.o. once a day for 7 days. 7. Colace 100 mg p.o. twice a day. 8. Aspirin enteric coated 81 mg p.o. once a day. 9. Percocet 5/325 one to two tablets p.o. p.r.n. q.4-6h. for pain. CONDITION AT DISCHARGE: Again, the patient was discharged in stable condition on [2191-2-18] to his rehab facility. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2191-4-11] 13:17:55 T: [2191-4-12] 09:15:37 Job#: [Job Number 60121]	[ "4240", "4280", "5849", "V5861", "V1582", "53081" ]
Admission Date: [2118-12-25] Discharge Date: [2119-1-15] Date of Birth: [2064-3-10] Sex: F Service: NEUROSURGERY Allergies: Codeine Attending:[First Name3 (LF) 78] Chief Complaint: slurred speech, aphasia, right facial twitching(r mouth) witnessed acute 10 mm L SDH Major Surgical or Invasive Procedure: [2118-12-27]: Left craniotomy and evacuation of SDH [2118-12-29]: Re-do Left craniotomy for evacuation of SDH and subdural drain placement History of Present Illness: This patient is a 54 year old female who complains of Subdural hematoma. 2 stretcher from outside hospital where she presented with a fascia drooling and decreased responsiveness. By report her daughter spoke to her last night and she was slurring her speech at around 11 AM. She was found on the floor and brought to the emergency department where CT scan showed a acute subdural hemorrhage 1 cm with small amount of shift. She was intubated for airway protection and mental status changes and transferred here for further evaluation. The patient is unable to give further history due to 2 intubation. Past Medical History: EtOHism, otherwise unknown Social History: unknown Family History: unknown Physical Exam: T: 97.5 BP: 113/78 HR: 85 R 17 Gen: Intubated and sedated; examined 10 min off of propofol HEENT: No obvious trauma Neck: in hard collar Lungs: CTA bilaterally anteriorly. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Slightly opens eyes to loud voice. Just barely sticks out tongue to command. No verbalizations. Pupils 5 to 2mm and very briskly reactive. No clear BTT. + gag. Briskly localizes with the left, and localizes (but a bit weaker) on the right. Withdraws lowers. PHYSICAL EXAM UPON DISCHARGE: AOx3, Speech clear, follows commands, MAE [6-16], PERRL, EOM intact. Nonfocal exam. Head incision C/D/I Pertinent Results: [12-25] CT Head- IMPRESSION: 1. Stable 1-cm left convexity subdural hematoma with mass effect upon adjacent sulci and gyri, but no significant shift of midline structures. The ventricles appear stable. No new hemorrhage. [12-25] CT Head- IMPRESSION: 1. Stable left acute-on-subacute SDH, with stable 3-mm rightward shift. 2. Bilateral temporalis fascial calcifications may reflect underlying autoimmune or rheumatologic disorder, less likely trauma. [12-25]: CXR- FINDINGS: No previous chest radiographs available for direct comparison. Cardiac silhouette is within normal limits. Lungs are grossly clear without focal infiltrates. There is some atelectasis at the left lung. There is no pneumothoraces. Bony structures are grossly intact. [12-26]: MRI c-spine: Mild cervical spondylosis. No evidence of acute post-traumatic changes in the cervical spine. [2121-12-25] EEG- [12-26] LENI's- No evidence of DVT. [12-26]: MRI brain Mild cervical spondylosis. No evidence of acute post-traumatic changes in the cervical spine. [2118-12-27] EEG This is an abnormal extended-routine EEG because of intermittent left temporal slowing indicative of subcortical dysfunction. The background otherwise showed a [10-22] Hz posterior dominant rhythm. No epileptiform discharges or seizures were present in the record. [2118-12-27] CT head 1. Partial evacuation of left frontal SDH, now measuring 7 mm in thickness. 2. Chronic right frontal SDH measuring 6 mm. [2118-12-28] CXR In comparison with the study of [12-25], the retrocardiac opacification is less prominent, consistent with some improvement in atelectasis in the left lower lobe. Upper lungs are clear and there is no vascular congestion. [2118-12-29] Head CT IMPRESSION: Acute rebleeding into left frontal SDH, now measuring 2.2 mm, with 1.4-cm right subfalcine herniation, early left uncal herniation, and 1-cm rightward shift. [2118-12-29] Head CT IMPRESSION: Near-complete evacuation of left subdural hematoma with residual air filled collection, 9-mm right subfalcine herniation, early left uncal herniation, and 8-mm shift at the level of the third ventricle. [2118-12-30] Head CT IMPRESSION: 1. Improved shift of midline structures, now measuring 3 mm to the right compared to 9 mm on [2118-12-29]. 2. No evidence of reaccumulation. Residual blood products in the subdural space. 3. Expected postsurgical changes, decreasing pneumocephalus. [12-31] Head CT FINDINGS: Changes from left frontoparietal craniotomy are again noted, with the subdural drainage catheter removed in the interval. Persistent, but decreased, pneumocephalus is seen in, predominantly, the left subdural space, but it appears that the entire extra-axial collection is overall unchanged. In the dependent portions, there is some layering hyperdensity, likely residual blood products. No new hemorrhage is seen. There is persistent 4.5-mm rightward shift of normally midline structures with continued effacement of the left-sided sulci and the body of the left lateral ventricle. Small right-sided subdural collection is also seen. No evidence of central herniation is seen. Mucosal thickening and air-fluid levels are seen in the right sphenoid sinus and bilateral ethmoid air cells. The mastoid air cells are clear. IMPRESSION: Essentially unchanged appearance, with slight interval decrease in the degree of pneumocephalus with persistent 4.5-mm rightward shift of the midline structures. Residual blood products are seen, dependently, without evidence of new hemorrhage. [2119-1-3] ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [2119-1-4] Liver/gallbladder Ultrasound: Impression: 1) Hemangioma at the dome of the liver and two simple hepatic cysts. 2) Otherwise unremarkable abdominal ultrasound. [2119-1-10] Head CT: IMPRESSION: 1. Improved appearance of the operative site with interval mild decrease in the size of the left sided SDH; no new hemorrhage is seen. Brief Hospital Course: Ms. [Known lastname ] was admitted to the Neurosurgery service in the ICU under the care of Dr. [First Name (STitle) ]. Her INR was initially 1.1 but was noted to increase to 1.7 so she was given 3 doses of Vitamin K and FFP. Repeat CT was stable. She was then noted to have left sided facial twitching so the neurology team was consulted for assistance with seizure management. She was initially on Dilantin and Keppra was added per the Neurology service who was consulted for the seizure management. She was extubated on [12-25]. She had a temperature of 101.7 F. Fever work up was initiated. On [12-26] LENIs were obtained for surveillance which were negative. MRI c-spine ruled out injury and a collar was discontinued. On [12-27], She went to the OR with Dr. [First Name (STitle) ] for evacuation of left frontal SDH. She tolerated the procedure well and was transferred back to NICU. EEG was in place and finalized as no seizure activity on this date. Post-op Head CT showed some residual left SDH now measuring 7 mm in thickness and some chronic right frontal SDH measuring 6 mm. She had a JP drain in place. CXR showed improvement in Atelectasis and urine cultures were negative. Blood cultures showed Gram Positive Cocci in pairs and chains. This will be repeated to rule out contaminant. She was transferred to the floor on [12-28] and the drain was removed on [12-29] and the prophylactic Ancef was stopped. Later that evening the RN noted increased aphasia, a Head CT was done emergently which showed reaccumulation of the left SDH with midline shift and early herniation. The patient was taken to the OR emergently for a re-do left craniotomy for evacuation. A subdural drain was placed. She was brought to the Neuro ICU post-operatively. Repeat Head CT was stable. She was extubated on [12-30] AM and a repeat CT was stable. Her exam remained stable. On [12-31] the subdural drain was discontinued. A repeat Head CT showed minimal change but interval decrease in the amount of pneumocephalus. She was also started on Levofloxacin for a positive blood culture. On [1-1] she was transferred to the floor from step down. She remained stable on [1-2] and worked with PT/OT to determine disposition post-discharge. After evaluation they [Hospital 91734] rehab. She was screened and ofered a bed which was accepted and she was discharged to rehab on the afternoon of [1-2]. On [1-3], ID was consulted. On [1-4], they recommended that a TTE and RUQ ultrasound be done given the positive blood cultures. They also recommended that she continue her current antibiotic regimen until [1-13] and a PICC line was ordered. She remains neuro intact on examination and PT recommends rehab. She refused transfer to [Hospital3 ] on [1-5] and they do not accept transfers over the weekend. Her dilantin level was 1.1 on [1-7] and Dr. [First Name (STitle) ] felt that this was no longer needed and it was discontinued. Ms. [Known lastname ] remained stable. Discharge planning was addressed again with the patient but she continued to refuse transfer to the facilities she qualified for. She remained inpatient to continue IV antibiotics. A head CT was performed on [1-10] to assess prior to discharge. The CT looked improved. Patient remains in hospital for IV antibiotic treatment and refuses available rehab facilty. On [1-12], question of orthostatic hypotension, encouraged more PO intake. Her exam remained intact. On [1-13], her last dose of IV Ampacillin was given at 1200 giving her one extra dose. Her PICC was removed and she was discharged home as planned. Medications on Admission: Librium Discharge Medications: 1. Keppra 750 mg Tablet Sig: One (1) Tablet PO every twelve (12) Disp:60 Tablet(s) Refills:3 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. chlordiazepoxide HCl 5 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day): Home Med. 5. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia: See PCP for refills. Disp:10 Tablet(s) Refills:0 6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [5-18] hours as needed for pain: DO NOT DRINK ALCOHOL WITH THIS [Street Address(1) 91735] WHILE TAKING. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bilateral Subdural Hematoma Seizures / focal motor Bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may NOT resume taking this on unless cleared by your neurosurgeon. ?????? If you have been prescribed Keppra (Levetiracetam), for anti-seizure medicine, take it as prescribed. DO NOT DISCONTINUE UNLESS DIRECTED BY YOUR DOCTOR. ?????? As you have had seizures, you may not drive for at least 6 months per MA law. Clearance to return to work can be discussed at your follow-up appointment. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. * Please refrain from drinking alcohol for 4 weeks * Followup Instructions: ??????Please call ([Telephone/Fax (1) 2102] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [First Name (STitle) ] in the Traumatic Brain Injury (TBI) clinic the phone number is [Telephone/Fax (1) 6335]. If you have any problems booking this appointment please ask for [First Name8 (NamePattern2) 16367] [Last Name (NamePattern1) 16368]. Completed by:[2119-1-13]	[ "5180" ]
Admission Date: [2175-6-26] Discharge Date: [2175-7-8] Date of Birth: [2108-5-17] Sex: F Service: MEDICINE Allergies: Dyazide / Prozac / Nsaids / Inderal / Cefazolin Attending:[Last Name (NamePattern4) 290] Chief Complaint: rigors, fever Major Surgical or Invasive Procedure: Temporary [Last Name (NamePattern4) 2286] line Intubated Gallbladder percutaneous drain Triple lumen History of Present Illness: This is a 67 year-old female with ESRD s/p failed cadaveric renal tx on HD, recent admission for line sepsis, CAD, dCHF, hx PE, who presented to the ED with fevers and rigors and is transferred to the MICU for hypotension/concern for sepsis in the setting of HD. . Her recent history is notably for being hospitalized at [Hospital1 18] from [Date range (1) 12089] with fevers and culture negative sepsis presumed to be due to a line infection for which her HD catheter was removed and replaced. She had a TTE which did not show any evidence of endocarditis, and as nothing ever grew from her cultures, she was discharged after completing 2 week course of Vancomycin, stopping on 6/31. . On arrival to ED initial VS: 99 102 240/92 20 94% with 2 L, she was actively rigoring with rectal temp of 104, she reported some dyspnea then in setting of fever. Initially very hypertensive but CXR witout fluid overload. Blood cultures were drawn and she was given a dose of vanc/zosyn. She had no possible peripheral access. Given SVC syndrome, attempts at RIJ placement were unsuccessful, as pt has L tunned HD catheter, a femoral line was placed. She was also given tylenol, zofran and 1L NS with improvement in her symtoms. She had 1 episode of bilious vomiting, but no abd tenderness on exam. No localizing symptoms for infection. CXR suggested retrocardiac opacity, pt pt without SOB, cough, hypoxia. A viral NOS/flu syndrome was suspected, pt was admitted on droplet precautions for flu r/o. She does make a small amount of urine, but not enough to send for culture in ED. Here CBC was unremarkable with a WBC of 8.2. She had a trop of 0.11, during last hospitalization wsa 0.8. Elevated K 5.8. LFTs normal. INR 1.9 on coumadin. . On the floor, she was awake and alert and noted to be rigoring, temp 101.9, and complaining of low back pain, chronic for her but more severe than usual. She had a recent sick contact, and for the past several days had been having cold symptoms with productive cough and shortness of breath. Her daughter also stated she had been complaining of a right sided headache, although she denied this at the time of interview. She was given 2mg of morphine and became more somnolent and nauseous but stated that her pain was better controlled. Per her daughter she had started rigoring at 9pm; the family initially assumed she was hypoglycemic and gave her [Location (un) 2452] juice before coming to the ED. . She was undergoing HD on the morning of transfer had became hypotensive with BP in the 80s. No fluid was removed and she was given 300cc. Purulent material was noted to be weeping from her HD line and she was also tachypneic. She was then transferred to the MICU for further management. . On presentation, she was alert and oriented and c/o of lower abdominal pain which was relieved by a BM. She proceeded to have two other BMs of liquidy brown stool. She denied SOB/CP but appeared uncomfortably, grunting with breaths. Past Medical History: -Line infections: Hospitalized in [4-1] for staph epi bacteremia, treated through, re-hospitalized end of [Month (only) 596] for culture negative sepsis, HD line removed. -ESRD - HD MWF -s/p cadaveric renal transplant in [2168] -DM II with retinopathy, neuropathy -h/o PE (dx [1-30]) -SVC syndrome ([1-30]) -Hyperlipidemia -HTN -s/p mult CVA's (recently [2173-8-23]) -CHF [12-26] diastolic function -CAD -Pulmonary artery hypertension -hyperparathyroidism -L2 compression fracture -depression -anemia Past Surgical History: 1. L AV graft [2171] Dr. [Last Name (STitle) 816] Multiple thrombectomies done by Dr. [Doctor Last Name 816] Dr. [First Name (STitle) ] and Dr.[Last Name (STitle) ] and Dr. [First Name (STitle) 2491] (IR). 2. cadaveric renal transplant 3. s/p cataract extraction Social History: Lives with daughter. Retired nurses aid. No tobacco or EtOH use. Walks with cane for balance. Born in [Country ]. HD at [Location (un) ] [Location (un) ] M/W/F. Family History: Father w/ DM and kidney disease and mother w/ HTN. Physical Exam: PHYSICAL EXAM: Admit Vitals - T:97.9 BP:111/50 HR:98 RR:18 02 sat:99% 10L face mask GENERAL: Uncomfortable, moaning HEENT: NCAT. MMM, sclera anicteric. Prominent L cervical node vs SVC/IJ clot. No meningismus. CARDIAC: Tachycardic and regular with harsh 2/6 systolic murmur. HD tunneled catheter on left chest. LUNG: poor air movement. rales at left base. ABDOMEN: Soft, non-tender. + BS, no tenderness over transplant. EXT: No edema. right femoral catheter in place. no rash. NEURO: Awake and answering questions appropriately, appears uncomfortably and grunting during breaths. No focal weakness. Oriented. Pertinent Results: [2175-6-26] 12:05AM BLOOD WBC-8.2 RBC-3.97* Hgb-11.4* Hct-36.8 MCV-93 MCH-28.8 MCHC-31.0 RDW-16.4* Plt Ct-255 [2175-6-26] 12:05AM BLOOD Neuts-84.2* Lymphs-8.6* Monos-5.1 Eos-1.8 Baso-0.2 [2175-6-26] 12:05AM BLOOD PT-20.7* PTT-33.7 INR(PT)-1.9* [2175-6-26] 12:05AM BLOOD Glucose-100 UreaN-48* Creat-7.8# Na-139 K-5.8 Cl-100 HCO3-24 AnGap-21* [2175-6-26] 12:05AM BLOOD ALT-13 AST-21 CK(CPK)-131 TotBili-0.4 [2175-6-26] 01:39PM BLOOD CK-MB-12* MB Indx-2.9 cTropnT-1.10* [2175-6-26] 11:13AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.7 [2175-7-1] 05:37PM BLOOD TSH-1.6 [2175-6-26] 09:25AM BLOOD Type-ART O2 Flow-5 pO2-90 pCO2-34* pH-7.52* calTCO2-29 Base XS-4 Intubat-NOT INTUBA Comment-SIMPLE FAC [2175-6-26] 09:33AM BLOOD Lactate-2.7* [2175-7-7] 06:13AM BLOOD WBC-23.2* RBC-3.46* Hgb-9.9* Hct-32.7* MCV-95 MCH-28.5 MCHC-30.2* RDW-17.4* Plt Ct-407 [2175-7-7] 06:13AM BLOOD Neuts-86* Bands-1 Lymphs-9* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-25* [2175-7-7] 06:13AM BLOOD PT-22.6* PTT-41.2* INR(PT)-2.1* [2175-7-7] 12:28AM BLOOD Fibrino-657# [2175-7-7] 06:13AM BLOOD Glucose-394 UreaN-46* Creat-8.4* Na-141 K-5.2* Cl-105 HCO3-14* AnGap-27* [2175-7-7] 06:13AM BLOOD ALT-2139* AST-7871* LD(LDH)-6740* AlkPhos-113 TotBili-0.4 [2175-7-5] 04:24AM BLOOD Lipase-118* [2175-7-4] 04:17AM BLOOD CK-MB-4 cTropnT-1.79* [2175-7-7] 06:13AM BLOOD Calcium-11.0* Phos-5.3* Mg-2.2 [2175-7-6] 06:10PM BLOOD Type-ART Temp-39.1 Rates-[11-4] Tidal V-450 PEEP-5 FiO2-30 pO2-104 pCO2-29* pH-7.32* calTCO2-16* Base XS--9 Intubat-INTUBATED Vent-CONTROLLED [2175-7-7] 11:57AM BLOOD Lactate-3.1* EKG [6-26] Sinus tachycardia. Baseline artifact. Incomplete right bundle-branch block and non-specific lateral ST-T wave changes. Compared to the previous tracing of [2175-5-16] anterolateral ST-T wave changes are not seen on the current tracing and the rate has increased substantially. Clinical correlation is suggested. Echo [2175-6-28] There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Mild to moderate ([11-25]+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: No valvular vegetations seen. Mild to moderate aortic regurgitation. EKG [7-2] Probable ectopic atrial rhythm. Deep T wave inversions in the anterolateral leads suggesting an extensive myocardial infarction. Very minimal ST segment elevation in leads V1-V2. Compared to tracing #1 no significant change. CT [7-2] IMPRESSION: 1. Filling defects consistent with thrombi versus fibrin sheath (from prior catheter) in the superior vena cava and left internal jugular vein. 2. Distention of the gallbladder with surrounding stranding. Acute cholecystitis cannot be ruled out. Suggest HIDA scan or [Month/Day (4) 4338] with Eovist for further followup. CT torso [7-6] CONCLUSION: 1. Multiple new hypodense geographic regions in the liver, spleen, native kidneys and renal transplant that are concerning for hypoperfusion / infarcts. 2. Cholecystostomy tube in situ, with post-procedural low-density lesions in either side of cholecystostomy tube within the right lobe of the liver that could represent biloma, hematoma, but cannot exclude abscess. 2. New low-density lesions identified in the dome of the right lobe of the liver felt most likely to represent infarcts; abscess at the hepatic dome felt less likely. 3. Gas within the lower pole of the renal transplant is new since the previous CT, and is felt likely to relate to prior instrumentation, although gas-forming organism cannot be entirely excluded if infection is present. 4. No intra-abdominal or pelvic drainable collections. Echo [7-7] IMPRESSION: Diffuse thickening of the mitral leaflets with moderate to severe mitral regurgitation. Moderate thickening of the aortic valve leaflets with moderate to severe aortic regurgitation. No discrete vegetation seen, though endocarditis cannot be fully excluded. There is no intracardiac thrombus. Compared with the prior TEE (images reviewed) of [2175-6-28], the mitral leaflets are now diffusely thickened and the severity of mitral regurgitation is markedly increased c/w endocarditis. Aortic valve morphology and severity of aortic regurgitation are grossly similar. Brief Hospital Course: ASSESSMENT & PLAN: 67 year-old female with ESRD s/p failed cadaveric renal tx on HD, recent admission for line sepsis, CAD, dCHF, hx PE, who presented to the ED with fevers and rigors and is transferred to the MICU for hypotension/concern for sepsis in the setting of HD, subsequently developed respiratory failure and was intubated. . # Sepsis: The patient presented with SIRS presumed to be secondary to line infection. Pus was expressed from around the patient's line and MSSA grew from blood cultures from that line. The line was removed. The patient was started initially on meropenem and vancomycin which was narrowed to nafcillin once MSSA was cultured. Other possible etiologies were examined including pneumonia, c.diff., cholycystitis, influenza, endocarditis, UTI, etc. No clear etiology was found through numerous imaging studies and blood cultures. The patient was given IVF to increase MAP and became fluid overloaded and subsequently developed respiratory failure requiring intubation. The patient was given phenylephrine to keep her pressures above a MAP of 65. . The patient remained febrile and a CT torso was conducted. It showed a distended gallbladder and an irregular HIDA scan prompted a gallbladder percutaneous drain. The culture showed normal bile. . For some time she was off pressors though not able to be weaned from the vent. However, she had labile blood pressures and did periodically have need for brief periods of pressors during short periods of hypotension. Starting on [7-6], the patient had consistent hypotension and new degrees of fever, and had a repeat echo and CT torso as well as broadening of antibiotic coverage to include vancomycin and meropenem. The CT torso showed multiple infarcts in the liver, spleen, native kidneys and renal transplant concerning for hypoperfusion/infarcts. Micafungin was added. . An echocardiogram on [7-6] showed thickening of the mitral valve leaflets compared to an earlier echocardiogram of [6-28], and was unable to exclude vegetation, suggesting though not proving endocarditis, which was consistent with the clinical picture. The patient continued not to improve on antibiotics and had dramatically increasing pressor requirements, requiring consistent use of two pressors. A family meeting was held at this time with the decision not to withdraw care, but not to advance care to further pressors or additional interventions. Thus, her pressor use and vent requirements remained the same based on this plan; but with this, she subsequently developed hypotension and acidemia which was followed by arrhythmia and death. The family was present throughout including her two daughters being present at time of death, and agreed with plan of care. Her two daughters consented to a limited autopsy. . Microbiology results which returned after her death showed VRE-positive blood cultures from [7-8] and urine culture from [7-5] (resulted on [7-9]), with blood cultures returning as positive in the setting of having been on vancomycin, meropenem, and micafungin at the time, suggesting that the VRE (as is common) was not sensitive to meropenem, though specific sensitivity testing to meropenem was not performed. . # Cardiac Enzymes/ECG changes: On admission to the unit the patient developed dynamic chages with STEs, RBBB and upright t-waves. This rhythm changed to a more rapid rhythm with deep lateral t-wave inversion and without RBBB. The patient had an elevated troponin-T with a CK-MB index of 2.9, which remained stable. The patient was started on heparin sliding scale, aspirin, statin, metoprolol for rate control (once pressures tolerated). Cardiology was consulted and said the likely cause was demand ischemia in the setting of hypotension. An echo on [6-28] was unremarkable. There was no plan for cath due to bacteremia. The patient subsequently developed sustained V-tach with perfusion. The patient's sedation was increased and lidocaine drip was started with resolution of arrhythmia. Lidocaine was discontinued with stable rhythms. Her CK increased, her statin was stopped with a down trend in CK. Ultimately as above, a later echocardiogram raised suspicion for endocarditis. . # Hypoxemic hypercarbic respiratory failure: The patient presented to the unit after receiving IVF for rescucitation. Her work of breath increased and she was intubated for hypoxemic hypercarbic respiratory failure. She had fluid removed with CVVH and HD and had CXR which showed improvement in her volume status. The patient was unable to be weaned from the ventilator secondary to agitation with lifting of sedation and poor NIF scores. Neuromuscular was consulted and conducted EMG studies which suggested that the patient had diffuse axonal neuropathy and muscular disease. This was not followed up further given her death from other causes as described above. . # ESRD, s/p failed kidney transplant: The patient presented after [Month/Day (1) 2286]. She was on a M,W,F schedule. Renal was consulted. Her HD line was removed due to suspected infection and was replaced 48 hours later. She required CVVH and HD to remove excess fluid and normalize her electrolytes. Her low dose prednisone was continued as were nephrocaps and cinacalcet. . [Month/Day (1) ] on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Month/Day (1) ]:30 Tablet(s) Refills:2 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Epogen Injection 9. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). [Month/Day (1) ]:30 Tablet(s) Refills:2 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 15U in AM, 2U in PM Subcutaneous twice a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Warfarin 6mg daily Discharge [Month/Day (1) ]: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "99592", "51881", "40391", "4280", "V5861" ]
Admission Date: [2175-9-9] Discharge Date: [2175-9-13] Service: ID/CHIEF COMPLAINT: This is a 73 year old female with a history of supraventricular tachycardia and coronary vasal spasm and previous myocardial infarction. PAST MEDICAL HISTORY: 1. Coronary vasospasm - The patient has had a previous admission in [2166] and [2170] with precipitation by stress. In the past she has had two previous myocardial infarctions and a previous coronary catheterization showing normal coronary arteries without blockages. Echocardiogram in [2171-8-26] showing anterior, septal, apical, inferoposterior hypokinesis with normal right ventricular function and an ejection fraction that was moderately depressed. 2. Hypertension 3. Myotonic dystrophy 4. Appendectomy 5. Deep vein thrombosis 6. Bilateral cataract surgery ADMISSION MEDICATIONS: 1. Diltiazem 2. Metoprolol 3. Vasotec 4. Serax ALLERGIES: Ativan causes agitation HISTORY OF PRESENT ILLNESS: The patient presented to [Location (un) 745] [Hospital 18896] Hospital with shortness of breath with walking. The patient was out walking with her husband and lost site of her husband and became anxious. At presentation at [First Name5 (NamePattern1) 745] [Last Name (NamePattern1) 18896] the patient's electrocardiogram showed ST elevation and Q waves inferiorly and anteriorly. The patient was lysed with TNK. Subsequently the patient had issues with hypotension and respiratory distress and was intubated. She was started on Dopamine infusion. Cardiac enzymes done at [First Name5 (NamePattern1) 745] [Last Name (NamePattern1) 18896] showed a CK of 244 and a troponin of 30. The patient continued to have ST elevations anterolaterally and was transferred to [Hospital6 256]. The patient was taken to the Cardiac Catheterization Laboratory which demonstrated normal coronary arteries. It was noted that the patient had sluggish flow through her coronary arteries and her TIMI fren count improved with intracoronary Diltiazem infusions. SOCIAL HISTORY: The patient drinks one drink per day and is a nonsmoker. She lives with her husband in an apartment. FAMILY HISTORY: The patient's father died of diabetes in his 70s and her mother died of a pulmonary embolism at the age of 58. Her mother also had a history of myotonic dystrophy. PHYSICAL EXAMINATION: On presentation to the Coronary Care Unit the patient was afebrile and was hemodynamically stable. General examination showed an older white female in no apparent distress. She appeared her stated age. Head and neck examination, the patient was intubated with no lymphadenopathy, tracheal deviation. Her pupils were equal and reactive to light. Neurologically the patient was awake, alert, responding to commands and moving all limbs. Respiratory examination was significant for some bilateral inspiratory crackles diffusely. Cardiovascular examination showed no jugular venous distention. She had normal heartsounds with no extra heartsounds and no murmurs. She did not have any peripheral edema. Abdominal examination was unremarkable. HOSPITAL COURSE: The patient was extubated the day following admission. She had cardiac enzymes done which trended downward during her admission. Her CK and MB trends were 352/23 to 315/16 to 149/6 to 114/7. The patient had another further episode of shortness of breath during her hospital stay which was related to anxiety upon hearing that her temperature was 100.6. She was noted to be in sinus tachycardia at 140 and her shortness of breath subsequently resolved following diltiazem bolus intravenously and p.o. Serax. Psychiatry Service was also consulted to provide input regarding the patient's anxiety management. It was recommended at that time that the patient start Paxil and continue with Klonopin for a week to two weeks post discharge to provide coverage while the Paxil was being loaded. The patient was discharged home on [2175-9-13] in stable condition. DISCHARGE MEDICATIONS: 1. Serax 15 mg p.o. q.h.s. 2. Colace 100 mg p.o. b.i.d. 3. Cardizem CD 120 mg p.o. q.d. 4. Amlodipine 5 mg p.o. q.d. 5. Enteric coated aspirin 325 mg p.o. q.d. 6. Paxil 10 mg p.o. q.h.s. 7. Metoprolol 25 mg p.o. b.i.d. 8. Sublingual nitroglycerin prn CONDITION ON DISCHARGE: The patient was discharged home in stable conditions. DISCHARGE INSTRUCTIONS: Follow up with primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] later this week or early next week. [Name6 (MD) 9272] [Name8 (MD) 9273], M.D. [MD Number(1) 9274] Dictated By:[Name8 (MD) 26201] MEDQUIST36 D: [2175-9-14] 14:26 T: [2175-9-14] 15:27 JOB#: [Job Number 92375] cc:[2175]	[ "4280", "4019", "412" ]
Admission Date: [2127-5-23] Discharge Date: [2127-6-5] Date of Birth: [2069-3-4] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: HCV cirrhosis/HCC Major Surgical or Invasive Procedure: [2127-5-23] liver transplant [2127-5-30] ercp with stent History of Present Illness: 58 y.o. M with HCV Cirrhosis, HCC s/p RFA [3-11] with recent CT-scan showing no evidence of recurrent disease. Has been feeling well. Had 2 teeth extracted a few weeks ago. Did not fill script for prophylactic antibiotics, but has not had any sx of infection. Denies recent illness/colds, recent ill contacts. Denies f/c/HA/LAD/cp/sob/abd pain/dysuria/back or joint pain/rashes/melena. Does have some problems with constipation Had CT scan today at [Hospital3 2358] as part of live donor liver transplant w/u. Ate egg whites/ice tea a few hours ago, otherwise npo since yesterday for the CT. Past Medical History: HCV cirrhosis [1-4] IVD, h/o rx with interferon, HCC s/p RFA [3-11], Barrett's esophagus, PSH: hernia repair as child, 2 teeth extracted recently Social History: Social History: Married. No children. Not currently working due to illness. Worked in the catering business. Habits: Smoked as "a kid". none since. No ETOH for 25 years. In AA. Does not do intravenous drugs any more. Did this as a teenager. Family History: FH: Mother died from ETOH. Father died of liver cancer. Physical Exam: PE:97.6 65 125/70 18 96%RA Wt: 94kg A&O, a little tense, Wife and friends present [Name (NI) ]: pupils equal, reactive, anicteric sclerae, no thrush, L upper & L lower tooth extraction sites appear to be healing well. Pharynx wnl Neck: 2+ carotids, no bruits, no LAD, No TM Lungs: clear Cor: RRR, no murmurs Abd: soft, + BS, NT/ND, No bruits, no HSM Ext: no cce, 2+ DPs bilat Neuro: A&O, no asterixis Pertinent Results: On Admission: [2127-5-23] WBC-6.0 RBC-4.73 Hgb-14.4 Hct-41.7 MCV-88 MCH-30.4 MCHC-34.5 RDW-13.7 Plt Ct-150 PT-13.2 PTT-27.7 INR(PT)-1.1 Glucose-83 UreaN-15 Creat-1.0 Na-141 K-3.9 Cl-105 HCO3-25 AnGap-15 On Discharge [2127-6-5] WBC-7.2 RBC-3.84* Hgb-12.2* Hct-35.9* MCV-93 MCH-31.7 MCHC-33.9 RDW-14.1 Plt Ct-197 ALT-822* AST-132* AlkPhos-216* TotBili-0.6 Albumin-3.1* AFP-2.5 tacroFK-17.2 Brief Hospital Course: On [2127-5-24] he underwent Orthotopic deceased donor liver transplant. Surgeon was Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]. Please refer to operative note for complete details. Per the operative report, "the donor liver had a markedly enlarged right lobe relative to the space. It fit well but there was some angulation to the portal vein from the recipient to the donor as a result of the large size of the right lobe". Also, " shortly after reperfusion the patient developed hypotension to the 60s and 70s associated with atrial fibrillation. Blood pressure returned relatively quickly, but he did remain in atrial fibrillation for approximately 20 minutes. He then converted spontaneously to normal sinus rhythm. He remained hemodynamically stable". Two [Location (un) 1661]-[Location (un) 1662] drains were placed. Postop, he was transferred to the SICU intubated for management. On pod 1, he was extubated. U/S obtained on POD 1 was normal with normal vasculature. He continued to proceed along the pathway until POD 5, when bilious drainage was noted in the Lateral drain. (14) An ERCP was done on [5-30] which demonstrated a bile leak. Extravasation in the biliary tree was treated with sphincterotomy and stent placement (10 Fr stent) Normal pancreatic duct was noted. Post ERCP the AST and ALT were noted to increase (228 and 903 respectively) Over the next 3 days, labs were monitored, and it was decided since they were again trending down that a biopsy would be deferred. Both Dr [Last Name (STitle) 497] and Dr [Last Name (STitle) 816] were discussing this plan. The patient was ambulating freely and tolerating diet. He was started on insulin, scripts for supplies were given. He demonstrated understanding of blood sugars, insulin administration and immunosuppression regimen with the self med program. He is discharged with one drain Medications on Admission: [Last Name (un) 1724]:Prilosec 40 prn, Aspirin 81 prn (has taken randomly in last few weeks "maybe 3-4 times in last few weeks for heart protection" Discharge Medications: 1. One Touch Ultra 2 Kit Sig: One (1) kit Miscellaneous four times a day. Disp:1 kit Refills:0 2. One Touch II Test Strip Sig: One (1) strip In [Last Name (un) 5153] four times a day. Disp:1 bottle Refills:2 3. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscellaneous four times a day. Disp:1 box Refills:2 4. syringes Sig: One (1) four times a day: low dose 1/2 cc (u 50), 30 gauze needle. Disp:1 box Refills:2 5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 6. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): Taper per transplant clinic recomendations. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection ASDIR (AS DIRECTED). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed: Do not exceed 4 tablets daily. Disp:28 Tablet(s) Refills:0 11. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection four times a day. Disp:2 bottles Refills:2 16. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO ONCE (Once) for 1 doses. 17. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day: Starting morning of [2127-6-6]. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: HCV cirrhosis HCC glucose intolerance while on steroids s/p liver transplant [2127-5-24] Discharge Condition: good Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if you have fever (101 or greater), chills, nausea, vomiting, inability to take any of your medications, jaundice, increased abdominal pain, incision redness/bleeding/drainage Labs every Monday and Thursday [Month (only) 116] shower, pat incision dry. No tub baths or swimming until directed otherwise Empty and record drain output daily and as needed. Bring copy of output record with you to your clinic visit No heavy lifting No driving while taking pain medication Followup Instructions: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2127-6-12] 9:00 [Last Name (LF) ],[First Name3 (LF) 156] TRANSPLANT SOCIAL WORK Date/Time:[2127-6-12] 10:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2127-6-18] 9:40 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2127-6-5]	[ "42731", "V1582" ]
Admission Date: [2168-12-24] Discharge Date: [2168-12-30] Date of Birth: [2126-6-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2698] Chief Complaint: dizzyness, presyncope, chest pain Major Surgical or Invasive Procedure: cardiac catheterization with stent (cypher) to RCA and PDA History of Present Illness: 42 yo man with pmh sig for hypertension on four antihypertensive medications, had three days of intermittent [4-18] left sided chest "pressure" associated with dizziness all occurring at rest but dizziness worse with standing. After three days of symptoms pt went to PCP's office, while there felt "so dizziy (he) might pass out" and was taken to the OSH ED. He noted that he discovered that he had been taking double his Tiazac dose for the past two days mistakenly. In OSH ED found to have bp 90s/60s, inferior STEMI with first degree AV block, was started on Heparin and Integrilin, as was found to be asymptomatic at time. As he also had an increased creatinine, he was admitted with plans to transfer to [Hospital1 18] at later date for cardiac catheterization. However, upon becoming symptomatic with AV dissociation he was immediately transferred to [Hospital1 18] for catheterization. At [Hospital1 18] he was found to have disease of the RCA and PDA, received cypher stents at each site, was also found to be in third degree AV block and was transferred to the CCU. Past Medical History: Hepatitis C Hypertension Social History: Lives with wife and daughter [Name (NI) 1403] for moving company Smokes marijuana Lat used cocaine three weeks ago Family History: CVA in parents Physical Exam: BP 100/70 HR 60s RR 14 O2 97% RA No acute distress No JVD Cardiac exam with regular rate and rhythm, nl s1s2, no mrg Lungs clear Abdomen soft nontender nondistended nabs Extremity wwp, co cce Groin site cdi Pertinent Results: [2168-12-24] 08:26PM PT-13.7* PTT-32.1 INR(PT)-1.2 [2168-12-24] 08:26PM PLT COUNT-344 [2168-12-24] 08:26PM WBC-13.8* RBC-4.47* HGB-12.5* HCT-37.8* MCV-85 MCH-27.9 MCHC-33.0 RDW-13.8 [2168-12-24] 08:26PM TRIGLYCER-141 HDL CHOL-33 CHOL/HDL-5.1 LDL(CALC)-108 [2168-12-24] 08:26PM CALCIUM-9.0 PHOSPHATE-2.4* MAGNESIUM-1.8 CHOLEST-169 [2168-12-24] 08:26PM CK-MB-8 cTropnT-1.46* [2168-12-24] 08:26PM ALT(SGPT)-33 AST(SGOT)-42* CK(CPK)-214* ALK PHOS-78 AMYLASE-114* TOT BILI-0.5 [2168-12-24] 08:26PM LIPASE-26 [2168-12-24] 08:26PM GLUCOSE-143* UREA N-17 CREAT-1.1 SODIUM-136 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-32* ANION GAP-10 . . Cardiac Catheterization: PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 French left [Last Name (un) 2699] catheter, advanced to the ascending aorta through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French JL4 and a 6 French JR4 guiding catheter, with manual contrast injections. Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: m2 HEMOGLOBIN: gms % ENTRY PRESSURES LEFT VENTRICLE {s/ed} 112/20 AORTA {s/d/m} 112/81/96 CARDIAC OUTPUT HEART RATE {beats/min} 65 RHYTHM JUNCTIONAL ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA DISCRETE 100 ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 40 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX DISCRETE 30 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 NORMAL 15) OBTUSE MARGINAL-2 NORMAL PTCA RESULTS RCA PDA BASELINE STENOSIS PRE-PTCA 100 100 TECHNIQUE PTCA SEQUENCE 1 2 GUIDING CATH 6FJR4 6FJR4 GUIDEWIRES CPTXS CPTXS INITIAL BALLOON (mm) 2.0 2.0 FINAL BALLOON (mm) 2.5 2.5 # INFLATIONS 4 5 MAX PRESSURE (PSI) 270 210 RESULT STENOSIS POST-PTCA 0 0 SUCCESS? (Y/N) Y Y PTCA COMMENTS: Initial angiography revealed a total occlusion of the mid RCA at the origin of what was felt to be a bifurcaiton point of the mid RCA and an acute marginal branch. We planned to treat the RCA with thrombectomy and stenting with rescue of the marginal branch if necessary. Eptifibatide was continued. A 6 French JR4 guiding catheter provided adequate support for the intervention. A ChoICE PT XS wire was easily directed pst the occlusion and into what was felt to be the distal RCA. A 2.0 x 20 mm Maverick balloon was uded to dotter through the occlusion and then dilate the stenotic area using 2 inflations of 8 ATM just distal to what was felt to be the acute marginal branch. This provided some restoration of flow which revealed significant thrombus. Thrombectomy was performed with a PercuSurg Export catheter. A 2.5 x 28 mm Cyoher DES was then deployed across the stenosis with good result. We then turned our attention to what we thoight was an acute marginal. After crossing into the vessel with the ChoICE PT xs wire, it became apparent that this acute marginal branch was really a sizeable PDA. After dottering with the 2.0 x 20 mm balloon and then dilating a significant proximal stenosis with inflaitons of 12, 12, 10, and 10 ATM. A 2.5 x 28 mm Cy[her DES was deployed across the stenosis at 14 ATM. Final angioraphy revealed no residual stenosis, no apparent dissection, and normal flow. The patient left the lab free of angina and in stable condition. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 41 minutes. Arterial time = 39 minutes. Fluoro time = 11.6 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 190 ml Premedications: ASA 325 mg P.O. Clopidogrel 300 mg po Eptifibatide gtt Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin [2163] units IV Other medication: Atropine 2 mg iv Eptifibatide gtt TNG 600 mcg ic Cardiac Cath Supplies Used: .014 [Company ], CHOICE PT XS, 300CM .014 [Company ], CHOICE PT XS, 300CM 2.0 [Company ], MAVERICK, 20 6F CORDIS, JR 4 SH 6F [First Name8 (NamePattern2) ] [Male First Name (un) ], ANGIOSEAL, 6F 200CC MALLINCRODT, OPTIRAY 200CC 2.5 CORDIS, CYPHER OTW, 28 2.5 CORDIS, CYPHER OTW, 28 3F [Company ], EXPORT ASPIRATION CATHETER COMMENTS: 1. Selective coronary angiography of this right dominant system revealed one vessel disease. The LMCA had mild luminal irregularities. The LAD likewise had mild luminal irregularities and a 40% lesion in the mid vessel. The LCX had mild diffuse disease with a more focal 30% stenosis in its mid-segment. The RCA was totally occluded in its mid-segment 2. Limited resting hemodynamice revealed moderately elevated left-sided filling pressures (LVEDP 20 mmHg). Systemic areterial pressures were normal and there was no gradient noted on catheter pull back across the aortic valve. 3. Successful PTCA and stenting of the distal RCA with a 2.5 x 28 mm Cypher DES. Final angiography revealed no residual stenosis, no apparent dissection and normal flow (see PTCA comments). 4. Successful PTCA and stenting oh the rPDA with a 2.5 x 28 mm Cypher DES. Final anigoraphy revealed no residual stenosis, no apparent dissection, and normal flow (see PTCA comments). 5. Successful deployment of a 6 French Angioseal device in the right femoral arteriotomy. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful placement of a drug-eluting stent in the distal RCA. 3. Successful placement of a drug-eluting stent in the rPDA. 4. Successful Angioseal. . . ECHO: EF 40-45% The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract well. 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 structurally normal. There is no mitral valve prolapse. Mild to moderate ([12-11]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation c/w papillary muscle dysfunction Brief Hospital Course: After catheterization with stent placement to the RCA and PDA pt was stable, continued to be in third degree AV block for several days but asymptomatic, hemodynamically stable, without elevation in creatinine or QT prolongation. On the third hospital day he began to show signs of return of AV function with periods of first degree AV block. On the fourth hospital day he developed chest pain which was relieved with nitro drip. By the fifth hospital day his rhythm wa predominantly first degree AV block, and he was asymptomatic and hemodynamically stable. Echo showed EF 40-45%, no akinesis or requirement for coumadin. He was discharged on the seventh hospital day with an appointment set up for follow up with PCP and Cardiology. Medications on Admission: Tiazac 420 mg po qd Diovan 160 mg po qd Atenolol 100 mg po qd HCTZ 25 mg po qd Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:30 Tablet(s) Refills:2 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Inferior wall myocardial infarction Complete heart block, followed by intermittent first degree heart block Discharge Condition: stable Discharge Instructions: Please return to the ER or call your doctor if you have any further chest pain, difficulty breathing, any weakness, numbness, or bleeding. . Please take all your medications as directed. Followup Instructions: 1)CARDIOLOGIST - Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD Where: [Hospital 4054] CARDIAC SERVICES Phone:[Telephone/Fax (1) 4022] Date/Time:[2169-1-19] 8:30 [Hospital Ward Name 23] Center is at [Location (un) ]. [Location (un) 86] - at [Hospital Ward Name 516] of [Hospital1 18] 2) Dr.[Name (NI) 59264] office - covered by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] appointment [2169-1-3] at 9am Completed by:[2168-12-30]	[ "4240", "41401", "4019" ]
Admission Date: [2146-12-10] Discharge Date: [2146-12-16] Date of Birth: [2087-4-23] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1406] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: [2146-12-12] Coronary artery bypass grafting x5 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, first obtuse marginal artery and sequential reverse saphenous vein graft to the second and third obtuse marginal artery. History of Present Illness: This is a 59 year old obese white male who experienced burning sensation in his chest 2 days ago prior to admission which did not resolve. Went to ER at MWMC where he was admitted. Serial enzymes were borderline. Started on Ntg and heparin drip. Underwent cardiac catheterization which revealed severe three vessel coronary artery disease. He was therefore transferred to the [Hospital1 18] for surgical revascularization. On transfer, he was pain free and off all drips. Past Medical History: Hypertension Dyslipidemia Obesity Social History: Lives with: girlfriend Occupation: [Name (NI) 87742] school principal at [Location (un) 730] HS Tobacco: 1/2ppd x 10yrs ETOH: none Family History: Denies premature coronary artery disease Physical Exam: Admission physical Pulse: 60 Resp: 18 O2 sat: 93% on RA B/P Right: 125/72 Left: Height: 69" Weight: 271lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [2146-12-12] Intraop TEE Prebyapss: No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. Very poor transgastric views. Post bypass: Patient is A paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Aorta is intact post decannulation. Blood Work: [2146-12-11] WBC-8.0 RBC-4.69 Hgb-14.2 Hct-42.2 RDW-12.8 Plt Ct-211 [2146-12-11] PT-13.9* PTT-25.6 INR(PT)-1.2* [2146-12-11] Glucose-103* UreaN-16 Creat-0.9 Na-137 K-4.0 Cl-98 HCO3-29 [2146-12-11] ALT-37 AST-38 LD(LDH)-166 CK(CPK)-295 AlkPhos-60 TotBili-0.4 [2146-12-11] CK-MB-3 cTropnT-0.06* [2146-12-15] WBC-8.5 RBC-3.42* Hgb-10.4* Hct-30.0* RDW-13.0 Plt Ct-155 [2146-12-16] WBC-8.3 RBC-3.45* Hgb-10.6* Hct-30.9* RDW-13.0 Plt Ct-229 [2146-12-15] Glucose-113* UreaN-17 Creat-0.8 Na-135 K-3.9 Cl-95* HCO3-27 [2146-12-16] Glucose-111* UreaN-20 Creat-0.9 Na-133 K-3.9 Cl-93* HCO3-31 [2146-12-16] 04:30AM BLOOD Mg-2.2 Brief Hospital Course: Mr. [Known lastname ] was admitted to the cardiac surgical service and underwent routine preoperative evaluation. Workup was unremarkable and he was cleared for surgery. On [12-12], Dr. [Last Name (STitle) ] performed coronary artery bypass grafting. For surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Amiodarone was started for ventricular ectopy and brief episode of atrial fibrillation. He otherwise maintained stable hemodynamics and transferred to the SDU on postoperative day one. He remained in a normal sinus rhythm. Ectopy improved and no further episodes of atrial fibrillation were noted. Beta blockade was advanced as tolerated. Over several days, he continued to make clinical improvement with diuresis and was cleared for discharge to home on postoperative day four. He will remain on Lasix at discharge. All surgical and cardiology appointments were made prior to discharge. Medications on Admission: Hydrocholorthiazide 25mg daily Lisinopril 20mg [Hospital1 ] Pravastatin 40mg daily Atenolol 25mg tid ASA 325mg daily Omeprazole 20mg daily Discharge Medications: 1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks: then resume HCTZ . Disp:14 Tablet(s) Refills:0 3. 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 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): take 400 mg twice a day for 5 days - on [12-22] decrease to 400 mg once a day for seven days then decrease to 200 mg once a day until follow up with cardiologist . Disp:62 Tablet(s) Refills:0 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 8. 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 9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:70 Tablet(s) Refills:0 10. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Coronary artery disease, s/p CABG Postop Atrial Fibrillation Hypertension Dyslipidemia Obesity Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Improved Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2147-1-4] @ 130PM [Telephone/Fax (1) 170] Cardiologist: Dr. [Last Name (STitle) ] - [2147-1-2] 1130AM @ [Hospital1 ] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 26056] in [5-9] 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:[2146-12-16]	[ "41401", "42731", "4019", "2724" ]
Admission Date: [2177-6-28] Discharge Date: [2177-7-4] Date of Birth: [2108-9-9] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2009] Chief Complaint: Fatigue and worsening hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 68 year old female with PMH significant for DM2 on insulin complicated by chronic left great toe ulcer requiring frequent debridement and peripheral neuropathy, renal cell carcinoma s/p nephrectomy in [2175] at [Hospital1 2025], HTN, hyperlipidemia, obstructive sleep apnea (noncompliant with CPAP), and [Doctor Last Name 933] Disease s/p radioactive iodine treatment twice presenting for further evaluation of fatigue and worsening hyperglycemia. She has noted polyuria with urinary urgency, but no dysuria. She thinks that she has had elevated blood sugars for quite some time, but is unsure because she has not been really checking her sugars at home. She reports taking Levemir and Humalog for sugar control. She has also noted flushing of her skin and dizziness over the last several days. . In the ED, initial vs at triage were: T=94.6, HR=106, BP=72/34, RR=17, POx=100% RA. She was therefore triggered for hypotension/hypothermia and per report her skin was cool, clammy, and appeared mottled. Her blood pressures increased to 128/87 upon second measurement without any intervention being made. Her subsequent temperature also increased to 96.6 without any intervention. Her finger stick was critically high and her blood glucose returned at 588. She was given 8 units of regular insulin. Upon repeat testing 3 hours later, her blood glucose had increased to 672 and she was given another 10 units of regular insulin. It was then decided to start her on an insulin drip to better control her sugars despite no anion gap being present. A UA showed moderate leukocyte esterase positivity and 15 WBCs. Blood cultures and a urine culture was sent. CXR reportedly did not show any acute process. An EKG reportedly showed NSR at a rate of 82 with T-wave flattening in lead III which was consistent with prior EKGs. She was therefore given vancomycin and Levaquin to cover infections from a skin and urinary source. Of note, the patient developed a pink rash all over her body which was most notable on her palms, shins, chest, and back before she received the vancomycin and it was thought that the rash was due to hyperemia from re-perfusion after initially being mottled. She was also bolused with 3 Liters of NS with a 4th Liter hanging upon transfer and her lactate decreased from 2.8 to 2.2. She has an 18 gauge peripheral for access. Transfer vitals were T=100.8, HR=88, BP=112/52, RR=16, POx=100% RA. . On the floor, the patient is alert and oriented, but inattentive and slow to answer questions. She admits to being confused and reports seeing [Doctor Last Name ] hair pasta on the walls and believes she heard that [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] has killed little children on TV. She remembers not feeling well when she first arrived in the ED. She denies any localizing symptoms at this time. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -Renal cell carcinoma s/p nephrectomy in [2175] -DM2 complicated by chronic left great toe ulcer requiring frequent debridement and peripheral neuropathy -HTN -hyperlipidemia -Restless Leg Syndrome -obstructive sleep apnea (noncompliant w/cpap) -[Doctor Last Name 933] Disease s/p radioactive iodine treatment twice and surgical thyroid cystectomy greater than 40 years ago -Thrombocytopenia -Vitamin D deficiency -Osteoporosis -H/O ectopic pregnancy -s/p hysterectomy in [2156] -s/p surgical hernia repair Social History: She lives with her dog but is otherwise by herself at home. She has 2 sons and 1 daughter. She quit smoking 20 yrs ago, but did smoke 1 ppd for greater than 20 yrs, occasional alcohol use but none recently, denies IVDU. Family History: Mother- lung cancer and still alive after surgical resection; Father also had cancer Physical Exam: Admission Exam: Vitals: T: 97.9, BP: 103/51, P: 89, R: 16, O2: 97% RA General: Pleasant female, alert and oriented, but at times confused and in no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, large ventral hernia noted in RLQ GU: Foley Skin: Flushing is noted over back, bilateral knees, and hands Ext: warm, well perfused, no clubbing, cyanosis or edema; chronic left great toe ulcer not erythematous, no warmth or active drainage Psychiatric: Inattentive, visual and auditory hallucinations, but otherwise alert and oriented times three . Discharge exam: Vital Signs: BP 131/77 HR 63, RR 18, 98% RA BS: 117/237/203/226/250 Gen: In NAD. HEENT: Mucous membranes moist. Neck: Supple. Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal respiratory effort. CV: RRR, no murmurs, rubs, gallops. Abdomen: soft, NT, ND, NABS, no HSM. Obese. Reducible surgical hernia. Extremities: warm and well perfused, no cyanosis, clubbing, edema. Left great toe with ulcer, s/p debridement. Pertinent Results: On Admission: [2177-6-27] 11:18PM WBC-8.2# RBC-4.84# HGB-14.0# HCT-41.5# MCV-86 MCH-28.9 MCHC-33.7 RDW-15.8* [2177-6-27] 11:18PM NEUTS-77.1* LYMPHS-15.6* MONOS-3.1 EOS-3.2 BASOS-1.0 [2177-6-27] 11:18PM PLT COUNT-147* [2177-6-27] 11:18PM GLUCOSE-588* UREA N-37* CREAT-1.4* SODIUM-126* POTASSIUM-5.4* CHLORIDE-87* TOTAL CO2-25 ANION GAP-19 [2177-6-27] 11:25PM GLUCOSE-GREATER TH LACTATE-2.8* NA+-128* K+-5.2 [2177-6-28] 01:55AM CK(CPK)-128 [2177-6-28] 01:55AM CK-MB-6 cTropnT-<0.01 [2177-6-28] 01:55AM OSMOLAL-318* [2177-6-28] 01:55AM TSH-2.4 [2177-6-28] 12:02AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.025 [2177-6-28] 12:02AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [2177-6-28] 12:02AM URINE RBC-11* WBC-15* BACTERIA-FEW YEAST-NONE EPI-6 TRANS EPI-<1 . [2177-6-29] 04:11AM BLOOD Ret Aut-1.7 [2177-6-28] 06:05AM BLOOD %HbA1c-15.1* eAG-387* . CXR: FINDINGS: The lungs are clear, and hyperinflated. There is minimal blunting of the right costophrenic angle, the result of hyperinflation. There is no pneumothorax. The heart size is normal, the mediastinal contours are notable for top normal pulmonary artery size, and mild prominence of the right hilus, which is unchanged since [2173]. The pulmonary vasculature is normal. There is degenerative change of the spine. IMPRESSION: No acute chest pathology. parvovirus Igg/Igm negative urine cx [6-28] contaminated ESR 45, CRP 5.1 . Discharge labs: [2177-7-4] 07:18AM BLOOD WBC-3.3* RBC-3.77* Hgb-10.6* Hct-33.2* MCV-88 MCH-28.2 MCHC-32.0 RDW-15.5 Plt Ct-100* [2177-7-4] 07:18AM BLOOD Plt Ct-100* [2177-7-4] 07:18AM BLOOD Glucose-257* UreaN-14 Creat-0.9 Na-137 K-4.6 Cl-105 HCO3-25 AnGap-12 Brief Hospital Course: To briefly summarize: 68 yo woman with diabetes complicated by neuropathy, renal cell cancer sp nephrectomy, obesity, hypertension, transferred from ICU after admission there with possible confusion, feeling sick and hyperglycemia. She is a poor historian. It appears that she may have had a rash several days prior, felt like she was getting the flu. She had been out on Tuesday, but not clear what happened on Wed/thurs. Her family brought her in to the hospital for evaluation. She was admitted to the ICU after initially being found to be hyperglycemic, hypotensive and hypothermic. . In the ED, she was found to be hyperglycemic but without a gap. She was treated in the ED with IV insulin, with modest control, but then transferred to the ICU on an insulin gtt. She also received a dose of vancomycin and levofloxacin in the ED. In the ER, she developed a considerable rash on her knees and hands. There was a question of joint swelling. . In the ICU, her infectious workup to evaluate for the hyperglycemia revealed a possible UTI. She remains on levofloxacin. She was also found to have recurrence of an ulcer on the base of her right great toe. She was restarted on long acting insulin, with moderate control, and observed overnight in the ICU. Her mental status progressively cleared to close to baseline. She was found to be pancytopenic today. Her rash improved. Her blood sugar control improved with sliding scale and increased levimir dosing. She had an acute encephalopathy in the setting of acute illness. . By problem: . #. Type II diabetes mellitus, poorly controlled, with complications - The patient's blood sugars were elevated as high as 672 and requried insulin drip and ICU admission. quickly weaned off. Her initial serum osm was 318. The precipitant was unclear, but was thought viral infection and a UTI. She seemed taking good POs without indiscretions or medication changes. Her AIC returned at 15. The [Last Name (un) ] was consulted, and she was started on an aggressive sliding scale and increased long acting insulin (lantus instead of levemir). She was advised to continue QID blood sugar check, and attempt better compliance. She will require ongoing teaching. . #. Possible Urinary tract infection- The patient's UA is mildly positive with moderate leukocyte esterase and 15 WBCs. She was treated with 3 days of levofloxacin 500 mg daily. Her urine culture was contaminated. . #. [Last Name (un) ]- Patient's creatinine was up to 1.4 on admission with last baseline in [2175] being 0.7. Likely prerenal etiology given profound volume depletion related to uncontrolled hyperglycemia plus lab interference given ketones. She received IVF and improved back to her baseline. . #. Skin rash - She had noticeable warmth and erythema over her bilateral knees, hands, and back. Her TSH was within normal limits (2.2). Parvovirus was negative. She was seen by rheumatology, but they did not believe there was concern for rheumatologic illness. . #. Pancytopenia - She initially had WBC of 8, HCT 34, PLT 117 and after IVF and correction of her glucose went down to 3.1, 31 and 59 respectively. She was seen by hematology. A smear was unremarkable. Workup revealed likely multifactorial etiology, with exacerbation of chronic thrombocytopenia, and leukopenia in setting of viral syndrome. . #. Acute encephalopathy, on admission. Likely related to hyperglycemia and infection. Treated with supportive care. . #. Diabetic foot ulcer. Debrided by podiatry. Will require wound care. . #. history of renal cell cancer, now with abnormal CXR - per pt, awaiting biopsy at [Hospital1 2025], in the next ten days. . Chronic issues: Restless legs syndrome, depression, peripheral neuropathy, hypertension: Continued on home medications, with gradual reintroduction back to home doses. . Transitional issues: 1. Pancytopenia: should have repeat CBC at follow up. 2. Abnormal CXR : follow up scheduled at [Hospital1 2025]. 3. Poorly controlled diabetes: Needs aggressive teaching and compliance assessment. Medications on Admission: -gabapentin 600 mg by mouth qam, 1200 mg q noon, 1200mg qhs -insulin detemir [Levemir] 50 units [Hospital1 ] -Humalog sliding scale up to 62 units daily -lisinopril 40 mg by mouth once a day -metformin 1000mg [Hospital1 ] -nortriptyline 25 mg by mouth at bedtime -pramipexole [Mirapex] 1 mg at 4PM -pramipexole [Mirapex] 2 mg before bed -raloxifene [Evista] 60 mg by mouth once a day -cholecalciferol (vitamin D3) 1,000 units once a day -multivitamin by mouth once a day -Crestor 10mg daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. pramipexole 1 mg Tablet Sig: Variable Tablet PO twice a day: 1 mg at 4pm, 2 mg qhs. 5. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 600 mg Tablet Sig: Variable Tablet PO three times a day: 600 mg po in the am, 1200 mg at 2 pm, and 1200 mg qhs. 8. insulin detemir 100 unit/mL Solution Sig: Fifty Six (56) units Subcutaneous twice a day. 9. Humalog 100 unit/mL Solution Sig: Sliding scale units Subcutaneous QAC and QHS: See sliding scale. 10. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO at bedtime. 11. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day. 12. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 13. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Pancytopenia Hypotension Poorly controlled type II diabetes mellitus, with neuropathy. Acute confusion and delirium Diabetic foot ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with high blood sugars and low blood pressure. With insulin and IV fluids, your symptoms improved. You did have low blood counts probably related to this illness, which are improving. One of your main problems is not taking your insulin - and you need to take the insulin and follow up with the [Last Name (un) ] as scheduled. You also had a foot ulcer, that one of Dr. [Last Name (STitle) 11738] colleagues debrided. . Medication changes: Increase LEVEMIR insulin to 56 units twice daily Follow the sliding scale insulin as written No other medication changes. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] S. Location: [Hospital3 ] HEALTHCARE AT [Hospital1 ] Address: [Apartment Address(1) 86994], [Hospital1 ],[Numeric Identifier 26419] Phone: [Telephone/Fax (1) 86995] Appt: [7-8] at 11:15am Name: NP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557] (works with [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] ) Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2378] Appt: [7-8] at 3:30pm Department: PODIATRY When: WEDNESDAY [2177-7-9] at 11:40 AM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 542], DPM [Telephone/Fax (1) 543] Building: Ba [Hospital Unit Name 723] ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "5849", "5990", "2761", "V5867", "4019", "2724", "32723" ]
Admission Date: [2187-4-27] Discharge Date: [2187-5-3] Date of Birth: [2105-7-27] Sex: M Service: CARDIOTHORACIC Allergies: Cardizem / pine oil Attending:[First Name3 (LF) 1505] Chief Complaint: Worsening Shortness of Breath Major Surgical or Invasive Procedure: [2187-4-27] 1. Aortic valve replacement 23 mm Biocor Epic tissue valve. 2. Tricuspid valve repair with a 30 mm [Company 1543] Contour annuloplasty ring. History of Present Illness: Mr. [Known lastname 38828] is an 81 year old man with past medical history of hepatitis C Virus genotype 2 with stage II liver fibrosis (biopsy [2177]) secondary to a blood transfusion in [2158]. He received blood transfusion after partial gastrectomy which was secondary to a benign gastric tumor. He has never been on treatment for his liver disease. In addition, he also has history of aortic stenosis, atrial fibrillation, hypertension and gout. He is not on anticoagulation for his atrial fibrillation. Over the past one year, he has developed progressive shortness of breath that is now limiting his activity climbing one flight of stairs and walking to his car. He does not complain of chest pain or lightheadedness. He does have significant lower extremity edema which he started developing few months ago. He is NYHA Class II for his symptoms. On Echocardiogram from [2185-4-6] Peak gradient across the aortic valve was 54 mmHg and the mean gradient was 39 mmHg. The calculated aortic valve area was 0.6 cm2. The RV Systolic pressure was 49 The LVEF was approximately 60%. There was moderate mitral regurgitation, moderate pulmonary hypertension and [Hospital1 ]-atrial enlargement. He under went cath today which showed not signifcant CAD but had a wedge pressure if 30. Cardiac surgery was consulted for consideration for AVR. Past Medical History: Aortic Stenosis Hypertension, essential with heart failure CHF - diastolic: NYHA Class III Atrial Fibrillation, not currently on anticoagulation History of Hepatitis C Virus genotype 2 with stage II liver fibrosis (biopsy [2177]) secondary to a blood transfusion in [2158] after partial gastrectomy Gout Hematuria, remote GI bleed unknown cause no bloody stool in 2 yrs Kidney stone, remote Lower extremity vasculitis Chronic rash to legs Social History: Race:Caucasian Last Dental Exam:9 months ago Lives with:Wife [Name (NI) 450] who is presently at rehab, she is dependent in him for all he ADL;s Contact: [Name (NI) ] [Name (NI) 38829] [Name (NI) 38828] [Name (NI) ] oncologist in [State 531] Phone # Occupation:Insurance Broker Cigarettes: Smoked no [x] yes [x] last cigarette 2002_____ Hx: Other Tobacco use: ETOH: 30yr of alcohol use/abuse quit in [2177] Illicit drug use: Denies Family History: No premature coronary artery disease Physical Exam: Pulse: Resp:16 O2 sat:100% RA B/P Right: 144/92 Left:134/89 Height: 225LB Weight:6 ft General: Skin: Dry [x] intact [x] Diffuse non blanching red patches/lesion of varining sizes bilateral lower extremites to thigh area, work-up/biospy by deramatologist Dr [Last Name (STitle) 33645] negative so far HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [] Murmur [x] grade [6-17] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [4] mdi abdoninal scar well healed Extremities: Warm [x], well-perfused [x] Edema [x] +3 right >left Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +1 Left: +1 DP Right: +1 Left: +1 PT [Name (NI) 167]: dop Left: dop Radial Right: +1 Left: faint Carotid Bruit Right: none Left: none Pertinent Results: Echo [2187-4-27]: PRE-BYPASS: Mild spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is present in the left atrial appendage. A definite thrombus is seen in the left atrial appendage. The thrombus is not mobile and appears laminated. 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. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 35-40 %). The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. The main pulmonary artery is dilated. The right pulmonary artery is dilated. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results at time of surgery. POST-BYPASS: The patient is AV paced. The patient is on no inotropes. Left ventricular function is improved (LVEF = 45%). Right ventricular function is unchanged. There is a well-seated bioprosthetic valve in the aortic position. No aortic regurgitation is seen. There is a mean gradient of 9 mmHg at a cardiac output of 4.9 L/min. There is a tricuspid annuloplasty ring in place. No tricuspid regurgitation is seen. Mitral regurgitation is unchanged. The left atrial appendage thrombus appears unchanged. The aorta is intact post-decannulation. . Head CT [2187-4-29]: No acute intracranial hemorrhage or mass effect. Correlate clinically to decide on the need for further workup. . Head MRA [2187-4-30]: 1. Area of slow diffusion in the posterior aspect of the pons, just anterior to the fourth ventricle, with corresponding increased T2 FLAIR signal representing a small subacute infarction. A punctate acute infarct is also located in the left paramedial vermis. 2. Unremarkable MRA examination. Brief Hospital Course: Mr. [Known lastname 38828] was a same day admit and was brought directly to the operating room where he underwent an aortic valve replacement and tricuspid valve repair. Please see operative note for surgical details. Following surgery he was transferred to the CVCIU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one beta-blockers and diuretics were started and he was gently diuresed towards his pre-op weight. On post-op day two he appeared to have new onset facial droop and complained of blurred vision. Neurology was consulted and he underwent a head CT. The CT showed no acute intracranial hemorrhage or mass effect. On the next day he underwent a head MRA which showed a small subacute infarct. Heparin and Coumadin were started. He remained stable and was transferred to the step-down floor on post-op day four. He was seen by opthamology for post-operative lateral gaze and dipolpia. Eye drops were recommended. He was told that if the symptoms persist he could patch either eye and follow-up with Dr. [Last Name (STitle) ]. He was seen in consultation by the physical therapy service. By post-operative day six he was ready for discharge to rehab at [Hospital6 ] in [Location (un) 246]. Follow-up appointments were advised. Medications on Admission: Atenolol 100mg daily,LISINOPRIL-HYDROCHLOROTHIAZIDE 20 mg-25 mg Tablet - 2 Tablet(s) by mouth once daily ASPIRIN 81 mg Tablet daily CALCIUM CARBONATE-VITAMIN D3 1 Tablet(s) by mouth once daily GLUCOSAMINE-CHONDROITIN 500 mg-400 mg Capsule - 3 Capsule(s) by mouth once daily IBUPROFEN - 200 mg Tablet prn MULTIVITAMIN WITH MINERALS by mouth once daily VITAMIN E 400 unit Capsule one Capsule(s) by mouth daily Discharge Medications: 1. warfarin 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): adjust dose for INR goal of [3-16] for afib. 2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. insulin regular human 100 unit/mL Solution Sig: per sliding scale Injection ASDIR (AS DIRECTED). 8. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [2-12] Drops Ophthalmic PRN (as needed) as needed for dryness. 10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO once a day. 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Aortic Stenosis and tricupsid regurgitation s/p Aortic valve replacement and tricuspid valve repair Past medical history: Hypertension, essential with heart failure CHF - diastolic: NYHA Class III Atrial Fibrillation, not currently on anticoagulation History of Hepatitis C Virus genotype 2 with stage II liver fibrosis (biopsy [2177]) secondary to a blood transfusion in [2158] after partial gastrectomy Gout Hematuria, remote GI bleed unknown cause no bloody stool in 2 yrs Kidney stone, remote Lower extremity vasculitis Chronic rash to legs Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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) ] on [2187-6-6] at 1:15PM Cardiologist: Dr. [Last Name (STitle) ] on [2187-5-23] at 9:40AM Please call to schedule appointments with your Primary Care Dr. [First Name (STitle) ] in [5-17] weeks If opthomalogical symptoms persist, may patch either eye and call ([Telephone/Fax (1) 18621] to make a follow-up 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 Completed by:[2187-5-3]	[ "4241", "4280", "42731", "4168", "4019" ]
