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Admission Date: [2102-10-9] Discharge Date: [2102-10-23] Date of Birth: [2102-10-9] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname 30814] is the 2725 gram product of a 37 5/7 weeks gestation born to a 25 year old gravida I, para 0 mother with the following prenatal laboratories. Blood type O positive, antibody negative, RPR nonreactive, Rubella immune, hepatitis B negative, GBS negative. Maternal history is significant for a history of seizure disorder. In addition, there is a paternal history of neurogenic scapuloperoneal amyotrophy. This infant was prenatally diagnosed with trisomy-21 as well as ventriculomegaly, hepatomegaly on prenatal ultrasounds. The patient's fetal echocardiogram was reported to be normal. In addition fetal MRA revealed dangling choroid bilaterally as well as an absent corpus callosum. This infant was born via primary cesarean section due to intolerance of labor due to the paternal history of neurogenic scapuloperoneal amyotrophic which is associated with vocal cord paralysis, the otolaryngology service from [Hospital3 1810] was present at the delivery. Patient's Apgar scores were 7 and 8 at one and five minutes. He was noted to have neonatal teeth during the delivery. He was also initially cyanotic. Patient received several seconds of positive pressure ventilation in the delivery room at which time regular respirations as well as resolution of cyanosis resulted. The patient was subsequently transferred to the Neonatal Intensive Care Unit for further management. PHYSICAL EXAMINATION: On presentation follows: Birth weight 2725 grams, head circumference 33 cm, length 45 cm. Vital signs: Temperature 98 degrees, heart rate 131, respiratory rate 40 breaths per minute, 92 percent O2 saturation on room air, blood pressure 57/48 with a mean pressure of 53. Initial D-stick was 70. General: Infant male in radiant warmer in no apparent distress. Head, eyes, ears, nose and throat: Anterior fontanelle soft and flat, positive red reflux bilaterally, Down's faces; epicanthal folds bilaterally, upward slanting palpable fissures bilaterally, relative macroglossia, low set ears bilaterally. Two neonatal teeth on alveolar ridge noted. Respiratory: Clear to auscultation bilaterally, no reactions. Cardiology: Regular rate and rhythm, S1, S2 normal, no murmur. Abdomen: Soft, nontender, hepatic margin 3 cm below costal edge no spleen palpated. Extremities: No cyanosis or edema, well perfused. Femoral pulses 2 plus bilaterally. Spine intact, no dimpling. Diffuse maculopapular rash on face and trunk. Neurologic: Mildly hypotonic, reactive on examination, suck, palmar, plantar, Moro reflex intact. SUMMARY [Hospital ] HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: Upon stabilization in the Neonatal Intensive Care Unit the patient was placed on a nasal cannula for several hours and was weaned off to room air in the first 12 hours of life. This patient remained on room air until hospital day number seven, [2102-10-16], at which time he was noted to have spontaneous desaturations into the mid 80 percent O2 saturation range. The baby was placed on nasal cannula of varying flows from 25 cc of 100 percent O2. Patient required nasal cannula for three days for these intermittent desaturations. On [2102-10-20] the patient was free of desaturations through time of discharge on [2102-10-23]. This patient exhibited no signs of apnea of prematurity. 1. CARDIOVASCULAR: The patient's fetal echocardiogram was reported to be normal. On day of life seven patient received full echocardiogram which revealed a patent foramen ovale. No other anatomic abnormalities were noted on cardiac echocardiogram. The patient did not have any episodes of bradycardia or other signs of cardiovascular instability during his hospital course. 1. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was started on breast milk/Special Care 20 at 20 kilocalories per ounce on day of life two. He demonstrated excellent P.O. intake and was placed on P.O. ad lib to mange these. On 1`[2101-12-17] caloric intake of the breast milk/formula was increased to 24 kilocals per ounce. Patient exhibited excellent weight gain. At time of discharge on [2102-10-23] patient was discharged on nonconcentrated breast milk 20/Special Care 20 kilocals per ounce formula on a P.O. ad lib schedule. 1. GASTROINTESTINAL: Patient's bilirubin at birth was 9.9 at which time double phototherapy was started. Phototherapy was continued until [2102-10-15] at which time his bilirubin was 9.8. Phototherapy was discontinued. 1. HEMATOLOGY: Patient's initial CBC revealed a leukocytosis, white count of 58.3, hematocrit of 48.9, platelet count of 378. Due to his history of trisomy-21 in addition to his marked hepatomegaly patient was followed with serial daily CBCs. On day of life three patient's white count was 49, platelets 389 with hematocrit of 45. In addition to the CBCs coagulation studies and liver enzymes were also serially followed. On day of life two ALT was 92, AST was 55, ALT 91. Day of life number three ALT 80, AST 47, ALT 100. Hematology/Oncology service was requested to evaluate the child for possible causes of leukocytosis. On [2102-10-17] a bone marrow aspirate was performed on the patient which revealed blast formation. Subsequent analysis of the bone marrow was consistent with transient myeloproliferative disorder. Flow cytometry and cytogenetic analysis were not available at the time of discharge. Patient's white count on day of life nine dropped to 27, platelets of 159, hematocrit of 42.5. Per hematology/oncology service patient is to continue with serial CBCs times two weeks in addition to follow up at the [Hospital3 328] hematology clinic. No treatment is deemed necessary for this disorder. 1. NEUROLOGIC: Patient did not exhibit any signs of neurologic problems during his hospital course. He showed no signs of neurogenic scapuloperoneal amyotrophy, or any other focal neurologic disorders. Neurology follow up was scheduled in conjunction with Down's syndrome clinic after discharge. 1. SENSORY: Audiology: Patient's hearing screen prior to discharge was referred bilaterally. Patient's parents were instructed to follow up at [Hospital3 1810] for a follow up hearing test. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. Name of primary pediatrician is Dr. [Last Name (STitle) 59728] in [Location (un) 8117]. Phone number is [Telephone/Fax (1) 59729]. Fax number [Telephone/Fax (1) 59730]. CARE RECOMMENDATIONS AT DISCHARGE: Feeds at discharge are breast milk/Special Care 20 kilocals P.O. ad lib schedule. No medications. Car seat position screening passed prior to discharge. State Newborn Screening: On day of life number 3 PK state newborn screening was seen with the subsequent result of a TSH at borderline levels of 25.1. Repeat state screen was sent. In addition, serum TSH and T4 levels were sent prior to discharge, results of which are not known prior to discharge. No immunizations received prior to discharge. FOLLOW UP APPOINTMENTS: 1. Down syndrome clinic at the [Hospital3 1810]. Coordinator [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], phone number [Telephone/Fax (1) 47723]. Appointment scheduled for [2102-10-30] at 1:30 P.M. 2. Hematology-Oncology: Patient scheduled for follow up on [2102-10-30] at 10 A.M. at the [Doctor First Name 4049] Fund Clinic at the [Hospital 59731] Cancer Institute with Dr. [Last Name (STitle) 47766]. Phone number is [Telephone/Fax (1) 59732]. 3. Follow up Genetics scheduled per parents. 4. Follow up hearing screen scheduled per parents. 5. Visiting Nurse scheduled to visit parents two days after discharge. 6. Initial visit with primary pediatrician, Dr. [Last Name (STitle) 59728], scheduled for [2102-10-25]. DISCHARGE DIAGNOSES: 1. Trisomy-21. 2. CNS: Ventriculomegaly with absent corpus callosum. 3. Hepatomegaly. 4. Transient myeloproliferative disorder. [First Name8 (NamePattern2) 1154] [Last Name (NamePattern1) ], MD [MD Number(2) 56585] Dictated By:[Last Name (NamePattern1) 56760] MEDQUIST36 D: [2102-10-23] 14:37:59 T: [2102-10-23] 15:38:35 Job#: [Job Number 59733] cc: Dr. Crocker Children's Hospital Down's Syndrome Clinic Dr. [Last Name (STitle) 59734], [Telephone/Fax (1) 59730]	[ "V290", "V053" ]
Admission Date: [2130-9-11] Discharge Date: [2130-9-13] Date of Birth: [2090-7-3] Sex: F Service: CCU HISTORY OF THE PRESENT ILLNESS: The patient is a 40-year-old female with a past medical history significant for chronic atrial flutter of idiopathic origin who presented to the [Hospital3 ] Hospital on [2130-9-11] for a third attempt at DC cardioversion. She was also started on propafenone 150 mg t.i.d. and Lopressor 25 mg b.i.d. The patient has a history of chronic atrial fibrillation, formerly diagnosed in [2124] but most likely present since her teenage years. She was successfully cardioverted on [2130-8-31]. However, she did not take her propafenone as prescribed and then went back into atrial fibrillation after one week. On [2130-9-8], she underwent repeat DC cardioversion and remained in sinus rhythm for about 10-15 minutes but then experienced palpitations and returned to atrial fibrillation. She returned on [2130-9-11] for a third attempt at cardioversion. The patient initially was in atrial fibrillation with rates in the 120s to 180s. She was symptomatic with palpitations but denied any other symptoms. She took propafenone and Lopressor for 3 1/2 days prior to admission. On the day following admission, she developed a cardiac arrhythmia. She had an eight second pause and a change in her rhythm to a junctional rhythm with left bundle block. She was bradycardiac to the 30s with a systolic BP in the 70s. She was thought to have blocked sinus node conduction with a junctional escape rhythm and to have a [Doctor Last Name ] A wave resulting in increased vagal tone, thus precipitating bradycardia and hypotension. The patient initially was given Atropine and Glucagon and started on a peripheral dopamine drip. The patient declined a central line placement. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 42749] MEDQUIST36 D: [2130-9-13] 12:01 T: [2130-9-14] 19:55 JOB#: [Job Number 42750]	[ "42731", "42789" ]
Admission Date: [2129-10-6] Discharge Date: [2129-10-11] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1943] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Enteroscopy with [Hospital1 ]-CAP electrocaudery of AVMs [2129-10-7] History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE 87 year-old man with prior GI bleeds from jejunal AVMs in past, CAD and CHF with EF of 30% s/p ICD and PPM for complete heart block who presents from OSH with GI bleed. He was in his usual state of health on until this AM when he awoke from sleep with acute shortness of breath and sharp chest pain radiating across chest. Was pleuritic in nature. No fevers, chills, or cough. Pt was unclear if this was "heart burn" or cardiac related and tried omeprazole however did not have any relief. Then tried sublingual nitroglycerin x 1 which relief however pain then returned. Pt then tried omeprazole again without relief and then called EMS for further assistance. EMS gave patient nebulizer treatment which per patient provided good relief. At outside hospital ED, patient was noted to have a hct of 25 down. Patient was then transferred to [Hospital1 18] for further evaluation. Of note, per patient, he has had several GI bleeds and has chronic anemia from GI loss requiring several blood transfusions. Has long standing history dating back to 2 years ago. Patient was last admitted at OSH from [9-26] to [9-30] during which time an enteroscopy was completed revealing stable AVMs. However he required 3 units of pRBCs. Per report, if patietn were to bleed, "spiral enteroscopy" was to be completed. Additionally, patient was also seen in ED on [10-2] for severe right nare epistaxis. Nasal packing was completed by ENT and patient was sent home. Since epistaxis, patient has had repeated episodes of melena however per patient, he has black stools regularly [1-26] iron supplementation. He denies any bright red blood. No dizziness/LH. At [Hospital1 18] ED, initial VS were 97.3 60 114/61 22 91% 4L. Patient initially had chest pain and SOB and was given 4mg of morphine. Several attempts at PIVs failed requiring RIJ placement. Hct was 24 and patient was transfused 1 unit of pRBCs. GI was consulted in ED. Trop was also elevated to 0.25 however there were no EKG changes. Cards was also consulted who did not feel this required any acute intervention. He had one episode of hypotension to 80s while positioning during CVL placement which prompted ICU admission. He remained hemodynamically stable in the ICU. On floor, he appeared well and had no complaints. He did endorse his usual congestion. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Coronary artery disease s/p MI x 3 - Systolic heart failure with EF of 30% - Diabetes mellitus, type II - Jejunal AVMs - Chronic kidney disease - Hypertension - Hyperlipidemia Social History: - Tobacco: 55ppd, quit 5 years ago - Alcohol: occ - Illicits: denies Family History: Mother with ovarian CA, father with renal CA. Physical Exam: Vitals: T: 96.0 BP: 126/49 P: 70 R: 22 O2: 93%1L General: well appearing NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: decreased breath sounds on left with crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, +2 pitting edema to mid shins Pertinent Results: [9-30] (from outside hospital): WBC 6.0, Hct 33, Plt 138 Na 136, K 4.4, Cl 104, HCO2 32, BUN 45, Cr 1.5, Ca 8.7 From [Hospital1 18]: [2129-10-6] 08:48PM CK(CPK)-70 [2129-10-6] 08:48PM CK-MB-7 cTropnT-0.22* [2129-10-6] 08:48PM IRON-65 [2129-10-6] 08:48PM calTIBC-256* FERRITIN-194 TRF-197* [2129-10-6] 08:48PM HCT-26.3* [2129-10-6] 02:25PM PT-13.2 PTT-27.7 INR(PT)-1.1 [2129-10-6] 02:05PM GLUCOSE-141* UREA N-44* CREAT-1.7* SODIUM-139 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16 [2129-10-6] 02:05PM estGFR-Using this [2129-10-6] 02:05PM CK-MB-8 cTropnT-0.25* [2129-10-6] 01:45PM WBC-8.6 RBC-2.45* HGB-8.3* HCT-24.8* MCV-101* MCH-33.7* MCHC-33.3 RDW-19.8* [2129-10-6] 01:45PM NEUTS-86* BANDS-0 LYMPHS-9* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2129-10-6] 01:45PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL [2129-10-6] 01:45PM PLT SMR-NORMAL PLT COUNT-160 ENTEROSCOPY [2129-10-7]: - Clotted blood on a background of dry oropharynx was noted. No active bleeding - Diffuse friability, erythema and nodularity of the mucosa with contact bleeding were noted in the antrum and stomach body. Cold forceps biopsies were performed for histology - At least 20 small AVMs were noted extending from D1 to distal Jejunum. Treated successfully with [Hospital1 ]-CAP Electrocautery. - Otherwise normal Enteroscopy to distal Jejunum PATHOLOGY: Stomach, antrum, biopsy [2129-10-7]: 1. Chronic inactive gastritis with intestinal metaplasia. 2. H. pylori immunostain is negative with adequate controls. Brief Hospital Course: 87 year-old man with history of CAD, systolic HF (EF 30%), DM, recurrent GI bleeds presenting with chest pain, SOB and drop in HCT. The patient was taken to enteroscopy and found to have numerous AVMs. Caudery was used to ablate the AVMs that were seen. HCT was monitored post-procedure and HCT was downtrending, but very slowly. It is very probable that the patient has other AVMs that were not visualized and may still be oozing blood. He had no frank blood in stool. His discharge hematocrit was 29.7. Patient was not short of breath and did not have angina on the day of discharge. PROBLEM LIST: #. Gastrointestinal bleeding from AVMs. The patient received a total of 4 units of PRBC transfusion (2 on [10-6] on [10-8], and 1 on [10-10]). He had push enteroscopy with electrocaudery of AVMs on [2129-10-7]. #. Anemia secondary to blood loss s/p caudery of AVMs [2129-10-7]. #. Chest pain/SOB: with elevated troponin concerning for demand ischemia v. ongoing new ischemia. EKG unrevealing in setting of paced rhythm. Could be related new ischemic event versus ischemia in setting of anema. Cards was consulted in ED who did not feel he required acute intervention. CP did resolve after blood transfusion. SOB improved after receiving Lasix. Ranexa continued to prevent anginal symptoms. Nebulizer meds were effective in controlling cardiac wheeze. #. CAD/CHF: EF 30% per report. S/P ICD/PPM placement for primary prevention. On Ranexa for refractory angina. Lisinopril not given because of low blood pressure. #. Epistaxis: Packed right nostril. Packing removed after several days. Epistaxis did not recur. #. Hypotension secondary to hypovolemia from hemorrhage. Resolved after transfusion. Lisinopril held throughout hospitalization. #. DM: No A1c on file. Insulin sliding scale given while in hospital. Glipizide restarted at discharge. # DVT prophylaxis: pneumoboots # Code: DNR/DNI (confirmed) TRANSITIONAL ISSUES: - Recheck HCT within 5-7 days; transfuse as indicated - Titrate glipizide dose - Restart Lisinopril if BP can tolerate Medications on Admission: Medications on Transfer: - Glipizide 5mg [Hospital1 ] - Lasix 120mg daily - Lasix 40mg QHS - Lipitor 10mg - Ranexa 500mg [Hospital1 ] - Omeprazole 20mg daily - Sublingual nitroglycerin prn - Lisinopril 10mg daily (patient states that he does not take this when his BP is lower) Discharge Medications: 1. Nebulizer Provide a nebulizer machine for delivering nebulized medications. Indication: reactive airway disease 2. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) unit dose Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:30 units Refills:0 3. glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day. 4. furosemide 40 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 5. furosemide 40 mg Tablet Sig: Two (2) Tablet PO every evening. 6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO BID (2 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. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes as needed for chest pain: if you still have chest pain after 3 doses, seek immediate medical attention. Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: - Arterio-venous malformations in jejunum - Anemia, chronic gastrointestinal blood loss - Coronary artery disease - Systolic heart failure - Diabetes mellitus, type II - Chronic kidney disease - Cardiac wheezing 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 transferred to the [Hospital1 18] for management of your gastrointestinal bleeding that is caused by AVM (arterio-venous malformation). You underwent a procedure called Enteroscopy and multiple AVMs were treated with caudery. After the procedure you were monitored for rebleeding. Your hematocrit did slowly trickle downward, but you did not demonstrate any visible blood in your stools. Your discharge hematocrit level is 29.7. MEDICATION INSTRUCTIONS: 1. DuoNeb one unit dose nebulized every 4 hours as needed for shortness of breath or wheezing. 2. STOP Lisinopril 10 mg daily until you see your regular doctor. This was not given because your blood pressure was lower during the hospitalization. 3. REDUCE DOSE Glipizide 2.5 mg twice daily for blood sugar control. If your sugars are consistently higher than 150mg, then you can go back to your previous dose of 5 mg twice daily. 4. Continue all other medications unchanged. HEART FAILURE INSTRUCTIONS: - Weigh yourself every morning. If you have greater than 3 pound weight gain, call your doctor. Followup Instructions: Name: [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Location (un) ] CARDIOLOGY Address: [Street Address(2) ], STE#6, [Location (un) 91155],[Numeric Identifier 33731] Phone: [Telephone/Fax (1) 91156] Appointment: Monday [2129-10-17] 1:45pm Name: [Doctor First Name ],MAMDOUH M. Address: [Male First Name (un) 71692] UNIT 2A, [Location (un) ],[Numeric Identifier 58635] Phone: [Telephone/Fax (1) 48385] Appointment: Tuesday [2129-10-18] 2:45pm	[ "41401", "4280", "25000", "40390", "5859" ]
Admission Date: [2144-1-20] Discharge Date: [2144-2-3] Date of Birth: [2089-4-19] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Vancomycin Analogues / Gentamicin / Ciprofloxacin Hcl / Cefazolin / Benadryl / Opioids-Morphine & Related Attending:[First Name3 (LF) 1185] Chief Complaint: epistaxis Major Surgical or Invasive Procedure: Right arm AV graft - [2144-1-29] by Dr. [First Name (STitle) ] History of Present Illness: 54F w/ hx of ESRD s/p renal transplant x 3, PE on coumadin anticoagulation, HTN, hep C p/w epistaxis and elevated creatinine. Since she has started anticoagulation she has experienced now 3 nosebleeds. 2 of these bleeds were approximately 2 weeks ago and short duration (< 10 min) but today starting at 2PM she experienced a persistent episode of epistaxis refractory to patient's own attempt at direct pressure. On presentation to the ED she was found to have INR elevated to 15.7 and hematocrit decrease of 8 points compared to [1-2]. She otherwise has been well although she does complain of fatigue over the past several months. She denies any light-headedness, syncope, fever, chills, chest pain, dyspnea, nausea, vomiting, abdominal pain or dysuria. She states her urine output has not decreased acutely over the past several weeks, and in particulary denies any pain over her renal transplant. She does have dark stool, but takes iron. . Of note she does complain of pain on the plantar surface of her left foot that is new onset today. She noticed this pain when she woke up this morning and denies any recent traumatic injury. She also describes painful "lumps" along the posterior aspect of her thighs bilaterally. . In the ED, initial VS were: 99.5 75 102/69 16 100% RA. She was given 2 units FFP and vitamin K 10mg IV. Renal transplant was contact[Name (NI) ] and will see the patient on [1-21] during the day. She was T&C for 2 units, but no blood was given in the ED. She was noted as a difficult stick but her portacath was being used for access. . On arrival to the MICU, she continued to complain of fatigue, but otherwise felt well. She does have the pain along the plantar surface of her left foot where she has a small hematoma. . Review of systems: - negative except as noted in HPI Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. End-stage renal disease (due to RPGN, baseline creatinine previously in the 2.1-2.2 range; now since [6-/2143] has been between 4.2-5, plans for new access establishment for possible future permanent HD needs; s/p renal transplantation x 3 (two failed transplant attempts), LRRT in [2117] (from brother), s/p DCD in [2120] and [2130] due to chronic allograft nephropathy (biopsy [9-/2138]) 2. Hypertension 3. GERD 4. Anemia of chronic disease 5. s/p gastric bypass surgery (had prior diabetes mellitus type 2 which was improved by the surgery) 6. Hepatitis C (secondary to blood transfusions) 7. Sinus bradycardia 8. s/p parathyroidectomy 9. s/p left chronic knee pain (following injury), s/p lumbar sympathetic block to limit pain on [2143-8-18] at pain clinic 10. Neuropathic foot pain (unclear etiology) 11. Spina bifida occulta 12. Chronic tension headaches 13. Fecal and urinary incontinence 14. Recurrent urinary tract infections 15. Osteopenia 16. s/p ventral hernia repair ([9-/2139]) - with Marlex mesh 17. s/p partial excision of left upper arm AV-graft and right upper arm AV-graft Social History: Lives with boyfriend. Not currently employed. Denies tobacco use or alcohol use; no recreational substance use. Family History: Father with lung cancer, maternal grandmother with [Name2 (NI) 499] cancer and stroke. Siblings with HTN and ESRD, DM, hypothyroidism. Physical Exam: General: Alert, oriented, no acute distress HEENT: MMM, 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: multiple surgical scars, soft, non-tender, non-distended GU: no foley Skin: several small areas of ecchymosis along her legs, plantar surface of foot Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, several small, mobile nodules TTP bilaterally along posterior thigh L foot: TTP along plantar surface w/ small hematoma Neuro: Grossly intact Rectal: noted to be trace heme positive on stool guiac Pertinent Results: Admission Labs: [2144-1-20] 07:45PM BLOOD WBC-9.1 RBC-3.18* Hgb-8.5* Hct-25.4* MCV-80* MCH-26.8* MCHC-33.5 RDW-16.3* Plt Ct-314# [2144-1-20] 07:45PM BLOOD Neuts-90.8* Lymphs-7.1* Monos-1.9* Eos-0.1 Baso-0.1 [2144-1-20] 07:45PM BLOOD PT-150 PTT-138.8* INR(PT)-15.7* [2144-1-20] 07:45PM BLOOD Glucose-121* UreaN-127* Creat-8.6# Na-142 K-4.4 Cl-105 HCO3-12 AnGap-29* Pertinent Labs: CXR: IMPRESSION: No acute cardiopulmonary abnormality. Renal US: IMPRESSION: 1. No hydronephrosis. 2. Patent renal vasculature. Mildly elevated resistive indices up tp 0.84 slightly increased (previously highest measurement 0.77) C diff toxin screen: Feces negative for C.difficile toxin A & B by EIA. Urine Culture [2144-1-22]: URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Discharge Labs: Brief Hospital Course: Primary Reason for Hospitalization: 54F w/ hx of renal transplant x 3, recent PE diagnosis on coumadin, HTN, hep C presented with epistaxis in setting of supratherapeutic INR, acute on chronic renal failure, admitted to the ICU for initial monitoring, experienced recurrent epistaxis on othe floor after re-initiating anticoagulation. . Active Issues: . # Epistaxis/Supratherapeutic INR: The patient was found to have epistaxis in setting of elevated INR to 15.7, found to have eight point hematocrit drop, nadir of 19.5. Anterior packing was done in the ED and on arrival to the MICU, the patient was no longer bleeding. She received FFP and vitamin K in the ED for reversal of her anticoagulation. While in the MICU, the patient was transfused 2U PRBC with appropriate hematocrit response. Her coumadin was held. Renal transplant team felt supratherapeutic INR was most likely due to drug interactions (coumadin, sirolimus). The packing was kept in for 4 days, and coumadin was re-started with a heparin bridge on day 3 of packing. Clindamycin used for Toxic Shock Syndrome prophylaxis. She experienced recurrent epistaxis about 36 hrs after packing was removed, with INR 2.0 and therapeutic PTT, required 1u pRBC transfusion. Left nostril was repacked by ENT on [1-26]; right nare was also noted to have bleeding, though ENT was unable to localize, controlled with surgifoam and afrin. There were intermittent maroon-colored stools secondary to epistaxis. On [1-31] her L nare packing was removed. Her Hct remained stable and she had no recurrence of epistaxis. On [2-1] she was started on IV heparin and restarted on coumadin 2mg daily (of note, IV heparin not started to bridge her to coumadin, but rather to monitor whether she would have recurrence of bleeding once anticoagulated). She did well without recurrence of bleeding, and on [2-2] IV heparin was stopped. On day of discharge her INR was 1.3. She should have her INR monitored very closely after discharge. She will be monitored by the [Company 191] coumadin clinic. . # Acute on Chronic Renal failure: The patient is s/p kidney transplant x3, again with failing graft. Most recent creatinine range from 4 to 5 over past several months, elevated to 8.6 on presentation, though returned to baseline during hospitalization. Ultrasound showed no hydronephrosis with patent vessels. The patient's spironolactone and lasix were held. She had no signs of uremia or need for urgent dialysis, though she will likely need to re-initiate dialysis in the next two months. Transplant surgery placed AV graft in RUE on [1-29]. Nylon stitches to come out at followup with Dr. [First Name (STitle) ] on [2144-2-20]. On discharge, her creatinine was stable at 4.5. Sirolimus was initially held on admission in setting of potential interaction with warfarin, but was restarted at 2mg daily on floor with appropriate sirolimus level. She was continued on home dose prednisone 5mg daily. She was advised to restart her home lasix dose but to continue holding her spirinolactone due to her risk of hyperkalemia with her worsening renal failure. She is scheduled to follow up with Dr. [Last Name (STitle) 7473] in nephrology clinic. . # Pulmonary Embolism: Ms. [Known lastname 102620] has been anticoagulated with coumadin for a pulmonary embolism diagnosed in [2143-11-2]. Anticoagulation was reversed with 2 units of FFP and 10mg of vitamin K due to severe epistaxis as described above. Her INR was 1.2 on [1-23] when coumadin (bridged with IV heparin) was restarted. After recurrent epistaxis episode [1-26], she was given another 1u FFP and 2mg po vitamin K. No further bleeding noted, and she was restarted on coumadin on [2144-2-1]. She was discharged on 2mg coumadin daily (no bridge). Her INR was 1.3 on discharge, and she will have her INR monitored closely by the [Hospital 191] [Hospital3 ]. . # Hypocalcemia Secondary to hypoparathyroidism after parathyroidectomy in past. Her calcitriol was increased from 0.25mcg daily to 0.5mcg daily. She was continued on calcium carbonate supplements. . # Left lateral foot pain: Small area of ecchymosis w/ hematoma on left lateral surface. Patient does not remember any recent trauma, but in setting of elevated INR minor inciting injury could be causative factor. Xrays show no fracture. Pain was worsened with walking but improved by time of discharge. . # Posterior thigh pain w/ painful nodules: On exam small, mobile nodules palpated along bilateral posterior thighs just deep to the subcutaneous tissue. Reproducible pain on palpation of these nodules. Differential includes lipoma, hematoma, lymphadenopathy. Likely lipomas, but will need to be followed for interval changes. As these did not enlarge as an inpatient, their evaluation can likely be deferred to the outpatient setting. . # Hypertension: Ms. [Known lastname 102729] home diltiazem, labetalol, lasix, and spirinolactone were held during her hospitalization. Upon transfer to the floor, her blood pressure was controlled with amlodipine 10mg daily. Lasix and spironolactone were not restarted as she remained euvolemic. Upon discharge she should restart her home lasix dose, but should continue to hold her spirinolactone as it increases her risk of hyperkalemia with her worsening renal failure. . # UTI: Ms. [Known lastname 102620] was discovered to have a grossly positive UA on [2144-1-22], cultures grew Klebsiella and Proteus. She was treated with a 10 day course of Ceftriaxone. . Chronic Issues: # GERD: The patient was continued on home omeprazole. . # Chronic pain: Per history has bilateral knee pain, some neuropathic foot pain. She was continued on her home oxycodone, lidocaine patch, cyclobenzaprine as needed. . # Transitional issues: - Medication changes: diltiazem, labetolol, and spirinolactone were discontinued, she was started on amlodipine for blood pressure control, sirolimus was decreased from 2.5mg daily to 2mg daily, calcitriol was increased from 0.25mcg daily to 0.5mcg daily. - She is scheduled to follow up with Dr. [First Name (STitle) ] (transplant surgery) and Dr. [Last Name (STitle) 4883] (nephrology). She is asked to also follow up with her primary care physician [Name Initial (PRE) 176] 1-2 weeks of discharge. - She was restarted on coumadin 2mg daily on [2-1] without a bridge. Her INR should be monitored every other day for at least the first week. Her INR will be monitored by the [Hospital 191] [Hospital3 ]. - She maintained full code status throughout her hospitalization. Medications on Admission: - multivitamin - loperamide 2mg TID for loose stools - prednisone 5mg daily - pantoprazole 40mg [Hospital1 ] - labetalol 50mg QAM, 100mg QPM - folic acid 1mg daily - lasix 20mg daily - calcitriol 0.25mcg daily - clonazepam 0.5mg QHS prn anxiety - diphenoxylate-atropine 2.5-0.025 mg Q6hrs for loose stools - prochlorperazine maleate 5 mg Q6hrs for nausea - hydroxyzine HCl 25 mg twice daily for pruritis - acetaminophen 500-1000mg Q8hrs for pain - spironolactone 25mg daily - lidocaine 5% (700mg/patch) topically daily - cyclobenzaprine 10 mg TID for pain, muscle spasm - sodium bicarbonate 650mg twice daily - oxycodone 5mg Q6hrs for pain - sirolimus 2.5mg daily - warfarin 3mg on Monday and Saturday, 2mg all other days - calcium carbonate 200 mg calcium QID Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO once a day. 2. loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) as needed for loose stool. 3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. 8. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 10. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a day as needed for itching. 11. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 13. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain: [Month (only) 116] cause drowsiness. Do not drive or operate machinery while taking. 14. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 16. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 19. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:0 20. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:0 21. darbepoetin alfa in polysorbat 40 mcg/0.4 mL Syringe Sig: One (1) injection Injection q3 weeks. 22. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Nosebleed (epistaxis) Recent Pulmonary Embolism Hypertension Chronic Kidney Disease stage 5 Hepatitis C Osteopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 102620], You were admitted to the hospital because you were having a lot of bleeding from your nose. You received blood transfusions and your nose was packed for a few days to stop the bleeding. You were also given antibiotics for your urinary tract infection. You have been restarted on your coumadin for the blood clot in your lungs. You should have your coumadin levels monitored very closely after you leave the hospital. If you have any signs of bleeding that concern you, please be sure to return to the Emergency Department. You had an AV Graft placed by the Transplant Surgery team while you were here. The nylon stitches will come out at your followup appointment. We made the following changes to your medications while you were in the hospital: -STOP labetolol -STOP spirinolactone -CHANGE sirolomus from 2.5mg daily to 2mg daily -CHANGE calcitriol from 0.25mcg daily to 0.5mcg daily -START amlodipine 10mg daily We made no other changes to your medications. Please continue taking the rest of your medications as prescribed by your providers. We have scheduled appointments for you to follow up with Dr. [First Name (STitle) ] in the transplant surgery clinic and Dr. [Last Name (STitle) 4883] in the nephrology clinic. We would also like you to see you primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 5781], within 1-2 weeks of leaving the hospital. Please call [Telephone/Fax (1) 250] to schedule. It was a pleasure taking care of you at [Hospital1 18] and we wish you a speedy recovery. Followup Instructions: You have the following appointments scheduled at [Hospital1 18]: Department: TRANSPLANT CENTER When: THURSDAY [2144-2-13] at 1:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: WEST [Hospital 2002] CLINIC When: WEDNESDAY [2144-2-26] at 9:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: [Hospital3 249] When: TUESDAY [2144-5-26] at 11:20 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) ] [Name8 (MD) ] MD [Doctor Last Name 1189]	[ "5849", "2762", "2760", "40391", "2851", "5990", "53081", "4280" ]
Admission Date: [2121-1-1] Discharge Date: [2121-1-9] Date of Birth: [2036-2-9] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Weakness Major Surgical or Invasive Procedure: [2121-1-2] 1. Coronary artery bypass grafting x3 with left internal mammary artery, left anterior descending coronary; reverse saphenous vein, single left from the aorta to the distal right coronary artery; as well as reverse saphenous vein graft from the aorta to the first obtuse marginal coronary artery. 2. Aortic valve replacement with a 21 mm [Doctor Last Name ] Magna aortic valve bioprosthesis History of Present Illness: 84yo [Male First Name (un) 4746] w known history of aortic stenosis who has experienced weakness, lightheadedness, DOE and visual floaters recently. Aortic stenosis has progressed to severe with an aortic valve area of 0.88cm sq. now. He denies SOB or pain and is in fact quite active, climbing stairs and working part time. Additionally, he has had episodes of supraventricular tachycardia. Past Medical History: Coronary Artery Disease Aortic Stenosis Colonic polyp Osteopenia Carotid artery stenosis Cataracts Past Surgical History: s/p R CEA [2102] s/p hydrocele repair s/p cataract surgery in [2116] s/p inguinal hernia repair Social History: Race: caucasian Last Dental Exam: edentulous Lives with: alone (+ dog) Occupation: part time at son's store Tobacco:d enies ETOH: denies Family History: Non-contributory Physical Exam: Pulse:76SR Resp:18 O2 sat: 97%RA B/P Right: Left: 165/81 Height: Weight: 116 lb General: Skin: Dry [x] intact [x] x excoriations b/l anterior legs HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: no edema, moderate varicosities b/l LEs (L>R) Neuro: Grossly intact X Pulses: Femoral Right: Left: DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: transmitted cardiac murmur Pertinent Results: [2121-1-8] CXR: Increased left basal and mid lung opacity, likely a combination of a small pleural effusion and a new lingular consolidation. There is no pneumothorax. Bilateral fibrotic changes in the apices, more evident on the right, unchanged. The patient is status post CABG and AVR, with normal post-operatory cardiac mediastinal silhouette. The mediastinal wires and prosthetic aortic valve are intact. [2121-1-2] Echo: PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Preserved [Hospital1 ]-ventyricular systolci fuunction. 2. A bio-prosthesis is visualized in the aortic position, well seated and stable, good leafflet excursion. 3. Peak trans-aortic valvular gradient is 11 mm Hg. 4. No other change [2121-1-1] Carotid U/S: Right ICA with no stenosis. Left ICA stenosis 40-59%. [2121-1-1] Chest CT: 1. While there is biapical scarring, much more pronounced on the right, indicative of previous tuberculosis, there is also multifocal infiltration in both upper lobes, on the right in the posterior segment, remote from the apical scarring, and there is also bronchiolitis and peribronchial inflammation in the lingula and right upper lobe anterior segment, respectively. All this points to the need to exclude active mycobacterial tuberculosis as well as non-tuberculous mycobacteria and in the case of the more consolidative abnormality, active bacterial pneumonia. 2. Moderately-severe emphysema. 3. Severe aortic valvular and atherosclerotic coronary calcification. 4. Small hiatus hernia. 5. Mild narrowing, right upper lobe bronchus attributable to anatomic distortion because of upper lobe retraction. [2121-1-1] 08:15PM BLOOD WBC-8.0 RBC-4.45* Hgb-13.5* Hct-40.9 MCV-92 MCH-30.2 MCHC-32.9 RDW-12.8 Plt Ct-313 [2121-1-9] 06:20AM BLOOD WBC-10.7 RBC-3.37* Hgb-10.1* Hct-30.8* MCV-92 MCH-30.0 MCHC-32.8 RDW-13.8 Plt Ct-313 [2121-1-1] 08:15PM BLOOD PT-12.4 PTT-27.7 INR(PT)-1.0 [2121-1-9] 06:20AM BLOOD PT-16.6* INR(PT)-1.5* [2121-1-1] 08:15PM BLOOD Glucose-95 UreaN-13 Creat-1.2 Na-139 K-4.0 Cl-99 HCO3-29 AnGap-15 [2121-1-8] 05:35AM BLOOD Glucose-133* UreaN-33* Creat-1.0 Na-140 K-3.6 Cl-104 HCO3-27 AnGap-13 [2121-1-1] 08:15PM BLOOD ALT-24 AST-43* LD(LDH)-283* AlkPhos-67 TotBili-0.5 [2121-1-7] 03:34AM BLOOD Calcium-8.6 Phos-1.6* Mg-2.2 Brief Hospital Course: Mr. [Known lastname 7749] was transferred to [Hospital1 18] following his cardiac cath which revealed severe 3 vessel disease. In addition he had severe aortic stenosis. He was appropriately medically managed and work-up for cardiac surgery. Which included usual lab work, carotid U/S, Echo and Chest CT. On [1-2] he was brought to the operating room where he underwent a coronary artery bypass graft x 3 and aortic valve replacement. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Mr. [Known lastname 7749] was placed in isolation room d/t findings on x-ray/chest ct which were concerning for TB. His sputum was cultured for AFB. Eventually the findings were found to be old (on previous x-rays for approximately last 10 years) and he had three negative AFB samples. Also during his post-op course he had multiple episodes of rapid atrial fibrillation. He was appropriately treated and was discharged in sinus rhythm with Amiodarone and Coumadin. Chest tubes and epicardial pacing wires were removed per protocol. He was transferred to the telemetry floor for further care on post-op day 5. On post-op day 6 there appeared to be a new left lung consolidation and he was started on antibiotics. On post-op day 7 he was doing well and discharged to rehab for further care. He will continue antibiotics for a total of 14 days. Medications on Admission: Alendronate 70mg q week, Calcium +D 600-200mg qd, MVI qd, metamucil, zocor 20mg qd Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days. 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Start [1-15]. 400mg QD for 7 days. Then 200mg QD until stopped by cardiologist. 10. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day: Please adjust dose for INR of [1-21].5. Discharge Disposition: Extended Care Facility: [Location (un) 38640] [Doctor Last Name ] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Aortic Stenosis s/p Aortic Valve Replacement Post-op Atrial fibrillation ?Post-op Pneumonia Past medical history: Colonic polyp Osteopenia Carotid artery stenosis Cataracts Past Surgical History: s/p R CEA [2102] s/p hydrocele repair s/p cataract surgery in [2116] s/p inguinal hernia repair Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Continue Amiodarone and Coumadin until stopped by Cardiologist (for post-op Atrial Fibrillation) Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) 914] in 2 weeks [Telephone/Fax (1) 170] Primary Care Dr. [Last Name (STitle) 74449] in [12-21] weeks Cardiologist Dr. [Last Name (STitle) 39975] in 4 weeks Completed by:[2121-1-9]	[ "4241", "486", "41401", "42731" ]
Admission Date: [2165-2-7] Discharge Date: [2137-2-18] Date of Birth: [2120-9-25] Sex: F Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 104077] is a 44 year-old female with a past medical history significant for cadaveric renal transplantation times two who presented to this institution on [2165-2-7] with complaints of nausea, vomiting, diarrhea and persistent emesis after eating. The patient's first transplantation failed due to chronic rejection. Her second transplant was complicated by ureteral necrosis requiring ............ DICTATION ENDED [Name6 (MD) 1344] [Name8 (MD) 1345], M.D. [MD Number(1) 1346] Dictated By:[Last Name (NamePattern1) 26023] MEDQUIST36 D: [2165-3-20] 07:17 T: [2165-3-21] 10:19 JOB#: [Job Number 104139]	[ "5070", "5845" ]
Admission Date: [2146-5-27] Discharge Date: [2146-6-17] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2777] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2146-5-31] Cardiac Catheterization History of Present Illness: This is an 83 year old female with long standing history of aortic stenosis. She was recently admitted to [Hospital 1562] Hospital with congestive heart failure. She ruled in for an NSTEMI with positive troponins. She required aggressive diuresis and was transfused with multiple packed red blood cells for anemia. She was also treated with antibiotics for an urinary tract infection. A most recent echocardiogram on [2146-5-24] showed an aortic valve area of 0.5cm2 with a peak gradient of 69 and mean of 47mmHg. LVEF was estimated at 55%. There was mild aortic insufficiency. Due to persistent symptoms of congestive heart failure, she was transferred to the [Hospital1 18] for further evaluation and treatment. Past Medical History: - Aortic Stenosis - Recent NSTEMI - Diabetes Mellitus - Peripheral Vascular Disease - s/p Left Popliteal Atherectomy - Hypertension - Dyslipidemia - Crohns Disease - Polymyalgia Rheumatica - History of Giant Cell Arteritis - Glaucoma - Colon Cancer - s/p Colonic Resection and Colostomy Reversal Social History: Quit tobacco many years ago. Denies ETOH. Family History: Denies premature coronary artery disease Physical Exam: Vitals: T 99.3, BP 156/62, HR 67, RR 22, SAT 97% on room air General: elderly female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, 4/6 systolic ejection murmur radiating to carotid Lungs: clear bilaterally Abdomen: soft, nondistended, mild tenderness, normoactive bowel sounds Ext: warm, trace edema, no varicosities Pulses: 1+ distally Rectal: normal tone, guaiac positive Neuro: alert and oriented, no focal deficits Pertinent Results: [2146-5-27] Chest X-ray: There is a focal increased density within the left lower lobe which is nonspecific and may be related to focal pneumonia in the proper clinical setting. There are increased interstitial markings at the bases bilaterally. Cardiomediastinal silhouette is within normal limits. [2146-5-30] Carotid Ultrasound: Less than 40% ICA stenosis bilaterally. [2146-5-27] 10:05PM BLOOD WBC-10.1 RBC-4.13* Hgb-12.7 Hct-37.5 MCV-91 MCH-30.7 MCHC-33.9 RDW-16.7* Plt Ct-354 [2146-5-27] 10:05PM BLOOD PT-13.0 PTT-22.0 INR(PT)-1.1 [2146-5-27] 10:05PM BLOOD Glucose-262* UreaN-29* Creat-1.1 Na-140 K-4.8 Cl-100 HCO3-29 AnGap-16 [2146-5-27] 10:05PM BLOOD ALT-22 AST-15 AlkPhos-34* TotBili-0.9 [2146-5-27] 10:05PM BLOOD Calcium-8.9 Phos-4.4 Mg-2.1 [2146-5-30] 05:21PM BLOOD CRP-39.6* [2146-5-30] 05:21PM BLOOD ESR-24* Brief Hospital Course: Mrs. [Known lastname 72597] was admitted to the cardiac surgical service and underwent routine preoperative evaluation for an aortic valve replacement. Cartoid non invasive studies showed less than 40% stenoses of the internal carotid arteries. She was seen by the dental service who cleared her for surgery after clinical and radiographic examination found no evidence of infection. She was also seen by the GI service who recommended to lower the Prednisone dose to 10mg daily, and found no contraindication for surgery. She eventually underwent cardiac catheterization which revealed a right dominant system with single vessel coronary artery disease. The left main, left anterior descending and circumflex had no angiographically apparent flow limiting stenosis. The right coronary artery was a dominant vessel with a 90% ostial lesion. From a cardiac standpoint, she remained relatively asymptomatic with minimal shortness of breath. During hospitalization, she had a rise in creatinine(peak 1.8) which prompted discontinuation of Lasix and Lisinopril. From a GI standpoint, she continued to experience nausea and vomiting with poor PO intake. She was admitted to the vascular surgery service for chronic mesenteric ischemia. On [6-2], she underwent diagnostic abdominal aortogram and pelvic arteriogram, selective catheterization of the celiac and superior mesenteric artery. A brachial artery puncture with first order catheterization was used x2 and a stent of the celiac and superior mesenteric artery was placed. She experienced post-procedure abd pain and hypotension and was admitted to the ICU. On [6-7] she was intubated for impending respiratory failure secondary to fluid overload. She was extubated for 3 hours and desaturated and was reintubated. She was extubated on [6-8]. She was started on vancomycin on [6-8] for MRSA+ sputum and blood cultures with a recommendation to remain on vanc for 6 weeks. Bronchoscopy was done on [6-9] which she was electively intubated for, which showed secretions and no infective process. She was again reintubated on [6-9] for respiratory distress. CT on [6-9] showed celiac/SMA stents are widely patent. [6-13] TEE no vegetations, EF >55%, severe AS [6-14]: extubated [6-16]: transferred to VICU, placed on regular diet, doing well [6-17]: transferred to floor, PICC line placed, transferred to rehab. ID recommends culture of pts valve during AVR and blood cultures prior to AVR. She will be continued on vancomycin IV for 5 more weeks. Medications on Admission: Alphagan eye gtts, Xalantan eye gtts, Cosopt eye gtts, Aspirin 81 qd, Celexa 40 qd, Folate 1 qd, Glucophage 500 [Hospital1 ], Regular Insulin sliding scale, Lasix 40 qd Levaquin 500 qd, Lisinopril 5 [Hospital1 ], Lomotil prn, Maalox prn, KCL 20 meq [Hospital1 ], Prednisone 20 qd, Protonix 20 qd, Mercaptopurine 50 qd, Synthroid 75mcg qd, Atenolol 12.5 qd, Zocor 20 qd Discharge Medications: 1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Disp:1 Refills:2 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:90 Tablet, Chewable(s) Refills:2 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Disp:1 Refills:2 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 8. 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 9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:1 Refills:2 13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. 14. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO daily () for 3 doses. 15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 5 doses. 16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 5 weeks: hold [6-17], restart [6-18]. 17. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 19. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 21. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Discharge Disposition: Extended Care Facility: [Location (un) 59839] Discharge Diagnosis: Aortic Stenosis Coronary Artery Disease - Recent NSTEMI Diabetes Mellitus Peripheral Vascular Disease - History of Left Popliteal Atherectomy Hypertension Dyslipidemia Polymyalgia Rheumatica History of Giant Cell Arteritis Glaucoma History of Colon Cancer - s/p Colonic Resection and Colostomy Reversal Chronic mesenteric ischemia - s/p Aortic Stenosis Coronary Artery Disease - Recent NSTEMI Diabetes Mellitus Peripheral Vascular Disease - History of Left Popliteal Atherectomy Hypertension Dyslipidemia Polymyalgia Rheumatica History of Giant Cell Arteritis Glaucoma History of Colon Cancer - s/p Colonic Resection and Colostomy Reversal chronic mesenteric ischemia s/p celiac and SMA stent Discharge Condition: Stable Discharge Instructions: Take medications as directed. Call EMS if start to experience chest pain or shortness of breath. Followup Instructions: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 72598] surgeon, call office for appointment ([Telephone/Fax (1) 1504] Dr. [First Name8 (NamePattern2) ] [Name (STitle) ]- call office for a 2 week follow up appointment [Telephone/Fax (1) 67148]	[ "4241", "41071", "4280", "41401", "25000", "4019", "2724", "V1582" ]
Admission Date: [2157-4-23] Discharge Date: [2157-5-11] Date of Birth: [2090-3-24] Sex: M Service: MEDICINE Allergies: Penicillins / Oxycodone Attending:[First Name3 (LF) 3984] Chief Complaint: Transferred from [Hospital 8641] Hospital for MRSA bacteremia, septic knee, respiratory failure Major Surgical or Invasive Procedure: Radial arterial line placement PICC placement History of Present Illness: Mr. [Known lastname 3321] is a 67 yo man with COPD, morbid obesity, OSA, h/o coronary artery aneurysm reparin, osteoartritis with recent B total-knee replacements and septic arthritis who is transferred from [Hospital 8641] Hospital for further management. Mr. [Known lastname 3321] was in his USOH until [3-31] when he underwent his TKR. His post-operative course was complicated by persistant drainage of fluid from his left knee for which he was placed on clindamycin as an outpatient, he then developed C diff colitis. He also developed a stage 4 decubitus ulcer. . He was admitted to an OSH on [4-14] where he was found to have MRSA septic arthritis and C diff colitis. He was documented to be bacteremic with MRSA for much of this time (last blood culture taken on [4-20] was positive 1/4 bottles). He was treated with vancomycin for the knee infection and underwent removal of his L knee arthroplasy and placement of a tobramycin spacer on [4-20] (and decubitus ulcer debridement). Post-operatively he has had continued spiking fevers to 102 and progressive dyspnea. He has had approximately 40-60 lbs weight-gain since his initial surgery and has been on bumex IV for diuresis . His C diff was initially treated with flagyl but he has had persistantly + stool, so this was changed to vancomycin. He denies abdominal pain but has had increasing abdominal distension. . He has had progressive dyspnea, no orthopnea. It appears that he has been treated for CHF exacerbation with IV bumex and was placed on BiPAP at 26/20. The patient much prefers being on BiPAP and has been on it for most of the past 2-3 days. . Currently he complains of severe fatigue, no appetite, thirst, general malaise. He also endorses back and LLE pain. No abdomial pain, nausea, vomiting. Within an hour of being at [Hospital1 18] he was febrile to 101.5 with 1/4 blood cultures positive for GPCs Past Medical History: Obesity OSA on home bipap h/o RCA aneurysm ligation in [2151]; post-op atrial fibrillation. h/o post-operative atrial fibrillation Stroke (1.5 yrs ago) with L-sided weakness (now resolved) COPD on home inhalers Osteoarthritis Hypertension Social History: Married, from NH, lives with wife. Retired product manager in a steel manufacturing plant. Enjoys playing blues harmonica. Former heavy smoker (quit 18 yrs ago). No EtOH or drugs. Family History: Non-contributory Physical Exam: T 100.7 BP 129-76 HR 114 RR SaO2 95% on 4L n/c CVP 3 when upright, 24 when supine General: obese man, uncomfortable, NAD HEENT: MM dry. PERRL, EOMI CV: tachycardic, unable to auscultate heart sounds. Lungs: In moderate distress, using accessory muscles and pursing lips. CTA B, poor airmovement. No wheezing, rales, ronchi. Abdomen: very distended and tympanic, non-tender, hypoactive bowel sounds. No rebound, guarding, or masses. flexiseal with brown loose stool Back: large decubitus ulcer, 3-cm deep area of debridement, scar tissue and scab ontop of granulation tissue. surrounding superficial extremities: L knee wrapped. R knee with sutures, no erythema or drainage. 3+BLE edema Pertinent Results: Admission labs: [2157-4-23] 10:29PM WBC-10.2 RBC-3.53* HGB-10.1* HCT-31.5* MCV-89 MCH-28.5 MCHC-31.9 RDW-16.6* [2157-4-23] 10:29PM NEUTS-65 BANDS-9* LYMPHS-13* MONOS-4 EOS-4 BASOS-0 ATYPS-2* METAS-2* MYELOS-1* [2157-4-23] 10:29PM PLT SMR-NORMAL PLT COUNT-374 [2157-4-23] 10:29PM GLUCOSE-156* UREA N-19 CREAT-1.2 SODIUM-140 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-26 ANION GAP-10 [2157-4-23] 10:29PM CALCIUM-6.7* PHOSPHATE-3.0 MAGNESIUM-2.1 [2157-4-23] 10:29PM PT-32.2* PTT-35.0 INR(PT)-3.3* . Discharge labs: [2157-5-5] 03:49AM BLOOD WBC-8.0 RBC-3.29* Hgb-9.0* Hct-29.1* MCV-89 MCH-27.5 MCHC-31.1 RDW-16.8* Plt Ct-434 [2157-5-5] 03:49AM BLOOD PT-27.0* PTT-29.3 INR(PT)-2.7* [2157-5-5] 03:49AM BLOOD Glucose-142* UreaN-40* Creat-1.4* Na-146* K-4.4 Cl-107 HCO3-31 AnGap-12 [2157-5-5] 03:49AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.5 [2157-4-28] 08:30AM BLOOD ALT-17 AST-36 LD(LDH)-341* AlkPhos-103 Amylase-43 TotBili-0.3 [2157-4-23] 10:29PM BLOOD proBNP-1176* [2157-4-24] 04:38AM BLOOD calTIBC-185* VitB12-1808* Folate-13.0 Ferritn-240 TRF-142* [2157-4-30] 02:33AM BLOOD TSH-1.1 [2157-5-3] 05:01AM BLOOD CRP-27.7* [2157-5-3] 05:01AM BLOOD ESR-17* . Studies: KNEE (2 VIEWS) BILAT [2157-4-24] RIGHT KNEE: Three views of the right knee demonstrate tricompartmental prosthesis in standard position, with no evidence of loosening or hardware failure. Corticated osseous density inferolateral to distal femur is likely related to prior injury or surgery. A 6-mm opacity within the knee joint is may potentially represent a foreign body. There is an apparent suprapatellar joint effusion. LEFT KNEE: Hardware has apparently been removed. A large, 13.6 cm x 7.2 cm diameter lobulated opaque structure extends from the distal femoral shaft to the proximal tibia and has likely been surgically placed for the provided history of washout for treatment of septic left knee joint following knee replacement procedure. The tibiofemoral joint space has apparently been obliterated. Apparent diffuse soft tissue swelling is present within the left lower extremity based upon increased thickness of the soft tissues compared to the contralateral right extremity. Additionally, the cortical margin of the posterior-inferior aspect of the left femur is not well demonstrated. The possibility of osteomyelitis cannot be excluded. Direct comparison to previous outside postoperative radiographs would be helpful. Alternatively, if clinical suspicion is high, nuclear medicine white blood cell scan or MRI could be considered. . US EXTREMITY NONVASCULAR [2157-5-2] FINDINGS: Small amount of fluid was noted anterior and superior to the patella. No definite fluid collection was noted above the patella to suggest knee joint effusion. Moderate amount of edema was noted within the anterior thigh region. . CHEST (PORTABLE AP) [2157-4-23] IMPRESSION: 1. Limited radiograph due to large body habitus and portable technique. Apparent widening of mediastinum which may reflect prominent vascular structures, but standard PA and lateral views are suggested for more complete assessment of this finding as well as a peripheral pleural opacity in the left mid lung, when the patient's condition permits. 2. Likely volume overload. 3. Bilateral effusions. . CHEST (PORTABLE AP) [2157-5-3] FINDINGS: AP single view obtained with patient in sitting semi-upright position is analyzed in comparison with a similar preceding study of [5-1]. There is status post sternotomy, and there are at least three small surgical clips identified in the right-sided mediastinum overlying the heart shadow. There is moderate cardiomegaly, and a rather marked widening and elongation of the thoracic aorta is present. This coincides with a congestive vascular pattern and diffuse hazy densities at the lung bases and most likely representing bilateral pleural effusions. There is no evidence of pneumothorax. The technical quality of the portable chest examination suffers from the patient's extreme dimensions (morbid obesity), and discrete local pneumonic infiltrates cannot be identified with certainty. Review of the total seven portable chest examinations from [4-23] through [5-1] is performed. All these studies suffer from difficulties to penetrate the lungs appropriately. It is noted that a previously present right jugular vein approach central venous line has been removed. Also a previously identified right-sided PICC line remains in unchanged position. Rather prominent distended azygos vein is compatible with hypervolemia as mentioned on previous reports. IMPRESSION: Stable chest findings are seen on technically limited single view exposures of this very obese patient. Brief Hospital Course: Assessment and Plan: 67 yo man with COPD, morbid obesity, OSA, osteoartritis with recent B total-knee replacements who is transferred from OSH with MRSA septic arthritis s/p removal of hardware in L knee, C. diff colitis, volume overload. . # Respiratory failure: This is multifactorial with components of 1) OSA on bipap at home, 2) obesity hypoventilation, 3) COPD exacerbation (sig. wheezing on exam), 4) volume overload (reported 50 lb weight gain in last month, anasarca on exam), and possible pneumonia (difficult to image due to obesity). Patient has been reportedly ruled out for PE at OSH and is anticoagulated on coumadin for atrial fibrillation. For his OSA, his bipap setting was adjusted to 25/21 with 4 L O2. For COPD, he was started on solumedrol on [4-29] and was gradually tapered; he has two remaining days of prednisone 10 mg daily. He was also started on monteleukast. He is also on standing albuterol/ipratropium nebulizers and home inhalers. For his volume overload, he was aggressively diuresed with Lasix. For empiric coverage of pneumonia, he was started on ceftazidime, quickly defervesed, and thus completed a 10-day course prior to discharge. For waxing and [Doctor Last Name 688] mental status and hyercarbia, patient was placed intermittently on BiPAP. . # L prosthetic knee infection/bactermia with MRSA: Orthopaedics was consulted and recommended outpatient follow up with his original orthopedic surgeon. An ultrasound of the left knee did not show any collection amenable to drainage. Blood cultures at [Hospital1 18] are all negative/ngtd. He had a TTE that did not show vegetations; a TEE was not pursued as there was low suspicion for endocarditis and patient would require 6 week course of vancomycin regardless of result. He was continued on vancomycin with a goal trough of 15-25; last day of planned course is [5-27]. He will follow up with the [Hospital ] clinic at [Hospital1 18] as an outpatient. He remains non-weight bearing on his left lower extremity and should wear his knee immobilizer at all times. Sutures remain intact and he will need to follow-up with his Orthopaedic Surgeon at [Hospital 8641] Hospital for further care plan. . # C. diff colitis: Pt was transferred on vancomycin therapy. Pt tested negative for C. diff toxin on admission. He was started on IV flagyl and transitioned to PO. His diarrhea had resolved by discharge. He is to continue flagyl to complete an additional two week course following completion of his vancomycin course. . # Acute renal failure: This occurred in the setting of diuresis with a UNa <10, 11 hyaline casts. He is likely intravascularly dry. No urine eos. Cr slowy improved to 1.3 by discharge. Medications were renally dose (vancomycin). . # Delirium: Patient's mental status waxed and waned throughout hospital course, likely related to worsening hypercarbia in the setting of COPD and OSA. Sedating medications were avoided. On [5-8] he was noted to have acute mental status changes in the setting of high-normal pCO2; a 25 mcg fentanyl patch that had been placed for pain control was removed, and his mental status quickly improved. . # Acute diastolic congestive heart failure/extravascular volume overload: Pt has no clinical history of CHF and BNP was measured at 1176. On exam, pt does have significant 3rd spacing, likely compounded by hypoalbuminemia. He did not have proteinuria on U/A. Patient was 21.5 liters negative for length of stay at [Hospital1 18]. On day of discharge, his lasix dose was reduced from 80 mg [Hospital1 ] to his home dose of 40 mg [Hospital1 ]. He should continue to be diuresed with a goal fluid balance of 1 liter negative for at least the next 7 days. Electrolytes should be carefully monitored with diuresis. . # Sinus tachycardia: This was initially thought to be due to intravascular depletion as pt c/o thirst and had dry mucous membranes; however, his HR did not respond to IVF boluses. He remained tachycardic throughout his entire hospital course although his heart rate did improve to the low 100-110 range. Etiology of his tachycardia is presumed multifactorial. . # Atrial fibrillation: Pt remained in sinus tachycardia while in house. His coumadin was adjusted to INR goal of [1-16]; he is currently on coumadin 3 mg daily (down from home dose of 7 mg daily) due to concurrent abx dose. If patient goes into a. fib with RVR, calcium channel blocker is recommended over beta-blocker due to significant bronchospasm. INR will need to be closely monitored with coumadin dose adjusted during and after completion of antiobiotic course. . # Decubitus ulcer, stage 4: This is s/p debridement at [Hospital 8641] Hospital and did not appear grossly infected. Per report, there was no evidence of osteomyelitis. This was followed by wound care nursing with dressing changes as per detailed discharge instructions. Wound was cultured and positive for VRE. . # Anemia: This is likely combination of blood loss from OR procedures and bone marrow suppression from infection. Vit b12/folate levels WNL. Iron studies were consistent with anemia of chronic disease. Hemolysis labs were neg. HCT is stable at 29. . # Code status: Full. . # Access: midline(1 lumen), placed by Interventional Radiology at [Hospital1 18] on [2157-4-26]. Medications on Admission: MEDICATIONS ON TRANSFER Vancomycin 250mg po Q6 hrs vancomycin 1.25g IV Q18 hrs aztreonam? 2gm IV Q? paxil 20mg po daily potassium 20meQ po bid coumadin 7mg po daily MVI bentyl prn pain metoprolol 5mg IV prn tylenol 650mg po prn protonix 40mg po bid rifampin 300mg po bid duoneb zinc bumex 2mg IV q 8 . HOME MEDICATIONS ambien, nystatin, acidophilus, foradil, spireva, zyrec, lasix, micro K, zinc, MVI, celebrex, asmanex, MS contin, tylenol, humibid-LA, nexium, Lopid, Nasonex Discharge Medications: 1. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed. 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please give after evening dressing change. 11. Megestrol 400 mg/10 mL Suspension Sig: One (1) PO BID (2 times a day): [Month (only) 116] d/c after patient regains appetite and resumes normal caloric intake. 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 18. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale Subcutaneous qACHS. 19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Continue for two weeks following completion of vancomycin course; end date [6-10]. 21. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime: Target INR [1-16]. 22. Vancomycin 500 mg Recon Soln Sig: Seven [Age over 90 1230]y (750) mL Intravenous Q 12H (Every 12 Hours): end date [5-27]. 23. BiPAP mask ventilation Sig: apply mask at bedtime: Settings 25/21. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: MRSA bacteremia Septic joint COPD Hypoxic hypercarbic respiratory failure Clostridium difficile colitis Delirium Stage IV decubitus ulcer CHF exacerbation Chronic renal insufficiency Pneumonia Discharge Condition: A&Ox3, HR 110s, BP 114/70 Discharge Instructions: You were admitted for a infected left knee with MRSA bacteremia. You were treated with the antibiotic vancomycin. You will need to continue this antibiotic for a total of 6 weeks, ending on [5-27]. You will also need to follow up with your Orthopedic surgeon. . You also had respiratory difficulties while you were hospitalized. This is likely due to a combination of entities. For your sleep apnea, you were continued on your bipap machine at settings of 25/21. For your COPD exacerbation, you were started on steroids and you have two additional days remaining in your taper. You also have fluid in your lungs; you have been getting the medication Lasix to help you urinate out extra fluids. Followup Instructions: Please keep the following appointments: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] BLOOD Division of Infectious Disease Phone:[Telephone/Fax (1) 457] Date/Time:[2157-6-1] at 11:30 am . Please also see your Orthopaedic Surgeon Dr. [Last Name (STitle) 35012] at [Hospital 8641] Hospital within the next two weeks. You will need to contact him regarding plans for suture removal. . You have been referred to see a Pulmonologist at [Hospital1 18] who is also a sleep specialist. If possible, please obtain a copy of your prior sleep study and bring this with you to this appointment: DR. [First Name8 (NamePattern2) ] [Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2157-5-13] 9:20 . Finally, please follow up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 35013] within 1-2 weeks following your discharge from the rehabilitation facility. Her clinic number is [Telephone/Fax (1) 35014]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "51881", "486", "5849", "4280", "25000", "42789", "32723" ]
Admission Date: [2117-7-17] Discharge Date: [2117-7-25] Date of Birth: [2060-9-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Transfer from OSH for further work-up of interstitial lung disease. Major Surgical or Invasive Procedure: Intubation. History of Present Illness: 56 y.o. man with hx of osteoarthritis, HTN, hyperlipidemia admitted from [Hospital3 ] hospital where he has been undergoing workup of severe unexplained dyspnea. Patient says that he last felt genuinely well back in [2116-8-22]. At that time he was able to ride a stationary bike for [3-31] miles without undue SOB. In [2116-9-22], he developed a red rash on his forehead, his knuckles, and his shins, he developed aches in his wrists, fingers, shoulders, and knees, R > L, and he began to feel a little tired. Patient thought he might have Lyme and tired to "ride it out" for about 2 months. The tired feeling persisted so he went to his PCP where he tested negative for Lyme. It's somewhat unclear but the rash resolved except for on his fingers and he received a 2 week course of doxycycline. . He next came to medical attention in early [Month (only) 116] when he noticed he had some SOB. He had a CXR and was diagnosed with PNA and treated with 10 days of moxifloxacin. A repeat CXR showed unresolving PNA and he received 10 more days of moxifloxicin. He didn't really improve and in [Month (only) 205] he had an episode while traveling. He says he was walking accross a hotel lobby when he "ran out of gas" and felt like he couldn't support the weight of his suitcase or take another step. He says that he stood there until he was helped by a friend to a seat where he recovered after about 30 minutes. He reports some dry non-productive coughing associated with the episode but felt the SOB was the [Last Name ] problem. [Name (NI) ] became concerned after this episode and saw a pulmonologist. He has since been undergoing work-up for his dyspnea. The work-up was interrupted by a cholecystectomy about two weeks ago. . Pt says that the dyspnea has been very slowly progressive since it began, better in cold environments and when he lays down, worse when sitting, with any exertion, or in humidity; Of note, he says that he has begun to feel slightly better over the past 2-3 days with slightly better air movement. . ROS: 35 # weight loss in past month, increase in constipation (1-2x per day, now QOD or less), no urinary complaints, + nausea, no vomiting, no congestion or nasal discharge; no new rashes Past Medical History: L ACL repair in [8-/2114] Osteoarthritis HTN Hyperlipidemia hx of scarlet and rheumatic fevers as child s/p appendectomy in [2095] Social History: Married, works in retail sales; travels 3 x per year to [State 2690]. Hx of tobacco use 1 PPD x 30 years, quit 7 years ago; Infrequent alcohol x "his whole life"; smoked marijuana in the past but says he never used it regularly; Has had sex with a prostitute ~ 30 years ago but says he used protection and has no other HIV risk factors - has never been tested. Family History: Brother with [Name2 (NI) ]; Mother is 85 without significant disease Physical Exam: VS: Temp: 96 BP: 124/85 HR: 98 RR: 22 O2sat: 100% on NRB GEN: man lying in bed, breathing with slight effort HEENT: PERRLA, EOMI, MMM, neck supple RESP: fine dry crackles in lower [11-23] lung fields, decreased air movement chest CV: regular, nl s1, s2, no m/r/g, + crepitus in chest wall, R>L ABD: soft, NT, ND, + BS, no HSM, well-healed surgical scars EXT: no edema, trace DP pulses, +2 popliteal pulses Skin: + Gottron's sign on hands BL Pertinent Results: Labwork on admission: [2117-7-17] 09:31PM WBC-8.9 RBC-5.09 HGB-13.6* HCT-40.8 MCV-80* MCH-26.7* MCHC-33.3 RDW-14.6 [2117-7-17] 09:31PM PLT COUNT-378 [2117-7-17] 09:31PM PT-10.9 PTT-26.6 INR(PT)-0.9 [2117-7-17] 09:31PM GLUCOSE-129* UREA N-18 CREAT-0.5 SODIUM-130* POTASSIUM-4.8 CHLORIDE-92* TOTAL CO2-31 ANION GAP-12 [2117-7-17] 09:31PM CALCIUM-8.4 PHOSPHATE-2.6* MAGNESIUM-2.8* . Wedge biopsies of lung, right lower lobe: a. Acute and organizing pneumonitis superimposed over a background of chronic interstitial pneumonitis with interstitial fibrosis and honeycomb change. b. Special stains for fungi and pneumocystis are negative. Note: An infectious process (viral or bacterial) superimposed over chronic interstitial lung disease such as usual interstitial pneumonia or fibrosing non-specific interstitial pneumonitis should be considered. . CHEST (PORTABLE AP) [2117-7-24] 12:17 PM CHEST: Compared to the prior chest x-ray of two hours before there is increasing opacities in both lungs against the background of interstitial lung disease. These appearances suggest failure. Right pneumothorax is again seen essentially unchanged in size since the prior chest x-ray. IMPRESSION: New onset pulmonary edema. Brief Hospital Course: 56 yoM with past medical history of osteoarthritis, hypertension, hyperlipidemia admitted from [Hospital3 ] Hospital for further work-up of his severe dyspnea. The patient had interstital lung disease diagnosed by biopsy, likely secondary to dermatomyositis vs. other collagen vascular disease. Patient developed a pneumothorax seven days into his hospitalization and required intubation. On Day 3 of intubation, the patient could not be oxygenated despite FiO2 100% and high pressures with O2sats to 60-70s. Family decided to make him CMO and he was extubated and passed within 20 minutes. Medications on Admission: Lipitor Lisinopril Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Deceased. Discharge Condition: Deceased. Discharge Instructions: Deceased. Followup Instructions: Deceased.	[ "51881", "4019", "2720" ]
Admission Date: [2178-4-21] Discharge Date: [2178-4-30] Date of Birth: [2102-7-16] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Demerol Attending:[First Name3 (LF) 443] Chief Complaint: Transfer for cath Major Surgical or Invasive Procedure: Intubation Central Line Placement PPM placement History of Present Illness: 75 F with COPD, htn, bilateral hip replacements, depression, anxiety transferred from OSH for NSTEMI. She was recently hospitalized at [Hospital3 ] from [4-10] to [4-13] for a R hip dislocation s/p closed reduction. The hospital course was complicated by respiratory failure requiring ICU stay for bilateral PNA and COPD flare. She was discharged to home on a course of doxycycline and steroid taper which she has not finished yet. At home, she really has not been active and on the night of [4-20], she felt so SOB she could not sleep. She had trouble lying flat but did not notice weight gain or leg edema. She also reports having increased clear sputum over the past three days. She was brought to [Hospital3 417] Hospital where initial CXR did not show infiltrate or CHF. She was thought to have another COPD flare and was given Ceftriaxone and steroids. She was thought to be dry in fact and was given fluids initially. Eventually, her cardiac markers came back positive: Troponins 8.8, 8.8 and 4.6, CK 237, 190, 163; MB 56, 43, 40. She was given plavix and lovenox and was transferred to [Hospital1 18] for cath. During cath, she was found to have diffuse disease and she got 4 DES to the LAD. She was hypoxic and got 40 IV lasix and put out 1L. A RHC was not done. She was on a non-rebreather saturating 100% with SBP 110. She was then transferred to the CCU. ROS: Denies chest pain, abd pain, n/v/d. Denies palpitations, LH, syncope. Denies claudications. Denies bleeding disorder or hematachezia or strokes. Past Medical History: COPD on home O2 at one pt, and required intubation in the past Bilateral Hip replacement Wrist fracture Anxiety Depression GERD Social History: Lives with her husband, 40 pack year smoking history, currently still smokes about 5 cigarretts a week. Retired school nurse. Family History: No early family history of CAD. Physical Exam: GEN: A+Ox3, NAD, mildly drowsy but answers questions appropriately HEENT: PERRL, EOMI, OP clear, MMM NECK: JVP to angle of jaw CV: RRR, no M/G/R, PMI at 5th intercostal space midclavicular line, no heaves or thrills PULM: Diffuse crackles and tight air movement, minimal wheezing, no rhonchi. ABD: Soft, NT, ND, +BS EXT: No peripheral edema NEURO: CN II-XII intact, mobilizes all extremities Pertinent Results: Admission labs: [2178-4-21] 07:51PM BLOOD WBC-13.2* RBC-4.24 Hgb-12.7 Hct-39.6 MCV-93 MCH-29.9 MCHC-32.0 RDW-13.9 Plt Ct-221 [2178-4-21] 07:51PM BLOOD PT-16.5* PTT-51.1* INR(PT)-1.5* [2178-4-21] 07:51PM BLOOD Glucose-117* UreaN-18 Creat-0.9 Na-137 K-4.5 Cl-98 HCO3-35* AnGap-9 [2178-4-21] 07:51PM BLOOD CK(CPK)-110 [2178-4-21] 07:51PM BLOOD CK-MB-15* MB Indx-13.6* [2178-4-22] 02:51AM BLOOD ALT-165* AST-68* LD(LDH)-417* CK(CPK)-76 AlkPhos-83 TotBili-0.2 [2178-4-22] 02:51AM BLOOD Triglyc-81 HDL-52 CHOL/HD-2.8 LDLcalc-78 [2178-4-21] 08:30PM BLOOD pO2-166* pCO2-91* pH-7.18* calTCO2-36* Base XS-2 [2178-4-21] 08:30PM BLOOD Lactate-0.6 Micro: Urine cx: negative x2 Blood cx: NGTD x2 RESPIRATORY CULTURE (Final [2178-4-24]): OROPHARYNGEAL FLORA ABSENT. YEAST, SPARSE GROWTH. MOLD, 1 COLONY ON 1 PLATE. Imaging: [2178-4-21] Cardiac cath: Selective coronary angiography of this right dominant system revealed nonobstructive left main and 2 vessel obstructive coronary artery disease. The LMCA had a 40% stenosis distally, extending into the ostium of the LAD. The LAD was a large vessel that supplied the apex, and was diffusely diseased and calcified. There was a 40% ostial stenosis, followed by sequential 70% and 90% stenoses of the proximal and mid LAD. The LCX was totally occluded, and was collateralized distally by the RCA. The RCA had lumenal irregularities up to 30-40% stenosis of the proximal and mid vessel, but was otherwise patent. Patient received 4 DES to the LAD. [2178-4-21] CXR: The heart size is mildly enlarged. The mediastinum is slightly shifted towards the right that might be due to atelectasis or scarring in the right upper lobe. Lungs are overall hyperinflated with start increase in interstitial prominence in both lungs which might represent interstitial pulmonary edema in the presence of emphysema. Round dense approximately 2 cm opacity projecting over the right hilus and may represent calcified lymph node. [2178-4-22] CXR: The ET tube tip is 5 cm above the carina. The cardiomediastinal silhouette is stable with slightly decreased heart size. It might be due to initiation of mechanical ventilation. The lungs remain over- inflated and essentially clear except for minimal opacity at the right base which may represent atelectasis versus small aspiration and linear right perihilar scarring. The previously suspected nodular opacity is not seen on the current study and may be obscured, thus evaluation with follow-up radiograph is recommended. Interstitial edema has resolved. [2178-4-22] ECG: Probable atrial fibrillation with rapid ventricular response rate at 165. Non-specific generalized repolarization changes consistent with tachycardia and/or ischemia. Cannot exclude left ventricular hypertrophy. Compared to the previous tracing of [2178-4-21] normal sinus rhythm with probable left atrial abnormality has given way to atrial fibrillation with rapid ventricular rate and the heart rate has nearly doubled. [2178-4-23] TTE: Moderate regional left ventricular systolic dysfunction (EF 40-45%) with severe hypokinesis of the basal to mid inferior and inferolateral segments and mild hypokinesis of the basal to mid anterior wall and anterior septum. Systolic function of apical segments is relatively preserved. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). (1+) mitral regurgitation. Mild pulmonary artery systolic hypertension. There is no pericardial effusion. [2178-4-26] ECG: Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing sinus rhythm has replaced atrial fibrillation. [2178-4-26] CXR: Severe hyperinflation reflects COPD. Elevation of the minor fissure reflects volume loss in the right upper lobe. Fullness in the right hilus may indicate adenopathy. Routine radiographs are recommended as a first step and to see if additional imaging with CT scanning is indicated. Lungs clear of focal abnormality. Heart size normal. Thoracic aorta is generally large but not focally aneurysmal. No pneumothorax. Brief Hospital Course: 1. NSTEMI: Patient transferred with positive biomarkers but already trending down at OSH. Event possibly from OSH admission when she developed respiratory failure from bilateral PNA, or shortly after discharge. Had diffuse disease now s/p 4 DES to LAD. Medical regimen includes aspirin, beta blocker, plavix, statin. Also encouraged smoking cessation, nicotine patch use. No further complaints of chest pain during hospitalization. Please note that she should have her aspirin dose reduced to 81 mg on [2178-5-19] (i.e. 4 weeks after her cath). [Last Name (un) ] 2. Acute on chronic systolic and diastolic HF: Had crackles all the way up the lung fields bilaterally on admission. She diuresed with good response to lasix 40 IV. EF in [12-6] was 45-50%, now 40-45%. She was continued on her blocker and [Last Name (un) ] (initially held with hypotension but restarted as hypotension resolved). Exam improved with diuresis. 3. COPD: Increased sputum production and wheezing as well as hypercarbia suggestive of COPD flare. Was treated with levofloxacin 5 day course and steroid taper, which she had still been on from her last COPD flare. Sputum culture with yeast and 1 colony of mold, no clinical evidence of infection. She was continued on her inhaler regimen, and started on tiotropium. 4. Afib/Arrhythmias: Pt developed afib with RVR on [2178-4-22] with HR to 150s. She was given IV diltiazem and amiodarone with good response. She had several subsequent episodes (approx 1-2 per day) which responded well to diltiazem IV. She was started on carvedilol which was uptitrated as tolerated, and amiodarone was continued PO. She was started on coumadin without bridge. However, on [2178-4-26] she had a 20 second asystolic episode, likely secondary to vagal episode. Code blue was called but patient quickly recovered blood pressure, heart rate and respirations wihtout intervention. Review of tele appeared to have sinus brady and slowing before 20sec pause then sinus tachy with recovering of pulse. She was transferred back to the CCU, beta blockers, amiodarone and coumadin were held in the preparation for pacemaker placement by EP. The pacemaker was placed on [2178-4-28]. She was treated with 72 hours of antibiotics following. She will have her device checked in the [Hospital ] clinic in one week. 5. Blood pressure: Patient developed hypotension requiring pressors after intubation likely related to intubation. Given initial concern for infection or sepsis since she had a fever on arrival, she was treated with vanc <24 hours. This was discontinued as patient's BP improved after extubation. Her losartan was discontinued since she was noted to be hypotensive, especially post pranidially. Medications on Admission: Prednisone taper (starting on [4-14]: 40mg x2d, 30mg x2d, 20mg x2d, 10mg x3d) Doxycycline Klonipin 0.5 in the AM and q4H PRN Paxil 20 Cozaar 50 Nexium 40 Simvastatin 10 Calcium Vit D 1200/400 Advair 250/50 [Hospital1 ] Spiriva Albuterol PRN MVI Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO q AM. 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 3 doses. 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 16. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months: After 1month change to 81mg daily. 18. Pneumoboots When in bed patient should have pneumboots on for DVT prophylaxis 19. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 6 weeks. 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. COPD Exacerbation 2. NSTEMI 3. Atrial Fibrillation 4. Vagal episode . SECONDARY DIAGNOSES: 1. Bilateral Hip replacement 2. Anxiety Discharge Condition: Stable. Patient is tolerating oral intake and ambulating with assistance. Discharge Instructions: You were admitted to the hospital with shortness of breath. This is most likely related to your COPD and heart disease. For your COPD, you were treated with steroids, antibiotics, and inhalers. For your heart disease, you underwent a cardiac catheterization which demonstrated disease in your heart vessels. You had several stents placed in your heart vessels. While you were hospitalized, you also had an abnormal heart rhythm. This was improved with medications. . your weight increases by 3 lbs. Please adhere to a low salt diet. . We have made the following changes to your medications: These medications were started: - Atorvastatin - Aspirin (please decrease to 81mg after one month) - Plavix - Lasix - Coumadin - Carvedilol - Xopenex (as needed): this is in place of your albuterol inhaler - Cephalexin (three more doses) . These medications were discontinued: - Albuterol - Simvastatin - Losartan . These medications were continued: - Advair - Spiriva - Paxil - Klonipin - Nexium - Calcium and Vit D . Please seek immediate medical attention if you develop chest pain, shortness of breath, light-headedness, dizziness, passing out, wheezing, swelling in your lower extremities, headache, fevers, shaking chills, or night sweats. Followup Instructions: Please follow-up with your primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on after you are discharged from rehabilitation. He can check your coumadin levels using a fingerstick test and will tell you how much coumadin to take. . Please also follow-up with your cardiologist Dr [Last Name (STitle) ] Phone: [Telephone/Fax (1) 62] Date/time: [6-8] at 2:00 pm [Hospital Ward Name 23] Clinical Center, [Location (un) ] [Hospital Ward Name 516], . Pulmonology: Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 80661] Date/time: [5-8] at 10:30am. . Pacemaker follow-up: DEVICE CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2178-5-5] 1:30 [Hospital Ward Name 23] Clinical Center, [Location (un) 436]. [Hospital Ward Name ] Completed by:[2178-4-30]	[ "41071", "51881", "4019", "3051", "42731", "4280", "2724" ]