Admission Date: [2114-1-13] Discharge Date: [2114-1-22] Date of Birth: [2066-11-17] Sex: F Service: FERNARD INTENSIVE CARE UNIT ADMITTING DIAGNOSIS: Obstructive sleep apnea. Note: The following is the summary of the [Hospital 228] hospital course in the [Hospital Ward Name 332] Intensive Care Unit from [2114-1-13], through [2114-1-22]. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old male with a history of obstructive sleep apnea, pulmonary hypertension, presumed obesity, hypoventilation syndrome, asthma, cardiomyopathy with severe systolic and diastolic dysfunction, ejection fraction of 20-30%, hypertension, diabetes, paroxysmal atrial fibrillation, who was referred from sleep study for nausea and insomnia. The patient was diagnosed with obstructive sleep apnea in [2112-12-9]. BIPAP was started in [2113-2-8], but the patient did not tolerate. The patient was referred to a sleep clinic for reattempt at BIPAP titration. During the sleep study, the patient was noted to have room air saturations of 86-87% on room air. Over night, the patient was noted to be saturating to 50-60% on room air. BIPAP titration was attempted, and the patient required high pressures at 26/16 and received 4 L of supplemental nasal cannula oxygen. In addition, the patient was given Ambien 10 mg p.o. q.h.s. for sleep. The patient did not tolerate the BIPAP. On the morning of the study, the patient complained of nausea, headache and shortness of breath. The patient was noted to be somnolent and was referred to the Emergency Room for evaluation. In the Emergency Room, the patient was afebrile and hemodynamically stable. He was noted to be somnolent and complained of headache and shortness of breath. Oxygen saturation was 60% on room air. ABG obtained was 7.17 with a paCO2 of 108 and paO2 of 230 on a nonrebreather indicating acute on chronic respiratory acidosis. Chest x-ray was done which revealed no acute cardiopulmonary process. The patient was given Toradol for his headache and Lasix for history of congestive heart failure. The patient's oxygen was titrated down to 1.5 L, and repeat ABG was 7.25, 94 and 74, and the patient was noted to have much improved mental status. The patient was admitted for urgent evaluation and tracheotomy for ventilation as treatment for obstructive sleep apnea and obesity hypoventilation. REVIEW OF SYSTEMS: The patient denied any recent fevers, chills, night sweats, cough. No change in baseline dyspnea on exertion. He denied orthopnea or lower extremity edema. No chest pain, abdominal pain, nausea, vomiting or diarrhea at the time of transfer. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea diagnosed in [2112-12-9] after a sleep study. As per the HPI, the patient was started on BIPAP in [2113-2-8] but did not tolerate. He also has a history of restless leg syndrome. 2. Iron deficient anemia. 3. Cardiomyopathy. Cardiac catheterization in [2111-8-9] revealed normal coronary arteries. Pulmonary artery pressure at that time was 70/45. The patient was with severe systolic and diastolic dysfunction. Echocardiogram in [2113-11-8] was with an LEF of 25-30%, mild symmetric left ventricular hypertrophy, marked inferior and septal hypokinesis, no valvular disorders. 4. Paroxysmal atrial fibrillation anticoagulated with Coumadin. 5. History of asthma since childhood. PFTs in [2113-11-8] with good study; FEV1 of 22% predicted, FEC 42% predicted, ratio 53% predicted, TLC 103% predicted, normal diffusion. 6. Hypertension. 7. NSAID induced gastritis and peptic ulcer disease. 8. Gastroesophageal reflux disease. 9. Type 2 diabetes. 10. History of nephrolithiasis. 11. Depression. 12. Dyslipidemia. 13. Gout. MEDICATIONS ON ADMISSION: Carvedilol 12.5 mg p.o. b.i.d., Enalapril 20 mg p.o. b.i.d., Singulair 10 mg p.o. q.d., Magnesium Oxide 280 mg p.o. q.d., Colchicine 0.6 mg p.o. q.d., Allopurinol 200 mg p.o. q.d., Protonix 40 mg p.o. q.d., Spironolactone 25 mg p.o. q.d., Atorvastatin 10 mg p.o. q.h.s., Lasix 80 mg p.o. b.i.d., Bupropion 20 mg p.o. b.i.d., Glucophage 1000 mg p.o. q.d., Advair 1 puff b.i.d., Potassium Chloride 20 mEq p.o. q.d., Tricor 160 mg p.o. q.d., Amiodarone 200 mg p.o. q.d., Coumadin, Albuterol p.r.n., Iron Sulfate 325 p.o. q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient lives alone. He is single and has no children. Next of [Doctor First Name ] is his sister [Name (NI) ] and mother who both live in [Name (NI) 8449]. He denied history of tobacco use. Rare alcohol. No regular cardiovascular exercise. He worked as a nurse [First Name (Titles) ] [Last Name (Titles) ] House during the night shift. He was unable to quantify baseline dyspnea on exertion. PHYSICAL EXAMINATION: Vital signs: On admission to the Intensive Care Unit, temperature was 100.2??????, pulse 80-97, blood pressure 141/63, respirations 28, oxygen saturation 78-90% on room air. General: The patient was alert and oriented times three. He was speaking full sentences. No accessory muscle use. No respiratory distress. HEENT: He had lateral gaze Palsy, otherwise normal. Neck: No lymphadenopathy. Cardiovascular: Regular rhythm. No murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Obese, nontender and soft. Extremities: No edema. LABORATORY DATA: White count 9.0, hematocrit 35.0, MCV of 89, platelet count 238; creatinine 1.1, bicarb 39; ALT 24, AST 18, alkaline phosphatase 49, total bilirubin 0.4; lipid profile with a total cholesterol of 172, triglycerides 263, HDL 47, LDL 72; ferratin 8.2; hemoglobin A1C 8.1; ABG obtained on room air at the patient's baseline, 7.36, 63, 77. HOSPITAL COURSE: 1. Respiratory: The patient is with a past medical history significant for severe obstructive sleep apnea, obesity, hypoventilation syndrome, asthma, pulmonary hypertension, who presented to the Sleep Clinic on the day of admission for reattempt at BIPAP titration. The patient did not tolerate BIPAP. The patient was noted to desaturate to 40-60% on room air during the night time. As the patient refused BIPAP for treatment of obstructive sleep apnea, tracheotomy was done with the patient's consent on [2114-1-17]. The patient tolerated the procedure well with no complications. Following tracheotomy placement, a PAT study was done to evaluate for central component of hypoventilation. During the PAT study, the patient demonstrated periods of apnea with desaturations to 40% on room air. Oxygen saturation improved with supplemental oxygen to the 90s. This suggested a component of obesity hypoventilation. In addition, BIPAP was reattempted. Ideal settings were [1-13]; however, the patient did not tolerate BIPAP for more than a few minutes. Given that the patient would not tolerate BIPAP with the tracheotomy, the patient was started on supplemental oxygen by tracheostomy with goal oxygen saturation of 85-88% over night to avoid CO2 retention. Per ENT, they planned to change from a 6.0 cuff trach cannula to a 6.0 cuff with trach cannula. The patient was fitted for a Passy-Muir valve. The patient will follow-up in the Sleep Clinic. At that time, he can consider the risks and benefits of respiratory stimulant such as Progesterone. For treatment of asthma, the patient was continued on Salmeterol, Flovent, Accolate and Albuterol p.r.n. 2. Cardiomyopathy: The patient is with a known history of cardiomyopathy with an ejection fraction of 20-30% with severe systolic and diastolic dysfunction. The patient was continued on Carvedilol and Enalapril. The patient's outpatient Enalapril dose was decreased from 20 mg b.i.d. to 10 mg b.i.d. secondary to relative hypotension with systolic blood pressure in the 70s. The patient was asymptomatic with low blood pressures. The patient remained euvolemic and was continued on Lasix 80 mg p.o. b.i.d. and Spironolactone 25 mg p.o. q.d. The patient is with a history of paroxysmal atrial fibrillation noted to be in atrial fibrillation prior to trach placement with a rate in the 70s to 90s. The patient currently is in normal sinus rhythm. The patient was continued on Amiodarone 200 mg p.o. q.d. On postoperative day #4, the patient was restarted on outpatient Coumadin dose. The patient is also with a history of hypertriglyceridemia. Lipid profile during this admission revealed triglycerides of 236. The patient had been on Tri-Chlor 54 mg p.o. q.d. and was increased to 160 outpatient q.d. 3. Iron deficiency anemia: The patient has a known history of iron deficiency anemia on iron supplements. Ferratin during this admission was low at 8.2 with a hematocrit of 35. The patient was continued on Protonix for history of peptic ulcer disease and gastritis. The patient will need outpatient colonoscopy. 4. Type 2 diabetes: Hemoglobin A1C during this admission was 8.1. The patient's Glucophage dose was increased from 1000 mg p.o. q.d. to 1000 mg p.o. b.i.d. LFTs during this admission were normal. 5. Gout: The patient was continued on Allopurinol and Colchicine. 6. Depression: The patient was continued on Bupropion. The patient will be called out from the Intensive Care Unit to the Medical Floor for further management and supplemental oxygen via trach mask at night time. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Last Name (NamePattern1) 1297] MEDQUIST36 D: [2114-1-22] 15:11 T: [2114-1-22] 15:25 JOB#: [Job Number 108987]	[ "4280", "42731", "51881", "4168" ]
Admission Date: [2170-8-31] Discharge Date: [2170-9-23] Date of Birth: [2102-8-29] Sex: M HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 43735] is a 67-year-old male who is a resident of [State 108], who had been traveling to [State 350] to visit his daughter. [Name (NI) ] reports a 2-week to 3-week history of a progressive onset of jaundice. He also denied any pruritus. He also had lower abdominal discomfort but denied any significant upper abdominal pain. He denies any nausea or vomiting. He states that his appetite has been poor over the past few weeks. The patient was initially seen at [Hospital ] Hospital for these symptoms and was found to have a bilirubin level of 32.4, and He subsequently underwent an abdominal ultrasound which was consistent with distal common bile duct obstruction and pancreatic ductal obstruction, though no definite lesion was seen. He also was noted to have a distended gallbladder with evidence of gallstones. The patient also underwent an endoscopic retrograde cholangiopancreatography at the outside hospital which demonstrated a markedly dilated bile duct with a distal stricture. Attempts were also made to introduce a biliary stent; however, one could not be successfully placed. He was then transferred to the [Hospital1 69] for further evaluation of his obstructive jaundice and possible surgical intervention. PAST MEDICAL HISTORY: Past medical history was unremarkable. PAST SURGICAL HISTORY: No past surgical history. SOCIAL HISTORY: The patient is married and has three children. He lives in [State 108]. He is a former smoker who quit 12 years ago. He states that he does drink two to three beers per day and at least two cocktails per day. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Weight was 174 pounds, blood pressure was 126/70, heart rate was 80. In general, the patient was a middle-aged male in no acute distress. Head, eyes, ears, nose, and throat revealed normocephalic and atraumatic. Scleral were icteric. Pupils were equal, round, and reactive to light and accommodation. Extraocular movements were intact. Neck was supple. No jugular venous distention. Lungs were clear to auscultation bilaterally. Cardiovascular revealed a respiratory rate. No murmurs, rubs or gallops. Abdomen was mildly distended, soft, nontender. No hepatosplenomegaly. Mild ascites. Extremities revealed no clubbing, cyanosis or edema. Neurologically, alert and oriented times three. No asterixis. Skin was notable for jaundice. PERTINENT LABORATORY DATA ON PRESENTATION: Hematocrit was 36.9, white blood cell count was 11.5. Sodium was 136, potassium was 3.6, chloride was 103, bicarbonate was 19, blood urea nitrogen was 26, creatinine was 1.2, blood glucose was 91. AST was 111, ALT was 22, alkaline phosphatase was 442, total bilirubin was 45.3. PT was 13.2, INR was 1.2, PTT was 34.9. CA19-9 from the outside hospital was 4278. Hepatitis A, hepatitis B, and hepatitis C serologies were negative. RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm at 85 beats per minute, and no evidence of ST changes. A CT of the abdomen with intravenous contrast revealed (1) pancreatic head mass measuring 2.4 cm X 2.6 cm with minimal small peripancreatic lymph nodes and minimal stranding of the mesentery, grade 0 involvement of the superior mesenteric artery and probable grade 1 or 2 involvement of the superior mesenteric vein; (2) normal celiac access; (3) ascites; (4) findings suggestive of mild cirrhosis. Endoscopic retrograde cholangiopancreatography ([2170-8-31]) revealed (1) ampullary mass; (2) biliary dilatation compatible with distal obstruction; (3) stent placement in the common bile duct; (4) gastric mucosal changes consistent with portal hypertensive gastropathy. HOSPITAL COURSE BY SYSTEM: 1. HEPATOBILIARY: The patient initially presented to an outside hospital with signs and symptoms consistent with obstructive jaundice. An endoscopic retrograde cholangiopancreatography and CT scan demonstrated a mass in the head of the pancreas consistent with adenocarcinoma. He was also noted to have mild ascites. Following the patient's CT scan, he developed an elevated creatinine to 2.4. He was therefore managed as an inpatient with rehydration and total parenteral nutrition until he was deemed suitable for surgery. On [2170-9-10], he was taken to the operating room for exploration, possible Whipple, and possible biliary bypass. Intraoperatively, the patient's liver was noted to be cirrhotic in nature and approximately 2 liters of straw-colored ascites fluid was also noted. In light of the patient's liver disease, the patient was deemed not to be suitable for a Whipple; and, therefore, a Roux-en-Y choledochal jejunostomy was performed. In addition, he also underwent a cholecystectomy, wedge liver biopsy, and transduodenal biopsy of the pancreas. The liver wedge biopsy revealed chronic obstruction with marked bile stasis and active cholangiolitis as well as mild steatosis with prominent regeneration. Also noted was marked portal and sinusoidal fibrosis. The pancreatic biopsy revealed invasive adenocarcinoma which was moderately differentiated. The patient continued to do well postoperatively. His total bilirubin levels came down dramatically from 45.3 to 5.5 on the patient's day of discharge. In addition, the patient's alkaline phosphatase levels also improved. He was evaluated by the Medical/Oncology and Radiology/Oncology teams for his pancreatic cancer. He was to follow up with them as an outpatient. The patient's liver disease was likely secondary to chronic alcohol use. He was noted to have ascites both intraoperatively and on his CT scan of the abdomen. He was started on Aldactone 100 mg by mouth daily for management of his fluid status. Urinary sodium levels were followed to assess for adequate diuresis. He was to continue this medication as an outpatient. On postoperative day eight, fluid from the [Location (un) 1661]-[Location (un) 1662] drain was sent for cell count, cytology, and cultures. The patient was found to have a white blood cell count of 6660 and 53% polymorphonuclear leukocytes. His absolute neutrophil count was determined to be [2108]; which was consistent with spontaneous bacterial peritonitis. He was started on intravenous Unasyn for treatment of spontaneous bacterial peritonitis. The culture from the [Location (un) 1661]-[Location (un) 1662] drain fluid also grew out alpha streptococcus and Staphylococcus epidermidis. The patient was then started on vancomycin intravenously which was subsequently dosed by levels. 2. INFECTIOUS DISEASE: As noted above, the patient was found to have spontaneous bacterial peritonitis as suggested by the cell count and culture from the [Location (un) 1661]-[Location (un) 1662] drain fluid. He underwent a diagnostic paracentesis on [2170-9-20] for further evaluation of his ascites fluid. The Gram stain revealed no evidence of polymorphonuclear leukocytes or microorganisms. However, his white blood cell count was found to be 1775 with 42% polymorphonuclear leukocytes. This also confirmed the diagnosis of spontaneous bacterial peritonitis since the patient's absolute neutrophil count was 911. He was continued on intravenous antibiotics until the day of discharge. He has remained afebrile and has not complained of any abdominal pain since that time. 3. RENAL: On admission, the patient's creatinine was within normal limits at 1.2. However, following the patient's CT scan with intravenous contrast, the patient developed an increase in his creatinine to 2.4. Since that time, his creatinine has remained stable, and on the day of discharge his creatinine was 2.6. 4. WOUND CARE: The patient's incision was healing well, and there was no evidence of a wound infection. The [Initials (NamePattern4) 228] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drain was removed on postoperative day eight. A stitch was placed at the [Location (un) 1661]-[Location (un) 1662] drain site, and there was no evidence of leakage for the next one to two days. However, on postoperative day 11, the patient noted leakage of straw-colored fluid from the [Location (un) 1661]-[Location (un) 1662] drain site despite the stitch that was placed previously. On the day of discharge, an additional two stitches were placed at the [Location (un) 1661]-[Location (un) 1662] drain site; however, there were still amounts of fluid coming out from the site. He was discharged home with an ostomy bag for fluid collection. He was instructed to remove the bag if he noticed that the fluid leakage had minimized. DISCHARGE DIAGNOSES: 1. Pancreatic adenocarcinoma. 2. Cirrhosis. 3. Status post cholecystectomy, Roux-en-Y hepaticojejunostomy, liver biopsy, and pancreatic biopsy. 4. Chronic renal insufficiency. 5. Spontaneous bacterial peritonitis. MEDICATIONS ON DISCHARGE: 1. Augmentin 875 mg p.o. b.i.d. (times 10 days). 2. Ciprofloxacin 500 mg p.o. b.i.d. (times 10 days). 3. Aldactone 100 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was good. DISCHARGE FOLLOWUP: The patient will be followed up at Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] clinic. He was instructed to call Dr.[Name (NI) 1369] office for a follow-up appointment. The patient also had an appointment with Dr. [Last Name (STitle) 150] on [9-28] at 3:30 p.m. at the Medical/[Hospital ] Clinic. He was instructed to return should he develop any fevers or persistent abdominal pain. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Name8 (MD) 7861] MEDQUIST36 D: [2170-9-23] 16:06 T: [2170-9-28] 01:46 JOB#: [Job Number 43736]	[ "5845" ]
Unit No: [Numeric Identifier 61201] Admission Date: [2178-4-4] Discharge Date: [2178-4-9] Date of Birth: [2178-4-4] Sex: M Service: NB SERVICE: Neonatology HISTORY: Baby boy [Known lastname 2470] is a 32 [3-2] week gestation, twin #1, admitted for prematurity. MATERNAL HISTORY: The mother is a 33-year-old G1, P0-2, [Location 43876] woman with the following prenatal screens: O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, GBS unknown. ANTENATAL COURSE: Estimated date of delivery was [2178-5-27] by last menstrual period on [2178-8-20] for an estimated gestational age of 32 3/7 weeks. These are diamniotic/dichorionic twin gestations complicated by preterm labor leading to admission for tocolysis and betamethasone on [2178-3-26]. Progression of labor leading to cesarean section today under spinal anesthesia. Rupture of membranes at delivery yielding clear amniotic fluid. No intrapartum fever or other clinical evidence of chorioamnionitis. NEONATAL COURSE: Infant was mildly hypertonic but otherwise vigorous at delivery. Orally and nasally bulb suctioned, dried, brief free-flow oxygen provided for central cyanosis. Apgar scores were 7 and 8 at 1 and 5 minutes of life respectively. PHYSICAL EXAMINATION: On admission, in general, the patient was a well appearing infant in no distress. The birth weight was 1,630 grams. Head circumference 29.5 cm, length 45 cm. Heart rate 164, respiratory rate 44, blood pressure 52/27, room air sat of 94%. HEENT: The anterior fontanelle open and soft. Nondysmorphic. Palate intact. Mouth: Normal. Normocephalic. Palate intact. Red reflex normal. Chest: Minimal retractions. Clear breath sounds bilaterally. No crackles. Cardiovascular: Well perfused. Regular rate and rhythm. Femoral pulses normal. There was normal S1, S2, no murmur. The abdomen was soft, nondistended. No organomegaly. No masses. Active breath sounds. Patent anus. Three vessel umbilical cord. GU: Normal penis with bilaterally descended testes. Neurologic: Active, alert, respiratory stimulation. Tone symmetric. Moves all extremities symmetrically. Grasp symmetric. Gag intact. Skin exam: Normal. Musculoskeletal: Normal spine, limbs, hips, and clavicles. HOSPITAL COURSE: 1. RESPIRATORY: The patient was stable in room air throughout the entire admission, had no apnea or bradycardiac spells of prematurity during this admission. 2. CARDIOVASCULAR: The patient was hemodynamically stable throughout the admission and has had no murmur on exam. 3. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was initially n.p.o. on total fluids of 100 cc per kg per day. Enteral feedings begun on day of life #1 and slowly advanced. The patient is currently on total fluids of 140 cc per kg per day, is feeding breast milk or Special Care 20 at 120 cc per kg per day. The weight at the time of discharge is 1,570 grams (birth weight 1,630). 4. GASTROINTESTINAL: The patient was monitored with bilirubin checks. The most recent bilirubin was on the date of transport which was day of life #5 which was 6.5/0.2. The patient was never on phototherapy. 5. INFECTIOUS DISEASE: The patient had initial benign CBC with a white count of 13.1, 7 polys, 3 bands. The patient was started on ampicillin and gentamicin which was discontinued at 48 hours when blood cultures remained negative. 6. NEUROLOGY: A head ultrasound was not indicated in this patient. 7. HEARING: A hearing exam has not yet been performed. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To [Hospital1 1474] level II nursery. PRIMARY CARE PEDIATRICIAN: A pediatrician has not yet been identified. CARE RECOMMENDATIONS: 1. Feeds at discharge are breast milk/Special Care at 120 cc per kg per day with the plan to advance 15 cc per kg twice a day to a maximum of 150 cc per kg per day. 2. The patient is on no medications. 3. Newborn screening will be sent on the day of transfer. IMMUNIZATIONS: The patient has not yet received any immunizations. DISCHARGE DIAGNOSIS: 1. Prematurity at 32 3/7 weeks. 2. Rule out sepsis, resolved. [Name6 (MD) ] [Last Name (NamePattern4) ], [MD Number(1) 55472] Dictated By:[Last Name (NamePattern1) 58729] MEDQUIST36 D: [2178-4-9] 11:38:46 T: [2178-4-9] 12:17:43 Job#: [Job Number 61202]	[ "V290" ]
Admission Date: [2187-10-23] Discharge Date: [2187-11-7] Date of Birth: [2135-4-29] Sex: F Service: MEDICINE Allergies: Amoxicillin / Sulfonamides Attending:[First Name3 (LF) 348] Chief Complaint: S/p fall with large pannus hematoma. Major Surgical or Invasive Procedure: None. History of Present Illness: 52yof w/CHF (EF 15-20%), AFib (s/p cardioversion x2, currently on amio), presented to ED s/p fall. Pt. was home alone morning of admission, fell forward while trying to get off of the toilet. She broke her fall with her hands, and there was no LOC or head trauma. She reports that her knees buckled and that following the fall she could not get up, so she crawled to her bedroom and called 911. . At baseline, she is ambulatory at home, but over the last several weeks, she (and her sister) have noted increasing SOB/DOE, leg edema, general malaise/fatigue, and a ?new fine resting tremor involving her digits and lips. On ROS, she denies HA, chest pain or pressure, cough, nausea/vomiting, diarrhea/constipation, fever/chills, dysuria, melena/hematochezia, recent illness. . Her only recent medication change was an increase in lasix from 40 to 80 PO BID on [2187-10-19]. . In the [Name (NI) ], Pt. found to have a Hct drop from baseline mid-30s to 27.8 to 20.8 and an INR of 5.7. She was initially admitted to the floor but given her decreased hematocrit was transferred to the CCU team. Past Medical History: 1. non-ischemic dilated cardiomyopathy, EF 15-20% 2. hypertension 3. paroxysmal AFib (dx in [2181], s/p CV x2, currently on amio) 4. obesity 5. reactive airway disease 6. restrictive lung disease 7. bilateral knee surgeries 8. obstructive sleep apnea Social History: Patient is not married and has lived in [Hospital1 778] for many years. She works for the city. She quit tobacco 30 yrs ago, quit EtOH in [2182] (occasional beer), no drugs. Family History: Mother died (MI in her 60's) Brother with CAD in 50's CA CVA [Name (NI) 1568] brother, nephew, father Physical Exam: PE: VS: T 96.9 \| 168/98 \| 74 \| 28 \| 94% on RA gen: NAD, Sitting up comfortably in chair. HEENT: no LAD, OP clear, MMM, no carotid bruit, unable to see JVD, no carotid bruit, no neck masses skin: no rashes CV: irreg irreg, nl s1s2, distant heart sounds, no murmurs chest: distant breath sounds, decr. at bases, no crackles or wheezes. abd: Morbidly obese with abdominal binder in place, large ecchymosis involving RLQ/inguinal area to midline, morbidly obese, tender to palpation esp. on L, +bs, no organomegaly. extr: warm, no cyanosis, venous stasis changes in LE including excoriation on L inner ankle. 2+ LE b/l edema, 1+ radial & dp pulses. neuro: a&ox3, cn ii-xii intact, motor sensory coordination and language grossly intact/nonfocal. rectal: guaic negative Pertinent Results: Echo [2187-10-30]: LVEF=25%. The left atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. [Intrinsic right ventricular systolic function may be more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. The aortic valve is not well seen. There is mild aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate to severe [3+] tricuspid regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. Compared with the prior study (tape reviewed) of [2187-9-5], left ventricular systolic function appears slightly more vigorous now in the setting of tachycardia. The pulmonary artery systolic pressure was elevated in the prior study (not noted in the prior report) and remains significantly elevated. . CXR [2187-10-30]: Marked cardiomegaly. Absence of overt pulmonary congestion and significant pleural effusion speak in favor of appropriate clinical management. . CT abd [2187-10-29]: 1. More superior portion of large hematoma of the right flank and anterior abdominal wall has become more homogeneous in appearance on today's exam. This suggests further interval bleeding. This portion of hematoma now measures 19.5 x 10.6 cm in greatest axial dimensions. 2. More inferior portion of hematoma of the anterior abdominal wall measures up to 19.4 x 10.0 cm in maximum dimension on today's exam. It is difficult to compare to [10-23], as the hematoma may have extended beyond the Gantry on both of these exams, but this portion is likely not significantly changed. 3. The liver appears dense on these non-contrast images. This may reflect prior amiodarone use or iron overload. Clinical correlation again recommended. . CT abd [2187-10-23]: There is a large soft tissue hematoma within the right flank and anterior abdominal wall, measuring 17 x 11 cm in maximum dimension. 2. The liver appears dense on these non-contrast enhanced images. This may reflect prior amiodarone use or iron overload - clinical correlation is recommended. . CXR [2187-10-23]: Stable cardiomegaly. This may be consistent with cardiomyopathy. . ECG [2187-10-23]: AFib with RVR (110s), nl. axis, low precordial voltages, no ST-T changes. . Echo [2187-9-5]: 1. The left atrium is markedly dilated. The left atrium is elongated. The right atrium is markedly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed. Severe global hypokinesis. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. At least moderate (2+) mitral regurgitation is seen. 6. Moderate [2+] tricuspid regurgitation is seen. 7. The estimated pulmonary artery systolic pressure is normal. 8. There is no pericardial effusion. . Cath [2186-4-10]: 1. Resting hemodynamics reveaeld elevated rigth sided filling pressures (RA mean 11 mm Hg, RVEDP 14 mm Hg). The PA pressures were significantly elvated (PA 62/30 mm Hg, mean PA 42 mm Hg). The PCWP was significantly elevated (mean PCWP 30 mm Hg). 2. Left ventriculography revealed an EF of 30% with severe global hypokinesis. There was no significant mitral regurgitation. 3. Selective coronary angiography revealed a right dominant system. The LMCA was angiographically normal. The LAD had a 30% distal stenosis. The LCX was angiographically normal. The RCA was the dominant vessel and was angiographically normal. Brief Hospital Course: A 52yoF with Afib, s/p fall with large abdominal hematoma and 10 point Hct drop. . On admission, Pt. was transferred to the CCU for management of enlarging pannus hematoma, SOB/DOE, and anemia, all in the setting of severe CHF, and AFib with supratherapeutic INR. In the CCU, the Pt. was transfused with FFP (6 units), pRBCs (12 units), and vit. K (10 mg x 2) and her blood counts slowly stabilized (Hct 29.5, INR 1.3). Surgery team was consulted and agreed with reversing her coagulopathy and suggested applying an abdominal binder. The Pt. did not tolerate the binder. The Pt. was also evaluated by EP and was initially scheduled to have a cardioversion but this was deferred given the reversal of her anti-coagulation. The current plan is to attempt cardioversion after 1 month load of amiodarone, which the Pt. began on [11-4]. . The Pt. was transferred out of the unit, and was initially restarted on a heparin bridge to coumadin, but unfortunately a rescan of her pannus hematoma showed extension of the bleeding, so all anticoagulation was stopped. During this time, the patient had several episodes of hypotension (SBPs in 80-90s). Small boluses of IVF were given for resuscitation, but these did not normalize SBP. Larger boluses were not given due to concern for pulmonary edema and 3rd-spacing due to very poor LVEF. The Pt. became oliguric during this time, but her Cr remained normal. Hypotension persisted, and due to blood pressure holding parameters on diuretics and AFib meds, the patient could not take these meds. Further lack of response to fluid boluses and unclear etiology of hypotension (no evidence of sepsis, so either cardiogenic or distributive most likely) led to transfer to MICU. In the MICU, Pt. was given a total of seven liters of fluid and was able to tolerate it well despite her severe CHF. She developed mild pulmonary edema after about 5-7L of fluid and was diuresed with lasix. Her BB and ACE-i were restarted on [10-30] and the ACE-i was slowly titrated up to achieve afterload reduction. . Back on the medical floor, on examination the Pt. was found to be total body fluid overloaded but was also likely intravascularly dry. She tolerated gentle diuresis (40 IV lasix QD), and her SOB/dyspnea improved during this time. Goal net output was 0.5-1.0 L/d. During this time, the Pt. was encouraged to sit up and transfer from bed to chair as much as possible, and plans for d/c to rehab were initiated. . The Pt. was found to have an Enterococcus UTI by urinalysis/culture on [10-26], associated with her foley; she was treated with ciprofloxacin for a two week course. The foley was switched but kept in due to the need to carefully monitor ins and outs. The foley was d/c'd at the time of discharge. . Daily weights and ins/outs monitoring will be essential to monitor diuresis as Pt. clearly has a small window of euvolemia with tendencies toward both hypotension on the one hand, and pulm. edema/volume overload on the other hand. The Pt. is back on her home doses of BB and ACE-i, and has had good bp control. . The Pt. will restart coumadin on [11-14], with frequent INR checks, in preparation for cardioversion in approximately 1 month. Medications on Admission: 1. coumadin 2.5 mg p.o. qhs 2. albuterol inh Q6H, flovent 110 2 puffs [Hospital1 ], flonase inh [11-19] [Hospital1 ] 3. iron sulfate 325 mg p.o. [Hospital1 ] 4. amiodarone 300 mg p.o. daily 5. lasix 80 mg p.o. daily 6. lisinopril 10 mg p.o. daily 7. spironolactone 25 mg p.o. daily 8. Toprol-XL 50 mg p.o. b.i.d. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 7. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: Two (2) Spray Nasal [Hospital1 ] (2 times a day). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): please do not inject into abdomen (Pt. has large hematoma). 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a day): hold for HR<55 or SBP<90 . 12. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please hold for SBP <90 . 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 16. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 17. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: PLEASE DO NOT START UNTIL [11-14]. 18. Outpatient [Name (NI) ] Work Pt. will start taking coumadin on [11-14]. Please check INR every 2-3 days starting on [11-14], and adjust INR dose for goal 2.0-3.0. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Right pannus hematoma secondary to supratherapeutic coumadin level 2. CHF 3. AFib Discharge Condition: Fair, stable. Discharge Instructions: Please continue to take all of your medications exactly as prescribed. If you experience fevers, chest pain, shortness of breath, or abdominal pain, please call your PCP or return to the hospital. . Your coumadin was stopped because your INR level was too high. Your coumadin will be restarted on [11-14]. Please make sure to check your INR frequently. . You had a urinary tract infection, which we treated with antibiotics, you will take 3 more days of antibiotics after discharge. . Please weigh yourself every morning, and [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: Provider: [First Name8 (NamePattern2) 674] [Last Name (NamePattern1) 11298], RN,BSN,MSN Phone:[Telephone/Fax (1) 250] Date/Time:[2187-11-7] 12:00 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2188-2-12] 1:00 Completed by:[2187-11-8]	[ "4280", "42731", "2851", "5990", "5849", "V5861", "4019" ]
Admission Date: [2169-2-24] Discharge Date: [2169-3-2] Service: MEDICINE CHIEF COMPLAINT: Bright red blood per rectum. HISTORY OF PRESENT ILLNESS: The patient is an 82 year-old Russian speaking male with a history of diabetes, coronary artery disease and cardiomyopathy who presented with bright red blood per rectum upon waking from sleep at 1:30 a.m. on the morning of admission. He denied any belly pain or diarrhea. He had no previous history of a GI bleed. He does endorse a history of constipation. There is a question of a history of a colonoscopy in the past, but this is remote. He was evaluated in the Emergency Room where he received 2 units of fresh frozen platelets for an INR of 2.9 as well as 10 mg of vitamin K. He was also transfused with 2 units of packed red blood cells for a hematocrit of 29.7. He was also given an nasogastric lavage, which was negative. He was admitted to the MICU for 1 liter output of rectal bleeding in the Emergency Room. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. Atrial fibrillation status post pacer in [2159]. 4. Coronary artery disease status post myocardial infarction with a coronary artery bypass graft and a recent positive stress test per Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. 5. Hypercholesterolemia. 6. Cardiomyopathy. 7. Hypothyroidism. 8. Benign prostatic hypertrophy. MEDICATIONS ON ADMISSION: 1. Coumadin 5 mg po q day. 2. Cozaar 50 mg po q day. 3. Glyburide 5 mg po b.i.d. 4. Glyset 25 mg po t.i.d. 5. Lanoxin 0.125 mg po q.d. 6. Lopresor 50 mg po b.i.d. 7. Multivitamin one cap a day. 8. Pravachol 20 mg po q day. 9. Proscar 5 mg po q.d. 10. Vitamin B-1 100 mg po q.d. 11. Senotab 8.6 mg po q.d. 12. Lasix 120 mg po b.i.d. 13. Terazosin 5 mg po q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION TO THE MICU: Temperature afebrile. Blood pressure 143/63. Pulse 69. Respirations 18. 99% on room air. In general, he was a pleasant Russian speaking male lying in bed in no acute distress. HEENT examination pupils are equal, round and reactive to light. Mucous membranes are moist. No carotid bruits. Heart was irregular irregular with a grade 2 out of 6 systolic ejection murmur. Lungs revealed mild crackles at the right base. The abdomen was soft, nontender, nondistended with positive bowel sounds. Extremities were warm with weak dorsalis pedis pulses bilaterally, but positive radial and femoral pulses. Neurological examination revealed the patient to be alert and oriented and communicating with Russian staff fluently. LABORATORIES ON PRESENTATION: White blood cell count 7.4, hematocrit 29.7, MCV 82, platelets 179. His baseline Hematocrit is known to be 33 to 36%. His INR was 2.9. His Chem 7 is remarkable for a BUN of 84 and a creatinine of 2.1 and a glucose of 391. HOSPITAL COURSE: 1. Gastrointestinal bleed: He was initially admitted to the Intensive Care Unit for large rectal bleeding output. His nasogastric lavage was negative. He was transfused as mentioned above and was seen by the gastroenterology team. He had also been seen by the surgery team as well. The results of an early nuclear scan for bleeding showed findings consistent with a cecal bleed. He was sent to interventional radiology for further diagnostic evaluation for localizing the site of the bleed and had a selective mesenteric angiogram. The patient was found to have active bleeding from the branch of the ileocolic artery, which was selectively embolized with four 2 mm by 2 cm coils with cessation of active extravasation of contrast. He was transfused 2 more units to support his anemia to a hematocrit of 25% and was called out to the floor when his bleeding stabilized. He was also seen by surgery who was concerned for ischemia of the embolized segment. For this reason the gastroenterology team also agreed that a colonoscopy would place the patient at a higher risk for perforation of the segment of the colon, which was effaced by ileocolic artery embolization. By [2-26] he had received 11 units of packed red blood cells and the patient was called out to the floor. He remained stable in terms of his bleeding. He did endorse a couple of episodes of small dark spotted blood with his bowel movements, but none of these resulted in a drop in his hematocrit. 2. Coronary artery disease: The patient was seen by Dr. [Last Name (STitle) ] in [2169-1-28] who had the patient go for a nuclear stress test, which revealed a moderate reversible perfusion defect in the anterior wall and anterior portion of the apex that was consistent with stress induced ischemia. He was held off his aspirin until his hematocrit stabilized and then restated on a baby aspirin. Dr. [Last Name (STitle) ] saw the patient while he was in house, recommending that the patient have his acute GI issues settle out before doing a cardiac catheterization at the end of [Month (only) 958]. He did not complain of any active chest pain. 3. Congestive heart failure: The patient continued to do well from a congestive heart failure point of view. He had his Lasix dose held and then reduced and appeared to do well on the reduced dose of 60 mg po b.i.d. 4. Atrial fibrillation: The patient was held off his Coumadin for gastrointestinal bleeding. He also had his pacemaker interrogated after having bradycardia down to the 30s one evening without pacemaker capturing. The electrophysiology team interrogated the patient and found that the pacemaker's battery had about a four month life left in the battery. They adjusted the setting and recommended that his batter be changed in two to three months time. At this time the patient is scheduled to have both his cardiac catheterization and pacemaker battery changed on admission to the hospital on [2169-3-22]. 5. Benign prostatic hypertrophy: The patient was continued on Terazosin and Finasteride. 6. Hypothyroidism: He was known to have a normal TSH on the last check. This was recommended to be followed up was an outpatient. 7. Diabetes: The patient was continued on regular insulin sliding scale instead of his oral hypoglycemics due to his diet changes in preparation for procedures. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To home with VNA Services. DISCHARGE MEDICATIONS: 1. Digoxin 125 micrograms po q day. 2. Pravachol 20 mg po q day. 3. Finasteride 5 mg po q day. 4. Multivitamins one cap po q day. 5. Losartan 50 mg po q.d. 6. Furosemide 60 mg po b.i.d. 7. Pantoprazole 40 mg po q day. 8. Metoprolol 50 mg po b.i.d. 9. Aspirin 81 mg po q day. 10. Docusate sodium 100 mg po b.i.d. 11. Glyburide 5 mg po q day b.i.d. 12. Glyset 25 mg po t.i.d. 13. Terazosin 5 mg po q.d. DISCHARGE DIAGNOSES: 1. Diabetes. 2. Hypertension. 3. Atrial fibrillation with pacemaker. 4. Coronary artery disease with a history of coronary artery bypass graft in myocardial infarction. 5. Hypercholesterolemia. 6. Ischemic cardiomyopathy. 7. Hypothyroidism. 8. Benign prostatic hypertrophy. 9. Acute blood loss anemia from gastrointestinal bleeding, status post ileocecal artery branch embolization in [2169-2-25]. FOLLOW UP PLANS: The patient is to follow up with Dr. [Last Name (STitle) ] on admission to the hospital on [2169-3-22] for cardiac catheterization and pacemaker battery change. In addition, he may be evaluated for automatic implanted cardioverter defibrillator at that time. He is also to follow up in heart failure clinic on [2169-3-30] at 1:30 p.m. with Dr. [Last Name (STitle) ]. Also he will have his creatinine checked on Friday [3-3] by the [Hospital6 407] and the results of which will be faxed to Dr. [Last Name (STitle) 24863] to ensure that his creatinine does not continue to rise upon discharge. Also he will have laboratories drawn on [3-20], which will be faxed to the cardiac catheterization service in preparation for cardiac catheterization. [First Name11 (Name Pattern1) 2515] [Last Name (NamePattern4) 4517], M.D. [MD Number(1) 4521] Dictated By:[Doctor Last Name 24864] MEDQUIST36 D: [2169-3-2] 03:46 T: [2169-3-3] 06:54 JOB#: [Job Number 24865]	[ "2851", "4280", "42731", "25000" ]
Admission Date: [2126-7-29] Discharge Date: [2126-8-22] Service: CHIEF COMPLAINT: Dark urine and painful skin lesions. HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old male with a past medical history significant for myelodysplastic syndrome diagnosed eight years ago and multiple basal cell carcinomas who presented with a 3-day history of dark red/bloody urine. The patient also complained of a painful skin lesion on the left flank. Regarding the hematuria, the patient reported painless hematuria with urine that was essentially dark red and never grossly bloody times one week. He denied any history of trauma as well as any dysuria, increased urinary frequency, hesitancy, or difficulty voiding. He also denied abdominal pain. The patient denied bright red blood per rectum, melena, hematemesis, hemoptysis, or epistaxis. He did admit to easy bruising and prolonged time to clot. The patient reported that his myelodysplastic syndrome had been stable until the Spring of this year when he started to feel very tired and lethargic. He had started receiving weekly packed red blood cell transfusions seven weeks prior to admission and had started weekly Epogen injections three weeks prior to admission. The patient was status post a bone marrow biopsy on [2126-6-18] that showed decreased erythroid elements with occasional dysplastic forms and decreased myeloid elements with limited maturation. However, there was no evidence of progression to acute leukemia. Regarding the skin lesions, the patient reports that the left flank lesion first appeared three to four weeks prior to admission and that over the past week it had become increasingly tender. He says the lesion started out looking like a blister and then "popped." The patient is unsure of the nature of the fluid that it drained. The patient also has a left axillary lesion which he says started out like a blister and has been present for three to four days prior to admission. In the Emergency Department, the patient received one dose of gentamicin and oxacillin. He was also transfused with 2 units of packed red blood cells and 1 unit of fresh frozen plasma. He was also given potassium chloride. PAST MEDICAL HISTORY: 1. Myelodysplastic syndrome diagnosed eight years ago; recently transfusion dependent. 2. Gout. 3. Basal cell carcinoma. 4. Squamous cell carcinoma. 5. Question history of inferior wall myocardial infarction. PAST SURGICAL HISTORY: Mohs surgery for basal cell carcinoma. SOCIAL HISTORY: The patient is a former psychologist at [Hospital 14852]. He is separated from his wife of 14 years. He has seven children. He drinks occasional alcohol. He has a 50 plus year history of cigar smoking and quit six to seven months ago. FAMILY HISTORY: His family history is significant for a daughter with diabetes. He had a brother who died of leukemia at the age of three and father who died of heart disease. MEDICATIONS ON ADMISSION: His medications included Epogen 20,000 units every Tuesday, colchicine as needed, multivitamin with iron, and Tylenol as needed. ALLERGIES: He has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: The patient's vital signs on presentation were as follows; temperature was 100.6, heart rate was 88, respiratory rate was 24, blood pressure was 107/63, oxygen saturation was 97% on 2 liters. The patient's physical examination on presentation was as follows; in general, he was a pale-appearing elderly male. He was in no apparent distress. His head, eyes, ears, nose, and throat examination revealed sclerae were anicteric. His conjunctivae were pale. His oropharynx was clear. There was no thyromegaly, and no cervical lymphadenopathy, and no jugular venous distention. His lungs revealed bibasilar crackles. His heart examination revealed a regular rate and rhythm with a 2/6 systolic murmur. His abdomen was soft and nontender, with positive bowel sounds. He also had a palpable spleen tip. His back revealed no costovertebral angle tenderness. On his skin were multiple facial telangiectasias. His nose appeared slightly disfigured which was consistent with prior Mohr surgery. He had multiple pink plaques, some with overlying scales distributed overlying scale distributed over his back, arms, and legs bilaterally. On his left flank was a well demarcated 7-cm to 8-cm indurated pink plaque with an area of central necrosis. He had a similar-appearing 5-cm to 6-cm pink plaque under his left axilla which; both of which were extremely tenderness to palpation. Neurologically, he was alert and oriented times three. He had no focal deficits. His rectal examination revealed occult-blood positive brown stool. PERTINENT LABORATORY DATA ON PRESENTATION: His laboratories on admission were as follows; complete blood count revealed a white blood cell count of 3.9, his hematocrit was 19.8, with a mean cell volume of 87. Of note, the patient had a hematocrit of 25.8 three days prior to admission. His platelet count was 15. The differential of his white blood cell count was as follows; 27% polys, no bands, and 51% lymphocytes. His Chemistry-7 was as follows; sodium was 132, potassium was 2.7, chloride was 98, bicarbonate was 22, blood urea nitrogen was 30, creatinine was 1.4, and blood glucose was 105. The patient's baseline creatinine is 1.1 to 1.2. The patient's coagulations were as follows; PT was 15.2, PTT was 41.9, INR was 1.6. The patient had a reticulocyte count that was sent in the Emergency Department and came back at 0.7. His urinalysis revealed brown cloudy urine, with large blood; it was nitrite positive, protein was greater than 300, glucose was negative, ketones were trace, there was a small amount of bilirubin, a moderate amount of leukocyte esterase; his red blood cell count was greater than 1000 with 3 to 5 white blood cells and many bacteria. There was also occasional uric acid crystals noted. Blood cultures and urine cultures were sent from the Emergency Department on [7-29] which were negative. HOSPITAL COURSE: The [Hospital 228] hospital course related chronologically was as follows. On the evening of [7-29], he was admitted to the CC Seven. He was initially treated with dicloxacillin for his skin lesions and started on intravenous ciprofloxacin for question pyelonephritis given the infectious-appearing urinalysis. It was unclear whether the patient's presentation with pancytopenia was secondary to blasts crisis; although, this was felt to be unlikely given that he has had a recent bone marrow biopsy which was negative for blasts, and his peripheral smear was also negative for blasts. His coagulopathy was treated with transfusions of fresh frozen plasma and vitamin K. On [7-30], the patient was seen by his outpatient hematologist who questioned whether the patient's skin lesions and hematuria could be secondary to septic emboli. The patient was ordered to get a transthoracic echocardiogram which he refused on several occasions. His antibiotics were also changed from dicloxacillin to oxacillin. On [7-31], the patient's coagulations were all evaluated despite vitamin K, and there was noted to be minimal correction of the anemia and thrombocytopenia despite transfusions. A disseminated intravascular coagulation screen was sent off and found to be positive. A Dermatology consultation was also called on this day for help in evaluating the skin lesions. They felt that the lesions were most consistent with a neutrophilic dermatosis such as pyodermic gangrenosum versus Sweet's disease which has a high incidence in myelodysplastic syndrome. Also on the differential diagnosis was exanthematic gangrenosum due to Pseudomonas infection as well as a deep fungal infection and cutaneous leukemia/lymphoma. The left axillary lesion was biopsied and sent for bacterial, and fungal, and atypical mycobacterial cultures. The Dermatology consultation agreed with intravenous antibiotics. On [8-1], the patient was felt to be functionally neutropenic; and given the question of Pseudomonas infection, he was started on intravenous ceftazidime. He was also continued on intravenous oxacillin. The Infectious Disease Service was consulted regarding the disseminated intravascular coagulation and choice of antibiotics. They agreed with ongoing ceftazidime and oxacillin. On their differential was bacterial infections; namely furunculosis or xanthomatous granulosum. They also considered sporotrichum infections, mycobacterial infections, tick-borne diseases. They also considered Sweet's disease in malignancy associated conditions. They recommended a CT of the abdomen if the workup was unrevealing. A renal ultrasound was also performed on [8-1] which showed multiple stones in the collecting system, but no evidence of hydronephrosis or renal abscess. On [8-2], the patient's skin biopsy Gram stain revealed 2+ polys and no organisms, and the aerobic culture grew out coagulase-positive Staphylococcus. At that point, it was decided to treat the patient for 10 days with intravenous oxacillin. The preliminary pathology report on the skin biopsy was as follows; clusters of plasma cells with infiltrative lymphocytes and neutrophils. On the differential was pyoderma versus infection versus plasma cell neoplasm. On [8-3], a serum protein electrophoresis and urine protein electrophoresis; which had been sent out earlier in the week, came back positive for monoclonal spike in the SPEP and two abnormal bands on the UPEP. A monoclonal intact immunoglobulin G lambda and monoclonal free lambda ([Initials (NamePattern5) ] [Last Name (NamePattern5) ]-[Doctor Last Name ]). These results were discussed with the patient's outpatient hematologist who agreed with consulting the inpatient Hematology Service. The Hematology Service recommended starting the patient on Decadron but holding off on melphalan. They said that overall, the association between myelodysplastic syndrome and multiple myeloma is not known, but they felt that people with malignancy and myeloma could develop severe disseminated intravascular coagulation which was consistent with the patient's clinical picture. On [8-4], the patient had a CT of the abdomen, chest, and pelvis to look for sources of occult infection. The CT of the chest was significant for a 1.2-cm nodule in the right upper lung adjacent to the major fissure. The CT of the abdomen and pelvis revealed a 1.2-cm cyst in the body of the pancreas. There was no lymphadenopathy that was noted in the mediastinum, in the axilla, or in the pelvis. On [8-6], the patient's diagnosis of myeloma was questioned by Dr. [Last Name (STitle) 2539] (who was the patient's outpatient hematologist), and it was felt that the monoclonal spike most likely represented myoclonal gammopathy of unknown significance rather than myeloma. At that point, the steroids were discontinued, and the decision was made to repeat the skin biopsy given the questionable read of plasmacytoma. In the meantime, the Infectious Disease workup continued; and [Doctor Last Name 3271]-[Doctor Last Name ] virus, cytomegalovirus, cryptococcal, and coccidia serologies were checked; which all came back as negative. Also, Babesia thick and thin smears were checked given a history of transfusions. On [8-7], the ceftazidime was discontinued after eight days secondary to no known organisms. The patient developed increasing transfusion dependence. Previously, he had only required transfusions prior to procedure. At this point, he required transfusions to stop bleeding from his intravenous sites and from his biopsy sites. On [8-8], the patient had frank bleeding from his skin biopsy site that required two hours of manual pressure and resuturing to achieve hemostasis. Also, the issues of access were raised given that the patient had only one peripheral intravenous line and was in need of multiple blood products. At that point, a peripherally inserted central catheter line was placed in Interventional Radiology. Also, on the evening of [8-8], the patient had an adverse reaction while getting transfused with cryoprecipitate. On [8-9], the patient had a repeat bone marrow aspiration and biopsy. At that point, it was felt that given that the skin biopsies were nondiagnostic that the question of whether the patient was transforming into an acute leukemia needed to be readdressed. This bone marrow biopsy returned the week later and was consistent with myelodysplastic syndrome with no evidence of acute leukemia. Subsequently, from [8-9] to [8-15], the patient continued to require aggressive blood product support through his disseminated intravascular coagulation with daily transfusions of platelets, packed red blood cells, cryoprecipitate, and fresh frozen plasma. Disseminated intravascular coagulation laboratories were checked twice a day, and factors and cells were replaced liberally as the patient continued to ooze through his peripherally inserted central catheter site and biopsy sites. On [8-14], the patient became acutely hypotensive with a systolic blood pressure in the 90s. He was also symptomatic and complaining of lightheadedness. The patient was boluses with fluids and received blood products with a return of his blood pressure to the 140s. He had a repeat episode on [8-16], to which he again responded to fluids and blood products. On [8-15], the patient's repeat skin biopsy was read as consistent with intracellular organisms. Toxoplasmosis stains done were positive, and the diagnosis of cutaneous toxoplasmosis was made with a question of toxoplasma-induced disseminated intravascular coagulation. On [8-16], the patient was started on medications for toxoplasmosis consisting of sulfadiazine, Pyrimethamine, and folinic acid. He was also started on G-CSF given his profound neutropenia and the possibility of a granulocytosis with a sulfa regimen. Multiple urine cultures from [8-14] to [8-16] were positive for enterococcus. The Infectious Disease consultants felt that this was most likely a contaminant and was not initially treated. However, on [8-16], the patient was started on vancomycin for an enterococcus urinary tract infection. On the morning of [8-17], the patient had multiple sets of blood cultures which came back positive as gram-positive cocci in pairs and clusters. He had also been spiking fevers, and this was felt to be secondary to Staphylococcus bacteremia. The patient was maintained on his toxoplasmosis medications as well as vancomycin. He was also on Flagyl at this point for stools positive for Clostridium difficile. On the evening of [8-17], the patient complained of [4-12] chest pain. The night float intern was called to see the patient, and an electrocardiogram was checked which was unchanged. His chest pain was treated with sublingual nitroglycerin, morphine, and Ativan. Several hours later, the patient again complained of chest pain, and at this time was markedly tachypneic with a respiratory rate in the 30s and a heart rate in the 100s. A blood gas was checked at this time which revealed a respiratory alkalosis with a large AA gradient. There was concern that the patient may have had a pulmonary embolism. An electrocardiogram was checked which showed ischemic changes across the precordium as well as in the lateral leads. Troponin were cycled and found to be elevated. On examination, the patient was found to be in an irregular rhythm. An electrocardiogram was again checked, and that showed that the patient was in atrial fibrillation. He had previously, throughout the course of the admission, been in a normal sinus rhythm. The patient was also tachycardic to the 180s and was given intravenous diltiazem with minimal effect. The Medical Intensive Care Unit Service was consulted and recommended cardioversion with amiodarone. However, the amiodarone could not be administered on the floor, and the patient required transfer to the Medical Intensive Care Unit for cardioversion. In the Intensive Care Unit, on amiodarone, the patient did cardioverted back to sinus rhythm. He was also placed with a femoral line given that his peripherally inserted central catheter line was infected and felt to be the source of his Staphylococcus bacteremia. On the evening of [8-19], the patient was transferred back from the Medical Intensive Care Unit to the floor initially in sinus rhythm; however, the patient converted back to atrial fibrillation shortly thereafter. On the following day, the sensitivities of the patient's blood cultures revealed the organisms were resistant to oxacillin, and the patient was continued on vancomycin. It was noted that his disseminated intravascular coagulation appeared to be stabilized. The patient was requiring fewer blood transfusions and was maintaining his counts for longer periods of time status post transfusions. However, it was notable that from a mental status standpoint, the patient was becoming quite frustrated with the number of complications that he was facing and was increasingly less optimistic about his prognosis. Previously during the admission, in fact it was on [8-16], the patient; in consultation with his son and with his attending, decided on a do not resuscitate/do not intubate code status. This was later changed to comfort measures only on [2126-8-21]. His house officer, his attending, and his consultants related the fact that while his overall prognosis was poor, that he was actually showing signs of improvement regarding his disseminated intravascular coagulation and his Staphylococcus infection. However, while the patient expressed a clear understanding of this, he wanted to continue with his decision to be comfort measures only. At that point, all intravenous fluids, medications, blood draws, and blood product support were withdrawn. He was ordered for intravenous morphine as needed, and for intravenous Ativan, and Valium as needed. Social Work and the Palliative Care Service were involved with helping the patient deal with this decision and helping the family also cope with the imminent loss of their father. NOTE: There will be an addendum that will be added at a later date. [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Name8 (MD) 9130] MEDQUIST36 D: [2126-8-22] 23:08 T: [2126-8-28] 12:02 JOB#: [Job Number 23730]	[ "2761", "2762", "42731", "5849" ]
Admission Date: [2144-7-3] Discharge Date: [2144-7-9] Date of Birth: [2066-6-12] Sex: M Service: NEUROSURGERY Allergies: Keppra Attending:[First Name3 (LF) 1854] Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: [7-3] Right Craniotomy for evacuation of R SDH dialysis History of Present Illness: Patient came from rehab facility for a complaint of left extremity weakness. He usually ambulates with a rolling walker and was seen to drag his left leg. He has a previous history of fall resulting in bilateral SDH in [Month (only) ] of 09. He underwent left burr holes. He states that he weakness has occurred within the past two days. He also reported some uninary frequency and frequency. Past Medical History: HTN, CAD, DM Social History: Married, lives with wife Family History: NC Physical Exam: O: T: 96.9 BP:107 / 61 HR: 86 R 30 O2Sats 95% on R/A Gen: WD/WN, comfortable, NAD. HEENT: Prior Burr hole site well healed. Pupils: 2.5mm to 2.0mm bil EOMs Full to Confrontation. Conjugate gaze. Neck: Supple. No upstrokes or bruits noted Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Trace pedal edema present Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Primary language Greek but speaks \English well. Orientation: Oriented to person, place, and date. Recall: [2-18] objects at 5 minutes. Language: Speech is slow and deliberate with good comprehension . Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,2.5mm to 2.0 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-/5 throughout both upper extremities. Right LE with 5/5 throughout. The Left LE is 4+/5 through the entire extremity. There is 3Beats Clonus Bilat,No pronator drift Sensation: Intact to light touch and propioception, bilaterally. Coordination: Slowed on finger-nose-finger Gait not observed. Exam upon discharge: alert and oriented x3, slight weakness L LE, wound with slight erythema Pertinent Results: [2144-7-7] 12:00PM BLOOD WBC-10.0 RBC-3.21* Hgb-8.4* Hct-27.9* MCV-87 MCH-26.1* MCHC-30.0* RDW-17.0* Plt Ct-204 [2144-7-3] 10:10AM BLOOD Neuts-68.3 Lymphs-23.0 Monos-5.7 Eos-2.3 Baso-0.7 [2144-7-7] 12:00PM BLOOD Plt Ct-204 [2144-7-7] 12:00PM BLOOD Glucose-191* UreaN-57* Creat-6.0* Na-135 K-4.7 Cl-95* HCO3-26 AnGap-19 [2144-7-4] 03:11AM BLOOD Amylase-206* [2144-7-3] 04:11PM BLOOD Glucose-115* Lactate-1.0 Na-139 K-4.6 Cl-99* Head CT [2144-7-3]:IMPRESSION: Bilateral acute on chronic subdural hemorrhages with associated extrinsic mass compression on the bilateral frontal and parietal lobes. A now interval progression in size with a 26-mm in transverse diameter right subdural collection and a 14-mm in diameter left subdural collection. Interval improvement in left-sided pneumocephalus in expected postoperative appearance of left-sided pneumocephalus. Head CT 7/19IMPRESSION: 1. Interval decrease in size of left predominantly iso to hypodense subdural collection. The collection persists overlying the left hemisphere at the vertex. 2. Slight decrease in size of the right subdural collection with slight decrease in pneumocephalus about the surgical site. 3. No shift of midline structures. No evidence for herniation. 4. No evidence for new hemorrhage. Head CT [2144-7-6] IMPRESSION: Status post right parietal craniotomy, stable right-sided subdural hemorrhage with pneumocephalus and stable left-sided subdural hemorrhage, both with a few linear areas of hyperdense material which are likely cortical veins and unchanged; however, close f/u study to be considered to exclude hemorrhage. No interval increase in size. Brief Hospital Course: Mr [Known lastname 82927] was admitted to the neurosurgery service and underwent right sided craniotomy for subdural evacuation. Post operatively he was monitored in the ICU he was extubated on post op day 1, he was receiving Dilantin for seizure prophylaxis. He had some difficulty with hypotension thought to be related to post dialysis fluid removal. He was started on Midrodrine which helped raised his blood pressure. He was transferred to the neurostep down on post op day 1. Follow up CT showed interval decrease in size of left subdural collection, predominantly isodense with a small focal hyperdensity, predominantly at the vertex. He was noted to have some right sided leg weakness post operatively. Physical therapy recommened the patient should go to rehab. On discharge he was tolerating a regular diet, his blood pressure was maintained in the low 100's. He was noted to have a slight right drift and facial asymmetry. His last dialysis was on [7-9]. He required bolus of dilantin [7-9] for low level and standing dosages was increased and this should be followed at rehab to maintain therapeutic level. his incision looked slightly erythematous on [7-9] and keflex was started for 7 day course. Staples should be removed [2144-7-10]. Medications on Admission: Tylenol 650mg po Q6hrs;prn, Anusol Supp 1Supp [Hospital1 ];PRN, Atorvastatin 20mg QD,Cholecalciferol VIT D 1000U QDay, Miconazole powder 2% top [Hospital1 ], Digoxin 0.125mg Q48hrs, Colace 100mg [Hospital1 ], Erythropoietin 20,000Units SC PRN Dialysis, Ferrous Gluconate 125mg IV; PRN Dialysis, Finasteride 5mg PO Daily, Lasix 40mg [Hospital1 ], Amaryl 1mg PO QAM, Heparin 5000u SQ Daily, Reg. Insulin Sliding Scale,Latanoprost 0.005% Opth 1drop each eye QHS, Ativan 1mg po QHS PRN anxiety or sleep, MVI Nephrocaps 1 Cap Non-STD, Metoprolol SR 25mg PO Daily, Pilosec 20mg daily, Percocet PRN, Miralax 17GM Po daily, Psyllium Metamucil 5.85GM Daily; PRN constipation, Flomax 0.4mg po QHS, Venlafaxine SR 37.5mg po daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Headache. 2. Hemorrhoidal Cream 0.25-1 % Cream Sig: One (1) Rectal twice a day as needed for Hemmorroids. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO Q48HRS (). 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO Qam () as needed for Anti diabetes. 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO NON DIALYSIS DAYS (). 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 15. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 16. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 21. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 22. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 23. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 7 days: take thru [2144-7-16]. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: Bilateral SDH chronic renal disease Discharge Condition: Neurologically stable Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have results faxed to [Telephone/Fax (1) 87]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office or have your staples out at rehab on [7-10] ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ], to be seen in 4 weeks. You need to have a CT at that time ?????? Completed by:[2144-7-9]	[ "40391", "25000", "41401", "412" ]
Admission Date: [2142-8-18] Discharge Date: [2142-8-27] Date of Birth: [2096-6-10] Sex: M Service: SURGERY Allergies: Unasyn Attending:[First Name3 (LF) 148] Chief Complaint: abdominal pain w/HIDA suggestive of biliary leak Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Exploration of retroperitoneum. 3. Exploration of common bile duct. 4. Cholangiogram with fluoroscopic guidance. 5. Choledochoduodenostomy. 6. Primary incisional hernia repair. History of Present Illness: This 46-year-old gentleman is a patient well known to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in our minimally invasive surgery group for morbid obesity. Dr. [Last Name (STitle) ] performed an open gastric bypass via a Roux-en-Y technique a number of years ago. Mr. [Known lastname 18097] also had a laparoscopic cholecystectomy performed prior to this in the distant past. He presents recently with a history of common bile duct stones. Given his prior open Roux-en-Y bypass, this was unable to be addressed through endoscopic retrograde cholangiopancreatography. Therefore, he had a percutaneous transhepatic cholangiography performed and during this, multiple stones were removed from the bile duct via radiology technique. His percutaneous tube remained in place until Friday, [8-17], when Dr. [Last Name (STitle) ] removed this in the office. There had been a question of a distal stricture in the bile duct on the recent PTC. Mr. [Known lastname 18097] [Last Name (Titles) ] and over the ensuing 3 days was admitted to the hospital and had abdominal and back pain. An initial workup with a CAT scan showed some mild peri hepatic fluid but no evidence of any hemorrhage or leak in the abdomen. Furthermore, there was a normal caliber bile duct and intra-hepatic radicals. He continued to have a [Last Name ] problem with an elevated bilirubin. A PTC attempt was made again and this was aborted due to small nondilated ducts. Given the patient's clinical down turn and an elevated bilirubin, concern was brought up for a leak. Therefore a HIDA scan was obtained the night of this operation. This scan was read by the attending radiologist and he indicated that this was indicative of a significant lateral leak from the bile duct. The patient was met directly before this procedure in the holding area. He was ill and toxic appearing. He had abdominal tenderness and back pain. He appeared somewhat confused and was not clear in his thoughts or conversation. Given these findings and the declaration of a bile duct leak with very few interventional or non invasive techniques available for a gentleman like this, an immediate exploration was warranted to drain the leak, if not permanently address the problem. Therefore, the patient was taken to the operating room on the evening of [2142-8-20]. Mr. [Known lastname 18097] understood that this was a major operation in an emergent setting and given his gross obesity and other factors, that this had a heightened risk profile. The risks were described in depth by our resident team and they included poor wound healing, bleeding and infection as well as the chance of a leak of any connection or persistent fistula from drainage. He understood these risks and wished to proceed and provided informed consent to that effect in the holding area tonight. Past Medical History: Morbid obesity. Sleep apnea. Hypertension. Gastroesophageal reflux. Osteoarthritis. Lap chole [2-6] Rou-en-Y bypass [9-6] PTC placement for biliary sludge/stone [7-8] Social History: He continues to smoke about one pack per day for the last 20 years. He drinks alcohol for the last 20 years and has recently drinks 2-3 beers/day. He denies any drug abuse. Family History: His father is alive with prostate cancer. Mother with congestive heart failure. Physical Exam: Vitals: T 97.5 P78 BP148/80 R20 O2 96%RA Gen: Large gentleman in no acute distress Chest: clear to auscultation bilaterally CV: regular rate and rhythm Abd: soft, nondistended, obese, with mild RUQ tenderness, no rebound, no guarding Pertinent Results: CT RECONSTRUCTION [2142-8-18] 11:39 AM IMPRESSION: 1. No ductal dilatation, abscess or drainable collections. 2. Small right pleural effusion. 3. Small amount of enhancement along the catheter tract consistent with inflammatory change and trace amount of fluid density in the right properitoneal space. Gallbladdar scan [8-19]: IMPRESSION: Pooled tracer adjacent to the gallbladder fossa which may represent tracer witin a biliary leak or aperistaltic loop of proximal bowel. Recommend correlation with CT. Findings discussed with the surgical team by Dr. [Last Name (STitle) 11925] after the study. CHOLANGIOGRAM,IN OR W FILMS [2142-8-21] 2:22 AM IMPRESSION: There is irregular narrowing of the distal two-thirds of the common bile duct, but there is no evidence of obstruction. There is mild upstream dilatation, suggesting that this could have a component of partial obstruction. [2142-8-24] 03:36AM BLOOD WBC-6.6 RBC-2.83* Hgb-9.3* Hct-27.0* MCV-96 MCH-32.7* MCHC-34.2 RDW-13.3 Plt Ct-160 [2142-8-24] 03:36AM BLOOD Plt Ct-160 [2142-8-24] 03:36AM BLOOD Glucose-102 UreaN-6 Creat-0.5 Na-139 K-3.8 Cl-108 HCO3-26 AnGap-9 [2142-8-20] 05:35AM BLOOD ALT-20 AST-13 LD(LDH)-143 AlkPhos-122* Amylase-23 TotBili-1.9* DirBili-0.9* IndBili-1.0 [2142-8-24] 03:36AM BLOOD ALT-21 AST-15 LD(LDH)-123 AlkPhos-94 TotBili-0.6 Brief Hospital Course: 46 yo morbidly obese male admitted on [2142-8-18] for abdominal and back pain. He was emergently taken to the OR late in the evening of [2142-8-20] for 1. Exploratory laparotomy. 2. Exploration of retroperitoneum. 3. Exploration of common bile duct. 4. Cholangiogram with fluoroscopic guidance. 5. Choledochoduodenostomy. 6. Primary incisional hernia repair. There was no hemodynamic instability throughout this procedure and the patient tolerated it well. He remained intubated on transfer to the SICU. Pt was placed on levo/flagyl/vanco. He was weaned from vent and extubated on POD2. His condition improved and pt was transferred to the floor on POD4. His alkaline phosphatase (from 122 to 83) and total bilirubin (from 2.2 to 0.5) [Date Range ] to normal values during his course. Physical therapy participated in his rehabilitation, but pt was ambulatory on his own by POD5. He continued to tolerate PO intake and his pain was controlled with PO analgesia. He was discharged home on [2142-8-27] in good condition and instructed to follow-up in Dr.[Name (NI) 1745] clinic on [2142-9-7]. Medications on Admission: none Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:50 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:20 Capsule(s) Refills:0 3. Advil 100 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Biliary stricture. 2. Probable cholangitis. Discharge Condition: good Discharge Instructions: - Showers OK, no soaking in tub or pool for several weeks - Please restart all medications you were taking at home - Please [Name8 (MD) 138] MD or return to ER if T>101.5, chills, nausea, vomitting, erythema/smelly discharge around wound, or for any other concern. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] on Friday, [2142-9-7] at 830AM [Hospital Ward Name 23] [Location (un) 470] surgical clinic ([Telephone/Fax (1) 18098]). Completed by:[2142-8-27]	[ "53081", "4019" ]
Admission Date: [2159-4-2] Discharge Date: [2159-4-11] Date of Birth: [2106-1-25] Sex: M Service: MEDICINE Allergies: aspirin Attending:[First Name3 (LF) 8388] Chief Complaint: Hepatic Encephalopathy Major Surgical or Invasive Procedure: Therapeutic Paracentesis x2 PICC line placement Endotracheal intubation History of Present Illness: History obtained from medical records as patient is intubated, obtunded, will follow basic commands but is unable to answer questions Mr. [Known lastname 110187] is a 53 y/o M with a h/o hepatitis C, prior alcohol abuse and resultant cirrhosis who was initially brought in to [Hospital 792]Hospital on [2159-3-31], after being found down at home. The morning of [3-31] he was found unresponsive at home by his father, per EMS report at that time his blood sugar was 180 and he was given narcan with no response. Per his sister who spoke to him the night before his admission, she felt that he was at his baseline. He was then taken to [State 44256], in the ER there he was intubated for airway protection and initially started on propofol, he was presumed to have severe hepatic encephalopathy, with an ammonia level of 560. A head CT head done on admission was negative for any acute process, his labs were notable for a Cr of 1.5, his chronic anemia and thrombocytopenia, urine tox screen was positive for marijuana only. His INR was elevated to 1.9 from 1.4, t-bili was 1.6, albumin improved from 2.0 to 3.4 after replacement. Of note the day prior to admission he had undergone an 8L paracentesis with only 25g of albumin replacement. During his course at [State 44256], he was started on lactulose and rifaximin to treat hepatic encephalopathy, on [4-1] he put out over 4L of stool. Additionally, he was noted to be oliguric for the first 48 hours at [State 44256], which improved with 175g of albumin. He had an ultrasound of his abdomen with dopplers that was a significantly limited study that showed patent vessels, cirrhotic liver, but without identification of the main portal vein and hepatic veins, along with moderate ascites. A KUB showed a nonspecific bowel gas pattern, multiple chest x-rays without any evidence of pneumonia, just stable airspace disease at the left base. He remained anemic and thrombocytopenic without any evidence of active bleeding. A CT of his head and c-spine did not show any acute process. After recieving lactulose, rifaximin and albumin his mental status had mildly improved on transfer so that he was opening his eyes and moving extremities. He remained hemodynamically stable, with SBP's in the 110's-120's, and was on a t-piece for the last 24 hours, with a weak gag. He has a RIJ and PIV's for access. Currently, the etiology of his obtundation is thought to be hepatic encephalopathy and has had prior episodes of decompensation with noncompliance with his lactulose, which his family does admit happens fairly often. On arrival to the MICU, his initial VS were: 99.8, 72, 163/44, 14, 100% on PSV 5/5, 40% FiO2. He is currently intubated . Review of systems: unable to obtain as patient is obtunded Past Medical History: 1. Diabetes. Of note, his blood sugars are more controlled now on the same oral antidiabetic agents. 2. Anemia. 3. Hepatitis C cirrhosis complicated by grade 1 varices 4. History of alcohol abuse. 5. Psoriasis. 6. Barrett's Esophagus Social History: The patient lives with his 82-year-old father. [Name (NI) ] is single and has no kids. His sister, [Name (NI) ], and his brother both live close by within a mile from his house. He also has a visiting nurse at home now which visits him once a week. He has history of tattoos and remote history of drug use; however, he denies any IV drug use. He also was a heavy alcohol drinker in the past; however, quit 20 years ago and has been sober since. He also quit smoking 20 years ago. [Known firstname ] states that by his old GI doctor he was given the permission for the use of medical marijuana and he grows marijuana at home, which he uses for his constant nausea. His nausea is worse when his ascites is large. . Family History: Negative for colon cancer, liver cancer. His grandfather has history of alcoholic-induced cirrhosis. . Physical Exam: PEx on admission: General Appearance: Well nourished, initially wheezing and working to breath, improved post bronchodilator Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: OG tube Cardiovascular: RRR, +S1/S2 Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: wheezes and coarse throughout Abdominal: Soft, Bowel sounds present, Distended, site of prior para leaking ascitic fluid with bag for collection in place Extremities: Right lower extremity edema: 2+, Left lower extremity edema: 2+, areas of ecchymoses on the anterior shin Skin: Warm Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone: Normal PEx on discharge: Vitals: 98.4 117/56 69 18 99%RA General: A+Ox3, improved but slow speech Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, Non tender, distended, + bowel sounds, no rebound tenderness or guarding, increased ascites (not tense), +umbilical hernia. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact Pertinent Results: Labs on admission: [2159-4-2] 10:30PM BLOOD WBC-5.8 RBC-2.58* Hgb-8.2* Hct-26.6* MCV-103* MCH-31.6 MCHC-30.7* RDW-16.7* Plt Ct-79* [2159-4-2] 10:30PM BLOOD PT-20.3* PTT-57.8* INR(PT)-1.9* [2159-4-2] 10:30PM BLOOD Glucose-116* UreaN-45* Creat-1.5* Na-150* K-3.9 Cl-126* HCO3-16* AnGap-12 [2159-4-2] 10:30PM BLOOD ALT-42* AST-53* AlkPhos-40 TotBili-1.7* [2159-4-2] 10:30PM BLOOD Calcium-8.3* Phos-3.0 Mg-2.2 Cholest-50 [2159-4-2] 10:30PM BLOOD Triglyc-63 HDL-9 CHOL/HD-5.6 LDLcalc-28 [2159-4-3] 12:08PM BLOOD Ammonia-40 [2159-4-3] 04:32AM BLOOD IgA-535* [2159-4-4] 04:07AM BLOOD Vanco-7.1* [2159-4-2] 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2159-4-11] 03:43PM BLOOD Type-ART pO2-122* pCO2-27* pH-7.47* calTCO2-20* Base XS--1 Intubat-NOT INTUBA [2159-4-11] 03:43PM BLOOD Hgb-7.6* calcHCT-23 O2 Sat-99 [2159-4-2] 10:30PM URINE Color-DkAmb Appear-Cloudy Sp [Last Name (un) ]-1.019 [2159-4-2] 10:30PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [2159-4-2] 10:30PM URINE RBC->182* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 [2159-4-7] 01:11PM URINE CastHy-4* [2159-4-2] 10:30PM URINE Mucous-OCC [2159-4-2] 10:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Ascites fluid: [2159-4-3] 10:50AM ASCITES WBC-8* RBC-3* Polys-0 Lymphs-0 Monos-0 [2159-4-3] 10:50AM ASCITES TotPro-0.7 Albumin-LESS THAN [2159-4-5] 03:42PM ASCITES WBC-165* RBC-120* Polys-3* Lymphs-9* Monos-6* Mesothe-14* Macroph-68* [2159-4-5] 03:42PM ASCITES TotPro-1.9 LD(LDH)-79 Albumin-LESS THAN Micro: [2159-4-7] URINE CULTURE-negative [2159-4-5] Bld cx negative x2 [2159-4-5] PERITONEAL FLUID cx - negative [2159-4-4] BLOOD cx negative [2159-4-3] HCV VIRAL LOAD- [2159-4-3] BLOOD cx - negative x2 [2159-4-3] STOOL C. difficile negative URINE CULTURE (Final [2159-4-5]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S NITROFURANTOIN-------- <=16 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S [2159-4-2] MRSA SCREEN neg [2159-4-2] 10:30 pm BLOOD CULTURE Source: Line-central. FINAL REPORT [2159-4-8] Blood Culture, Routine (Final [2159-4-8]): VIRIDANS STREPTOCOCCI. Isolated from only one set in the previous five days. SENSITIVITY REQUESTED BY DR. [Last Name (STitle) ] [2159-4-6] 9-0917. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. CLINDAMYCIN <= 0.12 MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ VIRIDANS STREPTOCOCCI \| CLINDAMYCIN----------- S ERYTHROMYCIN---------- 2 R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [2159-4-3]): Reported to and read back by [Known firstname ] [Doctor Last Name ] @1715 ON [4-3] - [Numeric Identifier 27113]. GRAM POSITIVE COCCI. IN CHAINS. Labs on Discharge: [2159-4-11] 04:23AM BLOOD WBC-4.0 RBC-2.32* Hgb-7.0* Hct-22.7* MCV-98 MCH-30.1 MCHC-30.8* RDW-17.2* Plt Ct-74* [2159-4-4] 04:07AM BLOOD Neuts-62.9 Lymphs-27.3 Monos-6.1 Eos-3.3 Baso-0.4 [2159-4-11] 04:23AM BLOOD PT-18.0* PTT-48.4* INR(PT)-1.7* [2159-4-11] 04:23AM BLOOD Glucose-204* UreaN-39* Creat-1.3* Na-137 K-3.8 Cl-108 HCO3-20* AnGap-13 [2159-4-11] 04:23AM BLOOD ALT-8 AST-51* LD(LDH)-219 AlkPhos-51 TotBili-0.5 [2159-4-11] 04:23AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.0 Mg-2.0 Imaging: EKG: Sinus rhythm. Borderline low limb lead voltage. T wave inversions in leads V1-V2 may be related to lead position. No previous tracing available for comparison. Clinical correlation is suggested. US: 1. Nodular hepatic architecture with no focal liver lesion identified. No biliary dilatation is seen. 2. Patent hepatic vasculature. 3. Splenomegaly. 4. Ascites. CXR: Since prior radiograph, endotracheal tube, orogastric tube, and right internal jugular lines have been removed. Pulmonary vascular congestion has significantly improved. Bibasilar atelectasis is present. There are no lung opacities concerning for pneumonia or aspiration. Mild enlarged heart size is stable. Mediastinal and hilar contours are unremarkable. There is no pleural effusion. ECHO: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No valvular vegetations or abscesses apprecitated. Normal left ventricular cavity size with mild symmetric left ventricular hypertrophy and preserved global and regional biventricular systolic function. Mild resting LVOT obstruction. Mildly dilated aortic arch. Mild aortic regurgitation. Indeterminate pulmonary artery systolic pressure. Rpt US: Normal renal ultrasound. Ascites. PFTs: [Known lastname ],[Known firstname ] [Medical Record Number 110188] M 53 [2106-1-25] Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of [2159-4-11] 2:40 PM SPIROMETRY 2:40 PM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 4.08 4.43 92 FEV1 3.32 3.25 102 MMF 3.35 3.30 102 FEV1/FVC 81 73 111 LUNG VOLUMES 2:40 PM Pre drug Post drug Actual Pred %Pred Actual %Pred TLC 6.30 6.52 97 FRC 3.72 3.62 103 RV 1.82 2.08 87 VC 4.50 4.43 102 IC 2.59 2.90 89 ERV 1.90 1.54 123 RV/TLC 29 32 90 He Mix Time 3.38 DLCO 2:40 PM Actual Pred %Pred DSB 16.44 27.42 60 VA(sb) 5.86 6.52 90 HB 7.00 DSB(HB) 23.79 27.42 87 DL/VA 4.06 4.21 96 Brief Hospital Course: Mr. [Known lastname 110187] is a 53 y/o M with a history of HCV/Etoh cirrhosis, history of hepatic encephalopathy who was found down at home, admitted to an OSH where he was intubated for airway protection, altered mental status from presumed hepatic encephalopathy, who has had some improvement after 1 day of lactulose and rifaximin therapy. Patient found to have 1 bottle from [2159-4-2] growing strep viridans that was empirically treated with cefazolin for 2 wk course. . #) Altered Mental Status: Patient was found down at home, no evidence of ingestion as a cause, no obvious ingestion, no evidence of active infection initially. He was started on aggressive treatment of hepatic encephalopathy with lactulose and rifaximin. Head CT on admission at the OSH was negative, no evidence of GIB or SBP. Abd u/s excluded portal vein thrombosis. Patient's mental status improved on treatment for hepatic encephaloapthy. It was discovered that patient had been unable to afford rifaximin due to insurance reasons and family members had mentioned that he may have been non-compliant with lactulose. Medications were authorized and patient was able to get them as outpatient. # GPC Bacteremia: Patient had grwoth of [12-25] bottles of GPCs from his blood. He was started empirically on vancomycin and switched to cefazolin for 2 wk course. TTE was negative for endocarditis and surveillance bld cxs were all NGTD. Perhaps could have been from intubation as patient did not have any oral procedures recently. No s/s of endocarditis. Afebrile during admission. Patient had PICC placed and completed course at home. #) Respiratory Failure: intubated at the OSH for airway protection, mental status appears to be slowly improving. He was quickly extubated without complication. . #) HCV/Etoh Cirrhosis: There was no evidence of decompensation during this admissin. Patient completed tranplant workup. He was continued on home lasix, spironolactone, and nadolol. Patient also had a couple of paracentesis for worsening ascites. #) Diabetes: Pt maintained on ISS while hosptialized. Medications on Admission: -Procrit 20,000 units per week -Lasix 80 mg a day, -glimepiride 1 mg a day, -lactulose titrated to [2-25] BM's per day -nadolol 40 mg a day -Zofran 4 mg p.r.n. -Protonix 40 mg daily -rifaximin which was not started -spironolactone 100 mg a day Discharge Medications: 1. cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous every eight (8) hours for 15 doses. Disp:30 grams Refills:0 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. Procrit 20,000 unit/mL Solution Sig: One (1) injection Injection once a week. 11. Outpatient antibiotic infusion pump For home IV antibiotics Discharge Disposition: Home With Service Facility: [Company 4916] Discharge Diagnosis: Primary: Hepatic encephalopathy Strep Viridans bacetermia Secondary: HCV Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 110187], You were admitted to the [Hospital1 18] because of confusion due to hepatic encephalopathy. Due to this you were initially intubated and requiried a breathing machine but after treatment you quickly improved and were extubated. During your admission we found that you had bacteria growing in your blood and started you on an antibiotic called cefazolin. Your condition continued to improve and your returned to baseline. You will need to continue this antibiotic to complete a 14 day course which will finish on [2159-4-16]. For this reason you had a long term IV placed on your arm. MEDICATION CHANGES: START: Rifaxamin 550 mg twice a day START: Cefazolin 2 g every 8 hours via provided pump until [4-16] No other changes were made to your medications. It was a pleasure taking care of you. Followup Instructions: Please keep the appointments below: Department: NUCLEAR MEDICINE When: FRIDAY [2159-4-13] at 10:15 AM With: NUCLEAR MEDICINE WEST [Telephone/Fax (1) 2103] Building: CC [Location (un) 591] [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: TRANSPLANT SOCIAL WORK When: FRIDAY [2159-4-13] at 11:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 14254], LICSW [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: NUCLEAR MEDICINE When: FRIDAY [2159-4-13] at 1:15 PM With: NUCLEAR MEDICINE WEST [Telephone/Fax (1) 2103] Building: CC [Location (un) 591] [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Name: [Last Name (LF) ],[First Name3 (LF) 251] J. Location: [Hospital ]HOSPITAL Address: [Doctor First Name 85238] APC 5, [Hospital1 ],[Numeric Identifier 85239] Phone: [Telephone/Fax (1) 85240] Appt: [4-17] at 2:15pm Department: TRANSPLANT When: THURSDAY [2159-4-19] at 10:00 AM With: TRANSPLANT FELLOW & [Doctor Last Name ] [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "51881", "5990", "2762", "2760", "2859", "5859", "2875", "V1582" ]
Admission Date: [2159-5-2] Discharge Date: [2159-5-30] Date of Birth: [2103-1-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10293] Chief Complaint: mental status changes Major Surgical or Invasive Procedure: Intubation History of Present Illness: Pt. is a 56 y/o w/ MMP including cirrhosis, chronic renal insufficiency, diabetes who p/w mental status changes. History per EMS report/daughter. Pt. w/ long h/o cirrhosis, unclear baseline mental status. Recently pt. w/ gait instability. One day prior to presentation, pt. flew from [State 8842] to here for evaluation by liver transplant team at [Hospital1 ]. On day of arrival to MAss., but was talking, but seemed confused. Over the next 24 hours, pt. had nausea/vomiting, but continued to take insulin. Pt. was unable to answer questions, not talking, seemed weak and was having difficulty walking. Daughter unable to confirm if pt. had complaints, but did note rigors in the a.m. and cough. Day of admission - pt's daughter called EMS and pt. was taken to [Hospital3 ]. . At OSH, pt. was tachycardic, but otherwise VSS. On evaluation, he was intermittently following commands, not answering questions. Pt. found to have ammonia for 236. Pt. given lactulose. Pt. w/ FS at OSH was 66 (given D50). Pt. was also given 2 L NS, thiamine and kayexalate(45 mg) for hyperkalemia. Pt. was transferred to [Hospital1 18] for further liver evaluation. . In [Name (NI) ], pt w/ mental status changes - oriented to person only. Pt. was sleepy, but combatative. Concern for encephalopathy given high ammonia level at OSH. Pt. was in need of infectious w/u including extensive CT scans. Concern for sedating pt. w/ MS changes and risking apneic arrest in [Last Name (LF) ], [First Name3 (LF) ] decision was made to intubate patient for airway protection. Per report from ED attending, pt. was oxygenating well w/ good sats at that point. In [Name (NI) ], pt. given vanco/levo/flagyl. Pt. hyperkalemic in ED - given kayexalate, D50, calcium gluconate. Pt. w/ lactate of 3.0. Past Medical History: Cirrhosis - supposed to get liver transplant eval w/ liver at [Hospital1 ] Esophageal Varices Renal Insufficiency(last (Cr 2.9) Diabetes - insulin dependent HTN GERD Gout Alcoholism - quit last [Month (only) ] Hypercholesterolemia Social History: Alcoholism - quit last [Month (only) ], married - lives in [State 8842] w/ daughter in [Name2 (NI) ], retired fire chief Family History: mom - ovarian CA, dad stroke Physical Exam: Gen: encephalopathic, open eyes to commands but no other response Skin: warm, multiple bruises HEENT: PERLA, ecchymosis along eye, sclera, anicteric, multiple petechiae on hard palate CV: RRR, loud S1/S2 Lungs: upper airway soundss Abd: umbilical herniation (reducicble), caput medusea, distended, soft, no rebound/guard, tympanic superiorly, fluid wave, no HSM appreciated, Ext: bruises, no c/c/e Neuro: nl tone, Pertinent Results: [2159-5-26] 04:35AM BLOOD WBC-13.8* RBC-2.80* Hgb-9.4* Hct-29.8* MCV-107* MCH-33.5* MCHC-31.5 RDW-24.5* Plt Ct-94* [2159-5-26] 04:35AM BLOOD Plt Ct-94* [2159-5-26] 04:35AM BLOOD PT-14.5* PTT-34.7 INR(PT)-1.3* [2159-5-26] 04:35AM BLOOD Glucose-277* UreaN-54* Creat-4.4* Na-147* K-3.8 Cl-111* HCO3-21* AnGap-19 [2159-5-19] 04:56AM BLOOD LD(LDH)-177 TotBili-2.1* [2159-5-19] 04:56AM BLOOD LD(LDH)-177 TotBili-2.1* [2159-5-26] 04:35AM BLOOD Calcium-9.9 Phos-4.9* Mg-2.1 [2159-5-21] 01:40PM BLOOD calTIBC-116* Ferritn-60 TRF-89* [2159-5-2] 10:43PM BLOOD Ammonia-156* [2159-5-16] 02:15AM BLOOD TSH-1.4 [2159-5-16] 02:15AM BLOOD Free T4-0.6* [2159-5-3] 02:50PM BLOOD PTH-174* [2159-5-4] 01:02PM BLOOD Cortsol-59.7* [2159-5-16] 02:15AM BLOOD CEA-13* PSA-1.5 [2159-5-17] 10:45PM BLOOD Type-ART pO2-89 pCO2-30* pH-7.30* calHCO3-15* Base XS--9 [2159-5-16] 11:56AM BLOOD Glucose-158* [2159-5-8] 03:53AM BLOOD Lactate-1.5 [2159-5-13] 11:43AM BLOOD freeCa-1.23 Brief Hospital Course: # Hepatic encephalopathy: MS changes from Cirrhosis and hepatic encephalopathy aggravated by pneumonia. Condition became progressively worse and then he was deemed not be a candidate for liver transplant. . # Renal Failure: complicated w/ hyperkalemia. Most likely from hepatorenal syndrome. Dialysis was performed intially but then team decided to stop once it was decided to make him CMO. . # Diabetes - pt. w/ insulin dependent diabetes. Pt. w/ hypoglycemia in ED. Will monitor sugars and ISS for now . # Code Status: after extensive discussion between Dr.[Last Name (STitle) 7033] and patient's wife and daughter, patient was made DNR/DNI and then CMO. He passed away in the morning of [2159-5-30]. Discharge Medications: EXPIRED Discharge Disposition: Expired Discharge Diagnosis: Hepatic failure from Cirrhosis Renal Failure Discharge Condition: EXPIRED Discharge Instructions: EXPIRED Followup Instructions: EXPIRED Completed by:[2159-5-30]	[ "0389", "51881", "4280", "5070", "5845", "40391", "2767", "99592", "25000", "V5867", "3051" ]
Unit No: [Numeric Identifier 65608] Admission Date: [2191-12-12] Discharge Date: [2191-12-26] Date of Birth: [2191-12-12] Sex: Female Service: NB HISTORY: [Known lastname ] [Known lastname 4068] is the 1590-g product of a 34-6/7 week twin gestation born to a 41-year-old G1, P0 now 2 woman. Prenatal screens: B+, direct Coombs negative, DAT negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, GBS unknown. MATERNAL HISTORY: Notable for asthma on Serevent, Pulmicort and albuterol; hypothyroidism on Levothyroxine; gestational diabetes on insulin. ANTENATAL HISTORY: Significant for IVF donor egg with dichorionic diamniotic twin gestation complicated by gestational hypertension treated with Hydralazine and Procardia. Mother received betamethasone on [11-21]. Underwent cesarean section for hypertension. No labor and no intrapartum risk factors for sepsis. Infant had weak cry and hypotonia on transfer to warmer. Orally and nasally bulb suctioned. Dried. Free-flow oxygen administrated. Subsequently pink and in no distress. Apgars are 7 and 8. PHYSICAL EXAMINATION ON ADMISSION: Birth weight 1590 g, head circumference 29.5 cm, length 44 cm. Anterior fontanel soft and flat, nondysmorphic. Palate intact. Neck, mouth: Normal. No nasal flaring. Pulmonary: No retractions. Good breath sounds bilaterally. No adventitious sounds. Cardiovascular: Well perfused. Regular rate and rhythm. Femoral pulses normal. S1, S2 normal. No murmur. Abdomen: Soft, nondistended. No organomegaly. No masses. Bowel sounds active. Anus: Patent. 3-vessel umbilical cord. GU: Normal female genitalia. CNS: Active, alert, responds to stimulation. Tone appropriate for gestational age and symmetric. Moves all extremities symmetrically. Suck, root, gag intact. Grasp symmetric. Musculoskeletal: Normal spine, limbs, hips and clavicles. HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [Known lastname ] has been stable on room air throughout her hospital course and has had no issues. Cardiovascular: Infant presented with a loud murmur on day of life #1. She had an echocardiogram performed on [12-16] revealing a 5 mm membranous VSD. She is being followed by cardiology and will be followed as an outpatient. It is expec [Male First Name (un) ] that she will develop congestive heart failure in time. She is currently not on any cardiac medications. She will be followed closely by the cardiology service at [Hospital3 18242]. Fluid and electrolytes: Initial birth weight was 1590 g. She was initially started on ad lib feeds of premature enfamil 20. She later required some gavage feedings. She achieved all po feedings. Currently she is ad lib feeding, taking in excess of 150 ml per kg per day of Enfacare 26 calorie to support weight gain. Her discharge weight is 1730. GI: Peak bilirubin was on day of life #3 of 8.7/0.2. She did receive phototherapy for a total of 24 hours at which time it was discontinued. Rebound bilirubin was 6.2/0.2. Infectious disease: CBC and blood culture obtained on admission. CBC was benign, and blood culture remained negative. She has not received any antibiotics. Hematology: Hematocrit on admission was 45.5. She has had no blood products and has not had any repeat hematocrit. Neurologic: Infant has been appropriate for gestational age. Sensory: Audiology: Hearing screen has been performed, and infant has passed. Psychosocial: A social worker has been involved with the family and can be reached at [Telephone/Fax (1) 8717]. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 38676] [Telephone/Fax (1) 38248] FEEDS AT DISCHARGE: Continue ad lib. feeding Enfacare 26 calorie. MEDICATIONS: Ferrous sulfate supplementation. CAR SEAT POSITION SCREENING: Was performed for 90 minutes, and the infant passed. STATE NEWBORN SCREENS: State newborn screens have been sent per protocol. Results are pending. IMMUNIZATIONS RECEIVED: Synagis given [12-26] per cardiol ogy recommendation for large VSD with expected congestive heart failure. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] in any infants who meet any of the following 3 criteria: 1) born at less than 32 weeks, 2) born between 32 and 35 weeks with 2 of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school-age siblings, or 3) with chronic lung disease. This infant is 24 months or younger with hemodynamically significant acyanotic congestive heart disease. She will bene fit from 5 monthly intramuscular injections of synagis per the American Academy of Pediatrics recommendations. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the 1st 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW-UP APPOINTMENTS RECOMMENDED: Cardiology at [Hospital3 18242] on [1-2] at 8:45 am ([Telephone/Fax (1) 46235]). DISCHARGE DIAGNOSES: 1. Premature infant born at 34-6/7 weeks. 2. Twin # 2. 3. Rule out sepsis. 4. Hyperbilirubinemia. 5. Ventricular septal defect. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 54936] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2191-12-25] 21:29:36 T: [2191-12-25] 22:08:57 Job#: [Job Number 65609]	[ "7742", "4280", "V290", "V053" ]
Admission Date: [2204-1-20] Discharge Date: [2204-1-25] Date of Birth: [2126-7-31] Sex: F Service: MEDICINE Allergies: Ticlid / Bactrim / Dilantin Kapseal Attending:[First Name3 (LF) 613] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: - None History of Present Illness: Ms. [Known lastname 8350] is a 77 yo female w/ h/o DMII, CHF, CAD, and s/p AVR who presented to the ED for a question of syncopal epsidose and was transferred to the MICU for managment of hypotension. The patient has dementia and is a poor historian. She got up to go to the bathroom today, was sitting on the toilet and was reported to have a wittnessed syncopal episode. She declines ever passing out, but does note that she was weak and unable to move for a period of time when she was on the toilet. It is unclear who witnessed the episode. The patient was evaluated by EMS; her sbp was 60 and glucose was 168. No upper respiratory symptoms. No sick contacts (other than living in nursing home). No f/c/n/v/cp/sob. No travel. . In the ED, initial VS were: [Age over 90 ] F, 94/43, hr 78, rr 22, saturation 90% 2L NC. She was treated with levofloxacin 750mg iv for questionable LLL infiltrate and with metronidazole 500mg iv once. In the ED her lowest blood pressure was 74/47. She recieved 4L IVF. Pressures increased to systolic 100 range. Her lactate decreased from 4.8 to 4.1 with 2L IVF. She also began to have profuse watery diarrhea mixed with loose stools. It was guaiac negative. A CTA of the abdomen and pelvis was performed to rule out AAA and other vascular . On arrival to the MICU, she continued to have diarrhea. She complained of lower abdominal cramping with the abdominal pain. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: squamous cell carcinoma chf DMII h/o squamous cell carcinoma HTN CAD status post PCI in [2189] restrictive lung disease Social History: Lives in a nursing home. Family History: NC Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE EXAM: VSS GEN: Obese female resting in bed in NAD. Pleasant. HEENT: NCAT. MMM. COR: Holosystolic blowing murmur heard throughout the precordium. PULM: CTAB, no c/w/r. [Last Name (un) ]: Obese. +NABS in 4Q. Soft, NTND. EXT: WWP, trace to 1+ LE edema. Pertinent Results: Admission Labs [2204-1-21] 12:00AM GLUCOSE-197* UREA N-38* CREAT-1.3* SODIUM-139 POTASSIUM-6.2* CHLORIDE-106 TOTAL CO2-21* ANION GAP-18 [2204-1-21] 12:00AM CK(CPK)-99 [2204-1-21] 12:00AM CK-MB-4 cTropnT-<0.01 [2204-1-21] 12:00AM CALCIUM-7.4* PHOSPHATE-4.3 MAGNESIUM-1.8 [2204-1-20] 04:59PM URINE HOURS-RANDOM [2204-1-20] 04:59PM URINE UHOLD-HOLD [2204-1-20] 04:59PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.016 [2204-1-20] 04:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2204-1-20] 04:59PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-<1 [2204-1-20] 04:59PM URINE GRANULAR-1* HYALINE-12* [2204-1-20] 04:59PM URINE MUCOUS-RARE [2204-1-20] 04:03PM LACTATE-4.1* [2204-1-20] 02:25PM COMMENTS-GREEN TOP [2204-1-20] 02:25PM LACTATE-4.8* [2204-1-20] 02:15PM GLUCOSE-292* UREA N-35* CREAT-1.4* SODIUM-139 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22* [2204-1-20] 02:15PM estGFR-Using this [2204-1-20] 02:15PM ALT(SGPT)-16 AST(SGOT)-26 CK(CPK)-110 ALK PHOS-54 TOT BILI-0.3 [2204-1-20] 02:15PM LIPASE-68* [2204-1-20] 02:15PM CK-MB-3 cTropnT-<0.01 [2204-1-20] 02:15PM WBC-10.7 RBC-4.85# HGB-14.2# HCT-44.2 MCV-91 MCH-29.3 MCHC-32.1 RDW-13.4 [2204-1-20] 02:15PM WBC-10.7 RBC-4.85# HGB-14.2# HCT-44.2 MCV-91 MCH-29.3 MCHC-32.1 RDW-13.4 [2204-1-20] 02:15PM NEUTS-56.6 LYMPHS-37.1 MONOS-2.4 EOS-3.1 BASOS-0.9 [2204-1-20] 02:15PM PT-10.5 PTT-31.5 INR(PT)-1.0 [2204-1-20] 02:15PM PT-10.5 PTT-31.5 INR(PT)-1.0 DISChARGE LABS: [2204-1-25] 07:30AM BLOOD WBC-13.6* RBC-3.75* Hgb-10.9* Hct-33.7* MCV-90 MCH-29.0 MCHC-32.3 RDW-13.4 Plt Ct-266 [2204-1-24] 06:00AM BLOOD Glucose-125* UreaN-9 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-28 AnGap-13 TTE: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis (expected upper limit is <23 mmHg). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is a mild mitral inflow gradient due to mitral annular calcification. Mild (1+) mitral regurgitation is seen (but may be underestimated). The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2202-6-15], findings are similar. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: 77 year old female with h/o CAD, CHF, DMII, dementia admitted to the MICU for management of hypotension and lower GI bleed. ACUTE DIAGNOSES: # Hypotension & Syncope: Very likely secondary to diarrhea of unknown duration in the setting on continued administration volume depleting medications. Lactate normalized with fluids and 1 unit of prbc. Hypotension resolved with fluids. # Diarrhea: Thought to be viral gastroenteritis. IV cipro & flagyl were initially started given mild leukocytosis & concern for possible diverticulitis. Her diarrhea became bloody during hospitalization. GI was consulted & recommended stool cx which were sent (she was c.diff negative), ischemic colitis was thought to be the most likely culprit. She received 1 unit of pRBCs without further recurrence of symptoms. CT abdomen was negative for diverticulitis but was positive for diverticulosis and significant atherosclerotic disease in the abdomen. Antiobiotics were discontinued. # Lower GI Bleed: Thought to represent ischemic colitis in setting of significant atherosclerotic disease in the abdomen & hypotension on admission. Pt received 1 unit of packed RBCs in the ICU. Had several small episodes of old blood on the floor, but normal bowel movements by the time of discharge. # Syncope: Pt syncopal event was poorly relayed in history. Her hypovolemia, in combination with her preload dependence due to aortic stenosis, likely caused her to zyncopize. # Aortic Stenosis: A repeat echo was obtained to determine if there was interval worsening in the degree of aortic stenosis. It was largely unchanged from prior. # Acute Kidney Injury: Most likely prerenal given hypotension on admission. Resolved with fluids. # Aortic Stenosis: Pt with known history of aortic stenosis s/p prosthetic valve placement. A repeat TTE was obtained that showed similar findings CHRONIC DIAGNOSES: # Chronic CHF: Furosemide was held given diarrhea, hyponatremia. The plan will be to restart lasix as outpatient after evidence of weight gain weight gain (2 pounds) from admission weight at [Location (un) 583] House. Restarting amlodipine and lisinopril as above. Discharged on atenolol. # Dementia: Monitor clinically # DMII: Glipizide held in house but restarted on discharge. ISS in house. # Depression: Continued citalopram # CAD: Continued baby aspirin, simvastatin # GERD: Continued pantoprazole # Chronic low back pain: Continued percocet TRANSITIONAL ISSUES: # Follow Up: She was given follow up appointments with her PCP & cardiologist. # Code Status: DNR/DNI Medications on Admission: percocet 5/325 1 tab qid advair 250/50 1 puff [Hospital1 ] amlodipine 7.5mg daily asa 81mg daily atenolol 25mg daily citalopram 40mg daily colace furosemide 40mg daily glipizide 5mg daily lisinopril 40mg daily simvastatin 20mg daily acetaminophen prn nitroglycerin prn Discharge Medications: 1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times a day). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: please hold for loose stools. 7. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual as directed as needed for chest pain: Q5MIN PRN chest pain for up to 3 tablets. 11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. 12. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day: Please restart on [2204-1-27]. 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Please take weight daily and restart when weight increases 2 lbs from admission weight. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Location (un) 583] House Rehab & Nursing Center Discharge Diagnosis: PRIMARY DIAGNOSES: - Gastroenteritis - Ischemic colitis - hypovolemia - acute renal failure SECONDARY DIAGNOSIS: - chronic diastolic Congestive Heart Failure - Atherosclerosis - DM II Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [Known lastname 8350], it was a pleasure to participate in your care while you were at [Hospital1 18]. You came to the hospital because you passed out after having episodes of nausea, vomiting, & diarrhea. When you came to the hospital your blood pressure was very low. You were admitted to the ICU where your blood pressure improved with intravenous fluids, but you then developed bloody stool. Our gastroenterology team evaluated you and felt the blood from your rectum was caused by a condition called "ischemic colitis" which can happen when the blood flow to your intestines is low. You slowly improved MEDICATION INSTRUCTIONS: - Medications ADDED: None. - Medications STOPPED: ---> Please restart lisinopril on [2204-1-27] and furosemide after gaining 2 pounds Followup Instructions: Please call to reschedule if you are not able to make any of your follow-up appointments: Department: CARDIAC SERVICES When: TUESDAY [2204-2-21] at 10:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], M.D. [Telephone/Fax (1) 127] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Last Name (LF) ],[First Name3 (LF) ] Specialty: INTERNAL MEDICINE Location: [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) ] Address: 545A CENTRE ST, [Location (un) ],[Numeric Identifier 6809] Phone: [Telephone/Fax (1) 608] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "5849", "2762", "2761", "2851", "4280", "25000" ]
Admission Date: [2161-3-26] Discharge Date: [2161-4-1] Service: MEDICINE Allergies: Nsaids / Bupivacaine / Sulfa (Sulfonamides) / Penicillins Attending:[First Name3 (LF) 69838] Chief Complaint: Syncope, altered mental status Major Surgical or Invasive Procedure: Endotracheal intubation. History of Present Illness: 84yo woman with past medical history notable for hypertension, hypothyroidsim, rheumatoid arthritis, CHF was brought into ED after syncopal episode. By EMS reports, she was walking outside on sidewalk when she told a bystander that she was not feeling well. She subsequently fell (no trauma, caught by bystander) and lost consciousness. When EMS arrived, they found her minimally responsive and s/p nausea/vomiting. . On evaluation in our ED, initial vitals were 98.9, 75, 146/70, 16, and 100% on RA; she was suspected to have had an aspiration event, and she was intubated for airway protection. Otherwise, her evaluation in ED was notable for the following: UA with negative LE, Nit, WBC, trace ketones. Normal CBC. Normal Coags. Negative serum and urine tox screen. Mild elevation in amylase at 208, but otherwise normal LFT's and lipase. Chemistry with mild elevation of BUN at 23, normal anion gap of 11, and elevated lactate at 3.3. Initial set of cardiac enzymes was CK 35, MB nd, trop < 0.01. Abdominal CT was done to evaluate abdominal pain and nausea/vomiting, which was negative for any acute abdominal pathology. Chest film had no acute infiltrates or other findings. CT and CTA of the head demonstrated no new pathology and patent cerebral and vertebral vasculature. . In ED, she received empiric levaquin/flagyl for possible abdominal infection. She also received fentanyl and versed for intubation/sedation. Past Medical History: Hypothyroidism Osteopenia h/o Congestive heart failure, though EF nl by TTE on this admission Rheumatoid arthritis Hypertension Bilateral L5/S1 lumbar radiculopathy by EMG Endometrial thickening s/p D&C h/o DVT when she delivered her son by [Name (NI) 32007] Social History: Denies tobacco, alcohol. Family History: Non-contributory Physical Exam: on admission to floor: VS - T 98.0, BP 143/71, HR 112, O2 sat 100% RA Gen - comfortable, NAD, speaking full sentences HEENT - NCAT, PERRL, EOMI, OP clr, MMM, no LAD Chest - clear anteriorly CV - tachy, but regular; no m/r/g Abd - NABS, soft, NT/ND, no g/r Ext - no edema, WWP Pertinent Results: labs on admission: GLUCOSE-186* UREA N-23* CREAT-1.0 SODIUM-141 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-26 ALT(SGPT)-14 AST(SGOT)-19 LD(LDH)-153 CK(CPK)-35 ALK PHOS-49 AMYLASE-208* TOT BILI-0.7 LIPASE-55 WBC-8.2 RBC-3.95* HGB-12.4 HCT-36.2 MCV-92 MCH-31.3 MCHC-34.2 RDW-13.2 PLT COUNT-291 - NEUTS-68.6 LYMPHS-25.7 MONOS-3.4 EOS-1.5 BASOS-0.8 BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG - RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 SED RATE-12, CRP-0.5 PT-11.9 PTT-24.5 INR(PT)-1.0 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG VitB12-260 Folate-10.6 TSH-5.8* SPEP pending. Ucx no growth Bcx no growth CXR [3-28]: Minimal patchy density at the right base, new compared with [2161-3-26]. Most likely etiology is some subsegmental atelectasis, but given the history of fevers, the possibility of an early pneumonic infiltrate cannot be entirely excluded. B LE u/s: Postsurgical changes of the left leg, with patent left common femoral and popliteal veins. The left superficial femoral vein can only be followed for a few centimeters proximally, where it is patent. Ct abd: 1. No acute intra-abdominal pathology. 2. 5 x 3 cm left adnexal cyst is smaller than on prior study. Slightly enlarged uterine cavity could be further evaluated with pelvic ultrasound when the patient's clinical status improves. CTA head and neck: No evidence of infarction. No evidence of hemorrhage. No vascular stenosis or occlusions detected. Echo: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2154-6-6], there is no definite change. Brief Hospital Course: Ms. [Known lastname 102770] is an 84yo woman with hypertension, untreated hypothyroidism, rheumatoid arthritis on prednisone and congetive heart failure. She reports symptoms lasting over months including lethargy, feeling presyncopal about once per week, pins and needles in her feet and hands with poor sleep at night, and recurrent chest pain. During her admission, her PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 2903] was out of his office so we could not speak with him direcly, however notes faxed form his office to [Hospital1 18] reported all of the above symptoms (except for presyncope/syncope) over the course of months. She presented to the hospital after a syncopal episode with nausea and vomiting. # Syncope: On arrival she was quite lethargic. She was seen by the stroke team, who found her exam to be nonfocal and not consistent with stroke. She was intubated in the ER for airway protection given her somnolence and nausea. There was fear of aspiration, however this was not noted on her intial CXR. She was transferred to the MICU for further care where she remained intubated until HD#2 when she was successfully extubated without evidence of respiratory distress. Subsequent work up of syncope, including CT of the head, abdomen, and pelvis were all unremarkable. Telemetry showed no arhythmia. A TTE was unremarkable, with no valvular disease, normal EF, and no wall motion abnormalities. She had no further episodes of syncope or presyncope throughout her stay. Cause of her syncope remains unknown but is likely multifactorial, including hypothyroidism, dehydration (the patient drinks a maximum of 2 glass water per day at home, orthostatics could not be checked given early intubation), and possible vasovagal component. # aspiration pneumonia: On hospital day 2, after extubation, she became febrile to 101.1, her CXR revealed evidence of likely aspiration PNA and she was started on levofloxacin and flagyl without difficulty. She was quickly weaned to room air and remained on this throughout her hospital stay without respiratory difficulty. On the day of discharge flagyl was discontinued as the patient complained of nausea. She is discharged to complete a 10 day course of levofloxacin. # Hypothyroid: On pasat records, the pateint has a history of hypothyroidism. Per discussion with Dr.[Name (NI) ] office as well as his faxed notes, she was previously treated with 125mcg synthroid which resulted in hyperthyroidism. She was subsequently treated with 100mcg synthroid which resulted in hyperthyroidism. She has not taken any synthroid since [Month (only) 216] [2160], however her TSH has been elevated during this time. She does seem symptomatic, noting months of lethargy, constipation, feeling sleepy, sleeping late in the morning. Her TSH was elevated at 5.8 during this hospitalization and she was started on 50mcg synthroid po qday. Her TSH should be checkedto monitor this dose in one month as an outpatient. . # Rheumatoid Arthritis: The patient came in on prednisone for her rheumatoid arthritis. After receiving dexamethasone poast extubation as above for facial swelling, she was tapered down to her homedose of prednisone and is discharged on this dose. She complained of continued leg and knee pain during her stay, which has been an ongoing problem for her as an outpatient. . # Bilateral lower extremity ?neuropathy: She notes tingling bilaterally in her feet, legs and hands. Her PCP believes that she has restless leg syndrome and did recommend that she see a neurologist, Dr. [Last Name (STitle) 31464], for this, however the patient has not seen him. The patient has no history of diabetes. Since her pain sounds neuropathic in origin, B12 and folate were checked and were normal. At the time of discharge SPEP for neuropathy workup is pending and should be followed up as an outpatient. We have made her a follow up outpatient appointment with Dr. [Last Name (STitle) 31464]. # Hypertension: Her blood pressure was well controlled on hydrochlorothiazide and lisinopril, as at home. . # ?CHF: The patient's echo on this admission shows improvement in her cardiac function and a normal EF of 55%. She was asymptomatic from this standpoint and it is unclear whether she does have CHF. Her leg swelling may be in the setting of fluid retention with prednisone use. . # Nausea: The patient had no complaint of nausea after extubation, until the day prior to discharge. Her abdominal exam remained benign and vitals were stable. She was tolerating POs. Nausea was felt likely secondary to PO flagyl and this was discontinued on the day of discharge. . # S/p extubation: The patient complained of facial swelling and feeling that her tongue was swollen. Family members corroborated this story though no definite clinical evidence of swelling was noted. Pt's family states they noticed it after being given antibiotics in the ED (levo/flagyl). Ms. [Known lastname 102770] was started on a 3 dose course of dexamethasone after complaining of facial swelling after extubation. She remained stable from a respiratory standpoint and she was changed to a prednisone taper. She was seen by swallow therapy who cleared her for a regular diet. She tolerates her pills, but I believe prefers them in apple sauce. . During her stay she was FULL CODE confirmed with her son who is HCP (cell [Telephone/Fax (1) 102771]). Medications on Admission: HCTZ 25 QD Zestril 20 QD Prednisone 5 QAM, 2.5 QPM Timolol 0.5% OU QD Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:4 Tablet(s) Refills:0 8. Anzemet 50 mg Tablet Sig: One (1) Tablet PO q8hr PRN for 30 doses. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 620] Discharge Diagnosis: Primary: -Hypothyroidism -Syncope . Secondary: -Osteopenia -History of Congestive heart failure, though EF (>55%) on TTE in [2161-3-12] -Rheumatoid arthritis -Hypertension -Bilateral L5/S1 lumbar radiculopathy by EMG -Endometrial thickening s/p D&C -History of DVT when she delivered her son by [Name (NI) 32007] Discharge Condition: -Stable. Tolerating PO liquids and solids. Discharge Instructions: -You were admitted to the hospital for an episode of syncope. You were initially intubated for protection of your airway, but extubated within 24 hours. Cardiac and neurological evaluations were performed to help explain a cause for your symptoms. Testing was negative. Most likely, decreased PO intake and hypothyroidism caused your symptoms. -In addition, you were started on several antibiotics for aspiration pneumonia. Speech and swallow evaluation was normal. You will continue on the medications prescribed on discharge. Several are new--levothyroixine and levofloxacin. Continue the levofloxacin until a ten day course is completed. -You need to keep all scheduled appointments (see below). You will need thyroid testing performed in one month. -If you experience any more syncope, weakness, lightheadedness, loss of consciousness, or any other concerning symptoms, Followup Instructions: -You have an appointment with your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2903] ([Telephone/Fax (1) ]) on Monday, [2161-4-20] at 12:00PM. His office is located on [Location ]in [Location (un) ], MA. -Please follow-up with Dr. [Last Name (STitle) 31464], a neurologist, on Tuesday [2161-4-14] at 10:20am. His address is [Location (un) 102772]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 69841] Completed by:[2161-4-1]	[ "5070", "4280", "4019" ]
Admission Date: [2132-12-15] Discharge Date: [2132-12-23] Date of Birth: [2049-11-29] Sex: M Service: MEDICINE Allergies: Vicodin / Percocet / Darvocet A500 / Oxycodone / Vancomycin / Adhesive Tape Attending:[First Name3 (LF) 1257] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: EGD X2 PICC and arterial line placement Hemodialysis History of Present Illness: This is an 83 year old male with a history of CAD (S/P CABG), ESRD on HD, AAA, who was transferred from [Hospital3 ] hospital for GI bleed. Per records, melanotic stool started at noon today. The patient mentions that he has had black stools for 1-2 days, and his aide was the one that pointed it out to him. He denies having felt lightheaded or dizzy. But felt "queasy" this morning. HCT at OSH was 21.4, WBC 21.6. He received 1 unit of PRBCs and was transferred to [Hospital1 18]. . Of note, patient has had prior rectal bleeds in the past. Colonoscopy in [2132-2-27] showed sigmoid diverticula and an ulceration consistent with ischemic colitis. He also has a history of hemorrhoids. Last EGD was performed in [2129] and was within normal limits. He believes that his GI bleeds have been in the setting of prednisone which he intermittently takes for Bullous pemphigoid. He is currently being tapered off of prednisone. . In the ED, initial vs were: T 97.9 HR 75 BP 109/35 RR16 100% on RA. While in the ED, he had a large amount of melanotic, liquid stool. Patient was given IV fluids, IV pantoprazole, Zofran. He got Calcium gluconate for a K of 5.9. NG lavage was negative. GI was consulted, and will evaluate her in the ICU. R IJ was attempted twice, however they were unable to thread the wire. As a result, they placed a L femoral triple lumen. Vitals prior to transfer were HR 80 BP 112/44 RR 20 99% on RA. . On the floor, patient is eager to go to sleep. But not in any pain or discomfort. Past Medical History: 1)CAD -s/p 3-vessel CABG in [2122] (LIMA-LAD, SVG-RCA-occluded, SVG-OM1/OM3 occluded) -s/p NSTEMI in [2-2] (DES in L main) 2)ESRD -LUE AVF, HD MWF -Per patient, has congenital left kidney hypoplasia 3)AAA -s/p repair ([2123]) 4)PVD -s/p aortobililiac graft in [2123] -s/p left CEA in [2123] ([2132-5-22] US showed right ICA 70-79% stenosis, left ICA 1-39% stenosis) 5)Ischemic colitis -Admitted [2132-3-9] for bloody diarrhea, uneventful hospital course 6)Spinal stenosis -s/p discectomy and arthrodesis at C5-C6 and C6-C7 [2130-12-4] -Baseline impairment in walking (uses motoroized wheelchair or walker) 7)Right renal tumor, suspicious for RCC, undergoing watchful waiting, followed by Dr. [Last Name (STitle) 3748] 8)Prostate cancer -s/p brachytherapy in [2122] 9)Abdominal wall abscess in [5-5], s/p I&D, cultures grew Actinomyces 10)Cholangitis -s/p CCK in [2130-3-21] 11)Bullous pemphigoid (diagnosed in [7-/2132]) -Dermatologist is Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ] 12)s/p Cataract surgery on left eye Social History: Lives alone at [Location (un) 33866] [Hospital3 400] Residency. He previously worked as a district manager for Metropolitan Life. 60 pack-year smoking history, quit 10 years ago. Occasional social alcohol use. Family History: One daughter (53) and son (57), both in good health. One sister with diverticulitis. Physical Exam: Vitals: T: BP:135/42 P:77 R: 15 O2: 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Incisonal scar present. Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 1+ pulses, 1+ pitting edema bilaterally. Pertinent Results: Labs on Admission: WBC-19.3# RBC-3.53 HGB-10.8* HCT-34.6* MCV-98 MCH-30.6 MCHC-31.2 RDW-19.2* NEUTS-94.1* LYMPHS-3.2* MONOS-2.2 EOS-0.2 BASOS-0.2 PLT COUNT-215# PT-13.2 PTT-44.7* INR(PT)-1.1 CK(CPK)-30, CK-MB-NotDone, cTropnT-0.19 GLUCOSE-103* UREA N-167* CREAT-7.0# SODIUM-138 POTASSIUM-6.0 CHLORIDE-98 TOTAL CO2-19* ANION GAP-27* . Studies: EGD [12-16] - Blood in the esophagus, no active bleeding site noted Blood in the stomach with blood clots, no active bleeding site noted Blood clot in the duodenum, no active bleeding site noted Otherwise normal EGD to second part of the duodenum . EGD [12-18] - Abnormal mucosa in the stomach (biopsy) Otherwise normal EGD to second part of the duodenum . Stomach fundus biopsy - Corpus mucosa with superficial [Month/Year (2) 1106] congestion and mild edema; no diagnostic abnormalities otherwise recognized. Hpylori negative (per pathologist). . Microbiology: Cdiff negative X2 Blood cultures ([2132-12-16]) No growth to date Brief Hospital Course: 82 year old male with a history of CAD (S/P CABG), ESRD on HD, AAA, who was transferred from OSH with lower GI bleed. . 1. Lower GI bleed: Nasogastric lavage negative. No bright red blood per rectum throughout this hospital stay. Only large amounts of melanotic stool initially that resolved as hospital course progressed. Patient has a history of diverticulosis, and prior rectal bleeding. He remained hemodynamically stable and hematocrit stabilized at 31-33 by [12-16] after 7 units pRBC and 2 units FFP (goal >30). [Month (only) ] Surgery was consulted and recommended CT abdomen with contrast which ruled out Aortoenteric Fistula (in setting of patient's AAA s/p repair). Patient was intubated from [Date range (1) 34518] but extubated and weaned successfully. Patient's initial EGD on [12-16] showed blood in esophagus, stomach and duodenum but was otherwise unelucidating -- the second EGD on [12-18] showed a fundus ulcer that had been previously bleeding but stabilzied. Biopsies taken from the ulcer were not concerning for malignancy or H.pylori infection. Patient was continued with active type and screen and telemetry until two days prior to discharge; no events were noted on telemetry. His blood pressures slowly improved and he was resumed on his home metoprolol. He was initially on a proton pump inhibitor gtt and transitioned to home Pantoprazole with good effect; he was also on stress dose steroids initially but transitioned to home Prednisone for management of his Bullous Pemphigoid. Of note, there was some concern that his upper GI bleed was in part due to the long-term steroids. - Continue Pantoprazole 40mg twice daily for one month * Please have patient discuss need for long term Pantoprazole twice daily with his gastroenterologist at his appoinment - Follow-up in [Hospital ] clinic with Dr. [First Name (STitle) ] [Name (STitle) ] on [2-5] at 1:30pm . 2. Delirium: Patient was mildly delirious starting [12-16] (per daughter) with waxing and [Doctor Last Name 688] throughout the days. Patient had been briefly intubated for his EGDs, on sedating/hypnotic medications, underwent significant GI bleed with multiple transfusions, in the ICU - all of which could have contributed to his delirium. By two days after discharge, his confusion had improved significantly. He was discharged with baseline mental status. . 3. Leukocytosis: White blood cells intiially 27.3, likely secondary to demargination and stress dose intravenous steroids. Infectious work-up was intiated although patient remained afebrile with no localizing symptoms. Urinalysis, urine culture, blood cultres, Cdiff toxin and chest xray were all negative. Patient's leukocytosis gradually trended down to ~13 by day of discharge, which is within normal limits considering patient's ongoing steroid use. . # ESRD on HD: Missed hemodialysis on day of admission and was found to be hyperkalemic to 6.0. Patient underwent hemodialysis and ultrafiltration with good effect on his significant anasarca. Patient was likely significantly volume overloaded due to the many transfusions he received and general immobility; left upper extremity remained significantly edematous >> right upper extremity but was negative for DVT on ultrasound. Patient did become hypotensive on hemodialysis so he was started on Midodrine 5mg to be given before hemodialysis on hemodialysis days. Medications were renally dosed while in-house, with avoidance of nephrotoxins as well. - Continue Midodrine 5mg PRIOR to hemodialysis on hemodialysis days, until Renal physicians at Hemodialysis decide otherwise - Continue to hold morning Metoprolol 25mg dose on hemodialysis days until after hemodialysis - Increased Sevelamer from 800mg three times daily to 1600mg three times daily . # Coronary Artery Disease: Three vessel CABG in [2122] and NSTEMI in [2123-1-27]. Patient was continued on Simvastatin inhouse but aspirin 325mg and beta blocker (Metoprolol 25mg twice daily) were held in-house in the setting of his GI bleed - DECREASE Aspirin to 81mg daily for now, given his GI bleed - Continue home Metoprolol 25mg twice daily and Simvastatin daily . # Back and hip pain: Managed with Tylenol in-house - Resume tramadol, oxazepam as outpatient, as blood pressure tolerates . # Bullous pemphigoid: Stable. Patient on prednisone taper (10mg daily for one month, starting [12-19] --> 5mg daily afterwards). There was concern that patient's long-term Prednisone use exacerbated, played a role in his presenting GI bleed - Continue 10mg daily until [1-19]; start 5mg daily on [1-19] for another month - Patient has an appointment to follow-up with his primary dermatologist, Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ]. Date/ Time: Tuesday, [1-13], 1pm Location: [Location (un) ], [Location (un) 55], MA Phone number: [Telephone/Fax (1) 3965] . # Code: Confirmed full with patient. Medications on Admission: 1. Acetaminophen 325 mg po q6h PRN pain 2. Oxazepam 10 mg po qhs PRN insomnia 3. Calcium Carbonate 500 mg po tid 4. Citalopram 20 mg po daily 5. Docusate Sodium 100 mg po bid 6. Calcium Acetate 667 mg po tid 7. Simethicone 80 mg po qid PRN gas pain 8. Ezetimibe 10 mg po daily 9. Minocycline 100 mg po bid 10. Simvastatin 80 mg po daily 11. B Complex-Vitamin C-Folic Acid 1 mg po daily 12. Senna 8.6 mg po bid PRN constipation 13. Sevelamer HCl 800 mg po tid 14. Metoprolol Tartrate 12.5 mg po qid 15. Tramadol 50 mg po q6h PRN pain 16. Clobetasol 0.05 % Cream Topical [Hospital1 ] 17. Pantoprazole 40 mg po bid 18. Aspirin 325 mg po daily 19. Prednisone 10mg daily x1 month until [2133-1-2]. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days: Please discuss with GI at your appointment the need to continue this medication dose. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO three times a day. 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 26 days: Decrease to Prednisone 5mg daily on [1-19]. 13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO four times a day as needed for gas pains. 14. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. 16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 17. Midodrine 5 mg Tablet Sig: One (1) Tablet PO QTUTHSA (TU,TH,SA): On hemodialysis days, PRIOR to hemodialysis. 18. Clobetasol 0.05 % Cream Sig: One (1) application to affected areas Topical twice a day. 19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Baypointe - [Hospital1 1474] Discharge Diagnosis: Primary: Upper GI bleed (stomach fundus ulcer) Secondary: Coronary artery disease, end-stage renal disease on hemodialysis, bullous pemphigoid 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 with blood loss from your gastrointestinal tract. You underwent an EGD that showed a bleeding ulcer in your stomach. You were transfused with 7 units of blood and 2 units of clotting factors with good effect; the bleeding from the ulcer has stopped. You were started on a medication that heals/protects ulcers. You also required extra hemodialysis because the transfusions caused you to swell with excess fluid. . -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> DECREASE Aspirin 325mg to 81mg daily (after your stomach bleed) --> DECREASE Prednisone 20mg to 10mg daily (until [1-19], start 5mg daily that day) --> INCREASE Sevelamer from 800mg --> 1600mg three times daily --> STOP Minocycline 100mg twice daily --> On hemodialysis days, take Metoprolol 25mg twice daily AFTER hemodialysis --> On hemodialysis days, START Midodrine 5mg BEFORE hemodialysis --> CONTINUE all other home medications . -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: You have a radiation oncology appointment on [Last Name (LF) 2974], [12-26]. Please take the CD we have provided you to this appointment. It contains imaging of your neck and chest that will help guide your radiation treatments for your oropharyngeal cancer. . Please follow-up with your dermatologist, Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ]. You have an appointment with her on Tuesday, [1-13] at 1pm. Location: [Location (un) ], [Location (un) 55], MA Phone number: [Telephone/Fax (1) 3965] . You also have an appointment with your cardiologist, Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911] on [1-22] at 3:40pm. You can reach his office at: [Telephone/Fax (1) 62]. . You have an appointment with your neurosurgeon, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 548] on [2-3] at 3:30pm. You can reach his office at: [Telephone/Fax (1) 3736] . You also have an appointment with Gastroenterology, to follow-up on your current stomach ulcer bleed. Please follow-up with Dr. [First Name (STitle) ] [Name (STitle) ] on [2-5] at 1:30pm. You can reach his office at: [Telephone/Fax (1) 463] .	[ "2851", "V4581", "2767" ]
Admission Date: [2102-12-25] Discharge Date: [2103-1-1] Date of Birth: [2030-9-29] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1436] Chief Complaint: worsening shortness of breath, recurrent pericardial effusion found on routine echo Major Surgical or Invasive Procedure: Pericardial window ([2102-12-28]) History of Present Illness: 72M with PMH of DM, AFib on coumadin, and RA complicated by pericardial effusion and tamponade in [5-6], transferred from [Hospital1 ]-[Location (un) 620] for further evaluation and management of recurrent pericardial effusion and tamponade seen on routine repeat echo. . Patient had past admission on [5-5]/09 for fatigue, edema, and decreased exercise tolerance. Found to have pericardial effusion, underwent pericardiocentesis with removal 300 cc clear slightly blood-tinged pericardial fluid, with decrease in pericardial pressure from 26 to 10 mmHg. Patient also underwent pericardial drain placement. Pericardial fluid culture and cytology returned negative. Fluid analysis revealed WBC# 6100 (81% PMN), RBC [Numeric Identifier 83167] TP 5.1 albumin 2.9 gluc 4 LDH 4230. The effusion was attributed to RA, but methotrexate was discontinued (and prednisone increased from 20 to 30 mg daily) in case the former was contributing. . Routine follow-up TTE today at [Hospital1 ]-[Location (un) 620] showed a small to moderate mainly anterior pericardial effusion with diastolic right ventricular collapse suggestive of tamponade. Transferred to the [Hospital1 18] ED for further management, where triage V/S 98 125 138/83 18 94%RA. HR 101 without intervention. Labs notable for INR 3.7, Hct 30.5. EKG showed low voltage in the limb leads. CXR showed only bibasilar linear atelectasis. Vital signs prior to transfer 95 132/87 20 97%RA. . On the floor, patient is feeling relatively well. Reports having some shortness of breath, but is at his baseline due to his COPD. Denies any chest pain, worsening SOB, orthopnea, palpitations, headache, lightheadedness, dizziness. 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: - Rheumatoid arthritis: Diagnosed within the past one year. Usually takes Tylenol for pain control. Recently (within the past one month) was started on methotrexate. - COPD Social History: Retired. Drinks once per week. Denies tobacco, illicit drug use now or in the past. Lives with wife. [Name (NI) ] a daughter. Currently volunteers at hospital cafe. Family History: No FH of RA. Denies history of early MI. Physical Exam: VS: T 98.2, BP 128/84, HR 97, RR 18, SO2 100% RA, Pulsus 5-7mmHg GENERAL: WDWN male in NAD. AAOx3. Mood, affect appropriate. Resting comfortably HEENT: NCAT. Sclera anicteric. PERRL, EOMI, MMM CV: RRR, S1S2, no murmurs, rubs. Slightly distant heart sounds LUNGS: Diffuse rhonchi, good air movement, resp unlabored ABD: Obese, soft, NT, ND, no HSM or tenderness EXT: WWP, 2+ radial and DP pulses. 1+ LE edema b/l SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: CBC [2102-12-26] 05:10AM BLOOD WBC-7.3 RBC-3.57* Hgb-9.1* Hct-28.5* MCV-80* MCH-25.4* MCHC-31.8 RDW-18.6* Plt Ct-264 [2102-12-25] 06:30PM BLOOD WBC-9.2 RBC-3.73* Hgb-9.6* Hct-30.5* MCV-82 MCH-25.7* MCHC-31.5 RDW-18.0* Plt Ct-253 Coags [2102-12-26] 05:10AM BLOOD PT-30.0* PTT-30.0 INR(PT)-3.0* [2102-12-25] 06:30PM BLOOD PT-35.8* PTT-30.3 INR(PT)-3.7* Chemistry [2102-12-26] 05:10AM BLOOD Glucose-190* UreaN-25* Creat-1.3* Na-140 K-4.3 Cl-104 HCO3-27 AnGap-13 [2102-12-25] 06:30PM BLOOD Glucose-274* UreaN-28* Creat-1.2 Na-138 K-4.3 Cl-102 HCO3-25 AnGap-15 Echocardiogram ([2102-12-25]) FINDINGS: Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a small to moderate sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. IMPRESSION: Limited study,. Overall left ventricular systolic function is low normal. A small to moderate mainly anterior pericardial effusion is present with diastolic right ventricular collapse suggestive of tamponade. Reffering physician [Name Initial (PRE) 13109]. Additional In-house Read: Small amount of pericardial fluid and no evidence of RV diastolic collapse. . ECHO [2102-12-30] GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or electrodes. Suboptimal image quality - body habitus. The patient appears to be in sinus rhythm. . Conclusions The left atrium is normal in size. Overall left ventricular systolic function is probably normal although views are technically suboptimal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is a trivial pericardial effusion. . Compared with the prior study (images reviewed) of [2102-5-26], the pericardial effusion is now smaller. . AP Chest [2102-12-31] Study is limited as the lung bases have been excluded from the field of view. There is again seen some streaky densities at the bases most consistent with subsegmental atelectasis which is unchanged. The upper lung fields are clear without focal consolidation or signs of overt pulmonary edema. Cardiac silhouette is unchanged, within normal limits. . CHEST (PORTABLE AP) Study Date of [2102-12-25] 6:28 PM UPRIGHT AP VIEW OF THE CHEST: Cardiac silhouette is normal in size. The mediastinal and hilar contours are unremarkable. Pulmonary vascularity is normal. Linear opacities within both lung bases are compatible with linear atelectasis. No focal consolidation, pleural effusion or pneumothorax is visualized. No acute skeletal abnormalities are seen. IMPRESSION: Bibasilar linear atelectasis. No acute cardiopulmonary abnormality otherwise visualized. . CXR [2103-1-1] IMPRESSION: Heterogeneous opacification at both lung bases has improved since [12-30], probably atelectasis. On the left, it is conceivable that pneumonia was present and is rapidly clearing, but there is no new or worsening consolidation. There is no pulmonary edema, pleural effusion or mediastinal widening. Heart size is normal Brief Hospital Course: 72M with PMH of DM, AFib on coumadin, and RA complicated by pericardial effusion and tamponade in [5-6], presents with recurrent pericardial effusion concerning of tamponade and complaints of some progressive shortness of breath. #. Pericardial effusion - patient has had history of pericardial effusion in the past, thought to be a complicaton of RA. Had a pericardiocentesis with drain placement in 5/[2101]. Initially had methotrexate discontinued for concerns of worsening pericardial effusion, but was restarted back on it in [Month (only) 205] when patient did not tolerate Humira well. Patient has been receiving regular follow up with his cardiologist with a repeat echo every 6 weeks. His echo read done at [Location (un) 620] showed a small to moderate mainly anterior pericardial effusion with evidence of diastolic right ventricular collapse suggestive of tamponade. An additional read done by cardiology service here showed small amount of fluid with no evidence of RV diastolic collapse. He was hemodynamically stable during his admission and breathing was not labored, although reported to be slightly worse over the last few weeks. Pulsus was checked twice a day and remained consistently around 7-8mmHg. Methotrexate was held given the reaccumulation of pericardial fluid. Patient was evaluated by thoracic surgery for pericardial window. Procedure was performed on [2102-12-28] with drainage of only 80cc of fluid and was complicated by afib with RVR. The drainage tube was subsequently removed and he is being followed with serial imaging which at the time of discharge showed a smaller pericardial effusion on echo and only atelectasis on CXR. Fluid culture was positive for propionobacterium acnes which was felt to be a contaminant. Biopsy from pericardial window showed unremarkable cartilage and skeletal muscle and fragments of pericardium with chronic inflammation and fibrin deposition. . #. A fib - patient takes warfarin at home, was found to be supratherapeutic at INR of 3.7 on admission. INR was reversed for the pericardial window. He was bridged on heparin drip to coumadin and the coumadin alone was continued once his INR was therapeutic. . #. HTN - patient was continued on home dosage of metoprolol, furosemide, and spironolactone during admission. Valsartan was substituted for his home dose of olmesartan during admission, but patient was switched back to olmesartan on discharge. . # Anemia: he was found to have a microcytic anemia consistent with anemia of chronic disease. An outpatient colonoscopy can be considered as an outpatient. . #. Hyperlipidemia - patient was continued on home regimen of pravastatin . #. Rheumatoid Arthritis - patient's home regimen of methotrexate was held for pericardial effusion. Was restarted on discharge after his pericardial window procedure. . #. COPD - currently at baseline, patient was in no respiratory distress. During admission he was maintained on home dose of spiriva. Advair was substituted for symbicort while admitted, but patient was restarted on symbicort on discharge. . #. DM - patient was continued on his home regimen of insulin as well as regular insulin sliding scale. . #. GERD - patient was continued on omeprazole . #. Glaucoma - patient was continued on prednisolone drop to left eye and artificial tears Medications on Admission: ASA 81 Warfarin 3 mg daily Pravastatin 20 mg daily Benicar 20 mg daily Metoprolol tartrate 25 mg [Hospital1 ] Furosemide 60mg QAM, 40mg QPM Spironolactone 25 mg daily Potassium chloride 10 mEq daily NPH insulin 34 units qAM, 32 units qPM Regular insulin 16 units qAM, 17 units qPM Symbicort 160/4.5 2 puffs [Hospital1 ] Spiriva 18mcg 1 puff daily Omeprazole 20 daily Folic Acid 1 mg daily Prednisone 7.5mg daily Methotrexate 6 tablets of 2.5 mg once weekly qTues Prednisolone drops left eye qHS Aritificial Tears PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Thirty Four (34) units Subcutaneous qAM. 8. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Thirty Two (32) units Subcutaneous qPM. 9. Insulin Regular Human 100 unit/mL Cartridge Sig: Sixteen (16) units Injection qAM. 10. Insulin Regular Human 100 unit/mL Cartridge Sig: Seventeen (17) units Injection qPM. 11. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 16. Prednisolone Acetate 0.12 % Drops, Suspension Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)). 17. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-30] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 18. Diltzac ER 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:30 Capsule, Sustained Release(s) Refills:2 19. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day. 20. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pericardial effusion Secondary Diagnosis: Diabetes Mellitus Rheumatoid arthritis complicated by pericardal effusion and tamponade requiring pericardiocentesis and drain placement in [4-/2102] Atrial fibrillation on warfarin Hypertension Hyperlipidemia Chronic Obstructive Pulmonary Disease Iron Deficiency Anemia Gastroesophageal Reflux Disease Glaucoma Discharge Condition: good, stable, afebrile mental status: alert and oriented to person, place, and time ambulatory status: able to ambulate well without assistance Discharge Instructions: You were admitted to [Hospital1 69] for recurrent pericardial effusion seen on a routine echocardiogram. During this admission, we reviewed the echocardiogram that was performed at [Location (un) 620] and found that while there is some fluid present, it is not causing any tamponade of your heart. A pericardial window was performed by thoracic surgery to help drain the fluid around your heart and prevent future reaccumulation. Please continue to regularly follow up with your cardiologist, Dr. [Last Name (STitle) 1016], as you have been doing. . The following changes were made to your medications. We CHANGED to: Metoprolol Tartrate 50mg three times a day. Diltiazem ER 120mg daily. . We STOPPED: potassium chloride 10meq capsule Sustained release tablet daily. . Please continue to follow up in [Hospital3 ] and change your dosage of warfarin as instructed. If you experience any chest pain, worsening shortness of breath, or any other worrisome symptoms, please return to the emergency room Followup Instructions: #1.MD: Dr. [First Name8 (NamePattern2) 1026] [Name (STitle) 1016] Specialty: Cardiology Date/ Time: [Last Name (LF) 2974], [1-5] at 10:00am Location: [Street Address(2) ], [Location (un) 620], [Numeric Identifier 3002] Phone number: ([Telephone/Fax (1) 8937] . #2: Dr. [First Name8 (NamePattern2) 30642] [Name (STitle) ] Specialty: PCP [Name Initial (PRE) 2897]/ Time: [Last Name (LF) 766], [1-8] at 10:30am Location: INTERNISTS ASSOCIATED, [Street Address(2) 21374], [Location (un) ],[Numeric Identifier 30643] Phone number: [Telephone/Fax (1) 6163] . #3: Please follow up with Dr. [First Name (STitle) ] of Thoracic Surgery on [1-16] at 9:00am at [Hospital Ward Name 23] 9 on the [Hospital Ward Name 516] at ([Telephone/Fax (1) 27079]. . #4.Please go to [Hospital Ward Name 23] [Location (un) ] Radiology on the [Hospital Ward Name 516] for a Chest X-ray, any time between 9am and 3pm on [2103-1-13]. This chest x-ray must be done before your appointment with Dr [First Name (STitle) ] on the 19th. . #5. Please continue to follow up in [Hospital3 ] for management of your warfarin as you have been doing.	[ "42731", "496", "40390", "5859", "25000", "2724", "53081" ]
Admission Date: [2155-7-20] Discharge Date: [2155-7-22] Date of Birth: [2090-6-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2901] Chief Complaint: Back pain and tightness Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 65 year old male with h/o of CAD and MI with 2 previous stents placed presented to OSH with upper back pain and tightness associated with nausea and diphoresis. The pain started after walking his dog the morning of admission. He sat down after the walk and developed the back pain which radiated down his arms, broke out into a cold sweat and felt very nauseated. He took nitro x 3 without relief and then had his wife drive him to the emergency room. He denied any SOB or palpitations at the time. 5 days prior to this admission he had a similar pain in his back which was less severe and resolved after taking aspirin and resting. EKG at the OSH showed ST elevations in II, III, and aVF with ST depressions in aVL, V1, and V2. He was given NTG, 300 mg Plavix, and 5000 units of heparin before transferring to [Hospital1 18] for cardiac catheterization. He stated that his back pain was continuous until after the catheterization. Patient denies DOE, PND, or claudication. Past Medical History: remote bleeding ulcer 25 years ago CAD - h/o MI, stents placed in OM2 and LAD in [2150], EF 64% deaf in left ear s/p hernia repair depression erectile dysfunction Social History: Married, lives in [Location 21318]. Has 2 grown children. Quit drinking and smoking 20+ years ago after development of gastric ulcers. Has 25 pack year hx. Worked for 30+ years as a 5th-6th grade teacher. Family History: No history of heart disease. Father died of cancer. Physical Exam: Vit: 97.0 102/58 80 with frequent PVCs 18 100% RA Gen: pleasant gentleman, resting flat in bed, in NAD HEENT: EOMI, MM dry Neck: no JVD CV: soft heart sounds, did not appreciate any MGR Pulm: CTAB, no w/c/r Abd: + BS, soft, NT, ND Ext: no cyanosis, clubbing, or edema Neuro: grossly intact, moving all extremities equally Pertinent Results: ADMISSION LABS: 6.2 > 11.3/31.8 < 116 MCV-90 N:82.7 Band:0 L:11.7 M:4.8 E:0.7 Bas:0.2 . 142 / 115 / 13 --------------< 118 3.4 / 20 / 0.7 . [2155-7-20] 10:30AM CK(CPK)-176* CK-MB-9 cTropnT-0.10* [2155-7-20] 04:10PM CK(CPK)-1539* CK-MB-162* MB Indx-10.5* [2155-7-20] 09:57PM CK(CPK)-1416* CK-MB-136* MB Indx-9.6* [2155-7-21] 04:05AM CK(CPK)-1091* CK-MB-100* MB Indx-9.2* cTropnT-4.21* . Tbili: 0.4 Alb: 3.3 . Triglyc: 49 HDL: 28 CHOL/HD: 3.1 LDLcalc: 49 . PT: 14.7 PTT: 93.9 INR: 1.4 . <B>EKG [7-20]</B> Poor quality tracing. Probable sinus rhythm. There are also probably QS complex with ST segment elevation in the inferior leads and ST segment depression in lead aVL and leads V1-V3. Since the previous tracing of [2153-5-10] the inferior ST segment elevation is new and the rate is faster. Consider recurrent inferior myocardial infarction despite pre-existing prior Q waves. Clinical correlation is suggested. . <B>CATH REPORT:</B> RIGHT ATRIUM {a/v/m} 12/12/9 RIGHT VENTRICLE {s/ed} 38/12 PULMONARY ARTERY {s/d/m} 38/15/24 PULMONARY WEDGE {a/v/m} 18/17/14 AORTA {s/d/m} 93/67/80 CARDIAC OUTPUT HEART RATE {beats/min} 88 RHYTHM SINUS O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 45 CARD. OP/IND FICK {l/mn/m2} 6.2/2.8 RESISTANCES SYSTEMIC VASC. RESISTANCE 916 PULMONARY VASC. RESISTANCE 129 . FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderate systolic ventricular dysfunction. 3. Mild diastolic ventricular dysfunction. 4. Acute inferior myocardial infarction, managed by acute ptca. PTCA of vessel. 5. Successful placement of a drug eluting stent into the mid-RCA. . <B>ECHO</B> The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Preserved global and regional biventricular systolic function. Mild mitral regurgitation. Brief Hospital Course: # CAD: In the cath lab the patient was found to have a mid RCA occlusion which was stented with a Cypher stent. He was hypotensive post cath 90's/50's admitted to the CCU for hemodynamic monitoring. He was continued on ASA 325mg, increased Lipitor to 80 mg QD, and started on Plavix 75 mg QD. His antihypertensives were held given low BP. He remained stable and was transfered to the floor on day 2. He was restarted on low dose Atenolol, 25 mg QD. He was started on gemfibrozil for further secondary prevention given low HDL. Patient will need to follow up with his PCP [Last Name (NamePattern4) ] [12-29] weeks to recheck BP and possibly add an ACE inhibitor if BP will tolerate it. He will also need follow up of his LFTs given the addition of gemfibrozil. . # Pump: ECHO post cath showed an EF of >/= 55% with good systolic function. MR 1+. Borderline PA systolic hypertension. . # Rhythm: He had occasional runs of NSVT which resolved without intervention, likely due to reperfusion. He was transferred to the floor on day 2 and his ventricular ecotopy improved. . # FEN: Electrolytes were repleted to maintain K>4 and Mg>2. He was started on a low sodium, heart healthy diet and was consulted by nutrition. . # Depression: Continued Zoloft at current dose . # Prophylaxis: Patient was kept on a PPI for ulcer prophylaxis and pneumoboots for DVT prophylaxis until he was able to ambulate. Pneumovax given . # Dispo: Patient was cleared by physical therapy for discharge to home. Medications on Admission: Aspirin 325mg qd Omeprazole Zoloft 150mg qd Atenolol 10mg qd Lipitor 20 or 40 mg qd (pt unsure of dose) Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Sertraline 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Myocardial infarction Discharge Condition: Good Discharge Instructions: tightness, shortness of breath, dizziness or palpitations. Followup Instructions: Follow up with your PCP (DR [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ], [Telephone/Fax (1) 3183]) in [12-29] weeks to recheck your blood pressure and your labs checked since you are starting a new cholesterol medication. Follow up with your cardiologist (DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Telephone/Fax (1) 33138]) in [2-28] weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909] Completed by:[2155-7-22]	[ "41401", "412" ]
Admission Date: [2111-8-1] Discharge Date: [2111-8-6] Date of Birth: [2056-8-1] Sex: M Service: HISTORY OF PRESENT ILLNESS: Open fracture of left frontal sinus, anterior table. Open nasal fracture. PHYSICAL EXAMINATION: General: Alert, oriented, appropriate. Cardiovascular: Regular, rate, and rhythm. Respiratory: Clear to auscultation bilaterally. Face: Sutures intact and in place, supraorbitally and the nasal bridge. Minimal to moderate ecchymosis periorbitally. Mild tenderness to palpation. Pupils are equal, round, and reactive to light. Extraocular movements are intact. LABORATORIES: On [2111-8-5], white blood cell count 9.7, H&H 14.3/42.7, platelets 221. Sodium 141, potassium 4.2, chloride 103, bicarbonate 25, glucose 106. SUMMARY OF HOSPITAL COURSE: The patient is a 55-year-old gentleman admitted through the Emergency Department following being struck in the forehead by a tree branch while trimming a tree on [2111-8-1]. Patient was taken to the operating room for an open fracture of the left frontal sinus and nose as indicated by CT scan. The lacerations were closed, and the patient was admitted originally under the Trauma Service and followed for a closed head injury. CT scan at time of admission showed an approximately 4 cm markedly depressed fracture of the anterior table of the left frontal sinus. This extended to a small minimal degree into the orbital rim on the left side. There was no evidence of cerebrospinal fluid leak clinically. The posterior table of the sinus was intact. There was no fracture in the neighborhood of the frontonasal duct. Followup CT scan on [8-2] showed: 1. Stable appearance of multiple sulci of intraparenchymal hemorrhage involving the right hemisphere. 2. Stable appearance of parafalcine subdural hematoma. 3. Comminuted left frontal sinus and nasal fractures. Patient also remained stable clinically. On [2111-8-5], the patient was taken to the operating room by the Plastics Service for reduction and fixation of the anterior table fragment and nasal fracture utilizing plates and screws. Patient's postoperative course was unremarkable except for one episode of confusion postoperatively, noted by RN during morning rounds on day of discharge. M.D. examined the patient, who was by then alert, oriented x4, appropriate, and lucid. The patient explained that he is "always confused in the morning." Vital signs remained stable throughout. Patient was deemed to be suitable for discharge and discharged on [2111-8-6]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Open reduction internal fixation of left frontal sinus fracture. 2. Open reduction internal fixation of nasal fracture. DISCHARGE MEDICATIONS: 1. Clindamycin 450 mg po qid. 2. Percocet 1-2 tablets po q4-6h as needed for pain. 3. Colace 100 mg [Hospital1 ]. FOLLOW-UP PLANS: In Plastic Clinic on [2111-8-11]. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 2647], M.D. [MD Number(1) 2648] Dictated By:[Last Name (NamePattern1) 21646] MEDQUIST36 D: [2111-8-18] 14:29 T: [2111-8-21] 12:42 JOB#: [Job Number 48471]	[ "2720", "4019" ]