Admission Date: [2189-5-5] Discharge Date: [2189-5-11] Date of Birth: [2128-6-3] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male, with a history of aortic insufficiency, presenting with increased symptoms of shortness of breath and dyspnea on exertion. The patient was referred by the primary cardiologist, Dr. [Last Name (STitle) 32729], for surgical evaluation at that time. PAST MEDICAL HISTORY: 1) Status post hernia repair, 2) Nasal reconstruction, [2149], [2150], [2151], [2152], 3) Hypertension, 4) History of heart murmur, 5) GERD, 6) Asthma, 7) History of chronic bronchitis. ALLERGIES: The patient develops pink spots on skin with amoxicillin. MEDICATIONS AT HOME: 1) prilosec 20 mg po qd, 2) Univasc 30 mg po qd, 3) desipramine 100 mg po qd, 4) Zoloft 100 mg po qd, 5) Flovent 2 puffs [Hospital1 ] prn shortness of breath, 6) Rhinocort 1 qd, 7) ginkgo biloba 1 qd, 8) multivitamins 1 qd, 9) melatonin 200 mcg po qd. PERTINENT LABS ON [2189-5-11]: White blood cells 7.3, hematocrit 27.7, platelets 227. PT 20.3, PTT 39.9, INR 2.7. Potassium 4.7, magnesium 1.9. PHYSICAL EXAMINATION: The patient is a well-developed, well nourished male in no apparent distress at the time of discharge. HEENT: Sclerae anicteric, mucous membranes moist, no evidence of oral ulcers, cranial nerves II through XII intact, no cervical lymphadenopathy noted. Chest: Clear to auscultation bilaterally. Heart: Regular rhythm and rate, mild systolic ejection murmur with positive click, staples intact, and no evidence of erythema noted. Abdomen: Soft, nondistended, nontender, positive bowel sounds noted. Extremities: There is no lower extremity edema, no evidence of rash noted. SUMMARY OF HOSPITAL COURSE: The patient is a 60-year-old male who underwent an uncomplicated aortic valve replacement (23 mm supra-annular St. [Male First Name (un) 923]) and ascending aorta replacement for severe aortic insufficiency and aortic aneurysm. Postoperatively, the patient was taken to the CSRU, intubated, with stable vital signs, receiving 1 unit of packed red blood cells. On postoperative day #2, the patient's chest tube, as well as sternal wires were discontinued, and the patient was initiated on Coumadin after extubation. By postoperative day #3, the patient was doing well, weaned off of pressors. The decision was made to transfer the patient to the floor. At this time, the patient complained of increased lethargy and fatigue, and positive orthostasis. Chest x-ray, as well as echocardiogram were obtained which revealed no significant change, and the patient received 1 unit of packed red blood cells at this time. Shortly thereafter, the patient's strength, stamina, alertness improved drastically. By postoperative day #4, the patient was ambulating and continued to diurese on lasix. At this time, physical therapy evaluation revealed that the patient had achieved Level 5 activity status, and had met physical therapy goal for discharge. By [2189-5-11], the patient's Coumadin was therapeutic with INR of 2.7, and the decision was made to discharge the patient to home with close anticoagulation follow-up with primary care physician. CONDITION AT DISCHARGE: Good. DI[Last Name (STitle) 408]E STATUS: To home with close anticoagulation follow-up with primary care physician, [Name10 (NameIs) ] [Name11 (NameIs) 702] with Dr. [Last Name (Prefixes) ] in [3-8] weeks. DISCHARGE DIAGNOSES: Status post aortic valve replacement, 23 mm, supra-annular St. [Male First Name (un) 923], and ascending aorta replacement. DISCHARGE MEDICATIONS: 1) percocet 5/325, 1-2 tablets, q 4-6 h prn pain, 2) desipramine 100 mg po qd, 3) sertraline 100 mg po qd, 4) Flovent 2 puffs [Hospital1 ] prn shortness of breath, 5) potassium chloride 20 mEq po q 12 h x 7 days, 6) metoprolol 25 mg po bid, 7) aspirin 81 mg po qd, 8) Prilosec 20 mg po qd, 9) lasix 20 mg po bid x 7 days, 10) Coumadin 1 mg on [2189-5-11], and patient is to have blood check for Coumadin redosing the following day. FO[Last Name (STitle) ]P PLANS: 1) The patient is to follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17103], and patient is to send INR results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17103] for titration of level. 2) The patient is to follow-up with Dr. [Last Name (Prefixes) ] in 4 weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 12370] MEDQUIST36 D: [2189-5-11] 10:53 T: [2189-5-11] 10:01 JOB#: [Job Number 48605] cc:[Last Name (NamePattern1) 48606]	[ "4241", "4019", "53081", "49390" ]
Admission Date: [2181-12-6] Discharge Date: [2181-12-13] Date of Birth: Sex: M Service: [Hospital1 ] CHIEF COMPLAINT: Diabetic ketoacidosis and pancreatitis. HISTORY OF PRESENT ILLNESS: This is a 53-year-old male with a history of human immunodeficiency virus, not on any antiretrovirals secondary to belief that they caused his diabetes. He has a history of hepatitis C also secondary to intravenous drug abuse, and insulin-dependent diabetes mellitus, who presents to the Emergency Department on [12-6] with diabetic ketoacidosis with a pH of 7.09, and fingerstick blood sugar of 400. The patient had complained of polydipsia, polyuria times four days, along with blurry vision and weight loss. He also complained of left lower quadrant and left flank pain over the same period of time which was relieved by urinating. The patient denied fever. He had some chills, though, while he was in the Emergency Department. He denied a cough, denied dysuria, denied diarrhea or changes in bowel habits. PAST MEDICAL HISTORY: (Significant for) 1. Human immunodeficiency virus. The patient is not on any antiretrovirals secondary to his belief that they caused his diabetes. 2. Hepatitis C, again from intravenous drug abuse. 3. Diabetes, but refuses to take insulin. 4. He has bipolar disorder. 5. Hypertension. MEDICATIONS ON ADMISSION: Bactrim, clonidine, azithromycin, Klonopin, Zyprexa, Percocet, Neurontin. SOCIAL HISTORY: He is married times 26 years. His son died, reportedly fell off the [Name (NI) 22639] bridge. He denies smoking, denies drinking. He had intravenous drug abuse for 35 years. He use to work as an animal research technician. He intravenous drugs in [2170]. PHYSICAL EXAMINATION ON ADMISSION: His pulse was 110. His blood pressure was 140/60, and his respiratory rate was 20, with 100% saturation on room air. In general, a thin, chronically ill-appearing male in no apparent distress. HEENT was normocephalic, anicteric. Pupils were equal, round, and reactive to light and accommodation. Chest was clear to auscultation bilaterally. Cardiovascular was tachycardic, but no murmurs, rubs or gallops were appreciated. Abdomen had positive bowel sounds. There was tenderness in the left upper quadrant. No rebound. No guarding. Extremities were thin without edema. His skin revealed diffuse reticular rash which was not pruritic. LABORATORY ON ADMISSION: On admission, a white blood cell count of 7.5, hematocrit 45, and platelets of 108. Sodium of 134, potassium of 4.5, chloride of 99, bicarbonate of 7, BUN of 17, creatinine of 1.3,, and glucose on admission of 434. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit and started on an insulin drip. He did well over the course of two days and was subsequently transferred to the floor. When he was transferred to the floor he was tolerating a clear liquid diet with no obvious source for the abdominal pain which was thought to be pancreatitis, but no source of pancreatitis was found. There was no alcohol history, no gallstones on an imaging study, but he did have increase in enzymes. The patient did well. His diabetic ketoacidosis was resolved. He underwent some teaching as far as the need to take his insulin. He was restarted on the psychiatric medications; he had apparently not been taking them. For his human immunodeficiency virus, no antiretrovirals were taken at present. We did continue the Pneumocystis carinii pneumonia prophylaxis, and he was to be followed by his primary care physician upon discharge. CONDITION AT DISCHARGE: He was discharged in good condition on [2181-12-13]. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Last Name (NamePattern1) 22640] MEDQUIST36 D: [2182-6-18] 13:32 T: [2182-6-20] 05:16 JOB#: [Job Number 22641]	[ "4019" ]
Admission Date: [2182-1-3] Discharge Date: [2182-1-7] Date of Birth: [2099-9-16] Sex: M Service: MEDICINE Allergies: Amoxicillin Attending:[First Name3 (LF) 2840] Chief Complaint: Hypertensive Emergency/UTI Major Surgical or Invasive Procedure: R arm PICC line placed History of Present Illness: The pt. is a 81 y/o M with an extensive past medical history including 3vessel CAD, Parkinson's disease, recurrent Klebsiella ESBL UTIs admitted to MICU from urology clinic with hypertensive urgency. The patient was sent to the ED from [Hospital 159] clinic this pm after being found to have a BP of 220/130 following cystoscopy. Per report, the patient had too much bleeding/clotting in bladder to complete the exam, on routine VS screen was found to have elevated BP. At the time the patient complained of headache and was sent to ED for eval. He denied chest pain, N/V. On arrival to the ED vitals T 98.9, BP 214/116, HR 106, RR 18, 97% RA. He was given labetalol 10mg IV X2 followed by a labetalol gtt. Morphine 2mg IVX1. ECG with TWI laterally. Cardiology was consulted, felt likely strain pattern related to HTN. Also given Vancomycin 1gm IV for concern of cellulitis. He was given 1L NS. . The patient has been evaluated by urology at [Hospital1 18] for hematuria with history of negative cystoscopy, felt related to UTI/prostatitis per notes. The patient does not recall the last time he received antibiotics for UTI. . He has been previously admitted in [2-10] for NSTEMI and hypertensive urgency, treated with nitro and labetalol gtts. . On the floor, the patient stated he was feeling improved but has mild headache. No vision changes. No CP/SOB. His low back pain is at his baseline. He relates he likely missed both his BP and pain medications earlier today pre-procedure. Pt states his lower extremity swelling and skin changes are at his baseline. Denies fever/chills. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies 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: 1)Parkinson's disease 2)3-Vessel Coronary Artery Disease - medically managed-[2180] for NSTEMI 3)Hypertension - hypertensive urgency in [2180] with NSTEMI 4)Hx of recurrent ESBL - Klebsiella Urinary Tract Infection with hx of Sepsis in [11-9] 5)Chronic renal insufficiency (baseline creat 1.2-1.5) 6)Chronic lower back pain 7)h/o melanoma s/p resection 20yrs ago 7)GERD 8)BPH 9)Chronic Systolic Heart Failure, EF~50%. 10)Hyperlipidemia. 11)4.4 X 4.2 X 4.1 cm Left Renal Cyst. 12)Dysautonomia with Syncope. 13)Hx MRSA Pneumonia. 14)Depression. 15)S/P Open Cholecystectomy. 16)Spinal Stenosis partial paralysis. Poor Functional Status Social History: Lives at [Hospital 100] Rehab with his wife. A former\International Relations professor. Walks with a walker. Smoked previously, but quit 45 years ago, had 5 years of 1ppd. Occasional alcohol at special occasions, dinner. No IVDA. Family History: son and daughter have renal cysts. Physical Exam: Vitals - T: 99.1 BP:176/60 HR:76 RR: 18 02 sat:99%RA GENERAL: Pleasant, well appearing in NAD but with evidence of resting tremor HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP=unable to assess [1-7] to habitus LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: 1+ pitting pretibial edema with evidence of chronic venous stasi, 1+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses, seborrheic keratosis of scalp NEURO: A&Ox3. Appropriate. Resting tremor and intention tremor. CN 2-12 grossly intact. Decreased sensation bilateral lower extremities. 5/5 strength throughout. [12-7]+ reflexes, equal BL. Normal coordination. Gait assessment deferred as pt is wheelchair bound but can walk with PT with walker. PSYCH: Listens and responds to questions appropriately, pleasant Discharge Exam: Afebrile, BP 170s/70s, HR 60-80 GENERAL: NAD HEENT: NO JVD, MMM., OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2 LUNGS: CTAB ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: 1+ pitting pretibial edema with evidence of chronic venous stasi, 1+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox3. Appropriate. Resting tremor and intention tremor. CN 2-12 grossly intact. Pertinent Results: [2182-1-3] 03:50PM GLUCOSE-132* UREA N-23* CREAT-1.3* SODIUM-133 POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-32 ANION GAP-12 [2182-1-3] 03:50PM estGFR-Using this [2182-1-3] 03:50PM CK(CPK)-64 [2182-1-3] 03:50PM cTropnT-0.18* [2182-1-3] 03:50PM CK-MB-4 [2182-1-3] 03:50PM WBC-8.8 RBC-3.81* HGB-11.3* HCT-32.5* MCV-85# MCH-29.6 MCHC-34.7 RDW-15.3 [2182-1-3] 03:50PM NEUTS-75.2* LYMPHS-16.4* MONOS-4.6 EOS-3.5 BASOS-0.4 [2182-1-3] 03:50PM PLT COUNT-180 [2182-1-3] 03:50PM PT-12.6 PTT-26.0 INR(PT)-1.1 . [2182-1-3] CT head: No intracranial hemorrahge or other acute intracranial abnormality. URINE CULTURE (Preliminary): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMIKACIN-------------- 16 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFTAZIDIME----------- =>64 R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Cystoscopy Operative Report: Upon entering the bladder, there was quite a bit of hematuria and debris making a full evaluation and pan cystoscopy difficult. There were no obvious filling defects in the bladder, but again the bleeding thorough inspection impossible. Brief Hospital Course: Patient's MICU course: In brief, Mr. [Known lastname 4901] is a 81 y/o M 3 vessel CAD, Parkinson's disease, recurrent Klebsiella ESBL UTIs admitted to MICU with hypertensive urgency. He was admitted with BP 220/130 following cystoscopy performed for hematuria that was too extensive to complete the procedure. He was also at the time c/o of headache, CT head here was normal. He was given labetalol 10mg IV X2 followed by a labetalol gtt. Had trop leak and cards was called for ECG had with TWI laterally. Cardiology was consulted, felt likely strain pattern related to HTN. Urology was consulted felt related to UTI/prostatitis per notes in OMR and recommended treating. Once on the floor, #. Hypertensive emergency - BP better controlled now on floor, ECG with no acute ischemic changes but strain pattern which may have accounted for trop leak but down trending(CKs flat), not likely having ACS. Started lisinopril for BP control. Can continue to titrate up in creatinine is stable. In addition, could try PO hydralazine. Beta blockers avoided because of AV block. He was monitored on tele, continued on Imdur, statin, aspirin, lasix 40mg PO qday. The patient has been started on Norvasc 5mg [1-6] to uptitrated as necessary. Please follow weekly K/Cr for lisinopril adverse effects. #. Hematuria - urology following, concern for ongoing UTI causing hematuria, continued with condom catheter as he was not retaining urine. Started Meropenem for Klebsiells UTI(ESBL) 500mg IV Q8 for 2 weeks ending [2182-1-16]. The patient has an appointment scheduled with Dr. [Last Name (STitle) 3748]. #Chronic venous stasis changes. No current systemic signs of infection. Continued lasix for LE edema. # CHF: mildly depressed systolic function only, pt w/ LE edema on exam but clear lungs, continued home dose lasix #. Anemia - down to 28 - baseline 32-35, microcytic, likely iron deficiency and ongoing losses from hematuria. Pt was hemodynamically stable. Trended hct. # Hyperlipidemia: continued statin # Parkinson's disease - continued Pramipexole, Primidone and carbidopa/levodopa #. Chronic renal insufficiency (baseline creat 1.2-1.5) - at baseline, continued to monitor. #. Chronic lower back pain - at baseline continue home dose oxycontin #. BPH - continued tamsulosin and finasteride Medications on Admission: Coreg 12.5 mg Tab 1 Tablet(s) by mouth twice daily Lasix 40 mg Tab 1 Tablet(s) by mouth daily Imdur 60 mg 24 hr Tab 1 Tablet(s) by mouth daily Sinemet 25 mg-100 mg Tab 1 Tablet(s) by mouth twice a day please alternate with 1.5 tablet dose Aspirin 81mg daily Vit D 1000U daily Colace Finasteride 5mg daily Gabapentin 300mg QHS Omeprazole 20mg daily oxycontin 20mg [Hospital1 ] oxycodone 15mg Q4 PRN PEG every other day Primidone 25mg QHS Senna Simvastain 40mg daily Tamulosin 0.4mg QHS Discharge Medications: 1. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 11. 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. 12. Primidone 50 mg Tablet Sig: .5 Tablet PO at bedtime. 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 19. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 22. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain. 23. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 24. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 9 days: Continue until [2182-1-16]. PICC line may be removed. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: hypertensive emergency hematuria urinary tract infection coronary artery disease Discharge Condition: stable, afebrile, hemodynamically insignficant hematuria, PICC line in place Discharge Instructions: You were admitted for increased blood pressure. You were treated in the ICU and given medications to lower your blood pressure. You were also noted to have blood in your urine and an urinary tract infection. You were examined by the urologists and the hematuria was thought to be from the urinary infection. We started you on two medications to lower your blood pressure and the doctors at rehab [Name5 (PTitle) ] continue to increase this medication as needed to control your blood. These medications are Lisinopril and Amlodipine. We also started you on an IV antibiotics to treat your urinary infection. Meropenem, for a 2 weeks course Do not restart your plavix until instructed to do so by a physician. We are not sending you home on subcutaneous heparin but we recommend pneumoboots to prevent deep venous thrombosis. Subcutaneous heparin should be restarted one hematuria improves. Please continue to follow up with your primary care doctor and the doctors [First Name (Titles) ] [Last Name (Titles) 100] rehab. Please follow with Dr. [Last Name (STitle) 3748] in 3 weeks as scheduled below. If you develop worsening bleeding, chest pain, shortness of breath, headache, dizziness, or back pain, please let your doctors at rehab know. Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2182-3-14] 11:45 Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 3752] Date/Time:[2182-1-31] 9:15 Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 3752] Date/Time:[2182-3-14] 1:00	[ "5990", "2851", "5859", "4280", "41401", "412", "53081", "2724" ]
Admission Date: [2173-12-23] Discharge Date: [2173-12-25] Date of Birth: [2127-3-1] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Tetracyclines Attending:[First Name3 (LF) 562] Chief Complaint: LOC Major Surgical or Invasive Procedure: Intubation History of Present Illness: 45 yo male drug abuser on methadone with AIDS ([5-2] cd4 292, vl>100k, h/o pcp pneumonia and [Month/Year (2) 11395] on HAART) and HCV+ found unconscious at his group home. He was on the couch and unresponsive for 3-4 minutes. EMS administered 1mg of narcan with good response, GCS 3-->14. His pupils were constricted but reactive. On arrival to the ED, he was minimally responsive, he received 1mg of narcan and became a+0x3. He was able to tell the team that he used iv heroine (which he later recounted), chewed two fentanyl patches, and ingested 2mg of klonopin. He became unresponsive to noxious stimuli, received 4.8mg of narcan and was started on a narcan gtt, intubated and given 50g of charcoal with sorbitol. Toxicology was consulted and felt not opioid overdose, instead likely benzo intoxication with possible narcotic withdrawal. He also received 5liters of NS. Past Medical History: # HIV- Question of compliance with HAART # hcv+- genotype 1 grade 1 hepatic fibrosis on bx [2169] # polysubstance abuse # past apap overdose # etoh related pancreatitis # DTs # CAD- s/p lcx stent [11-29], normal ef on echo # neurogenic bladder # hiv nephropathy- cr as low as 0.8-1.0 and as high as 7 in [2172] # herpes # zoster- [11-1] treated with acyclovir # peripheral neuropathy- likely [12-30] HIV # depression or anxiety given on zoloft in past and maybe currently Social History: Lives in group home. h/o EtOH and heroin use, though denies any use currently. No longer on methadone maintenance. Family History: NC Physical Exam: t96.1, p53, 96/57 (map 72), 100% on [4-1], fio2 40% Opens eyes to voice and squeezes hand. Pupils dilated but reactive. Neck Supple. Intubated. Brady s1/s2 CTA anteriorly Soft, +bs, no hepatomegaly, vertical scar to right side of umbilicus, and small surgica appearing scar in rlq No peripheral edema, no interdigitary injection sites, abreasions on shins, +dp and pt pulses bilaterally Pertinent Results: Labs on admission: WBC 8.0, Hgb 14.7, Hct 41.9, MCV 86, Plt 151 (DIFF: Neuts-52.6 Lymphs-37.7 Monos-6.2 Eos-3.0 Baso-0.5) Na 135, K 5.1, Cl 100, HCO3 19, BUN 20, Cr 3.1, Glu 79 Albumin 2.9, Ca 7.9, Phos 3.9, Mg 1.3* ALT 16, AST 32, AP 128, TBili 0.4, Amylase 92, Lipase 37 CK(CPK) 236, CK-MB 5, cTropnT <0.01 Serum Osm 276 serum tox screen: TCA+ urine tox screen: benzo +, negative opioids but did not check for fentanyl U/A: 1.010, 5.0, 30 prot, rare bacteria . Labs on discharge: WBC 4.5, Hgb 12.6, Hct 36.5, MCV 90, Plt 121 PT 11.2, PTT 27.8, INR(PT) 0.9 Na 137, K 4.1, Cl 108, HCO3 22, BUN 14, Cr 1.3, Glu 80 Ca 8.1, Phos 2.9, Mg 2.0 . Imaging: EKG [2173-12-23]: NSR @65bpm, nl axis, normal intervals, Qtc-420 unchanged except for Qtc 400 [7-2]. . CXR [2173-12-23]: AP single view of the chest has been obtained with the patient in supine position and is analyzed in direct comparison with a similar study obtained 1-1/2 hours earlier during the same day. The patient is now intubated. The ETT is terminating in the trachea, some 6 cm above the level of the carina. An NG tube has been passed, reaching well the fundus of the stomach. There is no pneumothorax or any other placement related complication. In comparison with the next preceding study, diffuse lateral pulmonary densities have developed and progressed significantly since the previous study obtained 1-1/2 hours earlier. The most likely explanation is CHF or perhaps fluid overload as the heart shadow does not identify marked cardiomegaly. . CT head [2173-12-23] :There is significant limitation of the study secondary to patient motion, but there is no evidence for intracranial hemorrhage. The [Doctor Last Name 352]-white matter junction is distinct. The ventricles, sulci, and cisterns demonstrate no effacement. There is no mass effect or shift of normally midline structures. The osseous structures are unremarkable. The visualized paranasal sinuses are clear. The mastoid air cells are well pneumatized. . CXR [2173-12-24]: AP chest radiograph shows endotracheal tube and nasogastric tube in stable position. The cardiac and mediastinal contours appear unchanged. Again seen are increased bilateral pulmonary densities consistent with CHF or fluid overload, unchanged from prior study. . Brief Hospital Course: 46 yo male with likely fentanyl overdose and benzo withdrawal vs. intoxication, s/p intubation for airway protection. . # Altered mental status: His mental status began to clear in the ICU after administration of narcan and activated charcoal. Intoxication with methylene or ethylene glycol were ruled out, as was hepatic encephalopathy. Toxicology was consulted to help in his management. Once his sedation (propofol) was weaned, he was able to be extubated and his mental status appeared to be back to his baseline. He was restarted on his outpatient medications which include klonopin, zoloft, elavil, neurontin and fentanyl. He was also given thiamine/folate/MVI for h/o EtOH abuse. Social work was consulted to address the patient's substance abuse issues and he noted that he has strong support system in place, through the [Hospital1 778] Health Clinic and AA. . # Anion gap metabolic acidosis: On admission, Mr. [Known lastname 429] had an AG metabolic acidosis, most likely from ARF. Ingestion of another toxin or alcohol was ruled out, EtOH was negative, salicylates were negative, and his lactate was normal (1.1 - 1.2). The AG acidosis resolved w/ the administration of IVF and his AG was down to 11 on discharge. . # ARF: Urine lytes were checked and were c/w prerenal etiology (FeNa 0.41%). He demonstrated a quick improvement in Cr w/ IVF which also supported that diagnosis. Urine eos were negative, so AIN was ruled out. IVF were discontinued once he was tolerating adequate POs. His Cr was down to 1.3 prior to discharge. . # AIDS: His HAART was held until [12-25] when his PCP could confirm his regimen. He is currently not on any PCP [Name9 (PRE) ] as he is allergic to Bactrim, but he and his PCP will discuss starting dapsone as an outpatient. . # FEN: Once extubated, he was given a regular diet. He was continued on IVF until his Cr came back to baseline. His electrolytes were checked daily and were repleted prn. . # PAIN: Pt has chronic pain, likely from HIV-related peripheral neuropathy. He was restarted on his outpatient regimen of gabapentin, amitryptyline, and fentanyl once he was transferred to the floor. On discharge, it was advised that he follow-up with the acupuncture clinic again to attempt to address his chronic pain needs. . # PPX: Heparin SC, bowel regimen, thiamine/folate/MVI. . # ACCESS: Peripheral IV. . # CODE: Presumed full code. . # DISPO: To home. Medications on Admission: listed by ED- but unsure if these are his real meds elavil zoloft epivir viread sustiva crixivan lipitor atenolol lisinopril neurontin fentanyl patches methadone novair Discharge Medications: 1. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day. 3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Gabapentin 800 mg Tablet Sig: Three (3) Tablet PO twice a day. 14. Amitriptyline 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Benzodiazepine and fentanyl overdose Acute renal failure Urinary retention . Secondary diagnosis: HIV Hepatitis C h/o polysubstance abuse CAD Discharge Condition: Good. Able to urinate on his own. Afebrile, BP 128/90, HR 76. Discharge Instructions: 1. Please follow up with your PCP or go to the nearest ER if you develop any of the following: fever, chills, chest pain, shortness of breath, difficulty breathing, worsening pain, rash, nausea, vomiting, or any other worrisome symptoms. 2. Please take all your medications as prescribed. 3. Please follow-up with your PCP in the next two weeks. Followup Instructions: 1. Please follow up with Dr. [Last Name (STitle) ] as previously scheduled. It is important that you follow-up with her to continue on your HAART regimen and to follow up on your renal failure. 2. Please follow up with [First Name11 (Name Pattern1) 674] [Initial (NamePattern1) ] [Last Name (NamePattern4) 13146], PA on [2173-12-29] at 1:00pm. Phone:[Telephone/Fax (1) 2422] 3. Please follow up with AA and the acupuncture group at [Hospital1 778*].	[ "2762", "5849", "41401", "V4582" ]
Admission Date: [2181-11-20] Discharge Date: [2181-11-23] Date of Birth: [2142-9-14] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3984] Chief Complaint: altered mental status, hemiplegia Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Ms. [Known lastname ] is a 39-year-old woman with a history of endometrial cancer with recently discovered poorly differentiated lesion to the right femur, s/p open reduction internal fixation on [2181-11-1] on prophylactic lovenox therapy presented with altered mental status and hemiplegia. [Last Name (un) ] was found at her facility tonight unreponsive and hemiparetic on the left with severe weakness, was at her baseline two hours prior. . Of note patient was recently hospitalized from [Date range (2) 100063] with episode of chest pain. No clear source was identified, however patient was noted to new metastatic lesions of the lung, femur, and adrenals on imaging. She was noted to have hypercalcemia which was managed with pamidronate. She completed her outpt workup for RLE mass which underwent open reduction and internal fixation. She was subsquently started on carboplatin, received one dose, with plans to follow up as outpt for [Doctor Last Name ]/taxol tx. She subsquently underwent 5 rounds of radiation tx to her right femur for pain control. Palliative care was also consulted for assistance with pain management. . In the [Hospital1 18] ED, vital signs were stable. Pt was noted to be drowsy with left sided hemiplegia, tachycardia, and RLE edema. Exam with L sided weakness, with some resistance to gravity. She was able to follow simple commands, alert and oriented to self and month. Code stroke was called at 2:53A. Due to initial concern for septic emboli from her surgical site she was treated with 1gm Vancomycin. CT head demonstrated multiple hyperdense lesions with surrounding edema thought to be hemorrhagic conversion of mets. Neurology will follow. Ortho also consulted for evaluation of RLE edema, thought to be related to recent surgery. RLE Xray with no acute pathology. LENI showed no DVT, CTA also ruled out PE. Compartment syndrome was thought to be highly unlikely. Vital signs on transfer HR 116 BP163/97 O2 sat 100% RA. . . On the floor, pt is very somnulant and not able to respond to questions. Past Medical History: Onc: - TAH/BSO/Lymphadenectomy on [2181-2-19] that revealed FIGO stage I, grade [2-8] endometrioid carcinoma. - Imaging from [2181-10-6]: bilateral hilar adenopathy up to 2cm, right adrenal nodule, multiple bilateral lesions in the kidneys, a 1.4 cm subcutaneous soft tissue nodule in the right inguinal region, andmultiple 1-cm right inguinal lymph nodes. 5X5X22 cm right distal femoral mass with soft tissue extension. - Femoral mass pathology poorly differentiated carcinoma "compatible with" endometrial carcinoma. -Hypertension -Hypercholesterolemia -DM -Back surgery on L5/S1 in [2173] Social History: She was born in the USA. She is not currently working. She has never smoked and does not drink alcohol or use illicit drugs. She has a mother, sister, and brother, no children Family History: The patient's father died from cancer (type unknown). She has no family history of clotting disorders or heart disease. Physical Exam: ADMISSION EXAM: Vitals: T:100.1 BP:109 P:121/86 R:21 O2:100% RA General: obtunded, unresponsive to sternal rub, nailbed pressure HEENT: Sclera anicteric, pupils small but reactive bilaterally, resists passive eye opening on the right, but not on the left. mouth open. oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses. RLE warm, nonerythemetous, twice the size of LLE, but edema nonpitting. small well healing incisions, at the right trochanter and right lateral femoral head. Neuro: pupils reactive, unable to assess other cranial nerves as pt not responsive, left facial droop. minimal to absent gag reflex. has tone in the RUE, protects arm when dropped, makes some spontaneous movements of the hand and arm. LUE flaccid. no posturing. reflexes minimal bilaterally. babinski equivocal bilaterally. . DISCHARGE EXAM General: More responsive this AM, able to follow commands HEENT: Sclera anicteric, pupils small but reactive bilaterally, oropharynx clear Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses. RLE warm, nonerythemetous, twice the size of LLE, but edema nonpitting. small well healing incisions, at the right trochanter and right lateral femoral head. Neuro: pupils reactive, strength is [5-10] on the right UE. Is not moving RLE due to pain. Cannot move left side. Facial droop on left. Pertinent Results: ADMISSION LABS: [2181-11-20] 01:20AM BLOOD WBC-23.8* RBC-4.44 Hgb-11.5* Hct-33.2* MCV-75* MCH-25.9* MCHC-34.6 RDW-16.4* Plt Ct-520* [2181-11-20] 01:20AM BLOOD Neuts-86.6* Lymphs-9.4* Monos-3.4 Eos-0.3 Baso-0.3 [2181-11-20] 01:20AM BLOOD PT-14.7* PTT-35.0 INR(PT)-1.3* [2181-11-20] 07:31AM BLOOD Glucose-153* UreaN-26* Creat-1.1 Na-135 K-4.5 Cl-100 HCO3-22 AnGap-18 [2181-11-20] 07:31AM BLOOD ALT-3 AST-20 AlkPhos-166* TotBili-0.2 [2181-11-20] 07:31AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.8 Mg-2.3 [2181-11-20] 07:31AM BLOOD TSH-0.56 [2181-11-20] 01:40AM BLOOD Glucose-148* Na-136 K-4.4 Cl-97 calHCO3-24 [2181-11-20] 04:17AM BLOOD Lactate-1.7 . No Labs obtained on discharge. . EEG: This is an abnormal continuous ICU video EEG study because of diffusely suppressed and slow background indicative of a moderate to severe encephalopathy. The frontally predominant delta frequency activity can be seen in toxic/metolic disturbances, but may also be seen in midline or subcortical dysfunction, including hydrocephalus. Thus, clinical correlation is recommended. No epileptiform discharges or electrographic seizures were present in the record. A note was made of sinus tachycardia and occasional premature wide complex beats. . CT head: IMPRESSION: Multiple hyperdense masses involving both the superficial and deep white matter and deep [Doctor Last Name 352] matter, with an area of vasogenic edema in the left occipital lobe. Differential diagnosis is broad, though findings are most likely secondary to hemorrhagic metastases given the clinical history. Other possibilities, though less likely include hemorrhagic infarcts secondary to dural venous or cortical venous thrombosis, spontaneous hemorrhage from complication of anticoagulation (given the recent history of orthopedic surgery), lymphoma or infection. Further characterization with MRI of the brain is recommended Brief Hospital Course: Mrs [Known lastname ] is a 39 y/o f with metastatic poorly differentiated carcinoma who was admitted for AMS and new left hemiplegia found to be likely d/t newly diagnosed malignant metastases to brain (multiple lesions) with hemorrhage into right thalamic lesion. After consultation with the oncology team and patient's family decision was made to focus care on comfort and patient was discharged home with hospice. ALTERED MENTAL STATUS (AMS) ?????? patient was transientently intubatied for airway protection to allow for disgnostic testing. Attributed to multiple brain mets, some with complication of bleeding, and surrounding vasogenic edema. No clinical or EEG evidence for active seizures. Treated with oral steroids and prophylactic anti-convulsant. BRAIN LESIONS ?????? Not previously recognized. Likely metastatic disease from her known poorly differentiated CA of uncertain primary. Evidence for hemorrhage into lesions per CT. Per our oncology team no further theraputic or palliative chemo/radiation can be offered that would be of benefit to the patient. HEMIPLEGIA, LEFT ?????? likely [2-7] to acute bleed into brain mets(consistent with right thalamic lesion and hemmorage seen on CT). Repeat Head CT without significant change. CARCINOMA ?????? metastatic poorly differentiated, unclear etiology. Per oncology team no plans for further chemotherapy. RIGHT LEG SWELLING ?????? recent orthopedic surgery ORIF. No further interventions with Orthopedic service. No evidence for DVT by LE NIVS. Goals of care: meeting was held with patient's family, ICU and Oncology team, per patient's dire condition and family's wishes decision to transition to comfort focused care. Patient was followed by palliative care and is now dicharged to out patient hospice. DISPOSITION -- returned home with hospice services. Discharge Medications: 1. methadone in 0.9 % sod. chlor 1 mg/mL (1 mL) Syringe Sig: 0.6 mg per hour Intravenous continuous via CADD pump: + Bolus 0.2mg every 20 minutes PRN breakthrough pain . Disp:10 100ml vials Refills:0 2. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Fourteen (14) units Subcutaneous at bedtime. Disp:30 ml Refills:0 3. One Touch Ultra System Kit Kit Sig: One (1) kit Miscellaneous four times a day. Disp:1 kit Refills:0 4. Dilaudid concentrate (20mg/ml) Sig: 0.5-1 mL Sublingual q2hr as needed for pain/respiratory distress: Please use 0.5-1mL (10-20mg) q2 hours sublinguially PRN for pain or respiratory distress. Disp:60 mL Refills:0 5. Ativan liquid (2mg/ml) Sig: 0.5 ml Sublingual every six (6) hours: Please use 1mg (0.5ml) sublingually q6hrs. [Month (only) 116] hold for sedation. Disp:30 mL Refills:0 6. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day: [Month (only) 116] hold for loose stools. Disp:30 suppositories Refills:0 7. acetaminophen 650 mg Suppository Sig: One (1) suppository Rectal every six (6) hours as needed for fever or pain. Disp:30 suppositories Refills:2 8. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1) liter Intravenous q nightly: Please run 1 Liter nightly at 100ml/hr over 10 hours. Disp:7 liters Refills:2 9. dexamethasone oral solution (10mg/ml) Sig: One (1) ml Sublingual every eight (8) hours: Please place 1ml sublingual q8 hours. Disp:60 ml Refills:0 10. supplies Please supply with One Touch Ultra testing strips. Dispense 100 strips, no refills 11. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscellaneous every six (6) hours. Disp:100 lancets Refills:0 12. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection five times a day as needed for IV flush: 10cc flush to IV site PRN. Disp:30 syringes Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 3005] Hospice Discharge Diagnosis: Primary: metastatic brain cancer Secondary: endometrial cancer 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: Dear Ms. [Known lastname ], It was a pleasure taking care of you at [Hospital1 827]. You were admitted because you were found unresponsive and with trouble moving the left side of your body. You had a head CT scan here that showed multiple areas of cancer in the brain. You were initially intubated to support your breathing but the breathing tube was quickly removed and you have been breathing well on your own. With the help of your family, we have arranged for you to be able to go home and be comfortable. Please take the following medications: 1. Please use a methadone pump at 0.6 mg per hour Intravenous continuous infusion via CADD pump: + Bolus 0.2mg every 20 minutes as needed for breakthrough pain 2. Please check blood sugars daily and give glargine 14 units for blood sugars >200. Please do not give if sugars are <200. 3. Please use Dilaudid for breakthrough pain control. Use 0.5-1 ml under the tongue as needed for pain every 2 hours. 4. Please use ativan to prevent seizures. Place 0.5ml under the tongue every 6 hours. This may be held if Ms. [Known lastname ] is too sedated and sleepy. 5. Please use bisacodyl 10 mg Suppository daily. This should be held for loose stools. 6. Use acetaminophen 650 mg Suppository every 6 hours as needed for fever or pain. 7. Take dexamethasone 1mL under the tongue every 8 hours. 8. Please take 1 liter of fluid (normal saline) nightly, to be run at 100cc/hr for 10 hours. Followup Instructions: Please follow up with the hospice facility who will be following you at home. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2181-11-23]	[ "25000", "2720", "4019" ]
Admission Date: [2141-5-10] Discharge Date: [2141-5-18] Date of Birth: [2070-4-7] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain and dyspnea Major Surgical or Invasive Procedure: [2141-5-12] 1. Urgent coronary artery bypass graft x3 -- left internal mammary artery to the diagonal, vein graft to the distal left anterior descending artery, and vein graft to the right coronary artery. 2. Aortic valve replacement with a size 23 mm [Doctor Last Name ] Magna Ease tissue valve. History of Present Illness: 71 y/o Hispanic male with PMH significant for PVD, DM, and hypertension who presented with fatigue after walking 2 to 3 blocks. Presented with chest discomfort in upper chest unrelated to activity. ECHO on [2141-4-11] showed mild concentric LVH with EF of 60-65%, sever AS with mean gradient of 53 mm HG and [Location (un) 109] of .63 cm2. Cardiac cath today showed severe AS with mean gradient of 54 mm Hg and [Location (un) 109] of .77 cm2, 50% ostial lesion of RCA, 70% D1 and diffuse disease of LCx. Transferred to [Hospital1 18] for further evaluation and treatment Past Medical History: Coronary artery disease IDDM hyperlipidemia moderate aortic valve stenosis with a valve area of [12-4].2 cm2 psoriasis Social History: The patient lives with his wife in an apartment complex. He is primarly Spanish speaking and denies tobacco, alcohol, or illicit drug use. Family History: N/C Physical Exam: General: NAD, alert, cooperative Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM []x Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade _3-4/6 SEM across precordium_____ Abdomen: Soft [x] non-distended [x] non-tender []x bowel sounds + [x] Extremities: Warm [], well-perfused [] Edema [] _____ Varicosities: None [][12-5]+ left pretibial edema with stasis dermatitis and amputation of rightsecond and third toes Neuro: Grossly intact [x] Pulses: Femoral Right: +1 Left:+1 DP Right:+1 Left:+1 PT [Name (NI) 167]: +1 Left:+1 Radial Right: +1 Left:+2 Carotid Bruit Right:murmur transmits to carotid Left:murmur transmits to carotid Pertinent Results: [2141-5-11] Carotid ultrasound Impression: Right ICA less than 40% stenosis. Left ICA less than 40% stenosis . [2141-5-11] CTA 1. No evidence of aortic aneurysm. No ascending aortic calcifications with calcifications seen only at the level of the aortic valve. 2. Extensive calcifications of the aortic valve itself consistent with known aortic valve stenosis. Extensive coronary calcifications. 3. Right lower lobe 6 mm spiculated nodule that should be reassessed in three months for assessment of stability to exclude the possibility of neoplastic growth. Additional pulmonary nodules mentioned in the body of the report can be reassessed at the same time. [2141-5-12] 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 mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [First Name (STitle) ] was notified in person of the results before surgical incision. POST-BYPASS: Preserved biventricular systolic functin. LVEF 55%. Intact thoracic aorta. The bioprosthetic valve in the native aortic position is well seated and moving well. The peak is 15 and mean is 5 mm of Hg. Trivial MR> . [2141-5-13] Head CT Arterial calcifications and signs of chronic sphenoid sinus inflammation, otherwise normal study. CXR [5-17]: Intact sternomy wires. Aortic valve prosthesis. Unchanged L hemidiaphragm elevation and atelectasis. [2141-5-17] 06:02AM BLOOD WBC-6.4 RBC-3.37* Hgb-9.3* Hct-29.7* MCV-88 MCH-27.7 MCHC-31.4 RDW-13.6 Plt Ct-113* [2141-5-17] 06:02AM BLOOD Plt Ct-113* [2141-5-13] 02:58AM BLOOD PT-15.4* PTT-36.7* INR(PT)-1.4* [2141-5-17] 06:02AM BLOOD Glucose-148* UreaN-21* Creat-1.0 Na-138 K-3.9 Cl-104 HCO3-24 AnGap-14 [2141-5-12] 04:30AM BLOOD ALT-117* AST-133* LD(LDH)-310* AlkPhos-130 TotBili-1.0 Brief Hospital Course: Mr. [Known lastname 13621] was transferred to the [Hospital1 18] on [2141-5-10] for surgical management of his aortic valve and coronary artery disease. He was worked-up in the usual preoperative manner. A carotid duplex ultrasound was obtained which showed less then a 40% bilateral internal carotid artery stenosis. A dental consult was obtained which found no contraindication for surgery after obtaining a Panorex x-ray of his teeth. A chest CT scan was performed which showed no significant aortic calcifications but did note a right lower lobe 6 mm spiculated nodule that should be reassessed in three months for assessment of stability to exclude the possibility of neoplastic growth. Labs showed that he had elevated liver function studies. On [2141-5-12], Mr. [Known lastname 13621] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels and replacement of his aortic valve with a tissue valve. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours he awoke and was extubated. He was noted to have some confusion, hallucinations and somnolence. A head CT scan was obtained which was negative. The stroke service was consulted who suspected a metabolic or possible infectious etiology to his confusion- no acute infection was detected. All narcotics were discontinued and his pain was managed with Tylenol only. Over the next day, his mental status cleared. Aspirin, beta blocker, statin therapy and diabetic management were continued. Mild confusion noted again on POD#4 and Ultram was discontinued.. Confusion improved. POD#5 he went into rapid a-fib and remained in it for several hours, was started on Amio and returned to SR for 24 hours prior to discharge. He failed first and second voiding trial, urology was consulted and it was determined that he would be discharged to home with the foley in place and will follow up with urology as an outpatient. After second foley placement his urine was noted to be cloudy. A UA C&S was sent and he was started on Cipro. Cultures were negative and Cipro was discontinued. He was noted to have some serosanguinous drainage from his mid sternal pole. He was afebrile, CXR showed intact wires, and WBC was normal. He was sent home on no antibiotics and will return for a wound check on [5-23]. He was seen by the physical therapy department and cleared for discharge. By time of discharge on POD #6 he was deemed safe for discharge to home. Follow-up appointments were advised. Medications on Admission: aspirin 81 mg QD, glipizide 5 mg QD, glucophage 1000 mg [Hospital1 ], lisinopril 5 mg QD, metoprolol extended release 50 mg QD Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain/fever RX acetaminophen 325 mg q 6 hours Disp #60 Tablet Refills:0 2. Aspirin EC 81 mg PO DAILY RX Adult Low Dose Aspirin 81 mg daily Disp #30 Tablet Refills:2 3. MetFORMIN (Glucophage) 1000 mg PO BID RX Glucophage 1,000 mg twice daily Disp #90 Tablet Refills:0 4. Simvastatin 20 mg PO DAILY RX simvastatin 20 mg daily Disp #60 Tablet Refills:2 5. Tamsulosin 0.4 mg PO HS RX tamsulosin 0.4 mg bedtime Disp #30 Tablet Refills:0 6. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days Hold for K+ > 4.5 RX K-Tab 10 mEq twice daily Disp #28 Tablet Refills:0 7. Glargine 24 Units Bedtime 8. Amiodarone 400 mg PO BID for 6 more days starting [5-18] then 400mg daily for 1 week, then 200mg daily RX amiodarone 200 mg twice a day Disp #90 Tablet Refills:2 9. GlipiZIDE XL 10 mg PO DAILY RX glipizide 10 mg daily Disp #60 Tablet Refills:2 10. Metoprolol Tartrate 50 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. [Last Name (NamePattern4) 9641] Lopressor 50 mg twice a day Disp #90 Tablet Refills:2 11. Furosemide 40 mg PO DAILY RX furosemide 40 mg daily Disp #7 Tablet Refills:0 12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days Hold for K > RX potassium chloride 20 mEq daily Disp #7 Tablet Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Aortic Stenosis Coronary artery disease Diabetes Peripheral [Location (un) 1106] disease Hypertension post-op urinary retention Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol only Incisions: Sternal - Healing well, no erythema, no tenderness - minimal serosanginous drainage from mid sternal pole Leg Left - healing well, no erythema or drainage. Edema trace lower extremity edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] Keep your urine catheter in place until you are advised by the VNA or your primary care doctor to remove it. 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: The office will call you and schedule the following appointments your Surgeon: Dr. [First Name (STitle) ]:[2141-6-20] at 2:15p Cardiologist: [Doctor Last Name 29070] [2141-6-9] at 8:45a Wound check: [2141-5-23] 10:45 [Hospital 159] Clinic for voiding trial: [Last Name (LF) 5929], [5-25] at 4:00 PM with [Name6 (MD) ] Crohn, NP - Shipiro Building [Location (un) 470] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] in [3-9] weeks *Nodular opacity of CT scan seen on this admission - NEEDS FOLLOW UP CT SCAN IN 6 MONTHS* Scheduled appointments: Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2141-6-2] 9:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2141-6-2] 10:30 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:[2141-5-18]	[ "41401", "4241", "42731", "4019", "2724", "25000", "V5867" ]
Admission Date: [2123-6-11] Discharge Date: [2123-6-21] Date of Birth: [2044-9-20] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 78-year-old male was admitted to [Hospital6 3872] on [6-10], the day prior to admission, after experiencing a syncopal episode at the [Location (un) 12424] Donuts with associated nausea and vomiting. He has no recollection of the event. He was brought to [Hospital6 3873]. The patient stated that he took a sublingual nitroglycerin just prior to the event for feeling woozy. Post procedure, the patient was diaphoretic and had a vagal episode with dropped saturations. Treated by the cardiology fellow at [Hospital3 1280]. He had a STAT chest x-ray also which showed CHF. PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease with a history of myocardial infarction in [2102]. A CT scan of his head was negative by report on the morning of [6-11]. 3. Glaucoma. 4. Non-insulin-dependent diabetes mellitus. 5. Right eye trauma from fall with small lacerations and sutures around the area of his right orbit which was swollen and ecchymotic. 6. Hypercholesterolemia. 7. Myocardial infarction with positive troponins. Cardiac catheterization showed a LAD 85% lesion, a diagonal one 75% lesion, a circumflex 90%, an OM 60% lesion, a 90% RCA lesion, a 75% acute marginal lesion, and a 50% lesion of the PDA. 8. Obesity with a weight of 240 pounds/height of 5 feet 9 inches. MEDICATIONS: Glucophage 500 mg p.o. twice a day, glyburide 5 mg p.o. twice a day, Protonix 40 mg p.o. once a day, Zocor 20 mg p.o. once a day, enteric coated aspirin 81 mg p.o. once a day, lisinopril 20 mg p.o. once a day, atenolol 50 mg p.o. once a day, hydrochlorothiazide 25 mg p.o. once a day. The patient was also on vitamin C and vitamin E and additional eye drops; pilocarpine 1% 1 drop once a day left eye only, Xalatan 0.005% 1 drop in each eye every evening, Alphagan 0.15% 1 drop each eye 3 times a day. ALLERGIES: He has no known drug allergies. LABORATORY DATA PRIOR TO ADMISSION: Hematocrit of 36.2, platelet count of 221, sodium of 139, K of 4.4, BUN of 23, creatinine of 1.4, magnesium of 2.1. Blood sugar that morning prior to transfer was 225. PHYSICAL EXAMINATION: On exam, he was in a normal sinus rhythm with a heart rate of 65% to 75% on O2 nonrebreather at 94% to 96%, a blood pressure of 140 to 170/80, and a respiratory rate of 16 to 24 breaths per minute. HOSPITAL COURSE: He was transferred to [Hospital1 190] from [Hospital3 1280] on the 27th in preparation for coronary artery bypass grafting surgery and was referred to Dr. [Last Name (STitle) ]. On exam on admission, he was in no apparent distress with a blood pressure of 160/80, in sinus rhythm at 75, with a right eye abrasion. He was alert and oriented. No JVD or bruits. His heart was regular in rate and rhythm with no murmurs. His lungs were clear bilaterally. His abdomen was soft and nontender. He had no edema in his extremities and no groin hematoma at his cath site. He was not allergic to any medicines. He has no history of prior surgery. The patient was seen and evaluated by Dr. [Last Name (STitle) ]. It was determined the patient should have a carotid Duplex ultrasound and a neurology consult as well as obtaining the final read of the CT of his head. Vascular laboratory performed a carotid ultrasound on [6-11] which showed a 70% to 80% narrowing of his right internal carotid artery and less than 40% on the left with normal antegrade flow of vertebral's. Please refer to the official report dated [2123-6-11]. On house day 2, he was seen by neurology to evaluate the neurologic event of syncope which was prior to admission at [Hospital3 1280]. They determined it was probably a cardiogenic syncopal event, and they recommended repeating a head CT. If no sign of any bleed, then he cultured be anticoagulated and put on a heart/lung machine and have his operation; which was planned. He was evaluated in the ICU that day and then transferred out to [Hospital Ward Name 121] Two on the 28th. On house day 3, he also had a CT of the chest which showed a 4.3-cm ascending aorta and prior right rib fractures x 2, which was associated with his syncopal fall. He remained in a sinus rhythm at 58. His creatinine remained up slightly from 1.5 to 1.7. His K was stable at 3.7 with a hematocrit of 37.5. His exam was unremarkable. He was given additional potassium for a K of 3.7 with a plan to check his creatinine again in the morning to evaluate the trend in preparation for surgery on Tuesday the 31st. He remained in sinus bradycardia. On house day 4, his creatinine remained stable at 1.7. He was saturating 94 percent on room air with a blood pressure of 184/70. He was given hydralazine for his blood pressure. He remained in sinus bradycardia with occasional PVC. Preoperatively, he was receiving Tylenol for his shoulder pain and rib pain from his fall. He was seen again by Dr. [First Name (STitle) ] [Name (STitle) ] on the 30th and consented for surgery. His baseline creatinine was noted to be approximately 1.4 by Dr. [Last Name (STitle) ]. His creatinine was 1.7 on that day. He was seen and evaluated on the floor by case management on the day prior to his surgery. On house day 5, his creatinine still remained 1.7; and it was determined to delay his surgery another day. His exam was otherwise unremarkable. The patient was also consented by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for the [Last Name (un) 30560] CABG study. He was also seen by Dr. [Last Name (STitle) 27992] preoperatively on the 1st in the morning who evaluated the plan and agreed for a CABG x 4. On the 1st, the patient underwent a CABG x 4 by Dr. [Last Name (STitle) ] with a LIMA to the LAD, a vein graft to the ramus, a vein graft to the diagonal, a vein graft to the PLV. He was transferred to the cardiothoracic ICU in stable condition on a nitroglycerin drip at 0.25 mcg/kg per minute, a propofol titrated drip, and an insulin drip at 2 units per hour. On postoperative day 1, the patient was on CPAP at 40% FiO2. He remained on an insulin drip at 5 units an hour, a lidocaine drip at 2, with a cardiac index of 2.6. He was in sinus rhythm at 73. He was on a Natrecor drip at 0.01 and a nitroglycerin drip at 0.1. He was in no apparent distress. He was moving all extremities. His sternum was stable. A Levophed drip at 0.014. This was weaned off during the course of the day. Lasix diuresis was begun. The chest tubes were discontinued, and he was extubated on the 2nd. On postoperative day 2, he continued with diuresis. His exam was unremarkable. He started beta blockade with Lopressor. His chest tubes were discontinued. His JP drain in his leg was discontinued, and his Natrecor drip was discontinued. He was seen and evaluated by physical therapy and transferred out to the floor after he was extubated and stabilized on the [5-18]. He was switched over to Percocet for pain but was refusing it at the time and had no complaints of pain. After his transfer, he had 2+ pedal edema. His pacing wires were grounded. He had good urine output. His Foley was discontinued that evening. He was encouraged to ambulate with the nurses and the physical therapist. He was also started back on heparin subcutaneously [Company 30561].i.d. He had an episode of rapid AFib in the morning. The Lopressor was increased to 50 b.i.d. but maintained a good blood pressure of 124/72. He was encouraged to ambulate and increase his p.o. intake. His creatinine was stable at 1.6 with a hematocrit of 30.5 and a white count of 9.6. He was saturating 97% on 3 liters nasal cannula. He was started back again also on his oral diabetes medicines. On the 4th, he removed in AFib with a rate of 80. He was also encouraged to use the incentive spirometer. His left leg incisions were clean, dry, and intact. His sternum was stable and clean, dry, and intact. Of note, the patient did continue to have bilateral 2+ lower extremity edema. He continued with Lasix diuresis. He was encouraged to keep his legs elevated when he was not ambulating. His chest dressing was intact. His pacing wires were discontinued, and he was seen and evaluated by Dr. [Last Name (STitle) ] who noted his continued pitting edema in his lower extremities. His blood sugar was slightly elevated. This was covered by a sliding scale regular insulin. He was ambulating on the unit with 1 assist. His creatinine decreased to 1.5. On the 5th, he was also back in a sinus rhythm in his usual sinus bradycardia between the 50s and 60s. His epicardial pacing wires were discontinued on the 5th. His lungs were clear bilaterally without any shortness of breath, and he was saturating 93% on room air. He was speaking in full sentences and was alert and oriented. He was encouraged to ambulate; which he did. He was moving all extremities and was ambulating with minimal assist without any difficulty. DISCHARGE STATUS: On [Last Name (LF) 766], [6-21], he was discharged to home with VNA services with the following discharge diagnoses. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting x 4. 2. Hypertension. 3. Myocardial infarction. 4. Glaucoma. 5. Non-insulin-dependent diabetes mellitus. 6. Right eye and right rib trauma from syncopal event. 7. Hypercholesterolemia. DISCHARGE INSTRUCTIONS: The patient was instructed to follow up with Dr. [First Name11 (Name Pattern1) 3613] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] (his primary care physician) in approximately 1 to 2 weeks post discharge (telephone number [Telephone/Fax (1) 1983]). He was to make an appointment to see Dr. [Last Name (STitle) ] in the office in 4 weeks for his postoperative surgical visit (telephone number [Telephone/Fax (1) 30562]). MEDICATIONS ON DISCHARGE: 1. Potassium chloride 20 mEq p.o. twice a day (for 14 days). 2. Enteric coated aspirin 81 mg p.o. once a day. 3. Colace 100 mg p.o. twice a day. 4. Zocor 40 mg p.o. once daily. 5. Protonix 40 mg p.o. once daily. 6. Brimonidine tartrate 0.15% ophthalmic drops 1 drop q.8h. 7. Latanoprost 0.005% 1 ophthalmic drop at bedtime. 8. Pilocarpine hydrochloride 1% drops 1 drop ophthalmic q.6h. 9. Tylenol No. 3 (30/300) 1 to 2 tablets p.o. q.4-6h. as needed (for pain). 10. Glyburide 10 mg p.o. twice a day. 11. Metoprolol 75 mg p.o. twice a day. 12. Amiodarone 400 mg p.o. twice a day for 7 days; then amiodarone 400 mg p.o. once a day for 7 days; then decrease to amiodarone 200 mg p.o. once a day. 13. Lasix 40 mg p.o. 3 times daily (for 14 days). 14. Glucophage 500 mg p.o. twice a day. DISCHARGE DISPOSITION: The patient was discharged to home with VNA services on [2123-6-21]. CONDITION ON DISCHARGE: In stable condition. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2123-6-21] 10:57:31 T: [2123-6-21] 15:28:30 Job#: [Job Number 30563]	[ "41071", "42731", "41401", "4019", "25000", "2720" ]
Admission Date: [2134-8-18] Discharge Date: [2134-8-22] Date of Birth: [2052-10-10] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 4327] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with drug-eluting stent placement Permanent Pace Maker History of Present Illness: Mrs. [Known lastname 3866] is an 81 y/o female with a h/o HTN, HLD and GERD who presented on [2134-8-17] to the [Hospital3 26615] Hospital ED c/o of chest pressure that radiated to her arms, neck and jaw. The patient had been at home watching TV and lying down in bed. After 45 minutes of chest pressure she went to the ED. She reports a similar episode approximately a week pror that resolved spontaneously after 2-3 hrs. She reports mild SOB with exertion, but not at rest and denies diaphoresis, dizziness or nausea. Of note she had a Cardiolite stress test on [2134-7-9] which was negative for ischemia, at that time she was noted to have an LVEF of 56% by gated study. . Per OSH report her EKG on admission showed left bundle branch block pattern, heart rate 64 beats a minute (which is her baseline from prior EKGs). At OSH ED, troponins were initially .04 (positive at their lab). Pain resolved with SL Nitro and Morphine. In OSH [Name (NI) ] Pt received ASA 325, Lovenox 1 mg/kg, and Statin. . Cardiology consulted that interpreted the situation as UA, recommended trending enzymes, Nitro paste 1 in q4-6H, ASA 325, Lovenox ppx, Low dose BB, Echo, Losartan 40 daily, Atorva 10 daily, Metop 12.5mg po bid, and Cardiac Cath. - Pt received Cardiac cath on [8-17] revealed LAD mid 75% stenosis and 2+ calcification and D2 ostial 50% stenosis, left circumflex mid 30% stenosis, OM3 proximal 40% stenosis, RCA right dominant vessel with mid 30% and distal 20% stenosis and subsequent to cath trop peaked at 0.36. A plan was made to transfer her to [Hospital1 18] for intervention. Overnight on telemetry she was noted to have multiple pauses (third degree AVB and a 7 second pause around 4am). The pauses were thought to be complete heart block and a temporary pacer was placed this morning [8-18] via left femoral vein. It's lower rate limit was 50 with an output of 5. . Pt transfered to [Hospital1 18] cath lab for PCI of LAD(OSH has no ability to perform PCI) and EP eval. . At OSH, Vital signs: T 97.7, BP 115/63, HR 67, RR 20. O2 sat 98% on room air. . Labs and imaging significant for: (1st set) CPK 87, MB 3.6, Troponin I less than 0.03. (2nd set) CPK is 90, MB 8.3, troponin-I 0.04. (3rd set) Troponin-I 0.36 LDL is 137, Na 139, K 4.3, Cl 99, HCO3 30, glucose 123, BUN 28, Cr 1.2. . CXR: WNL per OSH report . EKG (OSH): Sinus arrhythmia with ventricular rate about 64 beats per minute, axis -45, PR interval 0.20, QRS is 0.16; left axis deviation is noted; left bundle branch block is noted. No significant change compared to prior EKGs. . On arrival to the CCU patient was hemodynamically stable in no acute distress: HR = 69, BP = 135/74(90), SaO2 94% . REVIEW OF SYSTEMS On review of systems, she endorses chronic knee pain. She does complain of some epigastric pain at this time, chronic neuropathy, hand and foot. She denies any chest pain at this time, fevers, chills, nausea, vomiting, diarrhea at this time. She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. 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: - Dyslipidemia, - Hypertension - Myalgia with high dose Simvastatin (will confirm with PCP) - [2134-7-9] Cardiolite stress test at OSH which was negative for ischemia. She was noted to have an LVEF of 56% by gated study. - DJD. - Lumbar radiculopathy. - Facet joint hypertrophy. - Spondylolithiasis, Grade I, L4-L5. Laminectomy, lumbar. Trochanteric bursitis. Osteoarthritis. Osteopenia. Herpes Zoster. Cataracts Vertigo GERD Esophagitis Hypertension Hyperlipidemia. s/p Tonsillectomy. s/p Hysterectomy s/p Appendectomy. Social History: She is divorced. She lives with a daughter. CIGS - She is an ex-smoker who quit about 40 years ago. She has a 20 pack-per-year history. ETOH - She drinks one glass of alcohol qday. Family History: Negative for coronary artery disease. Physical Exam: ADMISSION: GENERAL: WDWN elderly female in NAD. Oriented x3. Mood, affect appropriate. Comfortable and appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no visible JVP. CARDIAC: RR, normal S1, S2 is split. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, mild TTP in RUQ. No HSM, No abdominial bruits. EXTREMITIES: No c/c, trace pitting edema in lower extremities with mild tenderness in calves bilaterally. No Erythema redness or palpable cords. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT dopplerable Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT dopplerable DISCHARGE: GENERAL: Very comfortable, in chair, tolerating full diet, communicating appropriately, ambulating on own. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no visible JVP. CARDIAC: RR, normal S1, S2 is split. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Breathing room air. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. - Pacemaker sight with bandage, clean/dry/intact. ABDOMEN: Soft. Feels somewhat "bloated" Non tender, non distended. EXTREMITIES: No c/c, no edema in lower extremities, no tenderness in calves. No Erythema redness or palpable cords. PULSES: Palpable DP/PT Pertinent Results: EKG: 66 bpm, sinus, LAD, PR < .2, QRS ~ .15, LBBB-chronic, I, aVL, V6 . Stress test ([2134-7-9]) The EKG is negative for ischemia. The test is negative for angina. The test is negative for arrhythmia. Cardiolite images have been reported separately. COMMENT: The patient received a total of 41.4 mg of IV Persantine over 4 minutes and followed by an injection of Cardiolite as per protocol. The patient experienced headache and nausea during testing which resolved shortly after receiving 100 mg of IV aminophylline. Heart rate and blood pressure response were appropriate. The patient experienced no chest pain. There were no arrhythmias noted throughout the study. Electrocardiogram demonstrates no ST-segment changes to suggest ischemia. Cardiolite images have been reported separately. . [2134-8-18] 08:42PM PT-13.2* PTT-32.5 INR(PT)-1.2* [2134-8-18] 08:42PM PLT COUNT-295 [2134-8-18] 08:42PM NEUTS-78.2* LYMPHS-13.5* MONOS-6.9 EOS-0.8 BASOS-0.5 [2134-8-18] 08:42PM WBC-9.8 RBC-4.44 HGB-13.8 HCT-40.8 MCV-92 MCH-31.1 MCHC-33.8 RDW-12.9 [2134-8-18] 08:42PM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.9 [2134-8-18] 08:42PM CK-MB-25* MB INDX-9.7* cTropnT-0.88* [2134-8-18] 08:42PM CK(CPK)-259* [2134-8-18] 08:42PM estGFR-Using this [2134-8-18] 08:42PM GLUCOSE-112* UREA N-12 CREAT-0.8 SODIUM-140 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 . ([8-21]) CXR: The left-sided pacemaker leads terminate in the expected location of the right ventricle. There is no evidence of pneumothorax. Heart size is top normal. Mediastinum is stable. Large hiatal hernia is projecting at the retrocardiac location. No pleural effusion is seen. . ([8-20]) ECHO:The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the mid to distal septal segments. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal left ventricular cavity size and wall thickness with mildly depressed left ventricular systolic dysfunction as described above. Increased left ventricular filling pressure. Mild tricuspid regurgitation. Mild pulmonary artery systolic hypertension. . DISCHARGE: [2134-8-22] 07:42AM BLOOD WBC-8.5 RBC-4.01* Hgb-12.2 Hct-35.9* MCV-90 MCH-30.5 MCHC-34.0 RDW-13.3 Plt Ct-288 [2134-8-22] 07:42AM BLOOD PT-11.4 PTT-35.3 INR(PT)-1.1 [2134-8-22] 07:42AM BLOOD Glucose-100 UreaN-21* Creat-0.9 Na-143 K-4.3 Cl-107 HCO3-29 AnGap-11 [2134-8-22] 07:42AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.8 Brief Hospital Course: Mrs. [Known lastname 3866] is an 81 y/o lady with a h/o HTN, HLD, who presented with CP diagnosed as NSTEMI at OSH on [8-17] and developed CHB prior to PCI. She was transfered here with temporary pacing wire, for PCI and EP consult. . # NSTEMI: Pt admitted directly to Cath lab, followed by DES to mLAD. Chest pain significantly resolved when presented to CCU. In CCU pt was hemodynamically stable, and in sinus rhythm, occasionally paced with temp transvenous pacer. Patient presented to OSH with CP that resolved with SL Nitro no ST changes on EKG and subsequently ruled in with elevated Troponins. Pt has no prior cardiac interventions and recent negative stress test. Pt has chronic LBBB, and on our EKG did not meet SG criteria. At the [Hospital1 ] cath lab pt received a DES to the mLAD and bivalrudin 126 mg/hr in addition to aspirin 325 mg, plavix 75 mg NAC 600 mg and zofran 4 mg. For the NSTEMI, she was discharged on ASA 325, Plavix 75, Metoprolol tartrate 12.5 mg TID, Atorvastatin 80 mg and Losartan. Repeat Echo here showed LVEF 45%, anterolateral as well as inferolateral walls at base and mid level with hypokinesis. On day of discharge pt was without chest pain, no SOB, ambulating on her own, and cleared by PT for home PT. Pt was tolerating a full diet, moving her bowels, and no difficulty urinating. . # Complete Heart Block: Pt was found to be in CHB at OSH, temp transvenous pacer was placed while at OSH, then transferred here for EP consult in addition to therapeutic Cath. In CCU pt was in sinus rhythm and using the pacemaker frequently. Received permanent pacemaker on [8-21]. The procedure was without complications. . # PUMP: No s/s of CHF currently or in the past. Euvolemic on exam. Although on Lasix per outpatient records. Per report, Cardiolite stress test on [2134-7-9] at OSH was negative for ischemia. She was noted to have an LVEF of 56%. Repeat Echo here showed LVEF 45%, anterolateral as well as inferolateral walls at base and mid level with hypokinesis. She did not require diuresis while inpatient and was euvolemic to slightly negative during this hospitalization. . # Hypertension: Pt was normotensive during this admission. At home on lasix, which was not given during this admission. She was continued on Metoprolol tartrate 12.5 mg TID, and Losartan was restarted prior to discharge. . #GERD: we continued home omeprazole while hospitalized. . #[Last Name (un) ]: Cr 1.2 at OSH. Cr was .8-.9 during entire course here. . #Depression: Stable on citalopram 20mg daily which was continued while inpatient. . TRANSITIONAL: - Cardiologist Dr. [Last Name (STitle) 112538] - f/u in device clinic in 1 week - Pt at high risk of sCHF given Anterior Lateral MI with EF 45%. - FULL CODE Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Losartan Potassium 50 mg PO DAILY hold for sbp < 100, hr < 55 2. Omeprazole 20 mg PO DAILY 3. Furosemide 40 mg PO DAILY hold for sbp < 100, hr < 55 4. Citalopram 20 mg PO DAILY Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Losartan Potassium 50 mg PO DAILY hold for sbp < 100, hr < 55 3. Omeprazole 40 mg PO BID 4. Aspirin EC 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 5. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 6. Clopidogrel 75 mg PO DAILY for the recommended duration RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 7. Metoprolol Tartrate 12.5 mg PO BID RX metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #30 Tablet Refills:1 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: NSTEMI (Heart attack) Complete Heart Block (abnormal Hearth Rhythm) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 3866], You were admitted to [Hospital1 69] after presenting with complaints of chest pain. You were found to be having a heart attack and were taken urgently to the catheterization lab where it was found that one of the arteries supplying blood to the heart muscle was blocked. This was treated by placing a stent in the artery to keep it open. You were started on a medication call Plavix which is similar to a "super aspirin" that helps to keep the artery open after having a stent placed. It is very important that you take this new medication daily until instructed to stop by your cardiologist, Dr. [Last Name (STitle) 77919]. In addition, you were also found to have a abnormal heart rhythm called "heart block" which prevented your heart from beating normally and required a permanent pace maker which was placed during this admission. It was a pleasure taking care of you, we hope that you have speedy recovery! Followup Instructions: Since we are discharging you on a Sunday, we are unable to schedule follow-up appointments for you. However, it is imperative that you be seen for follow-up from your recent hospitalization with the following providers: 1) Please schedule an appointment to see your primary care physician within one week from discharge for routine follow-up for your recent hospitalization. Name: NASEER,SAIRA Location: [Location (un) ] INTERNAL MEDICINE Address: [Street Address(2) ], [Location (un) ],[Numeric Identifier 32948] Phone: [Telephone/Fax (1) 13312] Fax: [Telephone/Fax (1) 112539] 2) Please schedule an appointment to see your Cardiologist Dr. [Last Name (STitle) 77919] within the next month to follow-up with him regarding your recent heart attack: NAME: [Last Name (STitle) ], [Last Name (un) ] ADDRESS: [Last Name (NamePattern1) ] Suite A [Location (un) 5028], [Numeric Identifier 12023] PHONE: ([Telephone/Fax (1) 110136] (Office) 3) Please make an appointment with Cardiology at [Hospital1 18] to set up an appoinmtent to have your pacemaker checked in the device clinic in 7 days: NAME: [Last Name (LF) ], [Name8 (MD) ] MD / OR ANYONE AT THE DEVICE CLINIC Office Location: [Location (un) ] 418, [Hospital Ward Name 23] Clinical Center PHONE: ([Telephone/Fax (1) 20575] Completed by:[2134-8-23]	[ "41071", "41401", "2724", "4019", "53081", "V1582", "311" ]
Admission Date: [2187-6-14] Discharge Date: [2187-6-16] Service: MEDICINE Allergies: lisinopril Attending:[Last Name (NamePattern1) 495] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ] year old female with a history of hip fracture s/p mechanical fall 1 week ago, s/p ORIF, course complicated by DVT and subsequent IVC filter placement, just discharged on [6-12] to rehab on coumadin, lovenox, and aspirin 325. She initially presented to OSH with a Hct of 15 from 30 on discharge two days ago. Her INR was 8.5. She recieved 10 mg IV Vitamin K. She is Jehovah Witness and the son was refusing blood product or [Name (NI) 9087]. CT scan at OSH showed large right [Name (NI) ] hematoma. Patient was transferred to [Hospital1 18] for further management. In the ED, her initial BPs were in the 70s/50s. Hct confirmed to be 15, INR had decreased to 4.2. She received 5 L NS total, with pressures improving to high 90s systolic. A compression bag was placed on the patient's [Hospital1 ] per surgery recommendations. Her urinalysis was also positive so she was given a dose of ceftriaxone. Per discussion with family in the ED, patient made DNR/DNI. On transfer, vitals were 97/56 78 100%2LNC. Past Medical History: CAD s/p STEMI [9-/2186] per [1-11] [Hospital3 ] d/c summary -cath with distal LAD disease, EF 40-45% -repeat cath [10/2186] at LGH CKD Aortic aneurysm at 4.3cm dilation noted in [10-11] HTN Peripheral Neuropathy nephrolithiasis OA h/o cellulitis actinic keratosis eczema allergic rhinitis recurrent lateral right foot edema h/o abnormal Pap (ASCUS) healthcare maintenance: colonoscopy summer [2180], [Last Name (un) 3907] [7-/2183], pneumovax [6-/2178], TDaP [11/2186] Hip fracture DVT s/p IVC filter placement Social History: Came from rehab, denies smoking, EtOH. Family History: Non-contributory Physical Exam: ADMISSION 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 Pertinent Results: ADMISSION LABS: [2187-6-14] 05:55PM BLOOD WBC-20.0# RBC-1.69# Hgb-4.8# Hct-16.4# MCV-97 MCH-28.4 MCHC-29.3* RDW-19.3* Plt Ct-487* [2187-6-14] 05:55PM BLOOD Neuts-84.0* Lymphs-11.8* Monos-4.0 Eos-0.1 Baso-0.1 [2187-6-14] 05:55PM BLOOD PT-42.9* PTT-42.2* INR(PT)-4.2* [2187-6-14] 05:55PM BLOOD Glucose-148* UreaN-29* Creat-2.0* Na-135 K-5.0 Cl-104 HCO3-22 AnGap-14 [2187-6-14] 05:55PM BLOOD ALT-23 AST-49* AlkPhos-90 TotBili-0.3 [2187-6-14] 05:55PM BLOOD Albumin-2.6* Calcium-8.9 Phos-4.9# Mg-2.4 [2187-6-14] 05:55PM BLOOD Lipase-15 [2187-6-14] 05:55PM BLOOD cTropnT-<0.01 [2187-6-14] 06:06PM BLOOD Lactate-2.6 [2187-6-15] 09:49AM BLOOD Lactate-2.8* [2187-6-15] 10:05AM BLOOD Lactate-3.1* . PERTINENT LABS: [2187-6-14] 05:55PM BLOOD Hct-16.4 [2187-6-14] 09:33PM BLOOD Hct-15.4 [2187-6-15] 03:57AM BLOOD Hct-13.6 [2187-6-15] 09:38AM BLOOD Hct-11.8 . MICROBIOLOGY: [2187-6-14] Blood culture: no growth to date [2187-6-15] Urine culture: GNRs ~4000/ml . IMAGING: [2187-6-15] CTA abdomen/pelvis: 1. Bilateral pulmonary emboli with small bilateral pleural effusions. 2. No evidence for active extravasation. 3. Right [Month/Day/Year ] hematoma, unchanged from comparison CT of approximately one day prior. 4. Appropriately positioned inferior vena cava filter containing trapped emboli. Brief Hospital Course: [Age over 90 ] year old woman s/p ORIF for hip fracture one week ago, c/b DVT with subsequent IVC filter placement, who presented with hypotension, found to have a large right [Age over 90 ] hematoma and new PEs. . # Hypotension: Secondary to hypovolemic shock in the setting of a HCT drop to 16.4 from 30 two days prior to admission. Patient was discharged on lovenox and coumadin and had a supratherapeutic INR (8.5 at OSH) on the day of admission. CTA revealed a large right [Age over 90 ] hematoma though no active extravasation. She was administered vitamin K, amicar, DDAVP, and over 10 liters of fluid resuscitation. A pressure dressing was placed over her right [Age over 90 ] to prevent further bleeding. She is a Jehovah's Witness, so declined blood products. Hematology and the blood bank were consulted regarding administration of recombinant factor VII. This had a risk of arterial thrombi, therefore after discussion with the patient's family, including her daughter (HCP), the decision was made to not administer recombinant factor VII. IR and surgery were consulted, however it was felt that there was no surgical or interventional procedure indicated. The family was made aware of the patient's very poor prognosis and she was made DNR/DNI. Her HCT further dropped to 11.8 and she had progressively worsening hypotension. She passed away at 07:05 on [2187-6-16]. The medical examiner was notified and is considering an autopsy. . # Urinalysis: UA with questionable UTI so the patient was given a dose of ceftriaxone at the OSH. Given her hypotension and shock, she was broadly covered with vanc and zosyn. . # PEs: Seen on abdominal/pelvic CTA. Given her bleeding, no treatment was initiated. Medications on Admission: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. 7. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily): hold for loose stools. 11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. magnesium citrate Solution Sig: Three Hundred (300) ML PO once a day as needed for constipation. 13. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): Continue until INR is therapeutic. 14. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): New medication, adjust dose as needed with frequent INR testing. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Right [Date Range ] hematoma Hypovomic shock PE Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[2187-6-16]	[ "5990", "5849", "2851", "41401", "40390", "5859", "412", "42731" ]