Admission Date: [2153-10-24] Discharge Date: [2153-10-29] Date of Birth: [2153-10-24] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: The patient is a 41 week gestational age male infant who was admitted for respiratory distress. MATERNAL HISTORY: 31 year-old G4 P2 now 3 woman with were O negative, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, GBS positive. PREGNANCY HISTORY: Estimated date of confinement was [2153-10-17] for an estimated gestational age at 41 weeks. Pregnancy was benign by report. Labor was induced. Rupture of membranes stained amniotic fluid. There is no maternal fever. No intrapartum antibiotics were started. Fetal bradycardia was noted, which prompted a stat cesarean section. NEONATAL COURSE: The infant was vigorous at delivery. He was orally and nasally bulb suctioned for large volume of green secretions. He was then dried with free flow oxygen being administered. Endotracheal intubation/suctioning was not performed given the vigorous appearance. Apgars were 8 and 8 at one and five minutes respectively. He was subsequently noted to have mild nasal flaring and retractions. He is transferred to the Neonatal Intensive Care Unit for further observation. PHYSICAL EXAMINATION: Heart rate 130. Respiratory rate 100. Temperature 98.7. Blood pressure 88/42 with a mean of 51. Oxygen saturation was 87% on room air and improved to 94% in FIO2 of 70%. Birth weight 3905 grams, greater then 90th percentile. Head circumference 35.5 cm and 75th percentile and length 51.5 cm 75 to 90th percentile. He had an anterior fontanel that was soft, open and flat. Nondysmorphic faces. Palette intact. Moderate nasal flaring. Moderate green secretions intermittently from oropharynx. Neck and mouth were normal in appearance. Chest had moderate retractions and grunting. Respirations fair breath sounds bilaterally. Coarse crackles bilaterally. He is well perfused with regular rate and rhythm. Femoral pulses were normal. S1 and S2 were normal. There is a 1 out of 6 systolic ejection murmur at the upper left sternal border without radiation. Abdomen is soft, nondistended, no organomegaly. No masses. Bowel sounds are active. Anus is patent. Three vessel umbilical cord with deep green staining. Genitourinary, normal male genitalia, testes distended bilaterally. He was active and responsive to stimulation with tone slightly increased due to agitation, but symmetric. He was moving all extremities symmetrically. Suck, root, gag, grasp were overall normal. He had mild peeling consistent with postmaturia of the skin. He had normal spine, limbs, hips and clavicles were intact. HOSPITAL COURSE: 1. Respiratory: The patient a few hours after arrival to the Neonatal Intensive Care Unit was intubated for respiratory distress. He received two doses of Surfactant. At approximately 20 hours of age he had weaned to minimal settings on the SIMV and was subsequently extubated. He required nasal cannula O2 for two additional days and was weaned to room air on day of life four. 2. Cardiovascular: Throughout his admission the patient was stable from a cardiovascular status. Upon admission he did require a single normal saline bolus. He had an umbilical arterial catheter in place for two days. There were no complications from this. A murmur was noted intermittently. On the day of discharge, there is a soft systolic murmur at the left lower sternal border. 3. Fluids, electrolytes and nutrition: The patient was initially maintained on intravenous fluids. D sticks were monitored as well as electrolytes, all were normal. He was commenced on breast feeding after extubation and resolvement of his respiratory distress. He currently is ad lib feeding with normal weight loss. His weight today on the day of discharge is 3965 grams. 4. Gastrointestinal: The patient is breast feeding without difficulty. He had a bilirubin checked on day of life three, which was 6.2/0.4. 5. Hematology: The patient's initial CBC was a white blood cell count of 13.8, differential 36 polys, 2 bands, hematocrit 43.3 and platelets 321. This has not been rechecked. 6. Infectious diseases: Given his respiratory distress and mom's GBS positive status he was treated with Ampicillin and Gentamycin for a total of two days. At this time antibiotics were discontinued as his blood culture remained sterile. 7. Neurology: The patient received morphine and Versed for his intubation on day of life one. He subsequently required no further analgesia or sedation. 8. Sensory: The patient passed hearing screening in both ears. 9. Psychosocial: [Hospital1 69] social worker was involved with the family. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home. Name of primary care pediatrician is Dr. [First Name4 (NamePattern1) 553] [Last Name (NamePattern1) 44964]. Phone number is [Telephone/Fax (1) 44672]. Follow up appointment on day after discharge. CARE AND RECOMMENDATIONS: 1. Feeds at discharge, breast feeding. MEDICATIONS: None. IMMUNIZATIONS RECEIVED: Hepatitis vaccine on [2153-10-29]. DISCHARGE DIAGNOSES: 1. Meconium aspiration syndrome. 2. Rule out sepsis. 3. Cardiac murmur- possible small VSD [First Name11 (Name Pattern1) 37693] [Last Name (NamePattern4) 37927], M.D. [MD Number(1) 37928] Dictated By:[Last Name (NamePattern1) 44965] MEDQUIST36 D: [2153-10-29] 08:38 T: [2153-10-29] 09:05 JOB#: [Job Number 44966]	[ "V290", "V053" ]
Admission Date: [2146-8-5] Discharge Date: [2146-8-11] Date of Birth: [2078-4-14] Sex: M Service: SURGERY Allergies: Percocet Attending:[First Name3 (LF) 148] Chief Complaint: Abdominal Pain Biliary leak Major Surgical or Invasive Procedure: CT guided percutaneous drainage of biliary fluid collection ERCP History of Present Illness: This is a 68 year old male s/p CCY at an OSH on [2146-8-4]. He now presents with abdominal pain and a CT scan showed subhepatic fluid collection suspicious for biliary leak. This subhepatic fluid was confirmed by a HIDA scan. He was transfered to [Hospital1 18] for an ERCP. Past Medical History: HTN, GERD, BPH, Hyperchol. Physical Exam: VS: 100.6, 122, 158/89, 22, 90% 4L Gen: NAD, sedated, responds appropriately Skin: No rash, no jaudice, no ecchymoses Neck: No cervical LAD, carotids 2++ Chest: decreased at the bases, Left basilar crackles CV: Sinus tachy. No rubs Abd: Soft, mildly diffuse lower abdominal tenderness, distended. No guarding, no hernia. Pertinent Results: CHEST (PORTABLE AP) [2146-8-6] 4:15 PM CHEST (PORTABLE AP) Reason: tube placement [Hospital 93] MEDICAL CONDITION: 68 year old man with acute desat, new O2 requirement s/p lap ccy REASON FOR THIS EXAMINATION: tube placement CLINICAL HISTORY: Acute desats. Increased O2 requirements, patient intubated. CHEST: The tip of the endotracheal tube lies in the region of the right main stem bronchus and should be withdrawn to better position. Atelectasis in the left lower lobe is seen, volume loss, and elevation of right hemidiaphragm is present. CT PERITINEAL DRAIN EXCLUDING APPENDICEAL [2146-8-6] 1:52 AM CT PERITINEAL DRAIN EXCLUDING ; CT GUIDANCE DRAINAGE Reason: drainage of biloma [Hospital 93] MEDICAL CONDITION: 68 year old man with biloma REASON FOR THIS EXAMINATION: drainage of biloma CONTRAINDICATIONS for IV CONTRAST: None. CT-GUIDED DRAINAGE INDICATION: Biloma after cholecystectomy. CT aABDOMEN WITHOUT CONTRAST: Selected axial images were taken over the hepatic area. No contrast was administered. The patient was positioned in the right anterior oblique position. There is a right pleural effusion. Around the liver, note is made of some fluid and some air. Just inferior to the right lobe of the liver, a pocket of fluid measuring 10 cm x 4.5 cm is identified coinsistent with a bile collection taht radiotracer went to on oustide HIDA study. Non-contrast images of the spleen, pancreas, adrenals and kidneys are unremarkable. CT-GUIDED DRAINAGE: Informed written consent was obtained. Timeout with patient identifiers was performed. Using aseptic technique, CT guidance and local anesthetic, an 8- French [Last Name (un) 2823] catheter was placed in the right subhepatic collection. Drain was secured to the skin with an adhesive device. Approximately 300 mL of bilious fluid was aspirated. Fluid was sent for cytology and biochemistry including bile. The procedure was well tolerated. No complications were encountered. Post-procedural CT revealed no evidence of any pneumothorax and good drainage of the collection with only a small amount remaining. IMPRESSION: Succesful placement of 8 French pigtail catheter in sub-hepatic collection with bilious material. CHEST (PORTABLE AP) [2146-8-7] 11:15 AM CHEST (PORTABLE AP) Reason: r/o PTX [Hospital 93] MEDICAL CONDITION: 68 year old man with s/p extubation REASON FOR THIS EXAMINATION: r/o PTX CLINICAL HISTORY: Status post extubation, evaluate for pneumothorax. The patient has been extubated. Elevation of the right hemidiaphragm is still present and some bibasilar atelectasis is seen. No infiltrates are seen. There is no evidence of a pneumothorax. A drainage catheter is seen extending into the right upper quadrant in the abdomen. IMPRESSION: No infiltrates, no pneumothorax, atelectasis. [2146-8-10] 06:05AM BLOOD WBC-7.2 RBC-3.88* Hgb-12.3* Hct-34.0* MCV-88 MCH-31.7 MCHC-36.2* RDW-13.2 Plt Ct-246 [2146-8-10] 06:05AM BLOOD Plt Ct-246 [2146-8-10] 06:05AM BLOOD Glucose-114* UreaN-12 Creat-1.0 Na-140 K-4.4 Cl-105 HCO3-27 AnGap-12 [2146-8-11] 06:15AM BLOOD ALT-160* AST-101* AlkPhos-217* Amylase-71 TotBili-1.3 [2146-8-11] 06:15AM BLOOD Lipase-110* [2146-8-10] 06:05AM BLOOD Albumin-3.0* Calcium-9.0 Phos-3.5 Mg-2.1 Brief Hospital Course: He was s/p CCY, and transferred here for an ERCP. On [2146-8-5] the ERCP was aborted due to the patient's agitation and intermittent hypoxia. He was then admitted to monitor for signs and symptoms of sepsis. On [2146-8-6] he went to CT for successful placement of 8 French pigtail catheter in sub-hepatic collection with bilious material. Later that same day he went to ERCP for a biliary stent was placed successfully across the cystic duct opening in the CBD with the distal stent in the duodenum. Resp: HD #3, he was extubated later that morning. His lungs were diminished at the bases. GI/Abd: He was NPO with a NGT. His abdomen was slightly firm and distended. The pigtail drain was D/C'd ON HD #3. His diet was advanced as tolerated and he was tolerating a regular diet at time of discharge. His abdomen was soft and nontender at time of discharge. He will need to F/U with ERCP in 4 weeks. ID: He was on Zosyn for Gram negative rods found in the sub-hepatic collection. He was changed to Levofloxacin and will continue for 2 weeks. Neuro: He had periods of agitation when initially extubated. He received Ativan for agitation with good effect. Medications on Admission: Lipitor 40', protonix", atenolol 25', NSAIDs 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. Atorvastatin 40 mg 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 Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 12 days. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Post Cholecystectomy Bile Leak Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain Please take all medications as ordered. You may shower and wash your incision with soap and water. Pat dry. Let the steri strips fall off on their own. Continue to walk several times per day and increase activity as tolerated. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 3 weeks. Call ([Telephone/Fax (1) 15807] to schedule an appointment. You will need to have an ERCP in 4 weeks. Completed by:[2146-8-11]	[ "4019", "53081", "2720" ]
Admission Date: [2164-9-4] Discharge Date: [2164-9-6] Date of Birth: [2097-6-17] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: Lower GI Bleed Major Surgical or Invasive Procedure: Colonscopy [9-5] History of Present Illness: The pt is a 67 y/o male with h/o HTN/DM who underwent a surveillance colonoscopy on [2164-8-23] with removal of 3 polyps who developed BRBPR the following day with multiple subsequent bloody/clot containing BMs. He went to [Hospital 5871] hospital where a Hct showed a decrease from 35.4 to 32.5 with a total of 6 units PRBC. The pt was stabilized and transferrred to [Hospital1 18] SICU for possible angiographic intervention. Past Medical History: HTN DM Hypercholesterolemia Social History: No EtOH, tobacco, and is a retired brick layer. Family History: Noncontributory Physical Exam: ADMIT EXAM: T:97.5 P:71 BP:134/70 RR:21 O2SAT:100 Gen: NAD CVS: RRR, no murmurs, clicks or rubs Resp: CTA bilaterally, no wheezes, rales or rhonchi Abd: soft/ND/NT/NABS. Rectal:positive guiac Ext: pulses papable distally in all extremities DISCHARGE EXAM: T:97.5 P:71 BP:134/70 RR:21 O2SAT:100 Gen: NAD CVS: RRR, no murmurs, clicks or rubs Resp: CTA bilaterally, no wheezes, rales or rhonchi Abd: soft/ND/NT/NABS. Ext: pulses papable distally in all extremities Pertinent Results: [2164-9-6] 08:53AM BLOOD Hct-29.1* [2164-9-6] 04:16AM BLOOD Hct-27.9* [2164-9-5] 09:03PM BLOOD Hct-28.7* [2164-9-5] 02:41PM BLOOD WBC-9.1# RBC-3.72* Hgb-11.1* Hct-30.7* MCV-82 MCH-29.9 MCHC-36.2* RDW-14.3 Plt Ct-161 [2164-9-5] 09:17AM BLOOD Hct-30.6* [2164-9-5] 03:48AM BLOOD WBC-5.7 RBC-3.76* Hgb-11.0* Hct-31.0* MCV-83 MCH-29.3 MCHC-35.5* RDW-13.9 Plt Ct-151 [2164-9-5] 12:12AM BLOOD Hct-27.1* [2164-9-4] 07:14PM BLOOD Hct-30.5* [2164-9-4] 02:41PM BLOOD Hct-28.9* [2164-9-4] 11:26AM BLOOD Hct-26.6* [2164-9-4] 10:32AM BLOOD Hct-26.7* [2164-9-4] 06:18AM BLOOD WBC-5.4 RBC-3.65* Hgb-10.8* Hct-30.4* MCV-83 MCH-29.6 MCHC-35.6* RDW-14.0 Plt Ct-185 [2164-9-5] 03:48AM BLOOD PT-14.6* PTT-29.5 INR(PT)-1.3* [2164-9-4] 06:18AM BLOOD PT-14.1* PTT-30.0 INR(PT)-1.3* [2164-9-5] 03:48AM BLOOD Glucose-138* UreaN-11 Creat-0.8 Na-142 K-3.3 Cl-109* HCO3-27 AnGap-9 [2164-9-4] 06:18AM BLOOD Glucose-114* UreaN-19 Creat-0.9 Na-144 K-3.8 Cl-110* HCO3-27 AnGap-11 [2164-9-5] 03:48AM BLOOD Calcium-7.5* Phos-2.1* Mg-1.6 [2164-9-4] 06:18AM BLOOD Albumin-3.6 Calcium-8.3* Phos-2.9 Mg 1.8 Colonoscopy [9-5] Diverticulosis of the left > right Pulsating vessel with active bleeding was found at the hepatic flexure at the site of previous polypectomy. The area had been tattooed with [Country ] ink. 4-5 cc of epinephrine 1:10,000 was injected and then vessel was cauterized (26 W) and a single hemoclip was deployed. The area was washed. No further active bleeding was noted. The vessel was no longer visible. Polyps throughout. Brief Hospital Course: The patient was transferred from an outside facility to Dr. [Name (NI) 25409] surgical service on [2164-9-4] for possible angiographic intervention of a lower GI bleed. The patient was directly transferred to the SICU where he remained stable. He underwent a colonscopy on [2164-9-5] which found a pulsating vessel with active bleeding was found at the hepatic flexure at the site of previous polypectomy and the vessel was cauterized (26 W) and a single hemoclip was deployed. The area was washed. No further active bleeding was noted. The vessel was no longer visible. Serial hematocrits were stable following the colonscopy. The patient was transferred to a regular surgical floor on HD 2, following his colonscopy and the patient was deemd stable for discharge on HD 3 with continued stable hemoatocrits. He tolerated a regular diet and will be discharged home today. He will followup tih Dr. [Last Name (STitle) ] in [1-30] weeks and folowup with his PCP [Last Name (NamePattern4) ] [1-30] weeks. Medications on Admission: Toprol Hydralatine Glucophage Teratozin Tegretol Glipitide Avandia Lipitor ASA Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed Discharge Condition: Stable Discharge Instructions: Please call your doctor [First Name (Titles) ] [Last Name (Titles) ] greater than 101.5, nausea/vomiting, inability to eat, abdominal pain not controlled by pain medications, bloody bowel movements or any other concerns. Please resume taking all medications as taken prior to this hospitalization. Please follow-up as directed. Followup Instructions: Followup with Dr. [Last Name (STitle) ] in [1-30] weeks Please call his office for an appointment. Followup with PCP [Last Name (NamePattern4) ] [1-30] weeks.	[ "2851", "4019", "2720" ]
Admission Date: [2121-5-6] Discharge Date: [2121-6-24] Date of Birth: [2075-12-28] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 943] Chief Complaint: eval for liver transplant Major Surgical or Invasive Procedure: [5-13] EGD R thoracotomy LP done through IR History of Present Illness: 45 yo m with h/o cryptogenic cirrhosis, end stage liver disease, frequent episodes of hepatic encephalopathy exacerbations. He presented on [5-4] to [Hospital ] hospital after being found unconscious [12-18] to missing a lactulose dose. He was given lactulose by NGT in the ER and his mental status cleared. The patient underwent a diagnostic tap in the ED there, but there was not sufficient fluid to send to cell count. He was tapped again on [5-6] at OSH and this tap showed increased cell count to 9045, 83% PNMs c/w SBP therefore he was started on cefotaxime. The patient reported blood in stools (patient thought this was from his hemorrhoids), therefore he underwent an upper and lower endoscopy. Upper showed grade I varices, gastropathy, and gastric varices. Lower showed diverticulitis, polyp (not clipped [12-18] to increase INR), and internal hemorrhoids. He was hypotensive after the procedure to systolic of 80's (had been 120 - 150) which responded to fluid boluses. Also significant was the fact his Cr increased from 1.8 to 2.6 during his short hospital stay, thought to be due to acute renal failure [12-18] bowel prep vs. hepatorenal syndrome. He was transferred to [Hospital1 18] for transplant eval on [5-6]. At [Hospital1 ]: # End stage liver failure: The cause of his liver failure is currently unknown and his MELD score was 30 on admission. He underwent a workup for a liver transplant - echo, PFTs, viral studies. He had multiple episodes of encephalopathy when not taking lactulose. He was continued on lactulose while here. Neomycin, which was started at RIH, was stopped for concern of nephrotoxicity. His diuretics were held [12-18] low BP. Pt. scheduled for transplant but chest CT showed nodules (SEE lung nodule hx below); intubated for surgery and weaned off on [5-19] in SICU...transplant deferred. . # Acute renal failure: His baseline Cr was 1.5 - 1.8 and he has had a sudden increase of his Cr from 1.8 -> 3.1 in a matter of 3 days. Of note, his Cr began to increase before he became hypotensive and before any procedure was done at the OSH. This is worrisome for hepatorenal failure exacerbated by infection and intravascular volume depletion [12-18] to colonoscopy prep. He was given 50mg of albumin x2 on admission and started on octreotide and midodrine. and renal consulted; transfused for improved forward flow and his creatinine improved. On txf from SICU, creat. trended down to 1.8. . # SBP: This was diagnosed on the day of admission at RIH and he was started on cefotaxime there. He was switched to ceftriaxone here. His cultures at RIH are currently not growing anything. He was gently hydrated on the night of admission for concern that his hypotension was [12-18] to infection (though he had a normal lactate). Switched from ceftriaxone to oral cipro for SBP therapy ([5-10]) - to end on ([5-22]) . # Hypotension/anemia: This is likely multifactorial . His initial BP at the OSH was between 120 - 150 and decreased after the colonoscopy. Perforation unlikely since has no pain. Possibly [12-18] to SBP, volume depletion from colonoscopy prep, or arterial and vasodilatation from HRS. on hospital day 2, his HCT dropped from 25.7 on [5-6] to 18 on [5-7]. It was thought that he was bleeding into his peritoneum from the paracentesis on [5-6] or from his gastric varices. (He did not have abdominal pain, vomiting, or BRBPR). His INR was 4.3 on [5-7] as well. He was given 2 units PRBC and 2 units FFP for this HCT drop and coagulopathy. His BP on transfer from ICU. . # Rectal bleeding at OSH: The patient underwent a colonoscopy and EGD on [5-6] that did not show evidence of active bleeding. He does have gastric varices therefore at high risk for bleeding event. Resolved on transfer to medicine. . # Lung nodules - Chest CT on [5-8] showed scattered small pulmonary opacities within both lungs, of varying sizes and morphologies, suggestive of an acute infectious or inflammatory process. Bronchoscopy performed [5-9] - normal on visual inspection, but BAL ctx grew out sensitive enterobacter and [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] sensitive to caspo/vori. Tx c caspo c plan for transplant after treatment of yeast infection in lungs. Continue caspo * 2 weeks ([5-18]) with repeat CT to assess for interval change. . # Panniculitis - tx c IV vancomycin. Swab sent for MRSA screen and pending; currently being treated with vancomycin. Past Medical History: cryptogenic cirrhosis right inguinal hernia - cannot repair [12-18] to liver disease Social History: No longer working but used to work as a chef. live with his mother, not married or has children. Does not drink or smoke Family History: positive for diabetes but no known history of iron overload. His father died of small cell carcinoma of the lung Physical Exam: vs: HR 60, BP 110/48, O2 sat 99%, 99.1 at 12:00, CVP 5 HEENT: EOMI, sclerae anicteric, oropharynx clear c no lesions Lungs: CTA at apices/bases Heart: RRR, S1, S2, no r/m/g Abd: soft, + splenomegaly, NT, obese, + striae Ext: [11-17] + edema to ankles b/l Skin: large area ecchymoses over L shoulder. No spider angiomas noted, + gynecomastia. Pertinent Results: Labs from outside hospital on morning of admission: Na 136, K 3.5, Cl 118, Bicarb 11, BUN 23, Cr 2.6 up from 1.8 on admission to RI, Glu 116. INR 2.3 up from 1.8 on admission. Tbili 40. up from 1.8, HCT 26, WBC 14.8 with 90% neutrophils Ascites: fluid cloudy yellow, Nu cells [Pager number ], RBCs 675, 89% Neutrophils therefore 7000 nuc cells. . Admission labs at [Hospital1 ]: [2121-5-7] 06:35AM BLOOD WBC-3.6* RBC-1.99* Hgb-5.9* Hct-18.2* MCV-92 MCH-29.7 MCHC-32.4 RDW-16.1* Plt Ct-65* [2121-5-7] 06:35AM BLOOD PT-25.6* PTT-57.8* INR(PT)-4.3 [2121-5-7] 06:35AM BLOOD Glucose-139* UreaN-31* Creat-3.1* Na-135 K-3.6 Cl-114* HCO3-10* AnGap-15 [2121-5-7] 06:35AM BLOOD ALT-37 AST-41* AlkPhos-98 TotBili-1.4 [2121-5-7] 06:35AM BLOOD Albumin-3.5 Calcium-8.1* Phos-4.7* Mg-1.7 Iron-47 [2121-5-7] 06:35AM BLOOD calTIBC-88* VitB12-1342* Folate-11.5 Ferritn-348 TRF-68* [2121-5-7] 06:35AM BLOOD TSH-1.4 [2121-5-7] 02:04AM BLOOD Lactate-1.5 . [2121-5-8] CT Chest and Abdomen: Patents portal and hepatic veins. IMPRESSION: 1. Scattered small pulmonary opacities within both lungs, of varying sizes and morphologies, suggestive of an acute infectious or inflammatory process. An additional area of fibronodular thickening within the right lung apex may be secondary to chronic lung disease, but could also be associated with the above described smaller nodular opacities. Correlation with the patient's clinical exam and follow up of these nodules, to document their stability or resolution, is recommended. Given the patient's history, a neoplastic process cannot be entirely excluded. 2. New bilateral pleural effusions, smaller in size. 3. Prominent mediastinal and axillary lymph nodes, none meeting the size criteria for pathologic enlargement, which may related to the above described process within the lung parenchyma. 4. Stable perihepatic and perisplenic ascites. 5. Gynecomastia. . [2121-5-8] Echo: The left atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60-70%). 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . [2121-5-7] blood cultures neg. x 2 [2121-5-8] RPR neg, VZV IgG pos, EBV IgG pos, EBV IgM neg, Toxo IgG neg, Toxo IgM neg, CMV IgG pos, CMV IgM neg, [2121-5-8] 05:37AM BLOOD HIV Ab-NEGATIVE [2121-5-10] 07:40AM BLOOD PEP-NO SPECIFIC ABNORMALITIES. [2121-5-9] 11:53 am BRONCHOALVEOLAR LAVAGE GRAM STAIN positive for 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE positive for ENTEROBACTER CLOACAE, ~[2115]/ML, but not considered a pathogen unless >=10,000 cfu/ml. BAL FUNGAL CULTURE (Preliminary): YEAST, PRESUMPTIVELY NOT C. ALBICANS. FURTHER IDENTIFICATION TO FOLLOW. ACID FAST SMEAR negative, ACID FAST CULTURE (Pending): [5-19] repeat chest CT 1. Thick walled, irregular right upper lobe cavitary lesion. Differential considerations include an infectious process such as reactivation TB, particularly given the lymphadenopathy. Vasculitis, such as Wegener's, can have a similar appearance and be associated with tracheal thickening as seen on this study. A cavitary neoplasm is considered less likely given the irregular shaped of the cavity. 2. Bibasilar consolidation and pleural effusions, right greater than left. Pleural Fluid [5-28] GRAM STAIN (Final [2121-5-29]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. ACID FAST SMEAR (Final [2121-5-29]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FLUID CULTURE (Final [2121-5-31]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . Lung Tissue [5-27] rare growth coag (-) staph, oxacillin resistant, no ctx growth - anaerobes, legionella, fungus, AFB . Histo Urinary Ag - P . LP [6-19]-->WBC, CSF 0 #/uL CLEAR AND COLORLESS PERFORMED AT WEST STAT LAB RBC, CSF 71* #/uL 0 - 0 PERFORMED AT WEST STAT LAB Polys 25 % 4 CELL DIFFERENTIAL PERFORMED AT WEST STAT LAB Lymphs 25 % Monocytes 50 % .. [6-22] CXR: There is continued large right pleural effusion, which is unchanged since the previous study. The previously identified mild congestive heart failure has been slightly improving. The right-sided PICC line remains in place. No pneumothorax is seen. Brief Hospital Course: This patient, who had initially seen Dr. [Last Name (STitle) 497] and transplant social work a few weeks ago, was transferred to [Hospital1 18] for an expedited liver transplant workup because he developed acute renal failure and SBP; was about to receive liver txp which was aborted because of lung infxn; currently undergoing tx for cavitary lesion in lung prior to txp. . End stage liver failure; followed by liver service. He was continued on octreotide and midodrine until his creatinine came down; he was considered to be out of hepatorenal syndrome and octreotide/midodrine stopped. Prior to R lobectomy, pt. was diuresed aggressively in anticipation of large amount of blood products during surgery. He was kept on lactulose with a goal of [1-17] BM daily. He was on cipro for SBP prophylaxis and protonix for gastritis/prophylaxis. Post lobectomy we continued to diurese him aggressively with lasix, spironolactone and repleted his electrolytes accordingly. It was determined the week of [6-9] that the pt. actually has cryptococcus in the RUL specimen, not histoplasmosis based on mucicarmine stain and Fontana-Masson1 stain. As a result, he had a w/u for CNS crypto which included an LP performed under fluoroscopy. However, this procedure was complicated by patient's coagulopathy, and pt required multiple transfusions of FFP and platelets. In addition, patient required 4800mcg of Factor VII, which was given immediately prior to procedure and successfully reversed his INR. As a result of the blood products, pt became fluid overloaded and developed a R sided pleural effusion. This was treated with aggressive IV diuretics in addition to his oral aldactone. Pt was kept in negative balance of at least 1.5L daily, and his weight was tracked as well. His creatinine remained between 1.3-1.4. Diuresis was slowly decreased once patient able to breathe comfortably on room air and his weight decreased by a few pounds. He was changed over to oral lasix and continued on the spironolactone. . SBP; this resolved with a 2 week course of cipro/ceftriaxone. He was kept on prophylaxis with cipro and did not c/o any increasing abdominal pain. . Lung nodules/cavitary lesion RUL; prior to R lobectomy, he was ruled out for TB with three negative induced sputums. He underwent R lobectomy and path showed large palisading caseating granulomas with many yeast forms ([1-18] microns) in the caseous material. Post lobectomy, he was treated with ambisome IV. A discussion whether he needed a w/u for disseminated histo occurred and it was decided that the w/u should include a MRI to assess for meningeal involvement as well as a BM biopsy/aspirate culture. This was considered necessary as it may impact his prognosis should he go for emergent liver txp as well as his relative response to a non-cidal [Doctor Last Name 360] (itraconazole) should he not tolerate ambisome. As of [6-6] he had a negative MRI and a BM aspirate culture was going to be done [6-6]. The BM was never done b.c. of high risk and possibility to treat empirically. Concurrently (see above) it was determined that he had cryptococcus, not histoplasmosis. This was based on fungal stains. As a result, he requires a LP to r/o CNS crypto. The LP was to be done under fluoroscopy because he has such poor landmarks and he is a high risk candidate, because of this, the [Hospital1 ] protocol for LP, which is that the procedure service must attempt, then neurology, then the pain service, and then IR as a last resort; was bypassed. The LP was negative for crypto, at which point the patient was changed from ambisome to oral fluconazole, 400mg daily, to complete an eight week course per ID recommendations. . Panniculitis; treated with IV vancomycin and this resolved; vanco stopped [5-23]. . Central line; pt. central line placed [2121-5-15]; plan was to remove central line [6-6] AM and position 2 peripheral IVs. Central line removed, tip (-) ctx, PICC placed for plan for outpt. abx, however, as patient did not require IV antibiotics, this PICC was removed prior to discharge. . Pt was also followed by thoracic service for management of chest tubes. Drained for nearly 1 week post surgery. Chest tubes pulled when drainage < 400 cc/24 hr. Pt. continued to have sporadic drainage usually worsened by activity. Pt. had ostomy bag intermittently applied over chest tube site to control drainage. Tramadol and oxycodone used for pain control and pt. able to use incentive spirometer. Stitch over CT site applied by thoracic team. As of [6-14], his chest tube site was draining minimal fluid and was covered with dry gauze. Staples over his incision site were removed 2 days prior to discharge and covered with steri-strips. . Patient was evaluated by PT/OT and was cleared for discharge to his home. VNA was arranged for the patient prior to discharge. After a stable dose of lasix was determined that would provide patient with optimal diuresis, patient was cleared for discharge to home with services. Patient was scheduled for follow-up appointments with Dr. [Last Name (STitle) 497], Dr. [Last Name (STitle) 4334], and Dr. [Last Name (STitle) 724]. On day of discharge, patient was ambulating, afebrile, hemodynamically stable, and tolerating a house diet. Patient was given a prescription for all of his medications as he stated that he did not have any at home. However, a few days after discharge, patient called needing clarification with two of the prescriptions, at which point he was [Name (NI) 653], but stated that the problem had already been resolved. Medications on Admission: on transfer: albumin 40mg IV q8 cefotaxime 2g q24 neomycin 500mg q6 lactulose 20 po q6 aldactone 50 po qam Discharge Medications: 1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for legs. Disp:1 Refills:1 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). Disp:1 Refills:2 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:1 Refills:1 6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:2700 ML(s) Refills:2 7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:112 Tablet(s) Refills:0 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA of [Doctor Last Name ] Discharge Diagnosis: cryptococcal pneumonia cryptogenic cirrhosis end stage liver disease Discharge Condition: stable Discharge Instructions: Please take all of your medications as prescribed. Please maintain all of your follow up appointments listed below. Please call your doctor or return to the hospital if you develop fevers, chills, nausea or vomiting, or develop chest pain or shortness of breath. Followup Instructions: 1.Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: LM [Hospital Unit Name 3126] Phone:[Telephone/Fax (1) 673] Date/Time:[2121-7-2] 3:20 2.Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: LM [Hospital Unit Name 4337] DISEASE Phone:[Telephone/Fax (1) 457] Date/Time:[2121-7-17] 10:30 3.Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4861], MD Where: LM [Hospital Unit Name 3126] Phone:[Telephone/Fax (1) 673] Date/Time:[2121-8-12] 10:00	[ "5849", "4280", "4019" ]
Admission Date: [2174-5-30] Discharge Date: [2174-6-1] Date of Birth: [2105-2-23] Sex: M Service: MEDICINE Allergies: Amiodarone / Spironolactone Attending:[Doctor First Name 1402] Chief Complaint: Recurrent Ventricular tachycardia Major Surgical or Invasive Procedure: Ventricular tachycardia ablation ([5-30]) History of Present Illness: This is a 69 y/o male with significant medical history of CAD s/p MI and [2146] and [2152] CABG( LIMA to LAD, and Y graft with SVG from the aorta to first OM and diagonal), systolic congestive heart failure (EF-15% [1-/2174]), chronic atrial fibrillation, severe ischemic cardiomyopathy, monomorphic ventricular tachycardia, ventricular fibrillation, biventricular [Company 1543] ICD, PVD s/p left fem-[Doctor Last Name ] bypass who is transferred to CCU s/p VT ablation on [5-30] due to hypotension. . The patient was admitted to [Hospital6 33] on [2174-5-24] with recurrent ventricular tachycardia (while on Sotalol, beta blocker, and ICD) associated with syncope while sitting in his chair at home. Device interrogation revealed an episode of VT that was initially treated unsuccessfully with pacing and required 1 shock of 30 joules. The patient's Sotalol was increased, with beta blocker continued, and his Coumadin was stopped in preparation for VT ablation. The patient denies chest pain, shortness of breath, lightheadedness, dizziness, orthopnea, LE edema or any further episodes of syncope. . In the cath lab, found to have inferoposterior and posterolateral scars, however he is presenting with hypotension. During the procedure two different ventricular tachycardias were induced which degenerated into ventricular fibrilliation and shocked, and both foci were radio frequency ablated. The procedure was done under general anesthesia, and he recieved 2.5 L fluids. The sheath pulled in recovery room. The patient has poor lower extremity pulses at baseline and continues to do so post ablation. He is currently on Dopamine 6 mcg/kg/min, with systolic BPs in 90s. . On review of systems, he denies any prior history of stroke, TIA, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Past Medical History: 1. CARDIAC RISK FACTORS: neg Diabetes, pos Dyslipidemia,(pos) HTN . 2. CARDIAC HISTORY: -CABG: [2146] and [2152] CABG -PERCUTANEOUS CORONARY INTERVENTIONS: [2173-9-6] cardiac catheterization: Occluded LAD, LCX and RCA. LIMA to LAD with minor luminal irregularities. Y graft with SVG from the aorta to first OM and diagonal was aneurismal proximal. Diffuse disease of LIMA to OM. LIMA to diagonal patent. -PACING/ICD: [2168] and [2170] Biventricular ICD-[Company 1543] . 3. OTHER PAST MEDICAL HISTORY: . PMH: HTN Hyperlipidemia Ischemic cardiomyopathy-EF 15% Amiodarone pulmonary toxicity Ventricular tachycardia Ventricular fibrillation [2168] and [2170] Biventricular ICD-[Company 1543] Atrial fibrillation CHF [3-/2170] STEMI [9-/2171] and [10/2171] Respiratory failure [2146] and [2152] CABG [2165] Left calf DVT [2165] [Location (un) 260] Filter [2173-9-6] cardiac catheterization: Occluded LAD, LCX and RCA. LIMA to LAD with minor luminal irregularities. Y graft with SVG from the aorta to first OM and diagonal was aneurismal proximal. Diffuse disease of LIMA to OM. LIMA to diagonal patent. PVD Left fem-[Doctor Last Name ] bypass Ventricular tachycardia ablation [5-30]. . ALLERGIES: Amiodarone-pulmonary toxicity, Spironolactone-gynecomastia (-) Food Allergy (-) Contrast Allergy Social History: (-) CIGS Smoked 1ppd x 48 years. Quit [2152]. Lives with: wife, [Name (NI) 3908] Occupation: Retired electrician. ETOH: Occasional ETOH and denies illicit drug use. Home Services: [Hospital3 ] VNA for weekly visits. Contact person upon discharge: [Name (NI) ] [Name (NI) 6123] (son). His cell phone# is [Telephone/Fax (1) 107692]. Family History: Father, brother and uncle with MI in their early 60's. Physical Exam: Ht: 5 feet 8inches Wt: 123 lbs VS: T=96.6 BP=104/60 HR=70 RR=14 O2 sat= 98% GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, crackles in the middle and lower lung fields bilaterally, 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. Right foot colder to touch than left foot. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: Admssion Labs . [2174-5-30] 11:45AM TYPE-ART PO2-86 PCO2-55* PH-7.27* TOTAL CO2-26 BASE XS--2 INTUBATED-NOT INTUBA [2174-5-30] 11:45AM GLUCOSE-129* LACTATE-0.9 NA+-138 K+-4.4 CL--100 [2174-5-30] 11:45AM freeCa-1.16 [2174-5-30] 07:15AM GLUCOSE-101* UREA N-36* CREAT-1.4* SODIUM-135 POTASSIUM-5.2* CHLORIDE-93* TOTAL CO2-35* ANION GAP-12 [2174-5-30] 07:15AM estGFR-Using this [2174-5-30] 07:15AM WBC-8.3 RBC-4.69 HGB-14.2 HCT-42.3 MCV-90 MCH-30.3 MCHC-33.6 RDW-15.3 [2174-5-30] 07:15AM PLT COUNT-210 [2174-5-30] 07:15AM PT-14.9* PTT-26.7 INR(PT)-1.3* . [2174-5-31] 06:08AM BLOOD WBC-6.8 RBC-4.07* Hgb-12.1* Hct-37.0* MCV-91 MCH-29.7 MCHC-32.7 RDW-15.4 Plt Ct-154 [2174-5-31] 06:08AM BLOOD Plt Ct-154 [2174-5-31] 06:08AM BLOOD Glucose-78 UreaN-19 Creat-0.8 Na-138 K-4.2 Cl-103 HCO3-30 AnGap-9 [2174-5-31] 06:08AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.1 . Discharge Labs . Reports . CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 107693] Reason: eval lung fields [Hospital 93] MEDICAL CONDITION: 69 year old man with h/o CHF, vtach. underwent VT ablation, VF arrested intraop. likely fluid overload. +crackles REASON FOR THIS EXAMINATION: eval lung fields Final Report REASON FOR EXAMINATION: Suspected fluid overload. Portable AP chest radiograph was reviewed with no prior studies available for comparison. The current study demonstrates moderately enlarged cardiac silhouette in a patient after median sternotomy and CABG. The pacemaker defibrillator leads terminate in right atrium, right ventricle, and left ventricular epicardial vein. There is bilateral hilar prominence with some minimal perihilar opacities, findings that might be consistent with mild volume overload. In addition, there are bibasal interstitial opacities that although might represent part of vascular engorgement, may also be attributed to chronic interstitial changes and should be reevaluated after diuresis. Small amount of bilateral left more than right pleural effusion is present. There is no evidence of pneumothorax. DR. [First Name4 (NamePattern1) 2618] [Last Name (NamePattern1) 2619] Approved: MON [2174-5-30] 5:18 PM [2174-6-1] 06:04AM BLOOD WBC-8.6 RBC-4.29* Hgb-13.1* Hct-38.3* MCV-89 MCH-30.6 MCHC-34.3 RDW-15.1 Plt Ct-156 [2174-6-1] 06:04AM BLOOD Plt Ct-156 [2174-6-1] 06:04AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-26 AnGap-14 [2174-6-1] 06:04AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.3 [2174-6-1] 06:04AM BLOOD WBC-8.6 RBC-4.29* Hgb-13.1* Hct-38.3* MCV-89 MCH-30.6 MCHC-34.3 RDW-15.1 Plt Ct-156 [2174-6-1] 06:04AM BLOOD Plt Ct-156 [2174-6-1] 06:04AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-26 AnGap-14 [2174-5-31] 06:08AM BLOOD Glucose-78 UreaN-19 Creat-0.8 Na-138 K-4.2 Cl-103 HCO3-30 AnGap-9 [2174-6-1] 06:04AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.3 [2174-5-30] 11:45AM BLOOD Type-ART pO2-86 pCO2-55* pH-7.27* calTCO2-26 Base XS--2 Intubat-NOT INTUBA [2174-5-30] 11:45AM BLOOD Glucose-129* Lactate-0.9 Na-138 K-4.4 Cl-100 Brief Hospital Course: 69 y/o male with ischemic cardiomyopathy, Biventricular [Company 1543] ICD, recurrent ventricular tachycardia and syncope referred for ventricular tachycardia ablation and presenting with hypotension. . # Hypotension- The patient had systolic blood pressures in the 90's (while he was on Dopamine drip) which is lower than baseline on presentation to the CCU. A potential cause could have been general anesthesia he tolerated the procedure underlying poor baseline systolic function secondary to systolic congestive heart failure. His baseline systolic blood pressures are usually between 95-110 as per patient. We monitored hemodynamics while in the ICU with goal MAPs > 65. We held home eplerenone, isosorbide, lisinopril, torsemide, and oxycodone overnight pending resolution of blood pressures. He wa weaned off his dopamine drip and tolerated well with increase in systolic blood pressure to 100-110. . # Ventricular tachycardia- Patient with monomorphic ventricular tachycardia, now with ICD in place. S/p catheter ablation with RFA of 2 foci. Will continue home sotalol and metoprolol as adjunctive therapy. Most likely caused by arrythmic substrate from past myocardial infarctions. We monitored hemodynamics overnight which remained stable. The patient remained in AV paced rhythm. . #Atrial fibrillation/ LV thrombus-Stopped coumadin for case. - We gave lovenox 1mg/kg [Hospital1 ]. and started warfarin home dose as well fr anticoagulation. . # Respiratory Acidosis - Patient did not look short of breath on presentation. In fact, the ABG sample which indicates respiratory acidosis was done intra operatively under anesthesia . The patient never felt short of breath in CCU and his O2 saturation on room air was [Last Name (un) 8585] 96&. . #Left fem-[Doctor Last Name ] bypass/PVD- Had poor lower extremity pulses which is consistent with baseline (1+ Left DP and 1+ Right DP) . We Considered vascular consult if patient has cold extremities or any other signs of very poor perfusion. However he was found to have pulses on [Last Name (un) ] bilaterally in lower extremities, during his stay in the CCU. . #Ventricular fibrillation - has [2168] and [2170] Biventricular ICD-[Company 1543] . #HTN- Continued home medications . #Hyperlipidemia-Continued home medications . #Ischemic cardiomyopathy-EF 15% on last echocardiogram [12/2173] -[2146] and [2152] CABG -[2173-9-6] cardiac catheterization:Occluded LAD, LCX and RCA. LIMA to LAD with minor luminal irregularities.Y graft with SVG from the aorta to first OM and diagonal was aneurismal proximal. Diffuse disease of LIMA to OM. LIMA to diagonal patent. . #CHF-Continued home medications, but held Eplerenone,Torsemide, and Isosorbide, for now because patient is hypotensive . He was discharged on home dose of Lisinopril. -Checked I and O's with the patient having adequate urine output. . FEN: Cardiac diet ACCESS: PIV's PROPHYLAXIS: -DVT ppx with pneumoboots on the floor, started lovenox and warfarin -Pain management with tylenol -Bowel regimen with senna/colace . CODE: Full. COMM: DISPO: Regular floos Medications on Admission: DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - one Tablet(s) by mouth daily EPLERENONE [INSPRA] - (Prescribed by Other Provider) - 25 mg Tablet - one Tablet(s) by mouth daily ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg Tablet Sustained Release 24 hr - one Tablet(s) by mouth daily LISINOPRIL - (Prescribed by Other Provider) - 2.5 mg Tablet - one Tablet(s) by mouth daily LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - one Tablet(s) by mouth daily at bedtime METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg Tablet Sustained Release 24 hr - 0.5 (One half) Tablet(s) by mouth daily OXYCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5 mg-325 mg Tablet - one Tablet(s) by mouth every 4 hours for shoulder pain POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq Capsule, Sustained Release - 3 Capsule(s) by mouth daily PRAVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - one Tablet(s) by mouth daily SOTALOL - (Prescribed by Other Provider) - 160 mg Tablet - one Tablet(s) by mouth twice a day TORSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth twice a day WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - one Tablet(s) by mouth daily as directed by Dr. [Last Name (STitle) ]. LD [2174-5-25] pre procedure. Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - one Tablet(s) by mouth daily CALCIUM CARBONATE - (Prescribed by Other Provider) - 600 mg (1,500 mg) Tablet - one Tablet(s) by mouth daily MAGNESIUM OXIDE - (Prescribed by Other Provider) - 400 mg Tablet - one Tablet(s) by mouth daily . Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Sotalol 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Pravastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringes Subcutaneous Q12H (every 12 hours): Please self adminster as taught. Disp:20 syringes Refills:0 7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain . Disp:30 Tablet(s) Refills:0 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation . 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: [11-20] tablet Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Post Ventricular Tachycardia ablation Discharge Condition: Medically stable to be discharged Discharge Instructions: It was a pleasure to care for you as your doctor. . You were brought to the hospital because of a cardiac arrythmia which was causing you symptoms of dizziness. You underwent a procedure to get rid of the 2 origins on your heart of this abnormal heart beat. You tolerated this procedure well. You initially had a low blood pressure however your pressure increased and you are medically stable to be discharged. . We made a few changes to the medications you were taking before coming to the hospital. We added: Enoxaparin Sodium 30 mg SC twice per day (for 10 days). . We discontinued the following two medications because of the concern of lowering your blood pressure too much: Eplerenone, Torsemide and Isosorbide. You should discuss these three medications with your primary care doctor, about potentially restarting them at a later date. . You will need to follow up with your cardiologist to discuss your health management as well as checking your INR; please follow up with the following outpatient appointments: . Provider:[Last Name (NamePattern4) ]. [Last Name (STitle) ] Date: [6-3] anytime for INR check Phone Number [0-0-] . Dr.[Last Name (STitle) ] Date: [6-6] 1:30PM Phone Number [0-0-] Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Provider:[Last Name (NamePattern4) ]. [Last Name (STitle) ] Date: [6-3] anytime for INR check Phone Number [0-0-] . Dr.[Last Name (STitle) ] Date: [6-6] 1:30PM Phone Number [0-0-]	[ "2762", "4280", "41401", "42731", "412", "4019", "496", "25000", "2724", "V1582", "V5861" ]
Admission Date: [2193-3-8] Discharge Date: [2193-3-16] Date of Birth: [2128-5-4] Sex: F Service: CARDIOTHORACIC Allergies: Erythromycin Base Attending:[First Name3 (LF) 4679] Chief Complaint: left lower lobe lung cancer Major Surgical or Invasive Procedure: [2193-3-8] 1. Left thoracotomy. 2. Completion left pneumonectomy. 3. Buttressing of bronchial stump with intercostal muscle. History of Present Illness: The patient is a 64-year-old woman who underwent a left upper lobectomy many years ago for stage 1 non-small cell lung cancer. In follow up she developed a deep lesion in the left lower lobe that on biopsy was positive for non-small cell lung cancer. We felt that this was a new primary cancer and therefore recommended a completion pneumonectomy. Staging workup was negative for metastatic disease and her pulmonary function was acceptable for the proposed operation. Past Medical History: 1. Thyroid cancer (papillary carcinoma), status post resection on [2180-6-30] and post-operative radioactive iodine; 2. Stage I nonsmall cell lung cancer (adenocarcinoma), status post left upper lobe lobectomy on [2180-6-30]; 3. Hypertension for over 5 years; 4. Hyperlipidemia for over 5 years; 5. Osteopenia/osteoporosis; 6. Possible asymptomatic chronic obstructive pulmonary disease. Social History: The patient is retired and was a former accountant. The patient started smoking cigarettes at age 15, and smoked 2 packs per day up to age 41. This places her at an approximate 50-pack-year history of smoking. There is no history of significant alcohol intake. There is no history of exposure to asbestos. There is no history of exposure to heavy chemicals or radiation. Family History: Has family history of cancer. Father had lung cancer. Mother had [Name2 (NI) 499] cancer as did maternal grandmother. [Name (NI) ] other cancers in the family. Physical Exam: Vitals: T 98.5, HR 74, BP 110/50, RR 20, O2 96% Gen: A&O, NAD CV: RRR Pulm: Decreased breath sounds on left. R CTA. Incision c/d/i without erythema/drainage/fluctuance Abd: S/NT/ND Ext: w/d, no edema Pertinent Results: [2193-3-15] 07:10AM BLOOD Hct-28.6* [2193-3-14] 07:35AM BLOOD WBC-11.1* RBC-2.77* Hgb-8.6* Hct-24.7* MCV-89 MCH-31.0 MCHC-34.8 RDW-15.5 Plt Ct-275 [2193-3-11] 09:32AM BLOOD PT-12.3 INR(PT)-1.1 [2193-3-14] 07:35AM BLOOD Glucose-100 UreaN-10 Creat-0.5 Na-137 K-4.2 Cl-100 HCO3-30 AnGap-11 [2193-3-11] 03:04AM BLOOD CK-MB-5 cTropnT-0.23* [2193-3-9] 02:10PM BLOOD CK-MB-8 cTropnT-<0.01 [2193-3-14] 07:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1 . CXR ([2193-3-15]): FINDINGS: The patient is status post left pneumonectomy. Slight increase in amount of pleural fluid since the prior study, with major air-fluid level now at the left sixth rib level. Small loculations of gas in the mid and lower left hemithorax has slightly decreased as well, and subcutaneous emphysema has slightly decreased. Within the right lung, ground-glass and reticular opacities at the right upper lobe and more confluent opacity at the right base have slightly improved. Small right pleural effusion is unchanged. Brief Hospital Course: The patient was admitted to the Thoracic Sugery service after elective operation. Her post-operative course is as follows: . Neuro: Epidural was placed pre-operatively which provided adequate pain control. The epidural was removed POD 4 and she was transitioned to oral pain medications with adequate control. . CV: The patient's vital signs were routinely monitored. On POD 1 she developed hypotension with systolic pressures in the 60-70 range. EKG showed lateral T-wave inversions. Cardiology was consulted and ECHO was obtained. This demonstrated EF >55%, no wall motion abnormalities, mild dilated RV with moderate PA HTN. She was started on aspirin per cardiology recommendations. She was started on Neo for blood pressure support and was given Albumin as well. On POD 2 she went into Afib with RVR which resolved after IV metoprolol was given. Serial cardiac enzymes were checked with peak trop of 0.11 likely demand ischemia, and cardiac enzymes trended down. Cardiology recommended continuance of medical management. She went back into AFib on POD 3 which resolved with metoprolol. A repeat ECHO suggested low intravascular volume and a central line was placed to assist with fluid management. She was given blood and fluids to maintain intravascular volume and the Neo was weaned off on POD 4. She remained hemodynamically stable thereafter for the remainder of the hospitalization. On POD 6 she was noted to become dizzy while standing up and was orthostatic. Hematocrit was 24 and she was transfused 1 unit of blood. On POD 7 she noted some chest discomfort after attempting ambulation with PT. An EKG was checked and was unchaged and the discomfort resolved spontaneously. She had no further episodes of chest discomfort. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. Her chest tube was removed after drainage was at an acceptable rate. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout this hospitalization. She required oxygen throughout her stay with low room air ambulatory saturations. She was discharged on home oxygen therapy. . GI/GU/FEN: Post operatively, the patient was made NPO with IVF. The patient's diet was advanced to regular on POD 4, which was tolerated well. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization, and repleted when necessary. . ID: The patient's white blood count and fever curves were closely watched for signs of infection. . Endocrine: The patient's blood sugar was monitored throughout this stay. She was continued on her home thyroid replacement medication. . Hematology: The patient's complete blood count was examined routinely. She received 2 units of blood on POD2 for hematocrit of 24, with good response and then 1 unit on POD 6. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge, the patient was doing well, afebrile with stable vital signs with normal O2 sat on oxygen. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. She was evaluated by PT who recommended home PT which the patient agrees to. She was discharged to home with clinic follow up. She will wear home O2, and has home PT and VNA services set up. Medications on Admission: ATENOLOL-CHLORTHALIDONE, ATORVASTATIN, LEVOTHYROXINE 88', LORAZEPAM, OMEPRAZOLE, ONDANSETRON, SERTRALINE, CaCO3, CoQ10, colace Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK (Six Times a Week). Disp:180 Tablet(s) Refills:2 6. levothyroxine 88 mcg Tablet Sig: 0.5 Tablet PO QSUN (every Sunday). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 11. home O2 low continuous O2, pulse dose for portability. Diagnosis: left lung cancer s/p left pneumonectomy Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Left lung cancer s/p left pneumonectomy. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital for lung surgery and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * wear your oxygen as provided * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol 650 mg every 6 hours in between your narcotic. If your doctor allows you may also take Ibuprofen to help relieve the pain. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk 4-5 times a day and gradually increase your activity as you can tolerate. Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2193-3-28] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please report 30 minutes prior to your appointment to the Radiology Department on the [Location (un) ] of the [Hospital Ward Name 23] Clinical Center for a chest xray.	[ "9971", "42731", "4019", "2724", "V1582" ]
Admission Date: [2201-12-4] Discharge Date: [2201-12-11] Date of Birth: [2139-12-17] Sex: F Service: CARDIOTHORACIC Allergies: Seroquel / Milk Of Magnesia Attending:[First Name3 (LF) 5790] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: [2201-12-4] Tracheoplasty [2201-12-7] Bronchoscopy History of Present Illness: Ms. [Known lastname 45465] is a 61 year-old female with severe TBM complicated by recurrent pneumonias. She has had interval evaluation for swallowing difficulties. She was also seen by [First Name8 (NamePattern2) ] [Doctor Last Name ] of Cardiology on [8-14]. Dr.[Last Name (STitle) ] stated that there is no need for any further testing prior to her undergoing tracheobronchoplasty as she has stable symptoms. She recommended that she remain on statin and Norvasc throughout the perioperative period and aspirin be discontinued for surgery and resumed when safe from the surgical standpoint. Currently, she is at her baseline. She stills gets SOB walking 10 to 15 feet. Past Medical History: Severe TBM Schizophrenia Anxiety/depression H/o sexual abuse Asthma COPD S/p ASD repair [2151] S/p L hip replacement [2191] S/p multiple R leg fractures [2191] Social History: Lives in group home in [Location (un) ] ("[Doctor First Name ] House"). Lives with a roommate. Mother lives nearby in family home; they are very close and see each other 1-2x/week. She has a h/o tobacco 3ppd x 10years, quit 10 years ago. Denies EtOH or other drug use. Has a h/o sexual abuse while in a hospital in the [2161]'s, and has been seeing the same psychiatrist ([First Name8 (NamePattern2) 9485] [Last Name (NamePattern1) ] [Telephone/Fax (1) 100807]) for 30 years. Family History: GM died of lung ca, mother survivor of lung ca Physical Exam: VS: T: 98.9, P: 92, BP: 124/70, 18, 96% 1LNC Physical Exam: Gen: pleasant in NAD sitting in chair, with baseline facial discoloration Lungs: clear bilaterally t/o to ausc. Chest: right thoracotomy incision healing without redness, purulence or drainage. CV: RRR, S1, S2, no MRG or JVD Abd: Active BS x 4 quadrants, distended but non tender to palpation Ext: warm, pulses intact, without edema. Pertinent Results: [2201-12-10] 06:25AM BLOOD WBC-9.2 RBC-3.35* Hgb-9.4* Hct-28.7* MCV-86 MCH-28.2 MCHC-32.8 RDW-14.8 Plt Ct-487* [2201-12-10] 06:25AM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-24 AnGap-16 CXR [2201-12-10] Impression: 1. Increased opacification of the left base likely secondary to atelectasis. 2. No significant change in the right basilar opacity. 3. Multiple loops of distended bowel, better seen on the lateral projection. Brief Hospital Course: Ms. [Known lastname 45465] was admitted on [2201-12-4] where she underwent thoracic tracheoplasty with mesh right mainstem bronchus/bronchus intermedius bronchoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, flexible bronchoscopy and bronchoalveolar lavage, by Dr. [Last Name (STitle) ]. Please see operative report for full details. The patient recovered in the Intensive Care unit. She was extubated post operative day 0. She had an epidural which was managed and followed by acute pain service, discontinued [2201-12-9]. On [2201-12-7] she underwent bronchoscopy for aspiration of secretions. The patient was transfered to the floor on [2201-12-8], undergoing further therapeutic bronchoscopy for secretions on [2201-12-9]. The patient had aggressive pulmonary toilet with chest physiotherapy. Her foley was dc'd after her epidural, with two straight catheterizations for retained urine, last [2201-12-11] at 3am, although she has voided well since. Her main issue is constipation. She had not had a bowel movement for days, despite aggressive bowel regimine. This is an ongoing issue for the patient. She did however have 4 small BM's on the date of discharge. She has tolerated a regular diet. Regarding her mood: the patient has been appropriate and resumed on her psych medications. She should follow up with her psychiatrist when discharged home. Physical therapy saw the patient while on the floor and recommended rehab, which she is cleared to go to. The patient was started on levaquin for possible mediastinitis which is due to end [2201-12-13]. It is noted that the patient is cleared by insurance for a less than thirty day rehab stay, per our case manager. Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours): Take until [2201-12-13] last dose . 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours). 3. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for secretions. 4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Chlorpromazine 100 mg Tablet Sig: Twelve (12) Tablet PO QHS (once a day (at bedtime)). 15. Buspirone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for groin and breast area. 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). units 21. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day) as needed for anxiety. 22. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal once a day as needed for constipation. 23. Magnesium Citrate 1.745 g/30mL Solution Sig: Three Hundred (300) ML PO once a day as needed for constipation. 24. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 25. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 26. Aspirin 81 mg po daily Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare-[Location (un) 86] Discharge Diagnosis: 1. Tracheobronchomalacia 2. COPD 3. GERD 4. Schizophrenia 5. Osteoarthritis 6. Skin discoloration from longtime thorazine use 7. Anxiety 8. Asthma 9. PTSD 10. Chronic constipation. Discharge Condition: stable Discharge Instructions: Ambulate with physical therapist or assistant 3 times per day. Use your incentive spirometer 10 times every hour. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ] in two weeks. [Doctor Last Name 2048] with Dr.[Name (NI) 14679] office will call to arrange appointments with your rehab. Eat nothing after midnight the night before to anticipate a bronchoscopy. Dr.[Name (NI) 14679] office number: [Telephone/Fax (1) 10084] Dr.[Name (NI) 2347] office number: [Telephone/Fax (1) 2348] Completed by:[2201-12-11]	[ "5180", "53081", "2449", "V1582" ]
Admission Date: [2183-8-24] Discharge Date: [2183-8-28] Service: MED Allergies: Celebrex / Pseudoephedrine Attending:[Last Name (NamePattern1) 293] Chief Complaint: Fever Major Surgical or Invasive Procedure: PICC line placed in L arm without complications. History of Present Illness: [Age over 90 ]yo F s/p tracheostomy 3 weeks ago for respiratory failure who was brought from [Hospital ] Rehab after developing a fever to 102.5 with thick and foul smelling secretions and decreased 02 sats to 87-89%. The staff were unable to place a PMV valve in her trach as well. Her vent settings were PS10/PEEP5/FiO230%. The patient reports feeling tired recently. She has also had abdominal pain for the past several weeks, worse on the L side. A KUB done that showed "dilated bowel loops." She describes her recent abdominal pain as sharp, intermittent, not associated with tube feeds, now resolved. She had a BM on the day PTA. ROS: No CP/SOB, + cough x several weeks, no N/V, reports normal BM's. Foley catheter in place. In the ED, she received vancomycin 1gr, flagyl 500mg, morphine 2mg IV. Past Medical History: Respiratory failure s/p trach placement 3 weeks ago H/o ARF AS HTN H/o fall B total hip replacements Aneia Dysphagia/GERD OA Osteoporosis S/p wrist fracture GERD Social History: No EtOH, no tobacco. Walks with a walker. Physical Exam: T100.0 HR79 BP116/52 RR18 O2sat98% 30%FiO2 Pleasant, elderly female, NAD, A+Ox3 EOMI, PERRL, OP-clear, MMM, neck supple, no lymphadenopathy Erythema and creamy discharge at trach stoma site. No fluctuance. Stoma site macerated. RR SEM at LLSB Decreased BS at L base, + rhonichi, no wheezes or crackles Obese, soft, NT, ND. +BS - hypoactive. G tube in place, site clean, dry, and intact. Extremities with no edema, 2+distal pulses. No rashes noted. Neruo grossly intact. Lines - L subclavian triple lumen catheter. Pertinent Results: [2183-8-24] 12:40AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM [2183-8-24] 12:40AM URINE RBC-[6-12]* WBC-[6-12]* BACTERIA-MANY YEAST-NONE EPI-0-2 [2183-8-24] 12:40AM WBC-14.9* RBC-3.38* HGB-11.3* HCT-33.3* MCV-98 MCH-33.3* MCHC-33.9 RDW-15.3 [2183-8-24] 12:40AM NEUTS-90.0* BANDS-0 LYMPHS-4.4* MONOS-3.6 EOS-1.6 BASOS-0.3 [2183-8-24] 12:40AM PLT COUNT-274 [2183-8-24] 12:40AM GLUCOSE-135* UREA N-41* CREAT-1.3* SODIUM-132* POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-28 ANION GAP-13 [2183-8-24] 12:40AM ALT(SGPT)-50* AST(SGOT)-35 LD(LDH)-187 ALK PHOS-110 AMYLASE-71 TOT BILI-0.5 [2183-8-24] 12:40AM LIPASE-30 [2183-8-24] 12:40AM TOT PROT-6.6 ALBUMIN-3.6 GLOBULIN-3.0 [2183-8-24] 12:41AM LACTATE-1.4 Brief Hospital Course: 1. The patient had a CXR suggestive of a LLL PNA, although it was unclear if this was a new process or a persistent old process. Sputum showed 3+GPC in pairs and clusters, and sensitivity showed MRSA. Blood cultures also grew MRSA. She was started on vancomycin on [2183-8-23], for a 14 day course. (Day of discharge is day 5 of 14 days.) At the time of discharge, the patient had been afebrile for several days. 2. Trach stoma infection/cellulitis. MRSA was grown from trach site and the patient was placed on vancomycin as above. Her trach was replaced on [2183-8-26] with improved fit. 3. The patient had a Foley catheter-related UTI. Her Foley was changed, and acinetobacter (pan sensitive) and enterococcus (sensitivities pending) was treated with ciprofloxacin, in addition to the vancomycin, for a 14 day course. On the day of discharge she was on day 3 of a 14 day course of ciproflox. 4. Abd pain was of unclear etiology, possibly a resolved partial SBO. The patient did not complain of abdominal pain during her admission. Tube feeds were restarted, which she tolerated well. 5. GI: Intermittent diarrhea. C. diff was negative. Lactulose was stopped while the patient had diarrhea. 6. Chest pain: Had very brief episode of CP on [8-24] evening --> EKG neg, enzymes neg. No interventions done. 7. A right shoulder anterior dislocation was seen on CXR. Ortho was consulted and recommended a splint for comfort. 8. Multiple foley catheters were placed during the patient's stay due to poor fit, the most recent on [2183-8-26]. She began to have hematuria after this placement, likely due to foley trauma. On [2183-8-27], the hematuria began to worsen, and SQ heparin was held while bleeding. The hematuria improved. 9. Lines: PIV. PICC line placed ([8-27]). 10. Prophylaxis: heparin SC (held on [2183-8-27]), PPI, compression stockings. 11. Full code. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO QD (once a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 9. Calcium Carbonate 1250 mg/5 mL Suspension Sig: Ten (10) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID PRN as needed for constipation. 12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 13. Naproxen 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for pain. 14. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 10 days. 15. Lorazepam 2 mg/mL Syringe Sig: [1-3] Injection Q4H (every 4 hours) as needed. 16. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed. 17. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 7 days. Discharge Disposition: Extended Care Discharge Diagnosis: Pneumonia, Urinary tract infection, bacteremia, tracheostomy site cellulitis Discharge Condition: Stable Discharge Instructions: Return to hospital if develop fevers, difficulty breathing, change in mental status, chest pain or any other critical symptoms. Followup Instructions: No follow up necessary beyond regular appointments with PCP. On the day of discharge ([2183-8-28]), the patient is on day 5 of 14 of vancomycin, and day 3 of 14 of ciprofloxacin.	[ "4241", "5990" ]
Admission Date: [2141-8-20] Discharge Date: [2141-9-1] Date of Birth: [2072-1-5] Sex: F Service: SURGERY Allergies: Prednisone / Erythromycin / Sulfa (Sulfonamides) / Fosamax Attending:[Last Name (NamePattern1) 4659] Chief Complaint: Colicky abdominal pain. Major Surgical or Invasive Procedure: Exploratory laparotomy, biopsy of mesenteric nodules x2, resection of ischemic ileum and primary anastomosis, biopsy of pancreatic mass. History of Present Illness: Ms. [Known lastname 32636] was transferred from [Hospital3 7571]to [Hospital1 18] on [2141-8-20]. She has been having 2-3 weeks of abdominal pain after eating. Her pain worsened the evening of [2141-8-19]. A CT scan obtained at [Hospital3 7571]was concerning for ischemia small bowel and a pancreatic mid body mass. The patient was transferred to [Hospital1 18]. Past Medical History: SVT Hypercholesterolemia Peptic ulcer disease Atrial fibrillation H/O XRT for bronchitis at age 2, now with chronic wound on back Social History: She denies alcohol abuse. She has a 30 pack year history of smoking, but quit in [2134]. Family History: Non-contributory Physical Exam: Temp 98.6 HR 113 BP 126/45 RR 15 O2 sat 97% on RA Gen: obviously in pain CV: regular rhythm, tachy Pulm: clear bilaterally. Large open wound on mid back with chronic XRT changes surrounding it. No infected. Abd: diffuse abdominal tenderness, rigid with guarding and rebound. Distended. No masses palpable. Pertinent Results: Pathology DIAGNOSIS: 1. Mesenteric node (A): Fibroadipose tissue with metastatic moderately differentiated adenocarcinoma; see note #1. No definite lymph node seen. 2. Mesenteric nodule (B): Fibroadipose tissue, no malignancy identified. 3. Proximal and mild ileum (C-L): Small bowel with mucosal and transmural hemorrhagic infarction. Margins are viable. 4. Distal ileum (M-O): Small bowel with mucosal ischemia present at one of two margins. 5. Pancreatic mass biopsy (P): Moderately differentiated adenocarcinoma; see note #2. Note #1: There is no unequivocal carcinoma present on the original frozen sections. Note #2: The tumor and the metastasis represented in specimens 1 and 5 are positive for cytokeratin 7; negative stains include CK20, ER, PR, mammoglobin, and GCDFP. These findings suggest pancreaticobiliary origin. However, other primary sites cannot be completely excluded. Echocardiogram Conclusions: The left atrium is normal in size. 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%). There is a mild (20mmHg peak) resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [2141-8-20] 08:50AM BLOOD WBC-28.1# RBC-4.52 Hgb-14.6 Hct-42.4# MCV-94 MCH-32.2 MCHC-34.3 RDW-13.7 Plt Ct-258 [2141-8-31] 05:30AM BLOOD WBC-14.2* RBC-2.80* Hgb-8.8* Hct-26.5* MCV-95 MCH-31.5 MCHC-33.4 RDW-16.5* Plt Ct-343 [2141-8-20] 08:50AM BLOOD Glucose-242* UreaN-20 Creat-1.1 Na-141 K-4.2 Cl-106 HCO3-16* AnGap-23* [2141-8-31] 05:30AM BLOOD Glucose-121* UreaN-29* Creat-0.6 Na-138 K-3.7 Cl-105 HCO3-26 AnGap-11 [2141-8-20] 08:41AM BLOOD Lactate-8.9* [2141-8-29] 08:03PM BLOOD Lactate-1.1 Brief Hospital Course: Ms. [Known lastname 32636] was transferred to [Hospital1 18] from [Hospital3 7571]hospital after a CT obtained there was concerning for ischemic small intestine. Her lactic acid was 8.9 on admission. After fluid resusitation, she was immediately taken to the operating room for an exploratory laparotomy where she was found to have infarcted small bowel. This section of small bowel was resected and a primary anastomosis was performed. Two mesenteric nodule were biopsied as well as the pancreatic mid body mass. Pathology ultimately revealed metastatic pancreatic carcinoma. Neurological: She is alert and oriented and her mental status appears to be back to baseline. Cardiovascular: On POD1 she became hypotensive and required pressors, which were quickly weaned. She also went into atrial fibrillation with a rapid ventricular response, which required a diltiazem drip. Her rate was well controlled on diltiazem and she converted back to a normal sinus rhythm. She was transitioned to IV then PO Lopressor. Respiratory: She was extubated on POD1 but remained very tenuous. She has increased work of breathing and was requiring an increased oxygen concentration to maintain normal saturations. Her respiratory status slowly improved with aggressive diuresis. She was weaned over one week to nasal canula and eventually weaned to room air. Gastrointestinal: Her infarcted small bowel was removed and a primary anastomosis was performed. Her lactic acid normalized on POD1. She remained NPO for a number of days post-operatively. Her bowel function returned and she was slowly advanced to a regular diet. She did require 3 days of TPN for nutritional support before she was switched to a PO diet. Skin: She has a chronic back wound secondary to radiation therapy received as a child. This wound requires daily dressing changes with Aquacel AG. Heme: She was started on anticoagulation due to the unknown etiology of her small bowel ischemia. It is suspect that this was caused by a hypercoagulable state from her malignancy. She and her husband have been given Lovenox teaching, so they can administer this medication themselves. Medications on Admission: Albuterol Atenolol 25mg [Hospital1 ] Metformin Reglan Omeprazole Discharge Medications: 1. Enoxaparin 100 mg/mL Syringe Sig: One (1) 100mg/ml syringe Subcutaneous Q12H (every 12 hours): Empty 10ml out of syringe before injecting. . Disp:60 100mg/ml syringe Refills:2 2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:2 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Nahoba VNA Discharge Diagnosis: Infarcted ileum, now status post small bowel resection with primary anastomosis. Metastatic pancreatic carcinoma. Discharge Condition: Good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [11-20] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. Take Motrin as needed for pain. Followup Instructions: Follow up with your scheduled appointments after discharge. Follow up with Dr. [Last Name (STitle) ] in [2-7] weeks. Call her office at ([Telephone/Fax (1) 15665] to schedule your appointment. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ] MD, [MD Number(3) 4661]	[ "42731", "2720" ]
Admission Date: [2197-11-12] Discharge Date: [2197-11-18] Date of Birth: [2131-11-15] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: colonoscopy rigid bronchoscopy (with stent placement) mechanical ventilation History of Present Illness: 65 yo woman with hx of stage 4 esophageal cancer s/p two sents, chemo, xrt who presented a month ago to OSH where she had LLL MRSA pna and was intubated. Found to have severe tracheal stenosis and couldn't be extubated. She went to [Hospital1 ] House where she has been on a vent for the past few weeks. Per report a [Hospital1 ] pulmonologist saw her and said they would stent the trachea. Wed she had melena, increased volume until yesterday with hct of 27, got 2u prbc, hct up to 39 but she continued to pass clotts and was tachy. Her BP was stable. Also presented today with CP, EKG is sinus tach with PACs. She was on solumedrol as outpatient for unknown reason. Past Medical History: Paroxysmal atrial fibrillation VRE, MRSA Hypothyroid Social History: Supportive daughter (health care proxy), son-in-law. Pt is former heavy smoker. Family History: Non-contributory Physical Exam: Gen: intubated,sedated female +ETT +Foley +PEG +Permacath HEENT: MMM,NC/AT CV: Nl s1/s2, no m/r/g Pul: +low pitched breath sounds, good a/m b/l Abd: soft,nt,nd, +bs Ext: wasted, w/wp Pertinent Results: [2197-11-12] 08:20PM PT-13.9* PTT-21.3* INR(PT)-1.2 [2197-11-12] 08:20PM GLUCOSE-119* UREA N-14 CREAT-0.2* SODIUM-134 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-26 ANION GAP-16 [2197-11-12] 08:20PM BLOOD WBC-3.9* RBC-3.84* Hgb-12.5 Hct-35.0* MCV-91 MCH-32.6* MCHC-35.8* RDW-14.9 Plt Ct-121* [2197-11-17] 04:15AM BLOOD WBC-5.8# RBC-3.32* Hgb-10.5* Hct-31.1* MCV-94 MCH-31.6 MCHC-33.7 RDW-15.2 Plt Ct-93* Brief Hospital Course: Pt was admitted on [11-12] with a GI bleed. Pt was evaluated by GI. The pt was prepped with golytely and a colonoscopy was performed. Two polyps were found, one of which was hemorrhagic in the sigmoid. The decision was made to perform a sigmoidoscopy one the patient was extubated. The patient was also evaluated by interventional pulmonology for tracheal stent placement. Ms. [Known lastname 42290] had a history of tracheoesophageal fistula. The decision was made to perform a rigid bronchoscopy and to place a stent so that she could be extubated. In the OR, a large defect in her trachea was visualized. Four stents were placed. Because of the extent of her repair, it was recommended that she should not be re-intubated. After a discussion with the family about her overall prognosis, the patient was made DNR/DNI. On [11-16] the patient was extubated. She was extremely uncomfortable with respiratory rate in the 30's. After another discussion with her family, the decision to place the patient on comfort measures only. A morphine drip was started and titrated to comfort. On [11-18] at around 6am the patient expired. The family was notified. Discharge Disposition: Home Facility: expired Discharge Diagnosis: esophageal cancer respiratory failure tracheoesophageal fistula lower gi bleed Discharge Condition: expired	[ "42731", "496", "2449", "25000" ]