Admission Date: [2182-12-24] Discharge Date: [2182-12-31] Date of Birth: [2123-11-19] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: s/p Pedestrian struck by auto Head pain Left side pain Back pain Major Surgical or Invasive Procedure: Right chest tube thoracosotmy [2182-12-24] History of Present Illness: 59 yo male pedestrina who was struck by auto @~20-30 mph; no reported LOC. He was transported from scene to [Hospital1 18] for further care. Past Medical History: Etoh abuse - reportedly in recovery for past 8 months Social History: Recovering alcoholic; reportedly sober x 8 months Family History: Noncontributory Pertinent Results: [2182-12-24] 10:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2182-12-24] 06:57PM ASA-NEG* ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2182-12-24] 10:15PM URINE RBC-[4-14]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [2182-12-24] 06:57PM GLUCOSE-126* UREA N-14 CREAT-0.9 SODIUM-139 POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15 [2182-12-24] 06:57PM AMYLASE-88 [2182-12-24] 06:57PM PLT COUNT-265 [2182-12-24] 06:57PM PT-12.7 PTT-25.6 INR(PT)-1.1 [2182-12-24] 06:57PM FIBRINOGE-229 CT HEAD W/O CONTRAST Reason: s/p ped v MVC [Hospital 93] MEDICAL CONDITION: 59 year old man s/p Ped v. MVC REASON FOR THIS EXAMINATION: s/p ped v MVC CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 59-year-old man, pedestrian struck by car. TECHNIQUE: Non-contrast head CT scan. FINDINGS: The examination is somewhat limited by patient motion. There is a vague, approximately 1cm area of high attenuation area along the right parietal region- ? early subarachnoid blood. An additional small linear focus of increased attenuation is noted adjacent to the left frontotemporal region, possibly a minute acute subdural hematoma. There is no mass effect, hydrocephalus, shift of normally midline structures, or major vascular territorial infarction. There is a right parietal scalp laceration and diffuse subcutaneous emphysema noted on the right side. No fractures are identified. Minimal right maxillary antral mucosal thickening is seen within the visualized portion of this sinus, likely inflammatory in origin. IMPRESSION: Study is somewhat limited by patient motion. High attenuation areas seen along the right parietal and left frontotemporal region could represent small amounts of subarachnoid and subdural blood, respectively. These issues should be re-evaluated on followup head CT scan. No mass effect or shift of normally midline structures at this time. CHEST (PA & LAT) Reason: Eval for ptx, acute cardiopulmonary process [Hospital 93] MEDICAL CONDITION: 59 year old man sp chest tube d/c REASON FOR THIS EXAMINATION: Eval for ptx, acute cardiopulmonary process INDICATION: Chest tube removal. COMPARISONS: [2182-12-25]. SINGLE VIEW CHEST, AP UPRIGHT: There is persistent elevation of the right hemidiaphragm with basilar atelectasis. Discoid atelectasis is seen within the left lung base. There are multiple right-sided rib fractures and a comminuted scapular fracture again identified. No pneumothorax is seen. Brief Hospital Course: He was admitted to the trauma service; a right chest thoracostomy was placed in the emergency department because of a tension pneumothorax. Once stabilized in the emergency department he was then transferred to the Trauma ICU for close monitoring. Neurosurgery and Orthopedic Surgery were consulted because of his injuries. His neurosurgical issues were nonoperative; he was loaded with Dilantin and remained on this for a total of 7 days. He did not have any reported or observed seizure activity throughout his hospital stay. Orthopedics was consulted because of his right scapula fracture. This injury was non operative as well. He was placed in a sling and is to remain non weight bearing in that extremity until follow-up up with Dr. [Last Name (STitle) ] in 2 weeks post hospital discharge. Physical and Occupational therapy were consulted and have recommended short term rehab. Medications on Admission: Olanzapine Trazadone Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. 2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 8. Bisacodyl 10 mg Suppository Sig: [2-11] Suppositorys Rectal DAILY (Daily) as needed for constipation. 9. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: s/p Pedestrian struck by auto Left frontotemporal subdural hematoma Right comminuted scapula fracture Right tension pneumothorax Multiple right rib fractures Discharge Condition: Stable Discharge Instructions: Return to the Emergency room if you develop any fevers/chills, severe headaches, visual disturbances, chest pain/tightness, nausea,vomiting, diarrhea and/or any other symptoms that are concerning to you. DO NOT bear any weight on your right arm; continue to wear your sling. Followup Instructions: Follow up in Trauma clinic in 2 weeks, call [Telephone/Fax (1) 6429] for an appointment. Follow up in [Hospital 5498] clinic with Dr. [Last Name (STitle) ] in 2 weeks, call [Telephone/Fax (1) 1228] for an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2182-12-31]	[ "25000", "311" ]
Admission Date: [2111-12-13] Discharge Date: [2111-12-23] Date of Birth: [2044-7-10] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ex-lap loa, choylcystectomy History of Present Illness: Pt was admitted to OSH for abdominal pain/distention and frequent N/V for a few days PTA. She has not had medical care for approximatly 20 years. At the OSH CT showed SBO and calcified gallbladder. She was noted to be in afib as well with mitral disease, EF 35%. she was transferred to [Hospital1 18] for further care Past Medical History: Hysterectomy C-Sectionx2 Social History: Heavy smoker Family History: Brother with CABGx4 Physical Exam: 96.7 88 120/72 16 NAD, AOx3 NGT in place/ sumping RRR, CTA-B ABD: soft, non-disteded RUQ tenderness, no rebound, +guarding EXT: no C/C/E Rectal: nl tone guiac neg Pertinent Results: [2111-12-13] 08:13PM GLUCOSE-102 UREA N-20 CREAT-0.8 SODIUM-142 POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14 [2111-12-13] 08:13PM ALT(SGPT)-10 AST(SGOT)-21 ALK PHOS-62 AMYLASE-49 TOT BILI-0.8 [2111-12-13] 08:13PM LIPASE-79* [2111-12-13] 08:13PM CALCIUM-9.5 PHOSPHATE-3.3 MAGNESIUM-1.7 [2111-12-13] 08:13PM WBC-12.4* RBC-5.23 HGB-14.9 HCT-44.5 MCV-85 MCH-28.4 MCHC-33.5 RDW-13.7 [2111-12-13] 08:13PM PLT COUNT-243 [2111-12-13] 08:13PM PT-14.3* PTT-28.7 INR(PT)-1.3 Brief Hospital Course: Pt was admitted to the hospital and cardiology was consulted for pre-op eval for surgery. Her NGT was continued. Her SBO did not clear, so she was pre-oped for x-lap, CCY and LOA. She went to the OR and underwent the above procedure which confirmed the above mentioned CT scan findings. She was admitted to the SICU, post op for close monitoring. NGT was continued and once stable, the patient was transfered to the floor. Aggressive pulmonary toilet was performed and once flatus and BM occured, her NGT was removed. She was started on sips, and her diet was advanced uneventfully. She had no PCP so one was arranged to follow INR as an outpt and as well for general medical care. She did require a few days of TPN. Coumadin was started in house for AFib anticoag. She was d/c'ed home with instruction to follow up her INR with her PCP. Medications on Admission: tylenol PRN Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 2. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: small bowel obstruction porcelain gallbladder Discharge Condition: good Discharge Instructions: Contact your doctor if you experience increasing pain bleeding or other concering signs. Have your primary care physician follow your INR. Followup Instructions: In 2 weeks with Dr. [Last Name (STitle) ], call his office for an appointment Follow up with Dr. [Last Name (STitle) 2093] in the next week. Have the blood draw service fax results to Dr. [Last Name (STitle) 2093] at [Telephone/Fax (1) 59519] (tele) Completed by:[2111-12-23]	[ "42731", "496", "4240", "V5861" ]
Admission Date: [2105-12-18] Discharge Date: [2105-12-24] Date of Birth: [2032-5-22] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4588] Chief Complaint: pre-syncope Major Surgical or Invasive Procedure: Foley Catheter Placement History of Present Illness: Patient is admits to forgetfullness, and requests details of medical history be obtained by HCP. [Name (NI) ] report, pt is a 73 yo M w/ CAD, h/o multiple reportedly hemorraghic CVA c/b seizures, s/p recent suspension microlaryngoscopy with excision of right vocal fold mass, who presents after an episode of near syncope at home. . Pt had vocal surgery with mass removal by Dr. [Last Name (STitle) 33748] on Monday [2105-12-14]. Mass was found during eval for chronic hoarsenss. Prior to surgery, patient was reported to be in "very good health" by his HCP. After operation, pt was feeling "generally unwell" per his HCP. [Name (NI) ] report, was seen in [Hospital ] clinic prior to hospital presentation. Was c/o genearlized weakness but also on increased pain medication. Symptoms included increased fatigue, urinary hesistancy/diffuclty urinating coupled with incontinence (w/o saddle aneshtesias), genearlized weakness, body aches, stomach soreness. Prior to presentation, patient on way to the bathroom had to sit down as he was too fatigued to keep walking. HCP reported period of unresponsiveness staring off to the wall. HCP attempted shaking/tapping pt. in face without response. Called paramedics and came to prior to EMS arrival. . In the emergency department VS were afebrile 120 107/84 85% 4L NC. Patient triggered upon arrival to the ED for hypoxia and tachycardia to the 120s (noted to be in AF w/ RVR, which resolved without intervention). Labs sig for Cre of 7.0, K of 3.7, Na 129, Trop-T of 0.07. EKG had ST depressions in V5-V6. CXR showed no focal consolidation. Guiac was positive. Received 2 L NS, CFTX IV x1 and Azithromycin PO x1 in the ED and 40 mEq of IV K for K of 3.1. Transferred to ICU . In the ICU, patient's VS were 80 130/80 20 100% on NRB. He was transitioned from NRB to 6 L NC, noted to be consistently satting 95%. ABG on 6 L NC was 7.46/41/80/30. Patient was alert and oriented and denied any acute symptoms at that time. RN noted the patient to briefly in AF w/ RVR with rates up to the 120s, which broke spontaneously. Foleyed with total urination of 2L. Had complete output of 4.5 L without diuresis. Had TTE which showed pulm htn. Had RUS with wet read showing no disease but did show bilateral pulmonary effussions. Spent one night in ICU with decrased O2 demands post void. . On call out, pt's vitals were HR:79 sinus, 141/82 16 98% on 2L NC. . On ROS: Patient currently denies any fevers, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting dysuria, diarrhea, or back pain. Denies any changes in his medication recently. Endorses constipatiion. . Past Medical History: 1. Coronary artery disease status post myocardial infarction in [2089]. 2. Strokes in [2092] and [2093] with left parietal occipital and right occipital hemorrhages. Also left pontine infarct. 3. Hypertension. 4. Hypercholesterolemia. 5. History of deep vein thrombosis treated with coumadin x 6 months. 6. History of small bowel obstruction. 7. Seizure disorder x 4-5 years after strokes. 8. Chronic renal insufficiency. Social History: lives with caretaker [Name (NI) 20872]. [Name2 (NI) ] is separated from his wife. Owns several bakeries and restaurants. Several children. Smoked from age 18-40 (1 pack per week). Denies tobacco use recently. No heavy EtOH use, IVDU or illicits. Family History: Father - stroke and MI Mother - ?cerebral anneurysm 2 children with IDDM, adult onset 1 sister with metastatic breast ca Physical Exam: VS: HR79,BP141/82, RR 16, O2 98% on 2L NC. GEN: elderly M appears in NAD on NC HEENT: PERRLA. Anicteric sclera. MMM. B/L cervical LAD 1cm. No erytema or oral lesions in mouth. NECK: neck supple. Thyroid nonpalpable. PULM: Expiratory crackles b/l throughout. No rhonchi or rales. CARD: RRR S1/S2 NL, [12-10] pansystolic murmur auscultated throughout precordium. ABD: Protuberant abdomen. Midline scar c/w prior abdominal surgery. Ventral hernia with intestinal outpouching. NBS. soft NT no g/rt. EXT: wwp no edema noted SKIN: mild chronic venous stasis changes NEURO: alert and orientedx2 (confused about year). CNII-XII in intact. Vision 20/70 B/L without corrective lenses. Very hoarse at baseline. [4-8] UE/LE bilaterally. Sensation to gross touch in tact throughout. MAE. No dysdiachokinesia with alternating hand movements. Mild past pointing. Gait not tested. Pertinent Results: CBC [2105-12-18] 09:20PM BLOOD WBC-9.0# RBC-4.39* Hgb-13.4* Hct-38.3* MCV-87 MCH-30.5 MCHC-34.9 RDW-13.1 Plt Ct-129* [2105-12-22] 05:40AM BLOOD WBC-6.2 RBC-4.38* Hgb-13.2* Hct-37.4* MCV-85 MCH-30.1 MCHC-35.3* RDW-12.8 Plt Ct-200 [2105-12-18] 09:20PM BLOOD Neuts-79.4* Lymphs-11.4* Monos-6.4 Eos-2.2 Baso-0.6 CMP [2105-12-18] 09:20PM BLOOD Glucose-182* UreaN-71* Creat-7.0# Na-129 K-3.7 Cl-86* HCO3-29 AnGap-18 [2105-12-24] 05:40AM BLOOD Glucose-112* UreaN-22* Creat-1.4* Na-138 K-4.0 Cl-106 HCO3-19* AnGap-17 [2105-12-19] 01:39AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.8* [2105-12-24] 05:40AM BLOOD Calcium-9.3 Phos-2.6* Mg-1.7 COAGS [2105-12-20] 07:30AM BLOOD PT-14.1* INR(PT)-1.2* CARDIAC ENZYMES [2105-12-18] 09:20PM BLOOD cTropnT-0.07* [2105-12-19] 01:39AM BLOOD CK-MB-4 cTropnT-0.05* proBNP-7830* [2105-12-19] 09:35AM BLOOD CK-MB-4 cTropnT-0.05* DIGOXIN LEVEL [2105-12-22] 05:40AM BLOOD Digoxin-0.7* URINALYSIS [2105-12-18] 09:20PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD MICROBIOLOGY BCX: NEGATIVE UCX: NEGATIVE IMAGING: CXR [2105-12-18] FINDINGS: Single frontal view of the chest was obtained. There is mild elevation of the left hemidiaphragm with overlying atelectasis. Slight decrease in volume of the left lung as compared to the right. Prominence of the hila is unchanged. The cardiac and mediastinal silhouettes are stable. The cardiac and mediastinal silhouettes are unchanged. No pleural effusion or pneumothorax is seen. IMPRESSION: Mild elevation of the left hemidiaphragm with overlying atelectasis. No definite focal consolidation or pleural effusion. ECHO [2105-12-19] The left atrium is elongated. 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 aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Mild to moderate ([12-6]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate pulmonary artery hypertension. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. Preserved global and regional biventricular systolic function. Compared with the report of the prior study (images unavailable for review) of [2103-5-2], the severity of tricuspid regurgitation and the estimated pulmonary artery systolic pressure are slightly increased. V/Q SCAN [2105-12-19] IMPRESSION: Low likelihood ratio for acute pulmonary embolism. RENAL US [2105-12-19] RENAL ULTRASOUND: The right kidney measures 11.7 cm. The left kidney measures 12.5 cm. The previously documented left interpolar subcentimeter cyst is no longer visualized in the current study. There is no hydronephrosis, hydroureter, renal mass or calculi. The spleen measures 12.3 cm. There are small bilateral pleural effusions, left greater than right. IMPRESSION: No hydroureteronephrosis, renal mass or calculi. CT SCANS CT HEAD [2105-12-21] FINDINGS: There is no acute intracranial hemorrhage, major vascular territory infarction, mass effect, or edema. The region of encephalomalacia in the right parietal lobe is similar to prior. Left pontine chronic lacunar infarct is again noted. There is no abnormal enhancement to suggest intracranial mass. The vertebrobasilar system is noted with atherosclerotic calcification of the left vertebral artery. No osseous abnormality is identified. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No abnormal enhancement or significant change from prior. CT NECK [2105-12-21] FINDINGS: There is slight asymmetry at the level of the right vocal cord (2:70), which may represent the patient's known laryngeal carcinoma. There is no abnormal enhancement. There is a slightly prominent level 5 lymph node, measuring 12.2 by 9.7 mm on the right, (2:72). No other prominent lymph nodes are identified elsewhere. Vascular structures are within normal limits. The visualized portion of the brain is unremarkable, but better evaluated on current CT head. Lung apices are clear. The thyroid gland is unremarkable. IMPRESSION: Slight asymmetry at the level of the right vocal cord may represent known laryngeal carcinoma. No abnormal enhancement. CT CHEST/ABDOMEN/PELVIS [2105-12-21] CT OF CHEST WITH INTRAVENOUS CONTRAST: The major airways are patent to subsegmental levels bilaterally. Patchy peribronchial opacities seen in the right upper lobe, likely represent infectious or inflammatory etiology. No suspicious pulmonary nodules or masses are identified. There are no pleural or pericardial effusions. No significant axillary, mediastinal or hilar lymphadenopathy is detected. This study is not tailored for evaluation of the pulmonary arteries. Within the limitations of this study, filling defects are seen within the lobar and segmental branches of the left upper and left lower lobe. Pulmonary emboli are also seen in the segmental branches of the right lower lobe. There is moderate atherosclerotic calcification of the aortic arch, coronary arteries and the mitral annulus. A small simple pericardial effusion is present. CT OF THE ABDOMEN WITH ORAL AND INTRAVENOUS CONTRAST: There is a well-defined hypoattenuating lesion in the segment VIII of the liver (2F:53) measuring 3.3 x 2.9 cm, with attenuation values consistent with a simple hepatic cyst. No concerning liver lesions or biliary dilatation is present. The gallbladder is contracted and unremarkable. The adrenal glands and pancreas are unremarkable. There is a subcentimeter hypodensity within the spleen (2F:57), too small to characterize, may represent hemangioma / cyst. Both kidneys enhance and excrete contrast symmetrically, without hydronephrosis or concerning renal masses. Subcentimeter hypodensity within the right kidney, is too small to characterize. The stomach, small and large bowel are unremarkable. The abdominal aorta has scattered moderate atherosclerotic calcification, without aneurysmal dilation. No significant retroperitoneal or mesenteric lymphadenopathy is detected. There is no intra-abdominal free fluid or air. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is nearly empty with a Foley catheter in place. The distal ureters are normal. The sigmoid colon and rectum are unremarkable. No significant pelvic lymphadenopathy or free fluid is detected. There is evidence of acute deep venous thrombosis involving the right common femoral vein and bilateral superficial femoral veins. Thrombus is also seen within the right great saphenous vein. BONES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are detected. Mild degenerative changes of the thoracolumbar spine are present, worse at L5 and S1 level. IMPRESSION: 1. No evidence of metastatic disease in the chest, abdomen and pelvis. 2. Patchy airspace opacities in the right upper lobe,likely represent acute infectious/inflammatory process. Recommended attention on follow-up studies. 3. Acute pulmonary embolism involving lobar and segmental branches of the left upper and lower lobes, and segmental branches of the right lower lobe. Small simple pericardial effusion. 4. Acute DVT involving both superficial femoral veins and the right common femoral vein. Brief Hospital Course: Acute on chronic renal failure in setting of urinary retention: Concerning for both pre-renal etiology in setting of decreased PO intake and post-obstructive renal failure in the setting of post-op urinary retention. Urinalysis was inconclusive for infection. Foley was placed with 2L output. Patient was resuscitated with IVF. Cr was trended, initially 7.0, dropped rapidly to 1.5 post catherization. Medications were renally dosed and nephrotoxins avoided. Renal ultrasound showed no hydroureteronephrosis. No renal stone or mass. Urine cultures were negative. Prostate exam showed significant prostatic enlargement. Patient was started on finasteride and tamsulosin. Attempted voiding trials which were unsuccessful. Patient discharged with foley in place, with urology follow up one week post discharge. Squamous cell carcinoma of the larynx: Prior to this hospitalization, patient was having prolonged hoarsenss and had vocal cord biopsy of vocal cord growth. On this admission, pathology reports came back positive for squamous cell carcionma. Patient had evaluation by oncology, who decided on in house radiographic examination for assessment of metastatic disease. Initial imaging showed no evidence of metastasis. However, incidental pulmonary embolisms and DVTs were seen (per below) Hypoxic respiratory distress presumably from pulmonary embolisms: Patient presented with significant A-a gradient on ABG, requiring a NRB oxygen demand. Was able to titrate down to RA over several days with no intervention. No evidence of pneumonia or volume overload on CXR. Clear CXR was concering for PE however initial V/Q scan was low probability. Cardiac enzymes were trended and remained stable. TTE showed Moderate pulmonary artery hypertension. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. Preserved global and regional biventricular systolic function. Not a significant change from prior. On general medical floors, patient was worked up for possible metastatic disease given diagnosis of squamous cell carcinoma of the larynx (see below). CT chest incidentally showed multiple subsegmental pulmonary embolisms, and pelvic imaging showed lower extremity DVT's. Patient remained asymptomatic. Discussed risks of placing on anticoagulation, as has history of stroke with hemorrhagic conversion. Patient and HCP decided to receive treatment with enoxaparin injections [Hospital1 ] for DVT/PE treatment. Should follow up any pulmonary symptoms, with reimaging in [2-7] months to assess for dissolution of clots. Pre-syncope: Likely in setting of renal failure versus hypovolemia, dehydration as patient appeared volume down on exam. No evidence of bleeding, Hct stable. Pt was volume resuscitated and orthostatics subsequently negative. No further episodes of presyncope in house. Atrial fibrillation: Patient briefly in AF w/ RVR on the floor and in the ICU. Perhaps self-limited in the setting of patient's renal failure and hypokalemia. Continued home labetolol and digoxin (latter initially renally dosed). Checked daily digoxin level to avoid toxicity. Continued aspirin in addition to intiation of enoxaparin per above. Seizure d/o: Associated with pt's hemorrhagic strokes; Continued Keppra (renally dosed initially) as well as gabapentin 100 mg qid. No seizure like activity while hospitalized, although did have episodes of forgetfullness. Guiac positive stools: hct stable. Patient without frank BRBPR. Known Grade I Hemorrhoids, diverticulosis, and cecal polyps on [8-/2105] colonoscopy. Follow up hematocrit on future visit to assure stability. Assure appropriate follow up colonoscopy. Pending Labs: None Transitional Issues: Issues with providing patient with enoxaparin. Post discharge, patient [Name (NI) 653] hospital as enoxaparin cost $1300. Spoke with case management which sent visiting nurse [First Name (Titles) ] [Last Name (Titles) ] in insurance processing for monetary coverage. Should reassess that patient's LMWH is amply covered by insurance to allow patient to continue anticoagulation for PE's and DVTs. Medications on Admission: ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - [12-6] Tablet(s) by mouth q 4-6 hours as needed for pain or cough AMLODIPINE - 5 mg Tablet - one Tablet(s) by mouth daily ATORVASTATIN - 40 mg Tablet - One Tablet(s) by mouth daily DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth daily GABAPENTIN [NEURONTIN] - 100 mg Capsule - one Capsule(s) by mouth four times a day HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth daily LABETALOL - 300 mg Tablet - 2 Tablet(s) by mouth twice a day LEVETIRACETAM [KEPPRA] - 500 mg Tablet - three Tablet(s) by mouth twice a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth daily RANITIDINE HCL - 300 mg Capsule - 1 Tablet(s) by mouth at bedtime Medications - OTC ACETAMINOPHEN - 500 mg Tablet - 2 Tablet(s) by mouth three times a day as needed for pain ASPIRIN - 325 mg Tablet - one Tablet(s) by mouth daily CALCIUM CARBONATE - 500 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth twice a day CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 (One) Capsule(s) by mouth once a day Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 8. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:0 10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 13. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:60 injections Refills:0 14. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Presyncope Acute on Chronic Renal Failure Pulmonary Embolisms Bilateral Deep Vein Thromboses Benign Prostatic Hyperpertrophy Urinary Hesitancy . Secondary: Squamous Cell Cancer of the Vocal Cord Atrial fibrillation Partial Complex Seizure Disorder Coronary Artery Disease status post myocardial infarction in [2093] Hypertenison Hypercholesterolemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [Known lastname 5903], You were admitted to the hospital due to increased weakness, difficutly urinating, and confusion. You were intitially admitted to the intensive care unit because you were requiring high amounts of oxygen on presentation to the hospital and your kidney function was impaired. You had a foley catheter placed which allowed you to urinate, and your kidney function returned to baseline. It seems your symptoms were most likely due to your acute renal dysfunction, and your symptoms gradually resolved when your kindey function improved. You will keep the foley in place until you are seen by your urologists in the outpatient setting. . Additionally, the results of your vocal cord biopsy returned, and you have been diagnosed with squamous cell cancer of the vocal cord. You have been seen by the oncology team (cancer doctors), and will be following up with them next week for further treatment. . Lastly, you were found to have blood clots in the vessels of your lungs as well as your the veins of your lower extremities. We discussed placing you on blood thinners to help treat these clots, and to prevent further blood clots from forming in your lungs. You understood being placed on anticoagulant therapy carried a risk of increased bleeding, including bleeding in the brain as you have had in the past. You and your health care proxy decided treating these blood clots for the next 3 to 6 months would be in your best interest. You have been placed on enoxaparin (AKA Lovenox), a drug that is similar to heparin. You will need to take these enoxaparin injections 2x a day. You will have a visiting nurse come to your home to [Known lastname ] you and show you how to use these injections for the first few days after your discharge. . You have been started on a new medications to help with your enlarged prostate: Tamulosin 0.4 mg at night- for urinary hesitancy Finasteride 5 mg daily- for urinary hesitancy Enoxaparin 80 mg subcutaneous injections 2x a day- for leg/lung clots . Please continue to take the rest of your medications as prescribed. . It has been a pleasure taking care of you [Known firstname ]! Followup Instructions: You have the following medical appointments: . Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2105-12-28] at 2:30 PM With: [First Name4 (NamePattern1) 4912] [Last Name (NamePattern1) 4913], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: GERONTOLOGY When: FRIDAY [2106-1-1] at 10:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RNC [Telephone/Fax (1) 719] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage This appointment is with Dr. [Last Name (STitle) ] nurse practitioner. . Department: Urology When: [2106-1-7]:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 98174] NP Building: [Location (un) ]/[Hospital Ward Name 23] Building Floor 3 Campus: East . Department: ENT When: Tuesday [1-12] at 2 PM With: Dr. [Last Name (STitle) ],MD [Telephone/Fax (1) 41] Building: LM [Hospital Unit Name ] [Location (un) 895] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: GERONTOLOGY When: WEDNESDAY [2106-3-10] at 9:00 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 719] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage .	[ "5849", "40390", "42731", "2720", "4168", "4240" ]
Admission Date: [2165-8-17] Discharge Date: [2165-8-23] Date of Birth: [2104-2-16] Sex: M Service: MEDICINE Allergies: Iodine Attending:[First Name3 (LF) 11495] Chief Complaint: Hortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization with bare metal stent to left circumflex artery History of Present Illness: 61 year old male with a history of hypercholesterolemia, CAD s/p MI in [4-2] s/p stent x3 (2 LAD, 1 D2)with 2 separate caths, CHF (EF 20-30%)[7-2], and non-sustained VT s/p ICD who presents with shortness of breath. Patient reports that he has been feeling more SOB for the past 2 weeks and this morning he was feeling fine and decided to go golfing. Before starting he developed acute SOB and some chest pressure. Denied N/V but had some palpitations. His ICD did not fire. On route to the ED he complained of some right arm pain which he reports is his anginal equivalent. Denies orthopnea or PND and says that he has been taking all of his medications but has not been following a low salt diet recently. Of note his SBP was 106 this am and he says it is normally around 95. He reports no change in his weight and says that his dry weight is around 150 lbs. He denies any chest pain on exertion but says he is unable to walk more than 30 yards as he develops LE pain. He had arterial dopplers of his LE rest and exercise [6-2] which were normal. He also reports that he has been having black stools for 2 weeks and occasional brigt red blood and pain on defecation when having hard BM. His last colonscopy was [1-29] which showed Grade 2 internal hemorrhoids otherwise normal Colonoscopy to cecum. Denies dysuria, nocturia, some increased urgency since being on lasix. Denies fevers, chills,dizziness, cough, palps. In the ED he recieved lasix 80mg Iv, morphine, nitro gtt, heparin gtt with bolus. He was put on BIPAP and was attempted to be weaned but sats dropped into 80's and was set to CCU for management of CHF. Past Medical History: 1)anterior STEMI [5-2]: 2 stents to the LAD, and had angioplasty x 2 (2 separate caths) as the diagonal restenosed within days after the first angioplasty. 2)Bronchitis 3)Hypercholesterolemia 4) CHF - EF 20-30%, 1+MR, 2+TR, apical akinesis, hypokinesis of most of LV, mild symmetric left ventricular hypertrophy 5) S/P ICD and Pacer Social History: Married, lives with wife, works in maintenance for the court system but has not yet returned to work. Smoked 1.5 ppd for 40 years, quit on last admission in [Month (only) 116] . Family History: Paternal GM with MI age 54 Paternal GF with MI age 58 Father with MI age 58 Uncle with MI age 46 Physical Exam: BP 108/73 HR 75 R 20 O2 sats 100% on BIPAP, 1400 cc out after lasix 80 mg IVx1 Gen: NAD, lying in bed breathing with BiPAP HEENT: PERRL, JVP to angle of jaw Neck: no carotid bruits Lungs: bilateral crackles [12-30] way up lung fields CV: RRR, nl s1/s2, no m/r/g Abd: soft, nt/nd, normal BS Extr: no c/c/e, DP 1+ bilat Neuro: AAOx3 Guaiac: negative but difficult to get good specimen secondary to pain on exam Pertinent Results: [2165-8-17] 10:00AM BLOOD WBC-5.0 RBC-3.59* Hgb-10.7* Hct-34.1* MCV-95 MCH-29.9 MCHC-31.5 RDW-15.1 Plt Ct-328# [2165-8-18] 02:02AM BLOOD WBC-6.3 RBC-3.02* Hgb-9.2* Hct-27.0* MCV-89 MCH-30.6 MCHC-34.3 RDW-15.0 Plt Ct-269 [2165-8-19] 06:05AM BLOOD WBC-4.3 RBC-3.43* Hgb-10.4* Hct-30.2* MCV-88 MCH-30.5 MCHC-34.6 RDW-15.8* Plt Ct-266 [2165-8-22] 06:45AM BLOOD WBC-7.0 RBC-3.56* Hgb-10.5* Hct-32.6* MCV-92 MCH-29.5 MCHC-32.2 RDW-15.2 Plt Ct-252 [2165-8-23] 06:35AM BLOOD WBC-5.8 RBC-3.39* Hgb-10.0* Hct-31.0* MCV-92 MCH-29.6 MCHC-32.3 RDW-15.0 Plt Ct-236 [2165-8-17] 10:00AM BLOOD Neuts-49.7* Lymphs-36.8 Monos-6.5 Eos-6.0* Baso-1.0 [2165-8-17] 10:00AM BLOOD PT-19.5* PTT-30.2 INR(PT)-2.5 [2165-8-21] 06:45AM BLOOD PT-15.8* PTT-48.9* INR(PT)-1.7 [2165-8-21] 05:25PM BLOOD Plt Ct-307 [2165-8-17] 10:00AM BLOOD Glucose-161* UreaN-17 Creat-1.0 Na-139 K-4.8 Cl-102 HCO3-22 AnGap-20 [2165-8-23] 06:35AM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-139 K-4.2 Cl-104 HCO3-26 AnGap-13 [2165-8-17] 10:00AM BLOOD CK(CPK)-185* [2165-8-17] 04:08PM BLOOD CK(CPK)-151 [2165-8-17] 08:24PM BLOOD CK(CPK)-137 [2165-8-18] 02:02AM BLOOD CK(CPK)-108 [2165-8-22] 01:01AM BLOOD CK(CPK)-401* [2165-8-22] 06:45AM BLOOD CK(CPK)-420* [2165-8-22] 03:49PM BLOOD CK(CPK)-297* [2165-8-23] 06:35AM BLOOD CK(CPK)-127 [2165-8-17] 10:00AM BLOOD CK-MB-5 [2165-8-17] 10:00AM BLOOD cTropnT-<0.01 [2165-8-17] 04:08PM BLOOD CK-MB-6 cTropnT-0.01 [2165-8-17] 08:24PM BLOOD CK-MB-5 cTropnT-0.02* [2165-8-18] 02:02AM BLOOD CK-MB-4 cTropnT-0.02* [2165-8-21] 03:00PM BLOOD CK-MB-2 cTropnT-<0.01 [2165-8-22] 01:01AM BLOOD CK-MB-68* MB Indx-17.0* cTropnT-1.30* [2165-8-22] 06:45AM BLOOD CK-MB-70* MB Indx-16.7* cTropnT-2.38* [2165-8-22] 03:49PM BLOOD CK-MB-38* MB Indx-12.8* [2165-8-23] 06:35AM BLOOD CK-MB-11* MB Indx-8.7* [2165-8-17] 10:00AM BLOOD Calcium-9.7 Phos-4.0 Mg-1.9 [2165-8-17] 04:08PM BLOOD calTIBC-384 Ferritn-139 TRF-295 [2165-8-17] 10:00AM BLOOD Digoxin-0.5* . [2165-8-17] CXR:FINDINGS: The heart is within normal limits in size. The mediastinal contours appear unremarkable. There is a left-sided pacemaker with single electrode in unchanged position. In comparison with [2165-5-16], there is development of diffuse bilateral interstitial opacities and probable slight prominence of the upper zone pulmonary vasculature. In addition, there is increase in hazy opacity within the right lower lung. No pleural effusion and no pneumothorax. The osseous structures appear unchanged. IMPRESSION: 1. Interval development of pulmonary vascular congestion. 2. Focal opacity in the right lower lung, suggestive of developing pneumonia. Repeat radiography after treatment is recommended . [2165-8-18] CXR: Comparison with the prior chest x-ray shows considerable improvement in the appearance of the failure over the past 24 hours with some residual changes in the right lung. There are no other significant alterations in the appearance of the chest. . [2165-8-21] Cardiac catheterization: 1. Selective coronary angiography revealed angiographic evidence of two vessel CAD. The LMCA was normal. The LAD had good flow and all stents were patent. The D1 and D2 were patent. The LCX was chronically occluded. The RCA had moderate disease with a 40% proximal lesion. 2. Hemodynamic evaluation revealed elevated filling pressures with mean PCWP of 21mm HG. There was borderline pulmonary hypertension with mean pressure of 27mmHG. The cardiac output and index were preserved. 3. A saturation run revealed a step up from SVC of 59% to PA of 66%. The patient is known to have an ASD. Formal shunt fraction calculation was not done as no arterial sat was drawn. 4. Successful PCI of the CTO LCX with three overlapping Minivision stents (2.5 x 23 mm, 2.5 x 28 mm, and 2.0 x 28 mm). Brief Hospital Course: 61 yo male with h/o CAD s/p MI in [4-2] s/p stent x3 (2 LAD, 1 D2), CHF (EF 20-30%)[7-2], and non-sustained VT s/p ICD who presents with acute shortness of breath and chest pressure . 1. CHF: Patient has EF of 20-30% on Echo from [7-2] and had been non-compliant with his diet. Chest x-ray revealed decompensated heart failure. In the ED he required BiPap and was attempted to be weaned but dropped his sats to the 80's. He was started on heparin drip, nitro drip, morphine and given Lasix 80 mg IV. CXR revealed decompensated heart failure. He was diuresed and his oxygen requirement decreased significantly by the second hospital day with improvement on chest x-ray. He was ruled out for MI with enzymes and was continued on his [Last Name (un) ] and BB and given IV Lasix for diuresis. Hi Coumadin was held given that he was planned to go to cath. He was transferred from the CCU to the floor where he remained stable on room air. However given his pain on admission and the degree of his CAD, he was taken to cardiac catheterization. His Coumadin was held during this time and was the restarted after catheterization his INR was 1.5 at discharge and will be monitored closely as an outpatient with a goal of [1-31]. 2. CAD: Patient is s/p stents x3 in [5-2] now presenting with shortness of breath and his anginal equivalent. Cath showed chronic occlusion of the left circumflex-OM and 3 overlapping minivision stents were placed. After the catheterization he had only mild chest discomfort but his enzymes ruled him in for MI. This was felt to be secondary to ischemia from instrumentation of left circumflex. The patient soon was pain free, satting well. His aspirin, Statin, Plavix, BB and [Last Name (un) ] were all continued and he was restarted on Coumadin as above for his apical akinesis. 3. GI: Patient reports having melena x 2 weeks. His colonoscopy showed internal hemorrhoids 2/[2160]. He was started on a PPI and his stools were guaiac negative. He will follow up for an outpatient colonoscopy and EGD. 4. Hypercholesterolemia: Continued on Statin. . 5. Anemia: Patient's baseline HCT 30. Given his recent melena his HCT was closely monitored and iron studies were checked. His HCT remained stable and his iron studies were within normal limits except for a low iron. He was started on ferrous sulfate for iron deficiency anemia. - Medications on Admission: Medications on admission: Aspirin 325 mg qd lipitor 80 mg po qd Plavix 75 mg qd digoxin 0.125 mg qd Coreg 3.125 mg qd Aldactone 12.5 mg qd Cozaar 25 mg qd Lasix 10 mg qd Coumadin 5mg 6 days, 2.5 mg sunday albuteral inh ipratropium inh . Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO once a day. 5. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day. 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 12. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Discharge Disposition: Home Discharge Diagnosis: 1. Decompensated CHF 2. Coronary artery disease s/p stent to LCX Discharge Condition: chest pain free, no shortness of breath, afebrile Discharge Instructions: If you have any chest pain, shortness of breath, palpitations, abdominal pain or any other concerning symtoms you should call your doctor or go to the mergency room. You should weight yourself every day. If your weight increases by more than 3 lbs you should call your doctor. Your should restrict your fluid intake to 1.5 liters and maintain a low sodium diet (2 grams). Check your blood pressure every morning and if your systolic blood pressure is <90, do not take the Coreg and call your cardiologist. Take coumadin 5 mg each night until you have your INR checked next week (the INR on day of discharge was 1.6) Followup Instructions: Please make an appointment to follow up with Dr. [Last Name (STitle) ] in [12-30] weeks, ([Telephone/Fax (1) 11176]. You should make an appointment with your primary doctor in [3-1] weeks. You should discuss having a colonoscopy as you were found to have an iron deficiency anemia. Continue you have you INR checked at [Company ]. You should have it checked sometime next week. Dr. [Last Name (STitle) ] will follow up the results.	[ "9971", "496", "4280", "41401", "4019", "412", "2724", "V5861", "V4582" ]
Admission Date: [2168-11-19] Discharge Date: [2168-11-25] Date of Birth: [2111-1-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1943] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 57 year old gentleman with trachoeobronchomalasia s/p y-stent placement, multiple prior admissions to ICU, p/w SOB x3 days. The patient had a sudden onset of SOB at night with subsequent increased difficulty breathing and increased sputum production for the next several days. He denies any fever, +/- chills, no lightheadedness or dizziness. No CP. He states that he sleeps semi-upright in bed and can not lie flat [2-15] sleep apnea. In addition, he endorses PND which he also attibutes to sleep apnea. He denies any lower ext edema in the past week. Per rehab notes, he was started on Unasyn today. The patient notes that he now feels significantly better that on arrival the the ED. Of note, he was recently discharged on [11-1] after a short admission for tracheostomy removal, stoma revision, and T-tube placement. These procedures were performed as patient had not tolerated "red-cap" and was noted to have malacia proximal to y-stent. In addition, he had an admission in [9-/2168] for y-stent placement which was complicated by renal failure and pulmonary edema requiring PPV. He was discharged on Vancomycin, Cipro and Cefepime with an unclear course. Review of systems is otherwise negative. In the emergency department, initial vitals were T98.3, 73, 118/48, 20-25, 98% 4L NC. The patient was found to be rhonchorous on exam with acessory muscule use. CXR was performed and was notable for retrocardiac opacity. Labs were significant for K 5.2 and BNP of 1700 (10,000 on last admit). EKG with no significant changes. D-dimer was positive at 1400. The patient was initially put on NRB, but was able to be weaned to 2 L NC. The patient was also noted to have secretions, blood cultures were sent and was started on Vanc/Zosyn empirically. The patient was evaluated by Interventional Pulmonology, who thought that it's unlikely stent plugging if no lobar collapse seen on CXR, may be more associated w/ secretions. Past Medical History: Diabetes Mellitus Atrial Fibrillation Obstructive sleep apnea Chronic Kidney disease Morbid Obesity Gout HTN Asthma Social History: Married, lives with wife and 24 year old son. Previously worked as a butcher, but now on disability secondary to chronic back pain and sciatica. Family History: Mother had heart and kidney disease and died at 89 from renal failure. Physical Exam: GENERAL: Pleasant, well appearing in NAD HEENT: tracheostomy with mild erythema and a small amount of brownish-yellow discarge; coughing frequently with purulent sputum CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP= 8 LUNGS: diffuse coarse rhonchi, no respiratory distress, + adbominal breathing w/o tachypnea ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: LABS ON ADMISSION: [2168-11-19] 06:55PM BLOOD WBC-10.9# RBC-3.30# Hgb-10.5# Hct-30.7# MCV-93 MCH-31.9 MCHC-34.3 RDW-14.3 Plt Ct-240 [2168-11-19] 06:55PM BLOOD Neuts-74.8 Lymphs-16.0* Monos-4.5 Eos-4.3* Baso-0.4 [2168-11-19] 06:55PM BLOOD PT-11.8 PTT-25.9 INR(PT)-1.0 [2168-11-19] 06:55PM BLOOD Glucose-135* UreaN-36* Creat-2.2* Na-133 K-5.2* Cl-102 HCO3-23 AnGap-13 [2168-11-19] 06:55PM BLOOD proBNP-1700* [2168-11-20] 08:40AM BLOOD Calcium-10.1 Phos-3.5 Mg-1.5* [2168-11-19] 09:23PM BLOOD D-Dimer-1489* [2168-11-19] 07:12PM BLOOD Lactate-1.1 LABS ON DISCHARGE: [2168-11-24] 05:27AM BLOOD WBC-6.1 RBC-3.05* Hgb-9.8* Hct-28.3* MCV-93 MCH-32.1* MCHC-34.6 RDW-14.1 Plt Ct-263 [2168-11-24] 05:27AM BLOOD Plt Ct-263 [2168-11-25] 04:44AM BLOOD Glucose-99 UreaN-22* Creat-1.2 Na-141 K-4.3 Cl-107 HCO3-27 AnGap-11 [2168-11-22] 06:24AM BLOOD proBNP-657* [2168-11-23] 03:53AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.7 Vanc Level [11-25]: 32 (note this was taken ~3.5 hrs before next q12 dose) EKG ON ADMISSION: Sinus rhythm. Non-specific intraventricular conduction delay. Prominent limb lead QRS voltage suggests left ventricular hypertrophy. Non-specific low amplitude T waves in the limb leads. Compared to the previous tracing of [2168-9-13] QRS change in lead V3 could be positional. CXR ON ADMISSION: PA AND LATERAL: Low lung volumes limit evaluation of the lungs. Bibasilar subsegmental atelectasis is noted. There is no evidence of pneumonia or congestive heart failure. The heart is enlarged. The aortic contour is not well seen; however, mildly tortuous. IMPRESSION: Cardiomegaly with no evidence of pneumonia or congestive heart failure. Brief Hospital Course: 1. [Hospital 16486] Healthcare Associated: Patient admitted with recent h/o both MRSA and Zosyn-resistant PNA as well as difficulty clearing secretions due to y-stents. Admitted to ICU afebrile, normotensive but with respiratory distress and hypoxia requiring non-rebreather. CXR with retrocardiac opacity atelectesis vs consolidation. History of pulmonary edema but CXR clear, no LE edema, no JVD, BNP of 657 vs 10,000 on prior admission. No evidence of lobar collapse on CXR. D-dimer elevated but low clinical suspicion for PE. Patient was started on Vanc, Levo and Meropenem based on prior sensitivities. The patient was given mucomyst IH, guaifenisin and regular nebulizer treatments, as well as frequent suctioning. Over the next day dyspnea significantly improved and patient was weaned down to room air. Bronchoscopy [11-22] showed no acute problems with his y-stent. Sputum cultures grew out overwhelming proteus which was cefepime-sensitive but could not rule out other organisms. He was continued on full 8-day course of antibiotics for HAP consisting of vanc, cefepime and levofloxacin. Vancomycin levels were adjusted twice for changing renal clearance. Dose on discharge 1250mg q24 hours. Antibiotic Course: -Levofloxacin: [Date range (1) 83204] -Vancomycin: [Date range (1) 83204] -Meropenum: [Date range (1) 83205] (switched to cefepime) -Cefepime: [Date range (1) 81061] 2. Blood Pressures: Initially hypertensive consistent with patient's baseline. Hypertension was controlled with patient's home regimen of hydralazine, isordil, metoprolol and amlodipine. The patient was noted to be transiently hypotensive on [11-21] with SBP in 90s and decreased urine output. However, his mental status remained normal, he remained otherwise hemodynamically stable and responded well to IVF. Anti-hypertensive medications were held in the context of relative hypotension and then restarted gradually with good effect. His BPs remained normal across the remainder of his hospitalization. 3. Acute Kidney Injury: Patient was admitted with a creatinine of 2.2 versus a baseline from [2168-7-13] of ~1.0. His creatinine resolved rapidly with treatment with IVF and was 1.1 at the time of discharge. 4. Atrial Fibrillation: Controlled on metoprolol. Aspirin was continued. 5. DM: Blood sugars were controlled with glargine and an insulin sliding scale. 6. OSA: The patient's tracheostomy was uncapped at night to allow for unobstructed breathing. Medications on Admission: Docusate Sodium 50 mg/5 mL Liquid [Year (4 digits) ]: One (1) PO BID (2 times a day). Senna 8.6 mg Tablet [Year (4 digits) ]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Fentanyl 25 mcg/hr Patch 72 hr [Year (4 digits) ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Quetiapine 25 mg Tablet [Year (4 digits) ]: One (1) Tablet PO QHS (once a day (at bedtime)). Heparin (Porcine) 5,000 unit/mL Solution [Year (4 digits) ]: One (1) mL Injection TID (3 times a day). Quetiapine 25 mg Tablet [Year (4 digits) ]: 0.5 Tablet PO QAM (once a day (in the morning)). Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [Year (4 digits) ]: [1-15] Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Month/Day (2) ]: 10-20 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. Guaifenesin 600 mg Tablet Sustained Release [Month/Day (2) ]: Two (2) Tablet Sustained Release PO q12 (). Benzonatate 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO TID (3 times a day) as needed for cough. Aspirin 325 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Isosorbide Dinitrate 30 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day) as needed for SBP >150. Acetaminophen 160 mg/5 mL Solution [Last Name (STitle) ]: 325-650 [Hospital1 ] mg PO Q6H (every 6 hours) as needed for fever. Metoprolol Tartrate 50 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q6H (every 6 hours). Hydralazine 20 mg/mL Solution [Hospital1 ]: Thirty (30) mg Injection Q6H (every 6 hours). Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [Hospital1 ]: 15-30 MLs PO QID (4 times a day) as needed for heartburn. Diabetes Management: Glargine 28 units qhs (stopped?) and Regular insulin sliding scale Discharge Medications: 1. Acetylcysteine 20 % (200 mg/mL) Solution [Hospital1 ]: 1-10 MLs Miscellaneous TID (3 times a day): Give as NEB for trach care. . 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [Hospital1 ]: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Fentanyl 25 mcg/hr Patch 72 hr [Hospital1 ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Guaifenesin 100 mg/5 mL Syrup [Hospital1 ]: 5-10 MLs PO Q6H (every 6 hours). 5. Docusate Sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 6. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Simethicone 80 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO QID (4 times a day). 8. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Quetiapine 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at bedtime). 11. Quetiapine 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO QAM (once a day (in the morning)). 12. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [Last Name (STitle) ]: [1-15] Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 13. Hydralazine 10 mg Tablet [Month/Day (2) ]: Three (3) Tablet PO Q6H (every 6 hours). 14. Amlodipine 5 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily). 15. Isosorbide Dinitrate 10 mg Tablet [Month/Day (2) ]: Three (3) Tablet PO TID (3 times a day). 16. 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. 17. Insulin Regular Human 100 unit/mL Solution [Month/Day (2) ]: sliding scale Injection twice a day: Please administer per sliding scale. 18. Levofloxacin 500 mg Tablet [Month/Day (2) ]: One (1) Tablet PO once a day for 4 days: Through [2168-11-28]. 19. Cefepime 2 gram Recon Soln [Month/Day/Year ]: Two (2) grams Intravenous twice a day for 4 days: 2 grams q12 IV for 4 days, through [2168-11-28]. 20. Metoprolol Tartrate 100 mg Tablet [Month/Day/Year ]: One (1) Tablet PO Q6H (every 6 hours). 21. Vancomycin 1,000 mg Recon Soln [Month/Day/Year ]: 1250 (1250) mg Intravenous every twenty-four(24) hours for 3 days: last dose on [11-18]. Discharge Disposition: Extended Care Facility: [Hospital 169] Center- [Location (un) ] Discharge Diagnosis: PRIMARY: 1. Healthcare associated pneumonia 2. Tracheobronchiomalacia 3. Hypertension SECONDARY: Diabetes mellitus Atrial fibrillation Obstructive sleep apnea Chronic kidney disease Morbid obesity Gout HTN Asthma Discharge Condition: Stable, breathing comfortably on room air, tolerating regular diet without difficulty Discharge Instructions: It was a pleasure taking care of you during your admission at [Hospital1 69]. You were admitted for shortness of breath. While you were here you were treated with nebulizers, fluids and antibiotics. We changed some of your medications while you were here. Please take all of your medications exactly as prescribed. Please call your physician or go to the emergency room if you experience any of the following: chest pain, worsening shortness of breath, vomiting, any loss of consciousness, fevers, chills, or other concerning symptoms. Followup Instructions: Lung Function Tests: Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2168-11-28] 10:00 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2168-11-28] 10:00 Pulmonary and Thoracic Appointment: Provider: [Name10 (NameIs) 1532] [Last Name (NamePattern4) 8786], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2168-12-6] 9:30 [2168-12-6] 11:00a [Doctor Last Name 17853] CLINIC DE [Hospital1 ] BUILDING ([Hospital Ward Name ] COMPLEX), [Location (un) ] INTERVENTIONAL PULMONARY (SB) [2168-12-6] 12:00p [Doctor Last Name ],CDC PROCEDURES [Hospital Ward Name ] BUILDING ([Hospital Ward Name ] COMPLEX), [Location (un) ] CDC PROCEDURES	[ "5849", "49390", "40390", "5859", "42731", "25000", "V5867", "32723" ]
Admission Date: [2114-9-10] Discharge Date: [2114-9-18] Date of Birth: [2031-7-8] Sex: M Service: NEUROSURGERY Allergies: Iodine; Iodine Containing / Codeine Attending:[First Name3 (LF) 2724] Chief Complaint: new back pain Major Surgical or Invasive Procedure: Transpedicular decompression, T10, of epidural metastatic disease with instrumented fusion from T8-T12. History of Present Illness: This 83 yo male who is a pt of Dr. [Last Name (STitle) ] with known history of prostate cancer and lytic lesion in T10 diagnosed in [2112] s/p radiation presents with complaint of severe lower thoracic back pain thought to be T11-12 radicular in nature. Of note patient came off his second line hormonal therapy in [Month (only) 205] after progression of disease was noted. He was taken off ketonconazole and had his hydrocortisone tapered. DES was started concurrently. At that time he began to notice a dull aching right side lower back pain. He underwent MRI of the lumbar spine, incomplete due to intolerance to pain as well as claustrophobia. At the beginning of [Month (only) 216], there was concern for possible progression of disease in the thoracic spine that may need XRT. Patient now presents with severe bilateral lower back pain that's different to the prior symptoms. His new pain is sharper and feels like a band around the back. He denies any parathesia or weakness of the lower extremities. He denies any bowel or bladder issues. He has no fever, chill or rigorm dysuria, or change in urinary frequency. . In the ED neuro exam was essentially intact and rectal tone was normal. He was noted to have severe hypertension which improved on pain meds as well as metoprolol. He was admitted for MRI of the thoracic spine to rule out cord compression, BP control, as well as pain management. Past Medical History: )CAD s/p CABG '[04] 2)Restrictive lung disease 3)Bronchiectasis 4)Bladder ca 5)Type 2 Diabetes 6)Hx of asbestosis exposure 7)Pulmonary nodule 8)Prostate ca as well as bladder ca 9)COPD 10) OA 11) HTN Social History: Lived with two daughters and grandson in [Name (NI) 701]. Currently living with girlfriend in [Name (NI) 5110]. Retired, used to work in dry cleaning. Quit tobacco 30 years ago, no ETOH, no illicits. Family History: NC Physical Exam: 97.8, 150/80, 64/min, 18/min, 94% on ra General: comfortable at rest, no apparent distress Neck: supple, no jvd, no nodes CV: rrr, nl s1+s2, no m/r/g Lungs: ctab, nl effort Abdomen: soft, non tender, nl bs Ext: no clubbing cyanosis or edema. Neuro: cns [3-8] intact, lower back pain band like, no rash, no papule, nl strength. delayed reflexes in upper and lower extremities. Babinski equivocal. a&o x 3 Exam upon discharge: Incision site was clean and dry without erythema, collection or drainage. Staples and drain stitch were in place. His LE's had full strength and sensation to light touch. There was no clonus noted. Pertinent Results: [2114-9-10] 01:30PM WBC-8.5 RBC-4.21* HGB-12.2* HCT-38.0* MCV-90 MCH-29.1 MCHC-32.2 RDW-13.4 [2114-9-10] 01:30PM NEUTS-78.0* LYMPHS-15.7* MONOS-4.8 EOS-1.2 BASOS-0.3 [2114-9-10] 01:30PM PLT COUNT-198 [2114-9-10] 01:30PM GLUCOSE-225* UREA N-15 CREAT-1.0 SODIUM-133 POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-27 ANION GAP-16 [2114-9-10] MR T spine - 1. Multiple lesions noted from the T8-T11 vertebral bodies, with extensive involvement of the T10 and T11 vertebral bodies, and a prominent epidural component, seen along the right side of the spinal canal from anterior to posterior aspects, causing displacement and compression of the cord, at T10 and T11 levels. Perineural/foraminal and right paravertebral components as well, as described above. 2. Involvement of the ribs along with soft tissue mass, related to metastatic involvement, from T8-T12 levels, inadequately assessed on the present study as not targeted. 3. Mild enhancement of the meninges/anterior surface of the thecal sac from T6-T12 levels. [2114-9-11] - CT Head No hemorrhage, edema or mass effect. [2114-9-14] Tspine xray FINDINGS: Metallic fixation is identified in the lower thoracic spine, of the T8, T9, T11 and T12 vertebral bodies. Satisfactory alignment on AP and lateral views. Prominent mural calcification of the aorta in keeping with atherosclerosis. Bowel gas pattern is unremarkable. A small right basal pleural effusion is seen. [2114-9-15] CXR FINDINGS: Compared to the most recent prior film the right CP angle is better visualized, now not cut off from view. There is an opacity in this region - more remote prior film showed a nodule in this area. I would suggest follow up of this region to see if this is evolving. Otherwise, there is no significant interval change. Orthopedic hardware stable in appearance. [2114-9-16] Shoulder right xray Four total radiographs are submitted. There is moderate osteoarthritis of the acromioclavicular joint. There is also moderate osteoarthritis of the glenohumeral joint with osteophyte formation and joint space narrowing. No fracture or malalignment identified. Visualized right Upper lungs are clear. Brief Hospital Course: 83 yo with metastatic prostate ca s/p xrt in [2112] for thoracic mets now progressing through second line hormonal therapy and was recently started on [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] presents with band like lower back pain without radiation or neurological deficit. He was being followed by oncology. He had a PSA near 60, this was increasing despite treatment with DES. Dr. [Last Name (STitle) ], his outpt oncologist, decided to stop [Name Prefix (Prefixes) ] [Last Name (Prefixes) 97322]. Coumadin which had been initiated with DES as prophylaxis was d/c'd also Lower back pain: Pt had no focal neurologic exams, but given new pain there was concern for cord compression. He received an MRI in ED which showed T10-12 compression. IV steroids were initiated. Neurosurgery and Radiation Oncology were consulted. Pain controlled with MS Contin and prn dilaudid. Surgery was decided to be the best option as pt has history of radiation in this area in the past. He was brought to the OR [2114-9-13] where under general anesthesia he underwent transpedicular decompression, T10, of epidural metastatic disease with instrumented fusion from T8-T12. He tolerated this procedure well, did require intra-op transfusions. He remained intubated and brought to the ICU overnight. Post op he had full strength. He was extubated on the first post op morning. His diet and activity were advanced. He had JP drain in that was monitored and removed [2114-9-15]. He was transferred to the floor [9-15]. He did have episode of hypertension [9-16] enzymes were flat and EKG unchanged. He was monitored on telemetry. He had shoulder pain on right and xrays showed no fracture or dislocation but osteophyte and osteoarthritis. he was tapered off his decadron. Wound was clean and dry. He was evaluated by PT/OT and felt safe for discharge to home. On [9-17], patient has been intermittently hypertensive, his lopressor was increased to 37.5mg [Hospital1 ] and prn hydralazine 10mg IV was administered. Patient's BP was reduce to the 130s. He remained stable and was discharged to home on [9-18]. Medications on Admission: DES 1mg daily Leupron - adminstered q3months, last dose [2114-8-30]. FINASTERIDE - 5 mg Tablet - 5 mg Tablet(s) by mouth take one pill a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff intraoral twice a day FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth q AM GLYBURIDE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day LISINOPRIL - 30 mg Tablet - 1 Tablet(s) by mouth once a day LORAZEPAM [ATIVAN] - 0.5 mg Tablet - 1 Tablet(s) by mouth q hs prn insomnia METFORMIN - 1,000 mg Tab,Sust Rel Osmotic Push 24hr - 1 Tab(s) by mouth qam METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth once a day MORPHINE - 15 mg Tablet Sustained Release - [Hospital1 ] OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth take one pill once a day OXYCODONE - 5 mg Capsule - 1 Capsule(s) by mouth take one or two as needed for pain every 4 hours PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth as needed every 6 hours as needed for prostate cancer TERAZOSIN - 5 mg Capsule - 1 Capsule(s) by mouth once a day WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth daily MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 (One Tablet(s) by mouth once a day Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:80 Tablet(s) Refills:0 9. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: metastatic prostate cancer to spine hypertension osteoarthritis of the right acromioclavicular joint and glenohumeral joint Discharge Condition: Neurologically stable Discharge Instructions: ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ take daily showers ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc.for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: follow -up with your PCP regarding the right shoulder pain you experienced during your hospital stay as well as your elevated blood pressure within the next 1-2 weeks. Your right shoulder xray on [2114-9-16] revealed moderate osteoarthritis. PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 6 WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT The following appointments have already been scheduled for you. They are listed here for your convenience. Provider: [First Name11 (Name Pattern1) 2946] [Last Name (NamePattern4) 3217], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2114-9-27] 11:30 Provider: [Name10 (NameIs) 5338] [Name8 (MD) 5339], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2114-9-27] 1:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15048], MD Phone:[Telephone/Fax (1) 9347] Date/Time:[2114-10-3] 9:00 Completed by:[2114-9-18]	[ "4019", "25000", "V4581", "V5861" ]
Admission Date: [2199-1-31] Discharge Date: [2199-2-14] Date of Birth: [2136-7-28] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2836] Chief Complaint: General surgery was consulted for sepsis, colitis Major Surgical or Invasive Procedure: [2-1]: Total abdominal colectomy with end ileostomy. [2-1]: Reopening of recent laparotomy, oversewing of mesenteric venous bleeder, placement of a vacuum dressing of about 50 cm2. [2-4]: Re-exploration with removal of packs, replacement of GJ feeding tube and closure of abdomen. History of Present Illness: Pt is a 62M with multiple medical problems who was recently hospitalized (1/25-28/09) in the MICU for pneumonia, sepsis, and C-Diff colitis. He was discharged on a course of Vancomycin IV for MRSA pneumonia as well as PO vanco for the C Diff. [1-31] he was noted to be febrile at his nursing home with mental status changes. He was also hypotensive. He was transferred to the [Hospital1 18] ED where he initially had a blood pressure of 66/38. His IV access is extremely difficult and a R femoral CVL was placed. He was volume resuscitated with 7L IVF and pressors were started. Once he somewhat stabled a CT of the abdomen was obtained demonstrating worsened distal colonic wall thickening and edema. The ED then requested this surgical consult. No other HPI can be obtained given the patient's inability to answer questions. Family reports the patient normally is able to speak Spanish and understand English. The ED reports patient answers questions in English by blinking eyes. Reportedly patient had endorsed abdominal pain and was tender in the LLQ for the ED resident exams. Of note, a discharge summary is not yet available from the recent hospitalization. Past Medical History: -Hypertension -CVA: bilateral embolic cerebellar [2188], hemorrhagic left thalamic [2190] -Type II Diabetes mellitus -Peripheral neuropathy -Constipation -Dysphagia -Depression -Hypothyroidism -h/o DVT Social History: Resident of [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ]. Family very involved in patient's care. Patient does not take anything by mouth due to history of aspiration. Spanish-speaking. tobacco: quit [2183]. 30+ yrs, 2ppd. alcohol: denies drugs: denies Family History: mother - died, DM father - died, Pneumonia other - brother - heart disease No family history of cancer. Physical Exam: On day of consultation: Dopa 20mcg/kg/min Levo 0.27 mcg/kg/min 101.8 80 107/43 21 98% 4L ED I/O: 7L IVF/1L UO Snoring. Does not arouse to voice or sternal rub No jaundice or icterus CTA B/L RRR Abd soft, non distended. unknown tenderness R femoral groin line in place Ext: All 4 extremities with severe contractures, cool, clammy Pertinent Results: [1-31] CT Abd / Pelvis Interval worsening of distal colonic wall thickening and bowel wall edema, which now extends from the rectum proximally to the splenic flexure, compatible with proctocolitis. Findings are likely secondary to an infectious cause, especially in the context of the patient's clinical history, but an inflammatory etiology is not excluded. No evidence of perforation, or obstruction. . [1-31] Colonic Pathology Pseudomembranous colitis involving the distal 25 cm of colon and margin, consistent with C. difficile infection . [2199-2-12] 04:48AM BLOOD WBC-17.9* RBC-3.05* Hgb-9.0* Hct-27.0* MCV-89 MCH-29.5 MCHC-33.3 RDW-16.2* Plt Ct-415 [2199-2-10] 04:14AM BLOOD Neuts-88* Bands-1 Lymphs-2* Monos-4 Eos-2 Baso-0 Atyps-1* Metas-1* Myelos-1* [2199-2-12] 04:48AM BLOOD Glucose-148* UreaN-11 Creat-0.3* Na-137 K-4.3 Cl-100 HCO3-30 AnGap-11 Brief Hospital Course: The patient was admitted to the ICU with a foley catheter in place, IVF, NPO, central venous line, vasopressors as needed, IV flagyl. There were increased pressor requirements and the patient was taken emergently to the operating room for the above procedure. He tolerated the procedure and was transferred to the ICU intubated, on pressors, foley catheter in place, and IV flagyl. He had increasing pressor requirements unresponsive to fluid and packed red blood cells and the decision was made to take him back to the operating room for re-exploration. A bleeding vessel was noted, oversewn and the abdomen was left open. He was again transferred to the ICU, intubated, on minimal pressors, IV Flagyl, vanc enemas, zosyn, and sedation as needed. He continued intubated, on vanc, zosyn, and flagyl, IVF, NPO, and supportive care in the ICU. Diuresis began [2-4] with IV lasix. He returned to the ICU [2-4] for placement of a J tube and closure of his abdominal wound. He remained intubated, IVF, NPO, NGT and foley catheter in place, antibiotics. [2-5] trophic tube feeds started [2-6] continued abx, tube feeds, ventilatory management, NPO, IVF, started lasix drip [2-7] extubated, continued tube feeds, antibiotics, NPO, IVF [2-8] advanced tube feeds towards goal of 70ml/hr, continued diuresis with IV lasix prn, antibiotics, patient refused speech and swallow evaluation [2-11] transferred to the surgical floor for continued monitoring, restarted coumadin dose, patient refused speech and swallow consultation again [2-12] discontinued antibiotics, continued tube feeds at goal Medications on Admission: 1. Warfarin 5mg daily 2. Simvastatin 20mg daily 3. Cymbalta 60mg daily 4. Colace 150 mg/5 mL Liquid [Hospital1 ] 5. Gabapentin 600mg TID 6. Morphine 15 mg q4hrs 7. Baclofen 20 mg QID 8. Mirtazapine 7.5 mg qHS 9. Lisinopril 5 mg daily 11. Insulin Sliding Scale with Novolin R 100 units/Ml Vial 12. milk of magnesia 30ml every other day 13. senna daily 14. Clopidogrel 75 mg daily 15. miralax 17gm daily 16. fentayl patch 25mcg q72 hrs 17. levothyroxine 25mcg daily 18. Multivitamin 19. reglan 5mg qhs Vancomycin, both IV & PO completed on [2199-1-22] Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] Discharge Diagnosis: Primary: Clostridium Difficile colitis s/p Total abdominal colectomy with end ileostomy complicated by intra-abdominal hemorrage requiring re-exploration Secondary: 1. Multiple cerebral vascular accidents (dysarthria, dysphagia [purees +TF] inability to walk) 2. Atrial fibrillation 3. Hypertension 4. Diabetes Mellitus 5. Depression 6. Neuropathic pain 7. Hyperlipidemia 8. GERD Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your 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. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * 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 ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Followup Instructions: Please call the office of Dr. [First Name (STitle) ] to arrange a follow up appointment in [1-22] weeks at [Telephone/Fax (1) 80453] Previously Scheduled Appointments: Provider: [Name10 (NameIs) 454],TWO [Name10 (NameIs) 454] Date/Time:[2199-3-11] 8:30 Provider: [Name10 (NameIs) 6122] WEST OUTPATIENT RADIOLOGY Phone:[Telephone/Fax (1) 8243] Date/Time:[2199-3-11] 10:00 Completed by:[2199-2-14]	[ "0389", "51881", "5849", "99592", "2449", "53081", "4019" ]
Admission Date: [2133-12-25] Discharge Date: [2134-1-25] Date of Birth: [2088-3-30] Sex: F Service: MICU CHIEF COMPLAINT: Cough, chest pain, and weakness. HISTORY OF PRESENT ILLNESS: Patient is a 45-year-old female with no significant past medical history transferred from [Hospital3 35813] Center in [Doctor Last Name 792]for continued management of ARDS/sepsis for pneumococcal pneumonia. She was in her usual state of health until [2133-12-12] when she reported the onset of [7-22] days of cold symptoms including sore throat, diarrhea, cough, and congestion, but no fever or chills. On [2133-12-19], she developed right sided chest pain, shaking chills, and subjective fevers. Her symptoms worsened over the next day and she is evaluated in the Emergency Department at the outside hospital. She is found to have extensive bouts of lobar pneumonia in the right middle lobe and right lower lobe, as well as being hypotensive to 88/55, hypoxic, and in renal failure with a creatinine of 4.5. She was also noted to be hypothermic on occasion with temperatures in the low 90s. She was given intravenous fluid, ceftriaxone, azithromycin, levofloxacin, and gentamicin. She was found to have a leukopenia with a white blood cell count of 2.2, which was left shift. Over the next 24 hours, the patient worsened significantly and was intubated for respiratory distress with a chest x-ray revealing bilateral infiltrates. She became progressively more hypotensive and felt to be septic in ARDS. She was started on Vancomycin, dopamine, and Xigris on [2133-12-21]. A Swan-Ganz catheter is placed on [12-21] as well. Blood and sputum cultures subsequently grew out Strep pneumoniae which was sensitive to penicillin and Levaquin. Her course had been further complicated by development of a right pneumothorax felt secondary to high levels of PEEP and required chest tube placement on [2133-12-23]. Her respiratory status has remained persistently poor escalating to requiring 100% FIO2 on assist control ventilation to keep her saturations above 90%. Repeat chest x-ray again showed worsening of bilateral infiltrates. Of note her previous hospitalization was also complicated by development of supraventricular tachycardia treated with prn Lopressor and digoxin. Patient is now transferred to [Hospital1 188] for further management. Her last Swan-Ganz number is reviewed. Cardiac output was 5.0, pulmonary capillary wedge 25, CVP was 13. In the interval since admission, her platelets have trended down to 47 with DIC screening revealing fibrinogen in the 700s, positive D diameter. White blood cell count is increased from 1.1 to 26.6. Creatinine has remained elevated at greater than 4. Her coagulation panel however, has remained stable. Urine Legionella antigen was sent and was found to be negative. PAST MEDICAL HISTORY: 1. History of tubal ligation. 2. Natural childbirth x2. No complications during pregnancy. ALLERGIES: No known drug allergies. OUTPATIENT MEDICATIONS: None. MEDICATIONS ON TRANSFER: 1. Ceftriaxone 1 gram IV q day. 2. Levophed 5 mcg/kg/minute. 3. Combivent four puffs tid. 4. Zantac 50 mg IV q day. 5. Xigris x4 days. 6. Lopressor IV prn. 7. Digoxin IV prn. 8. Propofol 31 mcg/kg/minute. SOCIAL HISTORY: She smokes a pack per day x10 years. Drinks alcohol socially. She works at [Company ]. She has no history of intravenous or recreational drug abuse. She is divorced and currently lives with the boyfriend. She has two children. She has no recent history of recent travel. PHYSICAL EXAMINATION: On presentation, temperature is 98.4, heart rate 123, respiratory rate 20, and blood pressure 88/44, and oxygen saturation of 88% on vent settings. AC 500 by 20 FIO2 of 100%, PEEP of 15%. Arterial blood gas was 7.2, 37, and 161. Swan numbers on admission: CVP 14, P.A. pressure 43/30, pulmonary capillary wedge pressure of 31, SVR 797, cardiac output 5.0. In general, the patient is comfortable, sedated, and unresponsive. Pupils were equal and reactive to light, but sluggish. She had negative doll's eyes. ETT was in place. Neck was supple. Right subclavian cordis was in place. The sight was clean, dry, and intact. Anterior chest tube was placed on the anterior right chest. The site was without significant erythema. On cardiovascular examination, she was tachycardic and was irregularly, irregular. On lung examination, she had bilateral rales and wheezes diffusely. Her abdomen was soft, nontender, nondistended with normoactive bowel sounds. She had [1-14]+ lower extremity pitting edema. Her extremities were warm with 2+ dorsalis pedis and posterior tibial pulses bilaterally. She had 2+ radial pulses bilaterally. Skin demonstrated no rash. On neurologic examination, she was unresponsive to noxious stimuli. INITIAL LABORATORY VALUES: White blood cell count 27.1, hemoglobin 11.9, hematocrit 34.8. Differential: 89% neutrophils, 8% bands, 3% lymphocytes. Platelets 40. PT 14.4, PTT 34.5, INR 1.4. D dimer greater than 2,000. FDP elevated at [Telephone/Fax (1) 14007]. Fibrinogen 64. Sodium 134, potassium 3.9, chloride 98, bicarb 28, BUN 62, creatinine 2.5, glucose 44. ALT 27, AST 63, LDH 838, alkaline phosphatase 166, total bilirubin 0.5, lipase 47, albumin 1.6, calcium 6.4, phosphorus 8.3, magnesium 1.7. Lactate 6.5. Pertinent microbiology data: 1. Blood cultures x15 no growth. 2. Quinton catheter tip positive for VRE. 3. Sputum culture x2, [Female First Name (un) 564] albicans, no microorganisms x5. 4. Urine culture, [Female First Name (un) 564] albicans. Radiographic studies: CT scan torso on [2134-1-1]: Moderate sized right pneumothorax, right middle lobe consolidation with air bronchograms suggestive of right middle lobe pneumonia. Diffuse ground-glass opacities throughout both lungs and dependent atelectasis. Moderate bilateral pleural effusions. Extensive subcutaneous emphysema tracking to thighs. Heterogenous appearance of spleen, possible splenic infarcts. Chest x-ray on admission [2133-12-25]: Diffuse patchy and opacities in the right lung, left lingula, and left lower lobe consistent with ARDS. Tiny pneumothorax in the right chest. IMPRESSION: A 45-year-old female with no significant past medical history who presented to outside hospital after complicated course including hypotension, sepsis, ARDS, ATN, and DIC who is transferred to [Hospital1 188] for further management. HOSPITAL COURSE: 1. Pulmonary: Patient was intubated at outside hospital and a chest tube was placed for a right pneumothorax. On hospital day #2, the chest tube was noted to be kinked and per chest x-ray, was found to be outside the chest wall leading to significant subcutaneous emphysema. As she was clinically unstable, the chest tube remained in suboptimal position for the next few days which was eventually pulled and replaced by three additional chest tubes on [2133-12-29]. The right pneumothorax and subQ emphysema gradually resolved over the next few weeks, and chest tubes were pulled on [2134-1-17]. After the chest tubes were pulled, an audible air leak was noted and two chest tubes were replaced into the right hemithorax. One of the chest tubes were discontinued on [2134-1-21], however, the remaining chest tube remains in place in the right hemithorax at the time of this dictation. She was slowly weaned from the ventilator keeping PEEP as low as possible with high respiratory rate, low volumes for optimal management of right pneumothorax and ARDS. She was extubated on [2134-1-13], however, necessitated reintubation on [2134-1-17] for tachypnea, decreased oxygen saturations, and respiratory distress. As she cannot be further weaned from the ventilator, a tracheostomy is placed on [2134-1-21] without any complications. She currently is on trache mask ventilation and tolerating it well. Cardiovascular: On presentation to [Hospital1 190], she was hypotensive secondary to septic shock. She was maintained on Neo-Synephrine, Levophed, and Vasopressin for optimization for blood pressure control. The Levophed and Neo-Synephrine were discontinued on hospital day #4, where as the Vasopressin was weaned to off on [2133-12-21], however, had to be restarted on [2134-1-4] for hypotensive episodes in the setting of increased fever and rising white count. Vasopressin was continued for two days and then stopped finally on [2134-1-6]. She remained off pressors and hemodynamically stable for the remainder of the hospitalization. Of note, she was found to be in atrial fibrillation with a rapid ventricular response on transfer which was resistant to cardioversion x2. She was loaded with amiodarone and continued on an amiodarone drip for approximately two weeks starting [2133-12-26], and was switched to po medication. Amiodarone was discontinued on [2134-1-12], and patient has had no ectopy since. The patient converted to normal sinus rhythm after amiodarone load. A transesophageal echocardiogram was performed on [2133-12-31] for concern for endocarditis given sepsis and continued spiking fevers. On transesophageal echocardiogram, she was noted to have two vegetations on the tricuspid valve with normal ejection fraction and 2+ tricuspid regurgitation. 3. Infectious Disease: On presentation to outside hospital, she is noted to have multilobar identified as Strep pneumoniae. Blood cultures at outside hospital grew 4/4 bottles for Strep pneumoniae which was sensitive to penicillin and Levaquin. Blood cultures x15 sets at [Hospital1 1444] have shown no growth. Urine culture grew yeast, but after treatment with seven days of amphotericin bladder irrigation, urine cultures have been negative. On admission, she was continued on penicillin, however, this was discontinued on [1-4] for secondary to rash and possible drug fever. The penicillin was then switched to Vancomycin for coverage of Strep pneumoniae endocarditis. She also completed a 21 day course of Levaquin for Strep pneumoniae/ventilator-associated pneumonia. Of note, catheter tip culture grew VRE, but repeat culture tip were found to be negative. Her pleural fluid from chest tube drainage was negative for Gram stain and culture after completion of her Levaquin course. At time of this dictation, her white blood cell count had normalized, and she had no further bandemia. She had been afebrile for approximately a week at this time. She is to continue on Vancomycin 1 gram q12h for six weeks to cover Strep pneumoniae endocarditis. It is felt that she should avoid cephalosporins as she had a rash and fever to penicillin. Renal: On presentation, the patient was in acute renal failure with a creatinine of 2.8. Over the course of the first week of hospitalization, her creatinine increased to as high as 4.4. The renal team was consulted, and she was setup for CVVH on [2133-12-28] secondary to anuria. Shortly after setting Quinton catheter, her urine output recovered, and therefore, she did not require dialysis. With aggressive fluid rehydration, her creatinine trended down, and at time of discharge, was back to baseline. It is thought that her rise in creatinine was secondary to ATN for hypovolemia/hypoperfusion due to septic shock. Of note, the patient was initially hyponatremic while on vasopressin, however, this corrected after discontinuation of the medication. She was mildly hypernatremic for the second half of her hospital course, which responded well to free water boluses interspersed with her tube feedings. GI: Prior to admission to [Hospital1 188], she had no po intake x1 week and was found to have an albumin of 1.6. She was continued on tube feeds for the majority of her hospitalization and a PEG tube was placed [2134-1-19]. Speech and swallow team were consulted on [2134-1-15] after initial extubation, and felt that secondary to her respiratory rate, she was having mild aspiration event. A repeat speech and swallow study is to be performed now that a tracheostomy has been placed. Of note, a nitrogen balance was calculated, while she was at tube feeds, and found to be positive, and therefore indicating that she received adequate nutrition. Hematology: DIC panels performed on admission and was found to be significantly abnormal. Her hematocrit fell as low as 19.6, and she required a total of 6 unit packed red blood cells during the hospitalization. Her platelets were also as low as 40,000 secondary to DIC and she received a total of 2 unit platelet transfusions. Peripheral smear was noted to have schistocytes, nucleated red cells, and helmet cells, which were consistent with DIC as well. HIT antibody was sent and was found to be negative. Through supportive care, her DIC slowly resolved and hematocrit trended up, but remained low around 27 at time of this dictation. With thought that this may be secondary to myelosuppression from sepsis and should recover. She was given one dose of Epogen 4,000 units on [2134-1-22] and was started on iron sulfate 325 q day. Endocrine: She was treated with a seven day course of hydrocortisone 50 mg q6 and Florinef 50 mg q day for septic induced adrenal insufficiency. She was continued on insulin drip during her steroid course, and transitioned to regular insulin-sliding scale, which was discontinued after fingerstick blood glucoses were within normal range after steroids had been stopped. Neurologic/psychiatry: The patient was intubated and sedated for the first two weeks of hospitalization. She was paralyzed with .................... for approximately three days. Propofol was weaned on numerous occasions, but secondary to extubation and reintubation, had to be restarted. She has been off propofol and sedation since [2134-1-22]. Once her mental status began to clear, she appeared very distressed over her illness, and significant denial over amputation of her feet in the future. She was seen by Social Work, and Psychiatry nurse, who felt that continued discussion and reinforcement of seriousness of her illness was warranted. Vascular: Secondary to DIC and pressor use, she had necrosis of bilateral toes as well as the dorsum of the right foot, and the tip of the middle finger on the left, and portion of the forearm on the right side. Vascular Surgery was consulted, and felt that due to absent dorsalis pedis pulses bilaterally, she would necessitate amputation in the future. They felt that the necrosis was dry gangrene, and therefore, did not require further antibiotics or emergent amputation. Throughout her hospitalization, her dorsalis pedis pulses slowly returned and although amputation was still deemed necessary it was felt that it would be less extensive than it originally thought and may be a transmetatarsal amputation bilaterally. The exact timing of amputation is to be decided, but it is felt to be mid [Month (only) 956] at this time. Dermatology: In addition, to the dry gangrenous areas of bilateral feet, the patient was noted to have a maculopapular eruption on bilateral knees and trunk, which was thought secondary to penicillin use. Dermatology was consulted and biopsied necrotic lesions on the right forearm and the dorsum of the right foot which showed epidermoid necrosis and microthrombi within superficial dermal bed vessels consistent with DIC. A biopsy from the truncal and knee rash was found to be consistent with erythema multiforme drug-like eruption. After penicillin was discontinued, the rash resolved. DISCHARGE DIAGNOSES: 1. Adult respiratory distress syndrome. 2. DIC. 3. Right pneumothorax. 4. Right sided endocarditis. 5. Atrial fibrillation, resolved. 6. Sepsis. 7. Ventilator-associated pneumonia. 8. Funguria, resolved. 9. Acute renal failure secondary to acute tubular necrosis from sepsis. 10. Status post tracheostomy on [2134-1-21]. 11. Status post PEG tube [2134-1-19]. 12. Sepsis-induced adrenal insufficiency, resolved. 13. Bilateral toe necrosis/gangrene secondary to DIC. 14. Penicillin induced drug eruption. A subsequent discharge summary will be dictated at time of discharge with patient's discharge medications and discharge plan. At this time, it is planned that she will be discharged to Pulmonary Rehabilitation Facility and return for amputation of bilateral feet per Vascular Surgery. Timing of this will be indicated in the subsequent discharge summary. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7585] Dictated By:[Last Name (NamePattern1) 6240] MEDQUIST36 D: [2134-1-25] 09:37 T: [2134-1-25] 09:36 JOB#: [Job Number ]	[ "51881", "486", "5845" ]
Admission Date: [2136-2-29] Discharge Date: [2136-3-7] Date of Birth: [2052-1-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2610] Chief Complaint: left hip fracture Major Surgical or Invasive Procedure: open reduction and internal fixation of left femoral intertrochanteric fracture. History of Present Illness: The patient is an 84 year-old female with a history of dementia, RA, PVD, osteoporosis and recent right femoral intertrochanteric fracture s/p ORIF [2136-1-3] who presents with left hip fracture. The patient was previously admitted to [Hospital1 112] after a mechanical fall on [2135-12-31] and found to have a right hip fracture. She also had some chest pain, mildly elevated trop 0.02, but no ECG changes. She was transferred to [Hospital1 18] because her PCP and rheumatologist are here. She underwent ORIF on [2136-1-3] and tolerated the procedure. However, she did develop post-op delerium for which she was treated with seroquel 12.5 qhs and prn. The patient was discharged to rehab. . Today the patient had a witnessed mechanical fall while reaching for her walker. She presented to the ED and found to have a left intertrochanteric fracture. She had a CT-head and C-spine that did not show any fracture or acute bleed. She also had CE x1 that were negative. The patient became very agitated in the ED with tachycardia to the 140's with lateral ST depressions. She was given a total of 10mg morphine (2mg x3, 4mgx1) and 3mg haldol (0.5mg x3, 1.5mg x1). She also was given ASA 325mg x1 and a total of 2L IVF. The patient continued to be agitated and tachycardic and felt that she would be unsafe on the floor. . On the floor the patient was calm and denied any pain. She was only oriented to self, but denied any other complaints. Past Medical History: Right femoral intertrochanteric fracture, s/p ORIF [December 2135] Rheumatoid arthritis Osteoarthritis Dementia Peripheral vascular disease - Left femoropopliteal bypass revised with a patch and several angioplasties for restenosis possibly due to intimal hyperplasia. S/p bypass surgery Osteoporosis - Bone density [2135-6-23] with T-score of spine minus 4.7 Chronic onychocryptosis Low back pain Social History: Smoke: 1 ppd x about 65 years EtOH: None Drugs: None Lives/works: Lives alone in [Last Name (NamePattern1) 18764] in [Location (un) ]. Lived here for about 50 years. Does not remember where she used to work. Patient has no children. She has two cousins nearby -- one in [Location (un) 686], Mass and one in [State 531] state. She is originally from [Country ] and grew up speaking [Hospital1 100], Polish, and [Doctor First Name 533]. Family History: Non-contributory Physical Exam: Tc:97.5 BP:158/82 HR:84 RR:16 O2Sat:100% on RA GEN: Elderly, cachectic, no acute distress, mumbling and incoherent, but occasionally more clear. Responding to questions. Appears MUCH improved from yesterday. HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MM appear dry, OP Clear. NECK: No JVD, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Limited exam due to lack of cooperation, but lungs appear CTAB. ABD: Soft, NT, ND, +BS, guarding, but no apparent tenderness. EXT: No C/C/E, no palpable cords. Pedal pulses symmetric. Feet slightly cool bilaterally but dry, left side csm intact. Left thigh incision c/d/i with staples NEURO: Alert, oriented to person only. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2136-2-29] 02:10PM WBC-12.5# RBC-4.07# HGB-12.4# HCT-39.1# MCV-96 MCH-30.5 MCHC-31.7 RDW-15.0 [2136-2-29] 02:10PM PLT COUNT-337 [2136-2-29] 02:10PM PT-11.5 PTT-38.6* INR(PT)-1.0 [2136-2-29] 02:10PM GLUCOSE-112* UREA N-26* CREAT-0.8 SODIUM-136 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14 [2136-2-29] 11:12PM CK-MB-8 cTropnT-<0.01 [2136-2-29] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: # Left femoral intertrochanteric fracture: The patient was admitted initially to the MICU for IV fluids, observation, and medical stabilization. She improved significantly after fluids, analgesia, and anti-psychotics. She was taken to the OR on hospital day #2 for ORIF by the orthopedics service. The procedure was performed without immediate complications, but she was noted in post-op labs to have a markedly reduced hematocrit, and was therefore transfused 2 units PRBC the evening following surgery. Patient is cleared for full weight bearing. # Anemia: The patient had a hematocrit of 39 on admission, 31 following significant fluid hydration, and then 23.5 following surgery. There was not evidence of ongoing blood loss aside from peri-operative losses, so this drop was attributed to fluid hydration combined with some traumatic loss, combined with surgical blood loss. The patient's hematocrit increased appropriately following transfusion, and remained stable thereafter. # Tachycardia: The patient was substantially tachycardic on admission, and mildly tachycardic post-operatively. EKG's showed sinus tachycardia, with some mild ST depressions, thought to represent demand ischemia. Troponins were negative, cycled x3. Following surgery she also became hypoxic, which combined with tachycardia prompted concern for possible PE. CTA performed on the evening of hospital day #2 showed no evidence of significant PE, and only very mild pleural effusions, no large consolidation. Her tachycardia has improved markedly overtime. # Leukocytosis: Likely reactive in the setting of pain, hip fracture, surgery. Blood cultures were drawn, and urinalysis showed no signs of infection. She was given peri-operative antibiotics. She did not spike a fever, showed no other signs of infection. # Dementia, agitation: She was continued on her prior regimen of low-dose Seroquel, with QHS dose for sleep. She also required occasional low dose Haldol for increased agitation, trying at one point to pull out her IV. # Disposition: the patient's family and HCP initially have arranged to transfer her to a facility in [Location (un) 15739], NY in order to be closer to family members. Medications on Admission: Folic Acid 1 mg daily Acetaminophen 1g TID Toprol XL 100 mg daily Cholecalciferol (Vitamin D3)800U daily Clopidogrel 75 mg daily Docusate Sodium 100 mg [Hospital1 ] Senna 8.6 mg [Hospital1 ] Multivitamin,Tx-Minerals daily Ibuprofen 400 mg q8 prn Thiamine HCl 100 mg daily Quetiapine 12.5 mg Tablet Sig: 0.5 qhs Quetiapine 6.75 mg PO Q6H prn agitation Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily): Complete total of 4 wks. 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Quetiapine 25 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Constipation. Discharge Disposition: Extended Care Facility: [Hospital1 ] Home of [Location (un) 15739], Inc. Discharge Diagnosis: left hip fracture. Discharge Condition: Fair condition, alert but disoriented Discharge Instructions: You were admitted to the hospital after falling and breaking your left hip. You were initially admitted to the ICU because your heart rate was very fast, but this improved with IV fluids and with medicines. Your hip was surgically repaired on the 2nd day of your hospital stay, and you were then transferred to the medicine service. You received two units of blood following the surgery, after which your blood levels returned to near normal levels. Followup Instructions: You should call to schedule a followup appointment with your primary care doctor in the next 1-2 weeks and an orthopedist in [1-28] weeks.	[ "2851" ]
Admission Date: [2172-7-3] Discharge Date: [2172-7-13] Service: MED Allergies: Amoxicillin / Aspirin / Clindamycin / Erythromycin Base / Bactrim Attending:[Last Name (NamePattern4) 290] Chief Complaint: confusion Major Surgical or Invasive Procedure: EGD Brief Hospital Course: Respiratory failure: The patient was intubated and maintained on pressure support ventilation from the time of admission due to respiratory failure with blood gas consistent with hypoxia. Respiratory failure in this patient was presumably due to impending hemodynamic collapse. There was no clear evidence of pneumonia or other primary pulmonary process on chest x-ray or on examination. The patient had small right pleural effusion on admission and developed left pleural effusion during her hospital stay, but these effusions were small and unlikely to contribute to respiratory distress. The patient was maintained on pressure support ventilation during her admission and oxygenation was maintained with acceptable parameters. Hypotension: The patient was hypotensive on admission with blood pressure as low as 60 over palpation in the emergency department. This was most likely secondary to GI bleed; although, the patient's elevated white count on admission and continuous hemodynamic instability during her hospital stay despite stable hematocrit indicated that there were likely other contributing factors. The patient was initially suspected of having sepsis, and was begun on empiric therapy with levofloxacin and Flagyl. In addition, cosyntropin stimulation test was performed to evaluate for adrenal insufficiency. This test was normal indicating that hypoadrenalism was likely not contributing to her hypotension. The patient was treated with levofloxacin and Flagyl during her entire hospital admission as empiric therapy for possible sepsis. She displayed labile blood pressure during her entire admission and required occasional fluid boluses to maintain her mean arterial pressure greater than 60. She required intermittent use of pressure medications during her admission with Dopamine being the principle [Doctor Last Name 360]. Upper GI bleed: The patient was admitted with hematocrit of 22 and signs of GI bleed including bright red blood per rectum. EGD on [2172-7-5] demonstrated a bleeding mass in the stomach suspicious for malignancy of the linitis plastica type. Biopsies were taken and showed adenocarcinoma of the stomach and also diffuse gastritis. This gastritis was likely the cause of the patient's GI bleed. On admission, the patient was transfused with 2 units of packed red blood cells raising her hematocrit to 27. Hematocrit was monitored closely during her hospital stay and the patient was transfused an additional time to raise her hematocrit to greater than 30. Her hematocrit remained stable at 30 during the majority of her hospitalization, indicating that GI bleed had stabilized after her admission. The patient was also treated with Protonix IV b.i.d., sucralfate 1 gram by NG tube q.i.d., and fluid resuscitation. No treatment was available for her diffuse gastric carcinoma and gastritis other than the above mentioned medications. Thrombocytopenia: The patient was admitted with normal platelet count, and platelets decreased suddenly to 87,000 early in her hospital admission. Given the stability of her white blood cell count and hematocrit, it was unlikely that this was a dilutional phenomenon. The possibility of consumptive coagulopathy was most concerning in this patient with gastric carcinoma. Fibrinogen and FDP were checked to evaluate for DIC, and were found to be within normal limits. Platelets were followed and were observed to raise to normal levels. The patient demonstrated no sequelae of thrombocytopenia during her admission. Pain: The patient was treated with Fentanyl drip in order to provide adequate analgesia. She was observed to be comfortable initially on Fentanyl drip with no signs of pain. There was no hypertension, tachycardia, or physical sign of pain. Eventually, the patient demonstrated physical signs of discomfort, and required Fentanyl boluses in addition to her Fentanyl drip. Fentanyl boluses were administered as required to maintain strong level of analgesia in the patient. Communication: The intensive care unit team was in frequent communication with the patient's family, especially the patient's daughter who was her healthcare proxy. The patient's family initially was hopeful of achieving cure in this patient, such that the patient would be able to convalesce at home and to recover among her family. However, during the hospital course, it became apparent to the intensive care unit team and to the family that the patient's disease was not amenable to cure, and that the patient would likely die of her disease during this admission. The family asked appropriate questions about end of life issues and end of life care and the family meeting was held to discuss the patient's code status and goal of care. On [2172-7-10], the family embraced comfort care as a goal of treatment. They directed that the intensive care unit team should withhold laboratory tests and medications except for medications that would maintain the patient's comfort. The patient was treated with Fentanyl drip and Fentanyl boluses to maintain analgesia and was observed to be comfortable during her hospital stay. After this decision was made, the patient's blood pressure was observed to trend down slowly and the patient's respiratory status was maintained with ventilation. On [2172-7-13], the patient died of cardiovascular collapse, secondary to her diffuse hemorrhagic gastric carcinoma. Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "5849", "51881", "2760", "2851", "2875", "5119" ]
Admission Date: [2166-11-3] Discharge Date: [2166-11-19] Date of Birth: [2085-8-11] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 2969] Chief Complaint: Esophageal Cancer Major Surgical or Invasive Procedure: Upper endoscopy and transhiatal esophagectomy with feeding jejunostomy. History of Present Illness: Mr. [Known lastname ] is an 81-year-old gentleman with diagnosis of esophageal cancer. His preoperative endoscope ultrasound stage was T2, N0, and a PET scan showed no evidence of metastatic disease. He is admitted for Upper endoscopy and transhiatal esophagectomy with feeding jejunostomy. Past Medical History: Hypothyroidism Hypertension Hyperlipidemia Multiple TIAs/CVA [2151] BPH PSH: s/p TURP '[46], R CEA [Numeric Identifier 7084], R Hernia repair '[50] Social History: Married, lives in [Location 41708] Tobacco: quit 30 years ago ETOH: none Family History: non-contributory Physical Exam: General: 80 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Card: regular, rate & rhythm, normal S1,S2, no murmur/gallop or rub Resp: decreased breath sounds otherwise clear GI: bowel sounds positive, abdomen soft non-tender/non-distended Extr: warm no edema Incisions: Left neck clean, dry intact, mid-abdomen with staples clean dry intact. Mild erythema along staple line. J-tube site clean, no erythema Neuro: non-focal Pertinent Results: [2166-11-3] WBC-5.3 RBC-3.31# Hgb-10.1# Hct-29.3* Plt Ct-96* [2166-11-11] WBC-16.8* RBC-3.62* Hgb-10.8* Hct-32.7 Plt Ct-335 [2166-11-18] WBC-7.4 RBC-3.52* Hgb-10.5* Hct-31.8 Plt Ct-586 [2166-11-3] Glucose-131* UreaN-17 Creat-1.0 Na-133 K-3.9 Cl-105 HCO3-20 [2166-11-11] Glucose-171* UreaN-19 Creat-0.9 Na-138 K-3.9 Cl-102 HCO3-26 [2166-11-19] Glucose-138* UreaN-14 Creat-0.9 Na-131* K-4.4 Cl-96 HCO3-31 CHEST (PA & LAT) [2166-11-11] FINDINGS: In comparison with the study of [11-9], the surgical clips and drain have been removed from the lower left chest. There has been some decrease in opacification at the right base, though residual combination of infiltrate of atelectasis, effusion, and possible pneumonia persists. There is little change in the increased opacification described previously at the left base. Pathology Examination SPECIMEN SUBMITTED: Esophagus and proximal stomach, left gastric lymph nodes. Procedure date Tissue received Report Date Diagnosed by [2166-11-3] [2166-11-3] [2166-11-10] DR. [Last Name (STitle) ]. BROWN/mb???????????? Previous biopsies: [-6/3994] GASTRIC BIOPSIES 2. A. Esophagogastrectomy specimen: 1. Barrett's esophagus with polypoid high grade dysplasia. No invasive carcinoma identified. Entire lesion examined. 2. Proximal margin with squamous mucosa. No glandular mucosa present. 3. Distal margin with gastric body type mucosa. No dysplasia. 4. One lymph node with no tumor seen. B. Left gastric lymph nodes: Seven nodes with no tumor seen. CTA CHEST W&W/O C&RECONS, NON-CORONARY CTA OF THE CHEST: There is no evidence of pulmonary embolism or aortic dissection. The aorta is tortuous with a moderate amount of plaque within the ascending aorta (3:29). Heart size is normal and there is a tiny to small pericardial effusion, measuring simple fluid density. Scattered coronary calcifications are noted within the LAD and RCA. The bronchi are patent to the subsegmental level. There are large bilateral pleural effusions, right greater than left, with associated atelectasis at the lung bases. The lungs demonstrate moderate paraseptal emphysema, worst at the lung apices. No suspicious nodules or masses are identified. Small mediastinal lymph nodes are noted, which do not meet CT criteria for pathologic enlargement. The patient is status post esophagectomy with gastric pull-through. This exam is not tailored for subdiaphragmatic assessment. An incompletely characterized cystic lesion is seen off the upper pole of the right kidney - correlation with recent PET CT suggests that this is a large simple cyst. There are no bone findings of malignancy. Multilevel degenerative changes are seen in the thoracic spine, with prominent anterior osteophytosis. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Moderate-sized bilateral pleural effusions with associated atelectasis. 3. Status post esophagectomy and gastric pull-through. [2166-11-19] 06:24AM BLOOD Glucose-138* UreaN-14 Creat-0.9 Na-131* K-4.4 Cl-96 HCO3-31 AnGap-8 Brief Hospital Course: Mr. [Known lastname ] was admitted on [2166-11-3] and underwent successful upper endoscopy and transhiatal esophagectomy with feeding jejunostomy. He was monitored in the PACU and transferred to the SICU in stable condition. While in the SICU he was hypertensive and a question of a new right bundle branch block was seen on ECG. Cardiology was consulted and he ruled out for an myocardial infarction. They recommended continuing beta-blocker and good blood pressure control. His pain was managed with an epidural by the acute pain service. His left chest-tube and nasal gastric tube were to suction. The neck drain was to bulb with moderate serosanguinous drainage. He remained hemodynamically stable and was transferred to the floor on POD #1. He was seen by nutrition who recommended Nutren Pulmonary tube feeds with a goal rate of 60cc/hr. Physical therapy was consulted. On POD day #2 the tube feeds were started at 20cc/hr. The chest-tube was placed to water seal with no leak. On POD #3 the chest-tube and epidural were removed and his pain was managed with a PCA. The foley was removed and he voided without difficulty. His tube feeds were slowly advanced to goal which he tolerated. His blood pressure and heart rate were well controlled. On POD day #7 he was administer PO grape juice which revealed no anastomotic leak. His neck drain was removed. He was started on a clear liquid diet which he tolerated. He was constipated and given laxatives with a good result. On POD day #8 his PCA was stopped and was converted to pain medication via J-tube. He was started back on his home PO meds. His neck staples were removed and every other abdominal staple removed. He had mild erythema along the staple line of his abdominal wound. On POD #9 the inferior portion of the neck wound begin to ooz. The neck and abdominal wound was open, the sites were clean and packed with a moist to dry dressing. He continued to require oxygen and on POD 14 a chest CT was obtained and no pulmonary embolism was seen but had bilateral pleural effusions which was tapped. A follow-up chest x-ray revealed no pneumothorax. He continued to work with physical therapy and was discharged to rehab on POD #15. He will follow-up with Dr. [Last Name (STitle) ] as an outpatient. Medications on Admission: Synthroid 75 mcg once daily Diovan 160 mg once daily HCTZ 12.5 mg once daily Terazosin 2 mg once daily Atenolol 50 mg once daily MAVIK 4 mg twice dialy Lipitor 20 mg once daily Omeprazole 20 twice daily Aspirin 81 mg once daily MVI Doxycycline b.i.d Hydralazine 50 mg every 8 hrs Discharge Medications: 1. Atenolol 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily): crush give via J-tube 2. Senna 8.6 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO BID (2 times a day) as needed. 3. Magnesium Hydroxide 400 mg/5 mL Suspension [Last Name (STitle) ]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 4. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: One (1) PO TID (3 times a day). 5. Bisacodyl 10 mg Suppository [Last Name (STitle) ]: One (1) Suppository Rectal DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Last Name (STitle) ]: 5-10 MLs PO Q4H (every 4 hours) as needed. 7. Levothyroxine 75 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily): Crush give via J-tube 8. Valsartan 160 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily): Crush give via J-tube. 9. Hydrochlorothiazide 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO DAILY (Daily): Crush give via J-tube hold while giving lasix. 10. Trandolapril 2 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO BID (2 times a day): crush give via J-tube. 11. Atorvastatin 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily): Crush give via J-tube. 12. Terazosin 1 mg Capsule [Last Name (STitle) ]: Two (2) Capsule PO HS (at bedtime): Crush give via J-tube. 13. Lasix 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day for 7 days. 14. Potassium Chloride 20 mEq Packet [Last Name (STitle) ]: One (1) PO once a day for 7 days: give via J-tube. 15. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) Injection TID (3 times a day). 17. Hydralazine 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO three times a day: Crush give via J-tube 18. Nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: One (1) PO four times a day: swish & spit. 19. Prevacid 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day: via J-tube. Discharge Disposition: Extended Care Facility: [Hospital1 11057] Nursing & Rehabilitation Center - [Location (un) 3320] Discharge Diagnosis: Esophageal Cancer Stage I Hypothyroidism Hypertension Hyperlipidemia CVA Multiple TIA's BPH Discharge Condition: Good Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 170] if you experience chest pain, shortness of breath, fever, chills, nausea, vomiting, diarrhea, or abdominal pain. If your feeding tube sutures become loose or break, please tape tube securely and call the office [Telephone/Fax (1) 170]. If your feeding tube falls out, save the tube, call the office immediately [Telephone/Fax (1) 170]. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Crush all medication administer via J-Tube: then flush tube with 100cc of water. Flush your feeding tube with 50cc every 8 hours if not in use and before and after every feeding. Daily weights: keep log when discharged to home Monitor CBC, lytes, BUN & Cre: repletes lytes as needed. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [12-11] at 2:00pm on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center, [Location (un) ]. Esophagus Swallow evaluation at 11:00am. [Telephone/Fax (1) 44714] on [11-25] Report to the [Location (un) 861] Radiology Department. HOLD TUBE FEEDS after Midnight [11-24] for barium swallow. Completed by:[2166-11-19]	[ "5119", "2449", "4019", "53081" ]
Admission Date: [2174-4-1] Discharge Date: [2174-4-5] Date of Birth: [2097-11-19] Sex: F Service: CCU CHIEF COMPLAINT: Syncope, MI. HISTORY OF PRESENT ILLNESS: This is a 76-year-old female with history of hypertension, hypercholesterolemia, and peripheral vascular disease, transferred from [Hospital3 29718], where she presented after an episode of syncope and found to have a MI. This was a witnessed episode and EMS took the patient to [Last Name (un) 4068]. There she was found to have a heart rate of 40 with 2-1 A-V block and ST elevations of [2-24] mm in II, III, and aVF. She also had [Street Address(2) 1766] elevations in V2 and V3 and 1-[Street Address(2) 1766] depressions in I and aVL. The patient reportedly was temporarily transvenously paced. She was given aspirin, Plavix, and Heparin, and Integrilin, and transferred to the [Hospital1 18] Cath Lab. There she had her RCA, which had a 90% calcified ostial stenosis, stented. She had two episodes of VT, which responded to cardioversion, and was on Levophed transiently for hypotension. Her filling pressures were noted to be very low with a wedge of 10 and RA of 3. By the end of the case, the patient did not need pacing as she was in normal sinus rhythm. PAST MEDICAL HISTORY: 1. Hypertension. 2. Peripheral vascular disease status post left CEA in [2170]. 3. Hypercholesterolemia. 4. Breast cancer status post right mastectomy and chemotherapy in [2168]. 5. Degenerative joint disease status post right TKR in [2162]. 6. Scoliosis. 7. Status post multiple falls with right hip fracture in [7-26]. MEDICATIONS AT HOME: 1. Cozaar 50 mg p.o. q.d. 2. Lipitor 20 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Fosamax 70 mg q week. 5. Multivitamin. 6. Vitamin C. ALLERGIES: Sulfa. SOCIAL HISTORY: Tobacco use three cigarettes a day, occasional alcohol. Lives at [Hospital3 ] in [Location (un) ]. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood pressure 109/61, pulse 110, respirations 18, and oxygen saturation 95% on 3 liters nasal cannula. In general, awake, agitated, and nonverbal. HEENT: PERRL. EOMI. Clear oropharynx, but mucous membranes are dry. Pulmonary: Clear to auscultation anteriorly, unable to auscultate posteriorly secondary to patient's agitation. Cardiovascular: Regular rate and rhythm, normal S1, S2, 2/6 systolic murmur at the left sternal border. Abdomen: Normoactive bowel sounds, soft, nontender, and nondistended, no masses. Extremities: Left lower extremity trace to 1+ pitting edema to mid shin with erythema and warmth; left medial malleolus with four shallow ulcers about 1-2 mm deep ranging from 1 to 3-4 cm in diameter with yellow base, no purulence. Right lower extremity: No lesions, no clubbing, cyanosis, or edema. 1+ pedal pulses bilaterally. Neurologic: Follows commands, moves all four extremities spontaneously. Occasionally having hallucinations. CATHETERIZATION DATA [4-1]: Left main 20% ostial stenosis, left circumflex 40% proximal stenosis, RCA 90% ulcerated calcified ostial stenosis with likely a thrombus, CI 1.83, PCWP 10, RA 3, PA 27/13, RV 27. Laboratory data significant for a hematocrit of 34.6, BUN 21, creatinine 1.2. INR 0.9. EKG done post procedure shows decreased ST elevations of [12-24] mm in inferior leads as well as V2 and V3. HOSPITAL COURSE: 1. Cardiovascular: A. Ischemia: Patient was continued on aspirin, Plavix, and Integrilin x18 hours. Given that her A-V block was resolved, she was started on metoprolol, which was changed to Toprol XL. She also was started on enalapril, and high dose statin though her triglycerides were 63 and LDL 57 (this may likely be decreased secondary to acute MI). Patient had cardiac enzymes cycled with a peak CK of 3282, CK-MB of 151, and troponin-T of 2.62. B. Rhythm: Patient was initially on amiodarone after cath given transient VT. This was discontinued, and patient had no further episodes of arrhythmia on telemetry or repeat EKG. C. Pump: Patient with low filling pressures. She was given 1.5-2 liters of normal saline over the first two days of her hospitalization with response in increased blood pressure and urine output. Goal initially was to have right atrial pressures [10-4], though patient had Swan pulled early, and this was unable to be monitored. She had a transthoracic echocardiogram on [4-4] showing EF of 40%, severe hypokinesis of the inferior and posterior walls, right ventricular systolic function depressed, diastolic dysfunction, and no significant valvular disease. D. Blood pressure: Initially hypotensive, but responded to fluids and tolerated beta-blocker and ACE inhibitor well. 2. Peripheral vascular disease: Patient will be setup with Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911] for followup at [Hospital3 4527] for vascular issues as well as cardiac management. She has not had prior peripheral angiography. 3. Left lower extremity cellulitis: Patient was started on oxacillin 1 gram q.4h. after drawing one set of blood cultures, which are still no growth to date. A left ankle film showed no evidence of osteomyelitis. Podiatry recommended Adaptic dressing over the medial malleolus and cleansing with saline gauze daily as well as dressing with dry sterile gauze. This should continue until the wound is healed. She will need IV antibiotics x2 weeks, and has received five days from [4-1] to [4-5] thus far. She had a left PICC line placed in preparation for continuing as an outpatient. 4. Altered mental status: Initially quite agitated, likely multifactorial due to medication and MI in elderly female. She did not respond to Haldol, but did to low-dose Ativan; however, this is not an issue after day two of hospitalization. 5. FEN: Cardiac diet. 6. Prophylaxis: Subq Heparin and Protonix. 7. Communication: Spoke daily to son, [Name (NI) ] [Name (NI) 36495]. 8. Code status: Full unless medically futile as per living will in chart. 9. Disposition: PT evaluated patient and deemed needing rehab as quite unsteady and tentative on feet. They will continue to work with patient until discharge, and we will re-evaluate on [4-5]. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To rehab facility. DISCHARGE DIAGNOSES: 1. Myocardial infarction. 2. Hypertension. 3. Peripheral vascular disease. 4. Coronary artery disease. 5. Degenerative joint disease/osteoarthritis. 6. History of breast cancer. 7. Status post falls. DISCHARGE MEDICATIONS: 1. Atorvastatin 80 mg p.o. q.d. 2. EC-ASA 325 mg p.o. q.d. 3. Clopidogrel 75 mg p.o. q.d. 4. Metoprolol XL 50 mg p.o. q.d. 5. Enalapril 10 mg p.o. q.d. 6. Oxacillin 1 gram IV q.4h. times additional nine days. 7. Multivitamin. 8. Pantoprazole 40 mg p.o. q.d. 9. Subcutaneous Heparin 5000 units q.12h. FOLLOW-UP PLANS: Patient will call her primary care doctor, Dr. [Last Name (STitle) ] for followup in the next 1-2 weeks. She will also follow up with Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911] for cardiovascular studies and issues at [Hospital3 4527]. She will be setup to have outpatient ABIs. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7169] Dictated By:[Last Name (NamePattern1) 1606] MEDQUIST36 D: [2174-4-4] 22:39 T: [2174-4-5] 04:57 JOB#: [Job Number 54691]	[ "41401", "2720", "4019" ]
Admission Date: [2102-5-11] Discharge Date: [2102-5-18] Date of Birth: [2054-4-13] Sex: F Service: MEDICINE Allergies: Compazine / Shellfish / Iodine; Iodine Containing Attending:[First Name3 (LF) 1115] Chief Complaint: chest pain, weakness, hypertension Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 48y/o females with a past medical history HTN, iron deficiency anemia secondary to menorrhagia who was seen by her PCP today with complaints of lightheadedness and DOE of a several day duration. Her DOE occurs with 1 flight of stairs or walking a short distance. She also reported 2 episodes of chest pain, the first of which occurred last evening. She describes it ass a substernal pressure associated with SOB and diaphoresis lasting for 90 minutes. She had a second episode this am when walking to the subway station. She rested and her symptoms resolved. At [Company 191] she was found to have a BP of 190/108. ECG was done and showed no acute changes. EMS was called for transfer to the ED for treatment of hypertensive emergency. Past Medical History: # Hypertension # Menorrhagia secondary to uterine fibroids. Baseline HCT 26-29 # Appendectomy # C-section X 4, bilateral tubal ligation # Sickle cell trait per the patient. Social History: married, lives w/ husband and 7 children ([11-1]). Works at federal govt. appeals office. -Tobacco history: quit 20 years ago -ETOH: no -Illicit drugs: no Family History: +HTN in mom and DM in aunt. Physical Exam: General: Alert, oriented, no acute distress, resting comfortably in bed, aroused from sleep HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: fluent speech, lower extremities strength 5/5, sensation grossly intact, remainder of exam deferred to am . On Discharge: VSS L-sided weakness of L arm and leg which is fluctuating in severity and location. Soft voice. Exam otherwise unchanged from admission Pertinent Results: On admission: . [2102-5-11] 06:00PM BLOOD WBC-10.4 RBC-3.84* Hgb-5.5* Hct-22.2* MCV-58* MCH-14.3# MCHC-24.8 RDW-21.1* Plt Ct-209# [2102-5-11] 06:30PM BLOOD PT-11.7 PTT-22.0 INR(PT)-1.0 [2102-5-11] 06:00PM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-138 K-5.6* Cl-107 HCO3-17* AnGap-20 [2102-5-12] 12:56PM BLOOD ALT-7 AST-15 CK(CPK)-133 AlkPhos-91 TotBili-1.2 [2102-5-11] 06:00PM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9 . On discharge: . [2102-5-18] 07:50AM BLOOD WBC-12.4* RBC-4.69 Hgb-8.4* Hct-29.6* MCV-63* MCH-17.8* MCHC-28.3* RDW-27.4* Plt Ct-305 [2102-5-18] 07:50AM BLOOD Glucose-97 UreaN-21* Creat-0.8 Na-141 K-4.4 Cl-108 HCO3-24 AnGap-13 . Studies: . [2102-5-12] CXR: Cardiomediastinal silhouette is stable. Lungs are essentially clear. There is no evidence of pulmonary edema, focal areas of consolidation or pneumothorax as well as there is no evidence of appreciable pleural effusion. . [2102-5-12] No acute intracranial pathology. Specifically, no findings of intracranial hemorrhage or large territory infarct. Can consider further evaluation with MRI as it is more sensitive for acute ischemia. . [2102-5-15]: MRI/MRA head neck No acute intracranial pathology. Specifically, no findings of intracranial hemorrhage or large territory infarct. Can consider further evaluation with MRI as it is more sensitive for acute ischemia. . EEG: prelim negative. final read pending Brief Hospital Course: # HTN/weakness/CP: On [5-12] in the setting of patient 3rd prbc transfusion, patient developed rigors and HTN. Remained hypertensive to SBP 180 despite hydralazine 30 mg IV, 2 inches of intro paste, and SLN x3. She developed LLE weakness and headache and started on a nitro drip. She was transferred to the MICU for further care however BP was quickly controlled and she was returned to the floor later the same night. Neuro was consulted for possible code stroke, however was felt to be unlikely given her presentation and head CT was negative. Evaluation for transfusion rxn was negative. She continued to have L-sided weakness and several similar episodes of htn/weakness/cp, which resolved with hydralazine/ativan/morphine. CEs and ECGs were unremarkable. Subsequent neuro w/u with MRI/MRA and EEG were unrevealing (final EEG read pending). She was evaluated by psych who felt that her sxs were consistent with Conversion Disorder and prior presentations of similar sxs, all of which have occurred in the hospital. She continued to have l-sided weakness and hoarse voice, with some improvement and fluctuating sxs in terms of character and location. She was sent home with assistive devices for ambulation and sl ativan. Her htn was otherwise controlled on home meds of lisinopril, metoprolol and hydrochlorothiazide (amlodipine was not needed to maintain her pressures in the hospital and discontinued on discharge). Plasma metanephrines were sent to eval for pheo in the setting of labile bps and were pending on discharge. . # Anemia: Improved with blood transfusion and stable with no further blood loss. Her anemia was attributed to blood loss from fibroids. EKG changes resolved and CE negative x 5 sets. Asa was held in the setting of bleed and crit was improved on discharge. Could consider dc'ing PPI in outpt setting for better iron absorption. . # Leukocytosis: thought to be secondary to stress reaction. No systemic sxs concerning for infection or localizing sxs. She should receive outpt f/u with repeat labs to ensure resolution. . # ARF: resolved with fluid repletion . # Out-pt follow-up: -final read eeg -plasma metanepherines (ordered to r/o pheo in setting labile bps) -amlodipine-consider restarting if pressures poorly controlled -consider dc'ing PPI to increase iron absorption in setting of anemia -fibroids-consider embolization as outpt -leukocytosis-repeat labs to ensure resolution Medications on Admission: ALBUTEROL - 90 mcg Aerosol - two inhalations every 6 hours as needed AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day ECONAZOLE - 1 % Cream - apply to left axilla twice a day LISINOPRIL-HYDROCHLOROTHIAZIDE - 20 mg-25 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL SUCCINATE - 100 mg Tablet Sustained Release 24 hr - 1 Tablet Sustained Release 24 hr(s) by mouth once a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day Medications - OTC IRON - 325(65)MG Tablet - ONE BY MOUTH TWICE A DAY . Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for headache, pain. 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for episodes of weakness, CP, inability to speak: please take sublingually during episodes. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Conversion disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - with assistance Discharge Instructions: You were admitted for hypertension, chest pain and L-sided weakness. After further evaluation, we do not think that your symptoms were caused by stroke, seizure or heart attack. You were still weak on admission and therefore discharged by ambulance with crutches to help you walk. We expect that your symptoms will get better at home over the next few days. . Please follow up with you doctors [First Name (Titles) 3] [Last Name (Titles) 4030] below. Continue to take your home medications as prescribed with the following changes: 1) Stop taking amlodipine. Your blood pressures were well controlled on your hospital regimen which did not include this medication. You should continue to take lisinopril/hydrochlorothiazide and metoprolol. 2) Additionally, if you have additional episodes similar to the ones you were having in the hospital, you should take 0.5 mg of sublingual ativan. If your symptoms change or progress, please contact your physician. . Also, please contact your physician if you have new fever, weakness that does not improve over time, unresolving chest pain, or any other sympomts that are concerning to you. Followup Instructions: Please follow up with your PCP as [Last Name (Titles) 4030] below: . Department: [Hospital3 249] When: THURSDAY [2102-5-25] at 3:00 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5849", "49390", "53081", "V1582" ]
Admission Date: [2140-10-27] Discharge Date: [2140-10-31] Date of Birth: [2079-6-12] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Transient speech difficulty Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 57230] is a 61 year old male with a history of HTN, CAD-s/p angioplasty x2, TIA (x2 in [2130] and [2135]), high cholesterol, paroxysmal Afib, and hx of PFO and Atrial septal aneurysm with both right to left and left to right shunts (on Coumadin) who was transfered from an outside hospital for evaluation of intracranial hemorrhage. He was in his USOH until Wednesday evening ([10-26]) at 7:15 when he had an acute onset of speech difficulty. He was having a conversation with his wife, when he noticed that he "couldn't get his words out". According to his wife, he was making sounds (some words and some nonsense), but not saying complete phrases. He was responding inappropriately to questions (i.e. saying "no" when he meant to say "yes"), but appeared to understand what was being said to him. He was aware of his deficit and frustrated by his inability to communicate. He denies associated numbness, weakness, dysarthria, visual deficits or swallowing problems. [Name (NI) ] did not have CP, palpitations, or dizziness prior to this episode. His wife called EMS. He was at the OH ER in about 30 minutes by which time his symptoms had resolved. He had a head CT there which showed 2.5 cm left temporal hemorrhage. He was then transferred here for further management. On arrival to the [Hospital1 18] ER, his BP was 220/98 and his speech was normal. Then, around 3:00AM he had another episode of language problems which lasted for a minute or so, then spontaneously resolved. He has been asymptomatic since. He was started on nipride in the ER for BP control. He developed a headache and chest pain (right sided, radiating to neck). This resolved with BP was better controlled. He has had similar episodes of language problems in the past. The first episode was in [2130] when he had an episode of slurred speech and mild right facial droop. He had a second episode of "inability to talk" in 8/[2135]. He was found to have "aphasia" and mild right hemiparesis at that time. He had a head CT which was negative and echo which showed PFO and atrial septal aneurysm. He was started on coumadin at that time. Past Medical History: 1. CAD, s/p PTCA in [2115] (s/p angioplasty x2) 2. HTN (historically difficult to control) 3. Hypercholesterolemia 4. TIA (x 2) 5. Paroxysmal Afib 6. PFO with ASD on echo with right to left and left to right shunts Social History: Lives with his wife. His is a high school buisness and government teacher. He has a 20 year old son who is in college. He denies smoking, EtOH or drugs Family History: Uncle: Died of MI in 70's Father: Leukemia, MI at age 65 Uncle: Died of MI in 40's Physical Exam: T 97 ; BP 220/98 (decreased to sbp 170s initially with nipride); HR 76; RR 18; O2 sat 96% RA gen - no acute distress. appears comfortable. heent - mmm. o/p clear. no scleral icterus or injection. neck - supple. no lad or carotid bruits appreciated. lungs - cta bilaterally heart - rrr, nl s1/s2, +sm abd - soft, nt/nd, nabs ext - warm, 2+ peripheral pulses throughout. no edema. neurologic: MS: Alert and Oriented x3. Cooperative with exam. Able to say [Doctor Last Name 1841] backwards. Registration intact to [2-24] objects at 30seconds, recall intact to [2-24] objects at 5 minutes. Repitition and Naming intact. Speech fluent without paraphasic errors or hesitancy. Follows commands well. Able to relate coherent and detailed HPI. CN: PERRL. EOMs intact without nystagmus. Fundi normal with sharp disc margins. Visual fields full to confrontation. Facial sensation and movement intact bilaterally. Hearing intact to finger rub. Tongue protrudes midline without fasiculations. Sternocleidomastoids intact bilaterally. Shoulder shrug intact bilaterally. Motor: Normal bulk and tone throughout. No fasiculations. No pronator drift. B T D WE WF FF FE IP Hams. Quad AT G [Last Name (un) 938] R 5 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 Reflexes: symmetric throughout. toes Sensation: Intact bilaterally to light touch, temperature, pinprick and vibration in all extremities. Coordination: [Last Name (LF) 43945], [First Name3 (LF) ], and FFM intact bilaterally Gait: deferred Pertinent Results: [2140-10-28] 03:00AM BLOOD WBC-13.9* RBC-3.94* Hgb-11.5* Hct-33.5* MCV-85 MCH-29.1 MCHC-34.2 RDW-15.0 Plt Ct-211 [2140-10-27] 02:00AM BLOOD WBC-10.7 RBC-4.95 Hgb-14.6 Hct-41.4 MCV-84 MCH-29.5 MCHC-35.2* RDW-14.7 Plt Ct-242 [2140-10-27] 02:00AM BLOOD Neuts-83.4* Lymphs-12.4* Monos-3.1 Eos-0.4 Baso-0.7 [2140-10-28] 07:00PM BLOOD PT-14.4* PTT-23.4 INR(PT)-1.3 [2140-10-28] 03:34PM BLOOD K-3.5 [2140-10-27] 02:00AM BLOOD Glucose-141* UreaN-14 Creat-1.0 Na-143 K-3.4 Cl-103 HCO3-28 AnGap-15 [2140-10-27] 05:27PM BLOOD CK-MB-4 cTropnT-<0.01 [2140-10-27] 11:25AM BLOOD CK-MB-4 cTropnT-<0.01 [2140-10-27] 02:00AM BLOOD CK-MB-4 cTropnT-<0.01 [2140-10-27] 02:00AM BLOOD CK(CPK)-161 [2140-10-28] 03:00AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0 [2140-10-28] 03:45AM BLOOD Type-ART pH-7.40 Brief Hospital Course: He was admitted to the neuro-ICU for close observation and blood pressure control, he was initially on a nipride drip which was changed to a labetalol drip for blood pressure control. All antiplatelet agents were held and his INR was reversed. He was started on dilantin for seizure prophylaxis. He had an MRI/MRA with gadolinium to evaluate the extent of the bleed and to assess for vascular malformation or underlying mass. The MR showed: 1. MRI of the brain demonstrates an acute left lateral temporal lobe hematoma with mild surrounding edema, as seen on the CT scan of earlier in the day. There is no enhancement in this location. There are numerous small foci of susceptibility artefact within the brain, likely representing hemorrhages from amyloid angiopathy or hypertension. Thus, the new hemorrhage may be of the same etiology. 2. There is no abnormal vascularity detected on MR angiography and there is flow in the major branches of this circulation. He had a repeat head CT on [10-27] which showed no progression of the bleed. He remained neurologically intact and did not have another episode of aphasia during his admission. On hospital day #2, his blood pressure medications were transitioned to oral meds and his blood pressure remained resonably well controlled although he required several doses of IV metoprolol to maintain SBP<140. An cardiac ehco was performed on [10-28]. The echo showed: 1. The left atrium is moderately dilated. 2. 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 difficult to assess but is probably normal (LVEF>55%). He was transfered to the neurology floor on [10-28] where his neurologic exam remained unchanged. His anti-hypertensives were increased to improve BP control. FOLLOW UP PLANS; He will be discharged with follow up with his PCP next week. He will resume taking an aspirin (325mg) next week. He will have a repeat head CT in 6 weeks (on [2140-12-28]) and should follow up with Dr. [Last Name (STitle) ] the following week ([2141-1-3]). At his follow up visit, we will consider the option of re-starting Coumadin (perhaps low dose to maintain INR between 1.5-2.5). We will also consider whether he may be a candidate for a PFO closure procedure at that time. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 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). Disp:60 Capsule(s) Refills:2 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Isosorbide Mononitrate 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 11. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Intracranial hemorrhage 2. Amyloid Angiopathy 3. Hypertension Discharge Condition: Improved-no neurologic deficit Discharge Instructions: Please continue to take your medications as directed. In one week, you should start to take a regular aspirin (325mg). You should NOT take coumadin. You may stop taking dilantin (for seizure prevention) in two weeks. You should have a repeat CT scan of the head in six weeeks (see appointments below). If you experience difficulty with speech, visual problems, numbness, weakness, dizziness, or increased headache, please come to the emergency room for evaluation. Followup Instructions: 1. Follow up with your primary care doctor next week. Please have your blood pressure monitored. Your systolic blood pressure should be maintained under 140. Please have your dilantin level checked (goal level [10-7]). 2. CT SCAN: [Hospital6 29] RADIOLOGY ([Location (un) ]) Phone:[Telephone/Fax (1) 327] Date/Time:[2140-12-28] 10:45 3. Follow up with Dr. [Last Name (STitle) ] in [2141-1-3] at 2:30PM. ([Telephone/Fax (1) 7394]. [Hospital Ward Name 23] building [Location (un) 858]. 3. [Hospital ] Clinic: [Last Name (LF) ],[First Name3 (LF) ] Where: RA [Hospital Unit Name ] ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX) NUTRITION Phone:[Telephone/Fax (1) 3681] Date/Time:[2141-1-11] 10:30 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "42731", "4019", "V4582" ]
Admission Date: [2111-10-22] Discharge Date: [2111-11-26] Date of Birth: [2062-6-1] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: polyarthritis, cough, dyspnea Major Surgical or Invasive Procedure: HD line placement VATS Bronchoscopy History of Present Illness: Ms. [Known lastname ] is a 49yo woman with minimal PMH who was recently admitted from [Date range (1) 97757] for cough, increased fatigue, and continued polyarthritis despite Azithromycin. She also had pruritic lesions on the extensor surfaces of bilateral elbows, chest and scalp. She was afebrile throughout the admission. Rheum and Derm consulted. Rheum workup was unrevealing. Derm believed that her rash was nonspecific but could be consistent with induced lichenoid eruption vs dermatitis herpetiformis vs non-specific eczema but w/u did no reveal any particular diagnosis. She was discharged on Naproxen and Levaquin with improving respiratory status and improving infiltrates on CXR. . She presented again to the [Hospital1 18] ED on [10-22] with persistent cough, SOB, N/V, chills, low grade fever, fatigue and joint pain preventing her from ambulation. She was found to be in severe acute renal failure and admitted to the [Hospital Ward Name 516] Hospitalist service. Since admission, she underwent renal evaluation and was found to have dysmorphic red cells and muddy brown casts in her urine. Initially it was suspected that she had NSAID induced ATN and/or RPGN. However renal biopsy revealed collapsing FSGS. She was started on high dose steroids. On [10-25] patient had increasing N/V and somnolence with asterixis, was started on HD for suspected uremia, with improving mentation after HD. Pulmonary was consulted for persistent pulmonary infiltrates and hypoxia. HIV ab was negative. Initially she was felt to be volume overloaded but HD did not clear her infiltrates and she was felt to be dry not wet. Ultimately it was decided to send her to diagnostic bronchoscopy, and she was transferred to the [Hospital Ward Name ] Hospital Medicine Service on [2111-11-16]. Past Medical History: 1. Cervical dysplasia in [2097-8-5] followed by cone biopsy and cryo for high-grade CIN III. 2. Breast cyst in [2099], benign. 3. Trichomonas and bacterial vaginosis in the [2093]. 4. Murmur in childhood. 5. Ductal carcinoma in situ left breast s/p lumpectomy in [2109] 6. Right shoulder bursitis Social History: Worked as LPN nurse [First Name8 (NamePattern2) ] [Last Name (Titles) ] detox unit, also a pediatric VNA. Divorced, lives with 7yo adopted daughter. [Name (NI) ] 3 grown children of her own. Sex: none current, >100 life-time partners, denies any h/o STDs. Pets: none. Travel: no international. Lived in FL & MA only. Tob: quit 1 month ago, denies significant history. EtOH: 1 glass wine 1-2x/month. IVDU: denies. Family History: Negative for kidney disease, cancer, or autoimmune disease by report. Physical Exam: GEN: dyspneic, one word answers to questions, avoiding eye contact VS: 98.2 125/87 126 20 98% on 6L NC, 76% RA, 96% 70% hydrated shovel mask HEENT: MMM, scattered white plaques and papules in the buccal and lingual mucosa, pink tongue, no sclaral icterus, no LAD or thyromegaly CV: RR, tachy, NL S1S2 no S3S4 MRG, pulses 2+ bilat at the radial and DP, 1+ bilat at the temporalis PULM: Bilat coarse crackles in the middle and lower lung fields ABD: BS+, NTND, no masses or HSM LIMBS: 2+ LE edema, no clubbing or cyanosis, no palmar erythema, full range of motion and no swelling, warmth, or tenderness SKIN: No rashes, darkening of the extensor surfaces ? acanthosis nigricans NEURO: PERRLA, EOM NL, good smooth and saccadic pursuit, no pronator drift, no tremor, no asterixis, reflexes 2+ at the radial and patella bilat, toes down bilat, moving all limbs, gait steady, Romberg no assessed, moving all limbs Pertinent Results: HBsAg neg, HBsAb pos, HBcAg/Ab neg [Doctor First Name ] 1:40, AMA neg, [Last Name (un) 15412] Pos (1:20), ANCA neg, dsDNA neg C3 100, C4 35, HIV Ab Neg, HCV Ab Neg AspGM neg, bdg neg, RPR neg CMV IgG pos, IgM neg EBV IgG pos, IgM neg PPD neg [11-13] ESR 122 CRP 48.8 [10-22] ESR 107, CRP 73.4 [10-2] ESR 46, CRP 16 [9-23] ESR 19, CRP 5.5 . STUDIES: [10-22] renal u/s: 1. No focal or textural abnormality of the liver. 2. No intrahepatic biliary ductal dilation. CBD top normal at 5 mm. 3. Enlarged echogenic kidneys bilaterally. The differential diagnosis includes HIV nephropathy as well as other medical renal diseases. 4. Prominence of the contracted gallbladder wall may be related to hepatitis. . [11-3]: CT abd/pelvis w/o contrast: 1. Enlarged fibroid uterus. 2. Small distal esophageal diverticulum. 3. No evidence of acute intra-abdominal pathology. 4. Mild fluid overload. Possible right lung nodule incompletely evaluated. . [11-8]: CT chest w/o contrast: 1. Slight improvement in diffuse peribronchovascular patchy and nodular opacities, which may again be due to vasculitic or infectious process. 2. Peripheral reticular opacities, with basilar predominance and with some architectural distortion, suggestive of a UIP pattern. . [11-10]: TTE The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is small with normal free wall contractility. 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 pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the findings of the prior study of [2111-10-22], no major change. . [2111-11-16]: Bronchoscopy: pending but with 2 white plaques on erythematous bases in the trachea and bronchi by report . [2111-11-18]: VATS lung biopsy R upper lobe: Results pending. . ADMISSION LABS: [2111-10-22] 01:30AM BLOOD WBC-9.7# RBC-4.47 Hgb-13.6 Hct-37.9 MCV-85 MCH-30.5 MCHC-36.0* RDW-13.9 Plt Ct-541* [2111-10-22] 01:30AM BLOOD Neuts-91.2* Lymphs-5.9* Monos-2.4 Eos-0.3 Baso-0.1 [2111-10-22] 02:42PM BLOOD PT-14.2* PTT-54.3* INR(PT)-1.2* [2111-10-22] 01:30AM BLOOD Glucose-116* UreaN-52* Creat-5.7# Na-124 K-4.1 Cl-99 HCO3-16* AnGap-13 [2111-10-22] 01:30AM BLOOD ALT-79* AST-208* LD(LDH)-1237* CK(CPK)-580* AlkPhos-185* TotBili-0.3 [2111-10-22] 05:11AM BLOOD TotProt-4.8* Albumin-1.5* Globuln-3.3 Calcium-6.5* Phos-5.2* Mg-2.0 Cholest-175 . DISCHARGE LABS: [2111-11-23] 07:45AM BLOOD WBC-8.8 RBC-2.89* Hgb-8.5* Hct-25.0* MCV-86 MCH-29.4 MCHC-34.1 RDW-15.8* Plt Ct-434 [2111-11-23] 07:45AM BLOOD Glucose-83 UreaN-47* Creat-4.9* Na-134 K-3.8 Cl-99 HCO3-28 AnGap-11 [2111-11-19] 07:45AM BLOOD ALT-14 AST-46* LD(LDH)-558* AlkPhos-149* TotBili-0.1 [2111-11-23] 07:45AM BLOOD Calcium-6.6* Phos-3.1 Mg-1.6 Brief Hospital Course: Her complicated hospital course will be divided into two parts, East and [Hospital Ward Name ]: . I. Brief Summary of [Hospital Ward Name 516] Course: . Pt was admitted to MICU with severe acute renal failure in setting of mild hypoxia. Renal and Rheumatology were consulted and patient was started on empiric pulse steroids. Pt's serologies sent out for extensive rheum/renal w/u - pt's sx started to improve with treatment. A renal biopsy was done on left kidney [10-22] and eventually showed collapsing FSGS. She also has b/l pulmonary infiltrates of unclear etiology, and along with polyarthritis, new onset renal failure, mild transaminitits, initial concern was vasculitis. However, renal biopsy did not show vasculitis and [Doctor First Name ]/ANCA negative. Pulmonary was consulted for further evaluation given concern for infectious process in the lungs. Infectious disease was consulted as well. PPD was placed, and was negative. Beta glucan and galactamannan were negative as well. Viral/infectious serology/cutlures sent and were negative. Pulmonary recommended a repeat chest CT, with initial plan for bronchoscopy with BAL and biopsy. However the repeat CT scan showed great improvement in the infiltrates with steroids and dialysis. They felt the infiltrates were likely secondrary to fluid overload from renal failure. The bronch was canceled. The patient's O2 sats stabilized. However, after two weeks of dialysis and steroids, repeat CT [11-8] did now show much difference from [10-22] other than decreased pleural effusions. Again, pulm consult service felt this was fluid, but clinically there some inconsistencies. She did not have any orthopnea, echo showed small LV/RV, she became tachycardic with standing (100-150s), and she had NO peripheral edema. This suggested volume depletion. Also, she was having intermittent fevers to 102 and intermittent O2 requirements. ID and Rheum also felt that there was something more inflammatory in etiology (ESR 122) that needed to be further evaluated, especially since the CT did not show much improvement in the reticulonodular/peribronchovascular opacities. Thus the CT service/Interventional Pulmonary service were consulted, and they recommended bronch/BAL on [11-16], followed by VATS if necessary. . As for her ARF, acute nephrotic syndrome, progressive renal failure, and renal biopsy c/w collapsing FSGS, the etiology was not clear. HTLV, HIV, parvovirus, lyme/EBV/CMV and other viruses were all negative. As she did not improve on pulse steroids (prednisone 100mg qod), and she became progressively uremic, she was started on HD. She underwent aggressive fluid removal for the first 2weeks, then appeared euvolemic/hypovolemic, then HD occurred MWF via a right vascath, then a tunneled catheter was placed on [11-10]. There is optimism among the team that she still may regain renal function. . II. Summary of [Hospital Ward Name 517] Course: On transfer from the [Hospital Ward Name ] to the [Hospital Ward Name ] Hospital Medicine Service, the [Hospital1 139] team reviewed her complex case and summarized as follows: . Ms. [Known lastname 35443] history begins approximately 2 months ago with development of a macular rash on her chest that she thought was acne. It was not pruritic or painful. Then she developed arthralgias and morning stiffness. According to her sister she was so sore and weak she could barely drive. She was seen by PCP in clinic on [9-23] c/o worsening arthritis/arthralgias symptoms, chest pain and non-productive cough. In PCP's office she was noticed to have darkening of palmar surface of hands bilaterally with scattered 2-4 mm areas of macular hyperpigmentation on the distal aspects of fingers bilaterally which was suspected to be [2-7] Parvovirus infection. She was treated with NSAID and Percocet and a hematologic w/u was started. A CXR revealed RML infiltrate c/w PNA and the Pt was Rx with Azithromycin on [10-6]. She was admitted briefly from [Date range (1) 97758] for PNA and polyarthritis, as outlined in HPI. . She again presented on [10-22] with cough, fatigue, and ARF, ultimately found to be FSGS of unclear etiology. She was treated with steroids and HD. Her course has also been notable for tachycardia and persistent hypoxia with pulmonary infiltrates. Her non-productive cough, DOE, and bilateral pulmonary infiltrates/opacities have persisted despite dialysis with fluid removal. She has had decreased O2sats on room air intermittently requiring supplemental oxygen. Rheumatologic workup thus far has included negative ANCA, [Doctor First Name ], anti-dsDNA, anti-mitochondrial, and NL C3C4. Anti-smooth muscle antibody is positive. A workup for elevated PTT has been non-specific with ongoing mild elevations in PTT with normal PT. Anti-cardiolipin IgG is negative while IgM is positive. She has not been on SQ heparin. There was also concern for breast cancer recurrence based on CT findings for her pulmonary work up, but diagnostic mammography was negative for Ca. . She was transfered the [Hospital Ward Name ] on [2111-11-16] for diagnostic bronchoscopy, after which the [Hospital1 139] Medicine team took over her care. The initial bronch report noted 2 white plaques in her trachea and bronchial systems with erythematous bases. The pt reports ongoing dry cough and SOB. Her saturation on transfer was 76% on RA and 96% on 70% hydrated face mask. Her cough improved with hydrated mask as compared to 6L NS dry O2. The definitive diagnosis of her multi-organ system dysfunction has remained ellusive, but each problem was addressed as follows: . # ARF/collapsing FSGS: Biopsy on [2111-10-22] showed collasping FSGS, and pulse steroids were started in addition to HD. She is still making urine and now appears euvolemic to mildly volume overloaded, in the setting of hypoalbuminemia. She has continued with HD on MWF. She has been continued on prednisone 100mg QOD (D1 was [2111-11-10]) as well as PPx with Bactrim SS QD. . # Pulmonary opacities/Cough/hypoxia: Bilateral brochovascular opacities, also reticular peripheral/basilar opacities, and mild mediastinal LAD likely reactive. Imaging was suggestive of vasculitis but [Doctor First Name ]/ANCA negative as noted above. Infectious work-up was negative, and she did not worsen on high dose steroids and off antibiotics. Bronchoscopy showed 2 adherent white plaques on erythematous bases concerning for [Female First Name (un) 564], so fluconazole was started. BAL fungal culture was positive. ILD vs sarcoidosis were also considered, and she underwent VATS with biopsy. Bx preliminarily showed dysplasia v. chronic inflammation but no granulomas. Today her pathology confirmed BOOP, and the Pulmonary consult team recommended continuing her on high-dose steroids. . # Tachycardia: Unclear etiology, worsened by fevers. ECG confirms sinus tachycardia. Pt clinically euvolemic to dry. Pulmonary embolism was considered, but UE/LE dopplers were negative, and echocardiogram showed small but normal RV, no pulmonary HTN. We were unable to obtain CTA or V/Q scan due to her poor renal function and abnormal CXR, respectively. She improved progressively on standing tylenol and with improved comfort and hydration. Her pulse is now in the 90s with transient tachycardia to 140s with exertion. . # Fevers: Now resolved. Infectious w/u negative as above, not on any antibiotics except for PCP [Name Initial (PRE) 1102]. Bronch and BAL findings as noted above, started on fluconazole with a plan to continue for 14 days (last dose [2111-12-2]). . # Anxiety/adjustment disorder: Pt was evaluated by Psychiatry and is thought to be at high risk for depression. Her anxiety is largely situational and is thought to contribute to the tachycardia. Also aggrevated by steroids. Pt particularly anxious at HD. Stable on clonazepam 0.25mg [Hospital1 ] plus ativan 0.5mg q4 PRN. . # Elevated PTT: Only very mildly elevated off heparin with normal PT, unclear clinical significance. Restarted heparin SQ given very high risk of DVT/PE in this Pt who was essentially bed-bound with nephrotic syndrome. . # Abd pain: Resolved. The pains occured only during dialysis, mostly lower quadrants, similar to menstrual cramps. CT [11-3] with fibroid uterus, and patient had been menstrating during the same period. However, time correlation with HD suggested symptoms may be correlated with decreased perfusion/low flow during HD. MRA done and showed patent mesenteric vessels. . # Abnormal breast opacity: H/o L breast DCIS s/p lumpectomy '[09], then partial masectomy. CT on [2111-10-29] showed L breast spiculated nodule and R breast opacity. Diagnostic mammogram on [2111-11-10] was negative for malignancy. . Medications on Admission: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:40 Capsule, Delayed Release(E.C.)(s) Refills:0 2. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash for 14 days: apply to elbows and upper chest twice a day. Use a small amount of ointment and cover these areas with a thin film. Disp:qs unit Refills:0 3. Derma-Smooth/FS Eczema 0.01 % Oil Sig: One (1) Topical [Hospital1 ] (2 times a day) as needed for scalp rash for 2 days: Apply to scalp twice a day for two weeks. Disp:qs 1 Refills:0 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours for 14 days: Do not take with any other medications that contain Acetaminophen. Disp:112 Tablet(s) Refills:0 5. Naproxen 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:60 Tablet(s) Refills:1 6. Pro Air HFA 1-2 puffs Q6 hours: PRN wheezing or shortness of breath Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[Numeric Identifier 2249] units Injection once a day as needed for line flush. 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) mg PO DAILY (Daily) as needed. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Please discontinue after [2111-12-2]. 11. Prednisone 50 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day): Please discontinue after [2111-12-22] and taper. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Docusate Sodium 50 mg Capsule Sig: One (1) Capsule PO BID:PRN. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [1-7] Tablet, Delayed Release (E.C.)s PO daily:PRN. 16. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H:PRN as needed. 17. Zofran 4 mg Tablet Sig: One (1) Tablet PO Q8H:PRN. 18. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) Appl Topical PRN (as needed). 19. Neomycin-BacitracnZn-Polymyxin 3.5-400-5,000 mg-unit-unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). 20. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO 5x daily: Please discontinue on [2111-12-7] Please continue on 400mg TID from [2111-12-8] until off steroids. 21. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary diagnosis: # collapsing focal segmental glomerular sclerosis # pulmonary candidiasis # bronchiolitis obliterans with organizing pneumonia (BOOP) # anemia of chronic disease # metabolic encephalopathy, multifactorial etiology . Secondary diagnosis: # history of breast DCIS # situational anxiety Discharge Condition: Hemodynamically stable, asymptomatic other than generalized weakness. Tolerating regular diet. Mental status much improved, alert, answers questions appropriately, follows commands. Discharge Instructions: You were admitted with polyarthritis, acute renal failure, cough, and hypoxia. A biopsy of your kidney showed collapsing focal segmental glomerular sclerosis. You were treated with high dose steroids and dialysis. We did a bronchoscopy and a biopsy of your lung to determine why you are coughing and have hypoxia. The bronchoscopy showed evidence of a fungal infection, which we are treating. The biopsy of your lung showed bronchiolitis obliteran organizing pneumonitis, or BOOP. The treatment for this is steroids. You may need oxygen intermittently, and you will need close follow-up with a pulmonologist. . Please take your medications as prescribed. . Please attend your follow up appointments. Followup Instructions: Provider: [First Name11 (Name Pattern1) 2389] [Last Name (NamePattern1) 2390], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2111-12-1] 1:45 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2111-12-16] 10:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 435] Date/Time:[2111-12-21] 1:30 [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2111-11-26]	[ "2761" ]
Admission Date: [2119-12-2] Discharge Date: [2119-12-5] Date of Birth: [2056-11-7] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 2080] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Upper Endoscopy History of Present Illness: 63M h/o DM, CAD on ASA and plavix with one week of abdominal bloating and distention. This morning developed nausea and emesis, initially was vomitting food. He then had some sips of water, with recurrence vomitus, which became bloody. The patient was also complaining of some diarrhea, however, he denies melena, BRBPR, or hematochezia. Denies abdominal pain. Denies chest pain/pressure, lightheadedness, and syncope. He also denies fever. Due to the persistence of these symptoms the patient presented to the ED. . In the ED, the patient presented with the following vital signs: 98.1 88 120/67 18 98% RA. Patient subsequently vomitted in ER with dark blood. Patient also noted to have guiac negative brown stool documented in the ED. His lowest blood pressure was noted to be 93/50. Two 18 gauge peripheral IVs were placed as well as an NG tube which yielded approximately 75cc of dark blood without clearing after 1L NS. Labs were notable for a HCT drop from 40 to 36 over 4 hours, platelets of 125 and a BUN of 25. The patient was given 3L of NS as well as protonix 80mg IV ONCE, then protonix gtt at 8mg/hr, as well as Zofran 4mg IV ONCE. . His vitals prior to transfer were the following: 82 145/68 20 98%. Past Medical History: 1) CAD s/p PCIs in [2115]. Pt on aspirin and Plavix 2) DM Type 2 3) Hypertension 4) h/o back surgery 5) h/o perforated gallbladder, pancreatitis, age 15, s/p ex-lap . Social History: Self-employed salesman. From Western Mass, visiting [Location (un) 86] for the holidays. Remote tobacco history, also social EtOH (with recent moderate use), denies illicits. Family History: Father with CAD, Mother d. lung Ca, Sister with leukemia, Sister with hypertension. No known GI or liver disease. Physical Exam: VS: Tc: 97.4 BP: 127/65 (105-127/65-88) HR: 60-70 RR: 18 O2: 96%RA BS: 130-160 GEN: pleasant, comfortable, NAD HEENT: EOMI, anicteric, MMM RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e NEURO: AAOx3. No gross deficits. Pertinent Results: Admission Labs: [2119-12-2] 01:25PM BLOOD WBC-8.3 RBC-4.85 Hgb-14.2 Hct-40.8 MCV-84 MCH-29.2 MCHC-34.7 RDW-13.6 Plt Ct-125* [2119-12-2] 01:25PM BLOOD Neuts-90.9* Lymphs-4.6* Monos-3.6 Eos-0.4 Baso-0.5 [2119-12-2] 01:25PM BLOOD PT-12.1 PTT-24.9 INR(PT)-1.0 [2119-12-2] 01:25PM BLOOD Glucose-172* UreaN-25* Creat-0.9 Na-141 K-4.1 Cl-106 HCO3-22 AnGap-17 [2119-12-2] 01:25PM BLOOD ALT-21 AST-28 AlkPhos-48 TotBili-0.7 [2119-12-2] 01:25PM BLOOD Lipase-29 CXR: FINDINGS: The lungs are clear. There are no pleural effusions or pneumothorax. The cardiomediastinal and hilar contours are normal. Pulmonary vascularity is normal. A nasogastric tube courses below the diaphragm with tip terminating within the stomach. The bowel gas pattern is nonspecific with no dilated loops of small or large bowel to suggest obstruction or ileus. There are no soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Normal chest radiograph, no evidence of pneumomediastinum EKG: Sinus rhythm. Non-specific inferior ST-T wave changes. No previous tracing available for comparison. Discharge Labs: [2119-12-5] 06:40AM BLOOD WBC-5.1 RBC-3.98* Hgb-11.8* Hct-33.5* MCV-84 MCH-29.7 MCHC-35.3* RDW-13.1 Plt Ct-125* [2119-12-4] 07:00AM BLOOD PT-11.6 PTT-28.5 INR(PT)-1.0 [2119-12-5] 06:40AM BLOOD Glucose-119* UreaN-9 Creat-0.8 Na-143 K-3.8 Cl-110* HCO3-27 AnGap-10 [2119-12-4] 07:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.1 HELICOBACTER PYLORI ANTIBODY TEST-PENDING EGD: Grade 3 esophagitis with ulceration Erosive gastritis Ulcer in the stomach body Erosion in the antrum Duodenitis of bulb [Doctor First Name ]-[Doctor Last Name ] tear Biopsies were not taken due to recent bleeding Otherwise normal EGD to second part of the duodenum Brief Hospital Course: 63yo man with CAD on aspirin + Plavix, diabetes, hypertension, p/w nausea, vomiting, and hematemesis never causing hemodynamic instability, thought to be [1-10] [Doctor First Name ]-[Doctor Last Name ] and gastritis. 1. Hematemesis: Felt to be [1-10] [Doctor First Name ]-[Doctor Last Name ] tear and gastritis. EGD showed [Doctor First Name ]-[Doctor Last Name ] tear as well as ulcerative esophagitis, gastritis, and duodenitis. He was started on pantoprazole and needs follow-up with GI in [1-12] weeks with repeat endoscopy in [5-16] weeks to ensure appropriate healing. Hematocrits were stable on the floor, no transfusions were needed. . 2. Thrombocytopenia: Unclear baseline but remained stable. RBC smear added on. Normal albumin and INR and lack of strong history of ETOH use argue against ETOH abuse. . 3. CAD - Aspirin was held initially, but was restarted after endoscopy. Plavix was held and should be done so until after the repeat endoscopy to ensure no more bleeding. This should be discussed with cardiology before restarting. Metoprolol and lisinopril restarted on the day of discharge. Pending Studies: Helicobacter pylori Antibody H. Pylori serology returned NEGATIVE Medications on Admission: Medications at home (need to be confirmed): 1) aspirin 81mg daily 2) Plavix 75mg daily 3) Lipitor 80mg daily 4) Metoprolol 50mg [Hospital1 ] 5) Metformin 500mg [Hospital1 ] 6) Lisinopril 40mg daily no NSAIDS Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. 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 3. aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear Esophagitis with ulceration Gastritis with ulceration Duodenitis Secondary diagnosis: Coronary artery disease Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 16098], It was a pleasure caring for you in the hospital. You were admitted because you were vomiting blood. You were closely monitored in the Intensive Care Unit. You had no further episodes of bleeding, and never needed to be transfused. You had an endoscopy done which showed inflammation of your esophagus and stomach, with stomach and esophagus ulcers. It also showed a tear in your esophagus, which may be the reason for your bleeding. The following changes were made to your medications: We STARTED Pantoprazole 40mg twice daily We STOPPED plavix. You should talk with your cardiologist about whether you need to restart this after you have your second endoscopy with the GI specialists to ensure there is no more bleeding. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] S. Location: [Hospital ] MEDICAL GROUP Address: [Location (un) 88259], [Location (un) ],[Numeric Identifier 88260] Phone: [Telephone/Fax (1) 88261] We are working on a follow up appointment with Dr. [First Name (STitle) 1887] within 1-2 weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above. You should follow up with the gastroenterologists in 4 weeks. If you would like to come here their number is: ([Telephone/Fax (1) 2233]. You need to keep seeing the gastroenterologist so they can take another look down your esophagus and make sure it has healed well. Please follow up with Dr. [Last Name (STitle) ], your cardiologist, to discuss whether you need to restart your plavix (blood thinner) after you have your appointment with the GI specialists to ensure your esophagus has healed. Completed by:[2119-12-5]	[ "2851", "41401", "4019", "25000" ]