Admission Date: [2156-12-22] Discharge Date: [2157-1-24] Date of Birth: [2128-3-22] Sex: F Service: MEDICINE Allergies: Penicillins / Haldol / Compazine / Desipramine / Chlorpromazine / Imipramine / Zoloft / Shellfish Derived Attending:[First Name3 (LF) 4654] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: 1. Intubation 2. Transesophageal ECHO 3. Right PICC line placement 4. Left PICC line placement History of Present Illness: Ms. [Known lastname ] is a 28 year old morbidly obese female with a history of asthma and of DVT/PE presenting with a chief complaint of chest pain. She was recently discharged after an ICU stay. She was admitted during that stay for this chest pain. PE and ischemia were ruled out as causes of her chest pain, however, her hospital course was complicated by an episode of hypercarbic respiratory failure and an episode of respiratory alkalemia, both requiring intubation. She complained of [2158-7-18] chest pain throughout her hospital stay. A thorough history and physical exam, EKG, Cardiac Enzymes, Echocardiogaphy (TTE & TEE), breast discharge cultures, blood cultures, chest x-rays, CT scan, abdominal ultrasound, and CT failed to discover an organic etiology of her pain. A comprehensive review of outside hospital records from [Hospital3 ], Caritas [Hospital3 ], Caritas [Hospital3 ], and [Hospital6 ] indicated that the she has chronically complained of unexplained chest pain in the past 6 months. Psychiatry was involved in her care and during her stay lithium was discontinued d/t polyuria and incontinence, risperdal was converted to abilify because of hyperprolactinemia. She was d/c'd to Shattock on [2156-12-16]. . At [Hospital1 ], she intermittently used her BIPAP. She complained of generalized sharp chest pain and SOB on [2156-12-19], EKG showed no changes, CXR was unremarkable, and Ddimer was 325. She spiked a fever on [2156-12-19]. Blood cultures were drawn and she was placed on vancomycin because of her history of MRSA. Staph simulans and enterococcus avium were grown from the PICC line. She was switched to daptomycin 1100 mg IV daily because the enterococcus was vancomycin resistant, but she refused the daptomycin. Her PICC was removed on [2156-12-22]. On [2156-12-21], a maculopapular rash was noted on her left maxilla and she complained of blurry vision. Vision was grossly intact at that time and there were no noted concerning physical findings. She refused any topical and oral/IV antibiotics per report. She denied any pain with EOM. She reported "blurriness" in her left eye. . Per report, she did not like her care at [Hospital1 ] and left AMA on the day of presentation. However, in the cab ride home, she developed chest pain and reported to the [Hospital1 18] ED. Her chest pain was similar to previous episodes, stretched across her left and right chest, radiated to her right shoulder, and was associated with N/V. She denied diaphoresis. She reported some worsening DOE over the last few days. . ED vitals: 100.0 HR 97 101/34 92% on 4L RR 20 CXR was poor quality and repeat was recommended. Her EKG had stable abnormalities from previous. Past Medical History: 1. Borderline personality disorder 2. Mood Disorder, NOS 3. History of self-mutilation 4. History of DVT/PE 5. Obesity hypoventilation vs. sleep apnea 6. Asthma 7. Urinary Incontinence 8. History of hypercarbic respiratory failure 9. Obesity 10. History of suicidal ideation with multiple past attempts 11. History of MRSA cellulitis 12. History of Pneumonia 13. History of Bacteremia Social History: Non-smoker, no IV drug use but does have a history of marijuana use. She has a history of alcohol abuse with DTs and withdrawal, occasional current use. Only child, raised by IV drug addict, physically abusive parents until age 8 when taken into DSS custody. States she was "mad at the world" and set fires. Was psychiatrically hospitalized and grew up between [Doctor Last Name ] homes, residential facilities, and inpatient psychiatric hospitals. Remained institutionalized in various settings including years in intermediate care at [Hospital6 4331]. One year ago, tried it on her own and describes struggling since being outside of a group home or other institutionalized setting. She has spent much of the past year bouncing between medical and psychiatric institutions, often creating medical complaints while in psychiatric settings to move to medical units. Of note, the anniversary of mother's death is [12-10] and the anniversary of her father's death is [8-13]. She generally psychiatrically decompensates and becomes suicidal on these dates. Family History: Parents deceased; otherwise noncontributory. Physical Exam: Vitals: T 99.3, HR 91, BP 102/52, 95% 2L NC General: Obese, NAD, laying flat in bed HEENT: NC/AT, PERRL, EOMI, nonicteric sclera. Mild erythema over left maxilla and bruising over left superior orbit Neck: supple, no elevated JVD Pulmonary: Lungs CTA bilaterally- no wheezing limited by habitus. Cardiac: RRR, nl. S1S2, no M/R/G noted. limited by body habitus. Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, notable well healed scars from cutting. Skin: no rashes or lesions noted. many well healed scars on forearms. neuro: aox4 grossly, cn 2-12 intact grossly, moves all extremities eye: vision 20/50 bilaterally Pertinent Results: Admission Labs: WBC-6.5 RBC-3.60* Hgb-9.2* Hct-31.0* MCV-86 MCH-25.6* MCHC-29.7* RDW-15.8* Plt Ct-443* Neuts-53.5 Lymphs-38.2 Monos-5.7 Eos-2.2 Baso-0.4 PT-16.0* PTT-24.2 INR(PT)-1.4* Glucose-118* UreaN-9 Creat-0.6 Na-139 K-3.8 Cl-102 HCO3-26 CK(CPK)-35 cTropnT-<0.01 Lactate-2.9* . [2156-12-22] 5:45 pm BLOOD CULTURE #2. Blood Culture, Routine (Preliminary): REPORTED BY PHONE TO [Last Name (LF) 53482], [First Name3 (LF) 8081] ON [2156-12-23] @ 1840. STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| STAPHYLOCOCCUS, COAGULASE NEGATIVE \| \| CLINDAMYCIN----------- 4 R =>8 R ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- =>8 R =>8 R OXACILLIN------------- =>4 R =>4 R PENICILLIN G---------- =>0.5 R =>0.5 R RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- 2 S 2 S VANCOMYCIN------------ 2 S 2 S Aerobic Bottle Gram Stain (Final [2156-12-23]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. . [2156-12-23] 5:05 am BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2156-12-27] Blood Culture, Routine (Final [2156-12-27]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| STAPHYLOCOCCUS, COAGULASE NEGATIVE \| \| CLINDAMYCIN----------- =>8 R =>8 R ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- =>8 R =>8 R OXACILLIN------------- =>4 R =>4 R PENICILLIN G---------- =>0.5 R =>0.5 R RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S 2 S VANCOMYCIN------------ 2 S 2 S Aerobic Bottle Gram Stain (Final [2156-12-24]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [2156-12-24]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. . Studies: [2156-12-22] EKG - Sinus tachycardia with baseline artifact. Diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [2156-12-13] heart rate is increased with new non-diagnostic repolarization abnormalities. [2156-12-22] CXR - FINDINGS: As compared to the previous radiograph, the right costophrenic sinus and the left distal part of the costophrenic sinus are still not included on the image. In the visible part of the thorax, there is no obvious abnormality. No parenchymal opacities, masses. The artifact described on the previous radiograph is no longer seen. Borderline size of the cardiac silhouette, no overhydration. [2156-12-23] TTEcho - The left atrium is normal in size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The number of aortic valve leaflets cannot be determined. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Limited study due to lack of patient cooperation. No mitral valve vegetation or significant regurgitation seen. [2156-12-24] EKG - Sinus rhythm. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [2156-12-22] the T waves are more flattened. [2156-12-25] Right finger x-rays - FINDINGS: There is a dislocation of the distal interphalangeal joint with persistent flexion at this level. No evidence of underlying fracture. [2156-12-26] Right UE ultrasound - IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. Right cephalic superficial venous thrombosis. [2156-12-27] TEEcho - No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A small color Doppler signal of left-to-right flow across the interatrial septum is seen at rest c/w a small secundum atrial septal defect with 2mm width. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 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. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No masses or vegetations are seen on the tricuspid valve. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular pathology or pathologic flow identified. Small secumdum ASD with left to right shunt. Normal biventricular systolic function. [2156-12-28] Left UE ultrasound - IMPRESSION: No evidence of deep venous thrombosis in the left upper extremity. [2156-12-28] Right finger x-rays - FINDINGS: Three views of the right fourth finger show no fracture. Again seen is a palmar subluxation of the distal phalanx. This is unchanged in appearance when compared to the previous study from [2156-12-25]. Joint spaces appear well preserved with no degenerative change. There are no soft tissue calcifications. [2156-12-30] IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC line placement via the right basilic venous approach. Final internal length is 53 cm, with the tip positioned in SVC. The line is ready to use. [2157-1-18] IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French intraluminal PICC line placement via the left brachial venous approach. Final internal length is 47 cm, with the tip positioned in SVC. The line is ready to use. [2157-1-22] Right hand x-rays - There are no signs for acute fractures or dislocations. In particular, the fourth PIP joint is well aligned. No bony erosions are seen. There is normal osseous mineralization. There is some soft tissue swelling throughout the whole hand and wrist. [2157-1-23] Left hand x-rays - final report not posted, but preliminary report states no acute fractures. Brief Hospital Course: Ms. [Known lastname ] is a 28 year-old morbidly obese female with severe borderline personality disorder a history of DVT/PE and OSA vs. obesity hypoventillation syndrome who presented after leaving AMA from [Hospital1 ] with her usual chest pain and in addition, recent fevers and documentation of bacteremia. The patient was initially admitted to the MICU due to her history of unresponsive episodes requiring intubation as well as difficulties with behavioral control on the medicine floor requiring frequent nursing attention during her previous admission. These issues were resolved and the patient was transferred to the general medical floor on [2157-1-11] where she remained until her discharge. # Borderline Personality Disorder / Psychiatric issues: Ms. [Known lastname ] has severe borderline personality disorder and may additionally have a mood disorder, although exact characterization is difficult due to the severity of her personality disorder. Previous providers have diagnosed her with "depression", "PTSD", and "bipolar disorder". The patient was actively followed by the psychiatry consult service who created a behavioral plan to assist the medical team in working with the patient and to minimize splitting of staff. The psychiatry consult service also provided recommendations regarding psychiatric medications for the patient. Many of the patient's former psychiatric medications were tapered and stopped as it was felt that they were providing little benefit to the patient and contributing to her somnolence. After her PICC line was placed on [12-30], droperidol 1.25 - 2.5 mg IV and ativan 05.- 1.0 mg IV were used for chemical restraint and the patient was also allowed to request these medications if she felt herself becoming agitated. While these medications did not completely calm the patient, they did help to take the edge off of her agitation. When the patient did allow EKG monitoring and blood draws after receiving these medications, no abnormalities were noted. Additionally, she did not become hypoxic after receiving ativan. After her guardianship hearing zyprexa [6-19] mg PO and ativan 0.5-1.0 mg PO were made available to the patient, however, she did not utilize the former. The only standing psychiatric medication that the patient was ordered for was Aripiprazole (Abilify) 10 mg PO daily, however, the patient routinely refused this medication throughout the course of her admission, taking it only intermittantly. The patient frequently exhibited difficulties around periods of transition and change in her care, often requiring additional monitoring for safety. The following is a summary of the behavioral plan extracted from Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 53483] note of [2157-1-11]: a) Emotional Dysregulation/impulsivity: Ms. [Known lastname ] tends to get very mad very quickly. During these times, trying to talk through the situation tends to only make the anger worse. When this happens use the following strategies: --Tell [Known firstname ]: "I see that you are very angry. I'm going to give you 20 minutes to cool off then come back to check in on you." Come back in 20 minutes and say, "[Known firstname ], it has been 20 minutes, I've come back to check in. Are you ready to discuss your medical care." --Encourage [Known firstname ] to utilize "distraction" techniques such as watching television, listening to music, or drawing/coloring. --Encourage [Known firstname ] to place ice on her arms/wrists to help decrease the urge to cut herself. --[Known firstname ] will rate her anxiety/agitation on a scale ("emotions thermometer"). If her self-rating is over 60, she may request .5mg IV lorazepam up to twice daily. This medication will be closely monitored given concern for respiratory depression. --If [Known firstname ] is acutely agitated c extreme agitation & warrants "chemical restraint", may use zydis 5mg, may repeat x 1 for max dose of 20mg in 24 hours. Alternatively, if refusing oral medication and in need of chemical restraint, may use IM olanzapine 5-10mg &/or lorazepam .5-2mg PO/IM/IV. Alternatively, --If possible, avoid placing hands on patient when she is dysregulated, unless there is a fear that patient is a danger to self, others, or is attempting to leave. In those cases physical force may be necessary and this was told to the patient. b) Consistency for [Known firstname ]: Ms. [Known lastname ] has a difficult time adapting to new treaters and changes in the routine. She does better with those she is more familiar with. As much as is possible in an academic hospital, she would do best with having the same staff involved in her care. At changes of shift, new staff should make an extra effort to introduce themselves and let her know the plan for the shift. c) Consistency for treaters: There should be extra efforts to ensure that all treaters are on the same page. All treaters should be instructed to read this treatment plan. We should have, at a minimum, weekly interdisciplinary team meetings to discuss ongoing challenges to providing Ms. [Known lastname ] with the highest level of care. d) Safety issues: Patient should have all sharps removed from room. She should be given only plastic silverware. Silverware should be removed immediately after she finishes eating. In further regards to safety, hospital security had to be called on several occassions to return the patient to her room when she left the MICU or to forcibly restrain her after she hit and spit at staff or after she refused to stop harming herself. During most of her hospital stay she was 1:1 with either a security sitter or a hospital staff sitter. Security were also called on several occassions when the patient's room was searched. # Facial cellulitis: On the morning of discharge the patient was noted to have an erythematous left cheek that was slightly warmer than her right cheek. No induration or fluctuance was noted. Given her history, it is possible that this finding was self-induced, though no evidence of trauma was noted. As the patient has a prior history of facial cellulitis she was started on bactrim for a 10 day course given her history of medication non-compliance. The area of erythema was outlined with a pen prior to discharge. If this area expands significantly or becomes indurated, a medicine consult should be obtained to evaluate for a change in therapy. # Positive blood cultures: Documentation from Shattock showed Staph. simulans (a coagulase negative Staph.) and Enterococcus. The Enterococcus was resistant to vancomycin. The two bacteria together were only both sensitive to linezolid and rifampin. Two blood cultures drawn at the beginning of this admission were sensitive to vancomycin. The nidus of the patient's infection was never discovered. A transthoracic echo showed no endocarditis or valvular vegetations. Her admission chest x-ray was without infiltrates. Urine culture on admission was negative. A dental consult was obtained, as the patient complained of tooth pain, however, dental panorex was negative for abscess and the dentist felt there was no acute oral disease. A right upper extremity ultrasound did show a partially occluded thrombus in the cephalic vein. However, blood cultures from [12-26] through [1-4] did not grow any bacteria. On admission the patient was started on a 14 day course of linezolid to treat her documented bacteremia at Shattock. The patient intermittantly refused to take this medication. She had no further fevers during her hospital stay. She did intermittantly have mildly elevated temperatures, but these often occurred in association with episodes of agitation. # History of DVT/PE: The patient has a documented history of DVT in the right subclavian and branchial veins with associated PE in [10-18] at Caritas [Hospital3 ]. A CTA performed at [Hospital1 18] on [2156-11-28] demonstrated no central or segmental pulmonary embolism. On this admission the patient was initially placed on a heparin gtt due to a subtherapeutic INR. Heparin was stopped when the patient's INR became therapeutic. The patient frequently refused warfarin as well as blood draws (despite having a PICC line) for INR monitoring. However, despite only taking about 50% of her prescribed doses (4 mg daily) the patient maintained an INR of ~2. Initial recommendations from the ICU team were for warfarin anticoagulation for a period of 6 months following her [10-18] PE. On transfer to the medical floor the patient continued to complain of chest pain and request a repeat CT scan. She was informed that this was not medically indicated and that she was already receiving the recommended medical therapy for this condition. She continued to frequently refuse to take warfarin, despite multiple conversations on this subject. On [2157-1-22] warfarin anti-coagulation was discontinued after the patient intentionally harmed herself by gouging herself with a pen, requiring three stitches, and punching her hand into a door multiple times. The following day she punched her other hand into a door. Given that the patient's DVT/PE occurred in the setting of having a PICC line, that she is now nearly three months after initiating anticoagulation with documented resolution of her PE in [11-17], that she is intermittantly compliant with warfarin therapy, that she routinely refuses blood draws for INR monitoring, and that she is at risk for intentionally harming herself and for bleeding, it is recommend that the patient no longer be anticoagulated. If, in the future, the patient agrees to take warfarin on a regular basis, to submit to INR monitoring, and stops physically harming herself, anticoagulation could be reconsidered. If this occurs, consideration of fingerstick monitoring of INR should be considered as placement of a PICC line imposes a risk of infection and permits the patient an opportunity to fight over the types of labs drawn and whether the PICC needs to be removed. If the patient has new hypoxia, it would be reasonable to initiate medical evaluation and reassessment for PE. # OSA / Obesity hypoventilation syndrome: On her prior [Hospital1 18] admission, the patient had an episode of somnolence with hypercarbia requiring intubation. It was felt that this episode was related to oversedation. Her psychiatric regimen has changed considerably since that episode and the patient has not been allowed to have ambien for sleep as the team wanted to be able to use ativan if necessary and not risk oversedation. During episodes on this admission in which the patient was found "unresponsive" and intubated, her blood gases were within the range of normal for her (baseline pCO2 50s-60s). Subsequently, the MICU team began further investigating these episodes. The patient's O2 sat was generally in the low- to mid-90s during these episodes and arm drop tests often indicated volitionality. The medical team subsequently decided to monitor O2 sats and not to proceed with further intervention if her O2 sat was > 85%. During her stay on the general medical floor, the patient became upset several times when her episodes of "unresponsiveness" were "ignored" by medical staff (i.e., O2 sat > 85%). When questioned further, the patient stated that she could hear what staff were saying when they came to check her O2 sat and she was "unresponsive". The patient was repeatedly advised to wear BiPAP/CPAP while sleeping and consistently refused to do so. She also refused supplemental oxygen by nasal cannula. Continuous O2 sat monitoring in the ICU demonstrated that the patient does occasionally desat to the 70s or 60s ([First Name9 (NamePattern2) 53484] [Location (un) 1131] was at times poor) while sleeping, but recovers spontaneously on her own. From a medical standpoint, the patient would benefit from wearing BiPAP/CPAP, but has clearly demonstrated that she is in no imminent danger when not wearing it and she consistently refuses to wear it. The change in her psychiatric medications with less sedating medications have likely helped in this regard. Her most recent ??????unresponsive?????? episodes appear to be psychogenic and not true medical emergencies. If the patient ever does indicate a willingness to wear a BiPAP/CPAP mask, she would benefit from a formal sleep study and fitting of an appropriate mask. # Suture removal: On the evening of [1-21] the patient gouged herself with a pen that she had hidden and was not discovered on a room search earlier in the evening. Three sutures were placed on [1-22]. They should be removed sometime between [1-29] and [2-1]. # Urinary incontinence: The patient has previously taken ditropan, but this medication was stopped as she claimed it was not helping her. She was frequently incontinent of urine, and often this incontinence was volitional. The patient requested a trial of Detrol, however, this medication was not started due to its anti-cholinergic effects and potential to exacerbate her underlying psychiatric issues. # Restless leg syndrome: The patient was formerly on Requip. That was changed to Gabapentin 100mg QHS per psychiatry recs. The patient frequently declined this medication. # Headaches: Could be related to a variety of factors including poor sleep cycle. The patient stated that she has a history of migraine headaches which she treats with caffeine, typically by drinking large amounts of coffee. This habit was discouraged and she was offered tylenol and ibuprofen, but often refused these medications. # Asthma: The patient was written for scheduled fluticasone and bronchodilators. She routinely refused these medications. There was no clinical suspicion for asthma exacerbation during her hospital stay. # Diarrhea: Most likely an antibiotic side effect which resolved with time. Her stools were C. diff negative x 3. Stool O&P negative x 2. The patient was written for prn immodium. # Vaginal yeast infection: The patient was treated several times during her admission for this condition with both miconazole vaginal cream daily x 7 days and oral fluconazole. She was advised to stop purposefully wetting herself and lying in her urine to prevent recurrence of yeast infections. She was also written for miconzole powder for yeast in her intertriginous folds. # Medication non-compliance: The patient frequently refused her scheduled medications and rarely used her prns. # The patient frequently refused to participate in her own medical care, but also often voiced somatic complaints as a way of seeking attention and often requested specific medical interventions. Many of these complaints and their subsequent evaluation are further outlined below. Additionally, she frequently quizzed staff on medical topics and then later manipulated that information when she voiced medical concerns. a) Chest pain - The patient frequently complained of chest pain during her admission. At times chest pain was reproducible with palpation. At times the pain was anterior, at other times lateral, and at times in her low to mid back. Multiple EKGs and cardiac enzyme checks during this hospitalization were negative for ischemia. The patient was already on appropriate therapy for PE as described above. As outlined in her previous [Hospital1 18] discharge summary and briefly reviewed in her HPI, this complaint has been a frequent and chronic one for the patient over the past year and despite multiple evaluations no organic etiology for her pain has been defined. The patient was written for omeprazole per prior regimens to treat presumed GERD, however, she took this medication only intermittently. b) Abdominal pain/Nausea - LFTs, amylase, lipase normal. UA normal. Vital signs normal, afebrile. The patient's intermittant abdominal pain and/or nausea was attributed to poor diet. c) Finger subluxations - The patient has repeatedly subluxed her right ring finger, and at times other fingers. The initial episode occured when attempting to push herself up from bed, however, multiple subsequent episodes appear to be purposeful and attempts to seek attention. Plastic surgery was consulted and saw the patient several times and finger x-rays were performed. Per plastic surgery, the patient has a swan neck deformity caused by a lax ligament which she can fix on her own or can be easily reduced by staff. The finger is not truly dislocated and does not require emergent/urgent reduction. They recommended a special splint for the patient, however, she refused to wear it. When the patient requested a hard cast, plastic surgery stated that this was not indicated. The patient was provided prn tylenol, ibuprofen, and ultram for pain. No narcotics were given. The patient also endorsed hypoasthesia in the dorsal aspect of the 4th and 5th digits, consistent with a disruption of the dorsal sensory branch of the ulnar nerve, potentially caused by one of her numerous lacerations to the right forearm and wrist. This is condition is chronic and does not require further evaluation. When the patient is more stable psychiatrically, and if she has no ongoing medical issues, the patient may pursue surgical correction of the lax ligament. The plastic surgery team felt that this should be done as an outpatient. d) Mouth lesion: The patient bit the inside of her lip while eating one day. Despite her request for stitches, these were not placed as it was not felt to be indicated. Her laceration is healing well. e) Polydypsia/polyuria: Blood glucose normal. Patient with high PO fluid intake at times. No need to evaluate further. f) Hot/cold flashes: The patient intermitantly complained of "hot flashes" or being extremely cold. She did not have any fevers during these periods and blood cultures were drawn and were negative during some of these occassions. TSH was 2.2 on [2156-12-9]. The patient requested "hormonal testing" and was advised that she should follow-up with an endocrinologist as an outpatient. Of note, during her previous [Hospital1 18] admission the patient did have hyperprolactenemia induced by risperdal and that medication was stopped. g) Left shoulder pain: For several days during her MICU stay the patient complained of left shoulder pain. It was unclear if this was an attempt to get attention or if it was real. She had full ROM of on exam and x-rays were deemed unnecessary. Ibuprofen, tylenol, and ultram were provided on a prn basis. After a few days the patient no longer complained of shoulder pain. h) "Laryngitis": One day prior to discharge the patient complained of "a sqeaky voice", speaking is a whispered/raspy voice in association with a sensation of throat swellinng and her typical chest and "lung" (really low back) pain. There was good air movement and no wheezing on exam. There was no evidence of facial or neck swelling. She was offered a cepacol losenge. The patient's voice improved markedly a few hours later when she became agitated at staff. By the following day her vocal issues had resolved. i) Unresponsive episodes: as outlined above. # Access: The patient is extremely difficult, if not impossible to obtain peripheral access in. A PICC line was placed by IR on [12-30]. It was removed a couple of weeks later due to discomfort at the site and continued picking at the site on the part of the patient. A new PICC line was placed in the opposite arm, however, the patient continued to complain of pain at the site (the patient routinely complained of IV or PICC site pain throughout her hospital course). As the patient repeatedly refused lab draws, even noninvasive lab draws from the PICC line, and due to the risk of infection and thrombophelbitis posed by invasive lines, it no longer made sense to maintain a PICC line solely for lab draws given tenderness at the PICC site. Reinsertion of a PICC line would be indicated if the patient develops a need for IV medications or treatment. # Indications for further medical evaluation: - widening area of facial cellulitis and/or induration or fluctuance - new hypoxia (room air O2 sat < 90% while awake, not holding her breath, or < 85% while asleep) - fever > 101 F # Legal: Given the patient's repeated demonstrations of emotionally-driven and often irrational behavior and choices not congruent with her own well-being, guardianship for this patient was pursued. In a court hearing on [2157-1-20] [First Name4 (NamePattern1) 3608] [Last Name (NamePattern1) 4334] (ph: [Telephone/Fax (1) 5350]) was appointed as the patient's guardian. Medications on Admission: Meds from [Hospital1 ]: Advair [Hospital1 ] mvi detrol 1mg po bid colace 100 [Hospital1 ] prn senna 2 qhs omeprazole 20 qday requip 1.5 qhs miconazole cream topical tylenol 650 q 6 hrs prn motrin 600 q 8 hrs prn celexa 60 qday abilify 10 mg qday prn anxiety abilify 15 qday percocet 5/325 q 6hrs prn pain ambien 5 qhs depakote 2000mg qhs combivent 2 puffs qid maalox 30cc p 8 hrs prn indigestion bipap nystatin powder topical coumadin 2mg qday (being held) . Allergies: Penicillins / Haldol / Compazine / Desipramine / Chlorpromazine / Imipramine / Zoloft / Shellfish Derived Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Not to exceed 4g in 24 hours. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 4. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Tramadol 50 mg Tablet Sig: 0.5 - 1 Tablet PO Q6H (every 6 hours) as needed. 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 11. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q8H (every 8 hours) as needed. 14. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 15. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO ONCE MRX1 PRN () as needed for agitation/anxiety. 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO ONCE MRX1 PRN () as needed for agitation, anxiety, sleep. 17. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Mucous membrane lozenge as needed. 18. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Discharge Disposition: Extended Care Facility: [Hospital6 5016] [Doctor Last Name 1495] Raphaels TCU - [Location (un) 7661] Discharge Diagnosis: Primary Diagnoses: 1. Severe borderline personality disorder 2. Bacteremia with coagulase negative Staph and Enterococcus 3. History of pulmonary embolism 4. Obstructive sleep apnea vs. obesity hypoventilation syndrome 5. Mood disorder NOS Secondary Diagnoses: 1. Asthma 2. Self-injurious behavior 3. Urinary incontinence 4. Facial cellulitis Discharge Condition: Good. Vital signs stable (SBP 90s-140s, HR 80s-110, O2 sat > 94% on room air, afebrile). Discharge Instructions: You were admitted to [Hospital1 18] with a complaint of chest pain. No specific cause for this chest pain was identified. You were also treated for a blood infection during your stay which resolved, and you were anticoagulated with warfarin because of your history of PE. Because you did not take this medication on a regular basis, refused blood draws to monitor your levels, and have recently demonstrated self-injurious behavior, you are not currently considered a candidate for this therapy. A previous CT scan here has demonstrated resolution of your previous PE. You were also recommended to wear CPAP/BiPAP at night for your obstructive sleep apnea. It will help you to feel less tired and better overall, however, you have repeatedly chosen to refuse this therapy. On the day of discharge you were started on the antibiotic bactrim for a 10 day course for left-sided facial cellulitis. You should complete this course. Please seek medical attention if the area of redness increases in size. Followup Instructions: It is recommended that you reside in a structured environment and seek further care for your psychiatric issues. [First Name8 (NamePattern2) ] [Name8 (MD) 474] MD [MD Number(2) 4658]	[ "0389", "51881", "99592", "32723", "V5861" ]
Admission Date: [2117-6-17] Discharge Date: [2117-8-6] Date of Birth: [2059-4-3] Sex: M Service: SURGERY Allergies: Codeine / Demerol Attending:[First Name3 (LF) 148] Chief Complaint: failure to thrive, persistent nausea and vomiting Major Surgical or Invasive Procedure: Roux-en-Y choledochojejunostomy, gastrojejunostomy, j-tube, Lysis of Adhesion IVC filter NGT History of Present Illness: This 58 yo male with long term nausea and vomiting [12-25] gastric outlet obstruction and hx of recurrent pancreatitis and etoh abuse went to outside ER with intractable nausea and vomiting fo the past 2 days and unable to tolerate po intake. He was admitted for failure to thrive and symptom control. In OSH he underwent EGD on [2117-6-15] which demonstrated high grade gastric outlet obstruction which is rather concerning. he's therefore transferred for further evaluation and management. on arrival pt has no complaint including pain. Past Medical History: -nausea and vomiting [12-25] gastric outlet obstruction at the level of duodenum due to extrinsic compression by the pancrease. - recurrent pancreatitis with multiple pancreatic pseudocysts and distal common bile duct stricture. - htn - niddm - c diff related diarrhea - gastric ulcer [2108] - alcohol abuse - major depression requiring ECT in the past - severe spinal stenosis from c3-c6 with myelomalacia and central cord syndrome with profund bilateral lower extremity weakness. - chronic pain - cervical laminectomy and fusion after decompression of c3-c6 [3-/2117] - cholecystectomy - appendectomy - partial gastrectomy for peptic ulcer perforation. Social History: non smoker, no alcohol or illicit drugs currently Physical Exam: temp 96.6, bp 119/71, hr 63/min, resp 18/min, sats 96% RA. comfortable at rest no jvd, no nodes rrr, nl s1+s2, no m/r/g ctab, nl effort [Last Name (un) 103] soft, mild epigastric discomfort, no rebound/guarding, nl bs no o/c/c a&o x 3, cns [1-4] intact Pertinent Results: [2117-6-23] 07:40AM BLOOD WBC-7.3 RBC-4.01* Hgb-12.2* Hct-36.0* MCV-90 MCH-30.6 MCHC-34.0 RDW-16.4* Plt Ct-221 [2117-6-23] 07:40AM BLOOD Glucose-130* UreaN-14 Creat-0.6 Na-142 K-4.1 Cl-111* HCO3-23 AnGap-12 [2117-6-21] 05:15AM BLOOD ALT-15 AST-26 LD(LDH)-123 AlkPhos-568* TotBili-0.6 [2117-6-18] 01:27AM BLOOD Lipase-29 [2117-6-21] 05:15AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.2 Mg-1.3* Iron-68 [2117-6-20] 04:30AM BLOOD CEA-2.6 . CTA ABD W&W/O C & RECONS [2117-6-19] 12:36 PM IMPRESSION: 1. Mass-like conglomerate of calcifications in the head of the pancreas that may be the cause of biliary obstruction. Marked intrahepatic, extrahepatic and pancreatic duct dilatation. 2. Apparent mass in the second portion of the duodenum that may be of inflammatory or neoplastic etiology. 3. Interstitial thickening and mild bronchiectasis at both lung bases that may be related to chronic aspiration. . EGD [2117-6-21] Retained fluids in stomach Deformity of the distal bulb A deformity was noted in the distal bulb. The endoscope could not advanced beyond this area.EUS: Changes c/w severe chronic pancreatitis noted in the body of the pancreas. Unable to advance the echoendoscope into the duodenal bulb and beyond. EUS was performed using a linear echoendoscope at 7.5 frequency: The body of the pancreas was imaged through the body of the stomach. Multiple hyperechoic strands and calcifications were noted within the body of the pancreas. The pancreatic duct could not be identified. These findings were consistent with severe chronic pancreatitis. The echoendoscope could not be advanced into the duodenal bulb, therefore, the rest of the pancreas could not be examined. Otherwise normal EGD to second part of the duodenum . CTA CHEST W&W/O C&RECONS, NON-CORONARY [2117-6-26] 1:47 PM IMPRESSION: 1. Pulmonary embolism involving segmental arteries of the left lower lobe. Findings are discussed with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at the time of dictation. 2. Interstitial thickening and scattered areas of tree-in-[Male First Name (un) 239] opacity. This is a nonspecific finding, as noted above, may be related to chronic aspiration. 3. Hilar lymphadenopathy and prominent mediastinal lymph nodes as noted. 4. Intrahepatic biliary dilatation again identified. . BILAT LOWER EXT VEINS [2117-6-27] 4:03 AM IMPRESSION: No evidence of deep vein thrombosis of the lower extremities. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [2117-7-6] 11:46 AM CONCLUSION: 1. No definite evidence of a segmental or subsegmental pulmonary embolism or an aortic dissection. 2. Interstitial thickening, scattered areas of tree-in-[Male First Name (un) 239] opacity and scattered patchy opacities in the lungs likely are a combination of recurrent aspiration and consolidation. 3. Incompletely evaluated intrahepatic biliary dilatation likely represents sequelae of obstruction due to pancreatic neoplasm. . Cardiology Report ECHO Study Date of [2117-7-6] INTERPRETATION: Findings: LEFT VENTRICLE: Severe global LV hypokinesis. Severely depressed LVEF. RIGHT VENTRICLE: Moderate global RV free wall hypokinesis. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. The patient has runs of a supraventricular tachycardia. Results Conclusions: 1. There is severe global left ventricular hypokinesis (LVEF = 20%) with minor regional variations. The bases are more dynamic in comparison to the distal aspects of the left ventricle. 2. There is moderate global right ventricular free wall hypokinesis, greater function in the base in comparison to the apex. 3. There is an echodensity in the right pulmonary artery (artifact vs thrombus). Cannot rule out thrombus in the PA. . PERSANTINE MIBI [2117-7-9] The calculated left ventricular ejection fraction is 30%. IMPRESSION: 1. No obvious ischemic changes with exercise - please see above discussion. 2. Moderate global hypokinesis, EF 30%, with mildly dilated LV cavity. . CT C-SPINE W/O CONTRAST [2117-7-16] 2:56 PM IMPRESSION: Moderate narrowing of the spinal canal at C5 level due to osteophyte. This is not an acute finding. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [2117-7-17] 4:52 PM IMPRESSION: 1. No evidence of any pulmonary embolus. 2. Scattered areas of alveolar infiltrate with tree-in-[Male First Name (un) 239] opacity bilaterally which are relatively unchanged when compared with the previous CT from [2117-6-26]. Note is also made of some mucous plugging and debris in the right mainstem bronchus. The overall appearances are most suggestive of chronic aspiration. 3. Subcentimeter mediastinal lymphadenopathy. . CT ABDOMEN W/CONTRAST [2117-7-26] 11:52 AM IMPRESSION: 1. Marked intrahepatic and extrahepatic duct dilatation with interval development of pneumobilia when compared with the previous CT from [2117-6-19]. 2. Pancreatic appearances consistent with chronic pancreatitis. 3. Dilatation of proximal loops of small bowel with fecalization and distal decompression. 4. IVC filter in situ. 5. Atelectasis in the left base and airspace disease which may represent chronic aspiration. 6. Bronchiectatic changes in right base. . ABDOMEN (SUPINE ONLY) [2117-7-29] 10:45 AM IMPRESSION: Few dilated loops of small bowel, consistent with ileus. Relatively unchanged compared to prior study. . Brief Hospital Course: 58 yo man with extensive gastric outlet obstruction history presented with n&v to osh. egd revealed high grade gastric outlet obstruction that they were unable to pass. pt's transferred for egd and further therapy. . #) GI: pt presents with nausea and vomiting and was noted to have high grade gastric outlet obstruction. - npo - iv rehydration. - for gi consult with plan for repeat egd in am. He had a repeat EGD on [2117-6-21] which should showed Retained fluids in stomach, deformity of the distal bulb. The endoscope could not advanced beyond this area. EUS: Changes c/w severe chronic pancreatitis noted in the body of the pancreas. These findings were consistent with severe chronic pancreatitis. The echoendoscope could not be advanced into the duodenal bulb, therefore, the rest of the pancreas could not be examined. Otherwise normal EGD to second part of the duodenum. He was NPO and started on TPN. The TPN continued for a week prior to the OR in order to maximize his nutritional status as he came in very weak and emaciated. #) Major Depression: He was seen by Social Work and Psych. He had previously been on Prozac, but states that he noticed diminished effect. He was NPO due to his GOO and so we started Remeron (dissolvable tabs) increased to 30mg HS. Social work and Psych continued with supportive care. Post surgery, when taking PO's, he was on Duloxetine. #)Pulmonary Embolism On [2117-6-26], he had an acute onset of dyspnea and was transferred to the SICU with LLL segmental PE. Lower extremity US showed no DVT. He was started on Heparin and his PTT was kept therapeutic. Vascular was consulted and performed a CT Venogram, followed by placement of an IVC filter through the right groin. He tolerated this procedure well. #)Pain He was on a Morphine PCA, and we continued with Fentanyl patch, Toradol, Remeron, Ativan. He complained of constant chronic pain, that was not well controlled initially. On discharge, his pain was well controlled with gabapentin 300mg qhs, oxycodone SR 40mg [Hospital1 ], oxycodone-acetaminophen [11-24] tab q4hr prn He was schedule to go to the OR on [2117-7-6]. While at holding area and following uneventful placement of a an epidural at C5 level. In route to OR, patient became apneic and 'blue", unresponsive and, reportedly, pulseless. BCLS/ACLS protocols were initiated. he was intubated and received 1 mg epinephrine, with immediate response and return of pulse and BP (sinus tach). TEE obtained in the OR showed global HK with an estimated LVEF 20% with moderate MR (a change from an outside echo that reported normal LV). A SG catheter placed showing mean PA pressure of 18 mmHg. He was transferred to SICU on Epi infusion (0.02 mcg/kg/min). he has since been intubated and able to converse. Hemodynamically he has been stable. Initial ABG: 7.14/63/202 Initial PA catheter numbers: CVP 5, PA 32/13/20, CO 6.8, CI 6.3, SVR 377 ECG showed TWI in V2-6 (new compared to ECG [6-21])but no gross ST segment deviation. Otherwise no change. CTA was performed to evaluate for recurrent PE and was negative for this entity but showed: "Evaluation of the lung parenchyma reveals areas of interstitial thickening and areas of tree-in- [Male First Name (un) 239] opacity, this is a nonspecific finding and most likely is related to chronic recurrent aspiration due to gastric outlet obstruction in this patient. There are scattered ill- defined patchy opacities in both lungs likely representing infectious/inflammatory etiology" Transthoracic echocardiogram was done as well and showed findings contradictory to those of the TEE (although labeled as a suboptimal study): Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. He then transferred out to the floor and continued to await surgery, continuing on TPN. A pharmacologic stress was performed on [2117-7-12] and showed no anginal symptoms or ischemic ST segment changes. He went to the OR on [2117-7-13] for: 1. Double bypass (choledochoenterostomy with a Roux-en-Y formation; gastroenterostomy). 2. Repair of small bowel enterotomies x3. 3. Takedown and repair of a coloenteric fistula. 4. J-tube placement. 5. Extended adhesiolysis. Post-operatively he went to the ICU and remained intubated overnight. He was extubated the next day and did well. Pain: His pain was moderately controlled with a PCA. He was seen by the pain service and they continued to adjust his meds. Once we started tubefeedings, Gabapentin 300mg HS, Acetaminophen 650mg, Duloxetine 30 mg PO were put down the tube. He was mostly comfortable at time of discharge, but still having some cervical pain. A CT of the cervical spine showed moderate narrowing of the spinal canal at C5 level due to osteophyte. A soft collar was worn for comfort. . Abd/GI: He had a NGT and was NPO with IVF and TPN. The NGT was self D/C'd on POD 2. He complained of some nausea and this was likely a combination of the large amount of narcotics and pulling the NGT early and ileus. His incision was C,D,I and staples were removed. Tube feedings were started and slowly advanced to goal. We also advanced his PO diet and he was tolerating a regular diet by POD 9. He was moving along well until POD 13, when he developed an Ileus, and vomit [Male First Name (un) ] over 1 liter. He was made NPO and received a NGT. He was put back on PO meds. The ileus resolved with conservative treatment of NPO and NGT. The patient's diet was advanced slowly from sips to clears to full liquids and eventually a regular diet. In order to supplement his nutrition, tube feeds were commenced starting at 10 cc/hr and were slowly increased to a goal of 80. The tube feeds were eventually cycled starting at 18hours per cycle starting at 4pm through 10 am, in order to encourage PO intake during the day. We decreased the tubefeedings to 70 cc/hr over 16 hours as he complained of some loose stool with the higher rate. The tube feedings were weaned off as his calorie counts revealed 1830 kcal and 83 gram of protein. PT: Physical therapy evaluated the patient and concluded there was significant deconditioning and soft tissue symptoms which would require rehabilitation as the patient is significantly below baseline. They recommend a short term rehabilitation stay as the patient has an excellent prognosis to regain independence. Due to his med/nutrition needs, rehabilitation can best meet all of his needs. Medications on Admission: zofran 4mg iv q6h prn, albuterol nebulizer qid prn, protonix 40mg daily [Hospital1 ], heparin 5000 units tid, viscous xylocaine 5 cc q3n prn, flagyl 500mg iv q8h, valium 2mg iv bid, zithromyax 250mg daily ativan 1 mg q6h prn iv, dilaudid 2mg iv q2h prn Discharge Medications: 1. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QHS (once a day (at bedtime)) as needed. Disp:20 ML(s) Refills:0 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day). Disp:60 Tablet Sustained Release 12 hr(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:1 5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:25 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 10. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Disp:15 Lozenge(s) Refills:2 11. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: See Sliding Scale Subcutaneous twice a day: Give 4 units 70/30 qbreakfast. 5 units 70/30 qdinner. . 12. Humalog 100 unit/mL Solution Sig: Sliding Scale Subcutaneous four times a day: See Humalog Sliding Scale. 13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital 3671] Rehabilitation & Nursing Center - [Location (un) 1514] Discharge Diagnosis: Recurrent EtOH pancreatitis Gastric outlet obstruction Nausea and vomitting Persistent Hyperglycemia Depression Chronic Aspiration PEA arrest after thoracic epidural bolus Chronic Neck Pain Central cord syndrome w/ profound bilateral extremity weakness Discharge Condition: good tolerating diet pain moderately controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 2833] Date/Time:[2117-8-27] 8:00 Completed by:[2117-8-6]	[ "5180", "5070", "25000", "4019" ]
Admission Date: [2106-12-8] Discharge Date: [2106-12-10] Date of Birth: [2054-12-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10488] Chief Complaint: Dyspnea and Syncope Major Surgical or Invasive Procedure: Tracheal Stenting History of Present Illness: 51 yo male with h/o HIV, SCC of larynx recently discharged on [2106-12-2] for evaluation of hemoptysis now here for increasing dyspnea. Pt was in downtown earlier today, paying a traffic ticket when he experienced a violent cough with SOB while climbing stairs. Pt states he then felt dizzy and passed out for 2 min, was then taken to [Hospital1 2025] initially where a CTA and CXR were done and were both neg. He was then transferred here. . In the ED, VS were stable. Pt denied CP, was breathing comfortably. States that he feels much better. No further imaging was pursued in the ED. First TnT was neg here. Pt is being admitted for syncope w/u and symptomatic treatment. On transfer, VS were HR 60 BP 110/80 RR 15 O2 sat 96% on RA. . On the floor, pt is comfortable, denies any dizziness. States cough is better now, feeling much better in general. Past Medical History: HIV (on HAART) laryngeal cancer s/p chemo, radiation hypertension seizure disorder hypothyroidism depression Social History: Ex smoker, smoked <5 cigarette /day for 10 years, no EtOH/drugs. He lives with his family , wife and two daughters. Contracted HIV sexually when young from a female partner. Family History: No family history of cancer per the patient. Physical Exam: General: alert, oriented, no acute distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: good air movement bilat, rhonchorous CV: RRR, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 5/5 strength in all ext, sensation intact Pertinent Results: [2106-12-8] 08:50AM GLUCOSE-89 UREA N-16 CREAT-1.5* SODIUM-141 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16 [2106-12-8] 08:50AM cTropnT-<0.01 [2106-12-8] 08:50AM TSH-1.6 [2106-12-8] 08:50AM TSH-1.6 [2106-12-8] 08:50AM WBC-6.5 RBC-4.92 HGB-15.4 HCT-44.3 MCV-90 MCH-31.4 MCHC-34.8 RDW-15.5 [2106-12-8] 08:50AM PLT COUNT-255 [2106-12-8] 01:55AM GLUCOSE-94 UREA N-14 CREAT-1.4* SODIUM-140 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-21* ANION GAP-14 [2106-12-8] 01:55AM estGFR-Using this [2106-12-8] 01:55AM cTropnT-<0.01 [2106-12-8] 01:55AM cTropnT-<0.01 [2106-12-8] 01:55AM WBC-5.3 RBC-4.67 HGB-14.7 HCT-41.6 MCV-89 MCH-31.4 MCHC-35.3* RDW-15.4 [2106-12-8] 01:55AM NEUTS-54.0 LYMPHS-33.7 MONOS-5.7 EOS-5.6* BASOS-1.1 [2106-12-8] 01:55AM PLT COUNT-229 [2106-12-8] 01:15AM URINE HOURS-RANDOM [2106-12-8] 01:15AM URINE GR HOLD-HOLD [2106-12-8] 01:15AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2106-12-8] 01:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: The patient yesterday was at the parking office, and then had a syncopal episode after he had a coughing spell. The patient was transferred to [Hospital1 2025] initially where he had a CTA of the chest done which was negative for PE however showed that there was only a 4mm opening of the trachea. The patient was transferred to [Hospital1 18] for further care. Syncope: The patient had syncope secondary to a vasovagal/possible hypoxemic episode after a coughing fit. It is unlikely to be seizure as the patient states that he has had seizures in the past that presented differently. He states that he had chest pain after the syncopal episode however he stated that this was secondary to CPR performed at parking office after his syncopal event. Ishcemia is also unlikely given that he had a stress test done on prior admission which was negative for ischemia. The diagnosis was confirmed when the patient had two additional syncopal episodes while in the presence of the interventional pulmonary fellows who agreed that the patient would need to be taken to the OR for stenting and debridment so the patient does not have any further episodes of syncope. Cough: The patient had a cough which is likely secondary to the SCC of the larynx that the patient has. He was given guaifenesin-dextromethorphan Tracheal Narrowing: The patient has laryngeal SCC which has narrowed the trachea to 4mm per the report from [Hospital1 2025]. Interventional pulmonary service was called and agreed that since the patient is poorly compliant that he would likely need to have a stent placed. Since he had lunch, he was added onto the OR schedule for tomorrow. However while the IP fellow was in the room, the patient had a coughing fit and syncopized. At this time the decision was made to transfer to the patient to the ICU and take him to the OR for an emergent intervention. IP placed a stent following coughing fit and procedure went well. He did not have any complications from his procedure. Patient maintained excellent ventilatory status during and after procedure, and felt well overnight. He was transferred to the floor where he was observed for an additional 24 hours. Subsequently the patient developed some hemoptysis consisting of blood tinged sputum. Initially the sputum was red colored, however subsequently it became brown colored. IP fellow was made aware of this and saw the sputum and agreed that he was ready for discharge. The patient states that at discharge his breathing was normal and much better than it has ever been. He was not complaining of shortness of breath or chest pain. The patient was made aware of the importance of following up at [Hospital1 2177] for cyberknife treatments. Fever: Overnight on [2107-12-9] the patient had a temperature of 100.4. A chest x-ray was checked, urine analysis was checked both of which were negative. Blood cultures were drawn and sent off to be followed up by his primary care doctor. The patient also did not have any additional fevers after the low grade temp of 100.4. Increased Creatinine: The patient had creatinine checked on a daily basis and it remained stable throughout his hospitalization. The patient will follow up with his primary care doctor for this. Medications on Admission: 1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atazanavir 300 mg Capsule Sig: One (1) Capsule PO once a day. 3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO once a day. 4. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Discharge Medications: 1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 8. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:100 ML(s) Refills:0 9. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:20 Tablet(s) Refills:0 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:20 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Syncope/ Transient Loss of Consciousness Syncope or fainting is a [Last Name ] problem caused by inadequate blood flow to the brain. There are many serious reasons for fainting, including internal bleeding, irregular heartbeat, and diseases of the heart muscle or valves or circulation. Other causes include diseases of the central nervous system, medications, low blood sugar, or dehydration. Vasovagal Syncope is the most common cause of syncope and can occur in healthy people at the sight of blood, hearing unexpected news, or while experiencing pain During your stay in the hospital, we did not find an immediately life-threatening cause for your loss of consciousness. Rarely, serious symptoms can develop later. Therefore it is <B>very important</B> to carefully monitor your condition at home and return to the Emergency Department immediately if you have any of the warning signs listed below. Treatment: * Drink plenty of liquids (unless your doctor has told you not to.) Do not consume alcohol until you are completely better. * Be sure to take any prescribed medications as you were instructed. Continue your previously prescribed medications unless you were instructed to do otherwise. Warning Signs: Call your doctor or return to the Emergency Department right away if any of the following problems develop: * You have recurrent loss of consciousness in the next 6 months. * You are not getting better in 24 hours, or you are getting worse in any way. * You experience new chest pain, pressure, squeezing, tightness, a rapid heartbeat or palpitations. * You have shaking chills, or a fever greater than 102 degrees (F). * You have new or worsening difficulty breathing. * You develop abdominal (belly) pain, vomiting, black or bloody stool. * You develop severe headache, dizziness, confusion or change in behavior. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: Department: RADIATION ONCOLOGY [Hospital ] [Hospital6 ] Name: DR. [Last Name (STitle) 4498] When: [2106-12-13] Address: [Location (un) 86592], [Location (un) 86], MA Phone ([Telephone/Fax (1) 86593] Department: [Hospital3 249]- Primary Care When: MONDAY [2106-12-13] at 2:35 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: Otolaryngology Name: Dr. [Last Name (STitle) 86594] [Name (STitle) 86595] When: Wednesday [2106-12-22] at 1:35 PM Address: [Location (un) 86592], [Location (un) 86], MA Phone [Telephone/Fax (1) 86596] Department: Chest Disease Center Name: Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] When: We are working on a follow up appt with Dr. [Last Name (STitle) ] for 2 weeks after your hospital discharge. You will be called at home with the appointment time and date. If you have not heard from the office in 2 business days, please call the number listed below. Location: [Hospital1 18] - DIVISION OF PULMONARY MEDICINE Address: [Location (un) ], [Hospital1 ] 116, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3020]	[ "40390", "5859" ]
Admission Date: [2160-3-20] Discharge Date: [2160-3-25] Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: The patient is an 83 year old male status post motor vehicle crash with no loss of consciousness, [Location (un) 2611] coma scale 15, right femur fracture, subsplenic hematoma. PAST MEDICAL HISTORY: Coronary artery disease, diabetes mellitus, hypertension, paroxysmal atrial fibrillation, congestive heart failure, ejection fraction of 35% with aortic stenosis 1 cm, 1+ aortic insufficiency plus mitral regurgitation and tricuspid regurgitation. PAST SURGICAL HISTORY: Coronary artery bypass graft, carotid endarterectomy in [2151]. MEDICATIONS ON ADMISSION: Lasix 20 mg q.d.; Imdur 30 mg q.d.; Accupril 10 mg t.i.d.; Lipitor 40 mg q.d.; Toprol XL 100 mg q.d.; Amiodarone 200 mg q.d.; Mirtazapine 15 mg q.d.; Coumadin 2 mg q.d.; Levoxyl 50 mg q.d.; Aspirin 81 mg q.d.; Oxycodone prn. LABORATORY DATA ON ADMISSION: White blood cells 10.8, hemoglobin 11.9, hematocrit 36.8, platelet count 110. PT 17.3, PTT 35.6 and INR 2.0. Fibrinogen 428, glucose 219, urea 36, creatinine 1.2, sodium 139, potassium 4.5, chloride 107, bicarbonate 24, anion gap of 13. CPK 96, amylase 67, calcium 8.2, phosphorus 4.2 and magnesium 1.8. Toxicology screen was negative. There was no pertinent microbiology. Radiology - Trauma Series performed without comparison showed a right femoral fracture, essentially subtrochanteric although a portion of the lesser trochanter appears to be attached to the distal fragment. Radiographs of the right hand reviewed showed a fracture at the base of the right fifth metacarpal. Computerized tomography scan of the abdomen revealed a right femoral fracture as described above, subcapsular splenic hematoma and contusion, slight enlargement of the right psoas with small areas of focal enhancement probably representing soft tissue injury associated with right femoral fracture, and chronic changes of the lungs at the bases. Radiographs of the spine revealed cervical spine, minimal anterolisthesis of C4 on C5, degenerative changes and osteopenia, no fracture detected. Thoracic spine with mild anterior wedge compression fractures of two upper thoracic vertebra bodies, questionable T4 and T5. These are of indeterminate acuity. Lumbar spine, osteopenia, no fracture detected. The sacrum was obscured. A computerized tomography scan reconstruction was cone on the spine computerized tomography scan, and showed no evidence of fracture, Grade 1 C4 on C5 anterolisthesis, degenerative changes most pronounced at C5-6 and C6-7 areas. The thyroid gland appears enlarged with multiple locations and a flexion, extension comparison of the cervical spine showed multilevel instability of the cervical spine with flexion, multilevel degenerative changes of the cervical spine. HOSPITAL COURSE: On [2160-3-21], an intramedullary rod was used to fixate the right subtrochanteric femur fracture by the Orthopedic Service without incident. The right fifth metacarpal fracture was splinted on [2160-3-20]. Flexion and extension views of the cervical spine were viewed by Dr. [First Name (STitle) 1022] of the Orthopedic Team and it was decided that the collar may come off. The patient was also cleared clinically with removal of the cervical collar. DISCHARGE DIAGNOSIS: 1. Right femoral fracture. 2. Subcapsular splenic hematoma. 3. Right fifth metacarpal fracture. 4. Questionable compression fracture of T4-5. 5. Coronary artery disease. 6. Diabetes mellitus. 7. Hypertension. 8. Paroxysmal atrial fibrillation. 9. Congestive heart failure. An addendum will be added upon discharge of the patient. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Last Name (NamePattern1) 52643] MEDQUIST36 D: [2160-3-25] 07:36 T: [2160-3-25] 07:49 JOB#: [Job Number 52699]	[ "42731", "V4581", "4019" ]
Admission Date: [2112-1-22] Discharge Date:[2112-2-4] Date of Birth: [2112-1-21] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname 59134] is a 2,575 gram, 34 week, twin number one male admitted secondary to prematurity. This infant was born to a 36 year old G-2, P-0-2 female. PRENATAL SCREEN: A positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, GBS unknown. This pregnancy was complicated by twins with twin B known to have [Location (un) 5263] syndrome (anhydramnios, bilateral multi- cystic dysplastic kidneys, short femurs, severe IUGR). This twin had a normal ultrasound with normal amniocentesis. Prior to delivery the parents met with neonatology and requested comfort measures only for twin B and a baptism. Betamethasone complete, presented on day of delivery with preterm labor and hypertension moving forward to a cesarean section delivery. This twin emerged vigorous with Apgar's of 8 and 9. PHYSICAL EXAMINATION: Premature male, comfort on room air. Temperature 98.8, heart rate 164, respiratory rate 60's, blood pressure 57/34, mean of 42, O2 saturations greater than 94 on room air. Birth weight 2,575 grams - 75th to 90th percentile, length 45 cm - 75th percentile, had circumference 32 cm - 50th to 7th percentile. Anterior fontanelle soft, flat, nondysmorphic, intact palate. Clear breath sounds. [1-17] murmur, soft. Abdomen - Three vessel cord. No hepatosplenomegaly. Normal male genitalia. Diaper wet with urine. Patent anus. No hip click. No sacral dimple. Normal tone and activity. REVIEW OF HOSPITAL COURSE BY SYMPTOMS: The infant remained on room air and has had an occasional drift of his saturation mostly with feedings. Cardiovascular - The baby had a soft murmur initially. This has resolved with no blood pressure instability. The baby did not require any pressor support. Fluid, electrolytes and nutrition - The baby was initially started on ad lib feedings with breast milk or special care- 20, continues to advance on total fluids and is currently min of 170 cc/kg breast milk or Neosure-20 PO . As he began to take larger volumes of feeds he had some suck/swallow and breathing coordination isssues with feeding. At the time of discharge this resolved. Weight at discharge was 2.670 kg. The initial D-stick was 71, subsequent D-sticks have been greater than 58 with no issues. Gastrointestinal - The baby had a bilirubin on day of life three which was [1-25] of 13/0.5 for which he received several days of phototherapy. A 48 hour rebound bili was 9.3. Hematology - The baby has not had a blood type done to date and has not required any blood products during this admission. Admission hematocrit was 47.6. Infectious disease - Because of preterm labor, the baby had a blood culture and CBC sent on admission with a white count of 14.7, 25 polys, 0 bands, 68 lymphs, platelets 298,000, 5 enucleated red blood cells and hematocrit of 47.6. Blood culture was sent and the baby was not started on any antibiotic therapy. Neurology - The baby is neurological appropriate for gestational age. No imaging has been done as the baby is greater than 34 weeks. Sensory - Audiology screening on [2-3] was normal. Psychosocial - The parents are quite pleased with [Known lastname 38887] progress. Of note, his brother [Name (NI) ] remained with the parents after delivery, was baptized and expired in Labor and Delivery with his parents. They did receive pictures of [Location (un) ] with his brother as well as independently and pictures of them as a family. Hepatitis B immunization - Given on [1-26]. Circumcision: [2-3]. Opthomology: Red reflex could not be obtained distinctively in both eyes. Have discussed with mother and notified pediatrician who will f/u with an outpatient visit at [Location (un) 2274] Optho. DISCHARGE DIAGNOSIS: Premature male twin 34 weeks gestation. Twin died with [Location (un) ] Syndrome. Hyperbilirubinemia S/P Feeding immaturity. Poor quality red reflex. CARE RECOMMENDATIONS: 1. F/U at [Location (un) 2274]/CAM,Dr.[Last Name (STitle) 21615] within 5 days of discharge. 2. VNA to come to home the day post discharge. 3. F/U Optho appointment to be arranged by Dr. [Last Name (STitle) 21615]. [Last Name (LF) ],[Name8 (MD) ] M.D. [MD Number(1) 38370] Dictated By:[Last Name (NamePattern4) 55464] MEDQUIST36 D: [2112-1-26] 01:57:38 T: [2112-1-26] 04:36:37 Job#: [Job Number ]	[ "7742", "V053", "V290" ]
Admission Date: [2127-1-7] Discharge Date: [2127-1-15] Date of Birth: [2062-3-25] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4679] Chief Complaint: right flank pain Major Surgical or Invasive Procedure: [2127-1-7] 1. Right thoracoscopy. 2. Right thoracotomy and right upper lobectomy. 3. Mediastinal lymph node dissection. [2127-1-9] Flexible bronchoscopy with therapeutic suctioning of secretions from the bronchus intermedius and right middle lobe. History of Present Illness: Ms. [Known lastname ] is a 64 year old woman with a history of emphysema and a new right lung mass seen on chest CT from OSH. Ms. [Known lastname ] was seen in Thoracic Surgery clinic [2126-10-17] for an initial evaluation of this mass. She returns today following repeat chest CT which showed slight enlargement of the spiculated right upper lobe, FDG avid mass. Since last being seen, Ms. [Known lastname ] [Last Name (Titles) 44646] continued R flank and iliac pain, for which she continues to be treated with low dose percocet. She underwent an MRI at an OSH for this pain and was notable for possible disc herniation as well as possible "spine cancer" per patient. Aside from this, Ms. [Known lastname ] says she feels "a little tired" but otherwise has no complaints, with no SOB, cough or increased sputum production. Past Medical History: Emphysema osteoarthritis Social History: Cigarettes: [ ] never [ ] ex-smoker [X] current Pack-yrs:_46___ quit: ______ ETOH: [ ] No [x] Yes drinks/day: _5-7___ Drugs: Exposure: [x] No [ ] Yes [ ] Radiation [ ] Asbestos [ ] Other: Occupation: Marital Status: [ ] Married [ ] Single [x] Divorced Lives: [ ] Alone [ ] w/ family [ ] Other: 2 children Other pertinent social history: Travel history: Family History: Mother: Parkinsons, Arthritis Father: Died from Liver Cancer at age 56 Physical Exam: BP: 144/88. Heart Rate: 81. Weight: 114.8. Height: 66.25. BMI: 18.4. Temperature: 97. Resp. Rate: 16. Pain Score: 0. O2 Saturation%: 98. GENERAL [x] All findings normal [ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings: HEENT [x] All findings normal [ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric [ ] OP/NP mucosa normal [ ] Tongue midline [ ] Palate symmetric [ ] Neck supple/NT/without mass [ ] Trachea midline [ ] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [x] All findings normal [ ] CTA/P [ ] Excursion normal [ ] No fremitus [ ] No egophony [ ] No spine/CVAT [ ] Abnormal findings: CARDIOVASCULAR [x] All findings normal [ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema [ ] Peripheral pulses nl [ ] No abd/carotid bruit [ ] Abnormal findings: GI [x] All findings normal [ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] All findings normal [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] All findings normal [ ] Strength intact/symmetric [ ] Sensation intact/ symmetric [ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact [ ] Cranial nerves intact [ ] Abnormal findings: MS [x] All findings normal, no tenderness for [ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl [ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl [ ] Nails nl [ ] Abnormal findings: LYMPH NODES [x] All findings normal [ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl [ ] Inguinal nl [ ] Abnormal findings: SKIN [x] All findings normal [ ] No rashes/lesions/ulcers [ ] No induration/nodules/tightening [ ] Abnormal findings: PSYCHIATRIC [x] All findings normal [ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect [ ] Abnormal findings: Pertinent Results: [2127-1-6] 11:00AM WBC-12.7* RBC-3.72* HGB-14.0 HCT-41.9 MCV-113* MCH-37.7* MCHC-33.5 RDW-12.1 [2127-1-6] 11:00AM PLT COUNT-414 [2127-1-6] 11:00AM PT-12.4 PTT-25.0 INR(PT)-1.0 [2127-1-7] 05:48PM GLUCOSE-121* UREA N-10 CREAT-0.5 SODIUM-137 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11 [2127-1-6] Chest CT : 1. Mild interval enlargement of a now 2.1 x 1.6 cm spiculated right upper lobe pulmonary nodule with associated adjacent pleural thickening, presumed malignant. 2. Severe upper lobe predominant pulmonary emphysema. 3. Stable, top normal right hilar, right lower paratracheal and prevascular lymph nodes. 4. Fusiform dilation of the ascending aorta and moderate aortic valve calcification of unknown hemodynamic significance. [2127-1-9] CTA Chest : 1. No pulmonary embolism is main pulmonary artery. Due to suboptimal opacification of lobar, segmental and subsegmental branches of pulmonary artery, assessment of emboli within these branches was limited. 2. There is no evidence of middle lobe torsion, however, it is remarkable for complete collapse secondary to the occlusion of middle lobe bronchus, likely from secretions. 3. Multifocal aspiration in left lung. 4. Complete occlusion of the right bronchus intermedius, likely from secrections with partial atelectasis of the right lower lobe. 5. Moderate, nonhemorrhagic, posterior right pleural effusion with compressive atelectasis of the adjacent lung, mild right pneumothorax and subcutaneous emphysema are likely following recent surgery. 6. Pulmonary artery hypertension. 7. Sever aortic valve calcification, unknown hemodynamic significance. Brief Hospital Course: Mrs. [Known lastname ] was admitted to the hospital and taken to the Operating Room where she underwent a right thoracoscopy and right thoracotomy with wedge resection of the right upper lobe. See formal Op note for details. She tolerated the procedure well and returned to the PACU in stable condition. She had an epidural catheter placed for pain control which was minimally effective. Following transfer to the Surgical floor she was able to use her incentive spirometer and her pain was controlled with a Bupivacaine epidural and a Dilaudid PCA. Unfortunately her epidural fell out and her pain medication was changed to Oxycodone. Late in the evening of post op day #1 she suddenly desaturated to the mid 80's and had a pO2 of 54 on 5L NC. She was placed on a 100% non rebreather and her saturations came up to 90%. Her chest xray showed a new LL lobe opacity and she subsequently had a Chest CTA done which ruled out PE but demonstrated RML collapse due to an occluded right [Hospital1 ]. Following transfer to the SICU she underwent a diagnostic and therapeutic bronchoscopy. She had thick mucous plugging which was aspirated and she immediately improved. She remained in the ICU for a few additional days for vigorous pulmonary toilet including nebulizers, mucolytics, chest PT and incentive spirometry. She was also placed on a 7 day course of Vancomycin and Zosyn. No sputum cultures were obtained. She continued to improve daily. She remained afebrile with a normal WBC (12K prior to starting ABX). Her chest tube was removed after the serosanguinous drainage tapered off and her thoracotomy incision was healing. Following transfer to the Surgical floor she continued to require oxygen and would desaturate off of it with exertion. The Physical Therapy service evaluated her and recommended rehab for pulmonary toilet. Hopefully in time her oxygen will be able to be weaned off prior to returning home. Although she is small and slight in stature she is able to tolerate a fair amount of narcotics and still has some discomfort but she also took Percocet prior to admission for multiple arthritic aches and pains. She takes prn Lorazapam at home and has continued on that but this morning Valium 5 mg was given additionally and was effective. Replacing the Lorazapam with Valium may be an option of needed. She was eating well and ambulating frequently. Her antibiotics will end on [2127-1-16]. After a prolonged hospital course she was discharged to rehab on [2127-1-15] and will follow up in the Thoracic Clinic in 2 weeks. Medications on Admission: Folic acid, Antacid, Cigotine smoking cessation aid Lorazepam 1 mg q hs for insomnia, Vitamins and herbs, Percocet5/325 [5-15] daily, fosamax, zoloft, calcium, fishoil, zinc, vit B12 Discharge Medications: 1. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 8. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q8H (every 8 hours). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for break through pain . 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 14. piperacillin-tazobactam 4.5 gram Recon Soln Sig: 4.5 Gm Intravenous every eight (8) hours: thru [2127-1-16]. 15. vancomycin 500 mg Recon Soln Sig: Seven [Age over 90 1230]y (750) mg Recon Soln Intravenous Q 8H (Every 8 Hours): thru [2127-1-16]. 16. sodium chloride 3 % Solution for Nebulization Sig: Fifteen (15) ML Inhalation Q 8H (Every 8 Hours). Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Nonsmall-cell lung cancer Post op RLL collapse Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital for lung surgery and developed pneumonia post op requiring readmission to the ICU. You've recovered well but you will need to go to rehab for a short time to regain your strength and continue pulmonary toilet. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol 650 mg every 6 hours in between your narcotic. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk 4-5 times a day and gradually increase your activity as you can tolerate. * You still need oxygen and the nurses at the rehab will help you wean off of it was you get stronger. Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2127-1-28] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please report to the Radiology Department on the [Location (un) ] of the [Hospital Ward Name 23] Clinical Center 30 minutes prior to your appointment with Dr. [First Name (STitle) ] for a chest Xray. Call Dr. [Last Name (STitle) 24522] when you get home from rehab to arrange for a follow up appointment Completed by:[2127-1-15]	[ "486", "5180", "3051", "53081" ]
Admission Date: [2153-6-20] Discharge Date: [2153-6-22] Date of Birth: [2076-1-16] Sex: F Service: MEDICINE [Hospital Ward Name ] 7 HISTORY OF PRESENT ILLNESS: Patient is a 77-year-old female with a history of hypertension, congestive heart failure, and cirrhosis due to hepatitis C, who is brought to the Emergency Room by her daughter for a one day history of change in mental status. The daughter reported that the patient had delayed response to questions and occasionally inappropriate responses. She seems confused, and her state of confusion continued to worsen throughout the day, however, she was able to follow simple commands. REVIEW OF SYSTEMS: Negative for chest pain, abdominal pain, nausea, vomiting, headache, dysuria, or any sick contacts. Negative also blurred vision. The patient has been on multiple antihypertensive medications in the past, and her usual blood pressures are in the 150s systolic/40s-50 diastolic. In the Emergency Department, her blood pressure was noted to be 242/103. She was given all of her usual oral medications, hydralazine 10 mg IV x2 with little improvement in her systolic blood pressure. However, after these medications were given, she was back to her normal baseline mental status, according to her daughter. PAST MEDICAL HISTORY: 1. Hypertension. 2. Congestive heart failure. 3. Hepatitis C. 4. Glaucoma. 5. Thrombocytopenia. 6. Esophageal varices grade three. MEDICATIONS AT HOME: 1. Cozaar 50 mg tid. 2. Lasix 60 mg [Hospital1 ]. 3. Inderal 20 mg [Hospital1 ]. 4. Protonix 40 mg q day. 5. Lactulose prn. SOCIAL HISTORY: Negative for smoking and alcohol. ALLERGIES: Tylenol. PHYSICAL EXAM ON ADMISSION: Temperature is 97.5, blood pressure 242/103, heart rate 55, respirations 12, oxygen saturation 99% on room air. Generally, pleasant elderly female in no acute distress. HEENT examination: Pupils are equal, round, and reactive to light. Extraocular movements was intact. Oropharynx is clear. Head was normocephalic, atraumatic. Neck is supple, no lymphadenopathy, no jugular venous distention. Lungs were clear to auscultation bilaterally. Heart sounds: Normal S1, S2, regular, rate, and rhythm with a 3/6 systolic murmur at the right upper sternal border. Abdomen was soft, nondistended, and nontender with normal bowel sounds. Extremities showed no edema or cyanosis. Neurologic examination: The patient was alert and oriented x2. Cranial nerves II through XII are intact. There was no asterixis. Skin was negative for rashes. LABORATORIES ON ADMISSION: White blood cell count 4.4, hematocrit 40.0, platelets 53. Sodium 142, potassium 3.9, chloride 108, bicarb 23, BUN 25, creatinine 1.2, glucose of 89. INR was 1.4. Urinalysis was negative for blood, protein, leukocytes, and red blood cells. CHEST X-RAY: No evidence of pneumonia or heart failure. CT SCAN OF THE HEAD: Negative for acute intracranial hemorrhage. Showed signs of previous lacunar infarcts, microvascular ischemia and infarctions. ELECTROCARDIOGRAM: Sinus bradycardia at 55 beats per minute, no acute ST-T wave changes. ECHOCARDIOGRAM: From [2150], ejection fraction is 55% with small amount of ASD, no left ventricular hypertrophy, and 2+ mitral regurgitation. SUMMARY OF HOSPITAL COURSE: 1. Increased blood pressure: Patient initially had a systolic blood pressure in the mid 200's. It did not improve with her po Cozaar, Lasix, and Inderal. It also improved only slightly using hydralazine, so it was decided to start a nitroprusside drip. Overtime, patient's blood pressure came down to 180/50, but after discontinuing nitroprusside drip, her pressure went back up. Hydralazine was then given with effect in addition to her oral medications. She was then, on [6-21], transferred to the floor with good control of her blood pressure. She was discharged home with the same medications she had prior to admission and the addition of losartan at 75 mg a day. 2. Change in mental status: According to family members, the patient's mental status improved while still in the Emergency Room after receiving her normal home medications and hydralazine despite her blood pressure being high at that time. Her mental status continued to be at baseline throughout her hospital stay. 3. Congestive heart failure: Patient is not in heart failure during this admission. Her Lasix was continued as before. 4. Gastrointestinal: History of cirrhosis due to hepatitis C and esophageal varices grade 3. Protonix was continued as was lactulose and Inderal. Patient had no GI complaints throughout her hospital stay. 5. Thrombocytopenia: Stable while in-house. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Hypertensive emergency. 2. Change in mental status resolved. DISCHARGE MEDICATIONS: 1. Propanolol 20 mg one po bid. 2. Lasix 60 mg q day. 3. Losartan 75 mg q day. 4. Lactulose as prescribed at home prior to admission. DISCHARGE INSTRUCTIONS: The patient was instructed to call her doctor if there was anything like change in mental status or if her blood pressure increased above 190 systolic. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6756], M.D. [MD Number(1) 6757] Dictated By:[Last Name (NamePattern1) 2543] MEDQUIST36 D: [2153-6-23] 13:56 T: [2153-6-29] 10:11 JOB#: [Job Number 93371]	[ "4019", "2875", "4280" ]