Admission Date: [2130-9-23] Discharge Date: [2130-9-28] Date of Birth: [2066-7-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Male First Name (un) 5282] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD and variceal banding History of Present Illness: MICU admission: 64yoF with multifocal hepatocellular carcinoma secondary to HepB cirrhosis, s/p RFA (clinical trial 08-256) of right liver lesions, but persistence of left liver lesions, now s/p TACE treatment with Doxorubicin on [2130-5-29], presented to the ED and was womiting blood, with repeat of this while in triage. She was admitted to MICU for an emergent upper endoscopy. Vomitted BRB at home and vomited BRB here 100cc. Called for emergency release blood, Hx of varices, getting pantoprazole, octreotide, blood. Has 2 18g and a 16g PIV. CAlled for 2U PRBCs and 2U FFP. T/C sent for 4 units. . Floor transfer: For full HPI please see MICU admission note. In summary, Ms. [Known lastname 86216] is a 64 year old female w/ HBV cirrhosis c/b varices, multifocal HCC s/p RFA (clinical trial 08-256) of right liver lesions, but persistence of left liver lesions, now s/p TACE treatment with Doxorubicin on [2130-5-29] who initially presented w/ hematemesis and transferred to MICU for EGD. She was treated w/ iv ppi and octreotide. She was intubated for EGD ([9-23]) that was notable for grade III - IV esophageal varices s/p banding. Patient was successfully extubated, and switched to po ppi, and is also on cipro. She has received a total of 3U pRBC. Her lamivudine was changed to tenofovir. Currently, pt does not complain of any pain. She reports feeling tired. Has had no bowel movements since admission. No abd pain or cough. Past Medical History: Past Oncologic History: - Hepatitis B, diagnosed in Nigera [4-22], when she presented with ascites, has been on Lamivudine since. - Moved to the US [1-25] and ultrasound at [Hospital1 2177] demonstrated two lesions in the liver concerning for HCC. - MRI [2130-2-27] showed a 5.6 x 4.3 cm lesion in segment VI that demonstrated arterial enhancement and contrast washout and a 3.0 x 2.3 cm lesion in segment III, also with arterial enhancement and contrast washout. Another 1.8x2.5 cm lesion was seen at the dome of the liver suspicious for hepatoma as well as other smaller lesions suspicious for hepatoma. - Referred to [Hospital1 18] for evaluation in the liver center and was found to have an AFP of 9508 ng/mL. - Enrolled in clinical trial 08-256 and underwent radiofrequency ablation on [2130-4-26] with some RUQ pain after that resolved, with adequate treatment of R sided lesions - Transarterial chemoembolization [2130-5-29] to treat the left sided lesions. . Other Past Medical History: 1. History of hepatitis B cirrhosis, diagnosed 05/[2127]. 2. Advanced multifocal hepatocellular carcinoma 3. Hypertension. 4. Chronic peripheral paresthesias. Her daughter states this started decades ago before she was born and resulted from a trip in [Country 16573] where she had to stand in the [Doctor Last Name ] for 2-3 days (?) 5. Multinodular thyroid gland seen on [2130-5-11] ultrasound with dominant right lobe nodule amenable for ultrasound-guided biopsy, likely after Tx for HCC, per Heme Onc notes Social History: Originally from [Country 16573] and has been living in United States with her daughter and her daughter's family since [1-25]. She denies any history of tobacco, alcohol, or illicit drug use. First language is Yoruba. Patient speaks English. Family History: No family history of malignancy. Physical Exam: VS - Temp 99.8F, BP 107/61, HR 73, R 18, O2-sat 100% RA GENERAL - well-appearing woman in NAD HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric NECK - supple, thryromegaly w/out nodules, + cervical LAD LUNGS - poor respiratory effort and poor air entry to lower lobes, mild crackles bibasilarly HEART - PMI non-displaced, RRR, [1-21] holosystolic murmur at RUSB ABDOMEN - soft, slightly distended, BS+, NT, no hepatomagelay EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake Pertinent Results: [2130-9-28] 05:25AM BLOOD WBC-3.0* RBC-3.32* Hgb-10.3* Hct-29.7* MCV-89 MCH-30.9 MCHC-34.6 RDW-17.3* Plt Ct-PND [2130-9-27] 05:10AM BLOOD WBC-3.5* RBC-3.33* Hgb-10.2* Hct-29.9* MCV-90 MCH-30.6 MCHC-34.1 RDW-17.1* Plt Ct-56* [2130-9-26] 07:05AM BLOOD WBC-4.0 RBC-3.40* Hgb-10.5* Hct-30.2* MCV-89 MCH-30.8 MCHC-34.6 RDW-18.0* Plt Ct-44* [2130-9-24] 05:22AM BLOOD WBC-2.9* RBC-3.33* Hgb-10.3* Hct-29.7* MCV-89 MCH-30.8 MCHC-34.5 RDW-17.6* Plt Ct-44* [2130-9-23] 04:12AM BLOOD WBC-6.0 RBC-3.05* Hgb-9.6* Hct-27.5* MCV-90 MCH-31.6 MCHC-34.9 RDW-15.2 Plt Ct-49# [2130-9-23] 01:25AM BLOOD WBC-8.8# RBC-3.42 Hgb-11.2* Hct-32.0* MCV-94 MCH-32.7* MCHC-34.9 RDW-15.0 Plt Ct-111* [2130-9-24] 10:50AM BLOOD Neuts-80.6* Lymphs-11.8* Monos-4.2 Eos-2.9 Baso-0.4 [2130-9-23] 01:25AM BLOOD Neuts-71* Bands-0 Lymphs-23 Monos-3 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [2130-9-28] 05:25AM BLOOD PT-18.3* INR(PT)-1.7* [2130-9-23] 01:25AM BLOOD PT-19.0* PTT-30.3 INR(PT)-1.7* [2130-9-28] 05:25AM BLOOD Glucose-77 UreaN-10 Creat-0.7 Na-139 K-3.5 Cl-108 HCO3-27 AnGap-8 [2130-9-27] 05:10AM BLOOD Glucose-89 UreaN-12 Creat-0.8 Na-141 K-3.4 Cl-110* HCO3-26 AnGap-8 [2130-9-26] 07:05AM BLOOD Glucose-78 UreaN-15 Creat-0.9 Na-134 K-3.6 Cl-105 HCO3-26 AnGap-7* [2130-9-23] 01:25AM BLOOD Glucose-126* UreaN-25* Creat-0.8 Na-137 K-6.5* Cl-106 HCO3-21* AnGap-17 [2130-9-23] 01:25AM BLOOD ALT-42* AST-135* AlkPhos-81 TotBili-1.7* [2130-9-25] 04:22AM BLOOD TotBili-1.8* [2130-9-23] 01:25AM BLOOD Lipase-77* [2130-9-28] 05:25AM BLOOD Calcium-7.5* Phos-2.4* Mg-2.2 [2130-9-23] 01:25AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.9 Mg-1.9 [2130-9-23] 04:12AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.7 [2130-9-26] 07:05AM BLOOD AFP-[2052]* . . CXR - No acute intrathoracic abnormality. . EGD: Continue octreotide gtt for 48 hours. Cipro 250 mg [Hospital1 ] x 5 days Continue ppi gtt for 48 hours total, then switch to oral. Consider sorafenib for unresectable HCC. Recommend oncology consult. Patient will need further variceal banding as outpatient. Okay to extubate. Clear liquids for next 24 hours. Then soft diet after. Carafate slurry 1g po qid for 5 days. Brief Hospital Course: [Known firstname ] [Known lastname 86216] is a 64-year-old woman with advanced multifocal hepatocellular carcinoma occurring in the setting of hepatitis B cirrhosis, s/p RFA p/w hematemesis from esophageal varices, s/p banding on this admission. . # Esophageal varices- p/w hematemesis and melena, EGD showed varices in the middle third of esophagus, s/p banding in 4 places on [9-23]. Pt was transferred from MICU the day following banding and was hemodynamically stable throughout. BPs were SBP 110s-120s throughout admission. HCT was stable around 28-30 and she did not require any blood transfusions. She completed 72-hr course of octreotide, had IV PPI, 5 days of ciprofloxacin and 5 days of sucralfate. Prior to discharge, her PPI was transitioned to oral omeprazole, she will follow up with Dr. [Name (STitle) 23173] in 2 weeks for repeat endoscopy and banding as outpatient. [Month (only) 116] consider starting nadolol at that time. . # Ascites - prior to discharge, pt reported abdominal distension, on exam mostly tympanitic with some dull areas, U/S was done to evaluate for fluid and showed moderate ascites. Pt was not uncomfortable with distension. We performed a diagnostic tap which was negative for SBP. She was started on lasix 20mg and aldactone was increased to 50mg from 25mg daily. She will f/u in liver clinic for titration of these medications. . # Hepatocellular carcinoma: diagnosed in [1-25], s/p RFA and transarterial chemoembolization in [2130-5-16], with lesions shown to be improving on CT surveillance. Most recent CT showed no new lesions, stable pulmonary nodule, and new PVT (see below). Oncology was made aware of her admission, and recommended that she follow up as outpatient for initiation of sorafinib for unresectable HCC. She has f/u appt with Dr. [Last Name (STitle) ] in 2 weeks. . # Hepatitis B cirrhosis: Lamivudine was changed to tenofovir to prevent resistant, pt discharged with Rx. . # Portal venous thrombosis - new thrombus found on CT from [2130-9-15] - complete occlusion of the posterior right portal vein, partial occlusion of the proximal anterior right portal vein, and near complete occlusion of the segmental left portal vein. Last CT in [Month (only) 205] so not clear when PVT originated. Given this chronicity and recent bleed, anticoagulation was not initiated. . # HTN: increased laxis to 20mg daily and aldactone 50mg daily, will f/u in liver clinic. Medications on Admission: HOME MEDICATIONS: LAMIVUDINE [EPIVIR] 150 mg daily LISINOPRIL 2.5 mg once a day SPIRONOLACTONE 25 mg daily CALCIUM CARBONATE-VITAMIN D3 500 mg-400 unit [Hospital1 ] DOCUSATE SODIUM [COLACE] 50 mg prn MULTIVITAMIN . TRANSFER MEDICATIONS: Ciprofloxacin 250 mg [Hospital1 ] Docusate Sodium 100 mg [Hospital1 ] Senna 1 tab [Hospital1 ] K/Mg sliding scale Pantoprazole 40 mg Q12H Tenofovir Disoproxil (Viread) 300 mg daily Discharge Medications: 1. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO twice a day. Disp:120 Capsule, Delayed Release(E.C.)(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Variceal bleed Secondary: HCC HBV 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 a variceal bleed. Your varices were banding during an endoscopy procedure. You were stabilized in the MICU and then transferred to the floor. Your blood counts remained stable and you were able to tolerate a normal diet. We did an ultrasound of your abdomen which showed some fluid, we took a sample of that fluid and it did not show an infection. You should have another endoscopy in 2 weeks with Dr. [Name (STitle) 23173] to make sure there is no more bleeding. Please make sure to come for this procedure on [2130-10-12]. . You should follow with Dr. [Last Name (STitle) ] at the appointment date below for your hepatocellular carcinoma. . We have made the following changes to your medications: Take 20mg lasix once daily and 50mg aldactone once daily to keep fluid out of your belly We have changed your lamivudine to tenofovir Take prilosec (omeprazole) to help reduce acid in your stomach and prevent future GI bleeding Followup Instructions: Dr. [Name (STitle) 23173] will call you with the date/time of your endoscopy (about 2 weeks from discharge) . Name:[First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 86217],MD Specialty: Primary Care When: Thursday, [10-12] at 10:10am Location: [Hospital6 5242] CENTER Address: [Location (un) 5243], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 798] . Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2130-10-16] at 4:00 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2502], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2130-9-28]	[ "5849" ]
Admission Date: [2148-6-13] Discharge Date: [2148-6-20] Service: MICU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 25699] is an 83-year-old male with a history of congestive heart failure, hypertension, atrial fibrillation, meningioma, gastroesophageal reflux disease, and pacemaker placement who presented with severe hypoxia and hypotension requiring emergent intubation. Several days prior to admission, the patient had been placed on levofloxacin at his nursing home for pneumonia. On the day of admission, he was noted by his nursing home staff to have a peripheral oxygen saturation of 77%, dyspnea, and increased pedal edema. On arrival to the Emergency Room, his blood pressure was 64/33. He was given a 500-cc normal saline bolus with some improvement in his blood pressure. A portable chest x-ray was read as consistent with acute pulmonary edema. The patient had worsening hypoxia by peripheral saturations, and the Emergency Department team was unable to obtain an arterial blood gas. The patient was placed on noninvasive positive pressure ventilation. His blood pressure dropped at that time to 56/palpation, and the patient was placed on a dopamine intravenous drip at 5 mcg/kg per minute. The patient's blood pressure improved to 150/63, and the patient was given Lasix 20 mg intravenously. However, at 2:30 p.m. on the day of admission, the patient's PO2 was noted to be 46, and the patient was endotracheally intubated for hypoxia. Initial laboratory work was notable for a decreased hematocrit and an elevated International Normalized Ratio. Nasogastric lavage was performed and was negative. A right internal jugular cordis was placed in the Emergency Room. After failed attempts at a right radial and right axillary arterial line, a left femoral arterial line was eventually placed in the Emergency Room. During the course of these procedures, the patient's blood pressure dropped to 50 systolic, and he responded to an increase in dopamine to 10 mcg/kg per minute. PAST MEDICAL HISTORY: 1. Congestive heart failure, with repeated admissions for exacerbations. 2. Hypertension. 3. Atrial fibrillation. 4. Meningioma. 5. Lumbago. 6. Gastroesophageal reflux disease. 7. Status post placement overdose dual-chamber pacemaker for tachy-brady syndrome. 8. Benign prostatic hypertrophy, status post transurethral resection of prostate. 9. Psoriasis. 10. Sjogren syndrome. MEDICATIONS ON ADMISSION: 1. Colace 100 mg p.o. b.i.d. 2. Albuterol meter-dosed inhaler 2 puffs q.i.d. 3. Multivitamin 1 tablet p.o. q.d. 4. Nitroglycerin patch 0.4 mg topically q.d. 5. Lisinopril 10 mg p.o. b.i.d. 6. Citalopram 20 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Dilantin 300 mg p.o. q.a.m. and 200 mg p.o. q.p.m. 9. Lasix 80 mg p.o. q.d. 10. ................ 2.5 mg p.o. q.d. 11. Potassium 20 mEq p.o. q.d. 12. Coumadin 5 mg p.o. q.d. 13. Levofloxacin 500 mg p.o. q.d. (of unknown duration). ALLERGIES: The patient had no known drug allergies. SOCIAL HISTORY: The patient is a resident at [Hospital3 98565] Home since [2148-3-29]. Per his wife [Name (NI) ], he is a full code. His primary care physician is [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 622] [Last Name (NamePattern1) ]. PHYSICAL EXAMINATION ON PRESENTATION: At the time of presentation the patient was afebrile, with a blood pressure of 125/60 (on dopamine 10 mcg/kg per minute), and a heart rate of 70. He had an oxygen saturation of 95%, and a central venous pressure of 15 with U waves. His skin was warm and well perfused with good capillary refill. Head and neck revealed the patient was intubated. Pupils were equal, round, and reactive to light. The lungs were clear to auscultation anteriorly. The heart had a regular rate and rhythm, with a [4-3] holosystolic murmur at the base without radiation. The abdomen was slightly firm but nontender with an anterior ventral hernia and positive bowel sounds, and he had 3+ symmetrical lower extremity edema. PERTINENT LABORATORY DATA ON PRESENTATION: At the time of admission the patient had a white blood cell count of 14.3, a hematocrit of 29.4, and platelets of 235. He had a sodium of 141, potassium of 5.4, chloride of 100, bicarbonate of 24, blood urea nitrogen of 109, creatinine of 3.4, and blood glucose of 111. His INR was 5.4, and PTT of 41. His initial arterial blood gas prior to intubation was 7.35/50/46 with a lactate of 1. His urinalysis showed moderate blood and 50 red blood cells, but only 3 to 5 white blood cells, and no casts. RADIOLOGY/IMAGING: His chest x-ray showed mild cardiomegaly, a right lower lobe consolidation with effusion, and mild congestive heart failure. Electrocardiogram was AV paced, poor anterior R wave progression, question anterior infarct of undefined age. HOSPITAL COURSE BY SYSTEM: 1. CARDIOVASCULAR: The patient's hypotension was initially thought secondary to sepsis, and he was started on broad spectrum antibiotics including vancomycin, ceftriaxone, and Flagyl; and blood cultures were drawn. Based on the initial suspicion that his septic etiology may be related to abdominal pathology, a Surgery consultation was obtained. The Surgery consultation recommended an I- CT scan of the abdomen and serial examinations. The I- CAT scan revealed free fluid in the right pericolic gutter and a possible gallstone, but no other notable pathology. The patient had a persistent pressor requirement of dopamine 10 mcg/kg per minute throughout the first hospital day. A trial of low-dose dobutamine was attempted on the second hospital day, but the patient's pressure dropped precipitously and it was discontinued. A transthoracic echocardiogram was obtained which showed a left atrium normal in size, right atrium moderately dilated, and mild regional left ventricular systolic dysfunction with hypokinesis of the anterior septum and apex. More notable, there was severe 4+ mitral regurgitation and severe 4+ tricuspid regurgitation. There was mild pulmonary artery systolic hypertension. Compared with a prior study of [2146-7-30], left and right ventricular function was worse, and tricuspid and mitral regurgitation was worse. This study was also reviewed by Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] who was covering the Medical Intensive Care Unit Green Service on [2148-6-15]. Dr. [First Name (STitle) 437] believed that the patient's left ventricular ejection fraction was closer to 20% than the initial read of 40%. In addition, Dr. [First Name (STitle) 437] was convinced that at least half of the patient's stroke volume was flowing backwards as a result of his severe mitral regurgitation. Thus, Dr. [First Name (STitle) 437] felt that the patient's likelihood of meaningful recovery was minimal, and he conducted a family meeting in which the patient was made do not resuscitate. The patient was continued on broad spectrum antibiotics, despite no evidence of infection on blood, urine, or sputum cultures and on dopamine at 10 mcg/kg per minute. Digoxin was started on [2148-6-17]; per discussion with the patient's cardiologist (Dr. [Known firstname ] [Last Name (NamePattern1) ]). Several attempts were made to wean the patient's dopamine over the next several days, but all were accompanied by severe drops in the patient's systolic blood pressures to the 40s to 60s. Another trial of dobutamine was attempted on [2148-6-17] which again failed secondary to hypotension. Given the patient's severe cardiac dysfunction and valvular disease on echocardiogram, and the team's inability to titrate his pressors after several days of broad spectrum intravenous antibiotics and optimized blood pressures on dopamine, family meetings were undertaken to discuss the patient's poor long-term prognosis. Family meetings were held on [6-18], [6-19], and [2148-6-20]. The family's concern for the patient's comfort were addressed with increases in sedation; and eventually, on [6-19], the decision was made to make no further increases in the patient's dopamine dose. On [6-20], the patient's son (his health care proxy, [Name (NI) ]) came to the decision to withdraw pressor support at 9:15 a.m. Pressors were discontinued at approximately 10 a.m. on [2148-6-20], and the patient's pressure immediately dropped to the middle 50s. The patient's pressure hovered in this area for several hours until he died at approximately 7 p.m. on [6-20]. 2. RESPIRATORY FAILURE: The patient was intubated in the Emergency Room, as stated before, and remained intubated throughout his hospital admission. On hospital day two, a thoracentesis was performed to rule out empyema or malignant effusion. The results of the pleural fluid were consistent with a transudate. There was never was any sputum of blood culture evidence of acute pneumonia, and the patient ventilated well throughout his admission. However, several attempts at ventilator weaning from [6-17] to [6-20] all failed. As stated above, the patient's pressor support was eventually withdrawn on [2148-6-20], and the patient died several hours later. 3. RENAL: The patient had a significantly increased blood urea nitrogen and creatinine on arrival to the Emergency Room, which was likely the result of his minimal renal perfusion secondary to severe congestive heart failure and mitral regurgitation. The patient's renal function did improve transiently while on pressors, but over the last two days of his admission it began to rise again. 4. HISTORY OF SEIZURES: The patient was continued on Dilantin throughout his admission with a therapeutic level. 5. INCREASED INR: The patient's INR was increased at the time of admission, likely due to overdosing of Coumadin. He was reversed with several doses of subcutaneous vitamin K to good affect. He was not anticoagulated again throughout the course of his admission. 6. PSYCHOSOCIAL: As stated above, the patient's family met with the Medical Intensive Care Unit team and the Medical Intensive Care Unit attending (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]) several times throughout this patient's difficult and emotional trying course. They emphasized their interest in the patient's comfort; and to this end, the patient was placed on a Fentanyl and Ativan drip throughout most of his admission. DISCHARGE/DEATH DIAGNOSES: 1. Severe congestive heart failure with 4+ mitral regurgitation. 2. Respiratory failure. 3. Acute renal failure. 4. Seizure disorder. 5. Increased International Normalized Ratio. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3851] Dictated By:[Name8 (MD) 30425] MEDQUIST36 D: [2148-7-15] 16:24 T: [2148-7-18] 18:17 JOB#: [Job Number ]	[ "4280", "4240", "5849", "42731", "53081", "4019" ]
Admission Date: [2143-10-8] Discharge Date: [2143-10-11] Date of Birth: [2088-5-6] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old man admitted to [Hospital3 ] Hospital to the Cardiac Intensive Care Unit after a stent to the left anterior descending artery. The patient initially developed chest pain on Sunday, two days prior to admission. At that time, he was placing bricks on his front walk. He developed pain in his chest with pressure, about [8-20] pain. The pain radiated to his neck. He denied nausea and vomiting. He also denied diaphoresis. However, he did have some shortness of breath. The patient blamed his persistent chest pain on muscle strain. It remained at about [2152-5-15] for the next two days. Two days after this pain developed he presented to his primary care physician's office on the morning of [10-8]. The primary care physician did an EKG which showed ST elevations anteriorly and he was sent by EMS to the [Hospital1 1474] Emergency Department. In the Emergency Department there, he was noted to have anterior and lateral ST elevations, given aspirin and sublingual nitroglycerin, and transferred to [Hospital6 1760] for cardiac catheterization. PAST MEDICAL HISTORY: The patient denies any medical problems. [Name (NI) ] past surgery. MEDICATIONS: The patient was on no medications at the time of admission. ALLERGIES: The patient has No known drug allergies. . SOCIAL HISTORY: The patient works as a printer. He smokes one pack per day x 40-50 years. He has occasional alcohol use. He lives with his wife and he has two healthy children. FAMILY HISTORY: Positive for a father with a CABG in his 60s and diabetes in his mother and maternal aunt. REVIEW OF SYSTEMS ON ADMISSION: The patient denies fever, chills, headache. Denies shortness of breath and wheezing. Also denies GERD symptoms, claudication. He says he has moderately poor exertional ability. Denies orthopnea and PND. Denies melena and bright red blood per rectum. PHYSICAL EXAMINATION: At the time of admission, the patient was afebrile, blood pressure 116/63, pulse 97, respiratory rate 26, O2 sat 99% on room air. HEENT - patient had pupils equal, round and reactive to light, extraocular movements full, anicteric. Moist mucus membranes. Neck was supple without JVD. Lungs were clear to auscultation bilaterally. Cardiovascular - regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops. Abdomen was soft, nontender, nondistended with normoactive bowel sounds. Extremities - he had 2+ pulses bilaterally and no edema. LABS ON ADMISSION: The patient had a white count of 16.9, hematocrit 39, platelets 243. His ABG on room air was 7.36, 44, 156, 26, sodium 138, potassium 4.7, chloride 102, bicarb 23, BUN 13, creatinine 1.0, glucose 168. His CKs were 963 with an MB fraction of 44, index of 5, trended down to 709, then 494, to 391, to 193. EKG on admission - the patient had a normal sinus rhythm at 78 beats per minute. Axis showed left anterior descending, interval 164, 83, 55. He had Q waves in V1 through V4 and II, III and S. ST elevations 1 mm in II and S, 4 mm in V2, V3 and F4, and 3 mm in V5, 2 mm in V6. HISTORY OF HOSPITAL COURSE: The patient went for a cardiac catheterization on the day of admission which showed an ejection fraction of 35%, apical and anterolateral hypokinesis. It showed RA mean pressure of 14, RV pressure 33/13, PA pressure 33/18 with a mean of 26, wedge 18, left ventricular pressure 103/20, cardiac output 3.6, cardiac index 1.8, SVR 1579 and peripheral vascular resistance 178. His PA sat was 63%. His catheterization also showed one-vessel disease, left main, no stenosis. He had a distal left anterior descending ulcerated 90% stenotic lesion past the origin of diagonal-2 and occluded with thrombus at the origin of D-3. He also had moderate systolic and diastolic ventricular dysfunction. 1) CARDIOVASCULAR COURSE - MYOCARDIUM: The patient is status post an anterior wall MI, now with an ejection fraction of 35% and anterior and apical hypokinesis. The patient was decided to be placed on coumadin for six months for his apical and anterolateral hypokinesis, as well as his anterior MI. The patient was begun on coumadin. His PT and INR was not therapeutic at time of discharge. However, the patient was started on Lovenox 60 mg subcu [Hospital1 ] which the patient was instructed how to give himself which he was able to do quite well. The patient was also begun on an ACE inhibitor and beta blocker, initially on captopril and Lopressor, eventually switched to Mavik 1 mg po qd and atenolol 25 mg po qd at time of discharge. CORONARY ARTERY DISEASE: The patient is status post stent to the LAD and acute anterior MI. He was started on aspirin 325 mg qd, Plavix 75 mg qd for 30 days. The patient's lipid levels were checked and were found to be total cholesterol 122, triglycerides 112, HDL 27, LDL 73. However, after much discussion with the team it was decided that his lipid levels may be falsely decreased in a setting of an acute myocardial infarction. The patient was begun on Lipitor 10 mg po q hs which his primary care physician and cardiologist can choose to continue or not as they see fit. CONDUCTION: The patient remained in normal sinus rhythm throughout the hospital course with no events. 2) PULMONARY: The patient continued to sat well on room air and no issues. He has decided to quit smoking cigarettes. He says that at this time he would like to try doing without any nicotine patches or medications. However, he says he will follow-up with his primary care physician if he has any difficulties quitting smoking. 3) RENAL: The patient had no renal issues during admission. 4) HEME: The patient was on Integrelin after the procedure and he was placed on a heparin drip while coumadin was started and later changed over to Lovenox. He is to be discharged on Lovenox, as well as coumadin 3 mg po q hs. He will check his INR and PT on Monday and fax results to his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 20426]. DISPOSITION: The patient is to be discharged to home to follow-up with Dr. [Last Name (STitle) 20426] on Wednesday, [10-16]. He will also follow-up with cardiology, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047]. DISCHARGE CONDITION: The patient was discharged in stable condition to home. DISCHARGE MEDICATIONS: Include 1) Mavik 1 mg po qd, 2) atenolol 25 mg po qd, 3) aspirin 325 mg po qd, 4) Plavix 75 mg po qd x 30 days, 5) Lovenox 60 mg subcu q 12 h until therapeutic INR, 6) coumadin 3 mg q hs, 7) Lipitor 10 mg po q hs and the patient has a prescription to check his INR and PT on Monday. He will also have VNA services come to his home to assist him with his new medications and adjustment to his decreased ventricular function and new myocardial infarction. DISCHARGE DIAGNOSES: 1) Coronary artery disease. 2) Acute anterior myocardial infarction. DR.[Last Name (STitle) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 12-270 Dictated By:[Last Name (NamePattern1) 1203] MEDQUIST36 D: [2143-10-11] 11:56 T: [2143-10-11] 11:03 JOB#: [Job Number 35294] cc:[Last Name (NamePattern4) 35295]	[ "41401", "3051" ]
Admission Date: [2138-7-1] Discharge Date: [2138-7-2] Date of Birth: [2062-4-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 330] Chief Complaint: OSH transfer for shock Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Mr. [Known lastname 174] is a 76 year old man with CAD s/p CABG, severe sCHF EF 12%, s/p prolonged repeated hospitalizations recently admitted to [Hospital1 2025] until [6-15] for pacer lead change c/b sepsis sent in from home to OSH ED for increased lower extremity edema and wound drainage, SOB, weakness and melena x 2-3 days. Family also noted decreased UOP, 5cc last 24 hours and elevated blood sugars 200s. At OSH ED, initial BP 77/46 and sats 99%3L. After receiving 2L NS for BP 60s-80s, he desatted to 80s so was placed on a NRB. He appeared to be sleepy and in worse respiratory distress so was intubated for distress and airway protection with etomidate/succ 7.5 ETT for hemodynamic instability and respiratory distress. Bp did not improve with IVF so he was started on dopamine and propofol drips. CXR significant for L pleural effusion and could not r/o infiltrate so he was given Zosyn 3.375g and transferred to [Hospital1 18] ED. He was also given calcium gluconate, insulin and D50 for hyperkalemia K 6.8. . In our ED, he was weaned off of propofol and dopamine but then started on low dose 0.1 mcg levophed for borderline hypotension. Labs significant for renal failure with Cr 3.0, hyperkalemia K 6.3, WBC 18K, ALT 190, AST 315, trop 0.04, CK 282, lactate 1.7. ABG 7.4/35/167. CXR revealed L lung whiteout and R mainstem intubation so ETT pulled back. RIJ was placed. He was given additional calcium gluconate, insulin, D50 and kayexalate for hyperK. Given ascites on exam of unclear etiology, he had CT torso which revealed ascites, diverticulosis, left pleural effusion, no apparent etiology of sepsis. He was given vanco for additional coverage as well as versed and fentanyl. GI was also called given melena on exam and he was given pantoprazole for melena despite normal HCT. . VS prior to trasnfer 105/55 60 100% on AC FiO270% Vt500 PEEP 5 RR 14. . On the floor, he is intubated and sedated. . 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: DM2 s/p BKA Left leg L CEA [2130] CAD s/p 4V CABG [2120] LIMA-LAD, SVG-OM1, SVG-OM2, SVG-RCA CHF EF 12% [3-/2138] HTN Defibrillator placed [2135] s/p pacer placement [1-/2138] Guaiac positive stool PAD Dyslipidemia s/p RLE bypass grafting CRI s/p total colectomy for colon CA Syncope due to VT with rib fx [2-/2138] RLE ulcer Infected ICD s/p explant-[2138-6-13] BiV new ICD placement MSSA bacteremia [3-/2138] s/p cpmpletion 6 weeks antibiotics Social History: Lives alone with 24 hour care form 5 children. Formerly emplyed in coal transport, as handyman, and at general Foods as forklift operator. Quit tobacco 40 years prior. Smoked approx. 10 years in the navy. . Family History: nc Physical Exam: on admission General: Intubated and sedated HEENT: Sclera anicteric, MMM, oropharynx clear. Dried blood in OG tube. Neck: Supple, JVP 10cm, no LAD. Scar L neck from CEA Lungs: Decreased BS L base. Bibasilar rales. No wheezes CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur LLSB radiating to axilla with laterally displaced PMI. Abdomen: soft, distended with fluid wave, hypoactive bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining scant clear-yellow urine with dried blood at urethral meatus Ext: Cool, doplerable pulses RLE. s/p L BKA. No clubbing, cyanosis. Diffuse 1 + edema. Skin: RLE with ulcer dorsum of foot with clean edges, slight erythema, intact pink granulation tissue. No purulent exudate. Multiple ecchymoses Pertinent Results: ============== Radiology ============== CXR [7-1] IMPRESSION: 4.2 x 1.1 x 3.2 cm fluid collection over the area of clinical concern in the left chest wall. This is amenable to US-guided aspiration . CT Head [7-1] IMPRESSION: 1. No intracranial hemorrhage. 2. Old right ACA infarct. 3. Small vessel ischemic disease, chronic. . CT Chest [7-1] 1. Large left pleural effusion with near complete collapse of the left lower lobe. 2. Large volume abdominal ascites and nodular-appearing omentum - in the absence of liver disease, these findings are concerning for underlying malignancy (peritoneal carcinomatosis versus omental caking). 3. Densely calcified atherosclerotic disease of the aorta, coronary arteries, celiac, SMA, and renal arteries. 4. Status post CABG, cholecystectomy, and right partial colectomy. 5. Diverticulosis without evidence of diverticulitis or perforation. 6. Status post left femoral neck fracture fixation. 7. Old right posterolateral rib fractures, fourth through seventh. . ============ Labs ============ [2138-7-1] 09:00AM BLOOD WBC-18.6* RBC-4.03* Hgb-11.0* Hct-34.6* MCV-86 MCH-27.2 MCHC-31.8 RDW-18.4* Plt Ct-360 [2138-7-1] 07:02PM BLOOD Glucose-208* UreaN-81* Creat-3.0* Na-125* K-5.5* Cl-92* HCO3-22 AnGap-17 [2138-7-1] 07:02PM BLOOD CK-MB-4 cTropnT-0.04* [2138-7-1] 12:54PM BLOOD CK-MB-5 cTropnT-0.04* [2138-7-1] 09:00AM BLOOD cTropnT-0.04* [2138-7-1] 09:00AM BLOOD Albumin-2.9* Calcium-8.1* Phos-6.5* Mg-2.6 Iron-27* [2138-7-1] 08:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2138-7-1] 09:10AM BLOOD Type-ART Temp-36.3 FiO2-100 pO2-167* pCO2-35 pH-7.40 calTCO2-22 Base XS--1 AADO2-530 REQ O2-86 Intubat-INTUBATED Brief Hospital Course: 76yo M with CAD s/p CABG, severe sCHF EF 12%, recent prolonged hospital course c/b pacer lead infection and explant transferred from OSH ED with hypotension and likely cardiogenic shock. Hypotension was felt to be due to cardiogenic shock as well as hypovolemia from GI bleed. Cardiogenic shock was supported cold/wet appearance on exam, pleural effusions, and increased ascites in the setting of increased LE edema and know low EF. Patient was initially treated with dobutamine for improved cardiac output and lasix drip. Initially covered with broad spectrum antibiotics with vanco, cefepime, and cipro for initial concern for sepsis. Respiratory failure was felt to be secondary to cardiogenic shock and possible contribution of pneumonia. Acute on chronic renal failure was thought to be due to cardiogenic shock as well. In regards to his gastrointestinal bleed, NG lavage was positive but stool was nonmelanotic yet guaiac positive. On the night of admission, family gathtered at the bedside and patient's son and HCP [Name (NI) ] [Name (NI) 174] [Name (NI) 1105] decided to pursue comfort measures only care. Patient was extubated at 1 am on hospital day #2 and was pronounced dead at 1 pm the following day with family at the bedside. Medications on Admission: Home Meds: ASA 81 daily Plavix 75mg Po daily Omega 3 fatty acid 1000mg Miralax 17 g daily Senna 2 tabs PO daily Keflex 500mg PO daily lasix 80mg PO daily Amio 200mg Po daily Coreg 6.25mg PO BID Salien nasal spray Simvastatin 80mg PO daily ergocalciferol [Numeric Identifier 1871] units once weekly Potassium 20 meq PO daily Albuterol prn Nitro SL Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Cardiogenic shock Gastrointestinal bleed Acute on chronic renal failure Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[2138-7-2]	[ "51881", "5849", "5119", "4280", "25000", "40390", "5859", "2724", "V4581" ]
Admission Date: [2161-1-24] Discharge Date: [2161-1-24] Date of Birth: [2124-11-25] Sex: F Service: HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname ] is a 36-year-old white female with a history of polysubstance abuse and bipolar depression who presents from an outside hospital after having a believed ingestion. At approximately 8:30 in the evening on [1-24], the patient's sister called EMS reporting an ingestion which appeared to consist of Seroquel, and Neurontin. Patient was found by EMS to be largely unresponsive with initial vitals in the field being a pulse of 136, blood pressure of 68/28, respiratory rate of 6 and oxygen saturation of 90%. She was started on oxygen by face mask, given 1.5 mg of Narcan and intubation was attempted in the field, but failed. Patient was then subsequently transferred to [Hospital6 10353] Emergency Department with subsequent vitals showing a blood pressure of 124/54, respiratory rate of 16, oxygen saturation 99%. In the Emergency Department at the [Hospital3 ], she was intubated and given activated charcoal. As there was no Intensive Care Unit beds available at the [Hospital3 ], she was transferred to the [Hospital6 2018] for further management. Of note, the alcohol level at the outside hospital was 189. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Polysubstance abuse including alcohol, cocaine, benzodiazepines and heroin. She has been admitted into detoxification greater than 20 times. 3. History of multiple overdoses, greater than eight hospitalizations in the past three years. Overdoses have included alcohol, benzodiazepines. She has been intubated four times in the past two years. 4. Depression, believed to be bipolar/dysthymic disorder. 5. Anxiety disorder. 6. Personality disorder with borderline features. Reportedly followed by Dr. [Last Name (STitle) ] at the [Hospital 4415]. MEDICATIONS ON ADMISSION: 1. Neurontin [2157] mg q.a.m., [2157] q.d. and 1200 mg q.p.m. 2. Seroquel 200 mg q.h.s. 3. Remeron of unknown dose. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient reportedly lives with her mother and has had significant tobacco and alcohol use since age 7. FAMILY HISTORY: The patient states that both her grandmother and mother are bipolar. PHYSICAL EXAMINATION ON ADMISSION TO THE [Hospital1 ]: Vitals: Showed a temperature of 97.2. Heart rate of 92. Blood pressure 121/72. Respiratory rate 13, oxygen saturation of 100%. In general, patient was intubated and sedated. Her pupils equal, round and reactive to light. The oropharynx showed an ET tube, but was otherwise clear and without erythema. Head was normocephalic, atraumatic. Neck was supple with no appreciable lymphadenopathy or jugular venous distention. heart was regular rate and rhythm, no murmurs, rubs or gallops. Lungs were clear to auscultation anteriorly. Abdomen was soft, nontender, nondistended with positive bowel sounds and no appreciable hepatosplenomegaly. Extremities showed no cyanosis, clubbing or edema. Skin was warm without cyanosis, clubbing or edema. Peripheral pulses were 2+ bilaterally. On neurological exam, patient was sedated, but moving all extremities to a noxious stimuli. DATA FROM THE OUTSIDE HOSPITAL: White blood cell count of 6.2, hematocrit of 41.9, platelet count 216,000. Sodium 147, potassium 3.6, chloride 113, bicarbonate 16.8, BUN 5, creatinine 0.5, glucose 107, anion gap was 17.2, serum osmolalities were 351, ETOH level 186 and calculated osmolalities was 342. Urine tox screen was negative, >.....<barbiturates, benzodiazepines or opiates. Acetaminophen level was less than 10. Salicylate level was 2.0. Arterial blood gas at the outside hospital was 733, with a pCO2 of 35.4 and a pO2 of 224. Chest x-ray showed no acute process. Head CT was also negative for any significant abnormalities. Electrocardiogram showed sinus tachycardia with a rate of 111 with normal intervals. There was no acute ischemic changes noted. HOSPITAL COURSE: The patient was transferred to the Intensive Care Unit directly from the [Hospital3 ]. Upon arrival, she was intubated but did not appear to have any primary pulmonary process. Over the next several hours, her sedation was weaned aggressively and patient was subsequently able to be extubated without any complications. Over the next 12 hours, patient remained completely stable. As her sedation lightened, she was seen and evaluated by the Psychiatry Service to whom she admitted that she had had a suicide attempt with over ingestion of her medications. At this time, it is felt that she is medically stable with no outstanding medical issues. She is currently stable on room air with no respiratory distress. Given her recent suicide attempt with drug overdose, it is felt best that she be admitted for inpatient psychiatry visit. There are currently no beds available at the [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) ]. She will be evaluated by the BEST physician for placement at an outside unit. DISCHARGE STATUS: To outside Psychiatry facility. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Neurontin [2157] mg po q.a.m., [2157] mg po q.daytime and 1200 mg po q.p.m. 2. Seroquel 200 mg po q.h.s. 3. Remeron unknown dose. Dictated By:[Dictator Info ] MEDQUIST36 D: [2161-1-24] 03:45 T: [2161-1-23] 15:51 JOB#: [Job Number 33517]	[ "51881" ]
Admission Date: [2153-4-28] Discharge Date: [2153-4-30] Date of Birth: [2112-6-12] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 9160] Chief Complaint: DKA Major Surgical or Invasive Procedure: None History of Present Illness: 40-year-old female with DM II with frequent admissions for DKA/hyperglycemia, depression, perineal abscesses who presented to ED with SOB and palpitations and was found to be in DKA. Pt states that she stopped taking all of her medications, including lantus and glimeprimide, 4 days ago because she could not afford her copays. Glucometer readings have been stating "error." She has had polydipsia, polyuria, and general malaise. She also had an episode of NBNB emesis a few days ago on a hot day when she was not hydrating herself. Has had rhinorrhea from seasonal allergies but otherwise no other localizing symptoms for infection. Only sick contact was her sister who had [Name (NI) 19456] symptoms. She has had frequent admissions for DKA/hyperglycemia, most recently [Date range (3) 95692], largely due to medication noncompliance. In the ED, initial VS were: 97.2 126 124/59 16 100% r/a. Labs remarkable for blood glucose 607, bicarb 8 with anion gap 22. ABG showed pH 7.08/27/61/8. CXR was unremarkable. U/A showed glucose and ketones but was otherwise not suggestive of infection. EKG showed sinus tachycardia at 112; no ischemic changes. She received 4L IV fluids. She also received 40meq potassium and 8units insulin prior to being started on insulin gtt. Vitals prior to transfer: 98.4 110 122/64 17 99%RA. Past Medical History: DM2 w/moderately severe B nonproliferative diabetic retinopathy HTN Depression- one psych hospitalization in [2150] for SI h/o EtOH abuse- never experienced withdrawal sx, no longer drinking Social History: Lives with her brother. Currently seeking disability, not employed. Denies tobacco use. Occasional marijuana use, none recently. Hx of prior alcohol abuse, now drinks once weekly. Last drink over one week ago. Denies hx of withdrawal. Family History: Mother with DM2, HTN. No known family history of cancer Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 98.8 132/71 86 24 99%RA General: Alert, oriented x 3, no acute distress HEENT: Sclera anicteric, dry MM, poor dentition, 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 DISCHARGE PHYSICAL EXAM: Vitals: 98.3, BP 126/78, HR 98, RR 16, 100% RA General: Alert, oriented x 3, no acute distress. Sitting in a chair eating her lunch HEENT: Sclera anicteric, MMM, very poor dentition, 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. Left knee has minimal effusion, mildly tender to palpation over medial joint line Neuro: CNII-XII intact, 5/5 strength in all extremities. Pertinent Results: ADMISSION LABS [2153-4-28] 01:35PM BLOOD WBC-6.1# RBC-4.42# Hgb-13.3 Hct-43.2# MCV-98 MCH-30.1 MCHC-30.8* RDW-13.2 Plt Ct-387# [2153-4-28] 01:35PM BLOOD Neuts-71.6* Lymphs-21.5 Monos-4.3 Eos-2.0 Baso-0.5 [2153-4-28] 01:35PM BLOOD Glucose-607* UreaN-17 Creat-1.1 Na-135 K-4.2 Cl-105 HCO3-8* AnGap-26* [2153-4-28] 01:35PM BLOOD ALT-10 AST-12 AlkPhos-141* TotBili-0.3 [2153-4-28] 01:35PM BLOOD Albumin-4.4 Calcium-10.1 Phos-4.0 Mg-2.1 [2153-4-28] 01:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2153-4-28] 02:28PM BLOOD pO2-61* pCO2-27* pH-7.08* calTCO2-8* Base XS--21 Comment-GREEN TOP [2153-4-28] 02:28PM BLOOD Lactate-1.9 IMAGING CXR-[4-28] FINDINGS: Frontal and lateral views of the chest were obtained. The lungs are well expanded and clear without focal consolidation, pleural effusion or pneumothorax. Heart size is normal. Mediastinal silhouette and hilar contours are normal. No acute osseous abnormality is identified. There is no free air under the diaphragm. IMPRESSION: No acute intrathoracic process. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: 40-year-old female with DM II with frequent admissions for DKA/hyperglycemia, HTN, depression, perineal abscesses who presented to ED with SOB and palpitations and was found to be in DKA. ACTIVE ISSUES BY PROBLEM: # Diabetic ketoacidosis: Blood glucose in 600s upon arrival to ED, urine positive for glucose and ketones, and pt with anion gap acidosis, all consistent with DKA. DKA likely precipitated by noncompliance with medications due to lack of ability to afford copay, including lantus and glimeprimide. No localizing symptoms to suggest infection. CXR unremarkable and U/A not suggestive of infection. Pt has longstanding hx of poorly controlled diabetes. Last A1c 12.7 on [2152-9-23]. She was started on an insulin drip and admitted to the medicine ICU for close monitoring. [Last Name (un) ] diabetes consult was called for help with management (standard protocol with DKA). Within the first day of hospitalization, her anion gap closed, she was restarted on her home insulin regimen, and she was able to start eating. The following day she was stable to transfer to the general medicine floor. There she was continued on Lantus, and her blood sugars stabilized. On discharge, [Last Name (un) ] consult recommended switching her to insulin NPH/regular (70/30) for ease of dosing and hopefully improved compliance. She was given prescriptions for new supplies and instructed to check her glucose four times daily while adjusting to her new insulin. She was asked to bring these readings to her follow up appointments with Dr. [First Name (STitle) ] at [Hospital1 ] and at [Last Name (un) ]. She will receive her Insulin free of charge from [Last Name (un) ]. # Knee effusion: appeared to have mild-moderate effusion of left knee. Joint aspiration was attempted in the ICU to rule out infection as possible trigger for DKA, however they were not able to obtain fluid on aspiration. She continued to have some swelling in the knee, but there was no warmth, erythema, or pain with flexion to support septic arthritis, so repeat tap was not attempted. CHRONIC ISSSUES: # Depression: Continued on paroxetine and trazodone, and social work visited while she was an inpatient. # Alcohol abuse: Pt with previous admission with alcohol intoxication. States that she only drinks once weekly now. Serum and urine tox was negative. TRANSITION OF CARE ISSUES: - DM: started on insulin 70/30, will need to follow up with outpatient providers for further titration of dosing. - Patient is to call to schedule an appointment in [Hospital ] [Hospital ] Clinic at [Telephone/Fax (1) 25521]. - FULL CODE this admission. Medications on Admission: 1. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime. 3. Lantus 100 unit/mL Solution Sig: 30 u Subcutaneous once a day. 4. glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day. 5. HISS Discharge Medications: 1. paroxetine HCl 20 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. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: Twenty (20) units Subcutaneous twice a day: 20 units in AM, 20 units at dinner. Disp:qs mls Refills:2 4. FreeStyle Lite Meter Kit Sig: One (1) meter Miscellaneous once a day. Disp:1 meter Refills:2 5. Insulin Syringe Ultrafine [1-1] mL 29 x [1-1] Syringe Sig: One (1) syringe Miscellaneous twice a day. Disp:60 syringes Refills:2 6. FreeStyle Lite Strips Strip Sig: One (1) strip Miscellaneous four times a day. Disp:120 strips Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Diabetic ketoacidosis Diabetes mellitus type II Secondary diagnoses: Depression Substance abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [Known lastname 13469], It was a pleasure being involved in your care at [Hospital1 18]. You were admitted to the hospital because of extremely high blood sugars from not taking your insulin. You needed to be monitored very carefully in the ICU at first, but your sugars improved and you were able to go to the regular medicine floor and now are safe for discharge. We have made changes to your insulin regimen so that you will only need to give yourself 2 injections each day. It is ESSENTIAL that you always continue to take this medicine. Each time you come in to the hospital for this, damage is being done to your body from the high sugars and you could eventually have a heart attack, stroke, or kidney failure from these problems. Changes to your medications: STOP levemir 30 units at night (your old insulin) STOP glimepiride (your oral diabetes pill) START insulin NPH/regular (70/30) 20 units in AM, 20 units at dinner. This is your new daily insulin regimen. Please check your sugars 4x a day and bring your list of recordings to your doctors Followup Instructions: Is is ESSENTIAL that you come to these follow up appointments for continued management of your diabetes Name:[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Specialty: Primary Care Location: [Hospital 3578] COMMUNITY HEALTH CENTER Address: [Hospital1 3579], [Location (un) ],[Numeric Identifier 3580] Phone: [Telephone/Fax (1) 3581] When: Wednesday, [5-2] at 3:30pm Please call [Hospital ] [Hospital ] Clinic at [Telephone/Fax (1) 25521] to set up in an appointment in the next week. There they can help you with diabetes education and help you get your medicines for free. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 9162]	[ "311", "4019" ]
Admission Date: [2176-6-24] Discharge Date: [2176-6-28] Date of Birth: [2124-11-21] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 922] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [6-24] Coronary artery bypass graft times 5/MAZE/Ligation of left atrial appendage History of Present Illness: Mr. [Known lastname 11762] is a 51 year old gentleman with a history of atrial fibrillation who recently presented to the emergency department with chest pain. A subsequent cardiac catheterization reveal multi-vessel coronary artery disease and he was therefore referred for surgical evaluation. Past Medical History: Cardiac History: Atrial fibrillation. Diagnosed ~[2166], initially in paroxysmal a-fib, occuring with exercise, more recently contstant afib for ~8 years. Rate controlled wiht metoprolol, blood pressure at baseline 120's / 80's. No other risk factors so not anticoagulated. Had TEEs in the past to evaluate for clot, most recently [2173], negative for clot and otherwise normal. Cardiac history negative for hypertension, hyperlipidemia, or diabetes. Other Past History: allergies actinic keratosis. Social History: Mr. [Known lastname 11762] is married and has two teenage children. He works as a sales engineer and exercises by rowing regularly. Other social history is significant for the absence of current or past tobacco use. He drinks socially and has no history of alcohol abuse. Family History: The patient's sister has atrial fibrillation, is s/p TIA and on Coumadin. His mother has osteoporosis, glaucoma, and late onset coronary artery disease. His father had atrial fibrillation, coronary artery disease s/p CABG in his 50's, died of testicular cancer at age 72. His father's 2 siblings also have atrial fibrillation. Physical Exam: At the time of discharge, Mr. [Known lastname 11762] was awake, alert, and oriented. His heart was of regular rate and rhythm with a rub. His lungs were clear to ausculation bilaterally. His abdomen was soft, non-tender, and non-distended. His medistinal incision was clean, dry, and intact. His sternum was stable. His vein harvest site was clean dry and intact. Trace edema was noted in his upper extremities. Pertinent Results: [2176-6-28] 05:40AM BLOOD WBC-8.5 RBC-2.98# Hgb-9.9# Hct-26.7* MCV-89 MCH-33.2* MCHC-37.1* RDW-14.7 Plt Ct-154 [2176-6-28] 05:40AM BLOOD Plt Ct-154 [2176-6-28] 05:40AM BLOOD PT-21.8* INR(PT)-2.1* [2176-6-28] 05:40AM BLOOD Glucose-104 UreaN-12 Creat-0.8 Na-138 K-4.2 Cl-100 HCO3-32 AnGap-10 Brief Hospital Course: Mr. [Known lastname 11762] [Last Name (Titles) 1834] a coronary artery bypass grafting times five (LIMA to LAD, SVG to DIAG1, SVG to DIAG2, SVG to Ramus, SVG to RCA)/MAZE/Ligation of left atrial appendage on [2176-6-24]. This procedure was performed by Dr. [Known firstname ] [Last Name (NamePattern1) 914]. He tolerated the procedure well and was transfered in critical but stable condition to the surgical intensive care unit. On post-operative day one he was extubated and his vasoactive drips were weaned. On the following day he was transferred to the surgical step-down floor. His wires were removed and he was gently diuresed. He was seen in consultation by the physical therapy service. His chest tubes were removed. Coumadin was started. The patient did remain in sinus rhythm throughout the hospital course. He was discharged in stable condition to home on POD#4. By the time of discharge, the patient was ambulating freely, the wound was healing and pain was controlled by oral analgesics. He was given extensive instructions regarding wound care, diet restrictions and necessary follow up. Medications on Admission: toprol XL 100mg aspirin 325mg multivitamin plavix 75mg 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: dose may change daily for goal INR [12-17], Dr. [Last Name (STitle) 3306] to dose. Disp:60 Tablet(s) Refills:2 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:60 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: coronary artery disease atrial fibrillation Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]). Please call for appointment. Please see Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (cardiologist) in [11-15] weeks. Please call for appointment. Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3306] (PCP) in [11-15] weeks ([Telephone/Fax (1) 4775]). Please call for appointment. coumadin f/u: spoke [Initials (NamePattern4) ] [Last Name (NamePattern4) 5638] at Dr. [Last Name (STitle) 3306]' office-- they will follow. vna to draw on [6-29]- fax to [Telephone/Fax (1) ], or call (after 12pm) [Telephone/Fax (1) 3308] for [Name8 (MD) 11582] MD Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2176-6-28]	[ "41401", "42731" ]
Admission Date: [2190-2-26] Discharge Date: [2190-3-8] Date of Birth: [2132-1-13] Sex: M Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) / pentamidine isethionate Attending:[First Name3 (LF) 10593] Chief Complaint: Transfer for GI bleed Major Surgical or Invasive Procedure: Angiogram RIJ line placement PICC line placement History of Present Illness: 58 yo M with hx of HIV who was transfered from [Hospital3 ] for initial presentation of COPD exacerbation and who then developed a massive GI bleed. Per OSH DC summary, he was admitted on [2-18] for a COPD exacerbation. COPD improved on nebs, IV steroids and IV antibiotics. Within 2-3 days of admission, patient developed a GI bleed, which started as a combination of melena and hematochezia. Felt likely UGIB and GI was consulted. Had an EGD which was negative. During course of bowel prep for colonoscopy he developed massive rectal bleeding. Colonoscopy was defered because GI was concerned about not being able to visualize anything given bleeding. Patient subsequently went into hypovolemic and hemorrhagic shock and was transferred to the ICU where he received continuous blood transfusions and fluid resuscitation. He remained persistently hypotensive and continued to bleed so he was started on pressors on [2-23]. GI continued to defer colonoscopy. IR was consulted and a bleeding scan was done which was nondiagnostic. He continued to bleed and require transfusions. . Per DC summary, on the day of transfer GI decided to do a colonoscopy despite the persistent bleeding. They were unable to clearly visualize any bleeding because the entire colon (from the cecum to rectum) was full of blood. The scope was sent right midway into the ileum where there was also blood suggesting a mid-point GI bleed, however GI was unable to locate a specific area. IR was reconsulted to consider angiographic embolization but was not comfortable performing this procedure. Entire team agreed that best course was transfer to tertiary care facility for possible IR embolectomy. He had received a total of ~14 units of packed red cells across his admission. . Other complications during his hospital course included a left iliac partial thrombosis. Also developed rising creatinine to ~1.3 and consulted renal who felt likely HIV nephropathy. Consulted ID for possible of PCP pneumonia and per ID note he was ruled out by sputums. . At the time of transfer to [Hospital Unit Name 153] at [Hospital1 18], his VS were stable on 1.5 mcg/kg of neo. He was noted to still be sleepy from sedation for his scope (done at 4pm on day of transfer). He was comfortable and in NAD. Abdomen noted to be firm and distended. He subsequently became very tachycardic and hypotensive, and was found to have large mealonic stool. He was intubated for respiratory distress, and received 6 U PRBC, 4 U plts, and 4 U FFP during the [Hospital Unit Name 153] stay. He underwent a CTA, which showed active bleeding in a loop of mid-to-distal ileum situated within the right hemipelvis. Unfortunately, once he went down to IR on the [Hospital Ward Name ], they were unable to find anything. IR did say, however, that the patient might have better luck with an IR machine on the [Hospital Ward Name ], and so he was being transferred West for this. . In the MICU, patient has had several more episodes of BRBPR, last one on [3-1] at 3pm. Patient had a second CTA on [2-28], but no active bleed was identified. On [3-1], patietn had tagged red cell scan done which was negative as well. Mr. [Known lastname 26211] also experienced some respiratory distress and pulmonary edema requiring 2 days of intubation. He was diuresed with Lasix IV and responded well. Patient was extubated on [3-1]. Solumedrol, which was started at OSH for COPD exacerbation, was tapered from 40mg IV bid to 40mg IV qd. He has not received blood transfusion since [96] hours prior to transfer to the floor. He has been transfused a total of 11 units pRBCs since admission to [Hospital1 18].. HCT increased from 32-> 39, and has remained stable. At this point, GI may attempt push enteroscopy. Surgery has requested to maintain hct >30, plts >100, fibrinogen >100 (ICU has been doing plts >50). Of note, TSH was checked and found to be 0.89, Free-T4:0.59 (low). Difficult to interpret in setting of acute illness, can re-evaluate as outpatient. . Today, patient states that he feels "ehh." Denies any sob, abdominal pain, nausea. States he has not had any BRBPR or melena today. . Review of sytems: positive as per above Past Medical History: HIV: on HAART, reports excellent compliance, per pt last CD4 ~200 and VL undetectable, sexually acquired COPD/emphysema: unclear hx (per one report no prior dx, per another has history of severe emphysema), continues to smoke 1 PPD, improved at OSH with steroids and nebs Osteoporosis Remote history of unspecified hematuria Hyperlipidemia History of KS of the skin Weight loss with low BMI and failure to thrive History of syphilis . Social History: - Tobacco: 1 PPD - Alcohol: rare - Illicits: none Lives alone. MSM. Family History: Unknown Physical Exam: Physical Exam on Admission: Vitals: T: 96.0 BP:96/80 P: 105 R: 22 O2: 94/4L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, faint sparse scattered wheezes, no rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Physical Exam on Discharge: Vitals: T 98 BP 132/90 P 80 R 16 O2 90% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear, thrush on lateral aspects of tongue Neck: supple, JVP not elevated, no LAD Lungs: clear to ausculation b/l except for several scattered wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis; edema in UEs b/l is resolved Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: Labs on Admission: [2190-2-26] 10:23PM WBC-31.9* RBC-4.28* HGB-13.1* HCT-35.1* MCV-82 MCH-30.6 MCHC-37.4* RDW-15.4 [2190-2-26] 10:23PM NEUTS-94* BANDS-0 LYMPHS-0 MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-8* [2190-2-26] 10:23PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-2+ OVALOCYT-1+ SCHISTOCY-OCCASIONAL BURR-OCCASIONAL STIPPLED-OCCASIONAL [2190-2-26] 10:23PM PT-14.0* PTT-29.6 INR(PT)-1.3* [2190-2-26] 10:23PM ALT(SGPT)-1685* AST(SGOT)-249* LD(LDH)-323* ALK PHOS-68 TOT BILI-3.2* DIR BILI-0.4* INDIR BIL-2.8 [2190-2-26] 10:23PM ALBUMIN-2.2* CALCIUM-6.4* PHOSPHATE-4.2 MAGNESIUM-2.1 [2190-2-26] 10:23PM GLUCOSE-131* UREA N-49* CREAT-1.3* SODIUM-146* POTASSIUM-3.6 CHLORIDE-120* TOTAL CO2-20* ANION GAP-10 . Relevant Labs: . [2190-2-28] 02:03AM BLOOD WBC-13.9* Lymph-2* Abs [Last Name (un) ]-278 CD3%-51 Abs CD3-142* CD4%-18 Abs CD4-51* CD8%-32 Abs CD8-89* CD4/CD8-0.6* [2190-3-1] 05:03AM BLOOD Ret Aut-1.8 [2190-3-5] 06:01AM BLOOD Hapto-<5* [2190-2-26] 10:23PM BLOOD Hapto-33 Ferritn-1693* [2190-3-2] 03:51AM BLOOD TSH-0.89 [2190-3-2] 03:51AM BLOOD T3-39* Free T4-0.59* [2190-2-26] 10:23PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [2190-2-26] 10:23PM BLOOD HCV Ab-NEGATIVE . Microbiology: . [2190-3-2] 3:51 am Blood (Toxo) CHEM# [Serial Number 92433]G [3-2]. FINAL REPORT [2190-3-5] TOXOPLASMA IgG ANTIBODY (Final [2190-3-5]): EQUIVOCAL FOR TOXOPLASMA IgG ANTIBODY BY EIA. 4.0 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final [2190-3-5]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. . [2190-3-3] 5:59 pm SPUTUM Source: Induced. FINAL REPORT [2190-3-4] Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2190-3-4]): NEGATIVE for Pneumocystis jirovecii (carinii). . Imaging: . Imaging at OSH: 1. Nuclear medicine GI bleeding scan [2190-2-25]: essentially negative GI bleeding study wuithout evidence of active GI bleeding during the 1 hr scan 2. CT Abdomen/Pelvis w/Contrast [2190-2-25]: Fluid-filled colon. No mass lesion. Moderate abdominal and pelvic ascites with mesenteric edema. Left internal iliac artery partially thrombosed aneurysm with diffuse aortoiliac athersclerotic vascular disease. Cholelithiasis, no intra- or extra-hepatic biliary ductal dilatation. 3. Renal US [2-25]: unremarkable 4. CXR: no acute process . Chest x-ray [2190-2-26]: The lungs are hyperinflated. The heart is not enlarged. The aorta is minimally unfolded. There is no CHF, frank consolidation, or gross effusion. However, there is minimal irregular opacity at the right costophrenic angle, ? related to localized scarring and/or pleural thickening. There are also smaller irregular opacities at the left costophrenic angle, biapical pleural thickening, and right apical linear scarring. . There is mildly distended transverse colon (6.6 cm), near the splenic flexure. A curvilinear sliver of gas projecting above the left hemidiaphragm likely represents an artifact due to superimposition of bowel loops, rather than free air. . CT abdomen/pelvis [2-27]: 1. Findings consistent with active small-bowel hemorrhage/extravasation. 2. Free fluid in the abdomen and pelvis. 3. Diffuse atherosclerotic disease with ectatic left common iliac artery and right common iliac pseudoaneurysm and thrombosed left internal iliac aneurysm with distal retrograde filling. 4. Left lung base ill-defined opacity could be infectious or inflammatory, to be followed. 5. Subcentimeter liver lesion, too small to fully characterize. . Mesenteric angiogram [2-27]: 1. Right femoral arteriogram demonstrated access of the right common femoral artery. 2. SMA-gram demonstrated no active extravasation. Normal branching vessels seen. 3. Angiograms from ileal branches and subsequently ileocolic branch did not demonstrate active extravasation, pseudoaneurysm or early draining vein. 4. A nuclear RBC scan is recommended to see if there is persistent bleeding. IMPRESSION: Uncomplicated fluoroscopy-guided mesenteric angiogram. . CTA abdomen/pelvis [2-28] (wet read): No active bleed at this time. However study somewhat limited by contrast filling the entire large bowel (likely from prior bleed). No bleed seen at the distal small bowel site, as seen previously. Mild increase in the abdominal- pelvic free fluid and anasarca. Stable findings include abdominal aorta atherosclerotic disease, celiac stenosis, R CIA pseudoaneurysm, thrombosed left internal iliac aneurysm. Bilateral moderate simple pleural effusions with basal atelectasis, slightly larger since prior study of [2-27]. Foley cath in place, with bulb in the bladder. A taggedRBC study may be helpful to localize the bleed. . Tagged RBC study [3-1]: Normal study with no evidence of GI bleeding during the time of study. . Chest x-ray [3-2]: Moderately severe pulmonary edema is new, accompanied by small bilateral pleural effusion, but heart size and mediastinal vascular caliber are normal. This could be due to transient effects of transfusion, either increased osmotic load alone, or in combination with TRALI. Close followup advised. . TTE [2190-3-4]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). Doppler parameters are most consistent with normal left ventricular diastolic function. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Small LV cavity size with hyperdynamic LV systolic function. No pathologic valvular abnormality seen. . Labs on Discharge: [2190-3-7] 06:45AM BLOOD Hct-42.5 [2190-3-8] 06:55AM BLOOD ALT-144* AST-46* AlkPhos-109 TotBili-9.3* DirBili-0.6* IndBili-8.7 Brief Hospital Course: 58M HIV+ who was hospitalized at OSH for COPD exacerbation where he developed massive LGIB with negative colonoscopy, transferred to [Hospital1 18] for possible IR embolization. . # Gastrointestinal bleeding: Patient developed massive LGIB at OSH, requiring large volume RBC transfusions. At OSH, patient had negative EGD. Multiple unsuccessful attempts at colonoscopies secondary to ongoing bleeding at OSH. Patient was transferred for possible IR embolization. He does have history of hemorrhoids, but no history of diverticulosis. Per patient, last colonoscopy 8 months ago was normal. Patient has required massive transfusion, a total of 25 units of pRBCs. Continued to bleed intermittently, unclear why. On CTA, there was bleeding visualized in a loop of mid-to-distal ileum situated within the right hemipelvis. However, attempt to [Hospital1 92434] and embolize was not successful. Repeat attempt was planned, but next CTA did not localize a bleed. General surgery was following, but did not require emergent surgery. Patient's hct stabilized. He had a capsule study which was normal and did not show any bleeding. After discharge, patient should follow up with gastroenterology. . # HIV: CD4 count 51 this admission, on HAART. Because patient was on liquid diet, he was on liquid Emtricitabine. However, liquid form has lower bioavailability thus patient was likely subtherapeutic. Additionally, he was on a PPI which interacts with retrovirals. Per outside records, patient patient was on dapsone 15mg daily for PCP [Name9 (PRE) ], though this dose sounds too low. Given this and subtherapeutic HAART, there was some concern for PCP [Name Initial (PRE) 1064]. Sputum PCP x1 was negative. During this admission, G6PD was checked and was normal, thus restarted on Dapsone 100mg qd. As outpatient, [Name8 (MD) ] RN at his ID physician's office, he was on Dapsone 50mg daily which is below recommended ppx dose. This was most likely secondary to rising LFTs in setting of Dapsone. When Dapsone 100mg qd was started, Tbili trended up, peaking at 9.5. Thus, Dapsone was discontinued. Discussed with patient monthly inhaled pentamadine vs. atovaquone, and decided to do pentamadine. Unfortunately, when patient received pentamadine treatment, he went into respiratory distress and required solumedrol. He should not ever again receive pentamadine. On discharge, patient was started on atovaquone for PCP [Name Initial (PRE) 1102]. Also, continued home HAART: truvada, retonavir 100mg qd, atazanavir 300 mg PO qd. . # COPD/Repiratory Failure: Originally admitted to OSH for COPD exacerbation. Patient was intubated shortly after arrival in ICU for airway protection in setting of massive bleeding, hypotension, and tachycardia. Per report, has never had diagnosis of COPD until this admission. However, based on imaging, as well as on smoking history, likely has COPD. Also had some pulmonary edema on chest x-ray and was diuresed with Lasix. Unclear why he had pulmonary edema, probably because of fluid overload given massive transfusions. TTE with small LV (no hypertrophy) and hyperdynamic EF. As patient was started on high dose steroids at OSH for COPD exacerbation, he was discharged on 2 week predisone taper. As outpatient, he will need PFTs to further evaluate for COPD. . # Hypotension: Likely secondary to GI bleed as has resolved with appropriate transfusions. On admission, patient was afebrile, but did have a WBC count, highly neutrophilic without bandemia, more suggestive of WBC count from steroids than infection. Off pressors and maintaining his pressures several days into the admission. . # Leukocytosis: Likely secondary to steroids. Patient had BCx, UCx, and C. Diff all of which were negative. Patient was started on steroids for COPD exacerbation on [2-18] . # Transaminitis: Notable for elevations in ALT, AST, bilirubin. Given trended down without alternative intervention besides hemodynamic stability, likely some element of hepatic shock. Hep A antibody positive, but otherwise hep serologies are negative. Most likely secondary to hypoperfusion. . TRANSITIONS OF CARE: -code: full -f/u with gastroenterology -f/u with pulmonary for PFTs -re-check LFTs/bilirubin Medications on Admission: Medications on Transfer (per DC summary): Azithromycin 500mg MWF Dapsone 50mg PO daily Lactiobacillus 1 tablet PO BID with meals Fluconazole 200mg IV daily Benzonatate 100mg PO TID prn Norvir 100mg PO daily at 6PM Reyetax 300mg PO q6pm Truvada 1 tablet daily Atrovent 0.5mg/2.5ml inhaled q4h prn Solumedrol 40mg by mouth Q8H IV (sic) Neosynephrine gtt 60mg in 250ml titrate SBP < 95 Albuterol suffate nebs Q4H Fat emulsion 20% 100ml IV daily except sunday Pantopraziole 40mg IV BID TPN nicotine patch 14mg/24hr Discharge Medications: 1. atazanavir 300 mg Capsule Sig: One (1) Capsule PO once a day. 2. ritonavir 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 9 days: Please take daily while taking prednisone; then you can STOP this medications. Disp:9 Tablet(s) Refills:0 5. prednisone 10 mg Tablet Sig: see below Tablet PO once a day for 9 days: -Take 30 mg (3 tabs) on [3-9]/7,[3-11] -Take 20mg (2 tabs) on [3-12]/10,[3-14] -Take 10mg (1 tab) on [3-15]/13,[3-17] -After [3-17], STOP taking prednisone. Disp:18 Tablet(s) Refills:0 6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). Disp:450 ML(s) Refills:2 7. atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY (Daily). Disp:30 tabs Refills:2 8. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): Please do NOT smoke when you have the patch on as this can be dangerous. Disp:30 Patch 24 hr(s) Refills:2 9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Primary: Lower GI bleed Possible COPD HIV 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 26211], You were initially admitted to an outside hospital initially with trouble breathing. During the hospitalization, you developed profuse bleeding from your gastrointestinal tract and were transferred to [Hospital3 ] Medical Center for further care. First you were admitted to the intensive care unit. You had an imaging study which showed the location of your bleed. The interventional radiology doctors tried to [Name5 (PTitle) 92434] and stop it but were unable to. Plans were made for a repeat attempt, but repeat imaging no longer showed the location of the bleed. You also had a capsule study in which you swallowed a camera. The video of your intestines was normal, confirming that you no longer were bleeding. During the admission, you required multiple transfusions of blood products. By discharge, you were no longer having bloody bowel movements and your blood counts were stable. After discharge, you should follow up with a gastroenterology doctor. It is very important that you follow up given how massive your bleeding was. Please ask your primary care physician to set you up with the specialist. . During the admission, you had a chest x-ray which showed that your lungs were quite inflated suggestive of COPD (chronic obstructive pulmonary disease) which is caused by an extensive smoking history. You should see a pulmonologist (lung doctor) for further evaluation, including pulmonary function tests. Please ask your primary care physician to set you up with the specialist. In the mean time, if you feel short of breath, you should use the albuterol inhaler as included in the prescriptions below. . During the admission, we also saw that your Dapsone was at a dose somewhat lower than ideal for PCP [Name Initial (PRE) 1102]. We increased your dose, but, this caused some blood test abnormalities suggesting that this medicine was causing your blood cells to [Doctor Last Name ]. Thus, we stopped your Dapsone. We discussed two alternative medications, Atovaquone which could be expensive and inhaled Pentamidine monthly. We spoke with you and you preferred the inhaled Pentamidine. Unfortunately, when you received the treatment, you had an allergic reaction and had strouble breathing. You were treated with IV steroids and nebulizers and responded well. In the future, you cannot use pentamidine again. Given your allergy to pentamidine, you should take the Atovaquone instead. A prescription is included. . We have made the following changes to your medications: START Prednisone taper (it is important that you decrease the dose gradually as it is dangerous to stop it abruptly): -Take 30 mg (3 tabs) on [3-9]/7,[3-11] -Take 20mg (2 tabs) on [3-12]/10,[3-14] -Take 10mg (1 tab) on [3-15]/13,[3-17] -After [3-17], STOP taking prednisone START Ranitidine 150mg daily while you are taking the prednisone. Once you finish the prednisone, you can stop the ranitidine. START Atovaquone 1500mg daily (this will replace the Dapsone) START Nystatin 5mL mouth swish 3 times per day for thrush START Nicotine patch daily to help you quit smoking. It is important that you DO NOT smoke while wearing the patch as that can be dangerous. START Albuterol inhaler as needed for shortness of breath. . Please follow up with your primary care physician and infectious disease doctor. Also, please ask your primary care physician to set you up with appointments to see a pulmonologist and a gastroenterologist. . It was a pleasure taking care of you, we wish you all the best! Followup Instructions: *It is recommended you follow up with a Gastroenterologist and a Pulmonologist within 2-4 weeks from discharge. Please discuss booking these appts during your follow up appt on Friday with [First Name9 (NamePattern2) 92435] [Doctor Last Name ]: . Name: NP, [First Name8 (NamePattern2) 3742] [Last Name (NamePattern1) ] (works with Dr [Last Name (STitle) ]) Location: [Hospital 46644] MEDICAL AT RIVERWALK Address: [Location (un) 46645], [Hospital1 ],[Numeric Identifier 46646] Phone: [Telephone/Fax (1) 34574] Appt: [3-12] at 9:50am . Name: Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location: [Hospital 46644] MEDICAL AT RIVERWALK Address: [Location (un) 46645], [Hospital1 ],[Numeric Identifier 46646] Phone: [Telephone/Fax (1) 34574] Appt: [3-19] at 11am Completed by:[2190-3-17**]	[ "51881", "2762", "5849", "2851", "3051", "2724", "2875" ]
Admission Date: [2163-10-13] Discharge Date: [2163-10-17] Date of Birth: [2087-6-20] Sex: M Service: MEDICINE Allergies: Heparin Agents / Lipitor / Statins-Hmg-Coa Reductase Inhibitors Attending:[First Name3 (LF) 4327] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: 76M with hx of CAD s/p CABG x 2 ([2140],[2148]), multiple NSTEMI, and PTCA ([2154],[2156]), HTN, DM2, MM on dex/Revlimid/Velcade presents with chest pain. It started at 5pm and went away with SL nitro at home. Returned at 6pm, took another nitro which did not help. Chest pain similar in quality to pain with prior MIs. Called 911. EMS gave ASA 325mg, morphine 4mg, and another SL nitro. . Of note, patient was recently d/c'ed from [Hospital1 2025] on [9-30] after NSTEMI with trop to 0.25 complicated by cardiac catherization in which rotoblade became lodged in the left circumflex. CT surgery felt emergent bypass was not possible. ECG at this time showed STDs in V1-V5, II, III, and aVF. He was admitted to the CCU, started on nitro gtt and lasix. He was medically managed with ASA, carvedilol, statin. Not anticoagulated given his thrombocytopenia and hx of HIT. The blade was thought to be the cause of a subsequent left lateral wall infarction, leading to inferior wall hypokinesis, mod/severe MR due to papillary muscle infarct, and a drop in EF from 60 to 40%. Patient was subsequently re-admitted to [Hospital1 2025] from [Date range (1) 112543] for recurrent chest pain and rising troponins (peaked at 2.27) thought to be related to continuing infarction. . Currently on Revlimid/Velcade/dex for MM (cycle 2, day 1 [2163-10-13]). Episode of chest pain leading to first [Hospital1 2025] admission was also preceded by chemotherapy that day. . In the ED, initial vitals were 7, 96.0, 74, 132/89, 18, 99% 4L. ECG showed ST depressions in V3-V6. Labs and imaging significant for lactate 4.1, trop 0.65, glu 381 with gap 13, UA with trace ketones and large glucose, calcium 10.9, WBC 2.5, Hct 30.8, Plt 92, and INR 1.4. CXR showed small bilateral effusions and some vascular fullness. In the ER, the patient still c/o of CP after additional SL nitro. Chest pain improved with morphine, but did not resolve. Chest pain finally resolved with nitro gtt. . On arrival to the [Hospital1 18] CCU, patient was free of chest pain. Vitals were 98.1, 80, 127/82, 12, and 97% on 2L. Past Medical History: - Diabetes - Dyslipidemia - Hypertension - CABG: [2140] 3v with LIMA to LAD, double right sided SVG; [2148] redo SVG to circumflex OM1, main right and posterior left ventricular coronary arteries - [2144] stent placement to vein in RCA; [2156] native distal LAD to LIMA anastomosis - T2 [Doctor Last Name ] 8 prostate ca x/p XRT - Multiple myeloma diagnosed in [7-/2163] on revlemid/velcade/dex (cycle 2 day 1 [2163-10-13]) - Gout - Type II HIT (PF4 Ab positive) Social History: -Tobacco history: 1ppd x 21 years, quit [2126] -ETOH: negative -Illicit drugs: negative -Lives with his wife. Family History: No h/o heart disease. Father died of esophageal cancer. Physical Exam: ADMISSION: Vitals were 98.1, 80, 127/82, 12, and 97% on 2L GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: 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. No wheezes or rhonchi. Mild decrease in breath sounds bilaterally. Crackles at the L base. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT dopplerable Left: DP 2+ PT 1+ . DISCHARGE: GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: 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. No wheezes or rhonchi. Mild decrease in breath sounds bilaterally. Crackles at the L base. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT dopplerable Left: DP 2+ PT 1+ Pertinent Results: ADMISSION: [2163-10-13] 08:02PM BLOOD WBC-2.5* RBC-3.19* Hgb-10.8* Hct-30.8* MCV-97 MCH-33.8* MCHC-34.9 RDW-17.1* Plt Ct-92* [2163-10-13] 08:02PM BLOOD PT-15.1* PTT-34.7 INR(PT)-1.4* [2163-10-13] 08:02PM BLOOD Glucose-381* UreaN-22* Creat-0.8 Na-133 K-4.9 Cl-99 HCO3-21* AnGap-18 [2163-10-13] 08:02PM BLOOD ALT-31 AST-43* AlkPhos-118 TotBili-0.9 [2163-10-14] 01:43AM BLOOD CK-MB-4 cTropnT-0.54* [2163-10-13] 08:02PM BLOOD Calcium-10.9* Phos-3.3 Mg-1.7 . STUDIES: ([10-13]) CXR:IMPRESSION: Mild pulmonary edema with bilateral small pleural effusions, left greater than right, and adjacent atelectasis. . ([10-15]) CXR: There is substantial interval improvement up to almost complete resolution of pulmonary edema. Heart size and mediastinum are unchanged in appearance including tortuous aorta. Small amount of pleural effusion cannot be excluded. There is no pneumothorax. . ([10-14]) ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40-45 %). The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with regional systolic dysfunction c/w CAD (PDA distribution). Moderate mitral regurgitation most likely due to papillary muscle dysfunction. Dilated ascending aorta. Pulmonary artery hypertension. CLINICAL IMPLICATIONS: The patient has moderate mitral regurgitation. Based on [2157] ACC/AHA Valvular Heart Disease Guidelines, a follow-up echocardiogram is suggested in 1 year. The patient has a mildly dilated ascending aorta. Based on [2161] ACCF/AHA Thoracic Aortic Guidelines, if not previously known or a change, a follow-up echocardiogram is suggested in 1 year; if previously known and stable, a follow-up echocardiogram is suggested in [2-25] years. Based on [2158] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . OTHER LAB RESULTS: [2163-10-17] 06:03AM BLOOD WBC-1.8* RBC-3.12* Hgb-10.4* Hct-29.7* MCV-95 MCH-33.3* MCHC-35.0 RDW-16.9* Plt Ct-59* [2163-10-16] 03:05AM BLOOD PT-14.0* PTT-31.7 INR(PT)-1.3* [2163-10-17] 06:03AM BLOOD Glucose-148* UreaN-14 Creat-0.4* Na-135 K-4.0 Cl-103 HCO3-27 AnGap-9 [2163-10-14] 03:10PM BLOOD CK(CPK)-43* [2163-10-14] 03:10PM BLOOD CK-MB-4 cTropnT-0.71* [2163-10-14] 08:40AM BLOOD CK-MB-5 cTropnT-0.69* [2163-10-14] 01:43AM BLOOD CK-MB-4 cTropnT-0.54* [2163-10-17] 06:03AM BLOOD Calcium-9.6 Phos-2.7 Mg-1.9 [2163-10-14] 02:16AM BLOOD Lactate-3.8* . EKGs: 2-3mm ST depressions in V3-V6 on admission; these decreased to ~1mm ST depressions on discharge when patient was asymptomatic Brief Hospital Course: 76M with extensive hx of CAD including multiple CABG with most recent cath on [9-23] c/b rotorblade impaction in the LCx presents to ED with chest pain, elevated troponin, and EKG changes. The chest pain appears to be associated with the timing of his chemotherapy for multiple myeloma. . # Chest Pain: Suspect demand ischemia secondary to chemotherapy agents (direct effect or volume induced pulmonary edema). Based on literature review, cardiac effects commonly seen with Revlimid/Velcade, and given his EF 45%, some aspect of overload could also contribute to this problem. In CCU, pt had an episode of [9-2] chest pain accompanied by shortness of breath and increased O2 requirement, which was likely ischemia with flash pulmonary edema. This resolved with Lasix, nitro drip, beta blocker, and morphine. Following this episode, he was without pain, and enzymes show negative CKMB and mildly elevated trop, indicating likely ischemia rather than new infarct. Nitro gtt was weaned later the day of admission, and he was placed on Imdur 30mg/day (in place of home isosorbide dinitrate). Pt was continued on ASA 81, but Plavix was held given thrombocytopenia (PLT in 50s). We continued his home BB (Metop tartrate 50 [Hospital1 ], which was eventually switched to metop succinate XL 100mg daily), [Last Name (un) ] (Valsartan 20 daily), and statin (pravastatin 80mg, increased from home dose of 40mg daily). We spoke with oncology, and they recommended holding chemotherapy in case it is implicated in the patient's demand ischemia. We communicated this to a covering colleague of the patient's outside oncologist. The oncologist may need to adjust the chemotherapy regimen to avoid further cardiac issues. On day of discharge, pt was without CP or SOB; he was breathing room air, had flat neck veins, trace ankle edema, and his lung sounds were clear. . # Acute on Chronic Systolic CHF: No change in LVEF on repeat ECHO (40%). Pt was admitted with oxygen requirement to 4L NC. On the first morning of his admission, he had what appeared to be an episode of flash pulmonary edema, which resolved with metoprolol, nitro drip, morphine, and Lasix. O2 was weaned over 2 days to room air on discharge (his baseline). CXR showed significant acute pulmonary edema which resolved over the next several days with diuresis. Electrolytes were stable and wnl during the diuresis. Pt was started on PO Lasix 40/day prior to discharge. . # Multiple Myeloma: Currently on chemo with pancytopenia without evidence of bleeding. Patient is neutropenic and afebrile. Cr WNL. Pt received Revlimid/Velcade/dex for MM (cycle 2, day 1 [2163-10-13]). The patient will meet with his oncologist on the day following discharge to discuss the potential impact of his chemotherapy on his cardiac disease and whether there are alternative agents. . # DM2: Patient was on high doses of home insulin with blood sugar in 300s and glucose in his urine. Pt was seen by [Last Name (un) ] (endocrinology consult) who recommended 70U Lantus qHS, then standing 15U Humalog prior to each meal with ISS after. Will need to monitor closely as outpatient. He has follow up with his PCP the day after discharge. . # GOUT: Not active. We continued home allopurinol. . TRANSITIONAL - Will need to avoid prior chemotherapy regimen (he has appointment with Dr.[Name (NI) 7517] the day following discharge) - Will need to follow his blood sugar control with outpatient PCP and home [Name9 (PRE) 269] - Will send d/c summary to cardiologist Dr. [First Name8 (NamePattern2) ] [Name (STitle) 79852] at [First Name5 (NamePattern1) 745] [Last Name (NamePattern1) 20468] (he has an appointment with him in early [Month (only) 359]) - Patient is confirmed DNI/DNR Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from dc summary. 1. Valsartan 20 mg PO DAILY 2. Oxybutynin 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Metoprolol Tartrate 50 mg PO BID 5. Nitroglycerin SL 0.4 mg SL PRN chest pain 6. Pravastatin 40 mg PO HS 7. Allopurinol 300 mg PO DAILY 8. Prochlorperazine 10 mg PO Q8H:PRN nausea 9. Vitamin D [2151] UNIT PO DAILY 10. Glargine 70 Units Bedtime Humalog 20 Units Breakfast Humalog 20 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Isosorbide Dinitrate 40 mg PO TID 12. Fish Oil (Omega 3) 600 mg PO DAILY Discharge Medications: 1. Allopurinol 300 mg PO DAILY RX allopurinol 300 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 2. Aspirin 81 mg PO DAILY 3. Glargine 70 Units Bedtime Humalog 15 Units Breakfast Humalog 15 Units Lunch Humalog 15 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Oxybutynin 10 mg PO DAILY 5. Pravastatin 80 mg PO HS RX pravastatin 80 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 6. Prochlorperazine 10 mg PO Q8H:PRN nausea 7. Valsartan 20 mg PO DAILY 8. Vitamin D [2151] UNIT PO DAILY 9. Furosemide 40 mg PO DAILY Hold for SBP<90 RX furosemide 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY hold for SBP<90 RX isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 11. Metoprolol Succinate XL 100 mg PO DAILY Hold for SBP<90, HR<60 RX metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 12. Fish Oil (Omega 3) 600 mg PO DAILY 13. Nitroglycerin SL 0.4 mg SL PRN chest pain Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Coronary artery disease Acute coronary syndrome Acute on chronic systolic heart failure Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 112544], Thank you for choosing [Hospital1 18]. You were admitted to the hospital for chest pain. Your symptoms are related to your coronary artery disease. Your acute increase in chest pain may have been related to the chemotherapy that you received prior to admission. Please talk to your oncologist at your appointment tomorrow about alternative medications for your multiple myeloma. You were also found to have extra fluid around your lungs, which we think was related to "heart failure," that is, decreased ability of your heart to pump blood. This improved significantly after you received water pills (Lasix, also known as furosemide). Please follow up with your cardiologist on [10-27] about the ongoing treatment of your heart disease. While you were in the hospital, you were seen by our diabetes specialist who recommended some changes in your insulin doses to better control your blood sugars. Attached you will find specific information about how much insulin you should take and when. Please follow up with your primary care doctor tomorrow about ongoing treatment of your diabetes. We made the following changes to your medications: STOP - isosorbide dinitrate - metoprolol tartrate START - furosemide 40 mg daily - isosorbide mononitrate extended release 30 mg daily - metoprolol succinate XL 100mg daily CHANGES IN DOSE - pravastatin, now take 80 mg daily - insulin (see attached for details) Thank you for allowing us to take part in your care. Followup Instructions: Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 112545],MD Specialty: Hematology/Oncology When: Tuesday [2163-10-18] at 9am Location: [Hospital ] CANCER CENTER Address: [2163], [Location (un) ],[Numeric Identifier 8934] Phone: [Telephone/Fax (1) 83767] Please be sure to keep this appointment. You need to see Dr. [Last Name (STitle) ] before your next chemotherapy appointment. Name: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Specialty: Primary Care and Endocrinology When: Tuesday [2163-10-18] at 1:30pm Address: [State ], [Apartment Address(1) 101800], [University/College ],[Numeric Identifier 3471] Phone: [Telephone/Fax (1) 98031] * It is VERY important that you keep this appointment. The office is closed on Wednesday and you need to be seen soon after discharge from the hospital. Name: [Name6 (MD) 251] [Last Name (NamePattern4) 112546], MD Specialty: Cardiology When: Thursday [2163-10-27] at 8:40am Location: [Hospital1 ] CARDIOLOGISTS Address: [2163] STE. 562, [Location (un) ],[Numeric Identifier 8934] Phone: [Telephone/Fax (1) 18278]	[ "412", "4019", "2875", "4280", "V4581", "V4582" ]
Admission Date: [2199-5-29] Discharge Date: [2199-6-1] Date of Birth: [2136-11-29] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: SOB Major Surgical or Invasive Procedure: ethanol septal ablation History of Present Illness: 62 F with history of HOCM, HTN, DM who had presented with increased shorntess of breath with exertion over the last couple of years. States the SOB first started getting bad approximately 4 years ago, however, this occurred concomitantly with GI bleeds and she attributed her fatigue to low Hct. She had GI surgery in [1-12] and since then her SOB has gotten worse even though she has had no subsequent bleeding. States SOB is variable, but she must do all activities slowly to avoid SOB. Denies chest pain, leg swelling, SOB at night. At times, she feels like her heart skips a beat and experiences an uncomfortable feeling. Denies any fainting or presyncope. Denies fevers, chills, nausea, vomiting, abdominal pain, or bloody stools. Past Medical History: 1. [Doctor Last Name ]-[Location (un) 805] syndrome (syndrome of GI bleeding and aortic stenosis). History of GI bleeding and arterio-venous malformations. In [2199-1-22] underwent right hemicolectomy, ileocolostomy, and repair of incarcerated umbilical hernia 2. Diabetes 3. Hypertension 4. Hyperlipidimia 5. Hypertrophic cardiomyopathy 6. COPD 7. Cholecystectomy 8. Appendectomy Social History: The patient has smoked 1-1.5 packs per day over the last 40 years. She quit last [Known firstname ]. She does not have a history of drinking alcohol. Lives with her nephew and wife Family History: Brother-History of hypertension. Mother-- died of colon cancer Mother, Maternal grandmother-- history of lower GI bleeding Sisted with history of arrthymia who died d/t infection from pacemaker wire. Physical Exam: 98.0 64 116/78 17 96% RA Gen: in NAD HEENT: MMM, OP clear. CV: RRR, III/VI HSM at RUSB increased slightly with valsalva. Lungs: CTA B anteriorly and laterally. Abd: s/nt/nd, + BS. no HSM. Groin: pacer in R groin with no ecchymoses or bleeding. Ext: no c/c/e. 2+ DP and PT pulses bilaterally. Neuro: A&Ox3. Pertinent Results: Echocardiogram [2199-5-29]: Baseline evaluation of gradient and coronary anatomy prior to intervention: There is moderate symmetric left ventricular hypertrophy with normal cavity size and hyperdynamic systolic function. (EF>75%). There is valvular [Male First Name (un) ] with a severe (100mmHg peak) resting left ventricular outflow tract obstruction. Right ventricular Moderate (2+) mitral regurgitation is seen. After injection of the 2nd septal with diluted (3:7) Optison, there is hyperenhancement in the distal third of the basal anterior septum There was no enhancement of the right ventricular free wall or inferior wall. Echocardiogram [2199-5-29]: Focused evaluation during ethanol ablation Hypertrophic cardiomyopathy: After injection of 1ml and 0.5ml of alcohol, there is intense hyperenhancement of the distal thrid of the basal septum. Continuous wave and pulsed Doppler demonstrated a 25-30mmHg peak LVOT gradient. After injection of diluted (3:7) Optison into the 1st septal, there was hyperenhancement of the mid-portion of the basal septum. Following alcohol injection (1.5ml total), there was further hyperenhancement of the region and the peak LVOT gradient was <20mmHg. Global systolic function remains excellent and valvular [Male First Name (un) ] persists. Minimal/mild mitral regurgitation is now seen. Brief Hospital Course: 62 year-old woman with HOCM, referred for ethanol septal ablation. ## Cardiac: a. HOCM: Pt tolerated EtOH septal ablation well. She was followed in the CCU and had no difficulties with heart block. She had a pacemaker in place for 48 hours but the pacer was not triggered and this was d/c'd. She had no chest pain and cardiac enzymes trended down. . b. HTN: The pt's outpatient meds were metoprolol and diltiazem. However, given her diabetes, she was switched from diltiazem to lisinopril. Her blood pressure remained in good range. She will follow up with Dr. [Last Name (STitle) ] and her PCP for further adjustment of these medications. 2. Diabetes: The pt's metformin was held post procedure and she was kept on sliding scale insulin while in house. She was restarted on metformin on discharge. 3. COPD: She was continued on Comibent and Advair. 4. Cholesterol- She was continued on Lipitor. 5. GI: Given h/o GI bleeding, Hct was followed but remained stable. She had no melena or BRBPR. Medications on Admission: Metformin 1000 mg [Hospital1 ] Diltiazem XR 120 mg daily Metoprolol 75 mg twice a day Protonix 40 mg daily Lipitor 10mg daily Iron 325 mg daily MVI daily Combivent 2 piffs qid Advair 100/50 one puff twice a day Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:2 inhalers Refills:2 7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 9. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: primary: HOCM s/p ethanol ablation anemia secondary: DM HTN h/o GI bleeding Discharge Condition: stable Discharge Instructions: Please continue to take all medications as prescribed. Your new medications include: 1. Aspirin 81mg once a day. 2. Lisinopril 5mg qday 3. Iron 325mg three times daily Please take the iron for the next few months to help your blood counts recover after the procedure (there was some blood loss during the ablation). Followup Instructions: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 10548] Date/Time:[2199-7-4] 10:30	[ "4241", "496", "25000", "4019", "2859" ]
Admission Date: [2183-11-5] Discharge Date: [2183-11-8] Date of Birth: [2125-2-3] Sex: M DIAGNOSIS: Status post craniotomy for excision of meningioma. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 1255] is a 58-year-old male facial pain, left infraorbital and cheek pain. The pain has been present for 3-4 years and Tegretol was giving him some pain relief. HOSPITAL COURSE: CT scan which was done eventually showed a left petrous sphenoid meningioma compressing the brain stem . The patient had no neuro deficit seizures, no incontinence or falls. Intraoperative course was unremarkable with occasional use of Neo-Synephrine and Nipride. The patient had left presigmoid approach occipital craniotomy, removal of left petroclival meningioma and after the surgery he was in the Intensive Care Unit for 12-18 hours. His condition preoperatively and postoperatively was stable. His preoperative hematocrit was 46.3, white cells 4.2 and platelet count 135,000. His preoperative sodium 144, potassium 4.1, chloride 114, CO2 23, urea 16 and creatinine 1.2 with blood sugar of 124. His liver function tests were normal preoperatively. His hematocrit at the time of discharge was 33.9 with a white cell count of 10.8, platelet count 152,000. Electrolytes were sodium 142, potassium 4, chloride 109, CO2 26, creatinine 0.9 and urea 14. In the immediate postoperative period his platelet count had dropped to 83 for which he had one unit of platelets transfused. CONDITION ON DISCHARGE: Stable. He had a degree of diplopia in the postoperative period which had cleared by the time the patient was discharged home. During the course of his stay the patient also had physical therapy and occupational therapy evaluation. He was found to have a slightly unsteady gait and he was given a cane which improved his walk. PT and OT consult was set up for his home follow-up as he lived in a house where there were a few steps. He was advised not to walk unassisted and it was confirmed that his wife was available 100% of the time to take care of Mr. [Known lastname 1255] at home. DISCHARGE PLAN: Mr. [Known lastname 1255] is advised to follow-up with Dr. [First Name (STitle) ] on [11-17] at 4 p.m. Prior to going to the Brain [Hospital 341] Clinic on the [Location (un) ] in [Hospital Ward Name 23], Mr. [Known lastname 1255] is to come to Far 5 to have his staples removed. A Cantonese interpreter was present when these were explained to Mr. [Known lastname 1255]. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Name8 (MD) 35814] MEDQUIST36 D: [2183-11-10] 16:00 T: [2183-11-13] 19:45 JOB#: [Job Number ]	[ "4019" ]
Admission Date: [2178-8-6] Discharge Date: [2178-8-15] Date of Birth: [2092-12-28] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Aortic valve replacement with a 19-mm Biocor tissue valve. History of Present Illness: 85 year old female with significant medical history of hypertension and hyperlipidemia. She reports shortness of breath with minimal activity relieved with rest. She also reports moderate lower extermity edema. Her echo results demonstrate severe aortic stenosis with a peak gradient of 78, a mean gradient of 42 and an aortic valve area of 0.8 cm. The LVEF was 55-60%. She was referred for cardiac catheterization and is now referred to cardiac surgery for an aortic valve replacement and coronary artery bypass graft. Past Medical History: Hypertension Hyperlipidemia Neck arthritis Degenerated joint disease Diverticulitis s/p sigmoid resection Social History: Lives with:husband Contact:[Name (NI) 1692] (son) Phone #[Telephone/Fax (1) 88604]. Occupation:retired Cigarettes: Smoked no [] yes [x] last cigarette 2 weeks ago Hx:4 cigarettes/day x 50 years Other Tobacco use:denies ETOH: < 1 drink/week [x] [2-9] drinks/week [s] >8 drinks/week [] Illicit drug use:denies Family History: none Physical Exam: Pulse:58 Resp:16 O2 sat:96/RA B/P Right:128/68 Left: 155/74 Height:5' Weight:197 lbs General: Skin: Dry [X] intact [] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade __III (holosystolic)____ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [] Extremities: Warm [X], well-perfused [X] Edema [X] _2+ Bilat____ Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: Palp Left:Palp No hematoma or PSA at insertion site (R) DP Right:Palp Left:Palp PT [Name (NI) 167]:Palp Left:Palp Radial Right:Palp Left:Palp Carotid Bruit Right:None Left:None Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 88605], [Known firstname 4617] [Hospital1 18] [Numeric Identifier 88606]Portable TTE (Focused views) Done [2178-8-8] at 1:58:01 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2092-12-28] Age (years): 85 F Hgt (in): 60 BP (mm Hg): 95/66 Wgt (lb): 210 HR (bpm): 87 BSA (m2): 1.91 m2 Indication: Valvular heart disease. H/O cardiac surgery. ICD-9 Codes: V43.3, 424.1 Test Information Date/Time: [2178-8-8] at 13:58 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Test Type: Portable TTE (Focused views) Son[Name (NI) 930]: Doppler: Limited Doppler and color Doppler Test Location: [Location 13333]/[Hospital Ward Name 121] 6 Contrast: None Tech Quality: Suboptimal Tape #: 2011W000-0:00 Machine: Vivid q-2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 60% >= 55% Left Ventricle - Stroke Volume: 72 ml/beat Left Ventricle - Cardiac Output: 6.29 L/min Left Ventricle - Cardiac Index: 3.29 >= 2.0 L/min/M2 Aortic Valve - Peak Velocity: 3.1 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 39 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 21 mm Hg Aortic Valve - LVOT pk vel: 1.10 m/sec Aortic Valve - LVOT VTI: 23 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A ratio: 1.00 Findings This study was compared to the prior study of [2178-8-6]. LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated descending aorta. AORTIC VALVE: AVR well seated, normal leaflet/disc motion and transvalvular gradients. No AR. MITRAL VALVE: No MS. Trivial MR. PERICARDIUM: No pericardial effusion. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. No echocardiographic signs of tamponade. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - bandages, defibrillator pads or electrodes. Suboptimal image quality as the patient was difficult to position. Suboptimal image quality - body habitus. Suboptimal image quality - patient unable to cooperate. Emergency study performed by the cardiology fellow on call. Conclusions 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 descending thoracic aorta is mildly dilated. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [8-6]/201, no change. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2178-8-9] 11:32 ?????? [2170] CareGroup IS. All rights reserved. [2178-8-15] 05:05AM BLOOD WBC-10.1 RBC-3.38* Hgb-10.8* Hct-32.5* MCV-96 MCH-31.9 MCHC-33.2 RDW-16.4* Plt Ct-267 [2178-8-14] 05:20AM BLOOD WBC-11.0 RBC-3.46* Hgb-10.8* Hct-33.0* MCV-95 MCH-31.3 MCHC-32.8 RDW-16.6* Plt Ct-214 [2178-8-15] 05:05AM BLOOD PT-24.7* INR(PT)-2.3* [2178-8-14] 05:20AM BLOOD PT-24.8* INR(PT)-2.3* [2178-8-13] 07:15AM BLOOD PT-22.1* INR(PT)-2.0* [2178-8-12] 05:00AM BLOOD PT-20.6* INR(PT)-1.9* [2178-8-11] 02:19AM BLOOD PT-15.7* PTT-28.9 INR(PT)-1.4* [2178-8-6] 12:29PM BLOOD PT-14.0* PTT-39.3* INR(PT)-1.2* [2178-8-6] 11:05AM BLOOD PT-14.6* PTT-37.2* INR(PT)-1.3* [2178-8-15] 05:05AM BLOOD Glucose-92 UreaN-39* Creat-1.3* Na-145 K-3.9 Cl-106 HCO3-29 AnGap-14 [2178-8-14] 05:20AM BLOOD Glucose-94 UreaN-41* Creat-1.2* Na-146* K-4.6 Cl-110* HCO3-27 AnGap-14 [2178-8-13] 07:15AM BLOOD Glucose-97 UreaN-41* Creat-1.2* Na-145 K-3.6 Cl-109* HCO3-27 AnGap-13 [2178-8-11] 02:19AM BLOOD Glucose-94 UreaN-52* Creat-1.6* Na-142 K-3.7 Cl-105 HCO3-26 AnGap-15 [2178-8-15] 05:05AM BLOOD Mg-2.1 [2178-8-14] 05:20AM BLOOD Phos-3.4 Mg-2.3 Brief Hospital Course: On [2178-8-6] Ms.[Known lastname ] was taken to the operating room and underwent Aortic valve replacement with a 19-mm Biocor tissue valve. Cross clamp time=47 minutes. Cardiopulmonary Bypass time=76 minutes. Please refer to operative report for further surgical details. She tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. She awoke neurologically intact and was extubated postoperative night without incident. She weaned off pressor support. Beta-blocker/Statin/Aspirin and diuresis was initiated. All lines and drains were discontinued per protocol. POD#1 she was transferred to the step down unit for further monitoring. On POD#2 she went into new postoperative Atrial fibrillation with ventricular response rate 40-50s and associated hypotension and oliguria. Ms.[Known lastname ] was transferred back to CVICU for further intensive care monitoring. A TTE was done and showed the aortic valve prosthesis well seated, with normal leaflet/disc motion and transvalvular gradients/no pericardial effusion/no echocardiographic signs of tamponade. Electrophysiology was consulted for rhythm recommendations. She was placed on Amiodarone once her rate improved and beta blocker resumed. Her rhythm converted back into sinus. However, anticoagulation was already initiated for her paroxysmal atrial fibrillation. She required PRBC transfusion for postoperative anemia likely due to hemodilution. More aggressive diuresis was initiated. Acute kidney injury occurred with a peak rise in creatinine to 2.0 from her baseline of 0.9. She continued to respond well to diuresis and over the remainder of her hospital course her renal function improved with her creatnine trending back down towards her baseline. She did exhibit some confusion and received Haldol. This cleared. Ms.[Known lastname ] slowly progressed and on POD#5 she was transferred to the step down unit. Physical Therapy was consulted for evaluation of strength and mobility. She was started on Cipro for a positive urinalysis. This was discontinued when the culture revealed contamination. On POD#8 she was cleared for discharge to [Hospital 1474] [Hospital ] rehab. All follow up appointments were advised. Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg Tablet - one Tablet(s) by mouth daily FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - [1-4] Tablet(s) by mouth daily Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - one Tablet(s) by mouth daily IBUPROFEN - (Prescribed by Other Provider) - 200 mg Capsule - three Capsule(s) by mouth as needed for neck pain Discharge Medications: 1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for bronchospasm. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for bronchospasm. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: dose to change daily for goal INR 2-2.5, dx: afib. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 40mg [Hospital1 ], then please re-evaluate. 15. potassium chloride 10 mEq Tablet Extended Release Sig: Four (4) Tablet Extended Release PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital 1474] Hospital TCU - [Hospital1 1474] Discharge Diagnosis: Critical symptomatic aortic stenosis. -s/p Aortic valve replacement with a 19-mm Biocor tissue valve. Past Medical History: Hypertension Hyperlipidemia Neck arthritis Degenerated joint disease Diverticulitis s/p sigmoid resection Discharge Condition: Alert and oriented x3 nonfocal Deconditioned, ambulating Incisional pain managed with Tylenol prn Incisions: Sternal - healing well, no erythema or drainage 2+ pitting edema bilateral lower extremities Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [9-9] at 1:30pm in the [Hospital ] medical office building [Hospital Unit Name ] Cardiologist:Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] on [9-8] at 3:20pm Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 6699] in [1-4] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-2.5 First draw [2178-8-16], then Monday, Wednesday, Friday until INR stable. Please arrange coumadin follow up upon discharge from rehab Completed by:[2178-8-15]	[ "4241", "9971", "5849", "41401", "4019", "2724", "42731", "2859" ]
Admission Date: [2152-11-24] Discharge Date: [2152-12-13] Date of Birth: [2076-9-19] Sex: M Service: SURGERY Allergies: Acetaminophen / Aspirin Attending:[First Name3 (LF) 2597] Chief Complaint: venous stasis ulcer Major Surgical or Invasive Procedure: Bilateral lower extremity debridement s/p Split thickness skin graft with VAC placement [2152-12-11] History of Present Illness: 76 yoM with h/o HTN, HL, dementia/anxiety presents for b/l LE venous stasis ulcers of 3 years. Pt has had ulcers followed by wound clinic for 7 months with last visit 1 year ago and currently has had home VNA come on a daily basis for dressing changes (unna boots, wet to dry dressings, debridements, etc.) for the last 2 years. Pt states that the ulcers wax and wane in improvement and worsening but notes that the ulcers have been worsening considerably in appearance and pain in the last few months. Pt was last seen by Dr. [Last Name (STitle) ] at his clinic on [2152-11-20] and it was decided that the pt would be admitted to the hospital for iv antibiotics and questionable OR debridement. Pt denies F/C/N/V as well as CP and SOB. Pt's PCP is [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD of [Hospital3 ] Medical Associates Past Medical History: PAST MEDICAL HISTORY: - HTN - HL - dementia - anxiety PAST SURGICAL HISTORY: - AAA [2144] Social History: SOCIAL HISTORY: Pt lives at home with ex-wife. Does not use cane/walker for ambulatory assistance. Suffers occasional mechanical falls at home. Quit smoking [2148]; previous 2ppd/40 yrs Quit drinking alcohol [2148]; previously 1-6packperday/40 yrs Denies illicit drug use. Family History: FAMILY HISTORY: Diabetes Physical Exam: Vital Signs: Temp: 97.3 RR: 18 Pulse: 74 BP: 90/44 Neuro/Psych: Oriented x3, Affect Normal, NAD. Heart: Abnormal: Murmur. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, Guarding or rebound. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. Popiteal: P. DP: P. PT: D. LLE Femoral: P. Popiteal: D. DP: P. PT: N. ULCERS VAC'D DONOR SITE WITH Xeroform over thigh donor site Pertinent Results: [2152-11-24] 5:55 pm SWAB Source: right lower leg. NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Final [2152-11-30]): ANAEROBIC CULTURE (Final [2152-11-26]): UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF SWARMING PROTEUS SPP.. [2152-11-29] 1:00 pm SWAB RIGHT LEG LATRAL ULCER. GRAM STAIN (Final [2152-11-29]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [2152-12-2]): PROTEUS MIRABILIS. SPARSE GROWTH. PRESUMPTIVE IDENTIFICATION. PROTEUS MIRABILIS. SPARSE GROWTH. SECOND TYPE. PROTEUS MIRABILIS \| PROTEUS MIRABILIS \| \| AMIKACIN-------------- <=2 S <=2 S AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 8 S 8 S CEFAZOLIN------------- <=4 S 8 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ =>16 R 8 I TRIMETHOPRIM/SULFA---- =>16 R =>16 R ANAEROBIC CULTURE (Final [2152-12-3]): NO ANAEROBES ISOLATED. Blood Culture, Routine (Final [2152-12-6]): NO GROWTH. [2152-11-28] 09:06PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.020 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ECHO: The left atrium is markedly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF 75%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. The aortic valve is not well seen. There is at least moderate aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. PMIBI: IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and systolic function. 3. Right ventricular enlargement with evidence of pressure/volume overload. CTA: R/O PE IMPRESSION: 1. No pulmonary embolus. 2. No thoracic aorta dissection. 3. Pulmonary hypertension probably responsible for right heart enlargement. 4. No pulmonary edema. 5. Calcification of aortic valve leaflets. Atherosclerotic coronary calcifications. 6. No pericardial effusion. 7. Bilateral small pleural effusions and mild adjacent bibasilar atelectasis. 8. Mild bronchial wall thickening could be due to asthma. 9. Small amount of perihepatic free fluid. Brief Hospital Course: Mr. [Known lastname 87601] is a 76 yoM who was admitted to the hospital on [11-24] for empiric IV antibiotics and possible wound debridement. Preoperatively, the Geriatric service was consulted for management and recommendations of patient's baseline dementia. Patient was deemed cabable of consenting to procedures by Psychiatry. On [11-29], he was taken to the operating room for bilateral leg debridement. OR cultures grew MRSA sensitive to Vancomycin and proteus sensitive to Unasyn and his antibiotics coverage was narrowed. In the am of POD 1, the patient became tachycardic, hypoxic, and hypotensive. His blood pressure improved with fluid bolus and patient was transferred to the VICU for closer monitoring. A few hours later he became hypotensive and tachycardic again, requiring fluid rescuscitation. EKG showed ST depressions, a Cardiology consult was called, and patient was transferred to the CVICU. Echocardiogram showed a dilated, hypokinetic RV with EF 70%. He ruled out for PE. Troponins peaked at 0.11. Per Cardiology, no need for cardiac catheterization. He was transferred back to the floor on POD 2. On [12-7], antibiotics were switched to PO Bactrim and cefpodoxine. Plastic Surgery was consulted for skin graft. A preoperative echocardiogram and a persantine stress test were done as part of cardiac clearance to return to the OR again for skin grafting. He was cleared from a cardiac perspective and on [12-11] he returned to the operating room for further debridement and split thickness skin graft with VAC placement with Plastic Surgery(Dr.[Last Name (STitle) ]) . Mr. [Known lastname 87601] had an uneventful postoperative course with good pain control. Foley was replaced on [12-12] for urinary retention. Flomax was started and foley was removed at midnight [12-13]. Pt voiding adequate amounts on discharge. VAC is to stay in place until arrangements are made by Plastic Surgery for pt to return for VAC change in the operating room (1 week). Medications on Admission: Aricept 5', Tamazepam 15prn, lasix 40', alprazolam 0.5TID, lisinopril 30', metaprolol 12.5", plavix 75', vicodin 7.5-750 [1-1] q6pain, colace" Discharge Medications: 1. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. simvastatin 40 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: Two (2) Tablet PO DAILY (Daily). 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. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 14. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 15. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 16. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day: prn. Discharge Disposition: Extended Care Facility: [Hospital 4542] Rehabilitation and Nursing of [Location (un) 38] Discharge Diagnosis: Bilateral lower extremity venous stasis ulcers Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the vascular surgery service for management of your bilateral lower leg ulcers. You had debridement in the operating room. Your legs are wrapped with aquacel Ag and ace wraps. Please keep them wrapped and elevated as much as possible. Please contact us if you experience any fever greater than 101.5, increased leg swelling or redness, thick drainage from your wounds, or worsening of your ulcers. Please take your antibiotics and other medications as instructed. Open Wound: VAC DRESSING Patient's Discharge Instructions Introduction: This will provide helpful information in caring for your wound. If you have any questions or concerns please talk with your doctor or nurse. You have an open wound, as opposed to a closed (sutured or stapled) wound. The skin over the wound is left open so the deep tissues may heal before the skin is allowed to heal. Premature closure or healing of the skin can result in infection. Your wound was left open to allow new tissue growth within the wound itself. The wound is covered with a VAC dressing. VAC will be changed when patient returns for VAC removal. The VAC: _ helps keep the wound tissue clean _ absorbs drainage _ prevents premature healing of skin - promotes healing When to Call the Doctor: Watch for the following signs and symptoms and notify your doctor if these occur: Temperature over 101.5 F or chills Foul-smelling drainage or fluid from the wound Increased redness or swelling of the wound or skin around it Increasing tenderness or pain in or around the wound Followup Instructions: Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2152-12-18] 11:00 Please call Dr [Last Name (STitle) 88297] office at [Telephone/Fax (1) 88298]. They will schedule an appointment for VAC removal. Please call the office daily for appt. Completed by:[2152-12-13]	[ "4168", "496", "4019", "2724", "V1582" ]
Admission Date: [2178-7-8] Discharge Date: [2178-7-17] Date of Birth: [2109-7-19] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1838] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 68 F, of unclear handedness, hx of DM2, HTN, HLD, prior DVT, CRF, and metastatic endometrial CA, s/p recent onset of taxol/carboplatin chemo, received her second cycle of chemo [7-2] and since then has been acting "disoriented" per her son with whom she lives. He notes for example, that she is easily distractable, will wander from one room to another while in the middle of a task (e.g. making a [Location (un) 6002]), however, has been able to complete her ADL's including cooking and going for walks to the market. This morning, he saw her last normal around 6:30 am and had helped give her insulin shot. When he returned from work around 5:30 pm, he found her sitting on the floor of their living room, very confused and seeming overall fatigued. He was able to move her to the couch and took her FS, which was 145. He then called EMS. He felt her speech was dysarthric, but felt that there was no focal weakness, sensory changes, HA, VC, ataxia, trouble understanding or expressing language, or any B/B incontinence. Of note, she had been on coumadin for her DVT up until [2178-6-6], and was then switched to lovenox [1-12] her chemo regimen. Past Medical History: hyperlipidemia hypothyroidism hypertension status post thrombophlebitis (DVT) metsatatic endometrial cancer s/p recent onset of taxol/carboplatin chemo diabetes type II Status post total abdominal hysterectomy, bilateral salpingo-oophorectomy IVC filter placement CRF Social History: Negative for alcohol or tobacco use. The patient lives with her son, who is her primary caretaker. Family History: HTN Physical Exam: 98.1F 112 110/67 16 100%RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple CV: irreg irreg, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no c/c/e; equal radial and pedal pulses B/L. Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place given mult choices, but not date. Inattentive, cannot say DOW forewards or backwards. Speech is fluent with normal comprehension but poor repetition; poor naming (calls fingers "hand", states "thumb" when asked to name pointer finger. (+) dysarthria (seeming more gutteral). Never learned how to read or write. (+) right left confusion. (+) Left neglect (thinks her L hand is the examiner's hand) Cranial Nerves: Pupils equally round and reactive to light, 5 to 4 mm bilaterally. Visual fields seem to show a L VF deficit (she has poor BTT coming from the left). Extraocular movements intact bilaterally, no nystagmus (though very difficult to get her to voluntarily look left, eyes able to move left on VOR having her fix on my nose and turning head side to side) Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor Not completely cooperative with full strength testing, but within this context, appears to have full strength in the UE and in the LE at the IP, Ham and Quad, with the exception of perhaps 5-/5 in the Left Ham (though could be [1-12] inattention. Did not cooperate with DF, PF, TE, TF testing) Sensation: Seems to indicate a decrease in [Last Name (un) 36] to LT and PP in the LUE and LLE, without a clear level. Otherwise intact to light touch, pinprick, and proprioception throughout. (+) extinction to DSS on the L. Reflexes: +2 and symmetric throughout except at patellae which were 0 (though again, not relaxing enough for appropriate testing) Toes downgoing bilaterally Coordination: Able to do finger to nose x 1 without clear ataxia or dysmetria. Could not cooperate with further coord testing. Gait: Narrow based, but very small steps, almost shuffling. Son states this is quite different from baseline. Romberg: Negative Pertinent Results: [2178-7-17] 02:22AM BLOOD WBC-10.2 RBC-1.75# Hgb-5.5# Hct-18.3* MCV-105# MCH-31.3 MCHC-29.9# RDW-18.6* Plt Ct-8# [2178-7-16] 01:30AM BLOOD WBC-17.2# RBC-2.48* Hgb-7.9* Hct-23.0* MCV-93 MCH-32.1* MCHC-34.6 RDW-17.3* Plt Ct-23# [2178-7-7] 05:54PM BLOOD WBC-5.3 RBC-3.74 Hgb-12.4 Hct-36.3 MCV-97 MCH-33.1* MCHC-34.1 RDW-14.1 Plt Ct-80* [2178-7-16] 01:30AM BLOOD PT-16.5* PTT-44.9* INR(PT)-1.5* [2178-7-11] 02:43AM BLOOD Fibrino-417* [2178-7-17] 02:22AM BLOOD Glucose-128* UreaN-56* Creat-4.5* Na-144 K-7.0* Cl-113* HCO3-5* AnGap-33* [2178-7-16] 01:30AM BLOOD Glucose-74 UreaN-48* Creat-3.8* Na-145 K-4.5 Cl-114* HCO3-12* AnGap-24* [2178-7-7] 05:54PM BLOOD Glucose-95 UreaN-24* Creat-1.8* Na-139 K-5.2* Cl-102 HCO3-25 AnGap-17 [2178-7-16] 01:30AM BLOOD CK(CPK)-1012* [2178-7-13] 06:16PM BLOOD ALT-71* AST-99* LD(LDH)-413* AlkPhos-35* TotBili-1.1 [2178-7-7] 05:54PM BLOOD ALT-56* AST-63* CK(CPK)-329* AlkPhos-74 TotBili-0.9 [2178-7-16] 01:30AM BLOOD CK-MB-21* MB Indx-2.1 cTropnT-0.52* [2178-7-15] 09:02PM BLOOD CK-MB-22* MB Indx-2.4 cTropnT-0.52* [2178-7-7] 05:54PM BLOOD CK-MB-6 cTropnT-0.34* [2178-7-17] 02:22AM BLOOD Calcium-7.9* Phos-11.3# Mg-2.8 [2178-7-8] 04:00AM BLOOD %HbA1c-6.2* [2178-7-8] 06:10AM BLOOD Triglyc-101 HDL-66 CHOL/HD-2.8 LDLcalc-102 [2178-7-7] 05:54PM BLOOD TSH-0.92 [2178-7-7] 05:54PM BLOOD Free T4-2.1* [2178-7-7] 05:54PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2178-7-17] 02:33AM BLOOD Type-ART pO2-73* pCO2-32* pH-6.85* calTCO2-6* Base XS--30 [2178-7-16] 11:52PM BLOOD Type-ART pO2-90 pCO2-42 pH-6.76* calTCO2-7* Base XS--32 [2178-7-12] 08:03PM BLOOD Type-ART pO2-105 pCO2-24* pH-7.37 calTCO2-14* Base XS--9 [2178-7-17] 02:33AM BLOOD Lactate-16.2* [2178-7-16] 11:52PM BLOOD Lactate-13.6* K-6.4* [2178-7-7] 05:49PM BLOOD Glucose-90 Lactate-2.1* K-7.6* [2178-7-7] 06:13PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2178-7-7] 06:13PM URINE RBC-0 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [2178-7-7] CT head; IMPRESSION: New rounded areas of hypodensity within the left temporooccipital and parietal lobes and left cerebellum concerning for metastatic disease in patient with history of endometrial cancer. An MRI with and without contrast is recommended for further evaluation. [2178-7-9] MRI brain: FINDINGS: There are multifocal areas of high T2/FLAIR signal intensity within the supra and infratentorial compartments, with large areas of abnormality involving the posterior right temporal and medial left temporal lobes. Additional foci are seen in the occipital lobes, deep white matter, and scattered throughout the cerebellum. The larger of the lesions demonstrate high signal on DWI with corresponding low signal on ADC, compatible with infarcts. The smaller lesions are too small to characterize on the ADC maps. There is no evidence of intracranial hemorrhage or shift of normally midline structures. No discrete mass is identified, though assessment is limited as there were no post- contrast imaging. The ventricles and sulci are mildly prominent, likely affecting age- related atrophy. Visualized paranasal sinuses and mastoid air cells are normally aerated. On MRA, the carotid and vertebral arteries appear within normal limits without evidence of stenosis, occlusion, or aneurysm formation. IMPRESSION: 1. Multifocal infarcts within the supra and infratentorial compartments, including watershed regions. These findings most likely represent embolic infarcts, as the vasculature appears patent without stenosis or occlusion. 2. Limited assessment for intracranial metastases as no post-contrast images were obtained, as detailed. [7-10] CT brain: IMPRESSION: 1. New parenchymal hemorrhage of the medial left temporal lobe, which may be hemorrhagic transformation in the region of the infarct on MRI [2178-7-9] or may be due to trauma. Probable parenchymal hemorrhage of the right temporal lobe and left cerebellar hemisphere. 2. Multiple foci of supratentorial hemorrhage, some subarachnoid in location, others may be parenchymal or subarachnoid hemorrhage. [2178-7-11] MRI brain; IMPRESSION: Multiple evolving infarcts identified in the supra- and infratentorial regions with enhancement at the site of the infarcts. Although most of the areas of enhancing lesions are likely due to infarcts, small associated metastatic lesion would be difficult to evaluate . A followup MRI can help to exclude associated tiny metastatic lesions. [2178-7-12] CT head; IMPRESSION: 1. Multiple foci of ischemia/infarction demonstrate evolution, with increase in size and more hypodense appearance. 2. Largest area of ischemia/infarction in the right temporoparietal region demonstrates an approximately 1 cm focus of hyperdensity consistent with a small focus of hemorrhage. [2178-7-13] transthoracic echocardiogram; The left atrium and right atrium are normal in cavity size. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild global left ventricular hypokinesis (LVEF = 40 %) (?related to the tachycardia). Systolic function of apical segments is relatively preserved (suggesting a non-ischemic cardiomyopathy). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is moderate [2+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild global left ventricular hypokinesis. Mild pulmonary artery systolic hypertension. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of [2178-7-8], the heart rate is much higher and the global LVEF is now mildly depressed. The severity of mitral regurgitation and tricuspid regurgitation have increased. Brief Hospital Course: Ms. [Known lastname 13834] is a 68 yo F, of unclear handedness, hx of DM2, HTN, HLD, prior DVT, CRF, and metastatic endometrial CA, s/p recent onset of taxol/carboplatin chemo, received her second cycle of chemo [7-2] and since then has been acting "disoriented" per her son, who today was found on the ground in with more substantial MS changes and dysarthria. Her NCHCT shows a L-PCA territory hypodensity as well as a L cerebellar hypodensity most c/w a subacute stroke. She also was found to have acute-on-chronic renal failure, mild hyperkalemia, and a thrombocytopenia at the time of admission. She was evaluated by cardiology given her troponin of 0.3 in the setting of creatinine of 1.8. It was thought she did not have any evidence of acute coronary syndrome and the troponin leak may have been due to imbalance of the autonomic nervous system with excessive sympathetic activity and catecholamine release secondary to her stroke vs. demand ischemia, and possibly also contributed from her renal failure. She was transferred to the medicine service given her multiple comorbidities and followed by the stroke consult service. For her likely embolic strokes, she was continued on lovenox and was deemed not to be an aspirin candidate due to her thrombocytopenia (platelet count in 30s-40s). On [7-10], the patient was found on the floor of her hospital room at approximately 4:30 PM after an unwitnessed fall. A repeat CT head on [7-10] revealed new parenchymal hemorrhage of the medial right temporal lobe. This may be hemorrhagic transformation in the region of infarct on MRI [2178-7-9] or due to trauma. Multiple foci of possible subarachnoid or intraparenchymal hemorrhage were seen on the [7-10] Head CT. However, subsequent MRI brain on [7-12] did not corroborate these areas of possible subarachnoid or intraparenchymal bleed. The patient could not provide any history but had no complaints when examined and denied headache or neck pain. She was transferred to the neuro ICU, lovenox was discontinued, and she was transfused platelets, fresh frozen plasma, and started on keppra for seizure prophylaxis. She was evaluated by neurosurgery who did not recommend any surgical intervention. The patient continued to be quite somnolent during the remainder of her hospital course, and became more lethargic over the next 24 hours, no longer following commands. She became hypotensive (SBP down to 60s), requiring three pressors, and intubated. On [7-13] her examination worsened. She was no longer withdrawing her right arm or leg to noxious stimuli and remained on three pressors. Her lactate was rising, renal failure worsening with very little urine output, and anemia and thrombocytopenia were worsening as well. On [7-17], the patient was no longer breathing over the ventilator and her pupils were fixed and dilated. Her MAP dropped to 40-50, and she was given IVF 250 cc boluses x2. There was question of SVT vs. atrial fibrillation on telemetry and EKG, and she was started on diltiazem gtt for 1 hour. This was turned off because her blood pressure had then dropped. The patient was turned at 9:30-10, and bradyed to the 40s and dropped her pressure to the 70s. She was given 0.5 Atropine, but never lost her pulse. She did not receive chest compressions. She was tachycardic after receiving Atropine. She was no longer overbreathing the vent. Her pH was 6.76, and bicarb was started. Her exam showed blistering of her skin which was very edematous, black colored fingernails and extremities very cold to the touch. Pupils are 7 mm and fixed, nonreactive to light. Unable to elicit corneal reflexes. Unable to elicit gag reflex. No spontaneous movement of her extremities, she does not withdraw any extremity to noxious. It was thought she had most likely herniated given that she has lost her brainstem reflexes. She remained on ICU-level care until her son could come in the following morning. She was pronounced dead shortly thereafter. Medications on Admission: ATORVASTATIN [LIPITOR] - 20 mg Tablet - take one Tablet by mouth daily ENOXAPARIN [LOVENOX] - 100 mg/mL Syringe - 1 injection subcutaneously once daily LEVOTHYROXINE - 50 mcg Tablet - 1 (One) Tablet(s) by mouth once a day LISINOPRIL - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth three times daily for 3 days following chemotherapy RISPERIDONE - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime TRUE TRACK LANCETS - - use twice daily Medications - OTC BLOOD SUGAR DIAGNOSTIC [TRUETRACK TEST] - Strip - use for glucose testing twice a day INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30 PEN] - 100 unit/mL (70-30) Insulin Pen - 22 u q am Previously on warfarin at the below dose, but DC'd [2178-6-6] and Lovenox started. WARFARIN [JANTOVEN] - 2 mg Tablet - 3 (Three) Tablet(s) by mouth 2 days a week and two tablets by mouth 5 days a week. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. multiple strokes, likely embolic etiology 2. intraparenchymal and subarachnoid hemorrhage 3. acute on chronic renal failure 4. metastatic endometrial cancer Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired	[ "41071", "5849", "5990", "99592", "78552", "40390", "5859", "2449", "42789", "V5867" ]
Admission Date: [2191-6-24] Discharge Date: [2191-7-1] Date of Birth: [2114-4-1] Sex: M Service: SURGERY Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2836] Chief Complaint: Pancreatic mass Major Surgical or Invasive Procedure: [2191-6-24]: 1. Pylorus-Preserving Pancreaticoduodenectomy 2. Harvest of left internal jugular vein and portal vein excision with reconstruction History of Present Illness: The patient is a very pleasant 77-year-old who had presented in [Month (only) 958] with acute pancreatitis. On imaging studies, he was noted to have a mass in the head of the pancreas. He subsequently underwent endoscopic ultrasound with fine-needle aspiration. Cytology on these aspirates was nondiagnostic. He subsequently developed obstructive jaundice and on [Month (only) ], he was noted to have a biliary stricture. A biliary stent was placed. He underwent a laparoscopic cholecystectomy with a presumed diagnosis of gallstone pancreatitis. The subsequent CT scan images showed complete resolution of pancreas mass. However, repeat [Month (only) ] showed persistence of biliary stricture. Brushings of the biliary stricture are suspicious for adenocarcinoma. The patient is well known for Dr. [First Name (STitle) ] and she was followed the patient along. The patient also had cholecystectomy done with Dr. [First Name (STitle) ] in the past. Dr. [First Name (STitle) ] evaluated the patient for possible Whipple procedure secondary to highly suspicious brushing results. During the evaluation all risks, goals and benefits were discussed with the patient and his family, and patient was scheduled for elective Whipple on [2191-6-24]. Past Medical History: PMH: HTN, vertigo episodes x2, Giant cell arteritis [2188], CAD PSH: lap CCY [2191-5-19] Social History: He has an 18-pack-year history of tobacco, but quit 13 years ago. He drinks alcohol only occasionally. There are no environmental exposures. Family History: Mr. [Known lastname 92312] reports a family history of pancreatic cancer. His sister died of it at age [Age over 90 ]. There is no other history of pancreatic disease or GI malignancy. Physical Exam: On Discharge: VS: 98.6, 70, 138/69, 12, 95% RA GEN: Pleasan with NAD NECK: Left longitudinal incision open to air with steri strips and c/d/i CV: RRR RESP: CTAB ABD: Bilateral subcostal incision open to air with staples, minimal erythema on middle portion of incision. RLQ JP drains x 2 to bulb suction, site c/d/i and covered with drain dressing. EXTR: Warm, no c/c/e Pertinent Results: [2191-6-29] 06:20AM BLOOD WBC-6.5 RBC-3.38* Hgb-10.7* Hct-33.0* MCV-98 MCH-31.5 MCHC-32.3 RDW-14.1 Plt Ct-205# [2191-6-29] 06:20AM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-139 K-4.0 Cl-105 HCO3-29 AnGap-9 [2191-6-29] 06:20AM BLOOD ALT-81* AST-82* AlkPhos-91 TotBili-2.7* [2191-6-29] 06:20AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.9 [2191-6-30] 09:55AM ASCITES Amylase-10 [2191-6-30] 09:55AM ASCITES Amylase-12 [2191-6-29] 10:16AM ASCITES TotBili-7.7 Albumin-LESS THAN [2191-6-28] LIVER DOPPLER: IMPRESSION: 1. Patent main and right portal veins. Flow within the left portal vein could not be detected. This could be due to technical factors or slow flow, however a thrombosed LPV cannot be excluded. 2. Pneumobilia 3. Right pleural effusion. [2191-6-29] ABD CT: IMPRESSION: 1. Patent main, left and right portal veins; however, some non-critical narrowing of the presumed graft. 2. Small non-hemorrhagic pleural effusions with adjacent compressive atelectasis. 3. Generalized anasarca. Brief Hospital Course: The patient was admitted to the General Surgical Service on [2191-6-24] for elective Whipple procedure. On same day, the patient underwent pylorus-preserving pancreaticoduodenectomy (Whipple) and portal vein excision with reconstruction, which went well without complication. The patient was transferred in ICU after operation for observation. On POD # 1, patient was extubated and was transferred on the floor NPO with an NG tube, on IV fluids, with a foley catheter and a JP x 2 drain in place, and epidural catheter for pain control. The patient was hemodynamically stable. Neuro: The patient received Fentanyl/Bupivacaine via epidural catheter with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Metoprolol was restarted on POD # 1. On POD # 2, patient was started on Aspirin 325 mg daily per Vascular Surgery, he was discharge home on this medication as well. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. The patient had two JP drains placed intraoperatively. On POD # 4, one JP output increased up to 1 L and patient underwent liver doppler to rule out portal vein obstruction. The doppler revealed patent main and right portal veins, but left portal vein was doppler was limited. The patient's JP # 1 output still high, JP bilirubin was sent and was elevated (7). On POD # 5, patient underwent abdominal CT which demonstrated patent main, left and right portal veins; however, some non-critical narrowing of the presumed graft. The patient's JP output was started to slow down. On POD # 6 JP amylase was sent from both drains and was normal. The patient was discharged home with both JP to continue monitor their output. GU: The foley catheter discontinued at midnight of POD#4. The patient subsequently voided without problem. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Wound was evaluated daily and small area of erythema was noticed on the middle part of the incision on POD # 3. The erythema subsided prior discharge, and though to be cause by staples. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. No insulin was needed upon discharge. Hematology: The patient was transfused with 2 units of pRBC intraoperatively secondary to blood loss. Post op patient's complete blood count was examined routinely; no further transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; 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. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Diazepam 5mg PRN; Lisinopril 5mg'; Metoprolol tartrate 12.5mg''; Percocet PRN; ASA 81mg'; Calcium carbonate; Vitamin D3; Centrum Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:80 Tablet(s) Refills:0 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. 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:5 8. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 9. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Carenet Discharge Diagnosis: Locally advanced cholangiocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [6-9] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. . JP x 2 Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Department: SURGICAL SPECIALTIES When: MONDAY [2191-7-11] at 2:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD [Telephone/Fax (1) 274] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Please follow up with Dr. [Last Name (STitle) ] (PCP) in [3-4] weeks after discharge Completed by:[2191-7-1]	[ "2851", "4019", "41401", "V1582" ]
Admission Date: [2106-6-30] Discharge Date: [2106-7-22] Date of Birth: [2044-7-20] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Transfer for carotid stenting and coronary artery bypass grafting Major Surgical or Invasive Procedure: [2106-7-6] Three vessel coronary artery bypass grafting utilizing the left internal mammary artery to left anterior descending; vein graft to right coronary artery; vein graft to ramus. [2106-7-1] Thoracic aorta, subclavian and carotid angiography with PTA/stenting to right internal carotid artery [2106-7-7] Bronchoscopy History of Present Illness: Mr. [Known lastname 406] is a 61 year old male with known coronary disease and multiple cardiac risk factors. He had a previous stent placed to his LAD. He also has a history of polymorphic VT and underwent AICD placment back in [2101]. On [6-21], he experienced a syncopal episode. During his evaluation at an outside hospital, he required defibrillation for several episodes of torsades. Outside cardiac catheterization revealed a 60% left main lesion; LAD had a 80% ostial lesion, and moderate in-stent restenosis; LCX had a 40% stenosis proximally; the RCA was totally occluded; the distal RCA had left-right collaterals. Left ventriculogram showed an akinetic anteroapical wall and basal aneurysm. His LVEF was estimated at 35%. Further evaluation revealed severe carotid disease. A carotid ultrasound showed 99% [Country ] occlusion, while the [Doctor First Name 3098] had an 60-80% stenosis. Based on the above results, he was transferred to [Hospital1 18] for further evaluation and treatment. Past Medical History: Coronary artery disease - history of MI and s/p LAD stent, CHF, AAA - s/p vascular stent, PVD - s/p bilateral iliac artery stents, Carotid disease, CRI, HTN, NIDDM, Hyperlipidemia, Polymorphic VT - s/p AICD, Prostate CA - s/p XRT, DJD, Migraine HA Social History: Former smoker, quit approximately 20 years ago. Admits to at least 20 pack year history. Admits to two drinks per night. He is retired and married. Family History: Father died at age 47 of MI. Grandfather died at age 57 of MI. Physical Exam: PE: 97.6, 107/39, 77, 20, 96% on 2L Gen: NAD, lying in bed comfortable HEENT: mmm, o/p clear, bruise under R eye improving CV: RRR, distant hs, -m/r/g PULM: cta b/l; crackles resolved since yesterday ABD: s/nt/nd, +bs Groin: cath sites healing well b/l EXT: +1 pulses in lower ext b/l NEURO: eomi, perrl, CN II-XII intact, 5/5 strength in all 4 ext Brief Hospital Course: On admission, the neurology service was consulted. Due to symptomatology, intravascular carotid stenting was recommended as he was not a candidate for carotid endarterectomy secondary to his cardiac condition. On [7-1], PTA and stenting to his right internal carotid artery was successfully performed. The final residual was 10% with normal flow. Angiography at that time was also notable for a 2.5 cm proximal aneurysm of the left subclavian artery. He remained neurologically intact throughout the procedure. He otherwise remained pain free on medical therapy. Given his cerebrovascular disease, his SBP was maintained between 120-160 mmHg. He intermittently required fluid boluses. He remained neurologically intact. No further ventricular arrhythmias were noted. His renal functioned remained relatively stable with creatinine ranging between 1.5 - 1.9. On [7-6], Dr. [Last Name (STitle) 1290] performed three vessel coronary artery bypass grafting. Following the operation, he was brought to the CSRU. Intravenous Amiodarone was started for ventricular ectopy. On postoperative day one, bronchoscopy was performed for left lower lobe collapse and copious secretions. Given pulmonary secretions, he was empirically started on broad spectrum antibiotics. He remained sedated and intubated for several more days. He was concomitantly noted to have bright red blood per rectum and his hematocrit dropped as low as 23%. He was intermittently transfused with packed red blood cells. A CT scan was obtained which found no evidence of retroperitoneal hematoma and an abdominal ultrasound found no evidence of stent graft leak . General surgery was consulted and anoscopy was performed. This was notable for grade I-II hemorrhoids with friable rectal mucosa. His proctitis was most likely related to prior radiation exposure. Over several days, his rectal bleeding resolved and his hematocrit stablized. Outpatient colonoscopy is recommended. He eventually awoke neurologically intact and was extubated. He was transitioned to oral Amiodarone. He maintained stable hemodynamics and transferred to the SDU on postoperative day six. His ventricular ectopy improved. He remained on antibiotics for persistent thick, yellow secretions. Sputum cultures were sent, all eventually returning negative. His pulmonary status gradually improved with diuresis. By discharge, he continue to have oxygen requirements with a final oxygen saturation of 95 percent on 4 liters nasal cannula. He was subsequently started on Flomax and by discharge was passing urine on his own. He worked daily with physical therapy and made steady progress and was able to walk stairs by discharge. Medications on Admission: Tri-Cor, Effexor, Crestor, Amiodarone, Toprol-XL, Lisinopril, Imdur, Digoxin, Lansoprazole, Aspirin, Plavix Discharge Disposition: Home with Service Facility: [Location (un) 582] Of [Location (un) 620] Discharge Diagnosis: Coronary artery disease - s/p CABG, CHF, AAA - s/p vascular stent, PVD, Carotid disease - s/p [Country ] stenting, CRI, HTN, NIDDM, Hyperlipidemia, Polymorphic VT - s/p AICD, Prostate CA, DJD, Proximal aneurysm of left subclavian artery Discharge Condition: Stable, good. Discharge Instructions: Patient may shower. No baths. No creams, lotions, or ointments to incisions. No driving for one month. Lift restrictions - no more than 10 lbs for 10 weeks. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) 1290] in 4 weeks Cardiologist, Dr. * in 2 weeks Local PCP, [Last Name (NamePattern4) ]. * in 2 weeks	[ "41401", "5180", "25000", "2720" ]
Admission Date: [2180-10-15] Discharge Date: [2180-10-23] Date of Birth: [2104-9-4] Sex: M Service: TRANSPLANT HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old male with end stage renal disease and a left AV graft status post thrombectoy in [2180-7-2]. After hemodialysis on the Friday prior to admission he developed fever to 102 degrees Fahrenheit and left shoulder pain with a decrease in range of motion. Pain improved slightly with Tylenol. The pain was worse on the morning of admission with pus exuding from the AV graft site. The patient is febrile, but denies chills, nausea, vomiting or respiratory symptoms. Appetite is baseline. The patient also reported some diarrhea on the Saturday prior to admission. The patient was also started on Levaquin for a right lateral heel ulcer prior to hospital admission. PAST MEDICAL HISTORY: Coronary artery disease, end stage renal disease on hemodialysis Monday, Wednesday and Friday, hypertension, congestive heart failure with an ejection fraction of 20%, total knee replacement, total hip replacement, carotid stenosis and gout, arthritis, AV fistula with a history of thrombectomy. MEDICATIONS PRIOR TO ADMISSION: 1. Aspirin 325 mg po q day. 2. Vioxx .5 mg po q day. 3. Lisinopril 20 mg po q day. 4. Isosorbide 30 mg po b.i.d. 5. Digoxin .125 mg q.o.d. 6. Phos-Lo 667 mg after meals. 7. Nephrocaps one po q day. 8. Allopurinol 100 mg po q day. 9. Colchicine 0.6 mg po q day. 10. Quinine 325 mg Monday, Wednesday and Friday. ALLERGIES: Codeine and Morphine. PHYSICAL EXAMINATION: The patient was afebrile. Vital signs were stable. O2 sat 98% on room air. The patient was alert and oriented times three and in no acute distress. Cranial nerves II through XII were intact. No focal deficits. Regular rate and rhythm. Clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended. Radial pulses were palpable bilaterally. Left upper extremity on the upper arms was open sore with questionable exposed graft, positive warmth over the graft. No erythema and no pus expressed. Pain was extension of the shoulder and manipulation of the sore. Pedal pulses were not palpable bilaterally. Healing right lateral malleolar ulcer. Feet were warm and well perfused. HOSPITAL COURSE: The patient was admitted to the Transplant Surgery Service and the plan was to revise an exposed AV graft and establish access for the patient for hemodialysis. Prior to going to the Operating Room the patient was seen by cardiology for an electrocardiogram, which showed some new changes including ST segment changes in multiple leads as well as an isolated troponin of 1.5. The patient was taken to the cardiac catheterization laboratory on [2180-10-16] where he was found to have two vessel coronary artery disease, the right coronary artery had a 100% proximal lesion with left to right collaterals to the distal vessel, left circumflex had 90% mid vessel lesion. A stent was placed in the left circumflex artery. The patient was then discharged to the cardiac floor for close monitoring post catheterization with a ReoPro drip and Plavix and aspirin q day. The patient did well post catheterization procedure with no hematoma and distal pulses all intact. The patient was started on Plavix 75 mg q day and aspirin 325 mg po q.d. to be continued for at least nine months per cardiology. The patient was taken to the Operating Room on [2180-10-18] for revision of exposed AV graft and right Perm-A-Cath placement. The procedure was unremarkable. For more details please see operative report. Postoperatively, the patient experienced increase in left shoulder pain as well as a white count that was elevated to 17. The patient was also noted to have severely decreased range of motion in the left arm. On [2180-10-20] orthopedics was consulted and they performed a joint tap aspirating fluid fro the left subacromial space as well as from the left anterior shoulder. Previous to this a CT scan showed a fluid collection in that area. Tap results were fluid with approximately 13,000 white blood cells and no crystals. The orthopedic attending deemed that this was not a septic joint considering that the white blood cell count was below their threshold of 50,000 and determined that the patient was not in need for a wash out in the Operating Room. The patient's pain improved post tap with Dilaudid prn as well as Tylenol. The patient was seen by physical therapy and occupational therapy and their evaluation was that the patient should go to a short term rehabilitation center prior to going home. The patient is in good condition and ready to go to short term rehab stay prior to going home. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To short term rehabilitation center. DISCHARGE DIAGNOSES: 1. Infected AV graft. 2. End stage renal disease. 3. Coronary artery disease. 4. Congestive heart failure. 5. Hypertension. 6. Arthritis. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Lisinopril 20 mg po q day. 3. Carvedilol 12.5 mg po b.i.d. 4. Digoxin 125 micrograms one po q.o.d. 5. Isosorbide mononitrate 30 mg po q day. 6. Atorvastatin 10 mg po q day. 7. Protonix 40 mg po q day. 8. Allopurinol 100 mg po q day. 9. Folic acid 1 mg po q day. 10. Calcium acetate 667 mg po t.i.d. 11. Nitro 0.3 mg sublingually prn. 12. Plavix 75 mg po q day. 13. Dilaudid 2 mg po prn. 14. Colchicine 0.6 mg po q day. 15. Nephrocaps one po q day. 16. Vancomycin 1000 mg intravenous q hemodialysis times one week for a total of three doses. FOLLOW UP PLANS: The patient is to follow up with Dr. [First Name (STitle) ] in the Transplant Center on [2180-11-2] at 10:40 a.m. Also follow up with Dr. [Last Name (STitle) 7111] from orthopedics on [2180-11-3] at 2:15. [Name6 (MD) 1344] [Name8 (MD) 1345], M.D. [MD Number(1) 1346] Dictated By:[Location (un) 14264] MEDQUIST36 D: [2180-10-23] 10:20 T: [2180-10-23] 10:37 JOB#: [Job Number 14265]	[ "41401", "40391", "4280" ]