Admission Date: [2191-5-15] Discharge Date: [2191-6-11] Date of Birth: [2111-10-25] Sex: F Service: SURGERY Allergies: Codeine / Lopressor Attending:[First Name3 (LF) 1556] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 79 year old woman who underwent an exploratory laparotomy with lysis of adhesions in [3-28] presented to [Hospital6 18346] with nausea and vomiting. This began with awaking with acute onset of pain at 2 AM. On [Hospital1 6687], her CT scan demonstrated poor perfusion to the pancreatic head as well as partial thrombus of the SMV and splenic vein. Past Medical History: Hypertension History of atrial fibrillation Surgical history: Ruptured appendix 3 years ago Small bowel obstruction, lysis of adhesions Social History: Ms [Known lastname 72820] lives with her [Age over 90 ] year old husband on [Name (NI) 6687] where she is a real estate [Doctor Last Name 360]. She has 3 daughters. One also lives on [Hospital1 6687] and works for the historical society. Ms [Known lastname 72820] is the primary caregiver for her husband. She denies tobacco use, reports EToH daily, a glass of wine. She denies recreational drug use. Family History: NC Physical Exam: T 96.8, P 80, BP 120/60 General: No acute distress Heart: Regular rate and rhythm Lungs: Diminished breath sounds at the bases Abdomen: Soft, nondistended, diffusely tender. Pertinent Results: Radiology: [5-15] RUQ U/S: Cholelithiasis without evidence of acute cholecystitis. [5-16] CTA Abdomen/Pelvis: 1. Acute necrotizing pancreatitis. Nonenhancement consistent with necrosis involves the body and neck region of the pancreas with significant peripancreatic stranding and fluid, some of which extends into the left anterior pararenal space. No gas within pancreas or and no discrete fluid collections. Thrombus is present within the SMV distally and near the SMV portal vein confluence. 2. 3.4 cm heterogeneously enhancing left renal mass, highly concerning for renal cell carcinoma. Left renal cysts. Probable tiny right renal cysts.\ 3. 1.9 cm right adnexal cyst. 4. Small bilateral pleural effusions [5-20] MRCP: 1) Necrotizing pancreatitis. 2) Near-occlusive thrombosis of the superior mesenteric vein, progressed since [2191-5-16]. 3) Left renal mass with appearance consistent with renal cell carcinoma. 4) Pancreas divisum. 5) Bilateral renal cysts [5-26] CT Abdomen/Pelvis: 1. Evolving pseudocyst(s) in the location of previously visualized necrosing pancreatitis changes, with interval increase in superior mesenteric vein thrombus. 2. Persistent enhancing left renal cortical mass, highly suspicious for renal cell carcinoma. 3. Interval increase in bilateral pleural effusions with associated lower lobe collapse. 4. New diffuse subcutaneous edema. 5. Redemonstration of an incompletely imaged right adnexal cyst. [2191-5-15] 03:40PM BLOOD WBC-16.1# RBC-4.68 Hgb-14.3 Hct-40.5 MCV-87 MCH-30.5 MCHC-35.2 RDW-14.4 Plt Ct-345 [2191-6-11] 08:05AM BLOOD PT-22.0* PTT-28.6 INR(PT)-2.2* [2191-5-15] 03:40PM BLOOD Glucose-154* UreaN-24* Creat-1.3* Na-139 K-5.0 Cl-105 HCO3-21* AnGap-18 [2191-5-15] 03:40PM BLOOD ALT-15 AST-39 AlkPhos-86 Amylase-1460* TotBili-0.3 [2191-5-15] 03:40PM BLOOD Lipase-2144* Brief Hospital Course: Ms. [Known lastname 72820] was admitted to [Hospital1 18] under the care of Dr. [Last Name (STitle) ] in the SICU for care for her necrotizing pancreatitis. For her SMV and splenic vein thromboses, she was placed on a heparin drip with a goal of 60-80 seconds for PTT. An arterial line was placed to more accurately follow her blood pressures. Meropenem therapy was initiated for her necrotizing pancreatitis on HD3 and a PICC line was placed. TPN was initiated. Cardiology was consulted for rapid atrial fibrillation on HD4. She was treated with diltiazem. On HD9, she was given Coumadin to begin transitioning to a PO anticoagulation regimen. She required a Neosynephrine drip to maintain her blood pressure. However, on HD10, she was intubated for respiratory failure. Her Neosynephrine drip was weaned to off. Her TPN was stopped, and tube feeding was initiated via [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-jejunal tube. Neosynephrine was reinitiated to maintain her blood pressure. On HD14, she had another bout of atrial fibrillation and was placed on an Amiodarone drip. On HD 15, her pressors were again weaned to off. On HD 17, she was extuabed. Her heart rhythm had converted to sinus on amiodarone and diltiazem. Active diuresis ensued. On HD18, she passed her speech and swallow evaluation and began to tolerate PO feeds. On HD19, she was transferred to the floor. On the morning of HD21, after missing 2 doses of PO amiodarone, she was noted to be in atrial fibrillation. She was given IV diltiazem with no effect. She was then transferred to teh SICU for an amiodarone bolus and drip. She converted back to siunes rhythm and was transferred to the floor on HD22. At this time, she was not therapeutic on Coumadin, and her doses were adjusted. She tolerated a regular diet and tube feeds were stopped. On HD24, her Foley catheter was removed. She was noted to have an INR of 2.0 on HD26. On HD28, she was deemed ready for discharge home. She is to follow up with Dr. [Last Name (STitle) ] in 2 weeks with a CT scan. She should follow up with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 3748]. She should follow up with Dr. [First Name (STitle) 2429], her PCP, [Name10 (NameIs) ] [Name11 (NameIs) 766] to discuss management of her coumadin and amiodarone. Medications on Admission: Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Medications: 1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:5 Tablet(s) Refills:0 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 1 months. Disp:120 Tablet(s) Refills:0 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [Hospital6 18346] Discharge Diagnosis: Necrotizing pancreatitis Discharge Condition: Good Discharge Instructions: Please call the office or go to the Emergency Room if you experience: --Fever above 101.5 F --Nausea that will not go away --Worsening abdominal pain --Bleeding that will not stop --Any other concerns You will be taking Coumadin. You should follow up with your PCP (Dr. [First Name (STitle) 2429] on [First Name (STitle) 766] to discuss dosing. Followup Instructions: Follow up with Dr [Last Name (STitle) ] in 2 weeks. You should have a CT scan performed the morning of this appointment. You should call his office at [Telephone/Fax (1) 3201] to arrange this. At that hospital visit, you should also follow up with Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 1231]) and Dr. [Last Name (STitle) 3748] ([Telephone/Fax (1) 3752]). You should see Dr. [First Name (STitle) 2429] on [First Name (STitle) 766] for discussions about Coumadin and Amiodarone.	[ "42731", "51881", "4280", "4019", "2859" ]
Admission Date: [2193-11-26] Discharge Date: [2193-12-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2641] Chief Complaint: transfer from OSH for MS change and abdominal pain Major Surgical or Invasive Procedure: transfusion with 5 units of pRBCs EGD ([2193-12-4]) R SC central line placement on [2193-12-4], pulled on [2193-12-10] History of Present Illness: History obtained from OMR and chart as patient is poor historian. She is an 85 year old female with h/o possible meningoencephalitis, CVA, HTN, TIAs, DM, hypercholesteremia who was admitted to [Hospital3 ] on [11-15] with generalized body aches and and shoulder pain. Felt to have PMR initially with ESR of 61 and started on prednisone. This was discontinued and she received steroid injection for subacromial bursitis. Dilantin level only 1.9, and reloaded with unknown dose. Had barium enema for anemia (diverticuli) and was treated for a UTI (no culture data). On [2193-11-23] became somnolent, transferred to ICU, found to have leukocytosis to 22.4, anemia down to 25.3 from 32.5, and supratherapeutic dilantin level (30 when corrected for albumin). LP, head CT, CXR, UA negative. Abd CT showed thickening of 2nd and 3rd part of duodenum and R retoperitoneal fluid, started on vanc, CTX, acyclovir, ampicillin, and and transferred to [Hospital1 18] SICU. Past Medical History: DM II HTN TIA [5-22] - R hand paresthesias/speech disturbances; w/u at [Hospital1 ] showed EF 60%, no carotid disease, MRI with small vessel disease. Started on ASA and plavix (after recurrence a few days later). Glaucoma Hyperlipidemia Vitamin D deficiency Meningoencephalitis [6-22] - Admitted to [Hospital1 18] with CSF pleocytosis, ultimately negative CSF infectious w/u. MRI with multiple bilateral infarctions of unclear etiology. Subsquent TEE negative for vegatations. CVA as above Possible seizures in setting of meningoencephalitis and CVA Social History: Married. Denies tobacco, EtOH, IVDU per OSH notes. Lives in [Hospital3 ] facility with husband. Family History: noncontributory Physical Exam: Admission PE to SICU: VS 99.1, 105, 173/129, 18, 100% 2L CVP 8 Gen: alert, poorly oriented,non toxic, NGT nonbloody CV: TAchy, no jvd Lung: coarse BS r>l abd: soft, ND, slight RUQ TTP, guaiac + ext: wwp 2+DP's . PE at the time of transfer from SICU to medicine on [2193-12-6] Vitals: 97.6, 77, 146/30, 22, 98, I/O + 3L [Location 33406]: PERRL, EOMI, left eye with conjunctival injection, prefers left lateral gaze, anicteric sclera, MMM, OP clear Neck: supple, no LAD, no thyromegaly Cardiac: RRR, NL S1 and S2, no MRGs Lungs: CTAB, decreased BS on right Abd: soft, NTND, NABS, midline abdominal scar, no RUQ tenderness, no HSM, no rebound or guarding Ext: warm, 1+ pedal edema, 2+ DP pulses2+ DP pulses, no C/C/E Neuro: somewhat inattentive, A&O only to person, occasionally answers simple questions (name of husband) but generally mute, CN [Name (NI) 33407] intact, MAE, strength 5/5 in LE, 4+ in UE Pertinent Results: Admission labs: [2193-11-26] 11:45PM BLOOD WBC-19.4# RBC-3.14 Hgb-9.8* Hct-27.6* MCV-88 MCH-31.2 MCHC-35.4* RDW-14.8 Plt Ct-241 [2193-11-26] 11:45PM BLOOD PT-11.9 PTT-25.6 INR(PT)-1.0 [2193-11-26] 11:45PM BLOOD Glucose-175* UreaN-15 Creat-0.9 Na-134 K-3.9 Cl-101 HCO3-21* AnGap-16 [2193-11-26] 11:45PM BLOOD ALT-11 AST-13 LD(LDH)-193 AlkPhos-131* Amylase-40 TotBili-1.2 Other Labs: [2193-11-27] 05:24AM BLOOD Lipase-44 GGT-42* [2193-12-6] 04:17AM BLOOD Lipase-60 05:00AM BLOOD calTIBC-173* VitB12-560 Ferritn-337* TRF-133* Iron-43 [2193-12-9] 05:21AM BLOOD Folate-12.7 [2193-12-6] 04:17AM BLOOD Triglyc-118 HDL-32 CHOL/HD-4.6 LDLcalc-92 Cholest-148 [2193-12-8] 05:00AM BLOOD TSH-3.4 SPEP negative, UPEP pending Vasculitis work up [2193-12-7] 06:15AM BLOOD ESR-30* [2193-12-7] 06:15AM BLOOD ANCA-NEGATIVE B [2193-12-7] 06:15AM BLOOD [Doctor First Name ]-POSITIVE Titer-1:640 [2193-12-7] 06:15AM BLOOD CRP-21.0, ACE 16 (nl), ssA and B antibody negative [2193-12-11] Blood dsDNA pending Discharge Labs: [2193-12-12] 06:40AM BLOOD WBC-5.9 RBC-3.28 Hgb-10.3* Hct-29.4* MCV-90 MCH-31.6 MCHC-35.2* RDW-17.2* Plt Ct-415 [2193-12-12] 06:40AM BLOOD Glucose-131* UreaN-14 Creat-0.9 Na-140 K-4.1 Cl-109* HCO3-24 AnGap-11 [2193-12-12] 06:40AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.0 Reports: TTE ([2193-12-11]) 1.The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. No aortic regurgitattion present. 5.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6.There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [2192-7-10], no change. No cardiac source of embolus seen. . 24 hr EEG ([Date range (1) 33408]) per neuro, negative for seizures. . Head CT ([2193-12-7]) 1. No evidence of intracranial hemorrhage. 2. Similar bilateral foci of hypodensity consistent with prior infarcts, not significantly changed, from prior study. MRI is superior to CT in detecting acute brain ischemia, if clinically feasible. 3. New air-fluid level in the right maxillary sinus and right frontal air cell, suggestive of sinusitis, also involving the right ethmoid sinus. . Carotid Doppler ([2193-12-6]) IMPRESSION: Minimal bilateral ICA plaque, no appreciable associated ICA or CCA stenosis. . EEG ([2193-12-6]) This is an abnormal EEG due to the right frontal slow transients, disorganized and slow background and bursts of generalized delta slowing. The first abnormality suggests right frontal subcortical dysfunction. The last two abnormalities suggest an encephalopathy, which may be seen with infections, toxic metabolic abnormalities, medications or ischemia. . CT abd/pelvis ([2193-12-4]) 1. Interval resolution of the peri-duodenal inflammatory stranding and retroperitoneal fluid collection. 2. Increased size of bilateral pleural effusions, right greater than left, and anasarca suggests volume overload. 3. Sigmoid diverticulosis without evidence for diverticulitis. 4. Two small 1.9 cm anterior abdominal wall fat-containing hernias located just superior to the umbilicus. 5. L2 compression fracture of indeterminate age without prior examinations for comparison. . EGD ([2193-12-4]) Impression: Erythema and edema in the antrum in the stomach Ulcer in the first part of the duodenum and second part of the duodenum Erythema and edema in the duodenum (biopsy) Otherwise normal EGD to second part of the duodenum Recommendations: Continue PPI Await biopsy results. . PATH from EGD bx [2193-12-4] - chronic duodenitis . MRI/A Brain [2193-12-2] IMPRESSION: (Subacute infarcts and hemorrhage) 1. Chronic watershed distribution infarcts in the occipitoparietal lobes and high frontoparietal lobes bilaterally. 2. New rounded areas of signal abnormality in the left basal ganglia and left posterior temporal lobes, most consistent with subacute infarction. There are several foci of susceptibility artifact in the left basal ganglia consistent with hemorrhage. 3. T2 signal hyperintensity in the mastoid air cells, left worse than right, that may represent fluid or mucosal thickening. Air fluid level in the right maxillary sinus, new compared to the CT scan of [2193-11-24], may suggest acute sinusitis. . CXR [2193-12-4]: Small bilateral pleural effusions and mild pulmonary edema are unchanged . Micro: [11-27] and [12-3] BCX NGTD [2193-11-28], [2193-12-4], [2193-12-7], [2193-12-8](toxcin B): C diff negative x 4 [2193-12-4] catheter tip cx negative [2193-12-8] RPR NR [2193-11-27], [2193-12-3] UA negative urine cx negative [2193-11-27] H pylori negative Brief Hospital Course: Patient is a 85 year old female with complicated PMH of possible meningoencephalitis, TIAs, CVA, HTN, hyperlipidemia, and possible seizures who presents from OSH with duodenitis, leukocytosis, and MS changes. Her hospital course during this admission is as follows: 1 Mental Status changes - She was extensively worked up and neurology followed the patient throughout her hospital course. It was felt that multiple reasons attributed to her metnal status chagnes, including toxic/metabolic with supratherapeutic dilantic levels as large contributor (which gradually resolved); in addition, with subacute infarcts and hemorrhage on MRI/A on [2193-12-2] which may also contribute to her mental status change; She underwent carotid dopper which showed minimal bilateral plaques; TTE showed normal LV and RV systolic function (EF>55%), 1+ MR, no AR, no source of emboli seen; multiple EEGs, including 24 EEGs showed no seizures, although she was kept on seizure prophylaxis given ? ho of seizure with dilantin intially bridging to keppra (she was off dilantin at the time of the discharge). Her other toxic/metobolic work up included TSH (3.4 nl), vit B12 (560 nl), and RPR NR; Fasting lipids TC 148; TG 118; HDL: 32; LDLcalc: 92; Vasculitis work up included ESR 30, CRP 21, [Doctor First Name ] positive with titer 1:640, ANCa negative, ACE 16 (nl), SSA negative, SSB negative; Given her [First Name9 (NamePattern2) 9374] [Doctor First Name ] titer, we send off ds DNA which was still pending at the time of discharge, and neuro recommended no LP, and close follow up with rheumaology regarding further workup of her positive [Doctor First Name ]. Once on the medicine floor, patient was initially A&O x 1, but gradually , her mental status improved, and she was A&O x 2 (person and place), and able to carry on conversation without any difficulty at the time of the discharge. 2 Duodenitis - Patient was initially admitted to the SICU for abdominal pain and possible surgery. In SICU patient had serial abd exams and HCT checks which remained stable. Given her relative [Name (NI) 33409] exam, she was placed on IV vanc/zosyn, no surgery was done. Her H. pylori was negative. She developed an acute Hct drop on [2193-12-3] with Hct nadired at 14.6, and she received 5 units of pRBCs, and her Hct responded to around 30. GI saw pt for HCT drop on [2193-12-4], she underwent EGD on [2193-12-4] which reviewed chronic duodenitis, non-bleeding duodenal ulcers. She underwent CT scan on [2193-12-4], and dudenitis appear to be resolved in the interim. She completed a 10 day course of IV [Doctor Last Name ]/Zosyn. Once she was transfered to the medicne floor on [2193-12-5], and she remained free of any abd pain. Although she was r/o for C.diff, we started her PO flagyl which she needs to complete a 10 day course (need to take 3 more days after discharge) given her leukocytosis during initial transfer, which was resolved at the time of discharge. she remained afebrile once she was called onto the medicine floor. 3 Leukocytosis - Patient was admitted with leukocytosis, thought to be d/t duodenitis. Her C diff remained negative x 4; she was started on flagyl on [2193-12-5], and her WBC started trending down. She remained afebrile, and her blood cultures and urine cx were negative to date. she had no evidence of abscess on CT abd/pelvis. Her WBC count was WNL at the time of discharge. 4 Hypertension - Given her stroke risks, we kept our goal SBP>140; She was initially on metoprolol IV scheduled and hydralazine IV prn; Once she started tolerated PO, she was changed to metoprolol PO which we gradually titrated up to metoprolol 25mg PO tid at the time of discharge. 5 Anemia - her baseline HCT around 30 in [6-23], initial guaiac positve on admission. She developed an acute Hct drop on [2193-12-3] with Hct nadired at 14.6, and she received 5 units of pRBCs, and her Hct responded to around 30. GI saw pt for HCT drop on [2193-12-4], she underwent EGD on [2193-12-4] which reviewed chronic duodenitis, non-bleeding duodenal ulcers. Post EGD, her Hct remained [Last Name (un) 2677] between 28-30, no BRBPR reported, No RP bleed on CT. she was guaiac negative once she was on the medicine floor prior to discharge. Iron studies c/w ACD, nl folate and nl VitB12. Her ASA was initially held given acute Hct drop, which responded to blood transfusion, but was resumed at the time of discharge as her Hct remained stable. 5 DM - Diet controlled, initially we kept her on FSqid, and SSI, and her sugar remained nl w/o any need for SSI; SSI and FS were D/c'ed prior to discharge. 6 FEN - initially NPO and on IV TPN given aspiration risks in the SICU; speech and swallow evaluated the patient at bedside on [2193-12-6], and recommended thin liquid, soft solids, meds crush/whole in puree. she tolerated the diet well and we gradually swtiched her IV meds to PO meds; repleted lytes prn 7 PPX - Bowel regimen, Pneumoboots in setting of GI bleed, PPI [Hospital1 ] 8 Code - FULL code Medications on Admission: Medicine at the time of transfer from SICU to medicine on [2193-12-6] Hydralazine 10 IV Q6 ISS Keppra 500 PO/NG [Hospital1 ], start 1000 [Hospital1 ] on [12-8] Metoprolol 10 IV Q4 Pantoprazole 40 IV Q12 Phenytoin 100 PO BID Zosyn 4.5 IV Q8 Vanc 1gm IV Q12 Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed: to groin and buttock. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP<120 and HR<60. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: Duodenitis (improved) mental status change (multiple reasons, supratherapeutic dilantin level, subacute infarcts and hemorrhage shown on MRI) anemia with acute Hct drop requiring blood transfusion duodenal ulcer shown on EGD + [Doctor First Name ] titer, will be followed by rheumatology and PCP Secondary diagnosis: HTN DM II history of CVA ? history of seizure Discharge Condition: afebrile, VSS, tolerating POs, OOB with assist Discharge Instructions: You were admitted for mental status changes, anemia with acute Hct drop, and duodenitis. Neurology team has been following you throughout this hospital course for your mental status change (multiple reasons including supratherapeutic dilantin level on admission, subacute infarct and hemorrhage on MRI, etc), which has greatly improved at the time of discharge. You need to continue keppra 1000mg twice daily for seizure prophylaxis. You will need to follow up with Dr. [Last Name (STitle) 43]/[Doctor Last Name ] at Neurology after discharge (see appointment time below). . You also had an elevated WBC count during this admission, and received 10 day course of IV Vanc and Zosyn, and you need to complete a 10 day course of PO flagyl after discharge (you need to continue for 3 more days). . You also had duodenitis, and acute Hct drop during this admission, which require 5 units of pRBC transfusion and EGD which revealed a duodenol ulcer. Since your EGD, you Hct has been stable. You need to continue take protonix 40mg twice daily. You need to follow up your Hct closely at the rehab and with your PCP. [Name10 (NameIs) 227] your Hct is stable for more than a week, we restarted you on ASA 81mg daily for stroke prevention. . In addition, you were found to have a positive [Doctor First Name ] titer during this admission, we have sent a multiple lab tests, including ds DNA and UPEP which remained pending at the time of discharge, and needs to be followed up both with your PCP and by Rheumatology during your next appointment time. . If you experience any fevers, chills, chest pain, SOB, dizziness, N/V/D, or any medical conditions concerning for you, please call your PCP or go to the emergency room immediately. . Please continue take all your medications. You need to continue flagyl for 3 more days to complete a 10 day course of antibiotics; continue keppra 1000mg twice daily . Please follow up all your appointments. (see appointment time below) Followup Instructions: Please make the following appointments: . PCP: [Last Name (NamePattern4) ]. [Last Name (STitle) 33410], [First Name3 (LF) ] [Telephone/Fax (1) 18361] on [2193-12-19] 10:30am (CBC check, and f/u you ds DNA titer, ssdna, and Ace level) . Rheumatology: Provider: [Name10 (NameIs) 3712] [Name11 (NameIs) 33411], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2193-12-17] 9:00 (It is very important to follow up with Rheumatology for further workup of your positive [Doctor First Name ] titer) . Neurology: Provider: [Name Initial (NameIs) 43]/[Doctor Last Name ] Phone:[Telephone/Fax (1) 44] Date/Time:[2194-1-16] 4:00 Completed by:[2193-12-12]	[ "25000", "4019", "2724" ]
Admission Date: [2199-9-27] Discharge Date: [2199-10-7] Date of Birth: [2122-4-23] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2199-10-1] Coronary Artery Bypass Graft x 5 (Lima to LAD, SVG to Diag, SVG to OM1, SVG to OM2, SVG to RCA), Mitral Valve Repair w/ 26mm CE Annuloplasty Band History of Present Illness: Ms. [Known lastname ] is a 77 y/o F w/ h/o CAD s/p PTCA to LAD, hyperlipidemia who presented with exertional chest pain x1 month. She noticed increasing chest pain over the past month while walking and swimming. Ultimately, 2 days prior to this admission, she was walking up to a mile up [Doctor Last Name ] and noticed increased severity of this pain. She presented initially to [Hospital3 ], where she had negative enzymes and no EKG changes. On stress, she completed 4 mins of [Doctor First Name ] protocol, nuclear imaging (MIBI) showed a large area of inferior ischemia (RCA territory) with EF of 60%. She was transferred to [Hospital1 18] for cath, which showed 3-vessel disease. Past Medical History: s/p PCI [2186], Hypercholesterolemia, Gastroesophageal Refulx Disease, Anxiety, Polymyalgia Rheumatica, s/p Lap Cholecystectomy Social History: Lives in a home with 6 other women while her house is remodeled this year. Social EtOH, No tob/illicits. Family History: Father d. 71 MI, Mother d. 73 MI Physical Exam: Vitals: T96.0 BP108/63 P66 R18 O2 96%RA Gen: Well-appearing woman in NAD. HEENT: NC/AT. MMM no erythema/exudate. JVP normal. Neck supple w/o LAD. Pulm: Clear to auscultation bilaterally. CV: Regular Rate and Rhythm, with no murmurs, rubs, or gallops. Abd: Soft, non-tender and non-distended. Bowel sounds are normoactive. Ext: 2+ dorsalis pedis pulses; no edema, clubbing, or cyanosis. Neuro: AAOx3. CNII-XII grossly intact. Pertinent Results: CXR [10-6]: There is increase in the left-sided pleural effusion with volume loss in the left lower lobe. There is a patchy area of volume loss in the left mid lung. There is a small right effusion. Echo [10-1]: The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal(LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch and descending thoracic aorta. There is no aortic valve stenosis. Mild (1+)aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation vena contracta is >=0.7cm. The mitral regurgitation jet is eccentric and directed posteriorly. The posterior leaflet appears restricted. POST-BYPASS: An Annular ring is noted in the mitral position. Trace MR is seen. Leaflets open well with a mean gradient of 4 and peak of 9 mm of Hg. No gradient across the LVOT is noted and no [Male First Name (un) ] is seen by 2D exam. [Hospital1 ]-ventricular systolic function is preserved. Carotid U/S [10-1]: Minimal plaque is identified. LE Vein Mapping [10-1]: On the right, greater saphenous vein is patent from the ankle to the groin with diameters ranging from 0.20-0.77 cm. On the left, the greater saphenous vein is patent from groin to ankle. The diameters range from 0.21 cm to 0.66 cm. [2199-9-27] 03:40PM BLOOD WBC-6.6 RBC-3.31* Hgb-10.8* Hct-29.8* MCV-90 MCH-32.5* MCHC-36.2* RDW-13.0 Plt Ct-198 [2199-10-1] 05:21PM BLOOD WBC-18.2* RBC-3.88# Hgb-12.1# Hct-33.4# MCV-86 MCH-31.2 MCHC-36.2* RDW-14.8 Plt Ct-127* [2199-10-5] 05:05AM BLOOD WBC-8.6 RBC-3.17* Hgb-9.6* Hct-27.5* MCV-87 MCH-30.4 MCHC-35.1* RDW-15.6* Plt Ct-121* [2199-10-7] 05:55AM BLOOD Hct-30.2* [2199-9-27] 03:40PM BLOOD PT-12.4 PTT-26.7 INR(PT)-1.1 [2199-10-1] 11:31PM BLOOD PT-14.1* INR(PT)-1.2* [2199-9-27] 03:40PM BLOOD Glucose-220* UreaN-12 Creat-0.6 Na-137 K-3.8 Cl-105 HCO3-26 AnGap-10 [2199-10-1] 06:20AM BLOOD Glucose-101 UreaN-11 Creat-0.7 Na-146* K-4.4 Cl-108 HCO3-30 AnGap-12 [2199-10-5] 05:05AM BLOOD Glucose-93 UreaN-21* Creat-0.7 Na-141 K-3.5 Cl-102 HCO3-30 AnGap-13 [2199-10-7] 05:55AM BLOOD UreaN-18 Creat-0.7 K-4.3 [2199-10-4] 06:20AM BLOOD Mg-2.3 [2199-9-30] 03:30AM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE [2199-9-30] 11:03AM URINE RBC->50 WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0 [2199-9-30] 11:03AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG Brief Hospital Course: As mentioned in the HPI, Ms. [Known lastname ] was transferred from OSH to [Hospital1 18] for cardiac cath. Cath revealed severe 3 vessel coronary artery disease. Echocardiogram revealed moderate to severe mitral regurgitation. She underwent extensive pre-operative work-up prior to surgery. She was brought to the operating room on [10-1] where she underwent a coronary artery bypass graft x 5 and mitral valve repair. Please see operative report for surgical details. She tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Very early on post-op day one she was weaned from propofol, awoke neurologically intact and was extubated. On post-op day two her chest tubes were removed and beta blockers and diuretics were initiated. She was gently diuresed towards her pre-op weight during post-op course. On this day she was also transferred to the step-down floor. On post-op day three her epicardial pacing wires were removed. Over the next several days she continued to make improvements with minimal complaints and no complications. Physical therapy followed pt for strength and mobility. She was discharged to rehab facility on post-op day six for continued PT with the appropriate follow-up appointments. Medications on Admission: Plavix 75mg qd, Crestor 40mg qd, Zantac 150mg qd, Prednisone 5mg qd, Imdur 30mg qd, Aspirin 81mg qd, SL NTG prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 10 days. Discharge Disposition: Extended Care Facility: Life Care Center - [Location (un) 3320] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 Mitral Regurgitation s/p Mitral Valve Repair PMH: s/p PCI [2186], Hypercholesterolemia, Gastroesophageal Refulx Disease, Anxiety, Polymyalgia Rheumatica, s/p Lap Cholecystectomy Discharge Condition: Good Discharge Instructions: You may take shower. Wash incisions and gently pat dry. Do not apply lotions, creams, ointments or powders to incisions. Do not take bath or swim. Do no 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 make all follow-up appointments. Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks Dr. [Last Name (STitle) 26191] in [1-28] weeks Dr. [Last Name (STitle) ] in [3-1] weeks [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2199-10-7]	[ "41401", "53081" ]
Admission Date: [2187-12-21] Discharge Date: [2188-1-15] Date of Birth: [2108-8-7] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Neurosurgery requested consult from Neurology to take over the care of Mr [Known lastname ]. Major Surgical or Invasive Procedure: none History of Present Illness: Mr [Known lastname ] was transferred from [Hospital3 25148] Center on [12-20] for an intracranial bleed. Mr [Known lastname ] is a 79-year-old right handed man with atrial fibrillation previously on coumadin (and ASA). According to Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 81916] note (because the patient is currently intubated and ventilated), he had a history of multiple falls, and he presented to [Hospital3 25148] Center on [2187-12-19] with left hip and leg pain. There was no reported head trauma. On [12-20] he was found to be confused, speaking nonsensical words, and his brain imaging showed a hemorrhage in the left lateral ventricle. His INR was 1.9, and he received vitamin K, and 1U of FFP. He was then transferred to [Hospital1 18], where he was admitted to Neurosurgery. Past Medical History: -lung cancer (underwent left sided lobectomy 25 years ago) -atrial fibrillation -hyperlipidemia -Hypertension Social History: Social Hx: drinks 2 scotches daily, non-smoker Family History: Unknown Physical Exam: O: T:100.8 BP: 130/69 HR: 86 Propofol at 30 mcg (off for 10 min prior to examination), given Dilantin 1 g AC/0.4/20/5 (98%) Gen: intubated, ventilated, C-spine collar on (neck has not been cleared) Lungs: CTA bilaterally. Cardiac: irregular. S1/S2 Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: unable to assess. Cranial Nerves: Anisocoria R>L, R 4--->3 mm, L 3---->2mm, eyes rolling upwards when he started to seize Dolls eyes could not be assessed as neck has not been cleared Positive corneals and nasal tickle, weak gag Motor: Increased tone and rhythmic twitching 0.5-1 Hz in the arms, legs, and trunk throughout (previous episode at 14:30 h) Sensation: No withdrawal from noxious stimuli Reflexes: B T Br Pa Ac Right 1 1 1 1 0 Left 1 1 1 1 0 Toes equivocal b/l Pertinent Results: [2187-12-20] 10:35PM BLOOD WBC-9.1 RBC-4.18* Hgb-13.7* Hct-38.4* MCV-92 MCH-32.7* MCHC-35.5* RDW-13.7 Plt Ct-205 [2187-12-20] 10:35PM BLOOD Neuts-87.6* Lymphs-8.8* Monos-3.4 Eos-0.1 Baso-0.1 [2187-12-20] 10:35PM BLOOD PT-21.1* PTT-29.7 INR(PT)-2.0* [2187-12-20] 10:35PM BLOOD Glucose-163* UreaN-20 Creat-1.0 Na-136 K-3.7 Cl-99 HCO3-26 AnGap-15 [2187-12-22] 03:33AM BLOOD ALT-13 AST-24 LD(LDH)-243 AlkPhos-70 TotBili-0.9 [2187-12-20] 10:35PM BLOOD Calcium-9.9 Phos-3.1 Mg-1.7 [2188-1-3] 07:15AM BLOOD Triglyc-165* HDL-31 CHOL/HD-6.6 LDLcalc-140* [2188-1-1] 04:20PM BLOOD TSH-0.83 [2188-1-1] 04:20PM BLOOD Free T4-1.5 [2187-12-25] 01:53AM BLOOD Vanco-13.0 [2188-1-4] 06:12AM BLOOD Digoxin-0.5* ALDOSTERONE, LC/MS/MS 4 RENIN PENDING Brief Hospital Course: TRANSFERRED TO Neurology ICU team: [12-24] 1. EEG 11/ 30 to 12/ 02: negative for seizures. Dc'd PHT. He was on ETOH withdrawal. 2. AF: Off AC, but started ASA 81 qd on 12/ 01. Rate control was difficult: on metoprolol, diltiazem, and digoxin, 3. HTN: difficult to control: on clonidine, labetalol, HCTZ, amlodipine, plus the above mentioned agents. Required a NTG drip for 2 hours on 12/ 09/ 08 4. ID: UTI (U cx EColi pansensitive) was treated and resolved. in addition, he had an aspiration PNA (RUL)treated for 7 days. Sputum cx: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Started on Nafxillin 2 g q6h on 12/ 03 (evening), stopped vancomycin and Zosyn on 12/ 04). 5. Extubated (12/ 04) 6. DVT ppx: on hep sc 5000 tid started on 12/ 01. 7. Contact[Name (NI) ] family: health care proxy confirmed he is Full code This 79 yo man was admitted with bilateral intraventricular hemorrhage to the ICU intubated. His ICU course was complicated by PNA and UTI that were treated with full courses of antibiotics. His ICU course was also complicated by persistent HTN and tachycardia. Cardiology was consulted and his rate and BP were controlled with a panoply of pharmacological agents, which were eventually titrated to an oral regimen that could be administered on the general floor. Efforts to elucidate secondary causes of HTN were unrevealing. Once transferred to the general floor, he remained afebrile and his BP and HR remained well controlled. His lipid panel was elevated and so his dose of home pravastatin was increased. Per discussion with both his family and PCP, [Name10 (NameIs) ] history of multiple falls recently precludes him from re-starting his coumadin despite his AF. His neurological exam on discharge was notable for ongoing disorientation, mild right NLF flattening, moving all ext antigravity, though probably with some weakness R > L, upgoing toes bilaterally, and able to transfer from bed to chair with max assist, but unable to functionally ambulate. Medications on Admission: coumadin 3mg pravastatin 20mg lisinopril (dose unclear) verapamil 240mg bisoprolol 5mg aspirin 81mg omeprazole 20mg Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 11. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 14. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: intraventricular hemorrhage sleep apnea Discharge Condition: stable Discharge Instructions: You have had a bleed into your brain ventricles, and your coumadin was stopped. Because of your history of recurrent falls, it will not be restarted. Please return to the ER if you experience any sudden weakness, change in sensation, vision, or language, any severe headaches, vertigo, or anything else that concerns you seriously. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 81917], MD Phone: [0-0-] Please follow-up with your PCP [Name Initial (PRE) 176] 1-2 weeks of discharge. Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 2574] Date/Time:[2188-2-26] 2:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3724], MD [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3172], MD (Sleep Clinic) Phone: [Telephone/Fax (1) 612] Date/Time: [2188-1-23] 8:00am Location: [Hospital Ward Name 23] [Location (un) 858] Neurology Completed by:[2188-1-15]	[ "5849", "2760", "5990", "42731", "4280", "32723", "2724", "V5861" ]
Admission Date: [2168-11-3] Discharge Date: [2168-11-16] Date of Birth: [2089-3-16] Sex: F Service: SURGERY Allergies: Penicillins Attending:[Last Name (NamePattern1) 4659] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Open cholecystectomy Ventral herniorraphy placement of swan-ganz catheter respiratory failure History of Present Illness: 79yF p/w acute onset of epigastric/Right sided abdominal pain for 18 hours. Pt awoke with constant burning pain and nausea and vomiting x7. Pain radiated to right side of back. Last BM 1 day PTA. Past Medical History: Colectomy for colon Ca [2167] HTN, CAD, h/o pericarditis Psoriasis Social History: Denies tobacco and EtOH Family History: Mother-CAD died age 76 Physical Exam: On addmission: 98.6 92 181/60 18 95RA A&Ox3, Russian speaking neck supple w/o LAD, PEARL, EOMI CTAB RRR abd soft/obese, midline scar w/ ventral hernia, reducible. +RUQ TTP and +[Doctor Last Name ] sign. Rectal: guaic negative est: warm w/o CCE Pertinent Results: [2168-11-3] 02:45PM BLOOD WBC-15.0# RBC-4.27 Hgb-13.0 Hct-38.2 MCV-89 MCH-30.5 MCHC-34.2 RDW-13.0 Plt Ct-315 [2168-11-15] 04:39AM BLOOD WBC-12.5 RBC-3.25* Hgb-9.7* Hct-29.5* MCV-91 MCH-29.7 MCHC-32.7 RDW-13.8 Plt Ct-454* [2168-11-3] 02:45PM BLOOD Neuts-73* Bands-12* Lymphs-12* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2168-11-15] 04:39AM BLOOD Neuts-61 Bands-2 Lymphs-23 Monos-7 Eos-0 Baso-0 Atyps-7* Metas-0 Myelos-0 [2168-11-3] 02:45PM BLOOD Plt Smr-NORMAL Plt Ct-315 [2168-11-15] 04:39AM BLOOD Plt Smr-HIGH Plt Ct-454* [2168-11-3] 02:45PM BLOOD Glucose-163* UreaN-18 Creat-0.8 Na-138 K-4.2 Cl-98 HCO3-25 AnGap-19 [2168-11-15] 04:39AM BLOOD Glucose-122* UreaN-11 Creat-1.0 Na-143 K-3.2* Cl-100 HCO3-34* AnGap-12 [2168-11-3] 02:45PM BLOOD ALT-14 AST-25 LD(LDH)-206 AlkPhos-90 Amylase-90 TotBili-0.6 [2168-11-7] 02:32AM BLOOD ALT-54* LD(LDH)-190 AlkPhos-94 Amylase-34 TotBili-0.3 [2168-11-3] 02:45PM BLOOD Lipase-25 [2168-11-7] 02:32AM BLOOD Lipase-14 [2168-11-5] 05:56PM BLOOD CK-MB-4 cTropnT-<0.01 [2168-11-6] 05:45AM BLOOD CK-MB-3 [2168-11-3] 02:45PM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9 [2168-11-15] 04:39AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7 [2168-11-5] 06:15PM BLOOD freeCa-1.15 [2168-11-11] 03:45AM BLOOD freeCa-1.14 Brief Hospital Course: Pt admitted to surgery through ED. To OR on [2168-11-4] for cholecystectomy, converted to open and ventral hernia repair. Pt taken to PACU in good condition, extubated with JP drains x2. [11-5]: L SCV PA catheter placed. Pt was extubated and transferred to the SICU on POD1 when pt demonstrated respiratory distress, low UOP, and elevated TBili. Pt was reintubated, cardiac enzymes were negative, and multiple boluses given--pt required almost 12 Liters including intra-op fluids. GI ERCP was consulted, decision to follow LFTs w/ plan to ERCP if LFTs increased. LFTs normalized throughout stay. Pt on dopamine for blood pressure support. Dopamine weaned to off on POD4, and put on CPAP on same day. Swab from wound bed grew pan-sensitive E.coli, on levo/fagyl. POD5 pt self extubated, maintained oxygenation and did not require re-intubation. PA cath changed to 3 lumen CVL. POD6 pt removed NGT, started on sips. Advanced to regular diet w/o incident. Pt discharged to rehab for PT and strengthening before returning home. Medications on Admission: Toprol 25 QD Norvasc 5 QD Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days. Disp:14 Capsule(s) Refills:0 and home meds Discharge Disposition: Extended Care Facility: Meadowbrook - [Location (un) 2624] Discharge Diagnosis: 1. Acute and chronic cholecystitis. 2. Cholelithiasis, cholesterol type Discharge Condition: Good Discharge Instructions: Please resume your home medications. Take all new medications as prescribed. You may shower, but keep the wound dry. The staples will remain unitl your follow up visit. You may resume your regular diet. You may resume your regular activities, but no heavy lifting (> a gallon of milk) for 6 weeks, unless directed otherwise. Please call your physician if you experience increased pain, fever (>101.5), inability to eat or drink, foul discharge from your wound, or other symptoms concerning to you. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ]. An appointment has been made for [11-24] at 4:00pm. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ] MD, [MD Number(3) 4661]	[ "4019" ]
Admission Date: [2188-2-22] Discharge Date: [2188-3-7] Date of Birth: [2113-1-23] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain/Jaw pain/shortness of breath Major Surgical or Invasive Procedure: [2188-2-29] Redo sternotomy, Redo [Month/Day/Year 8813] valve replacement with a size 23-mm [Last Name (un) 3843]-[Doctor Last Name ] Magna pericardial valve [2188-2-29] Exploration for postoperative hemorrhage following a redo [Month/Day/Year 8813] valve replacement History of Present Illness: 75 year old male who complains of Chest pain. He is s/p cardiac cath [1-28] with 1 stent placed. Presented to OSH with sudden onset of bilateral back pain and left jaw pain last night. Symtpoms resolved in terms of pain after 2 hours but the he then noted Shortness of breath on ambulation to the mailbox today. He was seen at OSH and referred back to [Hospital1 18] given recent cardiac stent. He is now being referred to cardiac surgery for redo-[Hospital1 8813] valve replacement. Past Medical History: Dyslipidemia Hypertension Diabetes Mellitus Congestive Heart Failure Peripheral artery disease Past Surgical History: s/p CABG x2(LIMA to LAD, SVG to OM)/AVR (porcine [Hospital1 43404]) in [2179] s/p Left Fem-[Doctor Last Name ] bypass [2176] s/p [2188-1-30] with drug-eluting stent deployment to RCA Social History: Race:Caucasian Last Dental Exam:[2187-11-9] Lives with:wife Occupation:retired Tobacco:smoked 1.5PPD for 30 years though quit 15 yrs ago ETOH:2 vodka/night Family History: Father died of MI at age 71 Physical Exam: Pulse:63 Resp:18 O2 sat: 97/Ra B/P 121/54 Height:5'[87]" Weight:94.9 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: systolic ejection murmur with radiation to both left and right carotids; healed median sternotomy incision Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: - Left: - PT [Name (NI) 167]: - Left: - Radial Right: + Left: + Carotid Bruit Right: referred murmur Left: referred murmur Pertinent Results: [2188-2-26] CT Chest: Status post [Month/Day/Year 8813] valve replacement and sternotomy, status post CABG. Extensive coronary and moderate-to-severe [Month/Day/Year 8813] calcifications. Mild centrilobular emphysema, no evidence of pulmonary edema. Mild pleural calcifications, several subpleural granulomas, none of which requires followup. Small hiatal hernia. [2188-2-27] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis 60-69%. [2188-2-29] Echo: PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (mobile) atheroma in the [Month/Day/Year 8813] arch. There are complex (mobile) atheroma in the descending aorta. The transaortic gradient is higher than expected for this type of prosthesis. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a very small pericardial effusion. Dr. [First Name (STitle) ] was notified in person of the results on Mrs. [Known lastname 43400] before surgical incision. POST-BYPASS: Overall LVEF 45%. Normal RV systolic function. Mild MR. [First Name (Titles) ] [Last Name (Titles) 43404] is in place, stable and functioning well with a mean gradient of 11 mm of HG. Intact thoracic aorta. [2188-3-3] CXR: In comparison with study of [2-29], the Swan-Ganz catheter and nasogastric tubes have been removed. The patient has taken a somewhat better degree of inspiration. Continued enlargement of the cardiac silhouette with probable small effusions and bibasilar atelectatic change. Coarse interstitial markings persist. [2188-2-22] 11:10AM BLOOD WBC-9.3 RBC-4.50* Hgb-13.1* Hct-37.1* MCV-82 MCH-29.1 MCHC-35.3* RDW-14.1 Plt Ct-175 [2188-2-29] 06:46PM BLOOD WBC-13.7* RBC-2.94* Hgb-8.2* Hct-24.3* MCV-83 MCH-28.0 MCHC-33.9 RDW-14.2 Plt Ct-204 [2188-3-5] 04:55AM BLOOD WBC-9.6 RBC-2.78* Hgb-8.2* Hct-23.4* MCV-84 MCH-29.6 MCHC-35.2* RDW-14.7 Plt Ct-182 [2188-2-22] 11:10AM BLOOD PT-13.2 PTT-26.1 INR(PT)-1.1 [2188-3-1] 02:38AM BLOOD PT-13.8* PTT-29.6 INR(PT)-1.2* [2188-2-22] 11:10AM BLOOD Glucose-125* UreaN-16 Creat-0.9 Na-142 K-4.0 Cl-107 HCO3-24 AnGap-15 [2188-3-5] 04:55AM BLOOD Glucose-83 UreaN-21* Creat-0.8 Na-132* K-4.7 Cl-99 HCO3-28 AnGap-10 [2188-3-1] 02:38AM BLOOD ALT-23 AST-53* AlkPhos-36* TotBili-1.6* [2188-2-22] 11:10AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.1 [2188-3-5] 04:55AM BLOOD Calcium-7.7* Phos-3.6 Mg-2.3 Brief Hospital Course: This 73-year-old patient who had a prior [Month/Day/Year 8813] valve replacement and coronary artery bypass graft x2 with left internal mammary artery to left anterior descending artery and a saphenous vein graft to obtuse marginal, presented with increasing cardiac symptoms and was investigated and was found to have critical [Month/Day/Year 8813] stenosis which has been worsening with a valve area down to 0.6. Coronary angiogram showed the grafts to be patent, and he had disease in the right coronary artery which was stented, and he was put on Plavix for that. He was referred for redo [Month/Day/Year 8813] valve replacement. His left ventricular ejection fraction was about 40%, and his previous surgery was about 9 years ago.The patient was admitted to the hospital and brought to the operating room on [2188-2-29] where the patient underwent redo sternotomy and redo [Date Range 8813] valve replacement with a size 23-mm [Last Name (un) 3843]-[Doctor Last Name ] Magna pericardial valve. Post operatively the patient had high volume of bloody drainage from the chest tubes and the decision was made to return to the operating room for reexploration. He was hemodynamically stable upon return to the operating room. Intraoperatively there was a significant amount of clot and blood in the mediastinum which was evacuated. The surgical sites were explored and no bleeding from the aortotomy or the cannulation sites was found. The only possible bleeder was on the right chest wall, probably from the sternal wire or needle hole, and no other significant bleeder was found. Hemostasis was achieved and he was again transferred to the CVICU in stable condition. He was weaned from all vasoactive medications and extubated on POD #1 without incident. Beta blockers were not started due to bradycardia with heart rate in the 50-60's. Lisinopril was started for blood pressure control. He was started on Lasix for gentle diuresis which was increased to 40 mg IV BID with patient complaining of shortness of breath on 3 L nasal cannula. He was transferred to the step down unit POD #2 in stable condition. Chest tubes and pacing wires were discontinued without complication. Oral diabetic medication was added back for better blood sugar control. The patient was evaluated by the physical therapy service for assistance with strength and mobility. His hematocrit trended down over several days and required multiple blood transfusions. Hematocrit at time of discharge was 25.8. In addition he underwent an echo on [3-6] which revealed no pericardial effusion/tamponade. Post-op he also required a free water restriction for hyponatremia. By the time of discharge on POD seven the patient was ambulating freely, the wound was healing well and pain was controlled with oral analgesics. The patient was discharged to [Male First Name (un) 4542] [Hospital3 ] rehab in good condition with appropriate follow up instructions. Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg Tablet - one Tablet(s) by mouth daily CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - one Tablet(s) by mouth daily FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - one Tablet(s) by mouth daily GLIMEPIRIDE - (Prescribed by Other Provider) - 4 mg Tablet - one Tablet(s) by mouth daily NIFEDIPINE - (Prescribed by Other Provider) - 30 mg Tablet Extended Rel 24 hr - one Tablet(s) by mouth daily POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq Tab Sust.Rel. Particle/Crystal - one Tab(s) by mouth daily Medications - OTC ACETYLCYSTEINE [NAC] - (Prescribed by Other Provider) - 600 mg Capsule - one Capsule(s) by mouth twice a day ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - one Tablet(s) by mouth daily DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100 mg Capsule - one Capsule(s) by mouth daily 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 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours: Please take 40 mg twice daily x 1 week. Then reduce to 40 mg daily. 6. potassium chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 7. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: Cape Code Nursing & Rehabilitation Center - [Location (un) 10072] Discharge Diagnosis: Bioprosthetic [Location (un) ] valve stenosis s/p Redo-sternotomy, [Location (un) ] Valve Replacement Past medical history: Dyslipidemia Hypertension Diabetes Mellitus Congestive Heart Failure Peripheral artery disease Past Surgical History: s/p CABG x2(LIMA to LAD, SVG to OM)/AVR (porcine [Location (un) 43404]) in [2179] s/p Left Fem-[Doctor Last Name ] bypass [2176] s/p [2188-1-30] with drug-eluting stent deployment to RCA Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [First Name (STitle) ] on [3-24] at 1:45PM Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [3-12] at 11:30AM Please call to schedule appointments with your Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5311] in [5-13] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2188-3-7]	[ "2761", "2859", "25000", "4241", "4280", "V4581", "V4582", "2724", "4019" ]
Admission Date: [2148-10-12] Discharge Date: [2148-11-11] Date of Birth: [2100-5-12] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 922] Chief Complaint: congestive heart failure (acute, systolic) severe aortic stenosis Major Surgical or Invasive Procedure: Intubated Cardiac catheterization x 2 Removal of 3 teeth [11-7] Aortic valve replacement History of Present Illness: 48 M with a h/o HTN, hyperlipidemia, bicuspid aortic valve, and tobacco abuse who was transferred from an OSH for further management of CHF and severe aortic stenosis. Pt has a known h/o bicuspid aortic valve. Did not seek medical care for the past three years for his cardiac history. He presented to his cardiologist on [2148-10-1] with progressive SOB and LE edema. He was tried on BB but he did not tolerate [12-30] to weakness and SOB. TTE in [2144] revealed a bicuspid aortic valve with moderate aortic stenosis. He also had mild-to-moderate aortic root dilatation and mild-to-moderate concentric LVH with normal EF. Cardiac catheterization on [2144-10-2] which revealed mild AS, valve area 2.1, normal coronaries, and normal LV function. He was then lost to f/u, re-presented on [2148-10-1]. Most recent TTE revealed severe aortic stenosis with worsening LV function. EF was 25%. RV pressure was 41 and had biatrial enlargement. Noted to have 2+ aortic insufficiency with mild MR [First Name (Titles) ] [Last Name (Titles) ]. He was sent home from cardiology clinic with Lasix and BB (which he did not tolerate), continued to have worsening SOB and LE edema, and finally presented to the OSH for evaluation. OSH course: He was admitted to the OSH on [2148-10-10] with CHF and LE edema. CEs negative. D. dimer positive. Treated for ethanol withdrawal with CIWA scale. TTE revealed severe aortic stenosis with an EF of 25% with LV dilitation. The AM of transfer, he developed acute respiratory distress with chest pain. He was given Lasix 80 mg IV x 1, SL nitro x 2, and morphine. He was transferred to the CCU on a 100%NRB. ABG was 7.55/20/172. He was then intubated. Right IJ was placed. CXR confirmed placement per OSH notes. I/O 120/360. Upon arrival to [Hospital1 18] CCU, he was hemodynamically stable. He then vomited (had no OG tube in place). He arrived with a R IJ and on the ventilator. Family accompanied the pt who confirmed the history. Past Medical History: hypertension Severe aortic stenosis, bicuspid aortic valve Tobacco abuse, 0.5 ppd h/o heavy alcohol use, now 6-12 beers on the weekend Hyperlipidemia s/p hernia repair Social History: Tobacco abuse, 0.5 ppd h/o heavy alcohol use, now 6-12 beers on the weekend Family History: Noncontributory Physical Exam: PE on Admission: T 100.2 HR 74 BP 93/64 RR 16 99% CMV TV 550 RR 10 PEEP 5 FiO2 40% General: 48 M, intubated and sedated, NAD. HEENT: NC/AT. Pupils pinpoint and reactive. ET tube in place. OG tube in place. Right IJ in place with 1/3 of line out of neck. Neck: No JVD. CV: S1, S2 with Grade III/VI systolic ejection murmur, RUSB, radiating to the carotids. Pulm: Faint bibasilar crackles, otherwise CTAB. Abd: Soft, NT/ND with normoactive BS. Ext: 2+ pitting edema B/L to mid-thigh. Distal pulses intact. Cool toes. Skin: No rash. Discharge: Pertinent Results: All urine, blood and sputum cultures without growth. ECHO [10-13]: There is symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 20 %). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. The ascending aorta is moderately dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. Significant aortic stenosis is present (not quantified). Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: severe global biventricular contractile dysfunction with significant (possibly severe) aortic stenosis ECHO [10-14]: Left ventricular hypertrophy with cavity dilation and severe global hypokinesis. Severe aortic valve stenosis with underlying bicuspid aortic valve. Dilated ascending aorta. Mild pulmonary artery systolic hypertension. ABDOMINAL US [10-13]: 1. Gallbladder sludge. Mild gallbladder distention without evidence of wall edema or pericholecystic fluid. No intra- or extra-hepatic biliary dilatation. 2. Mildly heterogeneous liver echotexture. This may be related to the patient's underlying cardiac disease. 3. Right pleural effusion, incompletely imaged. HEAD CT [10-20]: No acute intracranial process. CHEST CT [10-24]: Bilateral pleural effusions with bibasilar atelectasis, superimposed infection cannot be excluded. Left lower lobe nodular opacity versus infiltrate. Follow up is suggested. Cardiomegaly. Ectatic ascending aorta measuring 4.4 cm. Ascites. ABD US [10-25]: 1. Normal gallbladder. Interval resolution of gallbladder sludge. No intra- or extra-hepatic biliary ductal dilatation. 2. Left pleural effusion. CAROTID US [10-25]: Blunted common carotid artery waveforms bilaterally consistent with known severe aortic stenosis. Moderate heterogeneous plaque with bilateral 1-39% ICA stenosis. TTE [10-26]: The left atrial volume is markedly increased (>32ml/m2). The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. cardiac cath [10-30]: 1. No angiographically apparent flow-limiting coronary artery disease. 2. Moderate-severe aortic regurgitation. 3. Aortic root calcification. 4. Moderate ascending aortic enlargement. TTE [10-31]: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 20-30 %). The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. cardiac cath [11-4]: 1. Right heart catheterization revealed a mildly elevated right ventricular endiastolic pressure at 11 mmHg. The systolic and diastolic pulmonary artery pressure were moderately elevated at 50 and 29 mmHg, respectively. The PVR at rest was 131 dyness-1cm-5. The PVR did not change significantly with inhalation of 100% O2 (91 dyness-1cm-5) or nitric oxide (118 dyness-1cm-5). The cardiac index was depressed at 1.6 L/min/m2 under resting conditions and changed only modestly with inhalation of oxygen and nitric oxid to 1.8 L/min/m2. FINAL DIAGNOSIS: 1. Moderately elevated PCW pressure indicating increased left ventricular preload 2. Moderately elevated pulmonary artery pressure with normal PVR non-responsive to either inhaled O2 and nitric oxide 3. Depressed cardiac output Brief Hospital Course: 48 M with HTN, hyperlipidemia, severe AS, and tobacco abuse who was transferred from an OSH for further evaluation and management of his heart failure, aortic stenosis, and acute respiratory distress. On presentation, pt was in severe heart failure, thought to be multifactorial. The considered causes included secondary to known severe bicuspid AS, nutritional deficiency (pt with confirmed Vit C deficiency, presumed general malnutrition given alcohol abuse). Pt developed secondary pulmonary edema and respiratory distress, requiring intubation at OSH. Pt was treated with aggressive diuresis (at one point being net negative 14L) and nutritional repletion (Vit C, multivitamins, thiamine, folate). Pt appeared dry after diuresis and was repleted with small IVF boluses and then allowed to autoregulate. Pt was medically managed with beta-blocker. There were no indications for aspirin as he did not have any known CAD, and there were contraditions for ACEi (preload dependency) and statin (LFT abnormalities). Patient had an echo, confirming critical aortic stenosis and showing left ventricular hypertrophy with cavity dilation and severe global hypokinesis, severe aortic valve stenosis with underlying bicuspid aortic valve, dilated ascending aorta, mild pulmonary artery systolic hypertension. The patient underwent a preop workup for valvular replacement, with preop chest CT scan and carotid US (showing moderate heterogeneous plaque with bilateral 1-39% ICA stenosis). He also underwent a second cardiac cath with right heart cath to evaluate his pulm art pressures which showed no angiographically apparent flow-limiting coronary artery disease. The patient was intubated on presentation and not immediately extubated as he was being aggressively diuresed, and required EGD. His extubation was then furthur delayed by the development of an aspiration pneumonia requiring increased FIO2. There was difficulty assessing pt's readiness for extubation due to his alternating sedation and agitation when sedatives removed. Once extubated he had [Last Name (un) 6055] [Doctor Last Name ] breathing with frequent periods of apnea without desaturation. This was attributed to his severe CHF and toxic metabolic for unclear reasons. He was treated with several days of diamox to increase his respiratory drive. His ABGs and CXRs all continued to be normal. His respiratory status continued to improve to allow weaning of supplemental oxygen and improvement of shortness of breath sensation. He eventually was sating normally on room air without shortness of breath. On presentation pt was significantly jaundiced with a peak T Bili of 7.2, ALT and AST of 302 and 521 respectively. Liver was consulted and recommended checking viral hepatitis studies, and multiple antibodies, all negative. Pt had an abdominal ultrasound which showed gallbladder sludge. There was also "mild gallbladder distention without evidence of wall edema or pericholecystic fluid, and no intra- or extra-hepatic biliary dilatation. Mildly heterogeneous liver echotexture. This may be related to the patient's underlying cardiac disease." LTFs trended down very slowly and plateaued at a T Bili around 4, with persistent jaundice and Transaminases in the 70s. Repeat US showed resolution of gallbladder sludge. His elevated LFTs were thought to be due to hepatic congestion from his right heart failure. On [2148-11-7] he underwent an aortic valve replacement with a 29mm [Company 1543] Mosaic Porcine valve. Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensitve care unit. He was extubated and weaned from his pressors. His chest tubes were removed. By post-operative day three he was ready for transfer to the surgical step-down floor. His epicardial wires were removed. He was seen in consultation by physical therapy. By post-operative day 4 he was ready for discharge. Medications on Admission: Home medications: Lasix 40 mg PO daily Potassium 20 mEq PO daily Toprol XL 25 mg PO daily (stopped secondary to SOB) Medications upon transfer: Colace Pneumoccoccal vaccine, influenza vaccine Toprol XL 25 mg PO daily Potassium 40 mEq PO daily Lasix 40 mg PO daily, then 40 IV, then 80 IV Thiamine MVI Folic Acid Oxazepam CIWA scale PRN Maalox Ativan PRN Milk of Mag PRN Ambien PRN Morphine PRN Tylenol PRN Zofran PRN 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:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal DAILY (Daily) for 4 weeks. Disp:qs Refills:0 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:7 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Congestive Heart Failure, acute systolic Discharge Condition: good Discharge Instructions: Please stop smoking. Information was given to you on admission regarding smoking cessation. 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] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1022] in [12-31] weeks ([Telephone/Fax (1) 81482]) please call for appointment Dr. [First Name4 (NamePattern1) 4597] [Last Name (NamePattern1) 5017] 2 weeks Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2148-11-11]	[ "4241", "51881", "5070", "5849", "4280", "2724", "4019", "3051" ]
Admission Date: [2122-12-31] Discharge Date: [2123-1-1] Date of Birth: [2081-7-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11040] Chief Complaint: EtOH intoxication Major Surgical or Invasive Procedure: None History of Present Illness: This is a 41 year-old man with a history of ETOH abuse who was brought to [Hospital1 18] ER by police after being found wandering in the street. . Patient alert when seen in [Hospital Unit Name 153]. Reports he was drinking beer and vodka from store yesterday and yesterday evening with his girlfriend and also took percocet for his knee arthritis and then does not remember events of last night. . He says he had been abstinent of alcohol for the past 6months with prior abuse in past. He has been drinking in the past week and doesn't want his family to know. . Denies chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation. Says he is doing ok without complaint. . In the emergency room, frankly intoxicated, aggressive, concern given osmolar gap but tox screen positive only for opiates and ETOH of 392. (Acetaminophen level of 5.1)-both consistent with his history. Trauma work-up inlcuidng CT head, CT abdomen, CT C-spine, CXR negative. CK 1025 with normal trop and creatinine of 1.2 (non known baseline). Given 5 liters NS with improvement of osmolar gap, tachycardia. Tox called and felt osm gap likely secondary to etoh intoxication alone. Levoquin and flagyl given for unclear reason. . Tachycardic on admission, sinus at 155. BP elevated to 160s. Past Medical History: 1. H/o ETOH abuse 2. s/p gunshot wound (years ago while in Guatemalan army) 3. Arthritis of left knee--takes percocet from girlfriend. Social History: Occasional smoking with drinking. Drinking as above. Denies other medications or drugs. Originally from [Country 7192], lives with girlfriend. Cocaine in remote past. Works as a roofer. Family History: No h/o heart disease Physical Exam: VS: Temp:97.9 BP: 140/90 HR:97 RR:14 97%room air O2sat . general: smells of alcohol HEENT: PERLLA, EOMI, anicteric, small laceration on bridge of nose, no sinus tenderness, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules lungs: CTA b/l with good air movement throughout heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly extremities: no cyanosis, clubbing or edema skin/nails: no rashes/no jaundice neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: EKG: on presentation:Sinus tachycardia at 155 In ED at 8:26AM--sinus, TWI in V2-V3(new) In ICU: Sinus at 80, TWI in v1-V4. . [11-2]: STRESS: EKG: SINUS HEART RATE: 61 BLOOD PRESSURE: 150/90 PROTOCOL [Doctor First Name 569] - TREADMILL 41yo male with history of tobacco use who is referred to the stress lab for evaluation of chest pain. The patient was able to do 11min of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] protocol stopping for fatigue. He denied any chest, arm, back, or neck discomfort. This represents a good functional capacity for his age (13 METS). There were no significant ST segment changes. The rhythm was sinus with no ectopy. The hemodynamic response to exercise was appropriate. IMPRESSION: No anginal type symptoms and no ischemic EKG changes at a high workload. . Radiologic: [2122-12-31] CT abd/pelvis: 1. Distended gallbladder with mild wall enhancement. No edema or pericholecystic fluid. Right upper quadrant ultrasound is recommended for further evaluation. . [2122-12-31] CT head: No intracranial hemorrhage or mass effect. . [2122-12-31] CT C-Spine: No fracture or abnormal alignment. No change from prior study. . [2122-12-31] CXR 1. No focal consolidations. 2. Radiopaque foreign body--seen previously. . [2122-12-31] RUQ U/S: No evidence for cholelithiasis or cholecystitis. Adjacent fatty liver is seen, but not completely imaged. Please note that other forms of liver disease such as significant hepatic fibrosis and cirrhosis cannot be excluded on the basis of this examination. . [2122-12-31] 03:14PM BLOOD CK(CPK)-8545* [2123-1-1] 05:14AM BLOOD ALT-78* AST-181* LD(LDH)-373* CK(CPK)-6941* AlkPhos-101 TotBili-1.3 . [2123-1-1] 05:14AM BLOOD Glucose-129* UreaN-2* Creat-0.6 Na-137 K-4.0 Cl-106 HCO3-22 AnGap-13 . [2122-12-31] 12:41AM BLOOD CK-MB-13* MB Indx-1.3 cTropnT-<0.01 [2122-12-31] 06:33AM BLOOD cTropnT-<0.01 [2122-12-31] 03:14PM BLOOD CK-MB-50* MB Indx-0.6 cTropnT-<0.01 . [2123-1-1] 05:14AM BLOOD WBC-6.5 RBC-4.36* Hgb-13.2* Hct-36.3* MCV-83 MCH-30.2 MCHC-36.3* RDW-13.1 Plt Ct-176 [2123-1-1] 05:14AM BLOOD calTIBC-261 Ferritn-454* TRF-201 Brief Hospital Course: 41 year-old man with history of ETOH abuse presenting with alcohol intoxication. . # ETOH intoxication: He was placed on IVFs, thimaine, folate, mvi and was monitored on CIWA protocol. There was no evidence of withdrawal while inpatient. He will follow up with his PCP and for referral to substance abuse counseling. . # Tachycardia/TWI: Noted to have sinus tachycardia to the 150s in the ED. He received aggressive IVFs and repeat EKG revealed sinus rhythm at a rate of 90s. Additionally, EKG revealed TWI in V2-V3. He had no chest pain, shortness of breath, nor hypoxia to have suggested PE. Furthermore, cardiac enzymes were negative x 3 to r/o ischemia as a cause of TWI. . # CK elevation/rhabdo: CK peaked at 8545 and then began trending downward with continued aggressive IV fluids. His creatinine improved from 1.2 on admission to 0.6 on day of discharge. . # Distended gallbladder: Radiologic finding on CT abdomen without evidence of pathology on physical exam. RUQ U/S was obtained and showed no evidence of cholecystitis nor cholelithiasis. . # Anemia: MCV normal. Guaiac negative. Likely element of hemodilution given IVFs for rhabdomyolysis. This should be followed as an outpatient. . # Transaminitis: Likely secondary to his EtOH consumption given history and ratio of AST:ALT. RUQ U/S revealed evidence of fatty liver. Coags were normal as was his albumin. This, too, should be followed as an outpatient. Medications on Admission: Percocet prn from his girlfriend (for his knee pain) Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication Rhabdomyolysis (peak CK 8600) Discharge Condition: Good Discharge Instructions: Take all medications as prescribed. You should follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) 4656] your kidneys and liver within the next week. You had an ultrasound that may show fatty liver, this is likely from drinking too much alcohol. You should refrain from drinking alcohol Followup Instructions: Follow up with your PCP within one week as above.	[ "2859" ]
Admission Date: [2140-5-17] Discharge Date: [2140-5-20] Date of Birth: [2117-8-7] Sex: F Service: MEDICINE Allergies: Penicillins / Oxycodone Hcl/Acetaminophen Attending:[First Name3 (LF) 6734] Chief Complaint: Feeling unwell, Hypertensive urgency Major Surgical or Invasive Procedure: dialysis History of Present Illness: Pt is a 22 yo female with Lupus, end-stage renal disease on HD, HTN, multiple other medical problems as below who presents with feeling unwell and found to be in hypertensive urgency. Pt states that last Thursday, five days ago, she started to feel unwell. States that she had chills, no fever, a "weird feeling in my stomach" with cramps, and no cough. No diarrhea. No dysuria. Pt missed her dialysis session on Saturday because she was feeling unwell (3 days ago). Per patient she started to feel better that day, but today, started to feel unwell with the same symptoms. No sick contacts. . In the ED, VS on arrival were: HR: 73; BP: 222/128, 100% RA. She was given labetalol 20 mg IV, 40 mg IV, and then started on a labetaolol gtt.She was also calcium gluconate 1 am IV, kayexalate 30 mg po x 1, 10 units of insulin IV, and 1 amp of d50. . Of note, pt was recently admitted to [Hospital1 ] at the end of [Month (only) 547] for Left uveitis/endophthalmitis. She the developed [Female First Name (un) ] endophthalmitis and had her L eye enucleation. She states that she went to her appt at [Hospital ] 5 days ago. They said that her eye "looked good" and she was to continue on the same amount of prednisone that she is on. . Her last admission she was also noted to have coag negative staph bacteremia. She was discharged on 14 day course of vancomycin but she somehow did not receive this at dialysis. She has now had 4 sets bld cx + for coag negative staph and was started on vancomycin. Past Medical History: 1. Lupus - [2134]. Diagnosed after she began to have swolen fingers, a rash and painful joints. 2. ESRD secodary to SLE - [2135]. Was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in [2137] (T, Th, Sat). Awaiting living donor transplant from mother. 3. HTN - [2137]. Normal BPs run 180's/120's. Has had 1 hypertensive crisis that precipitated seizures in the past. 4. Uveitis secondary to SLE - [4-15] 5. HOCM - per Echo in [2137] 6. Vaginal bleeding [2139-9-20] 7. Mulitple episodes of dialysis reactions 8. Anemia 9. Coag neg. Staph bacteremia and HD line infection - [6-15] 10. H/O UE clot, was on coumadin, but no longer Social History: Lives in [Location 669] with mother and 16 year old brother. Graduated [Name2 (NI) ] School and then got sick so currently is not working or attending school. Denies any T/E/D. Family History: No family history of SLE. GF: HTN. No clotting disorders in family. No history of autoimmune disease. Physical Exam: VS: T: 97.8; BP: 203/133; HR: 100; RR: 15; O2: 100 RA Gen: Speaking in full sentences in NAD HEENT: Left eye patch. Refuses to let examine/look. Right eye reactive. Sclera anicteric. OP clear. Neck: No LAD CV: RRR S1S2. No M/R/G Lungs: CTA b/l with good air entry and flow Abd: Soft, NT, ND. Back: No spinal, paraspinal, or CVA tenderness Ext: No edema. DP 2+ Neuro: A&O x 3, MS intact. Pertinent Results: EKG: sinus at 75. Normal axis. Normal intervals. Early repolarization in anterior precordium. No acute changes. LVH. . Radiology: CXR PA/LAT [2140-5-17]- Large-bore inferior approaching right-sided dialysis catheter is unchanged in position terminating within the right atrium. The lungs are clear and cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal. No evidence of pneumothorax or pulmonary edema. . [2140-5-17] 06:20AM WBC-7.4 RBC-3.85# HGB-11.2# HCT-35.3# MCV-92 MCH-29.1 MCHC-31.8 RDW-20.9 [2140-5-17] 06:20AM NEUTS-91.1* LYMPHS-7.7* MONOS-1.1* EOS-0.1 BASOS-0 [2140-5-17] 06:20AM PLT COUNT-202 . [2140-5-17] 06:20AM GLUCOSE-100 UREA N-40* CREAT-5.2* SODIUM-138 POTASSIUM-6.3* CHLORIDE-109* TOTAL CO2-18* ANION GAP-17 . [2140-5-17] 04:10PM WBC-5.6 RBC-3.47* HGB-10.3* HCT-31.4* MCV-91 MCH-29.6 MCHC-32.7 RDW-20.6* . [2140-5-17] 04:10PM CALCIUM-9.1 PHOSPHATE-3.6# MAGNESIUM-2.3 [2140-5-17] 04:10PM LIPASE-54 [2140-5-17] 04:10PM ALT(SGPT)-20 AST(SGOT)-38 ALK PHOS-74 AMYLASE-267* TOT BILI-0.3 [2140-5-17] 04:10PM GLUCOSE-89 UREA N-40* CREAT-4.9* SODIUM-139 POTASSIUM-5.2* CHLORIDE-109* TOTAL CO2-20* ANION GAP-15 . [5-17] and [5-18] with blood cultures 4/4 + coag negative staphylococcus. [5-19] and [5-20] bld cultures no growth to date. . Ecchocardiogram: Severe symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Hyperdynamic LVEF >75%. Moderate resting LVOT gradient. LVOT gradient increases with Valsalva. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Echocardiographic results were reviewed with the houseofficer caring for the patient. Conclusions: The left atrium is elongated. The estimated right atrial pressure is 0-5mmHg. There is severe symmetric left ventricular hypertrophy with normal cavity size and dynamic systolic function (LVEF>80%). Regional left ventricular wall motion is normal. There is a moderate (25mmHg peak) resting left ventricular outflow tract obstruction that increased (64mmHg) with the Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Marked symmetric left ventricular hypertrophy with dynamic systolic function and resting LVOT gradient that increased with Valsalva. Compared with the prior study (images reviewed) of [2137-12-4], the severity of left ventricular hypertrophy has increased and trace aortic regurgitation is now identified. Dynamic LV systolic function and the resting intracavitary gradient are similar. . UE ultrasound 1. Abrupt occlusion of the right internal jugular vein and its distal most aspect as it joins with the distal subclavian vein. 2. Recanalization of the left subclavian vein with some peripheral residual clot. Recommend analysis of the SVC, central subclavians and internal jugular veins with dedicated magnetic resonance venography, which can be performed without intravenous contrast for a global assessment of the venous patency. Brief Hospital Course: Pt is a 22 yo female with SLE, ESRD on HD, amongst other problems who presented with symptoms likely [2-12] bacteremia. Found to be in hypertensive urgency after missing a run of dialysis. She is now transferred to the floor for further managment after dialysis x 1 and starting vancomycin. . In the MICU she was started kept briely on a labetalol gtt, and then restarted on her home antihypertensives and dialyzed x 1 with resolution of hypertension. She was found to be bacteremic and was started on vancomycin. She felt well and was transferred to the floor. . 1. Hypertensive urgency- Pt with long history of very difficult-to-control HTN. She was initially on a labetalol gtt as above, was dialyzed with resolution of her HTN urgency. She was then transitioned to her her outpatient medication regimen of valsartan, lisinopril, clonidine, labetalol, terazosin, and nicardipine at max doses, but because of persistent HTN to the 180's she was started on hydralazine 50mg po tid on discharge. . 2. Coag negative staph bacteremia: most likely source is line sepsis. She was started on vancomycin and her blood cultures cleared after 2 days in the hospital. The patient felt strongly about keeping her HD line, which was felt to be reasonable because her infection was coag negative staph. Ecchocardiogram did not show any valvular vegitations. She will continue on vancomycin for 3 weeks at hemodialysis. . 3. ESRD on dialysis-euvolemic clinically. Had dialysis inhouse. Continued sevelamer. . 4. Left uveitis/endopthalmitis-Continued prednisone 30 mg po qday. Will also continue bacitracin-polymyxin b. . 5. Lupus- not on any other medications than above. . F/E/N- insists on regular diet . Access: Right dialysis catheter . Prophylaxis: Heparin sc, PPI per outpatient . Code Status: Full Code Medications on Admission: Nephrocaps 1 CAP PO DAILY Vancomycin 1000 mg IV HD PROTOCOL Vancomycin 1000 mg IV X1 Duration: 1 Doses DiphenhydrAMINE 25 mg PO Q6H:PRN Labetalol 600 mg PO TID Heparin 5000 UNIT SC TID Acetaminophen 325-650 mg PO Q4-6H:PRN OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl BOTH EYES Q8H Terazosin HCl 8 mg PO BID Gabapentin 100 mg PO QTUESDAY, THURSDAY, SATURDAY Sevelamer 800 mg PO TID NiCARdipine 40 mg PO Q8H PredniSONE 30 mg PO DAILY Sulfameth/Trimethoprim DS 1 TAB PO QMONDAY, WEDNESDAY, FRIDAY Lorazepam 1 mg PO Q4-6H:PRN Senna 1 TAB PO BID:PRN Docusate Sodium 100 mg PO BID Pantoprazole 40 mg PO Q24H Clonidine TTS 3 Patch 1 PTCH TD QFRI Lisinopril 40 mg PO BID Valsartan 320 mg PO DAILY Ondansetron 4 mg IV Q8H:PRN Oxycodone SR (OxyconTIN) 70 mg PO Q8H Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMONDAY, WEDNESDAY, FRIDAY (). 4. Prednisone 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Nicardipine 20 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Terazosin 2 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3 hours) as needed. 10. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: 3.5 Tablet Sustained Release 12 hrs PO every eight (8) hours. 11. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QTUESDAY, THURSDAY, SATURDAY (). 13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous per hemodialysis for per hd days: per hemodialysis. 15. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q8H (every 8 hours). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QTUESDAY, THURSDAY, SATURDAY (). 18. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 19. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety. 20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol): 1g Q dialysis. 21. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary diagnosis: Hypertensive urgency Coagulase negative Staphylococcus Bacteremia Secondary diagnosis: Lupus ESRD s/p L eye enucleation Discharge Condition: Good. Blood pressure is in the 130s-150s systolic. Her vitals are stable, she is ambulatory, and taking in PO Discharge Instructions: Please follow up as below; I have also made a new cardiology appointment for you . Take all medications as prescribed; Other than giving you vancomycin we have added hydralazine (a blood pressure medicine), but otherwise we have not changed any of your medicines. If you have fevers, chills, light-headedness, or other problems then you should contact your doctor because this may be a sign that your infection is not resolving. You should go for hemodialysis as scheduled Saturday where they should give you vancomycin. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8157], M.D. Phone:[Telephone/Fax (1) 1971] Date/Time:[2140-5-30] 1:00 Dr. [Last Name (STitle) 4883] [Telephone/Fax (1) 60] Tuesday [5-31] at 3pm with Dr. [Last Name (STitle) ] in Cardiology. [Telephone/Fax (1) 5003] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 6735]	[ "2859" ]
Admission Date: [2124-3-11] Discharge Date: [2124-3-15] Service: CCU CHIEF COMPLAINT: 1. Chest pain. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 38265] is a 78 year-old gentleman with a history of inferior myocardial infarction in patient interpreted as indigestion starting at 11 P.M. in the evening prior to admission. The patient describes the pain being constant, increasingly severe. The patient did not come to clinical attention until approximately 12 hours later. He presented to an outside hospital where it was noted that positive creatinine kinase. He was not treated with thrombolytics due to the duration but he had substernal chest pain prior to seeking medical attention. However he continued to have chest pain and therefore was referred to [Hospital1 69] for emergent angioplasty. During the course of his evaluation at the outside hospital he developed bradycardia to the 40s and had a temporary pacing wire placed for prophylaxis prior to transfer here. He was started on IV Nitroglycerin and was pain free upon arrival to CCU. His cardiac risk factors are the following: 1. Tobacco. 2. Hypertension. 3. No diabetes. 4. No family history. 5. No hypercholesterolemia. He was taken to the cardiac catheterization lab where he was found to have a right dominant system with total occlusion of his proximal LAD with collateralization from his RCA, moderate left circumflex disease and 80% proximal RCA which collateralizing the LAD. The proximal LAD was angioplasty and descended successfully. PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease status post inferior myocardial infarction in [2112]. This was thrombolysed. MEDICATIONS ON TRANSFER: 1. Aspirin 325 milligrams po q day. 2. Plavix 75 milligrams po q day. 3. Heparin drip. 4. IV Nitroglycerin. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He smokes one and a half packs per day for 50 years. He denies any alcohol use. PHYSICAL EXAMINATION: Temperature 92.2 F, pulse 74, blood pressure 114/59, respiratory 16, saturation 94% on room air. In general he is an elderly gentleman, comfortable, lying flat in no apparent distress. HEENT - pupils are equal, round and reactive to light. The sclerae are anicteric. Oropharynx is clear. Neck - no JVP. Respiratory - clear to auscultation bilaterally. He has faint rales in the bases. Cardiovascular - regular rate and rhythm, no murmurs, rubs, or gallops. Abdomen exam is benign. Extremities - no cyanosis, clubbing or edema. He has 2+ distal pulses. LABORATORY DATA: White count 7.5, hematocrit 40.9, platelet count 171,000, sodium 143, potassium 4.7, chloride 109, bicarb 26, BUN 22, creatinine 1.1, glucose 134, PT 15, PTT 31. CK 1191 with an MB of 175, Troponin 1.49. EKG reveals normal sinus rhythm with a rate of 88. He had left axis deviation with normal intervals. He had 1 to [Street Address(2) 7093] elevations in V1 to V3. Chest x-ray revealed no evidence of infiltrate or CHF. HOSPITAL COURSE: Mr. [Known lastname 38265] had no post catheterization complications except for one six beat run of nonsustained ventricular tachycardia. He had his temporary pacing wire removed. Post catheterization without any consequence. The next day he returned to the cardiac catheterization lab where his proximal RCA was stented. The LV gram determined that his ejection fraction was 43% with apical akinesis with moderate anterolateral, inferior posterior hypokinesis. He had no mitral regurgitation. He had no further runs of nonsustained ventricular tachycardia. Examination of his left groin revealed no evidence of hematoma or femoral bruits. His distal pulses were 2+. His creatinine and hematocrit remained stable throughout two cardiac catheterizations. His CK fell steadily after his first catheterization and the patient remained chest pain free throughout his hospital stay. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. MEDICATIONS: 1. Toprol XL 25 milligrams po q day. 2. Lisinopril 10 milligrams po q day. 3. Plavix 25 milligrams po q day times 30 days. 4. Lipitor 20 milligrams po q day. 5. Enteric coated aspirin 325 milligrams po q day. 6. Sublingual nitroglycerin 0.4 milligrams q five minutes times three prn chest pain. FOLLOW UP: Follow up with your primary care physician in on week. She should arrange for you to follow up with a cardiologist as soon as possible. INSTRUCTIONS: Return to the emergency room if you develop worsening chest pain, shortness of breath or develop worsening back pain, flank pain or leg pain. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Hypertension. 3. Hyperlipidemia. 4. Acute myocardial infarction [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8227] Dictated By:[Last Name (NamePattern1) 7690] MEDQUIST36 D: [2124-3-16] 11:51 T: [2124-3-16] 11:58 JOB#: [Job Number ]	[ "41401", "4019", "412" ]
Admission Date: [2189-9-4] Discharge Date: [2189-9-8] Date of Birth: [2118-4-3] Sex: F Service: MED Allergies: Penicillins Attending:[First Name3 (LF) 281] Chief Complaint: S/p L mainstem bronchus stent removal Major Surgical or Invasive Procedure: Bronchoscopy with stent removal Intubation and extubation History of Present Illness: 71yo F with a history of stage IIIa non-small lung [Hospital 4699] transferred to the MICU after rigid bronch for observation. The patient was diagnosed with lung cancer in 4/00 and is now s/p RUL lobectomy, carboplatin tx, and radiation tx. Since then, she has had multiple bronchoscopies, including placement of a stent into the L main bronchus in [4-1]. On [8-20], she had a bronchoscopy which revealed significant narrowing of L main bronchus with formation of granulation tissue. She underwent rigid bronchoscopy on the day of admission ([2189-9-4]) showing almost 95 percent obstruction of the left mainstem bronchus. She was treated with stent removal, debridement of a large amount of granulation tissue, and argon laser coagulation. The patient was felt to be at risk for airway collapse and bleeding after the procedure, and was not extubated. She was transferred to the MICU from the PACU for further monitoring and evaluation. Past Medical History: 1. Right upper lobe lung cancer (adenocarcinoma, stage III). In [4-/2185], right wedge biopsy - adenocarcinoma. In 04/00, right upper lobe lobectomy. Positive hilar/paratracheal node involvement. 2. Hypothyroid. 3. Hyperlipidemia 4. Right arm surgery (? years ago, broken arm, unable to set, metal plates and screws, patient states that she has had numerous MRIs since the surgery) Social History: The patient is married, graduated from [University/College 4700]. No ethanol use, denies any tobacco use. She has three children, former bookkeeper/accountant. Supportive and involved husband. Physical Exam: HR 85 BP 145/90 O2 99% ventilated Intubated, sedated, withdraws x4 to pain PERRL, neck supple RRR, no murmurs, s1s2 nl Bronchial BS, R>L, with BS greatly reduced throughout on L Abd soft, ND, +BS Extr with no edema and 2+ DP pulses No rashes No extremity edema Pertinent Results: [2189-9-4] 07:01PM WBC-11.1# RBC-3.91 HGB-11.4* HCT-33.7* MCV-86 MCH-29.3 MCHC-34.0 RDW-13.2 [2189-9-4] 07:01PM WBC-11.1# RBC-3.91 HGB-11.4* HCT-33.7* MCV-86 MCH-29.3 MCHC-34.0 RDW-13.2 [2189-9-4] 07:01PM PT-12.2 PTT-22.6 INR(PT)-1.0 [2189-9-4] 07:01PM GLUCOSE-108* UREA N-15 CREAT-0.7 SODIUM-143 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-15 Brief Hospital Course: Plan: * 1. Respiratory. The patient was maintained on a ventilator after the procedure for airway protection. The patient was kept sedated for comfort but was A+Ox3 and communicative througout. On [2189-9-7], the patient had a repeated flexible bronchoscopy showing L airway patency, at which time she was extubated without complication. * 2. ID. Sputum culture from +GPC in pairs and the patient received 1 dose of vancomycin. * 2. FEN. An NGT was placed and TF's started while pt was intubated. * 4. Hyperlipidemia. The patient was kept on Lipitor. * 5. Hypothyroidism. The patient was kept on Synthroid. * 6. Prophylaxis: - Lanzoprazole - Pneumoboots - Heparin SC * 7. Precautions - MRSA + from previous bronchial washings ([4-2]) * 7. Access: Peripheral IV R, radial left A-line * 8. FC * 9. Communication: Son at [Telephone/Fax (1) 4701] ([Name2 (NI) ]t[Name (NI) ]) and husband. * 10. Discharge. The patient was discharged to home in good condition. Medications on Admission: Lipitor 20qd Synthroid 125qd Protonix 40qd Mytussin Tessalon pearls Ambien prn Discharge Medications: 1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for cough. 5. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 6. Mytussin DM Oral Discharge Disposition: Home Discharge Diagnosis: S/p left main bronchus stent removal Discharge Condition: Stable Discharge Instructions: Please return to the ER if you have difficulty breathing, chest pain, feel lightheaded or dizzy, or have bloody sputum or cough. Please take all your medications as directed. Followup Instructions: Please follow up with your PCP and pulmonary doctors as arranged. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 286]	[ "51881", "2449", "2724", "53081" ]
Admission Date: [2171-10-21] Discharge Date: [2171-11-30] Date of Birth: [2104-10-30] Sex: F Service: MEDICINE Allergies: Haldol / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1115] Chief Complaint: Rapid heart beat Major Surgical or Invasive Procedure: None History of Present Illness: 66 y.o woman medical history significant for asthma and paranoid schizophrenia who presented to the emergency room with right upper quadrant pain and was found to be in atrial fibrillation with an initial heartrate of 189. The patient reports that she had been feeling somewhat weak with nausea and subjective fevers over the past 10 days as well as having RUQ pain over the past 3 days. She also reports some dyspnea on exertion at her baseline. In the emergency room, the patient received multiple IV pushes of diltiazem to a total of 50mg and was started on a diltiazem drip initially at 10mg/hr, then up to 20mg/hr with poor response and a rate continuing in the 150s. The patient then received metoprolol 10mg and developed bronchospasm with significant wheeze, after which she received 125mg of solumedrol and a single duoneb. Cardiac enzymes were negative and imaging including a right upper quadrant ultrasound and chest x-ray were obtained. RUQ was negative for cholecystitis and the CXR showed only a small left pleural effusion. . The RUQ pain is not worsened by food, does not radiate, and is currently only a [2171-1-19] from a [10-27] previously. . On review of systems, patient states she has a chronic productive cough of white/clear sputum and admits to myalgias especially left hip. She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, joint pains, hemoptysis, black stools or red stools. She denies exertional buttock or calf pain. She denies dysuria, hematuria, and increased urinary frequency. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . In the ED, prior to transfer T: 99.7, HR 155, BP 118/77, RR 30, O2 Saturation 97% on 2L, . Past Medical History: -Smoking. -Asthma/COPD. -Positive PPD. -Schizoaffective disorder. -History of GI bleed. -History of hemoptysis. Social History: Lives at the YWCA one block away from clinic by herself with two cats; (+)tob - hand-rolled cigarettes, [1-1] cigs per day, (-)ETOH now - h/o alcoholism, tried cocaine once but now (-)drugs. Married twice - has not seen 2nd husband in several years. Has 5 children. On disability." Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: General: WDWN in NAD. Oriented x3. Affect circumferential and tangential HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, no carotid bruits appreciated Cardiac: PMI located in 5th intercostal space, midclavicular line. distant heart sounds, tachycardia with irregular rhythm. No m/r/g appreciated. Lungs: No chest wall deformities, scoliosis or kyphosis. End expiratory wheezing throughout, crackles greater at the bases. Abdomen: Soft, NTND. No HSM or tenderness. Neuro: Uvula midline, strength symmetric in upper and lower extremity, Shoulder shrug intact to resistance, tongue midline. Follows commands. Extremities: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Radial 2+ PT 2+; Left: Carotid 2+ Radial 2+ PT 2+ Pertinent Results: Admission Labs: [2171-10-21] 11:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2171-10-21] 04:20PM GLUCOSE-100 UREA N-13 CREAT-0.5 SODIUM-140 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 [2171-10-21] 04:20PM ALT(SGPT)-26 AST(SGOT)-37 LD(LDH)-185 CK(CPK)-29 ALK PHOS-121* TOT BILI-0.7 [2171-10-21] 04:20PM cTropnT-< 0.01 [2171-10-21] 04:20PM CK-MB-2 proBNP-2173* [2171-10-21] 04:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2171-10-21] 04:20PM WBC-5.3 RBC-4.25 HGB-11.4* HCT-33.6* MCV-79* MCH-26.7* MCHC-33.8 RDW-14.6 [2171-10-21] 04:20PM PT-15.7* PTT-41.9* INR(PT)-1.4* . [Month/Day/Year ] FUNCTION TESTS: [2171-10-21] 04:20PM BLOOD TSH-<0.02* [2171-10-24] 09:30AM BLOOD TSH-<0.02* [2171-10-25] 06:15AM BLOOD TSH-LESS THAN [2171-10-27] 06:38AM BLOOD TSH-<0.02* [2171-10-28] 06:52AM BLOOD TSH-<0.02* [2171-10-29] 09:15AM BLOOD TSH-<0.02* [2171-10-22] 06:08AM BLOOD T4-13.9* T3-250* calcTBG-0.57* TUptake-1.75* T4Index-24.3* [2171-10-24] 09:30AM BLOOD T4-11.3 T3-118 calcTBG-0.67* TUptake-1.49* T4Index-16.8* [2171-10-25] 06:15AM BLOOD T4-9.7 T3-77* calcTBG-0.71* TUptake-1.41* T4Index-13.7* [2171-10-27] 06:38AM BLOOD T4-8.3 T3-86 calcTBG-0.85 TUptake-1.18 T4Index-9.8 [2171-10-28] 06:52AM BLOOD T4-7.5 T3-104 calcTBG-0.88 TUptake-1.14 T4Index-8.6 [2171-10-29] 09:15AM BLOOD T4-7.8 T3-87 calcTBG-0.91 TUptake-1.10 T4Index-8.6 [2171-10-31] 06:03AM BLOOD T4-7.1 T3-103 calcTBG-1.00 TUptake-1.00 T4Index-7.1 . Test Name In Range Out of Range Reference Range --------- -------- ------------ --------------- TSI Positive Negative % THYROTROPIN-BINDING INHIBITORY IMMUNOGLOBULIN (TBII) Test Result Reference Range/Units TBII 66.0 H <=16.0 % [2171-10-25] 06:15AM BLOOD antiTPO-GREATER THAN ASSAY . Studies: CXR [2171-10-21] IMPRESSION: Left CP angle blunting could indicate small effusion or atelectasis. . RUQ U/S [2171-10-21] IMPRESSION: Cholelithiasis without secondary findings to suggest acute cholecystitis. . CARDIAC ECHO: [2171-10-31]: The left atrium is mildly dilated. 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 75%). The estimated cardiac index is high (>4.0L/min/m2). 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. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Trace aortic regurgitation is seen. 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. . Pathology Report Tissue: Right LobeThyroid, Left Study Date of [2171-11-29] (pending) . Discharge Labs: [2171-11-26] 03:00PM BLOOD WBC-7.2 RBC-4.80 Hgb-12.6 Hct-38.5 MCV-80* MCH-26.2* MCHC-32.7 RDW-17.9* Plt Ct-180 [2171-11-26] 03:00PM BLOOD PT-12.6 PTT-31.5 INR(PT)-1.1 [2171-11-30] 07:25AM BLOOD T3-64* Free T4-0.49* [2171-11-28] 11:15AM BLOOD Digoxin-1.2 Brief Hospital Course: 66 year old female with COPD, asthma, paranoid schizophrenia who was found to have atrial fibrillation not responsive to rate control in the ED. . # Atrial Fibrillation: Patient had asymptomatic afib in ED. It did not respond to IV diltiazem pushes or a maximal diltiazem drip. She was responsive to B-blocker but became brochospastic, likely as a result of underlying asthma and COPD. She received nebulizers and steroids and her respiratory status subsequently improved. Her rate was not controlled with diltiazem; she was transitioned to Digoxin and Verapamil in the CCU. Rates ranged 130s-140s on this regimen. Of note, the patient was not a candidate for cardioversion because she is not reliable for followup or taking medications; Her CHADS2 score was 0 and so she was maintained only on aspirin. On [10-26], she spontaneously converted from afib to sinus rhythm with HR 80s. Digoxin was held and Verapamil was continued with plans to continue as an outpatient. She was subsequently transferred to the general medicine floor, where she remained in sinus rhythm for about 24 hours before periodically reverting back to Afib with RVR to 170s, again asymptomatic. She did not respond to IV verapamil pushes, but tended to spontaneously convert within about 2 hours. Her CCB was increased to 120mg TID, though she continued to convert between NSR and asymptomatic Afib several times daily over the course of the following 6 days. Cardiology was reconsulted [10-31], who recommended reloading of digoxin in addition to a transition to verapamil ER 240BID. Per daily physical exams, the patient remained in NSR for several weeks prior to thyroidectomy. She was discharged on verapamil and digoxin. These medications can likely be discontinued as an outpatient. . # Hyperthyroidism: Patient was found to be hyperthyroid on testing of TFTs which is the presumed etiology of her presenting RVR. TFTs were trended and patient was treated with SSKI +PTU in the CCU under the direction of Endocrine. Anti-TPO and TSI-Ab were positive, suggesting a diagnosis of [Doctor Last Name 933] Disease. SSKI and PTU were subsequently stopped and Methimazole was started. Her TFT's normalized by [2171-10-24]. It was decided in conjunction with the endocrine and surgical teams that she would be better served by a thyroidectomy as opposed to a radioactive [Month/Day/Year ] ablation. A meeting was held with the patient and her family, including her guaridan and son, who agreed with the plan for thyroidectomy. The thyroidectomy was performed by Dr.[Last Name (STitle) ] without complication. Post-op Calcium level was 9.4. She was discharged on calcium supplementation. Methimazole was discontinued post-thyroidectomy. She was not discharged on synthroid but will follow-up with endocrine who will initiate [Last Name (STitle) ] hormone replacement and titrate. . # COPD: Note that B-blocker is contraindicated in this patient [2-19] COPD. Continued Ipratropium Bromide Neb Q6H + Levalbuterol Neb NF 0.63 mg/3 mL Inhalation q6h. Started Prednisone 60 mg q day for a five day course, with last day [2171-10-26]. Her steroids were restarted on [10-27] due to considerable wheezing on exam. This was slowly tapered, and was eventually stopped on [10-31] due to concern that it was driving some psychosis and agitation. She was started on advair [10-31] and transitioned off of xoponex in favor of ipratropium to avoid excess adrenergic stimulation and exacerbation of her afib. For the last several weeks of her hospitalization the patient's COPD was stable. She is discharged on her home inhalers. . # Schizoaffective disorder: Chronic problem; patient has stable paranoid delusions and poor insight into disease. Initiated treatment with Olanzapine 15 mg [Hospital1 ] per psychiatry recommendations. Per Psychiatry, the patient has no capacity, cannot leave AMA and as a result temporary guardianship for the hospitalization was awarded to her son [Name (NI) ]. Following resolution of her thyrotoxicosis, we asked the psychiatric team to reevaluate her in case her hyperthyroidism had contributed to her initial psychosis. She had attempted to leave AMA shortly before psychiatric reevaluation, but was detected before leaving the floor. She was paranoid and agitated when seen by psych again, and was again deemed to have no decisional capacity. Olanzapine was started. She initially required a 1:1 sitter, but eventually was happy to stay in the hospital and have her [Name (NI) ] problem treated so the sitter was discontinued. . # Abdominal pain on admission: Non-specific. Spontaneously resolved. RUQ u/s showed no signs of cholecystitis. No leukocytosis. She was placed on pantoprazole given her history of a GI bleed, but this should likely be STOPPED as an outpatient. . # Latent TB concern on admission: PPD placed [10-22] right arm - PPD negative. . # Health Care Proxy/Guardianship: Son [Name (NI) ] awarded temporary guardianship ([2171] . # Code Status: FULL Medications on Admission: Ventolin Atrovent Discharge Medications: 1. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). Disp:120 Tablet, Chewable(s) Refills:2 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:120 Tablet(s) Refills:2 3. verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q 12H (Every 12 Hours). Disp:60 Tablet Sustained Release(s) Refills:2 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Inhalation Inhalation [Hospital1 ] (2 times a day). Disp:1 disk Refills:2 5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. omeprazole 40 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 7. olanzapine 5 mg Tablet, Rapid Dissolve Sig: Three (3) Tablet, Rapid Dissolve PO BID (2 times a day). Disp:180 Tablet, Rapid Dissolve(s) Refills:2 8. Iron (ferrous sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:3 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 5 days. Disp:25 Tablet(s) Refills:0 11. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation twice a day. Disp:1 canister Refills:2 Discharge Disposition: Home With Service Facility: [Hospital ] Health Systems Discharge Diagnosis: Primary Diagnoses: Hyperthyroidism (likely Grave's Disease), Thyroidectomy, Atrial fibrillation secondary to thyrotoxicosis Secondary Diagnoses: Paranoid Schizophrenia, Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname 69068], You were admitted to the hospital because you had a very rapid heart beat in an irregular rhythm. We tried to control this heart beat with multiple medications. One of these medications exacerbated your COPD. We admitted you to the hospital to monitor and control your heart beat as well as to control your breathing. We found that you are hyperthyroid (meaning your [Known lastname ] is overactive) while you were here, and we started you on a medication to control this. Likely, your high [Known lastname ] level is the reason that your heart was beating very quickly. You had a thyroidectomy to remove your [Known lastname ]. You tolerated the procedure well and your pain was well controlled at the time of discharge. You will need to follow-up with the [Known lastname ] doctors to [Name5 (PTitle) ] [Name5 (PTitle) ] replacement therapy, monitor your levels, and titrate your dose. . Please make the following changes to your medications: You were STARTED on digoxin. You were STARTED on verapamil. You were STARTED on calcium. You were STARTED on omeprazole. You were STARTED on iron. You were STARTED on olanzapine. You were STARTED on aspirin. You were STARTED oxycodone for pain. . While you were here, your son, [Name (NI) ], was officially made your guardian. Followup Instructions: Department: DIV OF GI AND ENDOCRINE When: TUESDAY [2171-12-3] at 2:40 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 1803] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Name: [Last Name (LF) 87396],[First Name3 (LF) ] N. Location: [Hospital 2025] [Hospital ] HEALTH CENTER Address: [Last Name (LF) ], [First Name3 (LF) ],[Numeric Identifier 30452] Phone: [Telephone/Fax (1) 81665] Appointment: Friday, [12-6] at 11:15AM It is important that you go to the appointment above to continue your relationship with your primary care doctor You should also call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (your [Last Name (NamePattern1) ] surgeon) at [Telephone/Fax (1) 9] to schedule an appointment for follow-up to be sure your incision is healing well.	[ "42731", "2859", "3051" ]
Admission Date: [2142-8-24] Discharge Date: [2142-9-12] Date of Birth: [2063-7-17] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8104] Chief Complaint: L hemiplegia Major Surgical or Invasive Procedure: Intubation in the ED for airway protection. History of Present Illness: Patient is a 79 yo woman with PMH including HTN, hypercholesterolemia and remote hx of cervical cancer who has not seen her PCP [Name Initial (PRE) ] 2 years was found unresponsive in her bed. She lives in an [Hospital3 ] facility ([Hospital1 ] House of [Location (un) ], MA) and was last seen 48 hrs prior without any obvious signs of distress. Staff found her supine in her bed - she was mute with right sided gaze and not moving her left side. EMS was called and she had normal initial vitals including BP, HR and FSBG. EMS found her with facial droop and somnolent but was able to nod for answers and denied HA. Upon arrival at [Hospital1 18], she was "awake and nodding" but was intubated prior to CT for airway protection in the ED. She was then admitted to Neuro ICU service. Past Medical History: Last saw PCP (Dr. [First Name8 (NamePattern2) 1528] [Last Name (NamePattern1) ]) in [4-3]; refused most of screenings including mammograms and colonoscopy plus all vaccinations. 1. HTN 2. Hypercholesterolemia 3. Sciatica 4. Hx of cervical cancer s/p resection and radiation therapy in [2111] 5. Carpal tunnel syndrome 6. hx of syncope x2 - most recent in [4-3] --> normal stress test (MIBI) Social History: Lives in ALF ([Hospital1 ] House) - was homeless in the remote past per PCP. [Name Initial (NameIs) ] 2~3 cigarettes/day and no EtOH hx. Raised her grandchildren. Has [Name Initial (NameIs) 802] named [Name (NI) 32400] who was made her guardian/HCP during this admission. Family History: NC Physical Exam: T 98.1 BP 111/50 HR 111 RR 30 O2Sat 99% with 5L shovel mask HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx: ET tube in place Neck: Supple, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic examination: MSE: Somnolent but arousable to name - stirs to name. Does follow simple commands including open your mouth and moving R side. Cranial Nerves: II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. No blinks to visual threats bilaterally. III, IV & VI: Nomal oculocephalic movements - crosses midline. VII: R lower facial droop X: No gag. Motor: Diffuse, mild loss of bulk with decreased tone on L side. Moves R side antigravity but 0/5 on L side. Sensation: Grimaces to noxious stimuli bilaterally. Reflexes: +2 for biceps and brachioradialis but none for patella and 1 for Achilles. R toe mute but L toe upgoing. Pertinent Results: Microbiology: all blood cx's: negative for growth urine cx: [9-4] - pan sensitive proteus mirabilis, pseudomonas [First Name9 (NamePattern2) ] [Last Name (un) 36] to cipro and zosyn. sputum cx: mssa and proteus mirabilis [Last Name (un) 36] to ceftriaxone c. diff: negative ([9-5]) EKG: Normal sinus rhythm with atrial premature complexes. Intra-atrial conduction defect. Left ventricular hypertrophy with secondary repolarization abnormalities. Axis is plus 60 degrees suggesting a co-existent pulmonary or right ventricular disease. Since the previous tracing of [2133-3-16] diffuse ST-T wave changes and left ventricular hypertrophy are more prominent and axis has shifted rightward. Echo: The left atrium is normal in size. No atrial septal defect seen by 2D/color Doppler (cannot definitively exclude). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot definitively exclude). MRI/MRA: MRI IMPRESSION: 1. Acute right-sided corona radiata and periventricular infarct with acute wallerian degeneration extending to the right side of the midbrain. 2. Chronic multiple lacunes in the basal ganglia and small vessel disease. 3. Multiple microhemorrhages in the brain, suspicious for amyloid angiopathy. MRA IMPRESSION: 1. Diminished flow signal in the anterior circulation could be secondary to slow flow. 2. Non-visualization of the distal vertebral and proximal two-third of the basilar artery could be due to occlusion or slow flow from high-grade stenosis. EEG: Abnormal EEG to slow background with occasional suppressive bursts. These findings suggest a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. Hypoxia is another possible explanation. Conceivably, this pattern could also be seen in a prolonged post-ictal state. Nevertheless, there were no areas of prominent focal slowing although encephalopathies can obscure focal findings. There were no clearly epileptiform features. L ANKLE: Multiple vascular calcifications in the soft tissues. Duct-like calcifications projecting over the ventral frontal parts of the talus. There is an obliquely oriented lateral fracture of the malleolus, with only minimal displacement. A small fragment of bone seen along the medial aspect of the distal fibular represent a comminuted fragment. There is no other evidence of post-traumatic disease. Small plantar spur. Carotid U/S: FINDINGS: Duplex evaluation was performed of bilateral carotid arteries. There is heterogeneous plaque in the proximal ICA and distal CCA bilaterally. There is plaque in the proximal right ECA. On the right, peak velocities are 86, 97 and 66 cm/sec in the ICA, CCA and ECA respectively. This is consistent with less than 40% stenosis. On the left, peak velocities are 104, 95 and 112 cm/sec in the ICA, CCA and ECA respectively. This is consistent with less than 40% stenosis. There is antegrade vertebral flow bilaterally. IMPRESSION: Bilateral less than 40% carotid stenosis. Head CT: IMPRESSION: 1. No definite new abnormalities. Cortical hypodensity in the frontal lobes is likely related to beam-hardening artifact. However, subtle cytotoxic edema cannot be excluded. MRI is suggested for further evaluation. This was discussed with the ordering physician by Dr. [Last Name (STitle) 21881] when the study was obtained. 2. The acute infarction in the right lentiform nucleus and corona radiata is unchanged, allowing for differences in modalities. 3. Unchanged chronic infarction in the left lentiform nucleus and internal capsule. CXR: ([8-31]) IMPRESSION: Left lower lobe consolidation with small pleural effusion is very worrisome for aspiration, a component of atelectasis/collapse is suspected.. could be due to a mucous plug. Dobhoff tube was pulled back, now ends in the stomach. CXR taken on [9-1] and [9-2] remained unchanged. Labs: CBC - Hct 48 on admission, nadirs to low 20s on [8-29] and [Date range (1) 8967] requiring blood transfusions. WBC peak to 16.0 on [8-31], which decreased to 8s with initiation of antibiotics on [9-2] and was 7.7 on discharge. Chem-10: Cre stable at 0.4 throughout admission. Na briefly low to 130s, resolved w/ decreasing free H20 boluses. K 3.5-4.0 LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [2142-8-25] 01:09AM 231* 1681 55 4.2 142 Cardiac Enzymes: CPK ISOENZYMES CK-MB MB Indx cTropnT [2142-9-2] 10:43PM 0.071 Source: Line-PICC [2142-8-28] 02:55AM 4 0.101 [2142-8-27] 03:19AM 0.111 CHEMS ADDED 11:39AM [2142-8-26] 02:19AM 9 0.171 [2142-8-25] 06:34PM 13* 0.201 [2142-8-25] 03:04PM 13 0.201 [2142-8-25] 09:19AM 14 1.5 0.261 [2142-8-25] 01:09AM 11 1.5 0.241 [2142-8-24] 11:09AM 14 1.7 0.162 HEMATOLOGIC calTIBC VitB12 Hapto Ferritn TRF [2142-9-4] 05:38AM 104 1508* [Telephone/Fax (1) 109225]* 80* TSH: 1.6 Cortisol: 16.1 neg tox screen on admission. Lactate: 2.0 (0n admission) Brief Hospital Course: A/P: 78 yo F w/ HTN, HLD found down at [Hospital3 ] facility w/ L hemiparesis, found to have R basal ganglia infarct, likely 2' to uncontrolled HTN. Neuro ICU course: Patient was intubated in the ED for airway protection and admitted to Neuro ICU where she was successfully extubated after 3 days - she remained encephalopathic with L hemiplegia. EEG was done to rule out non-convulsive status given her encephalopathy but only confirmed moderate/severe diffuse encephalopathy without evidence of focality or epilieptic activity. Per head imaging, she has evidence of old infarcts on L hemisphere as well possible explaining minimal movements on R side as recrudescence due to multiple medical issues including severe/stage IV sacral decibitus ulcer which required bedside cauterization x2 for bleeding. She required 3 units of PRBC transfusion while in ED for anemia with hct as low as 10.9 at nadir. She had repeat head imaging when her somnolence increased to rule out hemorrhage which showed no change since admission and her somnolence decreased with transfusion supporting metabolic etiology behind her encephalopathy. On admission, she was afebrile without leukocytosis but start HD #3, her WBC trended upward and she spiked with fever up to 101.7. She was pan-cultured twice while in the ICU without identification of infective organism and because she deferevesced without intervention, she was not started on empiric ABX while in the ICU. Additionally, patient had elevated troponin (crested at 0.26) without signs of renal failure plus non ST-elevated EKG changes not previously seen likely supporting NSTEMI. Also, her L ankle seemed asymmetrically more swollen that R plus given hx of patient being found down, trauma series were performed and showed L ankle, non-displaced fibular fracture. [Hospital3 1957] was consulted and patient was fitted with aircast. Although still encephalopathic, she remained hemodynamically and neurologically stable hence was transferred out to neurology floor with telemetry on HD #9. Transferred to floor on HD #10. Floor Course: #Pneumonia: Patient with hospital acquired pneumonia vs ventilator associated PNA vs. aspiration PNA in setting of CVA, placement of NG tube, and intubation for three days (CXR from [9-1] showed increasing RLL opacity) Sputum GS grew Methicillin sensitive staph aureus and pan-sensitive proteus (received 3 days of Zosyn which was switched to ceftriaxone on [9-5].) She was initially covered with Vancomycin/Zosyn for HAP, which were switched to Nafcillin/Ceftriaxone after sensitivities returned for total 8 days of treatment. She was treated with ipratroprium and albuterol nebs, guafenesin as mucolytic, chest PT, and kept on aspiration precautions. She initially required a shovel mask for oxygenation, and was eventually weaned off of oxygen. Her breathing clinically improved and she was breathing in the high 90s on room air on discharge. In addition, patient had a speech and swallow consult which deemed her unable to swallow and with multiple secretions, and at risk for aspiration. S&S recommended PEG placement. Pt received meds and TFs through NGT. Eventually had a PEG placed by interventional radiology with no complications. Pt tolerated TFs and meds through PEG on day of discharge. NGT was removed. PEG should be used as bridge for feeding and medications while patient gets speech and swallow therapy at rehabilitation. #CVA: R basal gangla infarcts. Her stroke work-up included a TTE w/o ASD, thrombus, or focal wall motion abnormality, a carotid U/S shwoing <40% narrowing of ICAs. Lipid panel c/w hypercholesterolemia, hypertriglyceridemia. L sided weakness may be recrudescence of old stroke. She was continued on a baby aspirin, metoprolol, and a statin. The encephalopathy seen during her ICU course resolved with treatment of her HAP/urosepsis, and she remained mute with L hemiplegia, she was able to nod "yes/no" to questions and move the R side of her body. She was discharged to a rehabilitation facilty for physical therapy. #Anemia: Pt had coffee ground emesis on first day of admission, which resolved. Received 3 U PRBCs during the course of her neuro ICU stay. She had a hematocrit drop to low 20s (baseline is ~26). Transfused 2 U PRBCs on [9-4] with increase in Hct to 30. No evidence of gross blood in stool. guiac negative. Fe studies show ACD, but this could be confounded by transfusion. No B12 deficiency, no evidence of hemolysis. Sacral decub ulcer was not oozing blood. GI was consulted who recommended a short course of misoprostol while in house and EGD if patient continued to have evidence of continued GI bleed. She was continued on IV Protonix and switched to Lansoprazole for her NGT/PEG. Her Hct was stable in the low to mid 30s on discharge. She should be referred to GI by her PCP for an upper endoscopy as an outpatient after discharge/rehab. #Fevers and Hypotension: Likely urosepsis. Other etiologies included decubitus ulcer and pneumonia. Had chronic NG tube, but no evidence of sinusitis on exam. MS changes/encephalopathy resolved, and patient had good U/O. Unlikely cardiogenic or obstructive (TTE neg for tamponade, EF 55%), or autonomic dysfunction related to stroke. Her hypotension resolved with fluid boluses and her beta blocker was initially held. She was treated with antibiotics for HAP (see above) and treated for her urosepsis w/ Ciprofloxacin. She became afebrile x48 hrs and her hypotension resolved. Surveillence blood cultures negative. Her BB was restarted and titrated up to 37.5 mg PO TID. . #Tachycardia: likely associated w/ urosepsis/hypovolemia. resolved with fluids and antibiotics. Pt was continued on telemetry and a beta blocker. #UTI: complicated proteus/pseudomonas UTI. replaced foley, treated with 3 days of Zosyn and 7 days of PO ciprofloxacin. She will need 2.5 days of ciprofloxacin (5 doses total) at rehabilitation (end date [2142-9-14]). #Hyponatremia: Patient was hyponatremic on transfer to floor, likely related to excessive free h20 boluses. Pt not adrenally insufficient. TSH normal. Urine osms not overly concentrated, unlikely SIADH. Resolved with halfing of free H20 boluses to 250 ccs q12H. #Sacral decub: stage III-IV, debrided in ICU by plastics. Required cauterization of bleeding vessels, remained stable afterwards with no oozing. Plastics followed the patient, and they did not see bone exposure and did not believe patient was at risk for osteomyelitis. continued wound care w/ dressing changes [Hospital1 ]. Vit A, C, and ZnSO4 for wound healing (should get 5 more days of ZnSO4 at rehabilitation, then med should be discontinued.) Pt should see plastic surgery as an outpatient for follow-up of the sacral decubitus ucler and is scheduled for an appointment. #Ankle fracture: lateral malleolus fx, comminuted distal fibular fx. L leg in air cast w/o outpatient f/u w/ Dr. [Last Name (STitle) 1005] in one month. . #Guiac positive stools: Pt has intermittently guiac positive stools in setting of heparin sq. No frank blood or BRBPR. Hct stable. Hep SQ continued given need for DVT prophylaxis. Can have non-urgent EGD as outpatient. . #Hyperglycemia: Pt was kept on HISS for tight blood sugar control in setting of improved wound healing. Pt's FS were in the low 100s near the end of her hospital stay, and her HISS was d/c-ed. #FEN: -TFs with vit A, C, ZnSO4 (x10 days) supplementation for wound healing. -repleted electrolytes aggressively to prevent refeeding syndrome -free H20 boluses (250 q12H). -Initially fed through NGT. PEG eventually placed by IR for tube feeds ad NGT removed. #PPX: lanzoprazole, bowel regimen (colace as needed), pneumoboots #Access: PICC ([9-2]) #Code: Full Code #Communication: [Name (NI) ] [Name (NI) 32400] HCP/guardian. #Dispo: to rehabilitation center Medications on Admission: 1. HCTZ (unknown dose) 2. augmentin Discharge Medications: 1. Acetaminophen 325 mg Tablet [Name (NI) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 2. Docusate Sodium 50 mg/5 mL Liquid [Name (NI) ]: Two (2) liquid containers PO BID (2 times a day) as needed for constipation. 3. Aspirin 81 mg Tablet, Chewable [Name (NI) ]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet [Name (NI) ]: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Name (NI) ]: 5-10 MLs PO BID (2 times a day) as needed for dressing changes. 6. Heparin, Porcine (PF) 10 unit/mL Syringe [Name (NI) ]: 1-2 MLs Intravenous PRN (as needed) as needed for line flush. 7. Heparin (Porcine) 5,000 unit/mL Solution [Name (NI) ]: One (1) vial Injection TID (3 times a day). 8. Ciprofloxacin 250 mg Tablet [Name (NI) ]: One (1) Tablet PO Q12H (every 12 hours) for 5 doses. 9. Metoprolol Tartrate 25 mg Tablet [Name (NI) ]: 1.5 Tablets PO TID (3 times a day). 10. Vitamin A 10,000 unit Capsule [Name (NI) ]: One (1) Capsule PO DAILY (Daily). 11. Zinc Sulfate 220 mg Capsule [Name (NI) ]: One (1) Capsule PO DAILY (Daily) for 5 doses. 12. Ascorbic Acid 90 mg/mL Drops [Name (NI) ]: Six (6) mL PO DAILY (Daily). 13. Ipratropium Bromide 0.02 % Solution [Name (NI) ]: One (1) puff Inhalation Q6H (every 6 hours) as needed. 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 15. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [Last Name (STitle) ]: [4-7] MLs PO Q6H (every 6 hours) as needed for secretions. 16. Heparin, Porcine (PF) 10 unit/mL Syringe [Month/Year (2) ]: 1-2 MLs Intravenous PRN (as needed) as needed for line flush. 17. Albuterol 90 mcg/Actuation Aerosol [Month/Year (2) ]: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 18. Sodium Chloride 0.9 % 0.9 % Solution [Month/Year (2) ]: Three (3) ML Injection PRN (as needed) as needed for line flush. 19. Sodium Chloride 0.9 % 0.9 % Solution [Month/Year (2) ]: Three (3) ML Injection PRN (as needed) as needed for line flush. 20. Sodium Chloride 0.9 % 0.9 % Solution [Month/Year (2) ]: Three (3) ML Injection once a day: line flush. Discharge Disposition: Extended Care Facility: [Location (un) 582] of [Location (un) 583] Discharge Diagnosis: R basal ganglia stroke Secondary [Hospital 109226] Hospital Acquired Pneumonia Urosepsis Hypertension Hyperlipidemia Stage IV Sacral Decubitus Ulcer Discharge Condition: Good Discharge Instructions: You were admitted with a diagnosis of stroke to your R basal ganglia. You also had a pneumonia and a urinary tract infection, both of which was treated with antibiotics. At rehabilitation, you will need to take 5 more doses of Ciprofloxacin for treatment of your urinary tract infection (end date [2142-9-14].) You also were anemic and required 5 blood transfusions. Your blood levels were stable at the time of discharge. The following medication changes were made: -You were started on aspirin 81 mg daily and prevention of stroke -Metoprolol 37.5 mg by mouth twice a day was added for control of your blood pressure and prevention of stroke -Lipitor 10 mg by mouth daily for treatment of high cholesterol and stroke prevention -Vitamin A, Vitamin C, and Zinc Sulfate for wound healing -Ipratroprium and Albuterol as needed to improve your breathing after the pneumonia -Dextromethorphan-Guafenisen to decrease your lung secretions and make your breathing more comfortable. -Lansoprazole rapid dissolve twice a day to protect your stomach from gastritis and bleeding ulcers -Colace for constipation as needed You were discharged in stable condition. Please return to the emergency department or contact your primary care physician if you experience any of the following symptoms: paralysis, weakness, difficulty thinking or speaking, loss of bowel or bladder continence, fever > 101, shaking chills, loss of consciousness, chest, abdominal, back, or extremity pain, fall with trauma, low blood pressure, or any other symptoms not listed her that are concerning to you. Followup Instructions: Please follow up with your primary care physician [Name Initial (PRE) 176] [11-29] weeks after rehabilitation. [Last Name (LF) 5533],[First Name3 (LF) ] M. [Telephone/Fax (1) 3581]. You have an appointment scheduled for [2142-10-22] at 3:30 pm for physical exam. Your guardian/health care proxy can reschedule this appointment based on how long your rehabiliation takes. You will need a referal from your PCP for [Initials (NamePattern4) ] [Last Name (NamePattern4) 109227] upper endoscopy by a gastroenterologist as an outpatient. Please follow up with orthopedics at [Hospital1 18] in the [Hospital Ward Name 23] Center on [Hospital Ward Name 516] w/ Dr. [Last Name (STitle) 1005]. Appointment scheduled for : [10-2] at 3:15 pm. Phone # [Pager number 1228]Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2142-10-2] 3:15 Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2142-10-2] 2:55 Please follow up with plastics surgery for your sacral decubitus ulcer in [12-31] weeks time after discharge from the hospital. Their phone number is ([Telephone/Fax (1) 2868] in the cosmetic clinic. You are scheduled for Friday, [10-5] at 2:00 pm. [Hospital Ward Name 23] [Location (un) ] to see Dr. [Last Name (STitle) 23606]. Please discuss with them the continuation of your vitamin supplements for wound healing. Completed by:[2142-9-12]	[ "486", "5849", "5990", "2761", "2760", "4019", "2859", "2720" ]
Admission Date: [2142-10-19] Discharge Date: [2142-11-6] Date of Birth: [2124-7-28] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: s/p Rollover motor crash Major Surgical or Invasive Procedure: [2142-10-20] Repair of left hand extensor tendon/STSG History of Present Illness: 18 yo female unrestrained driver, s/p rollover MVC; ejected from vehicle. Was found ~50 ft from vehicle with obvious left hand deformity. She was intubated at scene secondary to combativeness. She was transferred to [Hospital1 18] for continued care. Past Medical History: None Family History: Noncontributory Pertinent Results: [2142-10-19] 03:25PM GLUCOSE-132* LACTATE-2.0 NA+-138 K+-4.6 CL--107 TCO2-21 [2142-10-19] 03:15PM GLUCOSE-146* UREA N-10 CREAT-0.8 SODIUM-141 POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-20* ANION GAP-14 [2142-10-19] 03:15PM AMYLASE-87 [2142-10-19] 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2142-10-19] 03:15PM WBC-19.8* RBC-4.11* HGB-12.9 HCT-35.1* MCV-86 MCH-31.4 MCHC-36.8* RDW-13.0 [2142-10-19] 03:15PM PLT COUNT-154 CT HEAD W/O CONTRAST Reason: ?ICH [Hospital 93] MEDICAL CONDITION: 18 year old woman with AMS on scene s/p rollover REASON FOR THIS EXAMINATION: ?ICH CONTRAINDICATIONS for IV CONTRAST: None. INDICATIONS: 18-year-old woman status post motor vehicle collision. COMPARISONS: None. TECHNIQUE: Non-contrast head CT. FINDINGS: There is a small left-sided acute subdural hematoma along the anterior left frontal convexity, up to 3 mm in thickness. There is also a suspected thin subdural along the posterior aspect of the falx cerebri up to 4 mm in diameter. A punctate 2 mm density in the subcortical white matter, within the right frontal lobe, is suggestive of a hemorrhagic contusion. Additional punctate densities along the medial periventricular white matter adjacent to the right lateral ventricle, and within the right side of the corpus callosum, are suspicious for diffuse axonal injury with hemorrhage, based on their locations. There is no mass effect, hydrocephalus or shift of the normally midline structures. The ventricles, cisterns, and sulci are unremarkable without effacement. The [Doctor Last Name 352]-white matter differentiation appears preserved. There is a small air-fluid level in the left maxillary sinus which can be seen in intubation. There is slight mucosal thickening in the sphenoid sinus. The mastoid air cells are clear. The osseous structures are unremarkable. There is bilateral soft tissue swelling above the orbits anteriorly. IMPRESSION: 1. Small left frontal subdural hematoma, with suspected small subdural along the posterior falx cerebri as well. 2. Small right frontal hemorrhagic contusion. 3. Dense foci along the right lateral ventricle, and within the corpus callosum, suspicious for diffuse axonal injury with hemorrhage. The findings were discussed shortly after the study with Dr. [Last Name (STitle) ] and posted to the ER dashboard. When clinically appropriate, an MR is suggested in order to better evaluate the extent of injury, as MRI is more sensitive, in particular, for detection diffuse axonal injury, particularly for foci not associated with hemorrhage. CT C-SPINE W/O CONTRAST Reason: ?fx [Hospital 93] MEDICAL CONDITION: 18 year old woman with AMS on scene s/p rollover REASON FOR THIS EXAMINATION: ?fx CONTRAINDICATIONS for IV CONTRAST: None. INDICATIONS: 18-year-old woman with altered mental status after motor vehicle accident. COMPARISONS: None. TECHNIQUE: Axial non-contrast CT images of the cervical spine were obtained, and sagittal and coronal reconstructions were also performed. FINDINGS: The alignment of the cervical spine is normal, without listhesis. There is no evidence of fracture, dislocation, bony destruction, or prevertebral soft tissue swelling. The osseous structures appear normal. The patient is intubated, and there is a nasogastric tube passing through the esophagus. In the left upper lobe, there is a peripheral 4-mm nodular density which may represent a lung nodule, or perhaps a small contusion, although there is no evidence of surrounding injury to suggest chest injury. There is mild dependent change in the visualized right apex. IMPRESSION: 1. No evidence of fracture or dislocation. 2. Small density in the left upper lobe, which could represent a small contusion or nodule. Follow-up after three months is suggested to ensure resolution. CHEST (PORTABLE AP) Reason: CP processes [Hospital 93] MEDICAL CONDITION: 18 year old woman with fever REASON FOR THIS EXAMINATION: CP processes IMPRESSION: 18-year-old with fever, status post motor vehicle accident. COMPARISON: [2142-10-31]. FINDINGS: Lungs are clear except some residual opacity in the right apex, not significantly changed from the previous examination. There are no pleural effusions. Cardiomediastinal silhouette is unremarkable. No evidence of central lymphadenopathy. Right PICC terminates in the distal SVC. A feeding tube terminates in the expected location of distal stomach. IMPRESSION: Unchanged appearance of residual right apical opacity, otherwise clear lungs Blood Urine CSF Other Fluid Microbiology Recent Last Day Last Week Last 30 Days All Results Hide Comments From Date To Date Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2142-11-6] 07:00AM 9.5 3.81* 11.6* 32.4* 85 30.4 35.8* 13.9 543* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [2142-11-1] 02:02AM 80.4* 12.7* 5.8 0.5 0.7 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [2142-10-20] 02:20AM NORMAL1 NORMAL NORMAL NORMAL NORMAL NORMAL 1 NORMAL MANUAL BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [2142-11-6] 07:00AM 543* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2142-11-6] 07:00AM 101 34* 0.8 134 3.7 98 24 16 [2142-11-5] 11:20AM 120* 37* 0.9 137 3.7 100 25 16 [2142-11-3] 07:15AM 106* 37* 1.2* 144 4.5 106 26 17 [2142-11-2] 06:51AM 125* 37* 1.2* 149* 4.2 112* 26 15 [2142-11-1] 02:02AM 143* 36* 1.4* 146* 3.7 110* 25 15 [2142-10-31] 12:37PM 129* 37* 1.3* 142 3.8 106 27 13 [2142-10-31] 03:03AM 159* 31* 1.4* 141 3.6 104 26 15 [2142-10-30] 12:45AM 104 9 0.6 138 3.9 99 26 17 [2142-10-29] 01:17PM 110* 138 3.8 101 27 14 Source: Line-art [2142-10-29] 03:46AM 83 12 0.5 136 3.9 101 28 11 [2142-10-28] 03:05AM 140* 9 0.5 139 4.2 106 25 12 [2142-10-27] 02:38AM 101 9 0.4 140 3.5 104 29 11 [2142-10-26] 02:01AM 89 10 0.5 142 4.1 108 27 11 [2142-10-25] 02:20AM 115* 8 0.4 141 4.1 109* 25 11 [2142-10-24] 11:36AM 3.7 Source: Line-a-line [2142-10-24] 04:01AM 115* 5* 0.5 142 3.6 110* 25 11 [2142-10-23] 02:23PM 3.7 Source: Line-aline [2142-10-23] 03:13AM 128* 3* 0.5 140 3.8 108 24 12 [2142-10-22] 02:31AM 109* 3* 0.6 139 3.8 111* 20* 12 ADDED ALB [2142-10-22] 8:35AM [2142-10-21] 11:34AM 94 21 0.5 137 3.7 112 20* 9 1 VERIFIED - CONSISTENT WITH OTHER DATA [2142-10-21] 02:55AM 92 3* 0.6 138 3.7 114* 17* 11 [2142-10-20] 04:55PM 81 0.6 140 3.5 112* 20* 12 Source: Line-art [2142-10-20] 02:20AM 91 10 0.6 139 3.4 110* 21* 11 [2142-10-19] 03:15PM 146* 10 0.8 141 3.6 111* 20* 14 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2142-10-19] 03:15PM 87 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2142-11-6] 07:00AM 9.8 4.4 2.0 ANTIBIOTICS Vanco [2142-11-2] 06:52AM 6.21 Vancomycin @ Trough 1 UPDATED REFERENCE RANGE AS OF [2142-9-5] == REPRESENTS THERAPEUTIC TROUGH NEUROPSYCHIATRIC Phenyto [2142-10-28] 03:05AM 3.2 TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp Barbitr Tricycl [2142-10-19] 03:15PM NEG NEG1 NEG NEG NEG NEG 1 NEG 80 (THESE UNITS) = 0.08 (% BY WEIGHT) LAB USE ONLY HoldBLu RedHold [2142-10-24] 04:12AM HOLD1 1 HOLD DISCARD GREATER THAN 24 HRS OLD Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS Intubat Vent Comment [2142-10-29] 01:30PM ART 82* 41 7.44 29 3 [2142-10-29] 09:52AM ART 37.9 50 187* 38 7.47* 28 4 [2142-10-29] 03:57AM ART [10-12] 400 5 50 200* 48* 7.40 31* 4 INTUBATED WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl calHCO3 [2142-10-29] 01:30PM 112* 3.8 [2142-10-29] 09:52AM 121* 0.8 HEMOGLOBLIN FRACTIONS ( COOXIMETRY) O2 Sat [2142-10-21] 06:30PM 85 CALCIUM freeCa [2142-10-29] 01:30PM 1.23 Brief Hospital Course: She was admitted to the trauma service. Neurosurgery and Plastic Surgery were consulted because of her injuries. Her neurosurgical issues were nonoperative; she was loaded with Dilantin and continued on a scheduled dose for 10 days; serial head CT scans were followed and were stable. She will follow up in [Hospital 4695] clinic in 5 weeks for repeat head CT scan. Plastic Surgery was consulted for her left hand degloving injury. She was taken to the operating room for repair of her extensor tendon and STSG. She will follow up with Plastic surgery in [1-8] weeks after discharge. Because of her [Doctor First Name ] Behavioral Neurology was consulted as patient was having behavior issues; periods of extreme restlessness and agitation. During her ICU stay she was receiving Haldol and Ativan and required 1:1 sitters. It was recommended that these agents be placed on hold as could have been contributing to her delirium. Her behavior dramatically improved, mental status such that she knew the date and place. During her ICU stay she was initially difficult to wean; discussions took place with family as to possibility of tracheostomy. She eventually was able to wean and then was extubated. She was transferred to the step-down unit [Unit Number ] days following her extubation. Speech and Swallow were evaluated early on during her hospital stay; initially she did not pass her bedside swallow; a Dobhoff tube was placed and tube feedings were initiated. She was re-evaluated by Speech several days later once her mental status improved; her diet was upgraded to nectar thick liquids and soft solids. Her tube feedings were cycled; she was also placed on calorie counts. Because of the dramatic improvement in her mental status it is expected that the Dobhoff will be very short term and she will eventually have her diet upgraded with continued evaluation by SLP once at rehab. On the morning of her discharge she was in the bathroom and while sitting on the toilet slipped hitting her right foot, on examination there was no point tenderness or swelling. No other injuries were identified. Physical and Occupational therapy were also consulted and have recommended [Hospital ] rehab stay. Case management initiated this process and she was accepted by [Hospital1 ]. Social work was closely involved with patient and family for coping and support. Medications on Admission: OCP Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day as needed for per sliding scale. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection [Hospital1 ] (2 times a day). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) ML's PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ML's PO BID (2 times a day). 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 8. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: REHAB HOSP OF CAPE AND ISLANDS Discharge Diagnosis: s/p Rollover motor vehicle crash Degloving injury left hand Small subdural hematoma Diffuse axonal injury Discharge Condition: Good Discharge Instructions: No procedures left arm because of the injury that was sustained. Followup Instructions: Follow up with Plastic Surgery clinic in 1 week, call [Telephone/Fax (1) 5343] for an appointment. Follow up with Neurosurgery, Dr. [Last Name (STitle) 548] in 5 weeks. Call [Telephone/Fax (1) 2992] and inform the office that you will need a repeat head CT scan for this appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2142-11-6]	[ "5070", "2859" ]
Admission Date: [2132-10-30] Discharge Date: [2132-11-23] Date of Birth: [2061-9-24] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Oxacillin / Heparin Agents Attending:[First Name3 (LF) 826] Chief Complaint: line sepsis Major Surgical or Invasive Procedure: hemodialysis hemodialysis catheter replacement mechanical ventilation transesophageal echocardiogram midline placement History of Present Illness: Mr. [Known lastname 4154] is a 71 year old man with PMH significant for ESRD on HD and endocarditis who was admitted to [Hospital3 105] on [2132-9-12] with respiratory failure and endocarditis following a hospitalization at [Hospital1 18] for MRSA septic shock. He had been recovering there until day of arrival, when he was found to have a fever of 101.0. He was found to be growing VRE and was started on linezolid on day of admission. It is not clear if this was from a surveillance culture or if he had been spiking fevers prior to day of arrival. While at [Hospital1 ], vanco had been dosed by level throughout his course, with the last level 30 on [10-28]. Of note, he was dialyzed today through the tunnelled catheter that was placed in his groin in [10-9] by IR. At baseline, the patient is oriented x [11-24] with periods of confusion. He was transferred to this facility for change of HD access. Past Medical History: 1. ESRD on HD, anuric, M, W, F tunneled catheter 2. Atrial Fib/DDD pacer [6-27] interrogation 3. CAD s/p stent mild 40% prox LAD on cath '[27]. Echo showed EF > 60% on [10-27], mod pulm HTN, no significant valve dz. Normal MIBI in [10-26]. 4. hypothyroid 5. PEG 6. h/o LUE DVT (on coumadin) 7. HTN 8. ? HIT 9. Left total knee replacement [2123] 10. multiple line infections 11. h/o presumable MRSA endocarditis and sepsis [9-27] (could not be confirmed with TTE) TEE not perfomred as pt has esophageal narrowing on EGD in past. 12. Anemia of chronic disease (on Epo) 13. Vented since [5-27] line sepsis, MRSA PNA, recurrent [2132-7-1] 14. history of TB as a child and now with negative PPD 15. DM (?) 16. VRE in urine in [6-27] Social History: Retired dentist, was living in [Location (un) ] with wife, kids, and [Name2 (NI) 7337], denies etoh/tob. Family History: Both parents died in 90's, healthy. Physical Exam: T 99.7 HR 69 BP 198/92 RR 30 93% vent: 550 x 12 40% PEEP 5 Gen: agitated, HEENT: MMM, pupils reactive Neck: trach in place, no LAD, bilateral 4-6 cm area of nontender edema over shoulders Cor: RRR 1/VI systolic murmur best heard over LLSB Pulm: CTAB no crackles Abd: obese, well healed surgical incisions, NTND + BS no hepatosplenomegaly Ext: WWP, DP/PT/Radial pulses 2+, no splinter hemorrhages, osler nodes Neuro: hand grip [3-27] otherwise patient did not comply with exam, + asterixis, could not evaluate cranial nerves although palate elevated symmetrically. Pertinent Results: Admission: [2132-10-29] 10:20PM BLOOD WBC-10.8 RBC-3.13* Hgb-9.1* Hct-27.6* MCV-88 MCH-28.9 MCHC-32.8 RDW-18.9* Plt Ct-186 [2132-10-29] 10:20PM BLOOD Neuts-90.6* Bands-0 Lymphs-5.1* Monos-3.8 Eos-0.4 Baso-0.2 [2132-10-29] 10:20PM BLOOD PT-17.1* PTT-28.0 INR(PT)-2.0 [2132-10-29] 10:20PM BLOOD Glucose-49* UreaN-34* Creat-2.2* Na-140 K-5.5* Cl-107 HCO3-27 AnGap-12 [2132-10-29] 10:20PM BLOOD ALT-44* AST-79* AlkPhos-471* TotBili-0.4 [2132-10-29] 10:20PM BLOOD Calcium-8.6 Phos-1.6* Mg-2.2 [2132-10-30] 09:34AM BLOOD Type-ART pO2-114* pCO2-35 pH-7.47* calHCO3-26 Base XS-1 [2132-10-29] 10:53PM BLOOD Lactate-1.7 [2132-11-23]: [2132-11-23] 04:33AM BLOOD WBC-14.7* RBC-3.68* Hgb-10.5* Hct-33.8* MCV-92 MCH-28.6 MCHC-31.1 RDW-18.4* Plt Ct-105* [2132-11-23] 04:33AM BLOOD Glucose-68* UreaN-40* Creat-3.1* Na-139 K-4.8 Cl-107 HCO3-24 AnGap-13 [2132-11-23] 04:33AM BLOOD Calcium-9.5 Phos-3.4# Mg-2.5 [2132-11-22] 11:46AM BLOOD Type-ART Temp-38.4 Rates-20/2 Tidal V-500 PEEP-10 FiO2-80 pO2-78* pCO2-55* pH-7.23* calHCO3-24 Base XS--5 AADO2-440 REQ O2-75 Intubat-INTUBATED Vent-CONTROLLED CT head [10-29]: No evidence of hemorrhage or infarction. Evidence of chronic ischemia and right maxillary sinus and bilateral mastoid opacification, unchanged since [2132-6-11]. CXR [10-29]: Bilateral multifocal pneumonia, and/or a moderate degree of congestive failure. ECHO [10-31]: 1. The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. There is an echogenic density in the right ventricle consistent with a pacemaker lead. 4.The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Physiologic mitral regurgitation is seen (within normal limits). 6.There is moderate pulmonary artery systolic hypertension. 7.There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2132-9-1], no change. IMPRESSION: No echocardiographic evidence of endocarditis. PICC placement [11-7]: 1. Successful placement of a 21 cm, single lumen [Last Name (un) ] midline catheter with tip in the left subclavian vein, ready for use. 2. Venogram demonstrates stenosis at the junction of the left subclavian and brachiocephalic veins. TEE [11-7]: Conclusions: Despite multiple attempts, the TEE probe could not be passed into the esophagus. At baseline, the patient was hypotensive, on vasopressors, with difficult intravenous access, therefore deeper sedation was deemed unsafe from the hemodynamic standpoint. TEE was therefore aborted. CXR [11-14]: No significant interval change in the appearance of the right mid lung infiltrate, pulmonary vascular congestion, and pleural effusion since the prior study. CXR [11-18]: Increased pulmonary edema compared to [2132-11-18] with unchanged probable multifocal pneumonia. Brief Hospital Course: Assessment: 71yo man with ESRD on HD< CAD s/p PCI, paroxysmal afib s/p PPM, ?HIT, recurrent line bacteremia, ventilator-dependent since [5-27], admitted with VRE line bacteremia and pseudomonas multifocal pneumonia, progressively deteriorated without alternative options for treatment, until goals of care were made to be comfort measures only. Hospital course is discussed below by problem: 1. Line sepsis: He was found to have VRE from his hemodialysis catheter. This was removed and replaced twice. In addition, he was treated with many antibiotics, including (at the end of his hospitalization) daptomycin, colistin, metronidazole, and ambisome. His lines continued to be infected. The idea of treating him with an "antibiotic lock" using ambisome, daptomycin, and argatroban in a heplock was considered, but no studies of safety and efficacy had been done investigating this method. The ID team was following his care closely throughout the hospitalization. 2. Hypotension: The patient was found to be recurrently hypotensive. This was most likely secondary to sepsis, as he had both a line infection and a pneumonia that could not be treated effectively. In addition, he became hypotensive with increases in PEEP and with hemodialysis. He was initially treated with small fluid boluses, changes in ventilator settings, and adjustments to hemodialysis, but eventually had to be placed on levophed. This medication, however, was not enough to maintain his blood pressure, and it was discontinued when the patient was made CMO. He did not have any available access to start another pressor. 3. Respiratory failure: This was thought to be secondary to either septic emboli from his line, pneumonia, or ARDS (from sepsis or volume overload). Volume overload was considered less likely as his respiratory status worsened after being dialyzed. Despite aggressive antibiotic treatment, including courses of linezolid, daptomycin, levofloxacin, cefepime, meropenem, colistin, and flagyl, the patient continued to decline, until his ventilator settings were difficult to manage in conjunction with his hypotension and desaturations. When the goals of care were changed to comfort measures only, the patient was taken off the ventilator. 4. Atrial fibrillation: The patient had several episodes of paroxysmal atrial fibrillation with rates in the 150s. These resolved quickly, once with the administration of po amiodarone (likely not causal given the route of administration). The patient was maintained on po amiodarone as well. He could not be given a beta blocker or calcium channel blocker due to his hypotension. 5. ESRD on HD: During the hospitalization, the renal service was closely following and administering hemodialysis when appropriate. This was stopped when it was no longer feasible given his hypotension and lack of access. 6. Leukocytosis: As above, this was likely secondary to infection. A TEE was recommended by the ID service but was unable to be performed due to the patient's agitation without sedation and hypotension with sedation. 7. Glucose control: He was maintained in the hospital on lantus while his tube feeds were running and a sliding scale of insulin for tighter blood sugar control. 8. Elevated INR: He was noted to have an elevated INR, temporally related to coumadin, which resolved s/p FFP, and vitamin K. 9. Access: His hemodialysis catheter and midline were both replaced, but there were no alternative ways of managing the HD catheter infection. He was getting levophed through his midline, but did not have any way to get better access. He had no good indication for central line attempts, as they would likely be unsuccessful and would cause more harm than benefit. His family decided to make the goals of care comfort measures only and all additional treatment measures were withdrawn. Medications on Admission: citalopram 30 Q48, linezolid 600 Q12, haloperidol 2 mg Q 8 PRN, lorazepam 0.25 mg Q 8, acetominophen 650 Q6 PRN, alteplase 2 mg IV 3 x week, bisacodyl 10 mg PR Q12 PRN, insulin regular Q12, hydroxyzine 25 mg Q8, nepro strength 50 ml/hr, epo 15,000 units 3 x week, percocet Q 6 PRN, lansoprazole 30 QD, iron 300 mg QD, b12 1000 mcg QD, amio 200 mg QD, senna 1 tab Q12, metoprolol 25 Q12, docusate 100 mg Q12, ipratrop/albuterol 4 puffs Q4 PRN. Discharge Medications: N/A Discharge Disposition: Extended Care Discharge Diagnosis: Sepsis Pseudomonal pneumonia Vancomycin resistent enterococcal line infection Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A	[ "2760", "42731", "99592", "2449", "4019" ]
Admission Date: [2173-11-28] Discharge Date: [2173-12-11] Date of Birth: [2144-1-16] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 21007] Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 29 yo female with history of anemia secondary to uterine fibroid bleeding, presents with pleuritic chest pain for approximately one week. She notes that she felt some left chest cramping last week; however, the pain did not become severe until [2173-11-26]. Pain initially radiated to back and now is going down to her left buttocks. This is in background of ~2 months of dyspnea on exertion which has noticably worsened in last two weeks. Also patient is reporting that she had sudden onset BLE edema that she first noticed after a plane trip to St. [Doctor First Name ] (4 hour leg to [First Name9 (NamePattern2) 8880] [Country ] was longest time on plane). She denies any LE edema at this time. Also denies cough, hemoptysis, fevers, chills, sick contacts. . Regarding her uterine fibroid bleeding, patient is seen in OB/Gyn by Dr. [Last Name (STitle) ]. She notes that her last menstral period (and start of her abnormal uterine bleeding) was [2173-9-27]. Patient took a high dose OCP taper starting [2173-10-22] for large uterine fibroids that were causing significant uterine bleeding. At time of admission she was taking one pill daily, though she had been instructed to start another high dose OCP taper due to increased vaginal bleeding in the last 4 to 5 days. She did not take the high dose OCPs due to not feeling well in the last few days. She had planned for an open myommectomy on [2174-1-12] due to persistent bleeding. As a bridge to surgery, patient was going to receive information about a Lupron injection this week. She explicitly denies any history of pregnancy, abortions, or miscarriages. . Upon presentation to the ED vitals were T 98.8, HR 96, BP 138/83, RR 16, O2Sats 100% RA. Presented with chest pain. Was found to have elevated d-dimer to ~[Numeric Identifier 7206] and subsequently found to have extensive bilateral PE on CTA chest. Was started on a heparin drip. EKG was without wigns of right heart strain. Troponin was negative at <0.01. Was originally destined for the floor, though the floor attending was concerned about full anticoagulation in the setting of recent uterine bleeding. Needs to be typed, crossed, and consented for blood products in the event of uterine bleeding while anticoagulated. Vitals prior to transfer to the ICU were T 98.4, HR 92, BP 119, RR 28, 100%/4L NC. . REVIEW OF SYSTEMS: (+)ve: pleuritic chest pain, dyspnea on exertion, menorrhagia, occasional abdominal cramping (-)ve: fever, chills, night sweats, loss of appetite, fatigue, palpitations, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: 1) Uterine fibroids 2) Anemia, iron-deficiency 3) Bacterial vaginosis 4) Gonorrhea 5) Trichomonas 6) Cosmetic surgery on left thigh (redundant skin) as a child Social History: Currently works as an art consultant. Past work as a law librarian at a law firm downtown. Tobacco: Rare EtOH: Occasional, less use since she has struggled with uterine bleeding Illicits: Denies Family History: MGM, MGF, PGF: Diabetes PGF: Died from MI No history of blood clots, sudden death, autoimmune disorders. Physical Exam: VS: T 100, HR 85, BP 126/91, RR 30, O2Sat 97% RA GEN: NAD, healthy-appearing female HEENT: PERRL, EOMI, oral mucosa moist NECK: Supple, JVP approximately 6 cm PULM: CTAB CARD: RR, nl S1, nl S2, no M/R/G ABD: BS+, somewhat firm midline, otherwise soft, non-tender, non-distended, no hepatosplenomegaly EXT: no C/C/E SKIN: no rashes NEURO: Oriented x 3, CN II-XII intact, grossly normal extremity motor exam, gait not asessed PSYCH: Mood and affect appropriate Pertinent Results: Admission Labs: [2173-11-28] 10:00AM WBC-6.8 RBC-4.18* HGB-9.6# HCT-29.6 MCV-71* MCH-23.1# MCHC-32.5 RDW-23.8 [2173-11-28] 10:00AM PLT SMR-NORMAL PLT COUNT-252 [2173-11-28] 10:00AM PT-12.6 PTT-24.2 INR(PT)-1.1 [2173-11-28] 10:00AM GLUCOSE-91 UREA N-10 CREAT-0.8 SODIUM-139 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15 [2173-11-28] 10:00AM CK-MB-NotDone [2173-11-28] 10:00AM D-DIMER-[Numeric Identifier 52934]* [2173-11-28] 10:00AM CK(CPK)-59 [2173-11-28] 10:00AM cTropnT-<0.01 Studies: [2173-11-28] CT Chest with and without contrast There are multiple filling defects in the bilateral pulmonary arteries supplying the right upper lobe, anterior segment (2, 23) and right lower lobe (2, 31-40). There is a nodular subpleural opacity within the periphery of the right lower lobe (2, 40) which may represent a small pulmonary infarct. Filling defects within the left upper lobe segmental arteries (2, 19), lingula (2, 24), and left lower lobe (2, 36) segmental arteries are also identified. There is no axillary, hilar, or mediastinal lymphadenopathy. There is no pericardial effusion. There is a small left pleural effusion. There is no evidence of bowing of the interventricular septum to suggest right heart failure at this time. Limited views of the upper abdomen are unremarkable. BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified. IMPRESSION: Extensive bilateral pulmonary emboli as described above. Possible right lower lobe pulmonary infarct. [2173-11-29] Transthoracic Echo 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) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. [2173-11-29] Bilateral Lower Extremity Ultrasound No evidence of deep vein thrombosis in either lower extremity. Brief Hospital Course: 29 yo female with history of anemia secondary to uterine fibroid bleeding who presented with pleuritic chest pain for approximately one week and was diagnosed with pulmonary emboli. #VB: She had increased bleeding in the 4 to 5 days leading up to presentation to the hospital. She was started on Lupron to minimize uterine bleeding on [11-28]. Her bleeding worsened after being placed on a heparin gtt for PE, and in the setting of acute Lupron injection but and she was followed closely by the gynecology service while in the ICU. She was transfused 1U overnight from [Date range (1) 52935] and her Hct responded appropriately. Given her continued bleeding, myomectomy and uterine artery embolization were considered, however after discussion with the gynecology team, decided that as long as Hct was responding, we should wait for Lupron to work. Hct was 27.2 upon transfer out of the ICU. #Anemia: On Hospital Day #4 ([12-1]), Ms. [Known lastname ] was transferred out of the Intensive Care Unit. On HD#6, her hematocrit trended down to 25 and she was transfused 2 units of packed red blood cells as the goal was to keep her hematrocrit >25. Her hematocrit showed an appropriate rise to 29.9 and it remained stable after that time and she did not require any additional blood products. #Tachycardia: Throughout the first 10 days of her hospital course she was tachycardic to 140s with ambulation. This eventually subsided and she remained in regular rate. Telemetry did not demonstrate any arrythmia. the tachycardia was attributed to the pulmonary embolism. #PE: She was continued on the Heparin gtt until HD#9 at which time, her vaginal bleeding had decreased significantly. She was kept on the Heparin gtt until that time in case as further intervention was required to stop the vaginal bleeding. On HD 9 Comadin was started at a dose of 5mg per day. A Lovenox bridge was chosen at the recommedation of the Heme-Onc service. On HD 11 her Coumadin was increased to 7.5. She was discharged on 10mg of Coumadin and her INR was 1.8. She was instructed to continue the Lovenox at home until she was therapeutic on Coumadin (with a goal INR of [1-19]). She had plans to follow-up with [Hospital 52936] clinic. Her 02 sat remained at 100% on RA. # Fever/Pelvic Pain: Her hospital course was complicated by recurrent fever and pelvic pain. She first spiked a fever on HD7 to a Temp max of 101.2 degrees F and she was intermittenly febrile through her hospital course from then on. She was started on Gentamyacin and Clindamycin on HD 7 but her fevers continued despite antibiotic therapy. The fevers and pain were attributed to degenerating fibroids in the setting of recent Lupron injections. The antibiotics were discontinued on HD 10. Several sets of blood cultures were drawn but showed no growth. A urine analysis was initally negative but on HD11 the urine culture grew Gardnerella and she was started on flagyl 500 twice daily to be continued for 7 days. An infectious disease consult was also obtained to help ensure that no occult infections were being missed given the recurrent fevers. The ID consultants agreed that UTI was unlikely to be causing fevers, but that the most likely etiology was degenerating fibroid given pain and no change in fever curve with antibiotics. They recommeded an MRV of the pelvis to rule out septic pelvic thrombophlebitis, repeat blood cultures, and a CT of the chest to rule out lung abscess. All these tests were done but all were negative. The CT demonstrated no abscess. A pelvic MRV/MRI did not demonstate septic pelvic thrombophlebitis but did show non-enhancing fibroids--consistent with the diagnosis of fibroid degeneration as an etiology for her fever. The blood cultures were again negative. Her pelvic pain, also attributed to degenerating fibroids, was poorly controlled on percocet alone. The addition of ibuprofen helped to control her pain but did not relieve it. Indomethacin was finally started which adequately controlled her pain. # Dispo: On HD 13 She was discharged home in stable condition. Her 02 sats were 100% on room air. Her pain was well controlled and her vaginal bleeding was minimal to moderate. The plan was for her to remain on Lupron for vaginal bleeding until which time she was no longer anticoagulated and then she will likely have a myomectomy. She will be followed by [Hospital 3052] at [Location ]clinic and she will follow-up with her primary OBGYN Dr [Last Name (STitle) ]. Medications on Admission: 1) Desogestrel-ethinyl .15mg-.03 mg tablet daily 2) Iron 325 mg [Hospital1 ] Discharge Medications: 1. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:1 3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day. Disp:28 syringe Refills:1 5. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Disp:120 Capsule(s) Refills:0 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bilateral Pulmonary Embolism Menorrhagia secondary to uterine Fibroid, status post-Lupron injection Discharge Condition: stable Discharge Instructions: Please call your doctor for: - Fever > 100.4, Chills - Dizziness, Lightheaded - Chest Pain at rest or with inspiration - Shortness of Breath - Severe Abdominal pain - Persistent nausea/ Vomiting - Heavy Vaginal Bleeding, saturating >1 pad/hr - Unilateral swelling, warmth or redness in extremities Followup Instructions: 1. Please call Dr.[Name (NI) 52937] office this week to schedule a follow-up appointment prior to [2173-12-30]. Your first blood draw should be Monday, [12-13]. You do not need an appointment for the blood draw. This blood draw has been ordered for you in the computer. 2. You have an appointment with [First Name8 (NamePattern2) 3130] [Last Name (NamePattern1) 3131], MD Phone:[Telephone/Fax (1) 7976] Date/Time:[2173-12-30] at 10:40a 3. You have an appoitment with your hematologist, [First Name4 (NamePattern1) 569] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2173-12-31] at 9:00a [First Name8 (NamePattern2) 3130] [Last Name (NamePattern1) 3131] MD, [MD Number(3) 21009] Completed by:[2173-12-13]	[ "2851", "V5861" ]