Admission Date: [2101-12-20] Discharge Date: [2102-1-1] Date of Birth: [2020-12-16] Sex: F Service: MEDICINE Allergies: Lipitor Attending:[First Name3 (LF) 530] Chief Complaint: s/p Mechanical fall Major Surgical or Invasive Procedure: Cast placement Blood transfusion CHOP chemotherapy History of Present Illness: 81 year old Russian speaking female with a PMHx significant for large B cell lymphoma (recently dx on EGD for GIB; s/p 1st cycle CHOP [12/2101]); who presented with confusion over the past few days. Her daughter found her in bed with a head laceration. The patient reports she got up during the middle of the night to go to the bathroom and fell down about 10 steps. Had a bedside commode but walked to the hallway instead due to a vivid dream, and opened the wrong doorway into a stairway rather than a bathroom. She was able to independently get back up and into bed. Daughter took her to [Hospital ] Hospital where she was found to have a subdural hematoma & nondisplaced right radial sylet fracture and was transferred to [Hospital1 18] for further management. . In the ED here, injuries were confirmed as above with the assistance of ortho trauma and neurosurgery consult team. Both felt no surgical intervention was indication. Her labs were remarkable for sodium 122 and Hct 23. She received 2u PRBC and fluid resuscitation with NS, then was admitted to trauma SICU for overnight observation. Repeat head CT after 24h showed no progression of SDH. She remained stable with q2h neuro check and was transfered to the BMT floor for further management. . On the floor, she reported feeling pain all over (per Russian translator) and reports feeling hungry. Denied headache, vision changes. Confirmed that her right arm had been red and swollen for a few days, at the site where her PICC line was during the last admission. Confirmed ongoing nocturnal urinary incontinence which was an improvement over 24h urinary incontinence prior to last admission. . Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: ONC HISTORY I. CERVICAL CANCER Diagnosed [2080] in the USSR. S/p resection and adjuvant chemo/xrt; treatment complicated by bowel necrosis requiring resection in [2081] s/p permanent end colostomy. [2083] pulmonary metastasis, s/p LUL pulm wedge resection + adjuvant chemo. II. Large B cell lymphoma, fall [2101] dx on upper endoscropy for GIB . NON-ONC PMH Multiple ventral hernias s/p repair Diabetes mellitus II S/p bilateral hip arthroplasty Hypertension Hyperlipidemia TIA Gastritis Social History: Lives alone; family in [Location (un) 86] include daughter and grandson who are physicians. Russian speaking. Originally from the [Location (un) 3156]. Denies tobacco use, alcohol use, or any drug use. . Independent of ADLs and some IADLs including cooking and accounting. She walks with a cane. She has help at home from Surburban Nursing - a Russian speaking helper helps her clean her apartment and shops for her. Family History: Mother had cervical cancer. Physical Exam: ADMISSION EXAM VS: 98.6 126/62 84 20 95% RA; [5-11] pain diffusely GEN: No apparent distress HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [5-6] motor function globally DERM: Right arm 7 cm x 5 cm erythmatous, warm, endurated area DISCHARGE EXAM Notable for rt arm induration decreased to 1.5x1.5cm with minimal surrounding erythema and small central eschar. Pertinent Results: ADMISSION LABS [2101-12-20] 09:28PM GLUCOSE-114* UREA N-15 CREAT-1.1 SODIUM-134 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-10 [2101-12-20] 09:28PM CALCIUM-6.9* PHOSPHATE-2.8 MAGNESIUM-1.1* [2101-12-20] 09:28PM WBC-5.8 RBC-3.04* HGB-9.1* HCT-26.6* MCV-88 MCH-29.8 MCHC-34.0 RDW-16.8* [2101-12-20] 09:28PM PLT SMR-VERY LOW PLT COUNT-43* [2101-12-20] 09:28PM PT-12.3 PTT-22.0* INR(PT)-1.1 [2101-12-20] 03:10PM COMMENTS-GREEN TOP [2101-12-20] 03:10PM HGB-7.4* calcHCT-22 [2101-12-20] 02:35PM URINE HOURS-RANDOM UREA N-363 CREAT-49 SODIUM-44 POTASSIUM-31 CHLORIDE-44 MAGNESIUM-0.8 [2101-12-20] 02:35PM URINE OSMOLAL-334 [2101-12-20] 01:28PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2101-12-20] 01:28PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 [2101-12-20] 01:28PM URINE MUCOUS-RARE [2101-12-20] 10:58AM LACTATE-1.5 [2101-12-20] 10:40AM GLUCOSE-182* UREA N-21* CREAT-1.2* SODIUM-122* POTASSIUM-3.5 CHLORIDE-88* TOTAL CO2-26 ANION GAP-12 [2101-12-20] 10:40AM WBC-4.4# RBC-2.64* HGB-8.1* HCT-23.0* MCV-87# MCH-30.6 MCHC-35.0 RDW-15.7* [2101-12-20] 10:40AM NEUTS-51 BANDS-7* LYMPHS-19 MONOS-16* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-2* PROMYELO-4* OTHER-1* [2101-12-20] 10:40AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL [2101-12-20] 10:40AM PLT SMR-VERY LOW PLT COUNT-52* [2101-12-20] 10:40AM PT-12.4 PTT-24.6* INR(PT)-1.1 . DISCHARGE LABS . MICRO: [12-21] - urine cx pending - blood cx pending - MRSA screen pending . [2101-12-20] Radiology CT HEAD W/O CONTRAST FINDINGS: There is small right frontal parietotemporal extra-axial hemorrhage (601b:51). There is a small posterior subfalcine subdural hematoma (601b:81) tracking along the right tentorial leaflet. There is no evidence of large acute territorial infarction or large masses. The ventricles and sulci are slightly prominent, likely age related. There is no shift of midline structures. There is possible nasal bone fracture (3:24). Mucosal thickening is seen in the maxillary sinuses and ethmoid air cells. There is large soft tissue hematoma-laceration in the subcutaneous tissue of the left frontoparietal region. A left parotid lesion measuring approximately 2.5 cm is seen and better assessed on prior studies. IMPRESSION: 1. Small right frontal acute temporoparietal extra-axial, likely subdural hemorrhage. 2. Small acute posterior subfalcine subdural hemorrhage layering along the right tentorial leafleft. Follow up as clinically indicated. 3. Large frontoparietal subcutaneous hematoma-laceration. 4. Stable lesions within the left parotid gland characterized as likely a venolymphatic malformation on last MRI brain from [2100-1-19]. 5. Possible nasal bone fracture. The study and the report were reviewed by the staff radiologist. . [2101-12-20] Radiology WRIST(3 + VIEWS) RIGHT FINDINGS: Subcutaneous edema. Ther.e is a subtle linear lucency through the radial styloid of the distal radius, consistent with a nondisplaced fracture. No other fracture. No dislocation. IMPRESSION: Subtle nondisplaced radial styloid fracture. This was also reported to Dr. [Last Name (STitle) 6570] by Dr. [Last Name (STitle) 8803] via telephone . [2101-12-20] Radiology CT C-SPINE W/O CONTRAST FINDINGS: The alignement of the cervical spine is preserved. There is no prevertebral soft tissue edema. There is diffuse osteopenia. No discrete acute fracture is seen. There are multilevel degenerative changes in the cervical spine. Posterior to vertebral bodies of C5-C6, there is a large osteophyte impinging on the thecal sac anteriorly. Thin lucent line between the osteophyte and vertebral body may relate to the orientation; however, trauma related changes cannot be excluded as no recent priors are available. Imaged portion of the lung apices show scarring in the left lung apex. Similar lesion within the left parotid gland seen on multiple prior studies. IMPRESSION: 1. Osteopenia. No discrete acute fracture is seen. Thin lucent line at C2 base can relate to artifact/osteopenia or very minimal fracture without displacement of the fragments. 2. C5-C6 level large posterior osteophyte impinging on the thecal sac and deforming the cord. Thin lucent line between the osteophyte and vertebral body may relate to the orientation; however, trauma related changes cannot be excluded as no recent priors are available.correlate clinically to decide on the need for further workup. 3. Stable lesion within the left parotid gland seen on multiple prior studies, characterized as likely a venolymphatic malformation. 4. Scarring in the left lung apex. The study and the report were reviewed by the staff radiologist. . [2101-12-20] Radiology CT CHEST/ABN/PELVIS W/O CONTRAST FINDINGS: The study is suboptimal due to lack of IV contrast; limitations were discussed prior scanning. CT CHEST: There is interval decrease in size of mediastinal, hilar and axillary lymph nodes. Scattered small lymph nodes are seen in the bilateral axilla, mediastinum, and hila, however, with interval decrease in size compared to last CT from [2101-12-9]. There are mild coronary artery calcifications. There is no pericardial effusion. There is a stable small right pleural effusion and adjacent opacity, likely small atelectasis. There is interval decrease in size of bilateral pulmonary nodules, largest in the right middle lobe measuring 5 mm (2:27). There is no pneumothorax. There is a stable linear scarring in the left lung apex. Scattered calcifications are seen in the thoracoabdominal aorta. CT ABDOMEN: Evaluation of solid organs is suboptimal due to lack of IV contrast. With this limitation in mind, the appearance of the liver and spleen appears grossly within normal limits. There is cholelithiasis. The pancreas appears grossly unremarkable. Bilateral adrenal glands are normal. Diffuse wall thickening is seen in the stomach from known lymphoma. There is interval decrease in stranding about the duodenum. There is interval decrease in size of ill-defined retroperitoneal mass, difficult to measure. There is a persistent bilateral moderate hydronephrosis and hydroureter to the level of the retroperitoneal mass with associated stranding. There is interval decrease in size of retroperitoneal and mesenteric lymph nodes. No free air is seen. There are no acute findings on a noncontrast CT thought to be related to the acute trauma. CT PELVIS: There are bilateral total hip prosthesis, which gives significant amount of artifact in the pelvis. Ill-defined soft tissue surrounding the cervix is better evaluated on the last MR pelvis. There is interval decrease in size of bilateral inguinal lymph nodes. The urinary bladder appears grossly unremarkable. Similar very large ventral abdominal wall hernia is seen containing loops of large and small bowel. There is trace fluid within the pelvis, similar to prior. There is a similar large parastomal hernia in the left lower abdominal quadrant. OSSEOUS STRUCTURES: Multilevel degenerative changes are seen. No acute fracture is seen. IMPRESSION: 1. No evidence of acute injury on a noncontrast CT torso. 2. Interval decrease in size of mediastinal, hilar, retroperitoneal and inguinal lymph nodes. 3. Interval decrease in size of the retroperitoneal mass. 4. Diffuse gastric wall thickening consistent with known gastric lymphoma. 5. Interval decrease in size in bilateral pulmonary nodules. 6. Persistent small right pleural effusion. 7. Stable large ventral wall hernia containing loops of large and small bowel. No evidence of bowel obstruction. 8. Persistent bilateral moderate hydronephrosis and hydroureter extending to the level of the retroperitoneal mass. 9. Ill-defined soft tissue surrounding the cervix, better evaluated on most recent pelvic MR from [2101-11-25]. The study and the report were reviewed by the staff radiologist. . [2101-12-21] Radiology CT HEAD W/O CONTRAST FINDINGS: There is no significant change in thickness or extent of the relatively thin right frontotemporoparietal region subdural hematoma, with little mass effect (2:12). Additional subdural hematoma along the right portion of the posterior falx is slightly decreased in size, possibly related to redistribution over the right leaflet of the tentorium cerebelli. There is no new intracranial hemorrhage, edema, shift of normally midline structures, hydrocephalus, or acute large vascular territorial infarction. Periventricular and subcortical white matter hypodensities are consistent with sequelae of chronic small vessel ischemic disease. Prominence of the ventricles and sulci represents age-related involutional change. Mucosal thickening is seen within the right maxillary sinus. The remainder of the visualized portions of the paranasal sinuses and mastoid air cells are well- aerated. The orbits are grossly unremarkable aside from evidence of bilateral ocular lens surgery. As before, there is a left frontoparietal subgaleal hematoma, unchanged in overall extent. Additionally, more edema is evident in the right frontoparietovertex subgaleal scalp (2:16). IMPRESSION: 1. No significant interval change in the extent of subdural hematoma overlying the right cerebral convexity. Decreased right parafalcine component, posteriorly, could relate to redistribution. 2. No new intracranial hemorrhage or evidence of acute large vascular territorial infarction. 3. No shift of midline structures or central herniation. 4. Stable left frontoparietal scalp subgaleal hematoma, without underlying fracture (better-assessed on yesterday's dedicated bone imaging). The study and the report were reviewed by the staff radiologist. . [12-24] CT HEAD NON CONTRAST FINDINGS: Again, there has been no interval change in the thickness or extent of the small right frontotemporal subdural hematoma. A small amount of subdural hematoma tracking along the falx is also unchanged. There is no evidence of new hemorrhage, edema, mass, mass effect, or infarction. White matter changes consistent with chronic small vessel ischemic disease again noted. The left frontoparietal subgaleal hematoma is markedly smaller. The remainder of the osseous structures and extracranial soft tissues show no interval change. IMPRESSION: No marked change from previous study to explain patient's worsening symptoms. . [12-24] CT C-SPINE NON CONTRAST INDINGS: There has been no interval acute change since the prior study three days ago. Once again noted is a prominent disc osteophyte causing moderate but non-critical stenosis of the vertebral canal, abutting the spinal cord at the C5-C6 level. There are several vertebral body lucencies at the C2, C3, and C4 levels, which are unchanged from the prior study but were not present on the MRI of the brain performed in [2100]. There is no marked change in the prevertebral soft tissues. IMPRESSION: 1. No acute interval change to explain patient's symptoms. If there is continued clinical concern, MRI of the neck is recommended for evaluation of the neural structures or ligamentous injury to the spine. 2. Several vertebral body lucencies in the cervical spine, new from [2100], which may be related to the patient's osteopenia; however, evaluation with MRI is recommended due to the patient's history of leukemia. . [12-23] RUE DOPPLER ULTRASOUND FINDINGS: [Doctor Last Name ]-scale and color Doppler imaging was obtained of the right subclavian, internal jugular, axillary, basilic, brachial and cephalic veins. There is nonocclusive thrombus seen in the right basilic vein which is a superficial vein. There is no thrombus seen in the deep veins which demonstrate normal flow, compressibility and augmentation. There is no abscess or fluid collection seen. IMPRESSION: Thrombus in the right basilic vein, a superficial vein. No evidence of DVT in the right upper extremity. No drainable fluid collection or abscess. DISCHARGE LABS [2102-1-1] 07:45AM BLOOD WBC-12.2* RBC-2.70* Hgb-8.5* Hct-25.0* MCV-93 MCH-31.7 MCHC-34.2 RDW-18.4* Plt Ct-311 [2102-1-1] 07:45AM BLOOD Neuts-84.3* Lymphs-9.0* Monos-6.5 Eos-0.1 Baso-0.1 [2101-12-31] 06:20AM BLOOD PT-10.4 PTT-28.7 INR(PT)-1.0 [2102-1-1] 07:45AM BLOOD Gran Ct-[Numeric Identifier 8804]* [2102-1-1] 07:45AM BLOOD Glucose-136* UreaN-32* Creat-1.1 Na-138 K-4.3 Cl-107 HCO3-21* AnGap-14 [2102-1-1] 07:45AM BLOOD ALT-25 AST-22 LD(LDH)-260* AlkPhos-117* TotBili-0.1 [2102-1-1] 07:45AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.1 [2101-12-29] 02:06PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.006 [2101-12-29] 02:06PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2101-12-29] 02:06PM URINE Hours-RANDOM UreaN-279 Creat-20 Na-45 K-18 Cl-41 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION 81F w/PMH cervical CA and recent diagnosis stage 4B-E DLBCL admitted after mechanical fall in setting of [2-3] days confusion at home, found to have stable subdural hematoma, nondisplaced right radial fx, hyponatremia, UTI, and R arm cellulitis surrounding former PICC site. . #. Right temporal SDH Noted on OSH CT head, confirmed here by radiology in the ED. In interviews with Russian interpreters she was alert and oriented, answering questions appropriately. Family noted some waxing/[Doctor Last Name 688] mental status. A third CT head/neck was performed on [12-24] (unchanged) when she c/o worsening L-sided headache and vertigo with neck flexion. Neurosurgery re-evaluated but felt no intervention necessary given lack of focal exam findings and serial head CT stable x3. She received 10 days of anti-epileptic therapy (3 days dilantin, then 7 days keppra) starting [2101-12-20]. Pain controlled with home lyrica TID + PRN percoset. She needs follow-up head imaging (head CT) and neurosurgery clinic evaluation 8 weeks from admission. . #C-SPINE INTRAVERTEBRAL LUCENCIES Neuroradiology did note some abnormal lucency within cervical vertebral bodies on all CT exams, which were stable but new since imaging in [2100], ddx included lymphoma vs osteopenia. Suggested f/u C-spine MRI which was not performed given the on going chemotherapy . #RIGHT ARM CELLULITIS Noted at former PICC site; patient reported redness and swelling on admission. Given exam findings of erythema and induration centered upon former PICC insertion sites, she was started on vancomycin. Doppler US of the R arm ruled out DVT or abscess, but confirmed superficial phlebitis which was consistent with exam. A repeat doppler of the PICC site itself reveal a small fluid collection that was too small to drain per surgery. The patient was started on Bactrim DS [Hospital1 ] after vancomycin was stopped 6 days after admission. The patient was afebrile for over 1 week prior to discharge. She was discharged to complete an additional 14 days of DS Bactrim . #ELEVATED PMN COUNT WBC acutely elevated from 6 to 23 on HD2 at time of transfer from TSICU to BMT floor, for which the differential included infection (PICC site cellulitis and/or UTI) but most likely reflects delayed response to neulasta received in outpatient clinic the week prior to admission. She was continued on vancomycin for her RUE cellulitis. The patient's WBC remained elevated into the 20 until a few days prior to discharge, which likely reflected the neulasta . # UTI/URINARY INCONTINENCE Admission UCx grew coag-negative Staph >100K. This was her second UTI in past 2 weeks, different organism; due for outpatient urology follow-up studies for ongoing unexplained urinary incontinence (which had resolved prior to admission, per patient report) and hydronephrosis/hydroureter. Patient seen by urology consult during last admission but deferred intervention (stenting vs nephrostomy tube placement) given patient's good urine output. She had been scheduled for functional bladder studies/cystoscopy in urology outpatient clinic but missed these appointments during this admission. Patient did report improved daytime bladder control during interim at home, possibly due to interval improvement in size of retroperitoneal mass after CHOP as seen on admission CT abd/pelvis. However, ongoing nocturnal urinary incontinence, hydroureter may contribute to recurrent UTI. She was continued on vancomycin per above. Repeat urine culture showed no growth. . # NONDISPLACED R RADIAL STYLOID FRACTURE Noted on outside hospital imaging. Ortho Trauma service consulted, placed soft cast. Recommend follow-up in 2 weeks (appointment request placed by ortho trauma at [Telephone/Fax (1) 1228]). Pain controlled with TID lyrica + PRN percoset. . #HX CONFUSION PRIOR TO ADMISSION This may have been the precipitating cause for her injuries. Potential causes include infection (R arm cellulitis, UTI), hyponatremia, and/or side effects of steroids received during last admission. She did report vivid dreams during last admission. Likely predisposed to mechanical fall. Discussed increasing home health aide options with her family after discharge. Of note, PT recommended [Hospital 4487] hospital discharge, which the patient refused knowing the risks and benefits. . #DLBCL Discovered on EGD workup for anemia prior to last admission. Started CHOP without rituxan during that admission, tolerated it without complications. CT torso performed during trauma workup in the ED here revealed interval decrease in size of diffuse adenopathy and interval decrease in size of retroperitoneal mass, no change in peri-cervical mass. Plt and Hct were stable after initial transfusion on admission. She was continued on ppx acyclovir and allopurinol (given recent hyperuricemia even prior to initiation of chemotherapy). She recieved C2 of CHOP prior to discharge. . #. Hypotension: Noted on admission, subsequently resolved. Received 250 NS bolus on [2101-12-21] in TSICU with good response. No recurrence. . #. Dyslipidemia Continued holding home simvastatin. . #. History of gastritis: [Month (only) ] EGD showed nonbleeding ulcers in fundus and antrum. She was continued on a PPi, initially IV while in the ICU, then returned to her home PO ppi when transitioned to the floor. . #. Hyponatremia: Initially 122 --> 134 --> 139. Stable wnl thereafter. Likely due to SIADH in setting of head trauma, but also may have pre-dated head trauma and therefore possibly contributed to confusion/fall. . #. DM2 Blood sugars wnl, conrolled on insulin sliding scale (rather than home glyburide). Diabetic diet. No notable hyperglycemia (much improved since last admission when taking steroids). . # Hx ARF Creatinine clearance wnl during this admission. Initially maintained on IVF, transitioned to POs with additional IVF PRN. Did have brief elevation of creatinine of unknown etiology, urine lytes were indicative of intrinsic renal disases. Creatinin returned back to baseline of 1.1 prior to discharge. . TRANSITIONAL ISSUES 1. NEEDS NEUROSURGERY FOLLOWUP SCHEDULED - 8 WEEKS FROM [12-24], ALSO NEEDS REPEAT HEAD IMAGING AT THAT TIME (PHONE NUMBER FOR NSG OFFICE STAFF IN DISCHARGE PAPERS). 2. NEEDS UROLOGY FOLLOW-UP RESCHEDULED, FOR CYSTOSCOPY & FUNCTIONAL BLADDER STUDIES PLANNED PRIOR TO ADMISSION TO FURTHER WORK UP URINARY INCONTINENCE. 3. C-SPINE MR [First Name (Titles) ] [Last Name (Titles) ] C-SPINE LUCENCIES SEEN ON CT C-SPINE Medications on Admission: ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - [1-2] Tablet(s) by mouth q 6 h prn ACYCLOVIR 400 mg 1 Tablet by mouth every eight (8) hours ALLOPURINOL 100 mg 2 Tablets by mouth Daily DIPYRIDAMOLE-ASPIRIN [AGGRENOX] - (On Hold from [2101-12-1] to unknown for GI bleed) - 25 mg-200 mg Cap, ER Multiphase 12 hr - 1 Cap(s) by mouth twice a day DONEPEZIL [ARICEPT] - 10 mg 1 Tablet by mouth once a day GLIPIZIDE - 2.5 mg ER 1 Tablet by mouth once a day OXYBUTYNIN CHLORIDE [DITROPAN XL] 5 mg ER one Tablet by mouth each morning PANTOPRAZOLE 40 mg E.C. 1 Tablet by mouth twice a day PREGABALIN [LYRICA] 150 mg 1 Capsule by mouth three times a day PROCHLORPERAZINE MALEATE 10 mg 1 Tablet by mouth q6 hours prn nausea SIMVASTATIN - 10 mg 1 Tablet by mouth once a day OTC: CAPSAICIN - 0.025 % Cream - apply to affected area tid prn CHOLECALCIFEROL (VITAMIN D3) - 2,000 unit [Unit Number ] Tablet by mouth once a day DOCUSATE SODIUM 100 mg 1 Capsule by mouth twice a day MULTIVITAMIN 1 Tablet by mouth once a day PSYLLIUM [REGULOID, SUGAR FREE] 1 Powder by mouth as instructed Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Do not take more than 6 tablets in one day. Do not drive while taking this medication. Disp:60 Tablet(s) Refills:0 2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 3. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 4. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 6. Ditropan XL 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. cholecalciferol (vitamin D3) 2,000 unit Tablet Sig: One (1) Tablet PO once a day. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. multivitamin Capsule Sig: One (1) Capsule PO once a day. 13. psyllium Powder Sig: One (1) dose PO once a day. 14. pregabalin 75 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 15. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. Disp:28 Tablet(s) Refills:0 16. prednisone 50 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days. Disp:4 Tablet(s) Refills:0 17. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [1-2] Tablet, Rapid Dissolves PO three times a day as needed for nausea. Disp:30 Tablet, Rapid Dissolve(s) Refills:0 18. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: Large B-cell Lymphoma Fracture of right radial subdural hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 8802], It was a pleasure to care for you at [Hospital1 18]. You were admitted to the hospital for a fall resulting in a fracture of your wrist. You also developed a small bleed within your head that has been stable. We found that you had a urinary tract infection that was treated with antibiotics. You also had a skin infection in your upper right arm that was treated with antibiotics. These infections may have contributed to your fall. You will need to follow up with Dr. [Last Name (STitle) 3759] this week. His office will call you with the appointment details. You will also need to follow up with orthopedic surgery and neurosurgery. You can make this appointments by following the insturctions below. Medication Changes: START Bactrim DS 1 tablet by mouth twice daily for 14 days START Prednisone 50mg tablet: 2 tablets by mouth once daily for 2 days (through [2102-1-3]) START Zofran (ondansetron) 4mg tabs: 1-2 tabs three times daily as needed for nausea START Percocet 5/325 tab: 1 tab by mouth every 6 hours as needed for pain. DO NOTE TAKE ANY OTHER MEDICINES WITH TYLENOL (ACETEMINOPHEN WHILE TAKING THIS) START Keppra 500 mg twice daily for 7 additional days, then stop. STOP Tylenol #3 STOP Caspacin STOP Aggrenox No other changes were made to your medications. Please keep taking them as prescribed. It has been a pleasure taking care of you. Followup Instructions: -Dr.[Name (NI) 8805] office will call you with the appointment details for this week. The appointment will be either [2101-1-4] or [2101-1-5]. If you do not hear from him by Tuesday afternoon, please call [Telephone/Fax (1) 3237]. You will need to schedule an appointment with the orthopedic surgeons this week to evlauate your broken wrist. Make this appointment by calling [Telephone/Fax (1) 1228]. You will also need to schedule an appointment with neurosurgery, Dr. [Last Name (STitle) ], in 8 weeks. Please make this appointment by calling [Telephone/Fax (1) 8806]; They will arrange for repeat imaging studies to [Telephone/Fax (1) 4656] the small bleed inside your head. Please see the following appointments that have already been scheduled: Department: [Hospital ] MEDICAL GROUP When: FRIDAY [2102-1-20] at 10:30 AM With: DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 133] Building: [Street Address(2) 3375] ([Location (un) ], MA) [Location (un) 858] Campus: OFF CAMPUS Best Parking: On Street Parking Department: NEUROLOGY When: THURSDAY [2102-1-26] at 10:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5990", "5849", "25000", "4019", "2859" ]
Admission Date: [2156-6-2] Discharge Date: [2156-6-8] Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: Patient is an 85-year-old male referred to the Cardiac Surgery service after cardiac catheterization revealed left main and two vessel disease with an EF of 55%. Patient reported chest tightness and shortness of breath for several years. More recently he has been experiencing fatigue and shortness of breath also consistent with claudication after walking 150 yards. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Arthritis. 4. Shingles. PAST SURGICAL HISTORY: 1. Appendectomy 30 years ago. 2. Cataract surgery. 3. Surgery to repair detached retina. 4. Basal cell removal. REVIEW OF SYSTEMS: Positive for claudication. Positive dyspnea on exertion. No orthopnea, no PND. Positive claudication and no edema. No peptic ulcer disease, gastritis, GERD. No nausea, vomiting, or diarrhea. No melena. No fevers, chills, or night sweats. No COPD, no asthma, and no diabetes. No history of stroke or TIAs, seizures. No history of DVTs. FAMILY HISTORY: [Name (NI) ] mother died at age of 52 from a MI. Father died at age of 67 from a MI. SOCIAL HISTORY: Positive tobacco use. Positive EtOH, [3-16] drinks per day. Denies recreational drug use. Lives with his son. ALLERGIES: The patient denies any allergies to medicines. MEDICATIONS AT HOME: 1. Aspirin 325 mg p.o. q.d. 2. Imdur 30 mg p.o. q.d. 3. Metoprolol 100 mg b.i.d. 4. Hydrochlorothiazide 25 mg q.d. Catheterization results showed left main disease at 90% LAD, 50% diffuse, 70% distal. Left circumflex: 90% origin diffuse disease with a OM, RCA mild luminal irregularities, an EF of 65%, and a LVEDP of 16. Patient's laboratory values showed a white count of 6.0, hematocrit of 39, platelet count of 220. Sodium of 137, potassium of 3.7, chloride of 103, bicarb of 25, BUN of 19, creatinine of 1, and a glucose of 217. PT was 12.8, PTT was 24.7, and INR was 1.1. ALT was 16, AST was 16, alkaline phosphatase was 52, total bilirubin 0.6, amylase was 34, albumin was 3.8. Urinalysis showed positive red blood cells, negative leukocytes, negative nitrite. Chest x-ray showed mild hyperinflation, no acute cardiopulmonary process. EKG was sinus rhythm with a rate of 63 with inverted T waves in aVL and Q waves in III. PHYSICAL EXAM: The patient was afebrile with stable vital signs. He was in no acute distress. Neck was supple with no lymphadenopathy. Pupils are equal, round, and reactive to light with intact extraocular motions. Patient was anicteric sclerae. Moist mucous membranes. Normal oropharynx. Chest was clear to auscultation bilaterally. Heart was regular, rate, and rhythm with a normal S1, S2. Abdomen was soft, nontender, and nondistended. Extremities were warm and well perfused with no varicosities. Neurologic examination: The patient was alert and oriented times three, follows commands, no focal defect. Cranial nerves II through XII were intact. Pulses were +2. Femoral +2, carotids with no bruits, +2 radial pulses, +1 DP and nonpalpable PT. ASSESSMENT AND PLAN: This is an 85-year-old man with hypertension and increased cholesterol. Referred to the Cardiac Surgery service with three-vessel disease by catheterization now seen preoped for CABG with Dr. [Last Name (STitle) 70]. On [2156-6-2], the patient was brought to the operating room for elective CABG x3. Patient had saphenous vein graft to OM, saphenous vein graft to ramus, and saphenous vein graft to LAD. Patient tolerated the procedure well. Was transferred to the ......... room, intubated on a Neo-Synephrine drip, and propofol drip. Patient had A-wires in place and chest tubes. On postoperative day one, the patient was weaned off his Neo-Synephrine drip. Was on an ethanol drip for suspected alcohol abuse. Patient was also on an insulin drip. Patient was afebrile with a T max of 99.5. Patient's heart rate was 88 and was paced. Patient's blood pressure was stable, and other vital signs are stable. Patient had been extubated overnight, and was saturating 97% on 50% face mask. Postoperative laboratories showed a white count of 13.2, hematocrit of 32.7, and platelet count of 173. Chemistries were all within normal limits. Patient was started on oral medications, and was out of bed with Physical Therapy. On postoperative day #2, patient was on Lasix 20 b.i.d., metoprolol 25 b.i.d. Patient had a T max of 100.1. Patient had a heart rate of 84 in sinus rhythm. Otherwise, vital signs were within normal limits. Patient was saturating 94% on 5 liters nasal cannula and a face shovel. Patient's hematocrit was 31.3. Other laboratory values were all within normal limits. Patient's diet was advanced. Patient was transferred to the floor. On postoperative day #3, patient was on aspirin 325, Lasix 20 IV b.i.d., metoprolol 25 b.i.d. Patient was also given folate and thiamine. Patient was afebrile. Heart rate was regular in sinus rhythm. Patient had some low O2 saturations on 92% on 4 liters. Was encouraged to do aggressive incentive spirometry. Patient's chest tube output had been high in the ICU, but had dropped off significantly since transfer. Patient's chest tubes were to water-seal. There was no air leak. The patient had atrioventricular wires. Patient's chest tubes and wires were both D/C'd. Patient's Lopressor was increased to 50 b.i.d. On postoperative day four, patient had episode of rapid AFib yesterday, which was controlled with Lopressor. Patient was afebrile with a T max of 97.6. Patient's heart rate was 82. Patient was in sinus rhythm. Patient's hematocrit was stable at 29.7. Patient's potassium was low at 3.5, and the potassium was repleted. Patient was ambulating with Physical Therapy and was on a regular diet. On postoperative day five, the patient continued to do well. Was on aspirin 325, Lasix 20 p.o. b.i.d., and metoprolol 75 b.i.d. Patient had a T max of 99.8, was 81 in sinus rhythm. Patient was out of bed with Physical Therapy. Chest tubes were removed. Patient's hematocrit was 30.4. Patient's metoprolol was increased to 75 t.i.d. Patient was working with Physical Therapy and was at physical therapy level of 5. [Name (NI) ] son came in and patient's discharge disposition was discussed. On postoperative day six, patient was afebrile with stable vital signs. Patient was ambulating with Physical Therapy. Was tolerating a regular diet. DISCHARGE DISPOSITION: To home. FOLLOWUP: Patient will follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3142] in Primary Care Clinic in two weeks. The patient will call for an appointment. Patient will follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70] in six weeks. Patient will call office for an appointment. Patient will be discharged home with VNA care. DISCHARGE MEDICATIONS: 1. Lasix 20 mg tablet p.o. b.i.d. 2. Potassium chloride 20 mEq p.o. b.i.d. 3. Colace 100 mg tablet p.o. b.i.d. 4. Aspirin 325 mg tablet one tablet p.o. q.d. 5. Percocet 5/325 1-2 tabs p.o. q.4-6h. as needed for pain. 6. Metoprolol 100 mg tablet one tablet p.o. b.i.d. CONDITION ON DISCHARGE: The patient is discharged to home in stable condition with VNA care for hemodynamic monitoring and wound evaluation. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 10638] MEDQUIST36 D: [2156-6-7] 23:01 T: [2156-6-8] 06:12 JOB#: [Job Number 54617]	[ "41401", "42731", "4019", "53081", "2720", "3051" ]
Admission Date: [2100-9-27] Discharge Date: [2100-10-1] Date of Birth: [2039-8-6] Sex: M Service: GU PRINCIPAL DIAGNOSIS: Carcinoma of the prostate. OTHER DIAGNOSES: 1. Hypertension. 2. Left adrenal adenoma. SURGERY: [9-27] - right limited pelvic lymphadenectomy, radical retropubic prostatectomy. SURGEON: [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9125], MD ASSISTANT: Dr. [First Name (STitle) ]. NARRATIVE SUMMARY: Mr. [Known lastname 31225] is a 61-year-old man diagnosed with carcinoma of the prostate. After consideration of various options for therapy, it was decided he would undergo a radical retropubic prostatectomy. During his preoperative evaluation, he was found to have a left adrenal mass. Although this was felt likely to be nonfunctional, he was considered for an endocrine consult preoperatively. He was seen and it was felt that he did not have pheochromocytoma. He was cleared for anesthesia. On the day of admission, he underwent the procedure. The prostatectomy was difficult because of periprostatic adhesions. There was no concern about a rectal injury, but inspection at the conclusion of the surgery was negative for this. However, postoperatively, he did complain of more rectal pain than average, and therefore he was kept on a liquid diet right up through the time of discharge. He did have a somewhat prolonged ileus and stayed an extra day. The drain was removed on time. The pathology was pending at the time of discharge. DISCHARGE CONDITION: Satisfactory. DISCHARGE MEDICATIONS: Percocet. He will continue on a liquid diet for the next 2 days pending decision about advancement as an outpatient. Followup provided through our office and Dr. [First Name4 (NamePattern1) 1790] [Last Name (NamePattern1) 1789]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Last Name (NamePattern1) 9125], [MD Number(1) 23434] Dictated By:[Name8 (MD) 23436] MEDQUIST36 D: [2100-12-12] 14:21:24 T: [2100-12-12] 21:12:59 Job#: [Job Number 31226]	[ "25000", "4019" ]
Admission Date: [2194-4-9] Discharge Date: [2194-4-19] Date of Birth: [2112-2-19] Sex: F Service: MEDICINE Allergies: Belladonna Alkaloids Attending:[First Name3 (LF) 800] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 108328] is an 81 year old [Known lastname 595] speaking female with a history of anemia and thrombocytopenia, Crohn's disease on chronic steroids, PE, returned from rehabilitation for somnolence. Found to be hypoxic and somnolent in the emergency room (VS T 98, BP 132/53, HR 92, RR 24, 95% on NRB). New infiltrate on CXR in the left upper lobe, and ABG showed hypercarbia. She was admitted to the ICU and started on meropenem and vancomycin. She was given IV fluids for hypotension and responded appropriately. She was started on bipap in the ICU which improved her somnolence, and mental status returned to baseline. Past Medical History: PAST MEDICAL HISTORY: -Anemia [3-3] CRI, chronic disease -MDS dx 3 yrs ago -Crohn's disease -CAD s/p NSTEMI '[89] -CRI w baseline Cr 1.5-1.8 -BL DVTs and saddle embolus in [2190], previously on warfarin now on Lovenox -Chronic BL LE edema -Breast cancer s/p lumpectomy & XRT -GERD -Intracranial bleed and fx after pedestrian vs car 20 yrs ago -Cataracts -Venous stasis dermatitis -Tinea pedis -?Arrhythmia unspecified which daughter says is tx with metoprolol -dHF with EF 60-70% . PAST SURGICAL HISTORY: -CCY 10 yrs ago -Lumpectomy 13 yrs ago Social History: Married; lives with her husband who is demented, her daughter [Name (NI) 108329], [Name2 (NI) 108330] husband and 6 [Name2 (NI) ] granddaughter. Presently in temporary housing while awaiting renovations on their [Last Name (un) ] which was damaged during a fire last winter. [Last Name (un) 108329] is the caretaker for both of her parents. [Last Name (un) 108329] very stressed and overwhelmed. Her mother-in-law in [Name (NI) 4565] died this past month which required her husband to leave for [Name (NI) 4565]. She is in the midst of trying to place her father in nursing care facility and is quite guilty about this decision. Ms. [Known lastname 108328] [Last Name (Titles) 108331]y recieves near daily RN visits from Suburban Home Care. [Last Name (Titles) 108329] is reliant on "sitters" to bring her mother to appointments. Family History: non-contributory Physical Exam: VS: T HR 84 BP 112/41 RR 15 O2 86% on 4L NC General: NAD, pleasant and interactive, NC in place [Last Name (Titles) 4459]: NCAT MMM anicteric pink conjunctiva Neck: no JVD appreciated, supple Lungs: crackles at LLL CV: RRR 2/6 SEM at LUSB, PMI nondisplaced Abd: soft, NT, ND, bowel sounds present, palpable non-moveable mass c/w ventral hernia Ext: + anasarca, LLE cellulitis - warm, erythematous, tender Skin: numerous ecchymoses and sites of skin breakdown over torso and extremities Pertinent Results: [2194-4-8] 05:56AM PT-13.2 PTT-25.0 INR(PT)-1.1 [2194-4-8] 05:56AM PLT SMR-LOW PLT COUNT-82* [2194-4-8] 05:56AM WBC-11.8* RBC-2.86* HGB-9.6* HCT-29.5* MCV-103* MCH-33.7* MCHC-32.6 RDW-18.8* [2194-4-8] 05:56AM CALCIUM-7.9* PHOSPHATE-3.9 MAGNESIUM-1.6 [2194-4-8] 05:56AM estGFR-Using this [2194-4-8] 05:56AM GLUCOSE-110* UREA N-67* CREAT-2.5* SODIUM-143 POTASSIUM-5.2* CHLORIDE-109* TOTAL CO2-27 ANION GAP-12 [2194-4-8] 10:11AM URINE MUCOUS-RARE [2194-4-8] 10:11AM URINE RBC-4* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 [2194-4-8] 10:11AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2194-4-8] 10:11AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.012 [2194-4-9] 03:00PM URINE RBC-[4-3]* WBC-[4-3] BACTERIA-FEW YEAST-NONE EPI-0-2 [2194-4-9] 03:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2194-4-9] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.010 [2194-4-9] 03:00PM URINE GR HOLD-HOLD [2194-4-9] 03:00PM URINE UHOLD-HOLD [2194-4-9] 03:00PM URINE HOURS-RANDOM [2194-4-9] 03:00PM URINE HOURS-RANDOM [2194-4-9] 03:45PM PT-14.2* PTT-29.3 INR(PT)-1.2* [2194-4-9] 03:45PM PLT SMR-LOW PLT COUNT-104* [2194-4-9] 03:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL STIPPLED-1+ [2194-4-9] 03:45PM NEUTS-74* BANDS-12* LYMPHS-6* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [2194-4-9] 03:45PM WBC-15.9* RBC-3.19* HGB-11.0* HCT-33.8* MCV-106* MCH-34.4* MCHC-32.5 RDW-19.2* [2194-4-9] 03:45PM CK-MB-NotDone cTropnT-0.07* [2194-4-9] 03:45PM CK(CPK)-18* [2194-4-9] 03:45PM GLUCOSE-107* UREA N-58* CREAT-2.3* SODIUM-144 POTASSIUM-5.3* CHLORIDE-110* TOTAL CO2-25 ANION GAP-14 [2194-4-9] 05:27PM freeCa-1.15 [2194-4-9] 05:27PM HGB-10.9* calcHCT-33 O2 SAT-92 CARBOXYHB-1 [2194-4-9] 05:27PM GLUCOSE-137* LACTATE-1.0 NA+-143 K+-5.4* CL--107 [2194-4-9] 05:27PM TYPE-ART PO2-69* PCO2-73* PH-7.18* TOTAL CO2-29 BASE XS--2 Brief Hospital Course: # Pneumonia: The patient was admitted to the medicine service for new left upper lobe pneumonia thought to be consistent with aspiration. She was started on vancomycin and meropenem. Given she was afebrile, no leukocytosis and was hemodynamically stable vancomycin was discontinued two days into admission meropenem was continued for a 10 day course. On day 10 of admission she was found to be somnolent in the morning. Per her daughter she received valerian root overnight for insomnia and anxiety. ABG indicated respiratory acidosis, with PCO2 at 81 (baseline high 50s to 60). She was transferred to the ICU for further management. She was started on BiPAP until her blood gas improved. She was able to come off to eat her dinner. She was put back on BiPAP overnight to get some rest. In the morning, she again came off and continued to do well. Patient did receive one 250cc bolus for hypotension and an appropriate increase in her blood pressure. She completed her 10 days of meropenem. Prior to discharge she was scheduled for a sleep study to further evaluate for home bipap. . # Diastolic Heart Failure: Echo done on previous discharge showed mild LVH, hyperdynamic systolic function (EF>75%), right ventricular pressure/volume overload, 2+TR, and moderate pulmonary artery hypertension. Her lasix was continued at 10mg daily and intake/output was monitored as well. She continued to do well without need for further intervention. Prior to discharge she was restarted on her home beta blocker (metoprolol succinate 12.5mg PO bid) with good BP control. . # CKD: Admitted with Cr of 2.3, which was near her baseline. With conservative treatment creatinine improved to 1.4. Nephrotoxins were avoided. . # Crohn's Disease: She did not experience frequent bouts of diarrhea on this admission. Prednisone [Year/Month/Day 15123] was initially continued, but changed to a slower [Year/Month/Day 15123] per daughters request. Ciprofloxacin and mesalamine was continued. . # MDS and Related Anemia: She was given 1U PRBC for hct 24, and weekly epogen was restarted on this admission. She will need further follow-up with hematology. . # DVT/PE: Patient had chronic DVT/PE in the past for which she was on lovenox. The patient's daughter refused heparin (previous history of worsening thrombocytopenia w/use although HIT Ab negative) and pneumoboot to arm given patients poor skin condition. Given her anemia and thrombocytopenia, her previous bloody stools, it was felt the risk of bleeding with anticoagulation was highter than her risk for worsening DVT or PE at this time. This should be re-evaluated by her PCP in the future. . # Wound care: the patients skin looked much improved since her last admission, with decreased extremity edema. Nursing wound care was continued per previous recommendations. . # GERD: omeprazole 20mg twice daily was continued . # Prophylaxis: Calcium and vitamin D were continued, bactrim was added for PCP [Name Initial (PRE) 1102] . # Social/psych: During this admission, social work and ethics were called to assist in determining what was the appropriate level of care for the patient (rehabilitation or home with services). A family meeting was held, and the medical team and family were in agreement that the patient can be cared for at home with 24h care to assist her daughter. She did not want to consider rehabilitation, although this would have been the ideal setting for the patient at this time. . # Code: DNR/DNI Medications on Admission: Acetaminophen prn pain Vitamin D 800 U q day Mesalamine 1200 [Hospital1 ] Camphor-Menthol lotion prn Miconazole powder prn Atrovent q 6 hours Albuterol q2 prn Ciprofloxacin 250 mg [Hospital1 ] Loperamide 2 mg PO QID Calcium Carbonate 1000 mg TID Timolol Maleate 0.5 drops daily Polyvinyl alochol-Povidone drops prn Predinosone 60 mg [Hospital1 15123] Lasix 10 mg daily Discharge Medications: 1. semi-electric bed [Hospital 485] hospital bed for diagnosis of respiratory failure and congestive heart failure 2. bipap bipap machine: ST pressures [11-3], with backup RR of 10 3. PICC flushes PICC heparin flushes: per NEHT protocol 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed: apply up to 4 times daily to affected area. Disp:qs 1 Refills:2 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 11. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): 35mg daily until [4-22]; [Date range (1) 85977] take 30mg daily then follow your outpatient doctors orders for [Name5 (PTitle) 15123]. Disp:10 Tablet(s) Refills:0 14. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection once a week. 15. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection once a month. 16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 17. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Topical twice a day: for venous stasis. 18. Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection once a day: On going daily flush for PICC line and PRN. Disp:30 syringes Refills:2 19. Calcium 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 20. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: hypercarbic respiratory failure diastolic heart failure Discharge Condition: hemodynamically stable and afebrile Discharge Instructions: You were admitted to the hospital for increasing shortness of breath and somnolence. You were treated for high bicarbonate levels with bipap and oxygen supplementation. You were also found to have a new pneumonia with was treated with meropenem for 10 days and vancomycin for 2 days. You will need to make an appointment with Dr.[Last Name (STitle) 3357] at your convenience to follow your anemia and other symptoms. Please make sure that you use your bipap machine at home and continue your medications as ordered. If you experience increasing shortness of breath, chest pains, fevers, chills or any other concerning symptoms please call your doctor or return to the emergency room. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:2L Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7290], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2194-4-24] 10:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 647], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2194-4-29] 3:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3014], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2194-4-29] 3:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 4606] Date/Time: [2194-5-6] 2:45 Please make sure to attend your sleep study on [5-2] at 12:45pm in the [Hospital Ward Name 1950] building. Please call [Telephone/Fax (1) 6856] for questions on directions or if you need to reschedule. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811]	[ "5070", "51881", "5849", "4280", "40390", "41401", "412", "53081", "V5861" ]
Admission Date: [2174-8-15] Discharge Date: [2174-8-23] Date of Birth: [2101-6-11] Sex: F Service: CARDIOTHORACIC Allergies: Crestor / Lipitor Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2174-8-15] - Redo sternotomy, Replacement of Aortic Valve (21mm [Doctor Last Name ] Pericardial Valve)/Replacement of Ascending Aorta . [2174-8-15] Mediastinal exploration for bleeding, status post aortic valve replacement and ascending aortic replacement earlier in the day. History of Present Illness: 73 year old female who now has recurrent exertional throat tightness and headache. She was scheduled for her routine office visit and reported her symptoms. This prompted a repeat exercise thallium. This demonstrated some anteroseptal and apical ischemia which was essentially unchanged from prior stress in [2173]. However she developed exercise induced hypotension and did report lightheadedness and throat tightness. Her [Location (un) 109] is now 0.6cm2 and peak gradient now at 121 mmHg and a mean of 76 mmHg. She was referred for aright and left heart catheterization. Upon cardiac catheterization she was found to have severe aortic stenosis. She is now being referred to cardiac surgery for redo-sternotomy and aortic valve replacment. Past Medical History: Coronary artery disease GERD Hyperlipidemia Aortic stenosis Obesity Cataracts s/p CABG x 2 at [Hospital3 2358] (LIMA to LAD and SVG to PDA)[2160] s/p mid RCA PTCA [2148] s/p Cypher stent to distal portion of SVG to PDA ([Hospital1 112]) [4-12] s/p 3 Taxus stents in a nearly occluded native RCA at [Hospital1 112] [2-12] Social History: Lives with:Husband Contact:[Name (NI) ] (husband) Phone #[0-0-] Occupation:retired teacher Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [x] [3-15] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: maternal uncles with MI x 2 in his 40's and her sister had PCI at age 65. Her son had multiple stents placed in his early 40s. Physical Exam: Pulse:56 Resp:18 O2 sat:99/RA B/P Right:103/63 Left:91/67 Height:5'6" Weight:220 lbs General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade __5/6 SEM loudest at right upper sternal border____ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] obese, well healed RUQ incision, no hernias/masses Extremities: Warm [x], well-perfused [x] Edema [x] __1+___ R groin dsg c/d/i Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 1+ Left: 1+ Carotid Bruit Right: NO Left: NO Pertinent Results: [2174-8-15] ECHO No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. 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 appears structurally normal with trivial mitral regurgitation. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION PREBYPASS: Critical aortic stenosis with mild aortic regurgitaion and mildly dilated ascending aorta. Trivial MR [First Name (Titles) ] [Last Name (Titles) 85249]d LV function. POSTBYPASS: 1. Preserverd [Hospital1 ]-ventricular systolci function. 2. Trace MRT and TR 3. Bioprosthetic valve in aortic position. Well seated with good leaflet excursion. Trace AI and minimal gradiet acrooss the valve. 4. A peri-aortic hemotoma is visualized around the sino-tubular junction 5. No other change . [2174-8-23] 10:30AM BLOOD WBC-10.3 RBC-3.18* Hgb-9.7* Hct-29.7* MCV-94 MCH-30.7 MCHC-32.8 RDW-14.6 Plt Ct-260 [2174-8-21] 06:30AM BLOOD WBC-7.8 RBC-3.04* Hgb-9.5* Hct-28.0* MCV-92 MCH-31.0 MCHC-33.8 RDW-14.8 Plt Ct-187 [2174-8-23] 10:30AM BLOOD UreaN-26* Creat-1.4* Na-138 K-3.9 Cl-97 [2174-8-21] 06:30AM BLOOD Glucose-109* UreaN-24* Creat-1.3* Na-139 K-3.9 Cl-100 HCO3-29 AnGap-14 Brief Hospital Course: Mrs. [Known lastname 85250] was admitted to the [Hospital1 18] on [2174-8-15] for surgical management of her aortic valve disease. She was taken to the operating room where she underwent replacement of her aortic valve using a 21mm [Doctor Last Name ] pericardial valve and replacement of her ascending aorta. Please see operative note for details. Postoperatively she was transferred to the intensive care unit for monitoring. Immediately post-operatively, significant sanginous output was noted in her chest tubes. The patient became more hypotensive with increasing inotropic pressor requirements. CXR showed a slightly more widened mediastinum versus normal post-operative changes. Multiple products were administered (PRBCs, Plts, FFP, Cryo, Protamine). She was taken to the OR again for washout and hemostasis (please see operative note) 4-5 hours after her initial operation. After washout and chest reclosure, she was taken back to the CVICU intubated. Over the next several hours, she was transfused and her inotopic pressor requirements decreased. She was ultimately weaned off of pressors and extubated. After extubation, she was found to have mental status changes with facial twitching. Neurology was consulted for a possible post-operative CVA vs. seizure. CT of the head was negative and EEG was inconclusive. Other labs were normal. Over the next few days, the patient's mental status recovered. She was A+OX3 and moving all extremities. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 8 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Rehab in [Location (un) ] in good condition with appropriate follow up instructions. Medications on Admission: ATENOLOL 25 mg Daily NEXIUM 40 mg every other day ZETIA 10 mg daily TRICOR 145 mg Daily FUROSEMIDE 80 mg Daily NITROGLYCERIN 0.4 mg PRN CRESTOR 10 mg daily ASPIRIN 325 mg Daily GLUCOSAMINE &CHONDROIT-MV-MIN3 1 tablet daily ALEVE 220 mg Daily Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Ezetimibe 10 mg PO DAILY 3. Rosuvastatin Calcium 10 mg PO DAILY 4. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN mouth pain 5. Metoprolol Tartrate 75 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. 6. NexIUM NF (esomeprazole magnesium) 40 mg ORAL QOD 7. Tricor NF (fenofibrate nanocrystallized) 145 mg ORAL DAILY 8. Glucosamine NF (glucosamine sulfate) 0 mg ORAL DAILY 9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 10. Acetaminophen 650 mg PO Q4H:PRN pain, fever 11. Furosemide 80 mg PO DAILY 12. Naproxen 220 mg PO DAILY 13. Ibuprofen 600 mg PO Q8H:PRN head ache Discharge Disposition: Extended Care Facility: tbd Discharge Diagnosis: Coronary artery disease s/p CABGx2 GERD Hyperlipidemia Aortic stenosis Obesity Cataracts Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with ultram Incisions: Sternal - healing well, no erythema or drainage Edema 1+ lower extremity edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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: The Cardiac Surgery Office will call you with the following appointments: Surgeon: Dr. [Telephone/Fax (1) 85251] in the [Hospital ] Medical office building, [Doctor First Name ], suite2A Cardiologist/PCP: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 8506] 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:[2174-8-23]	[ "4241", "2851", "2875", "53081", "2724", "V4581", "V4582" ]
Admission Date: [2168-3-17] Discharge Date: [2168-4-2] Date of Birth: [2114-1-25] Sex: F Service: EMERGENCY Allergies: doxycycline / Tetracycline Attending:[First Name3 (LF) 2565] Chief Complaint: Elevated creatinine Major Surgical or Invasive Procedure: Central line placement Hemodialysis line placement History of Present Illness: 54F with history of recently diagnosed EtOH abuse and alcohol induced cirrhosis during long admission at [Hospital1 18] ([2167-12-29] - [2168-2-18]) during which she received 30 days of steroids, now presenting from Spualding with increased confusion, report of elevated creatinine, and concern for decompensation. Of note, has been receiving large volume [Doctor First Name ] since discharge to control her ascites, last was [2168-3-14] with removal of 7.5L. She was sent in from [Hospital1 ] because report of increased ammonia levels, increased confusion, and Cr elevation to 2.2. Pt herself says that yesterday evening she was confused and very anxious. She describes a panic attack type episode last night, similar to an episode she had during her recent [Hospital1 ] admission. She says her confusion has resolved and she feels at baseline mental status now and no longer anxious. No fevers, chills, N/V, diarrhea, menala, BEBPR, anorexia, or abdominal pain. She has felt slightly off the last couple days, "blah" is the word she identifies with to describe how she feels. She also endorses constipation with no bowel movement since yesterday, still passing gas. Having intermittent crampy gas pains that come every few minutes. No acute rash, no recent trauma, no headaches, no cough, no SOB. She says the main reason they sent her in from [Hospital1 ] was concern that her kidneys were worsening. During recent hospitalization, she was diagnosed with alcoholic hepatitis with cirrhosis. Her viral hepatitis panel and autoimmune panel were neg. Ultimately the patient could not maintain adequate nutrition on her own, and an dobhoff tube was placed and tube feeds were started. Her MELD labs continued to trend up despite prednisone and ursodiol was started. Eventually her labs stabilized and her prednisone and ursodiol were stopped after 30 days steroids. She was initally treated with diuretics but this was complicated by [Last Name (un) ] so these were stopped. She also had hepatic ecephalopathy despite lactulose so rifaxamin was started which succesfully controlled her encephalopathy. She undewent endoscopy which showed grade I varices at the gastroesophageal junction. She did not undergo colonoscopy. She was discharged to [Hospital3 ] with plan for scheduled large volume paracentesis to control her ascites. In the ED, initial VS: 98.4 74 86/37 16 100%. Pt was given 1L NS due to elevated lactate, 2 PIV placed. Diagnostic para done showing 385 WBC (PMNs pending). All labs stable from recent discharge and Cr here was normal at 0.4 (not elevated at 2.2 as reported from [Hospital1 ]). Given lactulose in ED and admitted to CC7 for encephalopathy work-up. VS at transfer were 97.9 74 14 107/46 18 100%RA. Currently, pt with no complaints except for her gas pains. Also feels thirsty. Past Medical History: Alcoholic Hepatitis complicated by cirrhosis Bleeding peptic ulcer several years ago S/p L hip replacement [2164] Social History: Drank 1 L of wine/daily until [12-17]. Denies any tobacco, drug use, sick contacts. Lives with boyfriend, but ex-husband is HCP. [Name (NI) 4084] any IVDU, no travel. Has had blood transfusion before, about 5 years ago. Family History: No family history of liver disease Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 98.2F, BP 109/60, HR 80, R 20, O2-sat 100% RA, 66.8kg GENERAL - Alert, interactive, sickly appearing HEENT - PERRLA, EOMI, sclerae very icteric, dry MM, OP clear NECK - Supple, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, blowing systolic ejection murmur loudest over arotic band LUNGS - decreased breath sounds at the left base, otherwise clear ABDOMEN - distended, +shifting dullness, nontender, + caput medusa EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - multiple excoriated lesions over chest obliterating most of her spiders, grossly jaundiced LYMPH - no cervical LAD NEURO - awake, A&Ox3, able to say days of week backwards, +asterixis . PHYSICAL EXAM PRIOR TO MICU TRANSFER: VS - 96.8 (98.5) 71/28 (76-88/30-64) 59 (50s-60s) 18 100%RA (94-100%RA) I/O: 1160/150+ BMx3 GENERAL - Alert and interactive, jaundiced, slow speaking HEENT - sclerae icteric, OP clear HEART - RRR with holosystolic murmur over LLSB and apical area LUNGS - Rales [1-4]-way up lung fields bilaterally. ABDOMEN - soft, less distension, no shifting dullness, tenderness to deep palpation in the RLQ, caput medusa, dressing of paracentesis site clean/dry/intac EXTREMITIES - WWP, no peripheral edema, 2+ peripheral pulses SKIN - erythema and multiple excoriated lesions over upper chest/shoulders, few excoriations over abdomen with bleeding on LUE, skin jaundiced throughout NEURO: AAOx3, no asterixis Pertinent Results: ADMISSION LABS: [2168-3-17] 06:20PM BLOOD WBC-12.1* RBC-2.60* Hgb-9.3* Hct-24.8* MCV-95# MCH-35.8* MCHC-37.5* RDW-16.9* Plt Ct-114* [2168-3-17] 06:20PM BLOOD Neuts-86.1* Lymphs-8.9* Monos-3.0 Eos-1.6 Baso-0.4 [2168-3-18] 05:45AM BLOOD PT-26.7* PTT-48.7* INR(PT)-2.6* [2168-3-17] 06:20PM BLOOD Glucose-170* UreaN-36* Creat-0.4 Na-127* K-4.1 Cl-91* HCO3-21* AnGap-19 [2168-3-17] 06:20PM BLOOD ALT-57* AST-135* AlkPhos-122* TotBili-36.9* [2168-3-17] 06:20PM BLOOD Albumin-3.5 Calcium-9.8 Phos-4.4 Mg-2.6 OTHER PERTINENT LABS: [2168-3-28] 06:35AM BLOOD WBC-7.7 RBC-2.23* Hgb-7.5* Hct-22.8* MCV-102* MCH-33.6* MCHC-32.8 RDW-16.2* Plt Ct-62* [2168-3-29] 06:30PM BLOOD PT-34.3* PTT-72.9* INR(PT)-3.3* [2168-3-29] 06:35AM BLOOD Glucose-83 UreaN-92* Creat-8.4# Na-123 K-4.0 Cl-88* HCO3-12* AnGap-27* [2168-3-29] 06:30PM BLOOD ALT-22 AST-59* AlkPhos-58 Amylase-152* TotBili-38.5* DirBili-25.2* IndBili-13.3 [2168-3-30] 02:36AM BLOOD TotProt-6.3* Albumin-5.4* Globuln-0.9* Calcium-9.6 Phos-8.4* Mg-3.0* [2168-3-30] 02:36AM BLOOD Cortsol-14.0 [2168-3-17] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2168-3-29] 09:48AM BLOOD Type-[Last Name (un) ] pO2-157* pCO2-33* pH-7.22* calTCO2-14* Base XS--13 STUDIES: [2168-3-17] ECG: Sinus rhythm. Poor R wave progression. Left axis deviation Left anterior fascicular block. [2168-3-17] CXR: Overall improvement of the bilateral opacities identified on prior. However, there has been progression of disease at the left lung base suggesting possible new pneumonia and small effusion. Two-view chest x-ray may help further characterize. [2168-3-18] CXR: As compared to the previous radiograph, the patient shows no interval development of pneumonia. A small left-sided pleural effusion, better seen on the lateral than on the frontal view, is unchanged. Equally unchanged are signs of mild fluid overload. Borderline size of the cardiac silhouette. No lung nodules or masses. [2168-3-17] RUQ Ultrasound: 1. In comparison to [2168-2-6] exam, there is no significant change in hepatic vasculature which is widely patent. Hepatopetal flow in the left portal vein. The right portal and main portal veins demonstrate hepatofugal flow. 2. Heterogeneous echotexture and lobulated contour of the liver, compatible with underlying cirrhosis. 3. Gallbladder wall edema, likely related to underlying liver disease. 4. Moderate ascites. 5. Splenomegaly. TTE [2168-3-18]: Mild-moderate mitral regurgitation with mildly thickened leaflets, but without discrete vegetation. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [2168-1-1], the severity of mtiral regurgitation and the estimated PA systolic pressure are both higher. If the clinical suspicion for endocarditis is moderate or high, a TEE is suggested to better define the mitral valve. TEE [2168-3-22]: No vegetations or masses seen. Normal biventricular function. Moderate mitral regurgitation. Trivial tricuspid regurgitation with eccentric regurigation jet (may underestimate degree of regurgitation). CXR [2168-3-31]: FINDINGS: As compared to the previous radiograph, there is an increased loss of transparency of the left and right lung parenchyma, likely caused by mildly increasing fluid overload. The left lower lobe atelectasis that preexisted is unchanged. Unchanged aspect of the cardiac silhouette. Unchanged left and right central venous access lines. Brief Hospital Course: 54 year old female with h/o alcoholic cirrhosis and recent prolonged admission for alcoholic hepatitis who presented with acute renal failure and confusion (please see below for detailed floor course). MICU course: Patient was admitted with hypotension, worsening renal failure and coagulopathy in setting of worsening liver failure, worsening encephalopathy and acedemia. She had an HD line placed [3-30]. With CVVH, no singificant improvement was found in mental status despite some improvement in acidema. Broa spectrum antibiotcs were started for possible sepsis. Unfortunately, due to profound coagulopathy, patient continued to have blood loss from both, her L IJ triple lume as well as HD line. She required multiple transfusions of RBC, Platelets, FFP and Cryo. Given no significant improvement in her hypotension, renal failure, liver failure and encephalopathy and per discussion with her health care proxy, goals of care were geared towards comfort. Patient was made CMO on [2168-3-31] and died [2168-4-2] of suspected cardiac arrest in setting profound bleeding and coagulopathy. She appaered comfortable at time of death. Floor course: #. Acute renal failure: She had a rise in creatinine prior to admission from 1.0 to 2.0 at rehab. She was therefore readmitted, although her creatinine on presentation was similar to her recent baseline (around 1.3). She had been previously treated with midodrine/octreotide for hepatorenal syndrome on a prior admission, and was continued on midodrine on admission (octreotide had been stopped at discharge several weeks prior). Her renal function initially stayed stable with albumin and midodrine, but eventually her creatinine started to increase and urine output dropped. Diuretics were held on admission given likely HRS. This was felt to be related to hepatorenal syndrome and was unresponsive to albumin. Her midodrine was stopped and she was enrolled in the terlipressin placebo-controlled trial. Terlipressin vs placebo was started [3-28] with no improvement in her creatinine and she was transferred to the MICU [3-29] due to persistent acidemia, declining mental status, and hypotension. #. Hypotension: She was admitted with low blood pressures in the 80-90's and her BP remained in this range for first week of hospitalization. As her renal failure worsened, her midodrine was held in order to enroll her in the terlipressin trial, and her blood pressure became 70-80's/40's. She was eventually transferred to the MICU for persistent hypotension to 70/40 despite albumin administration. She was initiated on pressors overnight on [3-30] and treated for potential sepsis with broad spectrum antibiotics. #. Hepatic Encephalopathy: She was admitted with confusion and slowing of her speech, which improved with lactulose and rifaximin after admission. Her mental status remained clear for the first several weeks of her admission, although she was still had slowed speech and forgetfulness. The trigger for worsening encephalopathy was not entirely clear as an infectious workup on admission was negative. She was empirically treated for endocarditis initially, but this was stopped and her mental status remained stable until her renal failure worsened. She did get more confused on [3-9], potentially related to uremia in the setting of her renal failure. She was then transferred to the MICU. #. Alcoholic hepatitis and cirrhosis: She was admitted with persistently elevated bilirubin and cholestasis due to alcoholic hepatitis. Her poor prognosis was discussed with her multiple times given her multiple ongoing medical issues. Her MELD on admission was 32 and increased in the setting of worsening renal function. Her bilirubin continued to show no signs of improvement since her initial admission in 12/[2167]. She was continued on lactulose, rifaximin, and cipro prophylaxis for SBP. #. Heart murmur: She had a systolic apical heart murmur on admission that was louder than previously documented. Blood cultures were drawn and TTE revealed worsening MR without clear vegetation. She was treated empirically with 48 hours of vancomycin due to concern for endocarditis. TEE was performed which was negative for endocarditis and vancomycin was stopped. #. Anemia: She had persistent anemia during this admission and guaiac positive stools, although no frank bleeding noted from her GI tract. She was transfused several units of blood intermittently for anemia and her hematocrit responded minimally but remained stable. Given her persistent hypotension and other ongoing issues, EGD/colonoscopy was not performed. #. Rash: She had a rash felt to be secondary to hepatic and renal failure over her chest and extremities. She was seen by dermatology who recommended triamcinolone and other topical treatments, as well as treating her underlying disease. #. Stage III Pressure Ulcer: Noted on her coccyx on admission. Medications on Admission: Ciprofloxacin HCl 250 mg PO/NG Q24H Start: In am Furosemide 40 mg PO/NG [Hospital1 ] Spironolactone 100 mg PO/NG DAILY Lactulose 30 mL PO/NG [Name (NI) ] (pt says only taking [Hospital1 ]) Rifaximin 550 mg PO/NG [Hospital1 ] Multivitamins 1 TAB PO/NG DAILY Thiamine 100 mg PO/NG DAILY FoLIC Acid 1 mg PO/NG DAILY Start: In am Pantoprazole 40 mg PO Q24H Start: In am Simethicone 40-80 mg PO/NG [Hospital1 ]:PRN gas pains Sodium Bicarbonate 1300 mg PO/NG [Hospital1 ] Sarna Lotion 1 Appl TP [Hospital1 ]:PRN itching skin Ursodiol 300 mg PO BID TraMADOL (Ultram) 50 mg PO Q6H:PRN pain traZODONE 75 mg PO/NG HS:PRN insomnia Midodrine 10mg [Hospital1 ] Albuterol Inh or NEB Q6hrs PRN SOB/wheezing Cepacol Lozenges TID PRN Guaifenesin 200mg Q6hrs PRN Ondansetron 4mg Q8hrs PRN Discharge Disposition: Expired Discharge Diagnosis: Liver failure Discharge Condition: patient died Discharge Instructions: patient died. Followup Instructions: none Completed by:[2168-4-2]	[ "0389", "99592", "78552", "51881", "5849", "2762", "2851", "2761", "4240" ]
Admission Date: [2105-7-23] Discharge Date: [2105-7-26] Date of Birth: [2040-5-10] Sex: F Service: MEDICINE Allergies: Prednisone Attending:[Doctor First Name 13737] Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 65 yo woman with h/o DM2, CHF, chronic renal insufficiency, and HTN, who presented to the ED with Na of 113. She was in her usual state of health until last week, when she developed a UTI and was placed on Cipro 10 days ago. On [7-17], she had a basal cell cancer removed from her face. The procedure was performed under general anesthesia, and she tolerated the procedure well. Upon arriving home, she attempted to eat, and became immediatedly nauseated. For the next six day, the patient had persisent nausea, vomiting, and diarrhea. She states that the vomit was predominantly bile, and she had multiple episodes of diarrhea each day. She believes that drank approximately 4 glasses of water and Gatorade each day. She presented to her PCP yesterday afternoon for evaluation of fatigue, dysuria, and diarrhea. She was prescribed Cipro for a UTI, and BMP demonstrated a Na of 117. Of note, the patient's Lasix dose was increased two weeks ago to 80 mg daily. This morning, she was called by her PCP and presented to the ED for further evaluation. . In the ED, the patient's VS were T 97.8, BP 199/72, P 58, R 20, O2 94% on RA. Initial labs demonstrated Na of 113. She recieved 1L of NS, and repeat Na at 6 PM was 113 as well. She was given Metoprolol 25 mg in the ED for SBP of 180s, and she was started on HISS for FSBG of 327. . On the floor, she states that she feels fatigued and endorses dysuria. She denies confusion, seizures, headaches, altered sensorium, chest pain, and shortness of breath. Otherwise, she has no new complaints. . 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 constipation or abdominal pain. No recent change in bowel or bladder habits. Denied arthralgias or myalgias. Past Medical History: Acute on chronic diastolic CHF (EF 50-55% in [8-/2104]) Acute on chronic renal insufficiency, stage IV (baseline 2.9-3.1) Diabetes mellitus Type II Hypertension Hyperlipidemia Chronic anemia Social History: Works as kindergarten teacher in [University/College ]. Lives with husband in [Name (NI) 5176]. Has 2 cats, with immunizations up to date. No other known animal exposures. Has two children, son [Location (un) ] and daughter ([Name (NI) 26454]). Has received both flu vaccine and pneumovax. Non smoker, no EtOH or illicit drug use. Family History: Mother with [Name (NI) ]+ breast cancer Father with CVA Physical Exam: Admission physical exam: Vitals: T: 97.7, BP: 199/73, P: 68 R: 16 O2: 96% on RA General: Middle aged woman, pleasant, but anxious with depressed affect, in NAD HEENT: PERRL, EOMI, Oropharynx clear and without exudate. Ecchymoses over maxillary sinus on right. Dry mucous membranes Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: 3/6 systolic murmur. Regular rate and rhythm, normal S1 + S2. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission: CBC: WBC 11.0, Hct 26.9, Plt 238 BMP: Na 113, K 4.7, Cl 80, HCO3 23, BUN 46, Cr 2.9, Glucose 327 Urine: - Cr 22 - Na 22 . Micro on admission: U/A: 100 Protein, 1000 glucose, Trace blood Discharge labs: Sodium on discharge: 127 Urine lytes: [2105-7-26] Na-23, URINE Osmolal-304 . EKG: Sinus rhythm. The Q-T interval is prolonged. ST-T wave changes which are most consistent with underlying left ventricular hypertrophy, although ischemia or myocardial infarction cannot be excluded. Compared to the previous tracing the Q-T interval is longer. Rate PR QRS QT/QTc P QRS T 61 164 96 490/491 -9 25 161 Imaging: CXR ([7-26]): In comparison with study of [7-23], there is further enlargement of the cardiac silhouette with bilateral pleural effusions and increasing pulmonary venous pressure. Findings are consistent with the clinical impression of overhydration. Brief Hospital Course: 65 year-old woman with h/o CHF, chronic renal insufficiency, DM2, who presents with hyponatremia. # Hyponatremia: The patient was admitted to the ICU. She with hyponatremia with a nadir of 113 meq in the setting of nausea, vomiting, diarrhea, and an increase in her lasix dose. Nephrology was consulted and she was started on hypertonic saline, a high protein diet to increase osmoles, and a 1.2L fluid restriction, with improvement in her serum sodium. Hypertonic saline was stopped on [2105-7-24]. Her hyponatremia was thought to be a combination of a tea and toast diet, with decreased solute intake; fluid loses from vomiting and diarrhea; and increased lasix dosing. Her sodium climbed to 123 and she was transferred to the general medicine floors where she continued a fluid restriction and a high protein diet. On [7-25], she was given 20 cc/hr of hypertonic saline for 10 hr. Her sodium corrected to 127 on discharge. She will have renal followup. . # Hypertension: The patient has a history of HTN, for which she takes Metoprolol, Enalapril, and Furosemide at home. Her BP remained elevated as high as SBP~200. She was started on her home dose of Enalapril and Metoprolol and her blood pressures continued to be high. On discharge, she was given no further BP medications and will have followup with renal and her PCP for BP management. . #UTI: The patient presented with UTI on [7-16] and was prescribed 3 days of Cipro. She presented once again with UTI symptoms on [7-22] and was put on a 7 day course of Cipro 500, however, it was stopped on [7-25] because it has been linked to hyponatremia. On discharge, she had no symptoms of dysuria. . # DM2: The patient was switched from Januvia to a humalog insulin sliding scale. Her glucoses were high ranging from ~170-220. On discharge, she was switched back to her Januvia. #ANEMIA: The patient's crit was 27.6 on admission [7-22] and dropped as low as 22.5 [7-24] but has generally stayed in the mid to high 20s. She has had chronic low crits for the past year likely due to low EPO levels as a result of her CKD. Her latest iron studies showed normal iron and transferrin levels and an elevated ferritin. . #DIASTOLIC HF: EF 50-55% in 9/[2103]. No active symptoms. Medications on Admission: Enalapril 10 mg [Hospital1 ] Furosemide 80 mg daily Glipizide 10 mg daily Th, Fr, [Last Name (LF) ], [First Name3 (LF) ] Metoprolol XR 200 mg daily Pravastatin 80 mg daily Januvia 50 mg daily Triamcinolone 0.1% cream [Hospital1 ] prn ASA 325 mg daily Colace 100 mg daily Ferrous Sulfate 325 mg daily Cipro 500 mg daily Discharge Medications: 1. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for itching. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 8. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [Hospital3 3765] Homecare Program Discharge Diagnosis: Primary: 1. Hyponatremia 2. Urinary tract infection . Secondary 1. Hypertension 2. Chronic kidney disease 3. chronic diastolic CHF Discharge Condition: Stable. On room air. Patient ambulating. Discharge Instructions: You were found to have a low sodium level and were admitted to the ICU. Hypertonic saline was infused and your sodium levels rose. On the general medicine floors, you were restricted to 1.2L of fluid a day and also given some hypertonic saline. . Your low sodium might have been related to your use of furosemide, lasix. You should stop taking furosemide until you have followup outside of the hospital. You should also restrict your fluid intake to 1.2 liters a day and follow a high protein diet. . While in the hospital you finished your course of Cipro for your UTI. You felt pain on urination on [7-24], but a test revealed that you did not have an infection. . You had low oxygen levels with walking, and your chest x-ray showed fluid in your lungs. You should continue to walk short distances at home, refrain from strenuous exercise. You will follow-up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) 9533] a diuretic. . You should come back to the hospital or call your doctor if you have pain on urination, feel lightheaded or dizzy, cannot think clearly, or have any seizure-like activity. Followup Instructions: You should followup with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 26455], this week, Wednesday. She will repeat blood tests, check your blood pressure, and decide about [Last Name (STitle) 9533] Lasix or another diuretic. Please call tomorrow for an appointment. . [2105-8-3] 02:30p [Last Name (LF) ],[First Name3 (LF) ] (nephrology) [Hospital6 29], [Location (un) ] . [2105-8-12] 09:40a [Last Name (LF) ],[First Name3 (LF) ] H. [Hospital6 29], [Location (un) ] [Hospital 191] MEDICAL UNIT	[ "2724", "2761", "5990", "40390", "25000", "4280" ]
Admission Date: [2118-7-24] Discharge Date: [2118-7-30] Date of Birth: [2066-10-13] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Lisinopril Attending:[First Name3 (LF) 783] Chief Complaint: lip, tongue swelling Major Surgical or Invasive Procedure: Intubation/Extubation History of Present Illness: 51 yo F with h/o COPD, down syndrome, hypertension, diabetes insipidus, hypothyroidism, brought in by EMS with facial swelling and AMS. In the ED, she had enlarged lips, tongue WNL, and was satting 99% on 2-4L. Her pupils were pinpoint so she was given narcan. She complained of LLQ abd pain and developed a severe headache. ABG showed a profound resp acidosis, 7.18/108/71. She was then given benadryl, nebs, solumdrol. She was nasotracheal intubated in OR. Also found to have ARF. On admission to ICU, she denied pain in abdomen, headache. Past Medical History: 1) HTN 2) Hypothyroidism: TSH [1-2] 0.87 3) OSA: on BiPAP 16/10 at home - was supposed to also be on 2L NC at home 4) Restrictive lung disease - [4-2] PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO markedly reduced. Consistent with moderate restrictive ventilatory defect 5) Pulmonary artery hypertension: attributed to COPD/OSA 6) ASD with shunt: shunt study demonstrated R-> L shungt with 12% shunt fraction (precluding meaningful repair) 7) Central diabetes insipidis - ? pan- hypo pit: on prednisone 5 mg daily, levothyroxine, desmopressin 8) Down Syndrome 9) h/o CHF - [1-1] TTE: LVEF >55%, RV dilated, abnl septal motion c/w right ventricle pressure/volume overload, 2+ MR, 3+ TR, moderate pulmonary systolic hypertension, ASD vs stretched PFO on bubble study Social History: Lives with daughter, who is her primary care-giver and 2 grand children. Prior 45 pk-yr smoking history, quit [2112]. No EtOH or other drug use. Family History: NC Physical Exam: Physical Exam: T 98.5, BP 118/70, HR 70, RR 13, 100% on vent Genl: intubated, responds appropriately HEENT: pupils 2mm, min reactive, EOMI, lips and tongue swollen Resp: no wheezes, clear to auscultation CV: RRR no MRG Abd: soft, NT, ND, hypoactive BS Ext: trace edema in feet, 1+ pedal pulses. Pertinent Results: [2118-7-24] 11:10PM URINE HOURS-RANDOM CREAT-182 SODIUM-32 [2118-7-24] 11:10PM URINE OSMOLAL-509 [2118-7-24] 11:10PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2118-7-24] 11:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2118-7-24] 11:10PM URINE RBC-[12-19]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2118-7-24] 11:10PM URINE EOS-NEGATIVE [2118-7-24] 09:22PM TYPE-ART TEMP-37.6 RATES-20/0 TIDAL VOL-450 PEEP-5 O2-50 PO2-72* PCO2-62* PH-7.32* TOTAL CO2-33* BASE XS-2 -ASSIST/CON INTUBATED-INTUBATED [2118-7-24] 07:34PM TYPE-ART TEMP-36.7 PO2-125* PCO2-63* PH-7.31* TOTAL CO2-33* BASE XS-3 INTUBATED-INTUBATED [2118-7-24] 04:01PM TYPE-ART PO2-71* PCO2-104* PH-7.18* TOTAL CO2-41* BASE XS-6 INTUBATED-NOT INTUBA [2118-7-24] 03:23PM GLUCOSE-89 UREA N-19 CREAT-2.7# SODIUM-142 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-34 ANION GAP-13 [2118-7-24] 03:23PM ALT(SGPT)-25 AST(SGOT)-49* ALK PHOS-90 AMYLASE-120* TOT BILI-0.2 [2118-7-24] 03:23PM LIPASE-29 [2118-7-24] 03:23PM proBNP-1300* [2118-7-24] 03:23PM CALCIUM-9.5 PHOSPHATE-8.4# MAGNESIUM-2.5 [2118-7-24] 03:23PM TSH-9.8 [2118-7-24] 03:23PM WBC-12.3* RBC-4.15* HGB-12.4 HCT-38.9 MCV-94 MCH-30.0 MCHC-32.0 RDW-15.9* [2118-7-24] 03:23PM NEUTS-68.8 LYMPHS-21.9 MONOS-4.0 EOS-4.2* BASOS-1.0 [2118-7-24] 03:23PM HYPOCHROM-3+ MACROCYT-1+ [2118-7-24] 03:23PM PLT COUNT-126* [2118-7-24] 03:22PM LACTATE-1.0 Brief Hospital Course: A/P: 51 yo F with h/o Down Syndrome, COPD, hypothyroidism, central DI, admitted with angioedema and ARF. . #Angioedema: During this hospitalization, Ms. [Known lastname ] was given steroids, benadryl and H2 blockers which helped to decrease swelling of lips and tongue. After a discussion with the patient and her family, it did not appear that she had recently started taking any medications or had eaten any new food. Allergy was consulted who assessed the patient and felt that the most likely etiology of the angioedema is her ACEI, despite the fact that she had been on the medication for months. Her lisinopril was held. C4 was normal which ruled out C1 inhibitor deficiency. Facial and lip edema improved significantly and Ms. [Known lastname ] was extubated on [7-28] and transferred to the floor. Her course on the floor was uneventful; her facial edema had resolved. She was evaluated by speech and swallow and determined to be able to take thin liquids and soft solids. A steroid taper was begun and benadryl was discontinued. . #Hypercarbic respiratory failure: Ms. [Known lastname ] presented with profound hypercarbic respiratory failure on admission which resulted in hypoxemic respiratory failure. She was intubated in the ICU. Vent was titrated to maintain PCO2 of 50 given history of COPD. As her respiratory status improved, pt was extubated and transferred to the floor satting well on room air. #ARF: Pt presented to the ED in acute renal failure, likely secondary to hypotension. As angioedema was treated and pt received hydration, the creatinine trended down quickly. Upon discharge, her creatinine was at her baseline of 0.8. . #Pneumonia: One day after admission, Ms. [Known lastname ] [Last Name (Titles) 28316] a fever to 102.1. In light of increasing WBC and worsening CXR, she was started on a course of Unasyn. Pt has been afebrile since [7-26], with a stable CXR and WBC trending down. Once she was able to take PO, she was switched to Augmentin for a course of 7 days. (Day 1 [7-26]). . #Diabetes Insipidus: Patient has history of DI. She was continued on outpatient dose of 0.2mg [Hospital1 ]. . #Hypothyroidsim: Pt with history of hypothyroidism. She was switched to IV levothyroxine during acute episode, but then switched back to PO. Dose of levothyroxine was increased as free T4 was low with elevated TSH. Medications on Admission: Aspirin 81 mg QD Prednisone 5mg QD Desmopressin 0.2 mg [Hospital1 ] Levothyroxine 75 mcg QD Albuterol 90 mcg 1-2 Puffs IH Q4H Calcium Carbonate 500 mg TID W/MEALS Ipratropium Bromide 0.02 % IH Q6 Furosemide 40 mg QD Ibuprofen 400 mg Q12H PRN Oxygen at 2L continuous Lisinopril 20 mg QD KCL 20 meq QD Ranitidine 150 mg QD Tramadol 50 mg Q4 PRN Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation every six (6) hours. 4. Desmopressin 0.01 % Aerosol, Spray Sig: One (1) Nasal [Hospital1 ] (2 times a day). 5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for PNA for 3 days. Disp:9 Tablet(s) Refills:0 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 7. Prednisone 20 mg Tablet Sig: Six (6) Tablet PO QAM: Please take six tablets for two days, then take five tablets for two days, then take four tablets for two days, then take 2 tablets for 2 days, then take 1 table for 2 days, then take 10mg for 2 days (different prescription), then restart taking 5mg continously. Disp:42 Tablet(s) Refills:0 8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: for two days after you finished the 20mg prescription. Disp:2 Tablet(s) Refills:0 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day: Please restart after finishing prednisone taper. PLease take continously. Disp:30 Tablet(s) Refills:2 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Angioedema Hypercarbic respiratory failure Acute renal failure --------- Diabetes Insipidus Hypothyroidism Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet, Fluid Restriction Please take all of your medications as prescribed. If you begin to notice lip or tongue swelling, or difficulty Please do NOT take Lisinorpil. Please make sure you remove the Lisinopril from all your medications. Taking Lisinopril again may be life threatening to you. Please also do not take Lasix for now until Dr. [Last Name (STitle) 5351] restarts it. You need to take Amoxocillin for 2 more days in order to complete the course. Please take six tablets for two days, then take five tablets for two days, then take four tablets for two days, then take 2 tablets for 2 days, then take 1 table for 2 days, then take 10mg for 2 days (different prescription), then restart taking 5mg continously. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 5351] next week. Please also call Dr. [Last Name (STitle) 1837] at [Telephone/Fax (1) 7732] to make a follow up appointment. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "51881", "2762", "496", "4240", "5849", "4280", "486", "2875", "2449", "4019", "32723" ]