Admission Date: [2176-12-26] Discharge Date: [2177-1-16] Date of Birth: [2103-8-5] Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim / Aspirin / Compazine / Nifedipine / Morphine Attending:[First Name3 (LF) 30] Chief Complaint: Sudden onset of left sided weakness at 11.00 am today. Major Surgical or Invasive Procedure: IV tPA PEG tube placement Nasal packing for epistaxis History of Present Illness: 73 year old RH female with past medical history significant for atrial fibrillation (not on Coumadin), severe CHF, and hypertension, who awoke this morning at 6AM asymptomatic. At 10AM, she talked to her sister on the phone and was normal. Patient states that around she slipped in the bathroom, looked at her watch, which said 11AM, and activated life alert. Her son says that at 11:45AM, he heard the life alert voice go off saying that they were on their way. He went downstairs and found that she had fallen out of bed (not the bathroom). EMS states that the life alert was actually activated at 12:50PM. She was ten transported to [Hospital1 18] ED. At arrival to [Hospital1 ], she had a dense left hemiparasis, left hemisensory loss, in addition to a left neglect. A head CT was done, which confirmed a right MCA stroke and she was given tPA at 3PM. Repeat examination 30 minutes later was relatively unchanged. In review of systems, she does not have fever, cough, rhinorrhea, chest pain, shortness of breath, abdominal pain, dysuria, or rash. She does not have diplopia or blurred vision or dysphagia. Past Medical History: 1. Pulmonary hypertension 2. Severe [4+] tricuspid regurgitation 3. Atrial fibrillation--on Plavix. Had been on Coumadin, but developed hemoptysis in the setting if supratherapeutic INR of 22 requiring intubation and bronchoscopy in [4-2]. 4. TIA ([2166-1-28]) 5. Hypertension 6. SLE with joint involvement, malar rash 7. Chronic Pain syndrome 8. Fibromyalgia 9. OSA on CPAP--compliant. Uses 2L O2, but does not know pressures. 10. GERD 11. IBS 12. Gout 13. Anemia: Iron deficiency anemia with negative upper and lower endoscopy 14. H/o falls 15. Congestive heart failure, last echo [4-2], EF>55%, mod PA hypertension. Social History: Lives on her own, son in same building. Daughter moved out recently. Smoked in the past but unable to tell us how much, rare alcohol use, occasional drug use. Family History: Hypertension, CAD, Cancer. Both parents died of CHF. Physical Exam: T- 99.6 BP- 155/88 (180/90 with EMS) HR- 71 RR- 18 O2Sat 97 2L Gen: Lying in bed with head turned to the right HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid bruits CV: Irregularly irregular Lung: Clear to auscultation bilaterally, no wheezes Abd: +BS soft, nontender Ext: Some edema at the ankles NIH STROKE SCALE: 17 1a. LOC: alert(0) 1b. LOC questions: answer question correctly(0) 1c. LOC commands: closed eyes and gripped with (nonparetic) hand (0) 2. Best gaze: Forced deviation to right(2) 3. Visual: complete hemianopia(2) 4. Facial Palsy: partial paralysis(2) 5a. Left arm: no movement(4) 5b. Right arm: no drift (0) 6a. Left leg: no movement(4) 6b. Right leg: no drift (0) 7. Limb ataxia: not done 8. Sensory: severe sensory loss on left arm and left leg(2) 9. Language: no aphasia, normal (0) 10. Dysarthria: mild dysarthria (1) 11. Extinction/inattention: (0) Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and not date. Attentive with exam. Speech is fluent with normal comprehension. Follows 2 step commands. Dysarthric. Able to read and name. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields with questionable left visual field loss (vs neglect), eyes cross midline when looking left but not fully. Sensation decreased to LT on left V2-3 areas. Left UMN facial droop. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Trap [3-31]. Tongue midline. Motor: Normal bulk bilaterally. Tone decreased in left upper and lower and lower extremity. Good strength in right upper and lower extremity. 0/5 in left upper and lower extremity. Sensation: Intact to light touch throughout trunk and extremities on right but not on left upper and lower and left side of face. Reflexes: 2 on right upper extremity, 1 on left side upper extremity, 0 at patella and achilles. Toes downgoing on right, upgoing on left. Coordination and gait deferred. Pertinent Results: [2176-12-26*] 01:44PM BLOOD WBC-7.1 RBC-4.99 Hgb-14.6 Hct-44.7 MCV-90 MCH-29.3 MCHC-32.7 RDW-15.7 Plt Ct-215 [2176-12-27] 08:36AM BLOOD PT-14.8* PTT-30.5 INR(PT)-1.3* [2176-12-26] 01:44PM BLOOD PT-13.3 PTT-28.6 INR(PT)-1.1 [2176-12-27] 08:36AM BLOOD Glucose-163* UreaN-20 Creat-1.0 Na-140 K-3.9 Cl-103 HCO3-27 AnGap-14 [2176-12-26] 01:44PM BLOOD ALT-16 AST-25 LD(LDH)-205 AlkPhos-199* TotBili-0.9 [2176-12-26] 01:44PM BLOOD CK-MB-5 cTropnT-<0.01 [2176-12-27] 08:36AM BLOOD CK-MB-5 cTropnT-<0.01 [2176-12-27] 08:36AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.2 Cholest-PND [2176-12-26] 01:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2176-12-26] 01:47PM BLOOD Glucose-133* Na-140 K-4.1 Cl-93* calHCO3-33* . HCT: Large acute infarct of the right MCA territory. Hyperdense right MCA indicates acute thrombus. No hemorrhage is seen. . EEG: Abnormal EEG due to the marked interhemispheric asymmetry with the right hemispheric slowing in evidence both anteriorly and posteriorly. No frank discharging features were seen. . Transesophageal echocardiogram: The left atrium is dilated. Moderate to severe spontaneous echo contrast (smoke) is seen in the body of the left atrium. Severe spontaneous echo contrast is present in the left atrial appendage and presence of thrombus formation can not be excluded due to severity of dense smoke. The left atrial appendage emptying velocity is borderline depressed ( There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta and at least simple atheroma in aortic arch (compex atheroma can not be excluded). Sponteneous echo contrast is also seen in descending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Presence of dense spontaneous echo contrast in left atrium and left atrial appendage. Thrombus in formation in LAA can not be excluded. Complex aortic atheroma and spontaneous echo contrast in the descending thoracic aorta. . RUE ultrasound No evidence for DVT, right upper extremity. Brief Hospital Course: Ms. [Known lastname ] [Last Name (Titles) ] a 73 year old woman with a PMH s/f atrial fibrillation off of coumadin, diastolic CHF, and HTN who was initially admitted on [12-26] with sudden onset of left sided weakness. A head CT confirmed the presence of a right MCA stroke, and she was given tPA. She was initially admitted to the neuro-SICU for monitoring, and upon doing well she was admitted to the neurology service. Her residual deficits included left hemiparesis, left facial droop, and dysarthria. A TEE confirmed the presence of a left atrial thrombus, and her stroke was thought to be embolic secondary to afib off of coumadin. On [1-3] she was noted to be hypotensive to a SBP of 58 in the setting of a fever to 101.4, leukocytosis, EKG changes, and CK's peaking to 2500. She was transferred to the MICU for pressure support with neosynephrine, fluids and intubation. The MICU team felt her shock picture was more consistent with septic shock, and initially covered her with vancomycin, meropenam, and flagyl. Cardiology was consulted for her cardiac picture and it was felt that this was likely a NSTEMI secondary to demand, and the patient was medically managed without anticoagulation. Her cultures later revealed pan sensitive enterococcus and klebsiella in her urine, and MRSA on her bronchoscopy washings. She was started on a 10 day course of IV zosyn and a 7 day course of IV cipro. A PICC line was placed on [1-7] for long term abx, and a PEG tube was placed for tube feeds in the setting of severe dysphagia. Coumadin was re-started in the setting of her atrial thrombus confirmed on TEE, as her stroke was likely embolic in nature. We discussed this decision with both neurology and her PCP as she has a history of severe pulmonary hemorrhage in the setting of an INR of 22 in the past. As she is going to rehab and will be closely monitored we are comfortable with this decision. Current active issues include: 1. New fevers and leukocytosis off of cipro- A UA was positive in this setting. Foley catheter was removed and cipro re-started. She defervesced. She will complete a 10 day course for a presumed foley-associated UTI. Cultures will need to be followed up. 2. Volume overload: After a 5liter volume resuscitation she became short of breath. She resoponds to lasix 80mg IV, and atrovent nebs. She may need to be restarted on her home regimen of po furosemide when she is euvolemic. 3. AFR: creatinine is elevated in the setting of intravascular depletion and lisinopril. Lisinopril often induces ARF in this patient, so it is held. Medications on Admission: 1. AMBIEN 5 mg qhs 2. CLONAZEPAM 0.5 mg qhs prn insomnia 3. FERROUS SULFATE 325 mg [Hospital1 ] 4. IPRATROPIUM BROMIDE 0.2 mg/mL one nebulized solution QID 5. LASIX 80 mg [Hospital1 ] 6. LIDODERM 5 % (700 mg/patch) apply for 12h eachday 7. LISINOPRIL 10 mg daily 8. METOPROLOL TARTRATE 100 mg TID 9. PERCOCET 5 mg-325 mg prn 10. PLAVIX 75 mg daily 11. PRILOSEC 20mg daily 12. ULTRAM 100mg TID prn 13. Vitamin D 800 units daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: Apply for 12 hours each day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 8. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a day. 9. Atorvastatin 80 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). 11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 15. PICC line care per protocol 16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary: - Cardioembolic right MCA stroke - Left atrial thrombus - NSTEMI - MRSA pneumonia - Klebsiella / Enterococcal UTI - Epistaxis . Secondary: - Atrial fibrillation - Diastolic heart failure - Pulmonary hypertension - Cor pulmonale - Massive hemoptysis in setting of supratherapeutic INR - TIA - Hypertension - SLE - OSA - GERD - Gout - Iron deficiency anemia, (-) upper/lower GI workup Discharge Condition: Left hemiplegia. Discharge Instructions: You were admitted for left sided weakness and found to have a large right sided stroke. We also diagnosed a pneumonia and a urinary tract infection for which you are getting IV antibiotics. . Please take all of your medications as directed. . Please follow up as indicated below. . Return to the emergency department if you develop any concerning symptoms such as shortness of breath, chest pain, new lower or upper extremity weakness, bloody or tarry stools. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD Phone:[Telephone/Fax (1) 7976] Date/Time:[2177-1-13] 4:15 . Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) ] & [Doctor Last Name 12454] Phone:[Telephone/Fax (1) 44] Date/Time:[2177-1-22] 4:00	[ "41071", "99592", "78552", "51881", "5849", "5990", "2760", "42731", "4280", "4168", "32723", "53081", "V1582" ]
Admission Date: [2192-7-24] Discharge Date: [2192-8-2] Date of Birth: [2114-5-27] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 14802] Chief Complaint: bilateral subdural hematomas Major Surgical or Invasive Procedure: evacuation of left subdural hematoma History of Present Illness: 78M s/p fall while playing [Doctor First Name 13792] [Doctor Last Name 13793] [7-9], had known small SDHs at that time, was admitted for couple days and sent home. Per daughter, pt saw Dr. [First Name (STitle) ] then and has f/u scheduled for 2 days from now, but has had 5 falls in the last 72 hours. He reports the falls are all due to his right leg giving out on him, which is a new symptom since his [7-9] fall. Most recent fall prompted his daughter bring him in today. Pt with history of Afib, CAD, s/p CEA, COPD. Previously on coumadin, then on pradaxa, now off (except ASA 81) x 2 weeks Past Medical History: - hypertension - CAD - CABG x4 in [2176] - COPD - right carotid endarterectomy with hypoglossal nerve injury, tongue deviates to the right - knee surgery several years ago - h/o pulmonary embolism - on Coumadin - h/o polio as a child - intermittent gout - colonic adenomas - frequent colonoscopies, usually yearly - cataract surgery - atrial fibrillation - breast cancer - aortic stenosis Social History: He is a former smoker but quit after his CABG. He smoked 2 packs a day for 51 years. He denies any significant alcohol use and denied any other drug use. Family History: non contributory Physical Exam: O: T: 98 BP: 126/65 HR: 85 R 17 O2Sats 98% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 2->1.5 EOMs intact bilat 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. Recall: [1-28] objects at 5 minutes. Language: Speech fluent but slow with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [3-31] throughout except R hip flexor [1-30]. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally except over right shin (medial and lateral). Reflexes: intact bilaterally Toes downgoing bilaterally Handedness Right On Discharge: A&ox3 PERRL EOMs intact Full motor Incisions: c/d/i with staples Pertinent Results: CT/MRI: Bilateral subdural hematomas are enlarged since the [2192-7-9] examination, larger on the left. New hyperdense components are compatible with recent hemorrhage. Mild left suprasellar cistern effacement is unchanged. Bilateral hemispheric sulcal effacement is slightly worse, particularly on the left. The quadrageminal cistern remains preserved. No tonsillar herniation. Ct head [7-25] -Interval evacuation of the left chronic subdural hemorrhage with pneumocephalus, small residual hypodense subdural fluid and small hyperdense blood products. No intraparenchymal hemorrhage. 2. Slightly increased mass effect due to right mixed-density subdural hemorrhage, which is minimally larger, now with 4-mm leftward shift of normally midline structures. Pelvic x-ray [7-25] - No fracture. If clinical concern for fracture persists, MRI or CT would be of utility. CT HEAD W/O CONTRAST Study Date of [2192-7-26] 12:37 PM FINDINGS: There has been no significant interval change in the size of the bilateral subdural hematomas when compared to the most recent comparison from [2192-7-25]. There has been interval decrease in the amount of pneumocephalus within the left subdural space. The degree ofmass effect from the right subdural hemorrhage including a 4 mm leftward shift of midline structures has not significantly changed from the prior study. There is no evidence of new hemorrhage. The basal cisterns are preserved. There is no evidence of acute vascular territorial infarction. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No significant interval change in the size or mass effect from the bilateral subdural hematomas compared to the most recent prior study. CT HEAD W/O CONTRAST Study Date of [2192-7-27] 8:03 AM IMPRESSION: Slow interval growth of the right subdural hematoma over the past 48 hours with increased leftward shift of midline structures. [7-27]: CT Head- IMPRESSION: 1. Interval evacuation of right subdural hemorrhage with large subdural pneumocephalus, small residual hypodense subdural fluid and small new hyperdense blood products. 2. Persistent 11 mm leftward shift of normally midline structures. Effacement of the right lateral and third ventricles, with slight left lateral ventricle dilation, is probably stable but could be minimally increased; evaluation is limited by differences in positioning. Follow up is recommended. 3. Essentially stable left subdural collection, except for minimally decreased pneumocephalus, allowing for positional differences. [7-29] LENI's:No evidence of deep vein thrombosis in the lower extremities. CHEST (PA & LAT) [2192-7-31] Patient is known with bilateral subdural hematoma. New bibasilar small pleural effusion with consolidation is highly concerning for aspiration UNILAT UP EXT VEINS US [2192-7-31] No deep vein thrombosis identified. Occlusive thrombus seen in the left cephalic vein at the level of the antecubital fossa. [2192-8-1] CT head: Status post removal of the right subdural drain with unchanged mixed density subdural. The left-sided subdural predominantly hypodense subdural, although appears slightly more prominent, could be due to interval differences in slice selection and angulation. Continued followup recommended as clinically appropriate. Air within the subdural space again identified. [2192-8-1] Video Swallow: Trace aspiration and penetration with thin liquids. Penetration with honey-thick and nectar-thick liquid. Delayed oral phase. Vallecular residue. [2192-8-1] CXR As compared to the previous radiograph, the extent of the bilateral pleural effusions and the subsequent areas of atelectasis are unchanged on the right. On the left, they have minimally decreased. Unchanged moderate cardiomegaly with sternotomy wires but unchanged, absence of overt pulmonary edema. [2192-8-2] LENIS: prelim-no dvt in BLE Brief Hospital Course: The patient was admitted to the Neurologic Surgery Service for management of a subdural hematoma. The patient was taken to the OR on [7-25] and underwent an uncomplicated surgical evacuation. The patient tolerated the procedure without complications and was transferred to the ICU in stable condition. Please see operative report for details. Post operatively pain was controlled with intravenous medication with a transition to PO pain meds once tolerating POs. Post op head CT on [7-25] showed interval evacuation of left SDH and slight increase in right SDH. On [7-26] a repeat CT head showed no significant interval change in the size or mass effect of right SDH. He was transferred to SDU in stable condition. On [7-27], INR 1.5, drain total from day prior to this AM ~550cc. The Head CT was consistent with slow interval growth of the right subdural hematoma over the past 48 hours with increased leftward shift of midline structures. The patient underwent craniotomy for evacuation of right hematoma after administration of FFp and Vitamin K for INR of 1.5. Surgery was without complication and the patient tolerated it well. On [7-28] he was neurologically stable. One drain was removed and the other was left in place and he was continued on flat bedrest with high flow oxygen. On [7-29] the drain was again left in place but his activity was advanced and he was encouraged to increase his PO intake. His PCP was updated on his current care. He had LENI's to evaluate his LE edema, and they were negative for DVT. On [7-30], repeat head CT was performed which showed improvement in midline shift and less pneumocephalus. His R subdural drain was removed and staples were placed at the incision site. His foley was replaced for urinary retention. On [7-31], patient was seen to be tachypnic and SOB on exertion. CXR was ordered which revealed bilateral pleural effusions and basilar consolidations. He was started on triple antibiotic coverage for treatment of HAP. His LUE was erythematous and edematous which prompted UE dopplers, he was seen to have a small clot in the cephalic vein. Vascular was consulted and recommended warm compresses and elevation. In addition, he was evaluated by speech and swallow and it was determined that he could have a regular diet with ensure. On [8-1], he neurological exam was improved. Medicine was consulted for pneumonia after repeat CXR. They recommended that patient have 10 days of antibiotic treatment. He also went for a video swallow where it was determined that he have a soft and thin liquid diet for aspiration. Repeat head CT was stable. His foley was removed for a voiding trial. On [8-2], patient was stable on examination. He was given nebulizers for wheezing and lenis were ordered to evaluate for LE clots. A PICC line was placed for administration of antibotics. Lenis were completed which prelim showed no dvt. He was stable on discharge to rehab. Medications on Admission: albuterol, ambien, ASA 81, atenolol, clobetasol, crestor, furosemide, nicorette, spiriva, tamoxifen, zestril, zoloft, colchicine Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: bilateral subdural hematomas Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound was closed with staples. You may wash your hair only after sutures and/or staples have been removed. ?????? Your wound was closed with dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may safely resume taking this after your post operative follow up. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: ??????Please return to the office in [6-5] days(from your date of surgery) for removal of your staples. This appointment can be made with the Nurse Practitioner [First Name (Titles) ] [Last Name (Titles) ] [Name Initial (PRE) 19158]. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You may also have them removed at your rehab facility. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ] , to be seen in __4_weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[2192-8-2]	[ "42731", "4019", "496", "4280", "V4581", "4241", "V1582" ]
Admission Date: [2183-5-8] Discharge Date: [2183-5-20] Date of Birth: [2105-11-21] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 9240] Chief Complaint: Transfer from OSH for GI bleed, stroke and PE Major Surgical or Invasive Procedure: transesophageal echocardiogram History of Present Illness: This is a 77 year old woman with seizure disorder and unclear h/o CAD, and unclear h/o CVA who presented to OSH on [5-1] with painless BRBPR x 1 week. Gastroenterology w/u there thought the bleed could be from NSAIDs which she takes for back pain and aspirin. However, EGD and colonoscopy did not reveal a source of bleed. She was admitted with a hemaglobin of 8.5 and recieved 2 units of PRBC and stabilized to a hemaglobin of 9.7 before transfer to [Hospital1 18]. . Her course at OSH was complicated by neurologic findings. On [5-2], she was noticed to have a left facial droop and expressive aphasia. MRI of the head showed a small acute infarct in the left peritrigonal redion. Neurology was consulted and did not think the small area of infarct in that area could explain her word finding difficulties and thought his could be more from enchephalopathy rather than an aphasic disorder. . On [5-2], she also desaturated to 60% and cardiac enzymes were cycled. They were elevated and cardiology consult was called. EKG was "unintepretable due to LBBB" and an echo as done. Echo showed normal LV function but significant RV strain and RV overload with pulm htn. V/Q scan is high probability for large burden of bilateral PE's involving the segmental and subsegmental areas. . Given her GIB of unknown source and large burden of PE, anticogulation was an issue and she was transferred to [Hospital1 18] for further care. . Currently, she has expressive aphasia which makes taking her history difficult. She currently complaints of RUQ/R Rib pain. At OSH, she had unremarkable RUQ and KUB. . She denies chest pain or shortness of breath. . At OSH, vitals before transfer: 9736, 136/81, 80, 16, 92% on 4LNC. Past Medical History: 1. Remote CAD, unclear details, had angioplasty 2. Remote CVA event, unclear details 3. h/o PE's 4. Seizure disorder 5. Hypothyroid 6. Hypercholesterolemia 7. CRI (unknown baseline cr) 8. s/p Zenker's diverticulum 9. Degenerative joint disease 10. Multiple UTIs Social History: no tobacco, 2 vodka&waters/day, lives alone, only child, son and daughter Family History: non contributory Physical Exam: per Dr. [First Name8 (NamePattern2) 15989] [Name (STitle) ]: VITALS: 98.0, 164/94, 90, 20, 94%-2LNC GEN: A+Ox3, NAD, expressive aphasia HEENT: PERRLA, EOMI, MMM, OP clear NECK: no JVD CV: RRR, 2/6 SEM at LUSB, no gallop or rub PULM: CTAB, no w/r/r, coarse ABD: soft, NT, ND, +BS EXT: no c/e/c NEURO: Left eyelid lower than right. No clear facial droop. CN [1-27] otherwise intact. Strenth [4-19] all extremities. Sensation grossly intact. F to N intact. Her expressive aphasia on admission was notable for some word finding difficulties. She seemed to comprehend well. Pertinent Results: 137 92 28 -------------< 86 3.9 34 1.5 CK: 61 MB: Notdone Trop-T: 0.18 Ca: 9.6 Mg: 1.3 P: 4.0 . 10.5 3.9 >----< 245 33.2 PT: 11.6 PTT: 34.1 INR: 1.0 . Trends: WBC 3.9, 5.7, 5.3, 5.1, 6.4 Hct: 33, 32, 29, 27, 27, Platelet 245, 231, 216, 192, 200 Creatinine 1.5 - 1.5 - 1.4 - 2.7 Trop: 0.18 - 0.16 HbA1c-5.9 Cholest-127, Triglyc-123 HDL-59 CHOL/HD-2.2 LDLcalc-43 Valproa-46 - 56 Urine lytes: FeNA<0.1% on [5-11] . Micro: Urine: coag neg staph x1 urine: neg x1 blood cx; ngtd . At OSH: # VQ scan shows high probability of PE with evidence of multiple segmental and subsegmental defects throughout both lungs with the largest being posterior in the right lower lobe as well as superiory in the left upper lobe. # MRI brain: Acute small infarct in the left peritrigonal region and also small vessel changes # Echo: NL LV function. Right ventricular pressure overload with mildly reduced RV function and severe pulm htn. . Radiology: [5-9]: CT A Chest: 1. Atherosclerotic aorta without evidence of dissection or aneurysmal dilatation. 2. Findings consistent with mild volume overload. 3. Prominent mediastinal lymph nodes and single enlarged paratracheal node are likely reactive. However, follow-up chest CT is recommended following resolution of acute symptoms to exclude the possibility of neoplasm. 4. Small pericardial effusion. 5. Axial hiatal hernia. 6. Diverticulosis without diverticulitis. . [5-9] CT Chest abd pelvis without IV contrast: 1. Diffuse ground-glass opacities, which are nonspecific and likely represent pulmonary edema and less likely infection. 2. Moderate-sized pericardial effusion. 3. Large hiatus hernia and intrathoracic location of the stomach. 4. Pleural plaques indicating prior asbestos exposure. . [5-9]: Echo: The left atrium is elongated. The estimated right atrial pressure is 11-15mmHg. There is moderate symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%), without regional wall motion abnormalities. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small posterior pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Small pericardial effusion. Moderate LVH with preserved global and regional biventricular systolic function. Diastolic dysfunction with evidence of elevated right and left-sided filling pressures. Moderate pulmonary hypertension. . DVT scan neg . Renal U/S [5-11]: no hydro Brief Hospital Course: 77 year old female with GIB from unknown source, large PE burden and acute stroke at OSH. She was on the floor for one night then became hypotensive. Transferred to the MICU on [5-9]. received 2L IVF. Noted to have differences in right and leg arm BPs. CTA was ordered which showed no dissection. She was stabilized and returned to the floor on [5-10]. Remainder of hospital course by problem: . # GI Bleed: Possibly from her outpatient aspirin and NSAID use. She had been using NSAIDS for her back pain since [Month (only) 956]. EGD at OSH: hiatal hernia, no bleed. Colonoscopy at OSH: diverticulosis, no obvious source of bleed. We placed 2 large [Last Name (un) ] IVs and monitored her Hct closely. It trended down with IVF in the setting of hypotension but stabilized. We treated with a PPI. The Hct remained stable over the hospital course. . # PE: At OSH: VQ scan shows high probability of PE with evidence of multiple segmental and subsegmental defects. She was stable on 3-4L NC. We treated with heparin gtt and started coumadin. She had a therapeutic INR on coumadin dose of 5 mg QHS. She will need her INR checked every week and adjust the coumadin dose accordingly. . # CVA: OSH MRI showed small acute infarct in left peritrigonal region of less than 1cm. Neuro was consulted. Given the small area of the infarct, we anticoagulated as above. She initially was quite aphasic with a left eyelid droop. These symptoms improved substantially during her stay. She was able to speak coherently and act appropriately. She was alert and oriented x3, able to move all extremities, and interact appropriately. The carotid US showed L sided subclavian steal. Neuro was made aware of this. This issue will need to be addressed at her coming neuro appointment. She will follow up with Dr [Last Name (STitle) 72861] in neuro clinic at the [Hospital1 ]. . # ARF: The patient came in with creatinine of 1.5 (it had been up to 1.9 at OSH). On [5-11] it increased to 2.7 rather acutely and she became anuric. This was 48 hours after the administration of IV contrast. Renal was consulted Her FeNa was 0.1% c/w contrast nephropathy. Renal ultrasounds did not show hydronephrosis. She was anuric initially. did not respod to IVF. was started on diuril and lasix. the anuria resolved and she diuresed profusely even after stopping the lasix. the Cr trended down and was 2.3. . # SEIZURE DISORDER: unclear etiology for h/o seizures. At OSH valproic acid level was low and she was reloaded. Initially she was on valproic acid here but was found to have a subtherapeutic level. hence we discontinued the valproic acid. she will follow up with neurology here and a decision about restarting it can be made at that time. . # CAD: She has remote and vague history of CAD from OSH notes. At OSH, she has elevated enzymes and per cardiology consult note: EKG was uninterpretable due to LBBB. Her enzymes were elevated probably due to RV strain from PE's rather than from an ischemic event. The CE trended downward at our hospital and she was CP free. she was started on as[irin 81 mg and was continued on simvastatin. . # CODE: Full code (from OSH record) Medications on Admission: upon transfer # Allopurinol 300 mg PO DAILY # Furosemide 40 mg PO DAILY # Levothyroxine Sodium 100 mcg PO DAILY # Depakote 250 mg PO BID # Pantoprazole 40 mg PO Q24H # Simvastatin 40 mg PO DAILY # Multivitamins 1 CAP PO DAILY # Cyanocobalamin 100 mcg PO DAILY # Albuterol 0.083% Neb Soln 1 NEB IH Q6H # Ipratropium Bromide Neb 1 NEB IH Q6H # Ondansetron 8 mg IV Q8H:PRN Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Levothyroxine 100 mcg 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. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:PRN. 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO q4-6h: prn as needed for back pain. 19. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 20. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO QD:PRN as needed for back pain. Discharge Disposition: Extended Care Facility: [Hospital3 12564] Health Network Discharge Diagnosis: CVA GI bleed pulmonary embolism non-ST elevation myocardial infarction patent foramen ovale Discharge Condition: stable Discharge Instructions: Take all medications as directed. Do not stop or change your medications without first speaking to your physician. Follow up as oulined below. If you experience any shortness of breath, chest pain, weakness, dizziness, pain in abdomen, nausea, vomitting, diarrhea, difficulty in urination or any other concerning symptoms call the doctor on call or go to the emergency room. Followup Instructions: Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) ] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 44] Date/Time:[2183-6-10] 2:00 Please make a follow up appointment within 2 weeks of discharge with your primary care provider Dr [Last Name (STitle) 72862] ([Telephone/Fax (1) 72863]) Please remove the Foley catheter within 10 days of the rehab stay. Please check INR every 7 days and adjust the coumadin dose accordingly. Completed by:[2183-5-20]	[ "41071", "5849", "5859", "41401", "2449", "2720" ]
Admission Date: [2149-2-6] Discharge Date: [2149-2-9] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6994] Chief Complaint: cc:[CC Contact Info 13460] Major Surgical or Invasive Procedure: Intubation History of Present Illness: hpi: [Age over 90 ] M with a h/o CHF, CRI, CAD who was found unresponsive at home and in agonal breathing. Per the daughter he was normal one moment then started clenching jaw, clutching left arm and not responding. The family immediately called EMS. Of note he has had a cough and upper respiratory symptoms for three days per family report. He has had no GI symptoms however he had some diarrhea after arrival to the ED. He has been having a steady decline in mental status and functioning for the last several months for which he has been evaluated extensively by his primary care doctor. On arrival to the ED he was immediately intubated. VBG on arrival pH 7.09 and K 8.0, glucose 157, lactate 4.1. Pt had EKG changes consistent with hyperkalemia and was given calcium gluconate, D50, insulin. Repeat K 4.6. Also given vancomyin 1 gm IV and levoquin 500 mg IV x1 empirically for sepsis of unknown source. He had episode of hypotension to SBP's 70 responding to 1L NS but otherwise has not required pressors. CT scan head without ICH, CT abd poor study but no free air or peritonitis. Abdominal U/S with no cholecystitis. Seen by cardiology for NSTEMI and felt that not candidate for cath. Aspirin given but asked to defer heparin gtt as he was guiaic positive. Past Medical History: 1. h/o MI in 93'--> refused treatment MI [46]' --> s/p LAD stent Stress MIBI ([2-5]) -3 min on modified [Doctor Last Name 4001] protocol -no EKG changes -ischemic dilation; mod fixed apical defect; mod revers septal defect -global HK; EF 22% 2. BPH 3. dementia 4. HTN 5. GERD 6. hiatal hernia 7. zenker's diverticulum 8. hypercholesterolemia 9. anemia, transfusion dependent, unclear etiology 10.CRI- baseline cr 2.0-2.5 11.CHF -echo [10-5]: EF 30-35%, PASP 49, +1TR, +1 MR, apical/anteroseptal AK 12. Social History: -lives at home with daughter and son-in-law, not drinker, no Smoking -retired dentist Family History: not contributory Physical Exam: Tc 101.6 Tm 101.6 BP 150/61 HR 75 spO2 100% A/C: 500/20 PEEP 5 FiO2 40% PIP 29 ABG: 7.31/53/241 Lactate 4.1 Gen: sedated on prop; not responsive to pain; intubated HEENT: intubated Neck: low JVD although lying flat CV: RRR, nl S1S2, difficult to assess murmers secondary to respiratory sounds Pulm: crackles at bases b/l; secretions Abd: scaphoid, thin, nd, hyperactive bowel sounds ext: +2 pitt edema to mid thighs b/l; left arm infiltrated Pertinent Results: [2149-2-5] 08:30PM FIBRINOGE-355 [2149-2-5] 08:30PM PLT COUNT-328 [2149-2-5] 08:30PM PT-15.6* PTT-26.8 INR(PT)-1.7 [2149-2-5] 08:30PM WBC-6.2 RBC-3.74# HGB-12.6 HCT-39.0# MCV-105 MCH-33.7* MCHC-32.3 RDW-14.0 [2149-2-5] 08:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2149-2-5] 08:30PM CK-MB-14* MB INDX-7.5* cTropnT-0.54* [2149-2-5] 08:30PM CK(CPK)-187* AMYLASE-60 [2149-2-5] 08:30PM UREA N-69* CREAT-2.3* [2149-2-5] 08:34PM freeCa-1.18 [2149-2-5] 08:57PM URINE GRANULAR-0-2 [2149-2-5] 08:57PM URINE RBC->50 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-[4-6] Brief Hospital Course: Pt was intubated for respiratory distress and found to be RSV postitive. In addition, he was felt to have aspirated in setting of alter mental status. He was quickly weaned off the ventilator and extubated. Pt continued to be lethargic and unable to control his secretions. Blood gas showed 7.13/75/85. He was placed on BiPAP to improve his minute ventilation. Repeat ABG several hours later did not show significant improvement. Subsequently, family meeting was held to discuss his poor prognosis. Family decided to make him CMO. He was taken off BiPAP and on morphine gtt. He expired on [2149-2-10] at 12:25 AM. Medications on Admission: Plavix 75 mg Daily Metoprolol 50mg [Hospital1 ] Aspirin 325 mg Daily MVI Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Dehydration RSV Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A	[ "0389", "51881", "5849", "5070", "41071", "99592", "4280", "5859", "2767", "4240", "53081", "4019", "412", "2859", "2720" ]
Admission Date: [2195-12-3] Discharge Date: [2195-12-9] Date of Birth: [2148-5-4] Sex: F Service: ADMISSION DIAGNOSIS: 1. Pelvic mass 2. Asthma. DISCHARGE DIAGNOSES: 1. Postoperative from pelvic mass resection, sigmoid colon resection and reanastomosis, and lysis of adhesions. 2. Asthma. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old gravida 1 para 1 0-0-0, who underwent a hysterectomy in [2190] for endometriosis and had a CT on [2195-11-24] which showed a pelvic mass. She initially had pelvic pain and presented at that time. She had fevers, chills, elevated white count. Was admitted for IV antibiotics from [Date range (1) 95683]. She had dysuria and frequency at that time. She had a regular bowel movement, although slightly constipated from approximately five days since her last bowel movement. She denies any changes in stool size, shortness of breath, or chest pain. GYN HISTORY: Significant for menarche at age 12, regular periods, pain for half the month, multiple laparoscopies for endometriosis. She had a hysterectomy in [2190] with resolution of her pelvic pain from endometriosis. She denies abnormal Pap smears and has had none for the last two years. No history of sexually transmitted diseases or pelvic inflammatory disease. PAST OB HISTORY: IUFD in the past and two adopted children. PAST MEDICAL HISTORY: Asthma. PAST SURGICAL HISTORY: 1. Multiple laparoscopies for endometriosis. 2. She underwent a total abdominal hysterectomy and question of bilateral salpingo-oophorectomy. They were unable to visualize her ovaries on her surgery previously. 3. She also had a lung wedge resection for hemartoma. MEDICATIONS: 1. Flovent. 2. Flonase. 3. Singulair. 4. Serevent. ALLERGIES: 1. Narcotics p.o. cause nausea and vomiting. 2. Levaquin rash. 3. IV dye. SOCIAL HISTORY: Denies tobacco, alcohol, and drugs. Lives with her husband and two children. Works in information technology at [Hospital1 69]. FAMILY HISTORY: Mother diagnosed with breast cancer in her 30s. PHYSICAL EXAMINATION: Temperature 98, heart rate 93, blood pressure 145/67, respiratory rate 16, and O2 97% on room air. She was in no acute distress. Abdomen was mildly distended, soft except for mildly tender mass in the left lower quadrant. No rebound or guarding. Mass extends from pubic symphysis to near the umbilicus. Cheloid appearance of scars. Pelvic had normal female external genitalia. Palpable round mass at apex anterior portion of the vagina. Left lower quadrant contained a larger mass, left less brown. Rectal: No mass and guaiac negative. Sphincter intact. Extremities had no edema. GC and chlamydia were sent and pending. White count was 14.4 initially and is 9.9 on recheck. Her hematocrit was 32. Electrolytes are within normal. Urinalysis is negative except for glucose. CT showed a mid pelvic large septated cystic mass 7 x 11 x 13 cm displaced in the bladder. Right sided showed 1.9 x 2.9 cm adnexal mass, 1.4 x 1.1 liver cysts. ASSESSMENT: A 47 year old status post hysterectomy with new onset of subacute left lower quadrant pain and pelvic mass seen on CT. Patient was counseled regarding the mass and elected to undergo exploratory laparotomy and resection of pelvic mass. She underwent the following procedure on [2195-12-3]. Exploratory laparotomy and lysis of adhesions, radical resection of pelvic mass, sigmoid resection with anastomosis, enterotomy repair, omental pedicle wrap. Please see full operative note for details regarding this procedure. She postoperatively, was admitted to the Intensive Care Unit for monitoring. She was intubated at that time and maintained in the postoperative care overnight. She had repeat hematocrits which showed a decrease to 32.8. HOSPITAL COURSE BY SYSTEMS: 1. Pelvic mass: She was maintained on antibiotics. At the time of this discharge, the pelvic mass pathology was pending. 2. Respiratory: Patient was maintained on the ventilator until postoperative day one at which time she was extubated early in the morning. She tolerated this well. Was able to maintain her oxygen saturation and good respiratory effort. She was restarted on her asthma medications and her pulmonary function was good throughout her hospitalization. She was discharged home in stable condition with a slight cough, otherwise with O2 saturations within the normal range. 3. Cardiovascular: No cardiovascular issues. 4. Anemia: Her hematocrit was serially checked throughout her hospitalization. It was around the 30 range. She did not require any transfusion. 5. ID: She was maintained on Zosyn, gentamicin, and Flagyl. Her white blood cell count was followed throughout her hospitalization. Initially was found to be 11.8 with a maximum of 12.1. At the time of discharge, her white blood cell count was 7.9. 6. Fluids, electrolytes, and nutrition: She was maintained on IV fluids and NPO until postoperative day five at which time she was advanced to full clears. Electrolytes were checked daily and repleted as needed. Her diet of full clears was tolerated, and the day prior to discharge, she was advanced to a regular diet without difficulty. She did have some diarrhea. A Clostridium difficile culture was sent and was pending at the time of discharge. Initially her diarrhea on postoperative day five, had resolved by postoperative day six. She was discharged home in stable condition to followup with Dr. [Last Name (STitle) 2406] both for the pathology as well as her evaluation of her Clostridium difficile final culture. DISCHARGE MEDICATIONS: Ibuprofen 600 mg p.o. q.6h. prn. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2407], M.D. [MD Number(1) 2408] Dictated By:[Last Name (NamePattern1) 38853] MEDQUIST36 D: [2195-12-9] 10:56 T: [2195-12-10] 09:11 JOB#: [Job Number 102434]	[ "2851" ]
Admission Date: [2146-4-7] Discharge Date: [2146-4-14] Service: MEDICINE Allergies: Mevacor / Demerol / Adhesive Tape / Darvocet-N 100 Attending:[First Name3 (LF) 689] Chief Complaint: rapid pulse Major Surgical or Invasive Procedure: Lysis of pulmonary emboli with TPA Intubation Extubation History of Present Illness: (Per report, patient intubated) Ms. [Known lastname 656] is an 88 yo F who is very active and in her usual state of health until the morning of presentation. She has a history of vertigo and felt unwell this am. She additionally may have been slightly fatigued. Given this, she remained in bed most of the day. When her daughter, who is a retired nurse, visited her in the evening she took her pulse and found it to be 80. Given this this is a rapid pulse for the patient, she was brought to the ED. . In triage, initial ED VS were 97.6, 102, 122/87, 20. Found to be profoundly hypoxic. Though not recorded in ED records, patient was profoundly hypoxic and immediately placed on a NRB without much improvement. She was then intubated and continued to have poor oxygenation on 100% FIO2, 10 PEEP with 90% O2Sat. CXR did not reveal a clear source. EKG with 90 bpm, SR, slight LAD, rsR' V2. CT head negative for acute bleeding. CTA with bilateral diffuse pulmonary emboli. ABG on 80% FIO2 pH 7.40, pCO2 42, pO2 61, HCO3 27. She then suddenly had improved oxygenation with ability to decrease her FIO2 to 70 and decrease her PEEP. Given improvement, decision was made to heparinize rather the thrombolyse. . Upon arrival to MICU, patient is intubate, sedated and unable to provide further history. . Unable to obtain ROS. Past Medical History: 1. Anxiety. 2. Hypertension. 3. Hyperlipidemia. 4. Diverticulitis. 5. Breast cysts. 6. Osteoarthritis. 7. Osteoporosis. 8. Polycythemia [Doctor First Name ]. 9. Vertigo. 10. Skin cancer. 11. Right Rotator cuff problems . PAST SURGICAL HISTORY: 1. Status post breast cyst excisions x3. 2. Status post hemorrhoidectomy. 3. Status post surgical excision of basal cell carcinoma x2. . GYNECOLOGIC HISTORY: Gravida 3, para 2, 2 vaginal deliveries, 1 spontaneous abortion. Menarche in her teens. Menopause at age 55. Last Pap smear unknown. Last mammogram in 2/[2142]. Social History: She grew up in [Location (un) 3786], [State 350]. She is married, has a husband who has [Name (NI) 2481] disease. She has two grown children. She is a retired secretary and billing clerk. No tobacco use. Very rare alcohol use. No drug use. Family History: Positive for CAD in her mother, positive for diabetes in her mother, positive for hypertension in her mother, and positive for brain cancer in her father. Physical Exam: Vitals: T: 98.4 BP: 136/70 P: 87 R: 22 O2: 96/70% FIO2 General: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP distended, 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, thin Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Mildly mottled along chest ******** On discharge: ambulatory, breathing comfortably on room air. Pertinent Results: Admission labs: [2146-4-7*] 10:58PM TYPE-ART RATES-14/ TIDAL VOL-450 O2-100 PO2-61 PCO2-42 PH-7.40 TOTAL CO2-27 BASE XS-0 AADO2-628 REQ O2-100 INTUBATED-INTUBATED VENT-CONTROLLED [2146-4-7] 10:58PM LACTATE-1.4 [2146-4-7] 10:58PM freeCa-1.12 [2146-4-7] 10:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2146-4-7] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2146-4-7] 10:00PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [2146-4-7] 09:38PM GLUCOSE-158* UREA N-18 CREAT-0.9 SODIUM-135 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-24 ANION GAP-17 [2146-4-7] 09:38PM D-DIMER-3415* [2146-4-7] 09:38PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2146-4-7] 09:38PM WBC-13.2* RBC-4.83 HGB-15.5 HCT-46.4 MCV-96 MCH-32.2* MCHC-33.5 RDW-16.5* [2146-4-7] 09:38PM NEUTS-89.0* LYMPHS-6.8* MONOS-3.3 EOS-0.5 BASOS-0.4 [2146-4-7] 09:38PM PLT COUNT-399 [2146-4-7] 09:38PM PT-12.5 PTT-27.3 INR(PT)-1.1 IMAGING: CTA, CT Pelvis, CT Abdomen: 1. extensive pulmonary emboli extending from the distal main pulmonary arteries into essentially every major branch to the subsegmental level. 2. enhancing right renal mass measuring up to 2.3 cm, concerning for malignancy 3. splenomegaly 4. stable pancreatic ductal dilation up to 5mm, compared to [2140]. . CT Head no acute intracranial process . TTE: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. A right-to-left shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. There is no mass/thrombus in the right ventricle. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Dilated and hypokinetic right ventricle. At least moderate pulmonary hypertension. Small, underfilled left ventricle with normal systolic function. Patent foramen ovale/small ASD with right-to-left shunting . MRI HEAD:IMPRESSION: Small areas of acute infarct in the left parietooccipital region. Mild-to-moderate brain atrophy and small vessel disease. No evidence of chronic microhemorrhages. . Discharge labs: [2146-4-14] 06:03AM BLOOD WBC-7.8 RBC-4.08* Hgb-12.6 Hct-38.8 MCV-95 MCH-30.9 MCHC-32.5 RDW-15.2 Plt Ct-474* [2146-4-14] 06:03AM BLOOD PT-13.1 PTT-33.2 INR(PT)-1.1 [2146-4-14] 06:03AM BLOOD Glucose-98 UreaN-19 Creat-0.6 Na-141 K-4.3 Cl-107 HCO3-26 AnGap-12 [2146-4-14] 06:03AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.8 . [4-11] repeat echo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. A patent foramen ovale is present with premature appearance of contrast after saline injection at rest. . There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are structurally normal. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2146-4-8], the right ventricular cavity size is smaller and free wall motion is improved. Premature appearance of saline is still seen in the left heart, but the amount of saline contrast is reduced. . [4-13] MRI abdomen: 1. Study limited by respiratory motion artifact. No evidence of enhancement of the 2.3 cm right renal lesion of concern on CT [2146-4-7], which is compatible with a hemorrhagic cyst. 2. Other bilateral simple renal cysts measuring up to 6.4 cm. 3. Stable segmental dilatation of the main pancreatic duct, unchanged going back to [2141-7-20]. No evidence of obstructing pancreatic mass. 4. Small bilateral pleural effusions. 5. Splenomegaly. 6. Moderate lumbar dextroscoliosis. . u/s [4-8]: IMPRESSION: Partially occlusive thrombus of the left popliteal vein. Brief Hospital Course: # B/L pulmonary embolisms: Presenting with profound hypoxemia but minimal other symptoms. Large A-a gradient on admission. Seemingly up to date on cancer screening and without prolonged mobility or other RFs for PE however does have PCV which could increase her risk. Underwent TTE which showed RV dilation and PFO. LENIs showed DVt popliteal vein. because of hemodynamic compromise underwent thrombolysis in the ICU without any complications. Continued on hep gtt but converting to lovenox or coumadin held in light of tepeated LENIs which showed progression of clot and concern that she may need IVC filter. With PFO unclear best route for anti-coagulation +/- IVC filter; decdided to do anticoagulation first with filter as an option if the coumadin failed. Repeat TTE on the floor showed improvement in RV strain with less flow across PFO. As such, decided to transition to lovenox and coumadin bridge, with plan for extended coumadin course. Although patient with infarct findings on CT/MRI brain, neurology consultation showed benefit > risk for both lysis and anticoagulation. Cause for PE unknown, consider colonoscopy given patient has never had one, gyn w/u given increasing abdominal distention (MRI abd without evidence for malignancy, but consider MRI pelvis or u/s). Factor V Leiden pending on discharge (low probability, given it's patient's first clot, at age 88). . # Renall mass - seen on CT scan, concerning for malignancy; MRI demonstrated hemorrhagic cyst rather than lesion concerning for renal cell carcinoma. Decided benefit > risk for anticoagulation nonetheless. . # Hypertension - Hypotensive in ED during peri-intubation period. Improved with decreased propofol. Also with evidence of RV dilation on CT concerning for strain and decrease CO. Initially held home meds but became more hypertensive after extubation and low dose captopril and metoprolol restarted prior to transfer to the floor with good control. On floor, continued home medications and BP was well-controlled initially but then patient was orthostatic and lightheaded, so decided to hydrate her with IVF and hold diuretic temporarily. . # Hyperlipidemia. Stable. Continued low-cholesterol diet and Lipitor. . # Polycythemia [Doctor First Name ]: Followed by Dr. [Last Name (STitle) ]. Held hydroxyurea and allopurinol initially and then restarted [4-10]. . # Vertigo: Severe per report on morning of admission. Currently asymptomatic in ICU. On the floor, with some lightheadedness and some movement of objects, but unremarkable non-focal neuro exam. Non-focal neuro exam pointed away from bleed/TIA. Perhaps d/t long-standing vertigo versus hypoxia versus orthostatic hypotension d/t dehydration. . # Delirium: Confusion occurred x1 night in ICU and x1 night on floor. With reorientation, and by morning time, it resolved. Non-focal neuro exam pointed away from bleed/TIA. . # Shoulder pain: d/t rotator cuff injury, very significant, continued pain meds, set-up outpatient PT and OT f/u. . # Social stress: patient is sole caregiver for husband with alzheimer's. social work consulted, and services provided upon discharge to help patient and family with stress. . CODE status: FULL (confirmed with daughter on ICU admission) Medications on Admission: Active Medication list as of [2146-3-9]: ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth once a week ALLOPURINOL - 100 mg Tablet - one Tablet(s) by mouth once daily for 6 days out of the week. ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth once a day DIAZEPAM - 2 mg Tablet - [11-20] or 1 Tablet(s)(s) by mouth at bedtime as needed for insomnia FELODIPINE - 5 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day for BP HYDROXYUREA - 500 mg Capsule - one Capsule(s) by mouth once a day for six days a week LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply 1 patch to R shoulder maximum 12 hrs in a 24 hr. period MECLIZINE - 12.5 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for vertigo METOPROLOL TARTRATE - 50 mg Tablet - [11-20] Tablet(s) by mouth twice a day PROPOXYPHENE N-ACETAMINOPHEN - 100 mg-650 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for severe pain TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - 37.5 mg-25 mg Capsule- 1 Capsule(s) by mouth once a day ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth three times weekly Discharge Medications: 1. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO 6X/WEEK ([Doctor First Name ],MO,TU,WE,TH,FR). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Diazepam 2 mg Tablet Sig: Half to one Tablet PO HS (at bedtime) as needed for insomnia. 5. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 6X/WEEK ([Doctor First Name ],MO,TU,WE,TH,FR). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on, 12 hours off. To right shoulder. 8. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for vertigo. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for severe pain. 11. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours): Please give at 7am and 7pm daily. Continue this medication until your primary care physician tells you that your coumadin level is therapeutic. Disp:14 injection Refills:0 12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Daily at 4pm: Daily at 4pm: The dose of this medication will be adjusted by your primary care physician based on the INR (coumadin level). Disp:100 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Bilateral pulmonary emboli Acute infarct in the left parietooccipital region Deep venous thrombosis Hypertension Orthostatic hypotension Hypoxemia Respiratory failure Renal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with bilateral blood clots in your lungs, believed to be from blood clots in your legs originally. You were in the ICU, on a breathing machine, because of the severity of the clots resulting in low oxygen levels. After giving a medicine to break-up the clots, your breathing stabilized and you were then able to have the breathing tube safely removed. On the regular floor, your symptoms resolved, and your breathing stabilized. Your hospital course was complicated by confusion, and this also resolved, this was likely due to the hospital setting. A CT scan showed a concerning lesion on your kidney, an MRI was performed that showed a hemorrhagic cyst (benign). An MRI of the head showed small stroke lesions in your brain, but you did not clinically have symptoms from these very small lesions. . Please continue to take your regular home medications, and ADD the following: - START lovenox injections to prevent further blood clots until coumadin level is therapeutic - START coumadin to thin your blood and prevent further blood clots - Temporarily hold Triamterene-HCTZ (dyazide, a diuretic) until you follow-up with Dr. [Last Name (STitle) ] - Temporarily hold Aspirin until you follow-up with Dr. [Last Name (STitle) ] Followup Instructions: Please attend the following primary care appointment: . Department: [Hospital1 18] [Location (un) 2352] - ADULT MED When: TUESDAY [2146-4-19] at 12:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD [Telephone/Fax (1) 1144] Specialty: Internal Medicine Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site You will need to have labs checked at this visit. . Please attend the following hematology appointment: . Department: HEMATOLOGY/BMT When: THURSDAY [2146-4-21] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3238], MD [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2146-4-19]	[ "51881", "4280", "4019", "2724" ]
Admission Date: [2129-1-26] Discharge Date: [2129-1-27] Date of Birth: [2084-12-19] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: This is a 44 year-old female with a history of asthma, hypertension, diabetes, hypercholesterolemia, and GERD. Who presented with dyspnea. In the ED: VSS, afebrile, BP's 150-180, hr 120's. Received 60mg po prednisone, nebs, levoflox. CXR no acute process, CTA no PE/dissection. Labs wnl except for lactate 4.1--->5.0 even after 4L NS. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Asthma - in the winter only Hypertension Diabetes Hypercholesterolemia GERD Social History: Patient is single and lives with her mom. She has no pets. She works for the [Company 2318], driving the #39 bus. She reports an occasional 1 or 2 cigarettes as a teenager, but was never a pack-a-day smoker. She drinks alcohol very rarely. Family History: NC Physical Exam: Vitals: T:100.3 BP:164/85 HR:125 RR:15 O2Sat:98% on RA GEN: Well-appearing, well-nourished, no acute distress, obese HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2129-1-26] 10:45AM GLUCOSE-333* UREA N-12 CREAT-0.8 SODIUM-133 POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17 [2129-1-26] 10:45AM CK(CPK)-85 [2129-1-26] 10:45AM cTropnT-<0.01 [2129-1-26] 10:45AM CK-MB-NotDone [2129-1-26] 10:45AM CALCIUM-9.6 PHOSPHATE-3.2 MAGNESIUM-1.7 [2129-1-26] 10:45AM D-DIMER-234 [2129-1-26] 10:45AM TSH-0.25* [2129-1-26] 10:45AM WBC-9.7 RBC-4.28 HGB-13.5 HCT-38.2 MCV-89 MCH-31.5 MCHC-35.2* RDW-13.0 [2129-1-26] 10:45AM NEUTS-80.7* LYMPHS-11.8* MONOS-4.0 EOS-3.0 BASOS-0.7 [2129-1-26] 10:45AM PLT COUNT-440 [2129-1-26] 10:45AM D-DIMER-As of [12-7] [2129-1-26] 02:02PM LACTATE-5.0* [2129-1-26] 04:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2129-1-26] 09:10PM CK-MB-4 cTropnT-<0.01 [2129-1-26] 09:10PM CK(CPK)-103 [2129-1-26] 09:29PM LACTATE-5.9* ECG: Sinus tachycardia at 126 bpm, normal axis, LVH. ? v4-v6 STD IMAGING: CXR ([1-26]): Linear area of atelectasis in the left upper lobe with no acute cardiopulmonary process. Repeat AP and left lateral radiographs are recomended. CTA ([1-26]): 1. No aortic dissection or pulmonary embolism. 2. Indeterminate nodule in the left lobe of the thyroid gland, which can be assessed further with a non-emergent thyroid ultrasound. Brief Hospital Course: 44 year-old female with a history of asthma, HTN, HLD, GERD who presents with dyspnea and is admitted to the ICU with sinus tachycardia. Likely asthma exacerbation vs. viral infection. # Dysnpea: Unclear cause. By the time the patient arrived to the ICU on exam her lungs were clear with no wheezes or crackles. No [Location (un) ]. CXR and CTA negative. On room air currently without complaint. Has prior hx of asthma, spirometry in [5-/2128] suggestive of restrictive lung disease. Received prednisone 60mg x1 in ED, nebs and levoflox. No s/sx of infection, WBC wnl though lactate elevated at 5. Would also consider viral etiology with temp to 100.3. Other less likely possibilites include bacterial PNA given ? of productive cough though does not appear ill and CXR clear. Could consider flash pulmonary edema in setting of hypertension but CXR is clear and patient is on room air. Last echo in [2127] with preserved systolic and diastolic function without any structural abnormalities so new heart failure unlikely. She was treated with atrovent, fluticasone, and albuterol prn and placed [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ] taper of po prednisone for another 3 days of 40 mg prednisone daily for a possible asthma exacerbation (received 60mg of prednisone in ED). Her cultures were NGTD. # Tachycardia: The patient presented with sinus tach in 120's even after 4L NS in ED in addition to hypertension. She had no PE seen on CTA, no O2 requirement, and was not in pain. Temp to 100.3 in ED, possible viral etiology and hypermetabolic state. Her tachycardia may have been secondary to nebs received in ED though she was tachy on presentation in ED. She reports no missed HTN medication doses so medication withdrawal unlikely. Patient has thyroid nodule seen on CT not noted on prior CT in [2127]. Patient has rare EtOH use (last use was one month ago) so EtOH withdrawal very unlikely. No hx of drug use per patient or prior records. CE negative x2, EKG without clear evidence of ischemia. Overnight her tachycardia trended down to the low 100's. Her TSH was low, so a free T4 was checked and was normal at 0.93, so it is unlikely that her tachycardia was due to hyperthyroidism. # Elevated Lactate: Unclear cause, does not appear systemically infection, not hypotensive. Did not decrease with fluid initally. [Month (only) 116] be secondary to Metformin use. When rechecked in the am, it had decreased to 1.9. # HTN: The patient was hypertensive to 180's in ED, was 140-160's on transfer to the ICU. She was continued on her home meds including lisinopril and amlodipine. She remained hypertensive to the 150's in the ICU. Will have her follow up for outpatient management of her hypertension. # Thyroid Nodule: Unclear significance. Not noted on prior CT in [2127]. Her TSH was checked and was low at 0.25. Added on a free T4 which was normal at 0.93. Will need outpatient follow up, likely including an ultrasound of her thyroid. She has an appointment scheduled at her primary care physician's office for early next week. # Diabetes: Blood glc was 333 on admission. A1c 7.4% in [12-13]. On metformin and glyburide. Has glc of 1000 in urine, no ketones. Her PO medications were held and she was covered with SSI. She was continued on her home aspirin. # GERD: The patient was continued on her home omeprazole. # Code: Full code Medications on Admission: Medications Per OMR notes: Pneumovax in [2124], Influenza [10/2128] Albuterol 2 puffs q4h prn Amlodipine 10 mg qd Glyburide 5 mg Tablet [Hospital1 ] Lisinopril 40 mg qd Metformin 850 mg tid Omeprazole 20 mg Capsule qd ASA 81mg qd Simvastatin 20mg qd Fish Oil capsules Discharge Medications: 1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days. Disp:2 Tablet(s) Refills:0 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every four (4) hours as needed for wheeze, SOB. Disp:1 inhaler Refills:0 8. Fish Oil Oral 9. Metformin 850 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 inhaler Refills:2 12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 inhaler Refills:2 13. Peak Air Peak Flow Meter Device Sig: One (1) peak flow meter Miscellaneous twice a day: Check your peak flows twice daily or when you are having symptoms. Disp:1 device Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary - Asthma exacerbation Sinus tachycardia Thyroid nodule Secondary - Hypertension Diabetes Discharge Condition: Stable, sating well on RA. Discharge Instructions: You were admitted to the hospital due to tachycardia (high heart rate) and shortness of breath. You underwent a chest CT in the emergency room which showed no cause for your shortness of breath, although it did show a new nodule (small growth) in your thyroid. You shortness of breath resolved with neb treatments and was thought to be due to an asthma exacerbation. Your elevated heart rate decreased overnight. Your thyroid function was checked and was noted to be slightly abnormal. You will need to follow up closely with your primary doctor [First Name (Titles) ] [Last Name (Titles) 444] and workup for the thyroid nodule seen on CT. You blood sugars were also noted to be elevated during your hospitalization. You should check your fingersticks and follow up with your primary doctor for continued [Last Name (Titles) 444] of your diabetes. Medication changes: 1. You will need to take 40 mg of prednisone for two more days (you received today's dose at the hospital). 2. You should take a fluticasone inhaler 2 puffs twice daily to treat asthma as well as atrovent inhaler 2 puffs four times a daily. 3. Use 2 puffs of albuterol as needed every four hours for shortness of breath or wheezing. Otherwise continue your outpatient medications as prescribed. Go to the emergency room or call you primary docotor if you experience fevers, chills, shortness of breath, dizziness, wheezing, or chest pain. Followup Instructions: You already had an appointment scheduled with the NP[Company 2316] next week: Provider: [Name10 (NameIs) ] FERN, RNC Phone:[Telephone/Fax (1) 250] Date/Time:[2129-2-1] 10:40 It is very important that you keep this appointment, or reschedule it if you cannot make it. Please keep your other previously scheduled appointments: Provider: [Name10 (NameIs) 7158] [Last Name (NamePattern4) 7159], M.D. Phone:[Telephone/Fax (1) 250] Date/Time:[2129-4-5] 9:50 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 101846], [MD Number(3) 1240]:[Telephone/Fax (1) 95321] Date/Time:[2129-4-8] 10:30 Completed by:[2129-1-27]	[ "42789", "4019", "25000", "2720", "53081" ]
Admission Date: [2150-6-23] Discharge Date: [2150-6-30] Date of Birth: [2081-1-9] Sex: F Service: SURGERY Allergies: Percocet / Aspirin / Tylenol / Morphine Attending:[First Name3 (LF) 668] Chief Complaint: end stage renal disease admitted for kidney transplantation Major Surgical or Invasive Procedure: [2150-6-23] - deceased donor renal transplant [2150-6-26] - cardioversion History of Present Illness: Patient is a 69 year old female with ESRD [12-22] HTN maintained on peritoneal dialysis for the past 3 years. Her last hemodialysis was the night prior to presenting for transplant operation. At the time of admission patient had no active issues, she was afebrile, had no nausea or vomiting. Patient had no recent hospitalizations. Past Medical History: - ESRD [12-22] HTN - partial colectomy for colonic polyps - thyroid resection for benign disease - ventral hernia repair - ichemic left leg s/p common femoral and profunda endarterectomy, SFA embolectomy, four compartment fasciotomies Social History: - married, lives at a farm house with her husband - has 2 daughters and 1 son (one daughter and a son lives within a block of the patient) Family History: Noncontributory Physical Exam: gen: WD/WA, NAD, AOOX3 CV: RRR, nl S1, S2, no murmur appreciated pulm: CTAB abdomen: Soft/NT/ND, well healed midline scar, PD site c/d/i, post-tranplant incision is c/d/i, there is no edema, no erythema, no drainage extremities: no c/c, 1+ pitting edema left LE, 4 incision fasciotomy scars well healed on left foot Pulses: 2+ femoral b/l, 1+ Right DP/PT, 2+ left DP/PT neuro: CN II - XII intact Pertinent Results: admission [2150-6-23]: [2150-6-23] 10:32AM GLUCOSE-135* UREA N-52* CREAT-8.2* SODIUM-141 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15 [2150-6-23] 10:32AM CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-1.4* [2150-6-23] 10:32AM WBC-4.8 RBC-3.25* HGB-10.5* HCT-32.7* MCV-101* MCH-32.2* MCHC-32.1 RDW-16.3* [2150-6-23] 10:32AM PLT COUNT-286 [2150-6-23] 09:57AM TYPE-ART PO2-209* PCO2-40 PH-7.42 TOTAL CO2-27 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED COMMENTS-OR 16 [2150-6-23] 09:57AM GLUCOSE-102 LACTATE-1.7 NA+-136 K+-3.7 CL--99* [2150-6-23] 09:57AM HGB-9.8* calcHCT-29 [2150-6-23] 09:57AM freeCa-1.09* [2150-6-23] 09:00AM TYPE-ART PO2-170* PCO2-35 PH-7.50* TOTAL CO2-28 BASE XS-4 INTUBATED-INTUBATED VENT-CONTROLLED [2150-6-23] 09:00AM GLUCOSE-95 LACTATE-1.8 NA+-135 K+-3.4* CL--99* [2150-6-23] 09:00AM HGB-9.3* calcHCT-28 [2150-6-23] 09:00AM freeCa-0.89* [2150-6-23] 03:16AM UREA N-55* CREAT-9.1* SODIUM-140 POTASSIUM-5.6* CHLORIDE-98 TOTAL CO2-28 ANION GAP-20 [2150-6-23] 03:16AM estGFR-Using this [2150-6-23] 03:16AM ALT(SGPT)-18 AST(SGOT)-54* [2150-6-23] 03:16AM ALBUMIN-3.5 CALCIUM-7.8* PHOSPHATE-3.3 MAGNESIUM-1.7 [2150-6-23] 03:16AM WBC-8.1 RBC-3.56* HGB-11.1* HCT-35.9# MCV-101 MCH-31.0 MCHC-30.8* RDW-15.4 [2150-6-23] 03:16AM PLT COUNT-354 [2150-6-23] 03:16AM PLT COUNT-354 discharge: [2150-6-30] 05:20AM BLOOD WBC-6.1 RBC-3.20* Hgb-9.9* Hct-31.6* MCV-99* MCH-31.0 MCHC-31.4 RDW-15.9* Plt Ct-315 [2150-6-30] 05:20AM BLOOD PT-14.9* PTT-25.9 INR(PT)-1.3* [2150-6-30] 05:20AM BLOOD Glucose-95 UreaN-21* Creat-1.6* Na-136 K-4.4 Cl-105 HCO3-22 AnGap-13 [2150-6-28] 03:41PM BLOOD CK(CPK)-27 [2150-6-28] 05:44AM BLOOD ALT-5 AST-14 CK(CPK)-23* AlkPhos-116 TotBili-0.6 [2150-6-30] 05:20AM BLOOD Calcium-9.6 Phos-2.4* Mg-1.4* [2150-6-26] 06:01AM BLOOD TSH-0.52 [2150-6-30] 05:20AM BLOOD tacroFK-10.5 imaging: ECG [2150-6-25] Sinus rhythm. First degree A-V block. Premature atrial contractions. Non-specific ST-T wave changes. Compared to the previous tracing of [2150-6-23] QRS changes in leads V2-V3 could be due to lead placement. ECG [2150-6-26] Narrow complex tachycardia is sprobably due to sinus tachycardia with a long P-R interval. Diffuse ST-T wave changes are likely due to the rate. Compared to the previous tracing of [2150-6-25] atrial premature beats are not seen. the overall rate has increased. The ST-T wave changes are now more prominent, though they likely reflect repolarization abnormalities from a fast heart rate. CXR [2150-6-27] IMPRESSION: No evidence of failure. No cardiomegaly. Portable TTE [2150-6-29] IMPRESSION: Normal regional and global biventricular systolic function. Mild mitral regurgitation. Brief Hospital Course: HD1 [2150-6-23] Patient presented to the hospital and had a kideny transplant done on the day of admission. She tolerated surgery well, her post-operative course in the PACU was uneventful and she was transferred to the floor in stable condition. Her pain was controlled with PCA dilaudid. HD2 [2150-6-24] Patient was stable. Her urine output increased very shortly after the operation; she made about 400mL of urine in the initial 12 hours post-op and her creatinine decreased from 8.2 to 6.8. Her JP output was replaced with 1cc per 1cc replacement. She also recieved maintainence IV fluids. She was started on the sips of clears and continued to have PCA in place, yet had a minimal pain requirement. Her anticoagulation was resumed, she received coumadin 2mg. There were no cardiovascular or pulmonary issues. HD3 [2150-6-25] Patient's creatinine decreased further to 3.7. Her urine output increased to over 2200mL in 24 hours. Her JP output was now replaced with 1/2cc per 1cc, the maintaince IV fluids continued. Patient developed chest pain and shortness of breath. The work up was done, she had chest x-ray, EKG and cardiac enzymes sent out, which were all negative for any sign of cardiac ischemia. Her blood pressure increased a little but during the episode and she was tachycardic to 100, yet never experienced any oxygen desaturation. In the afternoon, patient developed cardiac arrythmia, atrial flutter. She recieved metoprolol IV pushes, to which she did not respond. Her blood pressure and heart rate remained elevated, her oxygen saturation was close tp 100% on room air, she was tachypnic. Cardiology was consulted. The recommendation was to increase metoprolol to 50mg [Hospital1 ], TTE was ordered for next day and the plan was to cardiovert the patient the next morning. She was started on Wellbutrin 75 mg [Hospital1 ]. She recieved coumadin 2mg. HD4 [2150-6-26] Her urine output was over 2L with still downtreanding creatinine level. Her cardiovascular status has not changed and the cardioversion was attempted unsuccesfully. Her medical managment was changed to metoprolol 75mg tid after cardioversion. Her tachypnea in 100s and hypertension in 150s/90s continued. Her Wellbutrin was increased to her home dose of 150mg [Hospital1 ]. She did not recieve her coumadin as she was supratherapeutic. She tolerated regular diet. The foley was removed. HD5 [2150-6-27] Patient's creatinine decreased further, her urine output was over 2L for the past 24 hours. She continued to be tachycardic now in 120- 150s and hypertensive. The change was made by cardiology and she was started on metoprolol 100mg tid and sotalol 40mg once daily. Later in the afternoon, electrophysiology fellow recommended that we stop the sotalol and start digoxin. She recieved one dose of digoxin that day. In the late evening patient was unchanged and develop shortness of breath, her heart rate was in 130-150s, bp was 160-170s/90-100s. She was transferred to ICU and started on amiodarone taper, her metoprolol was increased to 150mg tid. Her coumadin was held. Patient tolerated regular diet. HD6 [2150-6-28] Patient's urine output has dropped, but she was still making urine and her creatinine was downward trending. Her arrythmia resolved in the afternoon, yet she remained tachycardic and hypertensive. She recieved 24 hour IV amiodarone taper and was subsequently switched to an oral amiodarone. Her chest pain has resolved, all the workup was negative for an ischemic event. She continued to tolerate regular diet. HD7 [2150-6-29] Patient's urine output increased again and her creatinine was down to 1.6. Norvasc and hydralazine were added and adequate blood pressure control was achieved. Patient had no chest pain and continued to be in sinus rythm. She was transferred from the ICU to the floor. She tolerated regular diet. She recieved 0.5mg of coumadin. HD8 [2150-6-30] Patient's creatinine is still improving with good urine output. There were no cardiac issues at this time. The blood pressure was controlled in 140-150s/80-90s range. She tolerated regular diet. Throughout her hospitalization patient was afebrile. She did not have any infections and recieved no antibiotics. She denied any nausea, vomiting, diarrhea, constipation, chest pain, shortness of breath or pain at the time of dicharge. She was discharged with the JP drain in place. Medications on Admission: Alendronate 35 qmonth, Amlodipine 10', atenolol 25', nephrocaps 1', bupropion 150", calcium acetate 1334 QIDWMHS, sensipar 30', EPO, nexium 40', lactulose 30", lisinopril 10', KCL 20', simvastatin 20', renagel 800'''', sucralfate 2''', coumadin 2' on Mon and Fri, 1' TWThSSun Discharge Medications: 1. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. Disp:30 Tablet(s) Refills:1 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:2 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:60 Tablet(s) Refills:0 10. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 12. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 2 weeks: take 400mg twice daily for 2 weeks, then take 200mg twice daily for 4 weeks . Disp:56 Tablet(s) Refills:0 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 4 weeks. Disp:56 Tablet(s) Refills:0 16. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a month. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: end stage renal disease s/p deceased donor renal transplant new onset cardiac arrythmia/ atrial flutter Discharge Condition: stable Discharge Instructions: You are going home with your immunosupression medications. Please call transplant coordinator with any questions you may have regarding the medications or any other concerns/questions. The JP drain has not yet been removed, as it continues to drain fair amount of fluid. The VNA services will visit you at home and help with the JP drain managment. Dr. [Last Name (STitle) ] will see you in clinic and will determine when the JP will come out. It will be removed at the clinic. You may shower with the drain in place. You may eat regular diet, but ideally low in sodium and potassium to protect your new kidney. You may resume your previous activities as tolerated, however no heavy lifting for at least a month. You may keep the incision uncovered. You may shower with the staples in place. Staples will be removed at the clinic in a few weeks. Please monitor your output. If it drops significantly, please call the transplant coordinator or come to the emergency room. Also, if you develop any drainage from your incision, fever, nausea, vomiting or significant pain, shortness of breath, chest pain or palpitations please call the coordinator or go to emergency room. Followup Instructions: Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2150-7-2] 1:40 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] TRANSPLANT SOCIAL WORK Date/Time:[2150-7-2] 3:00 Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2150-7-9] 3:20 Provider: [Name10 (NameIs) ], [Name11 (NameIs) ], MD Phone: [Telephone/Fax (1) 32935] Date/Time:[2150-7-13] 10:30 Completed by:[2150-6-30]	[ "40391", "9971", "42731" ]

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