Admission Date: [2183-3-14] Discharge Date:[2183-4-1] Date of Birth: [2136-4-24] Sex: M Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: This is a 46-year-old man with a past medical history significant for alcohol and cocaine abuse who presented with rapidly increasing ascending weakness since five days prior to admission. According to his mother, whom I talked with (and whom he lives with), he was having general weakness and malaise, along with a cough (but no fevers, chills, nausea, vomiting, or diarrhea). Over the weekend prior to admission and then Sunday at 3:30 a.m., he got up to go to the bathroom, and his knees buckled, and he fell. He was admitted to an outside hospital that day, and since then, his weakness worsened. According to a neurologic exam at the outside hospital the day prior to admission, he had developed shortness of breath, using accessory muscles. There was a lower motor neuron right facial weakness, slurred speech, 3 out of 5 distal upper extremity weakness and 2 out of 5 proximal upper extremity weakness, and 2 out of 5 lower extremity weakness. There was also an absence of reflexes. Toes were downgoing. He was transferred to the [Hospital6 2018] for further evaluation and management for a question of [First Name9 (NamePattern2) 7816] [Location (un) ] syndrome. Reportedly in the first 24 hours of the process, he was having weakness in the lower extremities and paresthesias in his hands. PAST MEDICAL HISTORY: Alcohol abuse. Cocaine abuse. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Keflex 500 mg b.i.d., Clonidine 0.1 mg q.week, Folic Acid, Thiamin, Multivitamin, Labetalol 400 mg b.i.d., 10 mg IV p.r.n., Ativan p.r.n., he was also given a dose of Ampicillin, Rocephin, and Vancomycin prior to transfer from the outside hospital for an increasing white blood cell count at 12.7 up from 10.9 on admission. SOCIAL HISTORY: Alcohol and cocaine abuse. He lives with his mother. [Name (NI) ] smoking. PHYSICAL EXAMINATION: Vital signs: Temperature 97.8??????, blood pressure 119/54, heart rate 82, respirations 13, oxygen saturation 100% on room air. General: The patient was in no acute distress. He appeared comfortable. HEENT: Moist mucous membranes. Oropharynx clear. No scleral icterus or injection. Neck: Supple. No lymphadenopathy. No carotid bruits appreciated. Lungs: Clear to auscultation bilaterally anteriorly. Heart: Regular, rate and rhythm. Normal S1 and S2. Abdomen: Soft, nontender, nondistended. Extremities: Warm. There were 2+ peripheral pulses throughout. No edema. Neurological: Mental status exam showed the patient to be alert, awake, and following commands. He made attempts to mouth words but was intubated on admission. He became very agitated and anxious. By discharge, he had received a trach, and with his Passy-Muir valve, was able to talk very well. Cranial nerves: Pupils equal, round and reactive to light. Initially his extraocular eye muscles were intact; however, during most of the hospital course, he appeared to have some extent of ophthalmoplegia. This has been recovering well. The patient also has a right lower motor neuron cranial nerve facial palsy, although facial sensation is intact bilaterally and sternocleidomastoids intact bilaterally. At the time of admission, shoulder shrug was weak but present throughout the hospital course. The patient did lose the ability to shrug his shoulders; however, that has returned as well. Motor: The patient had normal bulk on admission, but extremities were flaccid. There were no fasciculations. The proximal upper extremities were 2 out of 5 bilaterally, and 3- out of 5 distally. In the lower extremities, 0 out of 5 bilaterally. Through most of the hospital course, the patient did developed quadriplegia; however, he did begin to improve, and by [2183-3-29], he could again lift his arms, and by [2183-4-1], his biceps were 4 out of 4 bilaterally, triceps 4 out of 4 bilaterally. The distal upper extremities were 3 out of 5 bilaterally, and the lower extremities were 3 out of 5 throughout. Sensation has been intact throughout the entire hospital course to pin/temp. LABORATORY DATA: On [2183-4-1], white count was 9.1, hematocrit 30.7, the patient's hematocrit was in the low 30s through most of his admission; all of his stool guaiacs were negative; platelet count 428; INR has been 1.0 throughout admission; serial urinalysis has been negative; CSF showed 1 white cell, 75 red cells; stool guaiac negative; glucose 144, BUN 25, creatinine 0.6, sodium 142, potassium 4.1, chloride 107, bicarb 25; ALT 37, AST 24, alkaline phosphatase 52, total bilirubin 0.4, calcium 9.5, phosphate 3.1, magnesium 2.1; IgA 323; total protein in the CSF was 176, glucose 76; sputum from [2183-3-28], showed sparse growth of oropharyngeal flora and sparse growth of gram-negative rods; sputum culture from [2183-3-26], showed staphylococcus aureus coag-positive, rare growth, and rare growth of gram-negative rods. The staph coag-positive was resistant to only penicillin; gram-negative rods also only resistant to penicillin; sputum culture from [2183-3-20], showed moderate growth of oropharyngeal flora and Staphylococcus aureus coag-positive, moderate growth; sputum culture from [2183-3-18], showed moderate growth of oropharyngeal flora, staphylococcus aureuss coag-positive, moderate growth; sputum culture from [2183-3-14], showed sparse growth of oropharyngeal flora; urine culture on [2183-3-28], showed no growth; urine culture on [2183-3-26], showed no growth; urine culture on [2183-3-26], again was no growth; urine culture on [2183-3-19], showed no growth; urine culture on [2183-3-18], showed no growth; urine culture on [2183-3-14], showed no growth; blood cultures from [3-28], [3-26], [3-19], [3-18], [3-14], were all negative, no growth; C-diff from [2183-3-27], was negative; second C-diff from [2183-3-27], was negative; fecal culture showed no salmonella or shigella, and Campylobacter culture was negative; MRSA screens were negative; VRE screens also were negative; bronchoalveolar lavage done on [2183-3-19], grew moderate growth of oropharyngeal flora, staph coag-positive, moderate growth, and beta streptococci not group A, moderate growth; CSF gram stain was negative, and fluid culture was no growth; blood fungal culture showed no fungus isolated; blood AVB culture showed no macrobacteria isolated. EMG revealed sensory nerve conduction studies of the left radial and right seral nerve which were normal. Sensory nerve conduction studies of the left median nerves and left ulnar nerve revealed markedly reduced response amplitudes. Ulnar conduction velocity was severely reduced and median conduction velocity was normal. Motor nerve conduction study of the left median nerve revealed severely prolonged distal latency, normal response amplitude, and mildly reduced conduction velocity. ................. responses were absent. Motor nerve conduction study of the left median nerve distal to the carpal tunnel revealed moderately prolonged DL with normal RA. Motor nerve conduction study of the left ulnar nerve revealed markedly prolonged VL, mildly reduced RA, and mildly slowed CV throughout the length of the nerve with more severe focal slowing of the elbow, ............. responses were absent. Motor nerve conduction study of the bilateral tibial nerves revealed moderately prolonged distal latency, markedly reduced RAs and normal CV in the right tibial nerve with mildly reduced CV in the left tibial nerve. ... responses were absent in both tibial nerves. Partial conduction block was identified in both tibial nerves by decreased in RA at 55% in the right tibial nerve and 62% in the left tibial nerve. Bilateral blink reflexes were absent. EMG of selected muscles in the right lower extremity representing the L1-S2 myotomes revealed markedly reduced recruitment of normal motor unit potentials in tibialis anterior and no motor unit activity in gastrocnemius and vastus lateralis. Poor activation was seen in the right iliopsoas, and evaluation of the motor unit potentials was suboptimal. Nonspecific increase insertional activity was seen in the right tibialis anterior and right vastus lateralis. EMG of the left tibialis anterior and left iliopsoas revealed moderately to markedly reduced recruitment of normal motor unit potential. No motor units were activated in the left deltoid. The impression was that this was an abnormal study. There is electrophysiologic evidence for a moderately severe acute generalized demyelinating polyneuropathy as in [First Name9 (NamePattern2) 7816] [Location (un) ] syndrome. HOSPITAL COURSE: The patient was admitted in transfer from an outside hospital on [2183-3-14]. He remained in the Intensive Care Unit until [2183-4-1]. On presentation, he had already been intubated, and he remained quadriplegic through most of the admission. He initially underwent a 5-day course of IVIG which was begun on the day of admission, and following this, the patient received supportive care and close monitoring for his neurologic condition. Respiratory wise, he developed what was felt to be an aspiration pneumonia with sputum cultures growing Staphylococcus aureus coag-positive, and a chest x-ray revealed left retrocardiac opacity, and he was treated with seven days of Zosyn and also received several days of Vancomycin. The patient continued to spike fevers throughout the course of antibiotics, and so on day #7, the antibiotics were stopped. The patient spiked fevers until [2183-3-27], and since has been afebrile. His last chest x-ray on [2183-3-27], showed marked improvement in the basilar patchy opacities, and there was no evidence of congestive heart failure. The patient's blood cultures and urine cultures revealed no growth. On [2183-3-25], the patient underwent placement of a tracheostomy and a PEG tube for further support. By [2183-3-28], the patient had been weaned off the vent and was maintained by trach collar. Cardiovascularly the patient had very difficult-to-control hypertension throughout the hospital stay. His heart rate also tended to be in the 80s to low 100s throughout the hospital course. Initially the patient was receiving Enalapril, Metoprolol, and would be sedated with Propofol, which also seemed to lower his blood pressure. As the days went on, he was changed to p.o. Labetalol and given a Clonodine patch to attempt to wean his sedation, as well as keep his blood pressure down. The Enalapril was also increased, and he was continued on the Hydralazine. He required Ativan in quantities of 25-30 mg/day after the Propofol was finally discontinued when the patient was weaned from the vent. In an attempt to decrease the amount of Ativan that was required, the patient's Clonodine patch was increased to three patches, and the patient was changed on [2183-3-29], to Klonopin, which is currently at 2.5 mg t.i.d., which has also helped reduce the amount of Ativan needed. Furthermore, the patient was started on Zoloft on [2183-3-31], for a question of depression and anxiety. The electrolytes have been mostly stable throughout his hospital course. Initially the patient was having decreasing sodium, and this was felt to be due to SIADH, likely related to his .................. syndrome. The patient was started on salt tablets 3 g t.i.d. per the Neurology SICU Service, and this was eventually weaned off, as his sodium became stable. For nutrition, the patient was maintained on tube feeds throughout the hospital course and also given protime pump inhibitor and bowel regimen for prophylaxis. He additionally has been getting regular fingersticks and a regular Insulin sliding scale to control blood sugars, which have ranged typically from 100 to 140 or 150. Renally the patient has not had any issues. On [2183-4-1], the patient was called out of the Intensive Care Unit to the floor. He has not been febrile since [2183-3-27]. His respiratory status is currently stable, and trach collar requires suctioning approximately every four hours. Neurologically the patient has dramatically improved and is now again able to lift all of his extremities, antigravity, and is somewhat stronger than that in the proximal upper extremities. He has received his Passy-Muir valve and is talking well and is interactive. The plan will be to monitor him on the floor until he is well enough to go to rehabilitation. He has been seen by Physical Therapy throughout his hospital stay, and this will continue when he is on the floor. He is also continued on Thiamin, Folate, and a Multivitamin in regards to his history of alcohol abuse. As far as his hypertension goes, he will be continued p.o. Labetalol, Enalapril, and for now the Hydralazine as needed; however, we will attempt to increase Labetalol in order to stop the Hydralazine, and the Clonodine patches are also stopped. The patient is on Klonopin for anxiety, and this should only be weaned very slowly to avoid withdraw if this is necessary. The remainder of the discharge summary will be dictated by the oncoming resident on the patient's discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 658], M.D. [MD Number(1) 659] Dictated By:[Last Name (NamePattern1) 10034] MEDQUIST36 D: [2183-4-1] 09:21 T: [2183-4-1] 10:47 JOB#: [Job Number 54673]	[ "5070", "5990", "51881", "4019" ]
Admission Date: [2133-8-18] Discharge Date: [2133-8-20] Date of Birth: [2133-8-18] Sex: M Service: NEONATOLOGY HISTORY: Baby [Name (NI) ] [Known lastname ] is a term male, who was admitted to the NICU for respiratory distress. His hospital course is most consistent with transient tachypnea of the newborn. Mom is a 29-year-old G3, P1-2 woman with the following prenatal laboratories: O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. Maternal history is significant for [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] disease with clinical bleeding requiring DDAVP in the past. Mom is followed by Dr. [Last Name (STitle) 6160] of Hematology at the [Hospital1 ]. She has had several effected family members including her own mother. Prenatal ultrasound for this infant had revealed the presence of bilateral clubbed feet. There had been prenatal counseling with Dr. [Last Name (STitle) 43562] at [Hospital3 1810] regarding this finding. Delivery was by repeat C-section on [8-18] at 9 a.m. Apgars were 8 and 9. The infant had a large amount of amniotic fluid present, which was suctioned from the oropharynx and stomach. Subsequent to resuscitation, patient was noted to have grunting and flaring, which improved transiently. However, he still was symptomatic when he was intended to move to the Newborn Nursery, and decision was made for an ICU admit. PHYSICAL EXAMINATION ON ADMISSION: Ruddy, pink, AGA male, tachypneic with intermittent grunting and flaring. Vital signs: Stable with a respiratory rate of 78, O2 saturation 68 percent on admission up to 100 percent on O2. Weight 3430, head circumference 36.5. HEENT: Anterior fontanel open and soft. Sutures mobile, no molding. Respiratory: Lungs are clear and equal, mild intermittent grunting with nasal flaring, tachypneic with respiratory rates 80-100. Cardiovascular: Regular, rate, and rhythm, normal S1, S2, no murmur present. Two plus pulses in extremities. Abdomen is nontender, nondistended, soft, and normoactive bowel sounds. GU: Normal male with testes descended bilaterally. Neurologic: Moving all extremities symmetrically. Tone appropriate for gestational age. Extremities: Bilateral equinovarus foot deformity, unable to move feet into neutral position. HOSPITAL COURSE BY SYSTEMS: Respiratory. Baby [Known lastname ] gradually improved in terms of his tachypnea and work of breathing. He came off oxygen approximately 36 hours prior to transfer to the Newborn Nursery. His respiratory rates had declined into the 40s to 60s prior to transfer. Cardiovascular. No issues from a cardiovascular standpoint without evidence of murmur. Fluid, electrolytes, and nutrition. Baby [Known lastname ] was initially NPO with his work of breathing. He started oral feeding approximately 24 hours prior to transfer. At this point, he has been off of IV fluids with adequate feeding and two stable chem sticks (70 and 73). Hematology. An admitting CBC had a hematocrit of 42.7, platelet count of 298. The patient's risk of [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] disease was discussed with the Hematology fellow (Dr. [First Name4 (NamePattern1) 57676] [Last Name (NamePattern1) 57677]). They advised the patient should not be circumcised. They counseled that testing is not always definitive at this age, but could be offered. This issue should be discussed with PMD as an outpatient. ID. Admitting white count 18.3 with a reasonable differential (73 polys and 1 and). Patient received 48 hours of ampicillin and gentamicin with negative cultures. Orthopedics. Patient with known bilateral clubbed feet for which Dr. [Last Name (STitle) 43562] will be casting on [8-20]. Parents have already been meeting with Dr. [Last Name (STitle) 43562] prenatally. Additional plans for long-term care per Orthopedics. FOLLOW UP: PMD is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Phone number is [Telephone/Fax (1) 57678]. DISCHARGE STATUS: Transferred to Newborn Nursery. CONDITION AT THE TIME OF TRANSFER: Stable. DISCHARGE DIAGNOSES: Newborn male. Transient tachypnea of the newborn. Bilateral equinovarus. Rule out sepsis. Maternal history of [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] disease. Reviewed By: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [MD Number(1) 36250] Dictated By:[Last Name (NamePattern1) 57679] MEDQUIST36 D: [2133-8-20] 12:39:19 T: [2133-8-20] 13:10:49 Job#: [Job Number 57680]	[ "V053", "V290" ]
Admission Date: [2122-6-27] Discharge Date: [2122-7-3] Date of Birth: [2044-9-13] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: Abdominal Pain and cough Major Surgical or Invasive Procedure: laparoscopic cholecystectomy History of Present Illness: PCP: [Name Initial (NameIs) 7274]: [Last Name (LF) ],[First Name3 (LF) 275] A./[First Name4 (NamePattern1) 401] [Last Name (NamePattern1) ] PA/ Location: [Hospital ] MEDICAL ASSOCIATES, PC Address: 20 GRANITE STATE COURT, [Location (un) ],[Numeric Identifier 77660] Phone: [Telephone/Fax (1) 27649] Fax: [Telephone/Fax (1) 77661] confirmed by paperwork sent with pt from doctor's visit on the day of presentation. Last saw urgent care PA on [2122-6-26]. Also confirmed pt's doctors with dtr. . Cardiologist Dr. [First Name4 (NamePattern1) 487] [Last Name (NamePattern1) 77662] Pulmonologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3501] The patient is a poor historian in terms of dates and timing so much of the history is obtained from his dtr. His dtr confirms that he does have short term memory deficits. . HPI: 77 year old male sent from [Hospital3 635] hospital with known history of cholelithiasis with recurrent RUQ pain x 1 month which began one month ago, other complicated medical history including CABG, implanted defibrillator, bladder CA s/p urostomy, orthostatic hypotension sent to [Hospital1 18] for CT today showing 9 mm stone in CBD. Of note he was admitted to [Hospital3 ] Hospital on [2122-5-25] for PNA s/p L thoracentesis. He was also having abdominal pain then. An US was performed which demonstrated cholelithiasis but there was no cholecystitis so there was no intervention. He then went to rehab from [5-28] to [6-5]. He improved somewhat but still walking with a wheelchair. He then started home VNA. Two days later he developed nausea with non bloody, bilious emesis. He did not take the last doses of the levaquin because his family was concerned that this might be contributing to his nausea and vomiting. He continued to report RUQ abdominal pain, burping, worse with palpation. Two days PTP his blood pressure was lower than baseline 77/33. The home VNA. His lasix and potassium was held. His BP continued to fluctuate. He remained ill with malaise and worsening abdominal pain. He then went to his PCP-> [Hospital3 ] Hospital -> Hospital. He also reports ongoing cough of productive white sputum. Per his daughter there is no change in his baseline. Pain with deep inspiration. T = 100.9 the night prior to presentation. Tbe patient is unable to identify any ameliorating or triggerin factors. Pain not relived with IV morphine. He reports spasms of sharp pain which lasts seconds. He reports that he has had a cough for a while. He is on 2L of oxygen at home. Per his dtr the pain is worse with eating and there has been no change in his baseline cough. There may have been some improvement since he is on mucinex. . In ER: (Triage Vitals: 19:16 10 98.8 70 135/44 16 96 ) Meds Given: unasyn 3 g IV, morphine 2 mg IV, coreg 3.125 mg po, zocor 20 mg po, advair 250/50 2 puffs INH Fluids given: none at [Hospital1 18] but 500 cc at CCH po intake in ED UOP 300cc Radiology Studies:, consults called: surgery; admit to medicine for ERCP. ERCP aware Vitals 98.7, 71, 125/52, 16, 95% on 2L . PAIN SCALE: [11-8] location: RUQ _______________________________________________________________ REVIEW OF SYSTEMS: as per HPI Past Medical History: Coronary artery disease s/p CABG x [2120-3-31] - s/p defibrillator placed in [2120-3-30] because he developed V-tach s/p ablataion which was not effective - L ventricular anneurysm - H/o hyperlipidemia - H/o malignancy s/p bladder resection for bladder cancer - Orthostatic hypotension choledolithiasis s/p ERCP ?[2120] @ [Hospital1 112] - did not undergo surgery at this time given history of heart disease. Recurrent abd pain since that time. + alcoholic encephalopathy- recovering alcoholic + neuropathy - admitted to [Hospital3 ] Hospital with Klebsiella PNA on [5-25] [2122] s/p L lung thoracentesis Thrombophlebitis of L arm at site of IV during recent rehab stay [2122-5-30] Social History: SOCIAL HISTORY/ FUNCTIONAL STATUS: DNR per conversation with daughter [Name (NI) 2808] - HCP who lives with him. Family contact information: [Name (NI) 2808] [Name (NI) 77663] [Telephone/Fax (1) 77664] cell [Telephone/Fax (1) 77665] [Doctor First Name ] can also answer questions (daughter in law) Cigarettes: 50 pack years, quit [6-/2117], recovering alcoholic 2 drinks/day: Drugs: none Occupation: unemployed Marital Status: Divorced, lives with daughter . Independent of ADLs but dtr helps him put on his socks He walks pushing a wheelchair and he sits down when he is tired. Dtrs does accounting, dtr's partner cooks. [Name2 (NI) ] does not drive. Dentures/hearing aides/eye glasses No recent falls PPD negative Family History: + for coronary artery disease and CVA. Mother died of colon CA Physical Exam: PAIN SCORE: [11-8] VS T = 97.2 P = 65 BP = 146/122-> 120/48 on re-check RR = 20 O2Sat = 91% on 2L GENERAL: Thin male laying in bed. Nourishment: At risk Grooming: OK Mentation: Alert, not delirious but a difficult historian since he cannot clearly tell me when his pain started, what makes it worse, etc. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Decreased breath sounds at the bases b/l Cardiovascular: RRR, nl. S1S2, no M/R/G noted but heart sounds are distant Gastrointestinal: soft, tender in the RUQ with deep palpation. Genitourinary: Periumbilical urostomy bag draining clear yellow urine. No prostate tenderness Guiac negative brown stool Skin: no rashes or lesions noted. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP pulses b/l. L arm more swollen than right. Lymphatics/Heme/Immun: No cervical, lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to do DOWB -cranial nerves: II-XII grossly intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. + urostomy catheter draining clear yellow urine. Site C/D/I Psychiatric: appropriate full affect ACCESS: [X]PIV []CVL site ______ UROSTOMY CATHETER FOLEY: [X]present []none UROSTOMY: :[X]present []none [ ]site C/D/I Pertinent Results: [2122-6-26] 10:28PM COMMENTS-GREEN [2122-6-26] 10:28PM LACTATE-1.0 [2122-6-26] 08:00PM GLUCOSE-97 UREA N-11 CREAT-1.1 SODIUM-135 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-28 ANION GAP-14 [2122-6-26] 08:00PM estGFR-Using this [2122-6-26] 08:00PM ALT(SGPT)-13 AST(SGOT)-29 ALK PHOS-80 TOT BILI-0.7 [2122-6-26] 08:00PM LIPASE-14 [2122-6-26] 08:00PM ALBUMIN-3.3* [2122-6-26] 08:00PM WBC-8.3 RBC-3.87* HGB-12.2* HCT-37.1* MCV-96 MCH-31.6 MCHC-33.0 RDW-15.0 [2122-6-26] 08:00PM NEUTS-84.4* LYMPHS-9.1* MONOS-5.3 EOS-1.0 BASOS-0.2 [2122-6-26] 08:00PM PLT COUNT-160 . ECG: SR at 69 bpm, Q in III and avF, RBBB. No acute changes. LABS: OSH LIpase/Amylase WNL D bili = 0.4 T bili = 1.1 WBC = 9.5 with 84 % PMNS. UA +ve . CXR: CCH Chronic atelectasis of the R lower lung field. Increasing L pleural effusion and LLL atelectasis. . CT SCAN: CCH Moderate amt of sludge filling [2-1] of the GB with a 9 mm stone at the neck. No pericholecystic fluid or GB wall thickening is seen. With addition of contrast there is chronic enhancement similar to previous exam. No son[Name (NI) 493] [Name2 (NI) ] sign. CBD = 9 mm. Impression: Possible obstructing CBD stone. Acute cholecystitis cannot be ruled out. . ERCP [4-/2120] Normal major papilla Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. Cholangiogram showed a mild dilation of CBD and CHD. The cystic duct was filled with contrast. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire to prevent future biliary obstruction. Balloon sweep was performed which did not show stone because of earlier passage of stone. Recommendations: Return to outside hospital under referring physician 's care NPO overnight , then advance diet as tolerated in AM. Consider cholecystectomy No ASA or NSAIDs for 10 days. Follow-up with Dr. [Last Name (STitle) ] Additional notes: The procedure was performed by Dr. [Last Name (STitle) ] and the GI fellow. The patient's reconciled home medication list is appended to this report. . Brief Hospital Course: ASSESSMENT: The patient is a 77 year old male with multiple medical problems including CAD s/p CABG x 2, L ventricular anneurysm, s/p defibrillator placement, COPD on home O2 2L, short term memory deficits, who presented with recurrent abdominal pain and was found to have cholangitis/choledolithiasis. . Cholangitis/choledolithiasis: Patient was started on IV Unasyn. He underwent an ERCP on [2122-6-28] with removal of a 12mm nonobstructing common bile duct stone. There was also noted to be a stone at the cystic duct. He tolerated the procedure well and returned to the floor postop. He continued to have intermittent RUQ pain. The patient also underwent a thorocentesis on [2122-6-30] for his recurrent bloody pleural effusion. Discussions were held with the patient, his family, the medical (primary) service, and the surgical service and the decision was made for laparoscopic cholecystectomy given continued pain and evidence of cholecystitis on imaging combined with his presentation of choledocholithiasis. His medical team felt that no further cardiac testing was required and that he would tolerate surgery. Discussions were held regarding his increased risk of needing to remain intubated postoperatively given his chronic pulmonary issues and the patient agreed to this and a perioperative suspension of his DNR/DNI order. He underwent a lap ccy on [2122-7-1] after evaluation by anesthesia for tolerance to general anesthesia. This was uncomplicated and he tolerated the procedure well. He was extubated postoperatively and his respiratory status was stable, however after IV fluids and pain medications, on POD1 he became SOB and hypoxic w/ O2 sats at 86% on 6L face mask. He was also found to be transiently hypotensive so he was transferred to the ICU for further management. In the ICU his Cxray showed worsening moderate interstitial pulmonary edema and moderate bilateral pleural effusions so he was started on lasix gtt. He was also kept on Unasyn for possible pneumonia. There he was maintained on nonrebreather, but eventually developed hypercarbia. Bipap was tried, but the patient could not tolerate it. He also developed worsening renal failure thought to be due to the hypotension as well as a pan sensative enterococus UTI. After a family meeting, it was decided to transition the patient to comfort measures and he expired soon after. Medications on Admission: Confirmed with dtr on admission protonix 40 mg po qd after breakfast amiodarone 200 mg after breakfast Zocor 20 mg po qd after dinner Coreg 3.125 mg T after dinner on M/W/F MagOx = 400 mg [Hospital1 ] Niferex 150 mg qhs spiriva T qd Florinef 0.1 mg qd after breakfast aspirin 81 mg po qd mucinex 600 mg [Hospital1 ] ibuprofen 600 mg tid prn lasix 20 mg po every other day after breakfast. His last dose was Friday [6-26] B12 q month advair 250/50 [Hospital1 ] proair hFA 2 puff q4 prn O2 2L Potassium 10 MEQ QOD with lasix Vitamin C 500 mg [Hospital1 ] MVT Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: choledocholithiasis cholecystitis respiratory failure Discharge Condition: Expired Discharge Instructions: n/a Followup Instructions: n.a	[ "78552", "0389", "99592", "5849", "486", "5119", "4240", "496", "4168", "2875", "4280", "412", "V4581", "V1582" ]
Admission Date: [2167-5-22] Discharge Date: [2167-6-1] Date of Birth: [2098-1-23] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 30] Chief Complaint: CHEST PAIN AND SHORTNESS-OF-BREATH Major Surgical or Invasive Procedure: -Operative treatment of left intertrochanteric hip fracture with trochanteric femoral nail - PICC line placement History of Present Illness: 64F with uncontrolled DM, HTN, HLD who presents to the ED with chief complaint of chest pain and difficulty breathing. Patient said that she was in her usual state of health until this morning. She was lying on the couch with her granddaughter for about 1.5 hours dozing in and out of sleep when she suddenly woke up by a sense of diffuse chills and shaking. She became very short of breath and then began to have sharp midline chest pain over her sternum that radiated over her right breast. She also had associated nausea without vomiting. She became very concerned and had her daughter call EMD. According to EMS she reported a few days of chest pain and back pain. She was found to have a temp of 101.2 and was hypertensive. EMS reported bilateral rales as well. She was brought to the ED for further evaluation. . The patient denies recent fevers, chills, night sweats, URI symptoms, vomiting, abdominal pain, diarrhea, urinary frequency, dysuria, joints, muscle pains, anxiety or depression. She does say that she has long history of weeping fluid from her RLE. Over the last two weeks, she feels that her RLE has become slowly increasingly eryhematous, painful to touch and warm. This has not occurred on the left. She also feels that it is weeping more than usual. She has a long history of being unable to make it to see her PCP at [Name9 (PRE) ]clinic and has not been there since [2165]. In the ED, initial VS were: 101.2 120 141/110 30 97% 15L Non-Rebreather. Physical exam in the ED (according to signout) - anxious appearing, tachypnic, tachycardic but RR normal S1S2, lungs difficult to assess but no obvious wheezing or rales, bilateral lower extremity edema with weeping on R. Labs significant for a WBC of 11.2 (N:90.4 L:5.7), lactate of 3.1, BNP 118, trop <0.01, CXR showed mild right basilar atelectasis and concern for pleural effusions, given Lasix 20mgx1, Morphine 5mg x1, Vanc/Ceftriaxone/Azithromycin. IVF running slowly for tachycardia. Past Medical History: -Uncontrolled IDDM (last A1C 9.3 on [2-5]) -Hepatitis C (viral load 1,230,000 IU/mL in [2161]) -HTN -T spine compression fractures -H/O exertional dyspnea -Vertigo Social History: Lives with daughter and with her daughter's three children. She is widowed. She does not drink, smoke or use any illicit substances. Former teacher, currently disabled. Family History: No early MI, malignancy. Reports DM in mother. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: BP: 180/69, HR: 120, RR 27, 93% 2L General: Alert, oriented, very agitated and anxious about being in the ICU and not sleeping, welled up in tears that she could not sleep. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP difficult to assess, no LAD CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Difficult to asucultate, but could her faint inspiratory crackles at the bases bilaterally that did not clear with cough Abdomen: large abdomen, soft, non-distended, bowel sounds present, no organomegaly that could be palpated, tenderness to palpation in RLQ and RUQ, no rebound or guarding GU: Foley in place 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. . DISCHARGE PHYSICAL EXAM: Vitals: 98.3 98.3 151/69 [115-155/52-69] 90-111 20 95% RA I/O: 790/950 General: obese elderly F, tearful, appears uncomfortable, lying supine in bed. AAOx1.5 (to person,hospital [but thinks this is [Hospital1 2177]], year but not month/day of week) HEENT: NCAT. MMM. OP clear NECK: Supple; no JVD, LAD or thyromegaly COR: +S1S2, RRR, no m/g/r. PULM: CTAB anteriorly, no w/r/[Initials (NamePattern4) ] [Last Name (NamePattern4) ]: +NABS 4Q, soft, ND, slight TTP in right periumbilical area EXT: L hip bandaged, did not take down. DP pulses 1+ bilaterally. Sensation intact bilaterally. RLE cellulitis has significantly receded from marked borders since admission; +several nonpurulent appearing yellowish crusts on right anterior shin. NEURO: moving all extremities equally. Able to wiggle toes of left foot. Poor flexion/extension of left hip [2-26] pain. Pertinent Results: ADMISSION LABS: -WBC-11.2# RBC-4.48 Hgb-14.5 Hct-46.4 MCV-104 MCH-32.4* MCHC-31.3 RDW-13.4 Plt Ct-143* -Neuts-90.4* Lymphs-5.7* Monos-2.8 Eos-0.7 Baso-0.3 -Glucose-443* UreaN-10 Creat-0.6 Na-136 K-4.5 Cl-101 HCO3-24 AnGap-16 -ALT-37 AST-60* AlkPhos-170* TotBili-0.9 -Calcium-8.5 Phos-2.5* Mg-2.0 -D-Dimer-652* -Lactate-3.1* -URINALYSIS: Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 Blood-SM Nitrite-NEG Protein-100 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG RBC-4* WBC-4 Bacteri-FEW Yeast-NONE Epi-1 . HCT TREND: -[2167-5-22]: 46.4 -[2167-5-23]: 42.6 -[2167-5-24]: 37.3 -[2167-5-25]: 41.2 -[2167-5-26]: 38.4 -[2167-5-27]: 38.0 -[2167-5-28]: 36.1 -[2167-5-29]: 34.1 -[2167-5-30]: 33.8 -[2167-5-31]: 31.1 -[2167-6-1]: 31.6 . ANEMIA WORKUP: - B12: 914* (high) - Folate: 11.4 - Iron: 28* (low, normal is 30-160) - TIBC 267, Ferritin 85, Transferrin 205 . DISCHARGE LABS -WBC-6.0 RBC-3.04* Hgb-9.9* Hct-31.6* MCV-104* MCH-32.5* MCHC-31.2 RDW-15.1 Plt Ct-306 -Glucose-134* UreaN-34* Creat-0.7 Na-144 K-4.2 Cl-112* HCO3-28 AnGap-8 . MICROBIOLOGY: - BCx ([5-22]): 2/2 bottles group B strep, pan-sensitive to antibiotics - BCx ([5-23], final): negative - BCx ([5-24], final): negative - BCx ([5-26], pending): no growth to date - HCV viral load ([2167-5-29]): pending . CHEST X-RAY ([2167-5-22]): A small hazy opacification at the right base most consistent with atelectasis. No other consolidations are present. There is no pleural effusion or pneumothorax. There is no pulmonary edema. Mild-to-moderate enlargement of the cardiac silhouette is unchanged from the prior exams. IMPRESSION: 1. Mild right basilar atelectasis. 2. No acute cardiopulmonary process. . CTA CHEST ([2167-5-22]): No nodules are seen in the unenhanced thyroid gland. The thoracic aorta is normal in caliber without evidence of intramural hematoma or dissection. Pulmonary arterial vasculature is visualized to the subsegmental level without filling defect to suggest pulmonary embolism. There is no axillary or hilar lymphadenopathy. A top normal size precarinal lymph node measures 1.0 cm in short axis, previously 1.2 cm on [2166-4-25] (3:18). The heart is enlarged with moderate coronary artery calcifications. The pericardium and three-vessel takeoff are within normal limits aside. There is no pericardial effusion. A trace right pleural effusion is seen. No left effusion. Evaluation of the lung fields is limited by motion artifact, particularly at the lung bases. There is right basilar atelectasis adjacent to the effusion. Mild left basilar dependent atelectasis. There is no worrisome nodule, mass or consolidation. Airways are patent to the subsegmental levels bilaterally. This study is not tailored for subdiaphragmatic evaluation. The visualized portions of the liver, spleen, and kidneys are unremarkable. Again seen is a right adrenal lesion measuring 2.9 x 3.2 cm, previously 2.7 x 2.9 cm, with attenuation of 5 [Doctor Last Name ], compatible with an adenoma.Soft tissue in the left hypochondrium represents the patients known spelnorenal shunt. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. Compression deformities in the mid thoracic spine are unchanged from [2166-4-25]. IMPRESSION: 1. No acute aortic pathology or pulmonary embolism. 2. Left adrenal adenoma is slightly increased in size from [2166-4-25]. . AP/LATERAL HIP X-RAY ([2167-5-26]): There is a comminuted intertrochanteric fracture of left proximal femur, with slight varus angulation. There is a separate lesser tuberosity component. There is an equivocal additional greater tuberosity component. The hip joint itself is obscured by overlying soft tissues and underpenetration. . LEFT LOWER EXTREMITY FLOUROSCOPY ([2167-5-26]): Fluoroscopic images of the left hip from the operating room demonstrates interval placement of a short intramedullary rod with distal interlocking screw and proximal pin. There is also a minimally displaced lesser trochanter fracture fragment. The total intraservice fluoroscopic time was 178.9 seconds. Please refer to the operative note for additional details. Brief Hospital Course: 64 yo F with poorly controlled IDDM, HTN, HLD p/w chest pain and difficulty breathing, found to have GBS bacteremia and RLE cellulitis, with course c/b left hip communuted intertrochanteric fracture and anemia. . # GROUP B STREP BACTEREMIA [2-26] RLE CELLULITIS: Patient was febrile with mild leukocytosis and left shift on admission; WBC increased to max of >20K/mL within 24 hours of admission. Exam was notable for prominent nonpurulent RLE cellulitis and marked BLE and dusky appearance, suggesting that an underlying chronic venous stasis could have contributed to development of cellulitis. Patient empirically started on Vancomycin in ED. BCx from [2167-5-22] subsequently grew pan-sensitive Group B strep, and patient was narrowed to Ceftriaxone 2mg IV q12 hours to complete a total two week course (last day [2167-6-9]). Repeat blood cultures on [5-2] and [5-26] all returned negative. . # DYSPNEA/HYPOXEMIA: On presentation to ED, patient was initially tachypneic and hypoxemic with O2 sat 94% on 3L. Acuity of her respiratory symptoms (along with presence of sinus tach not responsive to IV fluids) was concerning for PE, dissection, or myocardial ischemia but CTA chest, chest x-ray, EKG and cardiac enzymes were all reassuring. She briefly required NRB in ED so was subsequently admitted to ICU and started on standing nebs. O2 was rapidly weaned and she was called out to the regular medical floor the next morning. After this her O2 sats remained stable in high 90s on room air throughout rest of hospitalization. Ipratropium/albuterol standing nebs were continued during hospitalization. She will continue albuterol PRN on discharge. . #.COMMINUTED INTERTROCHANTERIC LEFT FEMORAL FRACTURE: On [2167-5-27] patient suffered a mechanical fall and was found to have comminuted intertrochanteric left femoral fracture. She had uncomplicated surgical repair by Orthopedic Surgery on [5-27] with placement of left trochanteric femoral nail. Pain management was provided with IV dilaudid, then tapered to PO oxycodone. She continued to report poor pain control although per her daughter she has extremely low threshold for pain and did report severe pain even before fracturing her hip. On discharge she is prescribed oxycontin 10mg PO q12 hours and oxycodone 5mg PO q4 hrs PRN breakthrough pain, as well as standing Tylenol 1000mg PO q8 hrs. For DVT prophylaxis she was started on Lovenox 30mg SC q12 hours, to be continued for a total of 4 weeks. She will follow up with Orthopedics for repeat x-rays, suture removal and examination on [2167-6-9]. . # DM2/HYPERGLYCEMIA: Patient has uncontrolled IDDM; last A1c 9.3 in 1/[2167]. Blood glucose was in 400's on admission. UA showed proteinuria (100) and glucosuria (1000), likely representing early diabetic nephropathy. She was started on her home Lantus 33units qAM as well as insulin sliding scale, which are to be continued on discharge to rehab. She will need follow-up insulin regimen monitoring/diabetes education by PCP/home VNA. . # HEPATITIS C: In [2161], viral load was 1,230,000 IU/mL. HCV viral load was rechecked during this hospitalization and is pending upon discharge. . # HYPERTENSION: Normotensive on admission. Continued lisinopril 30mg PO Daily. . # VERTIGO: Asymptomatic throughout hospitalization. Continued home meclizine 12.5mg PO q6 hrs PRN dizziness. . # LEFT EYE BLINDNESS: reported by patient and family on admission; has not seen an ophthalmologist. Significant cataract apparent on exam. She will need outpatient ophthalmology f/u for this issue. . =================== TRANSITION OF CARE: -Please check CBC on [2167-6-3] (pt HCT trended down to ~31 after hip fracture secondary to hip and abdominal hematomas) -Please F/U HCV viral load Medications on Admission: - Lantus 100 unit/mL Sub-Q 33 units once a day - aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth DAILY (Daily) - lisinopril 30 mg Tab 1 Tablet(s) by mouth DAILY (Daily) - meclizine 12.5 mg Tab 1 Tablet(s) by mouth every six (6) hours as needed for dizziness Discharge Medications: 1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 7 days. Disp:42 Tablet(s) Refills:0 2. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet Extended Release 12 hr(s) Refills:0 3. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous every twelve (12) hours for 9 days: First day = [2167-5-27] Last day = [2167-6-9]. 4. insulin glargine 100 unit/mL Solution Sig: Thirty Three (33) units Subcutaneous qAM. 5. 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. 6. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 3 weeks. Disp:42 syringes Refills:0 10. 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. 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 19. Outpatient Lab Work Please check CBC on [2167-6-3]. 20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 21. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous qAC,HS: please dose according to enclosed sliding scale. Discharge Disposition: Extended Care Facility: [Hospital ] rehab Discharge Diagnosis: PRIMARY DIAGNOSIS: - Right leg cellulitis - Group B Strep bacteremia SECONDARY DIAGNOSIS: - Comminuted intertrochanteric fracture of left femur (from fall during hospitalization) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure participating in your care at [Hospital1 771]. You were admitted to the hospital for fever and shortness of breath. You were found to have bacteria growing in your blood (probably caused by an infection of your right leg), so you were admitted to the ICU for close monitoring and IV antibiotics. . Your symptoms improved greatly with antibiotics, but unfortunately you then had a fall in the hospital and broke your left hip. The hip fracture was repaired by orthopedic surgery. . Please attend your follow-up appointment with Orthopedic Surgery listed below. They will perform x-rays, examine your leg and remove the stitches placed during surgery. . We made the following changes to your medications: 1. STARTED oxycontin 10mg by mouth every 12 hours 2. STARTED oxycodone 5mg by mouth every 4 hours as needed for breakthrough pain 3. STARTED enoxaparin (lovenox) 30mg subcutaneous every 12 hours for four (4) weeks 4. STARTED tylenol 1000mg every 8 hours 5. STARTED Ceftriaxone 2 grams every 12 hours for two weeks (first day = [2167-5-27], last day = [2167-6-9]) 6. STARTED docusate (Colace) 100mg by mouth twice daily for constipation until no longer taking oxycodone/oxycontin 7. STARTED senna one tab twice daily for constipation until no longer taking oxycodone/oxycontin 8. STARTED bisacodyl and polyethylene glycol (Miralax) daily as needed for constipation 9. STARTED calcium 500mg by mouth three times daily 10. STARTED vitamin D 800mg by mouth daily 11. STARTED Sarna lotion four times daily as needed for itching 12. STARTED albuterol nebulizer every 6 hours as needed for wheezing/shortness of breath Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [2167-6-9] at 10:40 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2167-6-9] at 11:00 AM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital 9380] CLINIC When: TUESDAY [2167-6-23] at 4:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "496", "V5867", "4019", "2724" ]
Admission Date: [2184-3-11] Discharge Date: [2184-3-16] Date of Birth: [2116-9-7] Sex: F Service: MEDICINE Allergies: Ranitidine / Prilosec / Aciphex / Paxil / Celexa / Prozac / Zoloft / Cimetidine / Zestril / Lasix / Atenolol / Cozaar / Celebrex / Reglan / Norvasc / Nexium / Carafate / Metoprolol / Doxycycline / Hydrochlorothiazide / Triamterene Attending:[First Name3 (LF) 1936] Chief Complaint: transfer for bilateral pulmonary embolism Major Surgical or Invasive Procedure: none History of Present Illness: 67 y/o F with PMHx of Esophageal Dysmotility and Raynauds who presented to an OSH with fatigue x 3wks found to have NSTEMI and hypoxia. At the OSH CE were positive (CPK 95 CK mb 10.3 trop I 0.68 ). She was loaded with plavix, given ASA, ativan, lopressor, nitro paste and started on a heparin GTT (7500 bolus, 1450 u/hr). The ECG at the OSH showed sinus tachycardia. She was transferred to [Hospital1 ] for further care. In the [Hospital1 18] ED, initial vs were: T 98.7 P 103 BP 130/75 RR 24 O2 sat 89 RA. She underwent a CTA to eval for PE, given hypoxia and tachycardia which revealed bilateral large PE's. The ECG here showed sinus tach with non-specific TWF. She received 1L NS and the heparin GTT was continued. 3 weeks ago the pt. received cortisone injections for back pain. Since that time she has not felt well. She has experienced flushing and "elevated BP. Last tuesday she had CP and took SL NTG and ASA with good result. She went to [Hospital ] hospital, where ECG and CE were nromal per pt. She was sent home but still had CP and DOE while climbing stairs. She also reports palpitations. She again had chest pain this last Saturday and presented to [Hospital1 18]. CE were normal and the ECG was normal. She underwent [Initials (NamePattern4) ] [Last Name (NamePattern4) 4001] protocol on Sunday which did not show any ischemic changes. Her symptoms were thought to be due to GI issues. She underwent an endoscopy on [2184-3-10]. Per the pt. her 02 sat after the procedure was 89% on RA. That night, she had a pre-syncopal event at home and felt "she was dying." EMS was called and she presented to [Hospital ] hospital as above. . current vitals in ED 113/52, 98, 94% 3.5L, rr 20 . Review of sytems: She reports right calf pain since Sunday. She has felt unwell for the past 3 weeks. + URI symptoms- productive cough. poor appetite for 3 weeks. 17lbs weight loss over 3 weeks. CP, palps, DOE, SOB, fatigue as in HPI. denies F/C/NS. no diarrhea, abd pain, N/v, hemetemasis, BRBPR. Past Medical History: Hypertension Raynauds Esophageal Dysmotility Syndrome Fibromyalgia Arthritic Symptoms Social History: She is married, does not smoke cigarettes or drink alcohol. 2 children. Family History: Son with h/o 2 PE's (has a PAI-1 mutation). 2 sisters with clotting hx (1- DVT, 1- ?retinial thromobosis). Brother- MI at 68. 2 brothers with CA (esophageal CA, lymphoma) Physical Exam: Vitals: T: 96.6 BP: 124/67 P: 98 R: 18 O2: 94% on 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: bilateral rales at bases L>R CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. slight right calf tenderness Pertinent Results: Labs: Trop-T: 0.15 CK: 106 MB: 10 MBI: 9.4 . 137 102 11 BS 144 AGap=18 --------------- 4.4 21 0.7 . WBC 12.2 Hgb 14.3 Hct 40.5 Plts 241 N:76.4 L:19.9 M:2.6 E:0.7 Bas:0.3 . PT: 13.0 PTT: 22.9 INR: 1.1 . Images: CTA [2184-3-11] Prelim- large bilateral PE's, small hiatal hernia, thyroid nodule. recommend ultrasound on non-emergent basis stable left lower lobe pulmonary nodule. ETT [2184-3-7] INTERPRETATION: This 67 yo woman with uncontrolled HTN was referred for evaluation of chest pain. The patient performed 7 minutes of [Initials (NamePattern4) ] [Last Name (NamePattern4) 4001] protocol ~3.8 METs and stopped for an exaggerated BP response and fatigue. This represents a limited exercise tolerance. The patient presented with 3/10 left upper chest "pressure", however before exercise, she denied this symptom. No other symptoms were reported throughout the procedure. In the presence of baseline non-specific ST-T waves, there were no significant changes at peak exercise. Rhythm was sinus without ectopy. Heart rate response to exercise was appropriate. IMPRESSION: Limited exercise tolerance. Exaggerated resting and exercise BP. Non-anginal symptom with no significant EKG changes from baseline. . EKG: rate 108 NSR, normal axis, q waves in III, aVF (new since [2184-3-7]), low voltage in pre-cordial leads INDICATION: 67-year-old female with shortness of breath since endoscopy yesterday with troponin bump at outside hospital. Evaluate for pulmonary embolus. COMPARISON: [2176-5-9]. TECHNIQUE: Non-contrast and contrast-enhanced MDCT acquired axial images of the chest from the thoracic inlet to the upper abdomen. Multiplanar reformatted images were obtained. FINDINGS: Large filling defects in the bilateral main pulmonary arteries extending into the segmental branches are compatible with pulmonary embolus. The thoracic aorta maintains a normal caliber and contour. The main pulnoary artery diameter equals that of the aorta, indicating dialation. The heart size is normal. There is dilatation of the right ventricle compared to the left with RV/LV ratio of 54:38 = 1.4 (normal 0.9) indicating right ventricular strain. There is no pleural or pericardial effusion. The lungs show diffuse hypoventilatory change . 12 mm pulmonary nodule in the left lung base which is unchanged since the [2176-5-9]. The airways are patent to the subsegmental level however there is collapse of the airway on these apparent expiratory images suggestive of tracheobronchomalacia. There is no mediastinal or axillary lymphadenopathy. The visualized upper abdomen is notable for a 2- cm cyst in the interpolar region of the right kidney. Hypodense nodules are identified in each lobe of the thyroid for which further evaluation with ultrasound is recommended on a non-emergent basis. A small hiatal hernia is present. The bones show no lesions worrisome for osseous metastases. IMPRESSION: 1. Large bilateral PEs with evidence of right ventricular strain. 2. Stable left lower lobe pulmonary nodule. 3. Bilateral hypodense nodule in the thyroid gland for which further evaluation with ultrasound is recommended on a non-emergent basis. 4. Small hiatal hernia. 5. Collapse of the airways on apparent expiratory images is suggestive of underlying tracheobronchoalmalacia. STUDY: Bilateral lower extremity veins ultrasound. INDICATION: Bilateral pulmonary embolism and lower extremity pain. FINDINGS: Grayscale, color and pulse Doppler son[Name (NI) 867] was performed on bilateral common femoral, superficial femoral and popliteal veins. Normal flow, compression, augmentation and waveforms are demonstrated. No intraluminal thrombus detected. IMPRESSION: No lower extremity DVT identified. Provisional Findings Impression: [Name (NI) 25790] FRI [2184-3-12] 9:35 AM Slightly limited examination of the lower common iliac seen secondary to patient body habitus. No definite evidence of intraluminal thrombus within the visualized venous system of the abdomen and pelvis. 2.3 cm right renal lesion, not completely characterized. Followup characterization by ultrasound or MRI is advised. PFI AUDIT # 1 [First Name9 (NamePattern2) 25790] [Doctor First Name ] [2184-3-11] 7:49 PM Slightly limited examination of the lower common iliac seen secondary to patient body habitus. No definite evidence of intraluminal thrombus within the visualized venous system of the abdomen and pelvis. Right renal lesion, definitely demonstrate to be a cyst by CT. Followup characterization by ultrasound or MRI is advised. Preliminary Report !! PFI !! Slightly limited examination of the lower common iliac seen secondary to patient body habitus. No definite evidence of intraluminal thrombus within the visualized venous system of the abdomen and pelvis. 2.3 cm right renal lesion, not completely characterized. Followup characterization by ultrasound or MRI is advised. . Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Increased IVC diameter (>2.1cm) with <35% decrease during respiration (estimated RA pressure (10-20mmHg). LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). No resting LVOT gradient. RIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV free wall hypokinesis. Abnormal septal motion/position consistent with RV pressure/volume overload. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Short (<140ms) transmitral E-wave decel time. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: The patient appears to be in sinus rhythm. Resting tachycardia (HR>100bpm). Conclusions The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate to severe pulmonary artery systolic hypertension (given elevated RA pressures). There is no pericardial effusion. IMPRESSION: Dilated and hypokinetic right ventricle. Preserved global and regional left ventricular systolic function. Moderate to severe pulmonary hypertension. Moderate pulmonary hypertension. Brief Hospital Course: (1) Bilateral Pulmonary Embolisms: While in the MICU she was treated with Hep gtt and started on warfarin. Her O2 sats gradually improved and her tachycardia resolved. She was transitioned to lovenox [Hospital1 ] and coumadin. Daily INR's were checked with a goal of [3-9]. At discharge her INR was 2.3 and she did not require further bridging with lovenox. She will continue lifelong coumadin treatment. Her INR will be checked at local lab and the results will be faxed to her PCP who will titrate her coumadin dosing as appropriate. -With strong FH of clots and no strong initiating factor for PE, we were concerned for a genetic hypercoagulability work-up. We sent hypercoagulability studies including Factor V Leiden, prothrombin mutation analysis, Plasminogen Activator Inhibitor-1 Activity, homocysteine, anti-cardiolipin, lupus anticoagulant. Some of these tests are still pending and will be followed up by her primary care physician. (2) Right heart failure: She had severe RV failure as well as moderate pulmonary hypertension. This is likely the result of the PE's causing increased stress on the right ventricle. Initially it was thought that she had had an NSTEMI, however, the troponin leak was likely secondary to dilation of RV and NSTEMI medications, including plavix, were discontinued. She will have a follow up appointment in the department of cardiology for a repeat echo to monitor her recovery. She was started on an ACE-I for cardiac protection as well as for slightly elevated BPs (140s), however she developed a cough and thus was switched to [First Name8 (NamePattern2) ] [Last Name (un) ]. (3) Sinus tachycardia: Likely secondary to PE's. Responded well to IVF boluses. (4) Renal cysts? : CT revealed renal lesion that was suspicious for more than just a simple cyst. As per radiology recommendations, performed renal ultrasound to evaluate lesion which confirmed that this was just a simple cyst. (5) Esophageal dysmotility: With reynauld's, there was a question of whether the patient could have scleroderma which may have contributed to hypercoagulability as well. Labs were sent to evaluate for scleroderma and are pending at time of discharge. She was continued on her home management for esophageal dysphagia and her pcp will follow up the results of the scleroderma labs. (6) HTN: Stable throughout admit. (7) Weight loss: 14-17 lb weight loss during last 3 weeks. Had a Pan-CT scan for malignancy given the PEs. This was negative. Patient is up to date on all cancer screening except her yearly mammogram which she missed because her husband was [Name2 (NI) ]. Breast exam was WNL, however the patient will need to schedule a mammogram to be performed after she is discharged from the hospital. She is aware of this and will do this upon discharge. (8) Thyroid Nodules: Patient had CT scan that showed thyroid nodules. It is recommended that she follow up with a thyroid ultrasound to characterize these nodules. Her PCP will arrange for this after discharge. Medications on Admission: Alprazolam Prevacid Discharge Medications: 1. Outpatient Lab Work Please have INR check 2 days after discharge and again 2 days later. Please have results faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8522] (fax: [Telephone/Fax (1) 25791]). She will adjust the dose of your blood thinner, warfarin, accordingly. 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 3. Alprazolam 0.25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day) as needed. 4. Enoxaparin 100 mg/mL Syringe [Last Name (STitle) ]: One (1) injection Subcutaneous Q12H (every 12 hours). Disp:10 injection Refills:2 5. Warfarin 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 6. Valsartan 80 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily) as needed for HTN. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA, [Hospital1 1559] Discharge Diagnosis: Bilateral Pulmonary Emboli Discharge Condition: The patient was afebrile, hemodynamically stable, and not requiring oxygen prior to discharge. Discharge Instructions: You were admitted to the hospital with blood clots in your lungs. We think you got these clots because you have a gene that makes your blood thicker than normal. You were treated with a blood thinner (warfarin) and will need to stay on this blood thinner for the rest of your life. You will need to have your blood drawn to monitor the levels of this medication. Many other medications can change the levels of the blood thinner so if you start a new medication you will need to let your PCP know so that they can change the dose of your blood thinner. Also, when you had your ct scan we found some nodules in your thyroid gland. This is a common finding and usually benign, however, we would like you to have a followup thyroid ultrasound to make sure. Medication Changes: START: Warfarin 5mg by mouth daily START: Valsartan 80mg by mouth daily Please come back to the hospital or call your doctor if you have fainting, headaches, vision changes, difficulty speaking, shortness of breath, chest pain, palpitations, bloody or black stools, weakness of your arms or legs, pain in your legs or any other concerning symptoms. Followup Instructions: Please follow up with the cardiologist, Dr. [First Name (STitle) 437] ([Telephone/Fax (1) 62]), on Wednesday [2184-3-31] at 9am. He is located on the [Location (un) 436] of the [Hospital Ward Name 23] building at [Hospital3 ] Hospital. He will review the ultrasound of your heart and give you appointments for another ultrasound to monitor your heart's recovery. Please follow up with your primary care doctor, [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 8522], ([Telephone/Fax (1) 8577]) on [2184-3-23] at 1:45. She will check your warfarin level and adjust your dose accordingly. Please have your blood drawn to check your warfarin levels 2 days after discharge using the prescription we have provided for you. Please have the lab fax these results to Dr.[Name (NI) 25792] office ([Telephone/Fax (1) 25791]). She will call you to tell you how much of the blood thinner (warfarin) to take after she gets these results. Completed by:[2184-3-16]	[ "4019", "53081", "4168", "4280", "42789" ]
Admission Date: [2133-2-18] Discharge Date: [2133-2-23] Date of Birth: [2087-2-4] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 14964] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD, SVG->[Last Name (LF) 11641], [First Name3 (LF) ]) [2133-2-18] History of Present Illness: 45 y/o male with no known CAD who experienced chest pain while shoveling snow. Went to OSH and had ST elevations. He was hypotensive there, so was begun on dopamine and medflighted to [Hospital1 18] for cath. At cath, he was noted to have an RCA occlusion s/p PCI with 2 cypher stents. He had a 60% LMCA, 95% prox LCx, 80% [Hospital1 11641] intermedius which were not intervened upon. He was placed on the IABP b/c of the prox Cx lesion and his RCA stent. Pt. improved and was d/c'd home and now returns for an elective CABG. Past Medical History: CAD s/p MI and stents to RCA [2133-2-10] h/o A. Fib post-cath h/o Lymphoma '[15] s/p chemo/XRT GERD ADHD s/p R. knee arthroscopy Social History: Denies smoking (occ. cigar), ETOH, and recreational drug use. Family History: Non-contributory Physical Exam: T 97.5 P 89 R 20 BP 120/65 General: NAD Heart: RRR Lungs: CTAB Abd: Soft NT/ND, +BS Neuro: A&O x 3 Ext: -c/c/e Pertinent Results: [2133-2-18] 05:11PM BLOOD Hct-35.9* [2133-2-23] 08:50AM BLOOD WBC-6.4 RBC-3.33* Hgb-10.9* Hct-30.7* MCV-92 MCH-32.7* MCHC-35.5* RDW-12.9 Plt Ct-224# [2133-2-18] 12:42PM BLOOD PT-16.2* PTT-31.5 INR(PT)-1.7 [2133-2-18] 12:42PM BLOOD Plt Ct-150 [2133-2-23] 08:50AM BLOOD Plt Ct-224# [2133-2-18] 02:05PM BLOOD UreaN-12 Creat-0.7 Cl-113* HCO3-26 [2133-2-19] 03:45AM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-139 K-4.0 Cl-108 HCO3-27 AnGap-8 [2133-2-23] 08:50AM BLOOD Glucose-115* UreaN-11 Creat-0.7 Na-140 K-4.0 Cl-102 HCO3-29 AnGap-13 Brief Hospital Course: Pt. was a direct admit for a CABG, following an MI s/p RCA stents x 2 approx. 1 wk. ago. He was brought to the OR and underwent a coronray artery bypass graft x 3. Please see operative note for full surgical details. Pt. tolerated the procedure well and had total CPB of 61min and XCT of 43min. Pt. was transferred to the CSRU in stable condition with a MAP 83, CVP 6, PAD 8, [Doctor First Name 1052] 12, HR 80 NSR and being titrated on a propofol drip. Later that day propofol was weaned, pt. became awake and he was extubated and breathing on his own, neurologically intact. POD #1 - Pt. was receving neo for bp support. b-blocker and diuretic started. POD #2 - Neo weaned off. Chest tubes removed. Pt. appeared stable and was transferred to floor. POD #3 - Foley removed. Voiding well. no events POD #4 - Pt. continues to improve well. slight temp of 100.8, otherwise vs stable. PE unremarkable. Pt. cont. to get OOB with increased mobility. D/C pacing wires. POD #5 - Pt. doing very well with uncompicated post-op course. VS stable and pt. was D/C'd home today with VNA. D/C PE: T 69.9 P 86 BP 106/62 RR 18 Neuro: alert, oriented, non-focal Pulm: CTAB Cardiac: RRR Sternum: -erythema/drainage Abd: soft, NT/ND +BS Ext: Inc. C/D, warm w/ 1+ edema Medications on Admission: [Last Name (LF) ], [First Name3 (LF) ], Lipitor, Protonix, Toprol 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Fluvoxamine Maleate 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)): 100 mg at bedtime. Disp:90 Tablet(s) Refills:0 8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Coronary artery disease, s/p CABGx3(LIMA->LAD, SVG->[Last Name (LF) 11641], [First Name3 (LF) ]) [2133-2-18] s/p MI and stents to RCA [2133-2-10] h/o A. Fib post-cath h/o Lymphoma '[15] s/p chemo/XRT GERD ADHD s/p R. knee arthroscopy Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) ] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) 70] for 6 weeks. Completed by:[2133-3-9]	[ "41401", "53081" ]
Admission Date: [2181-10-15] Discharge Date: [2181-10-17] Date of Birth: [2181-10-15] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: This infant was born at 35-5/7 weeks' gestation and admitted to the NICU for respiratory distress. ANTENATAL HISTORY: Mother is a 27-year-old, G2P1 woman with prenatal screens of blood type A+, antibody negative, rubella immune, RPR nonreactive, GBS unknown. [Last Name (un) ] of [2181-11-13]. She has a past history of Crohn's disease for the last 6 years and is on Remicade therapy. She has had prior flare-ups of rectal abscesses needing drainage. She also has had a history of migraines and a breast cyst. Her pregnancy was uncomplicated apart from hyperemesis. Fetal survey was normal with the last ultrasound scan on [2181-10-1], showing normal BPP with fetal growth. She has had 1 previous cesarean section and she proceeded for repeat elective cesarean section on the day of delivery. At delivery the infant was born as by elective cesarean section due to previous cesarean section. Infant cried at birth and was vigorous and active, required no resuscitation other than blow-by oxygen. Apgar scores were 8 and 9 at one and five minutes. She was taken to the NICU due to prematurity. PHYSICAL EXAMINATION AT BIRTH: Birth weight of 3200 g which is 90th percentile, head circumference of 34.5 cm which is 90th percentile, length of 47 cm which is 50th percentile. Physical exam at birth showed pink and well-perfused infant with some grunting. HEENT showed normocephalic, anterior fontanel level sutures normal, no dysmorphic features, ankyloglossia tongue tie, intact clavicles, neck supple, bilateral red reflexes. Respiratory: Grunting with mild subcostal retractions. Cardiovascular: Pink, well perfused, normal S1 and S2, no murmur. Abdomen soft, nondistended, no masses. Genitalia: Prominent clitoris with normal limits for gestation. Anus patent. Hips and extremities normal. Neurologic intact. Normal tone. Handles well. HOSPITAL COURSE: 1. Respiratory: The infant was briefly on nasal prong CPAP and weaned to room air shortly after birth. The infant has remained stable in room air since that time. The infant has had no apneic or bradycardiac episodes. 2. Cardiovascular: The infant has maintained cardiovascular stability while in the NICU with normal heart rates and blood pressures. No murmur has been auscultated. 3. Fluid, electrolytes and nutrition: Due to respiratory distress on admission to the NICU, the infant was started on IV fluids and made NPO at that time. Initial D-stick was 42 which resolved with IV fluids to a normal range. The infant was started on enteral feedings on [2181-10-16]. IV fluids were Hep-Locked in the early a.m. of [2181-10-17]. The infant is presently ad lib p.o. feeding by breast or supplementing with E20 ad lib. D-sticks are stable. The infant is voiding and stooling normally. No electrolytes have been measured on this infant. The most recent weight is 3070 grams. 4. GI: Bilirubin will be drawn on day of life 3 with a state screen. 5. Hematology: Hematocrit at birth was 49.9 with a platelet count of 300. No further hematocrits or platelets have been measured. The infant has had no blood typing done and has required no blood product transfusions. 6. Infectious disease: CBC and blood culture were screened on admission to the NICU due to the respiratory distress. CBC was benign. The infant was started on ampicillin and gentamicin for 48-hour rule out pending blood cultures and clinical status. 7. Neurology: The infant has maintained a normal neurologic exam for gestational age. 8. Sensory: Audiology: A hearing screen will need to be performed prior to discharge to home. It has not been done thus far. 9. Psychosocial: A [Hospital6 256] social worker has been in contact with the family. There are no active issues at this time, but if there are any concerns, she can be reached at [Telephone/Fax (1) 8717]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to the newborn nursery. PRIMARY CARE PEDIATRICIAN: [First Name4 (NamePattern1) 1692] [Last Name (NamePattern1) 45269] from [Hospital 1426] Pediatrics, telephone #[Telephone/Fax (1) 37802]. CARE RECOMMENDATIONS: Ad lib p.o. feeding by breast with supplementation of E20 ad lib as needed. MEDICATIONS: None. IRON AND VITAMIN D SUPPLEMENTATION: 1. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. 2. All infants that receive predominantly breast milk should receive vitamin D supplementation at 200 international units which may be provided as multivitamin preparation daily until 12 months corrected age. CAR SEAT POSITION SCREENING: Recommended prior to discharge to home. Has not been done thus far. STATE NEWBORN SCREEN: Will need to be sent on day of life 3 with a bilirubin level. Has not been done thus far. IMMUNIZATIONS RECEIVED: The infant has not received any immunizations thus far. Hepatitis B vaccine has not been signed by the parents yet. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 4 criteria: 1) born less than 32 weeks' gestation, 2) born between 32 and 35 weeks' gestation with 2 of the following: Either day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, 3) chronic lung disease, or 4) hemodynamically significant congenital heart defect. 2. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. 3. This infant has not received the Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. FOLLOW-UP: Follow-up appointment is recommended with the pediatrician after discharge from the hospital. DISCHARGE DIAGNOSIS: 1. Late preterm infant born at 35-5/7 weeks' gestation. 2. Sepsis, ruled out. 3. Transitional respiratory distress, resolved. 4. Hypoglycemia, resolved. [Name6 (MD) ] [Last Name (NamePattern4) ], [MD Number(1) 55472] Dictated By:[Name8 (MD) 62299] MEDQUIST36 D: [2181-10-17] 00:15:24 T: [2181-10-17] 09:53:29 Job#: [Job Number 75259]	[ "V053" ]
Admission Date: [2118-2-2] Discharge Date: [2118-2-4] Service: MEDICINE Allergies: Levaquin Attending:[First Name3 (LF) 3326] Chief Complaint: Neck mass Major Surgical or Invasive Procedure: none History of Present Illness: 81 y.o. woman with recent neck trauma, now on ventilator, presents with right neck mass noted at [Hospital3 ]. The mass was noted yesterday and noted to bulge out during cough or Valsalva. There was concern for a tracheo-subcutaneous fistula so she was sent to ED for evaluation. A neck CT did not show evidence of subc air. It was concerning for either jugular vein dilatation or a mass in the supraclavicular fossa. However, further characterization could not be made based on a non-contrast CT so further imaging would be required. Pt is otherwise at her baseline. There are no acute resp issues and she is hemodynamically stable. She denies pain or dyspnea. Past Medical History: 1) s/p fall with neck trauma 2) central cord syndrome 3) Respiratory failure secondary to cord involvement with psuedomonas, serratia and MRSA VAP. 4) HTN 5) Asthma 6) CAD s/o CABG, PAF 7) s/p thyroidectomy in teens 8) s/p hysterectomy Social History: No history of tobacco or recent EtOH. Did not obtain history on former occupation. Currently resides at [Hospital3 ]. Has multiple children involved in care. Family History: Non-contributory Physical Exam: Gen arousable, responsive to commands, communicates nonverbally, in NAD HEENT NCAT, PERRL, anicteric. OP clear with dry MM. Neck: 5x2cm area above right clavicle that bulges with straining, no fluctuance, crepitus, erythema, tenderness, palpable mass. Lungs coarse BS b/l CV: RRR, nml S1S2, 3/6 systolic murmur. Abd: G-tube. soft, NT, ND, naBS Ext: no edema, warm/well perfused. Neuro: moves both upper extrem minimally to command, does not move LE to command (chronic) Pertinent Results: [2118-2-2] 02:23AM WBC-15.2* RBC-3.03# HGB-9.8# HCT-28.0* MCV-92# PLT COUNT-480* NEUTS-82.9* LYMPHS-9.9* MONOS-3.5 EOS-3.6 BASOS-0.2 . GLUCOSE-98 UREA N-41* CREAT-0.7 SODIUM-137 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-28 ANION GAP-11 . PT-12.5 PTT-23.2 INR(PT)-1.0 . Neck CT: 1. There is no air within the subcutaneous tissues of the right supraclavicular fossa to suggest a tracheal subcutaneous fistula. There is likely an enlarged right internal jugular vein v. a mass in the supraclavicular fossa on the right, though IV contrast could not be administered for confirmation. This finding could be confirmed with ultrasound. 2. Small lymph nodes within the neck and superior mediastinum. 3. Heavily calcified aorta. 4. Intralobular septal thickening and possible scarring at the lung apices. 5. Status post anterior fixation of the cervical spine. . Ultrasound: Right supraclavicular lesion represents the bulb of the right internal jugular vein. Brief Hospital Course: 81 y.o. woman with recent neck trauma, now on ventilator without failure to wean, presenting with new neck deformity. Pt is asymptomatic, and there does not appear to be any compromise of airway or circulation. .. 1) Neck Mass: Imaging findings were consistent with a dilatation/aneurysm of the R internal jugular vein. Vascular surgery evaluated the patient and determined no need for intervention at this time. They recommended a repeat ultrasound to evaluate the mass in 1 week. They also suggested a CT with venous phase contrast in 1 week to evaluate for any progression of the aneurysm. .. 2) Respiratory Failure: Pt has reportedly not been able to be weaned at [Hospital1 ]. We continued her on current vent settings and did not attempt further weaning. She was stable on her current vent settings. .. 3) Ventilator associated pneumonia: She is on meropenem, colistin, and linezolid, which we contined as at rehab. She had a low-grade fever on arrival here, but otherwise showed no evidence of active infection and was afebrile thereafter. Antibiotics should be continued for the planned course (linezolid to be continued until [2-9], meropenem until [2-10], and colistin until [2-7], per the medication list from [Hospital1 ]). .. 4) CAD: We continued lopressor at her usual dose. It is not clear why she is not on ASA. .. 5) Asthma: Continue spiriva, salmeterol, albuterol, and flovent. We held her mucomyst. . 6) F/E/N: Tube feeds were continued. Electrolytes were repleted as needed. .. 7) PPx: SC heparin for DVT ppx and PPI. Medications on Admission: Linezolid 600mg [Hospital1 ] Meropenem 1g q8h Diflucan 400mg qd (to complete [2-3]) Digoxin 125mcg every other day Lopressor 12.5 mg PO q6h Spiriva Flovent 220 2 puffs [Hospital1 ] Albuterol prn Mucomyst nebs Ativan Prevacid Neurontin 300mg tid Questran 4g tid Fragmin 5000U daily Discharge Medications: 1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 2. Digoxin 50 mcg/mL Elixir Sig: 0.125 mg PO EVERY OTHER DAY (Every Other Day). 3. Bacitracin Zinc Topical 4. Feosol 220 mg/5mL Elixir Sig: Three [Age over 90 ]y Five (325) mg PO once a day. 5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 6. Xenaderm Ointment Topical 7. Foradil Aerolizer 12 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation twice a day. 8. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 9. Proventil 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 10. Mycostatin 100,000 unit/g Powder Sig: One (1) application Topical twice a day. 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO q2h as needed for agitation. 13. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 15. Fragmin 5,000 anti-Xa u/0.2mL Syringe Sig: 5000 (5000) units Subcutaneous once a day. 16. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO TID (3 times a day). 17. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: 10-15 MLs Mucous membrane [Hospital1 ] (2 times a day). 18. Citracal 950 mg Tablet Sig: Two (2) Tablet PO q8h (). 19. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 20. Acetaminophen 500 mg/5 mL Liquid Sig: Six [Age over 90 1230]y (650) mg PO every four (4) hours as needed for fever or pain. 21. Meropenem 1 g Recon Soln Sig: 1000 (1000) mg Intravenous Q8H (every 8 hours) for 7 days: End date is 12/2905. 22. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days: End date is [2118-2-9]. 23. Colistimethate Sodium 150 mg Recon Soln Sig: One (1) Recon Soln Injection [Hospital1 ] (2 times a day) for 4 days: End date is [2118-2-7]. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: right internal jugular aneurysm Discharge Condition: stable Discharge Instructions: 1. For new or concerning symptoms, please call your doctor or return to the emergency room for evaluation. 2. Please continue all medications as prescribed, we have not made any changes to your medications. 3. You will need a repeat ultrasound to evaluate your neck mass in about 1 week. A CT with venous phase contrast in 1 week may also be useful to evaluate the extent of the mass. Followup Instructions: Please obtain repeat ultrasound of neck mass in 1 week. CT with venous phase contrast in 1 week may also be useful.	[ "486", "42731", "2859", "V4581", "49390", "4019" ]
Admission Date: [2105-11-20] Discharge Date: [2105-11-27] Date of Birth: [2030-11-10] Sex: M Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: This is a 75 year-old male with a history of multiple myeloma on thalidomide who was found in the field having generalized tonic clonic seizures for 20 minutes. There was no family to provide history at this time. He was given 4 mg of Ativan at the scene which broke his generalized activity. He was still observed to have bilateral abdominal convulsions and was then given 2 more mg of Ativan. At this time, around 7:35 A.M. he arrived at the [Hospital1 69] emergency department and neurology was called. On initial observation he was unresponsive to verbal and noxious stimuli and was noticed to rhythmic abdominal contractions. He also had a mild right eye deviation. He was immediately started on phenytoin and 500 mg was infused over ten minutes. To expedite the infusion the remaining 500 mg was infused as Cerebryx. After the Dilantin load his gaze was in primary position and there were no longer any abdominal contractions. Stat laboratories and blood cultures were drawn. The patient was started on ceftriaxone after an initial rectal temperature of 102.5 was confirmed. Pertinent history from the prior notes: "his treatment initially included radiation to an L2 plasmacytoma, as well as a full course of Melphalan and prednisone completed on [2104-4-1]. Since that time he was treated with pulse dexamethasone for approximately 11 months through the end of [8-29]. His treatments also included Aranesp every two weeks and Zometa every three weeks. At his last clinic visit we did change Mr. [Known lastname 13927] therapy from pulse dexamethasone to thalidomide at 100 mg daily. This was due to the fact that Mr. [Known lastname ] had been on dexamethasone for almost one year. Prior to switching therapy a repeat bone marrow biopsy was done on [2105-8-4] which revealed a hypercellular marrow with involvement of known plasma cell myeloma as well as decreased iron stores. There was no evidence of dyspoiesis. Mr. [Known lastname ] took approximately 19 days of thalidomide at 100 mg daily. Since the thalidomide was started e was then started on Ritalin for the side effects of slowness due to the thalidomide. PAST MEDICAL HISTORY: B12 deficiency with a peripheral neuropathy, prostate cancer, PSA was 6.5 in [7-28], conservative treatment was undertaken, peptic ulcer disease, esophagogastroduodenoscopy consistent with gastritis, multiple myeloma as above, hypertension and status post appendectomy. MEDICATIONS: Iron 325 mg daily, Zoloft 50 mg daily, vitamin B12 2,000 mcg daily Roxicet p.r.n., folic acid 1 mg daily, ranitidine 250 mg b.i.d., thalidomide 100 mg q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is widowed but is quite independent in has activities of daily living and lives with his family. PHYSICAL EXAMINATION: Initially the patient was unarousable and unresponsive to verbal and tactile stimulus. By the time of discharge the patient was sitting up, alert, awake and answering questions appropriately following simple commands. Had no motor deficit, was without pronator drift and otherwise has intact coordination. LABORATORY STUDIES: The white count on [11-26] was 6.6, hematocrit 33.3, the hematocrit has ranged from 25.6 to 33 throughout the hospital course. Platelet count 425, INR 1.0. Urinalysis has been negative On [11-25]. However, it was positive on [11-21]. The patient received [Doctor Last Name ] days of Bactrim. Cerebrospinal fluid: white count 0, red count 0. Liver function tests: ALT 9, AST 27, alk phos 66, amylase 78, total bilirubin 0.6, troponin less than .01. Vitamin B12 919. The phenytoin level on [11-27] was 16.6. Initial tox screen was negative. Total protein in the cerebrospinal fluid 20, glucose 80. Urine cultures were no growth. MRSA screens were negative. Blood cultures were no growth. Cerebrospinal fluid gram stain and culture. The gram stain was negative. The culture was contaminated with coagulase negative staphylococcus, cryptococcal antigen negative, fungal culture negative, viral cultures negative. Head CT showed no hemorrhage, only some atrophy and old infract. MRI of the head showed evidence of small vessel disease, no acute infarct or abnormal enhancement. The video swallow on [2105-11-25] showed no evidence of aspiration or penetration. Cytology of the cerebrospinal fluid was negative for malignant cells. EEG consistent with severe encephalopathy or extensive bilateral subcortical disease. Beta activity likely represents intercurrent medication effects. This can be seen with benzodiazepines or barbiturates. No evidence of ongoing seizure at this time. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit for seizures. He was initially intubated and his Dilantin level was titrated up to about 15. He remained intubated for a couple of days until he self extubated. He did well after this point and went to the floor. Once on the floor he did remain somewhat lethargic with phenytoin level of 20 to 21 as well as urinary tract infection. The urinary tract infection was treated. He completed a course of three days of Bactrim. The Dilantin dose was decreased to 250 b.i.d. and 100 t.i.d. to 100 t.i.d. The patient began to be more alert and on discharge was nearly at his baseline. However, his family noted that he did seem to be still somewhat more lethargic than usual. He was discharged to [Location 13928] in good condition on [2105-11-27]. His medication are Metoprolol 75 mg p.o. b.i.d., thiamin 100 mg p.o. q.d., vitamin B12 2,000 mcg p.o. q.d., ferrous sulfate 325 mg p.o. q.d., multivitamin 1 capsule p.o. q.d., folic acid 1 mg p.o. q.d., Phenytoin 100 mg p.o. t.i.d., flumotidine 20 mg p.o. b.i.d. The patient will follow up in neurology clinic with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268], M.D. [MD Number(1) 4269] Dictated By:[Last Name (NamePattern1) 10034] MEDQUIST36 D: [2105-11-27] 13:51 T: [2105-11-27] 15:03 JOB#: [Job Number 13929]	[ "5990", "4019" ]
Admission Date: [2141-1-13] Discharge Date: [2141-1-15] Date of Birth: [2061-4-25] Sex: M Service: MEDICINE Allergies: Ampicillin / Levaquin / Vicodin / Rituximab Attending:[First Name3 (LF) 6473] Chief Complaint: hypoxia, fatigue Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Mr. [Known lastname ] is a 79 yo gentleman with a history of ESRD on HD, restrictive/interstitial lung disease on home 2LNC, untreated CLL, RCC s/p nephrectomy, prostate cancer, bladder cancer who was sent to the ED from outpatient follow up appointment for hypoxia. . Of note, he was recently admitted from [Date range (1) 98353]/08 for hyperkalemia after missing HD due to a clotted AV fistula. He was intially treated medically for hyperkalemia and then admitted to the MICU. Surgery tried to remove clot from fistula unsuccessfully and fistula was converted to graft. Tunnelled R IJ HD catheter placed intraoperatively and he received HD. O2 requirement was at patient's baseline after HD. While in ICU, he was found to have UTI with culture showing >100,000 colonies of lactobacillus and alpha hemolytic strep. He completed 5 days of ceftriaxone. . He is typically receiving HD on T/Th/Sat but due to the holiday this week, received HD Mon/Wed, and was due to restart regular HD schedule on Sat. He presented to an outpt surgery appointment to have sutures removed from his new LUE AV graft. At that time, he was found to be hypoxic to low 80s on baseline 2LNC. O2 sats improved to low 90s on 3-5L NC by report. Patient noted significant fatigue x 3-4 days but otherwise denies any chest pain, SOB, N/V, fevers, chills, or any other complaints. He was transferred to the ED for further evaluation. . Upon arrival to the ED, afebrile, hemodynamically stable, SBP 110s-120s, HR 70s. RR 26 and patient appeared to have increased WOB although he denied any subjective SOB. O2 sats on arrival 74% on RA, 87-88% 30-40% ventimask, low 90s on 45% ventimask. RR 24-26. Labs significant for WBC 98, Hct 30 at recent baseline, BUN/Cr 32/5.1. CXR showed pulmonary edema. . In the ICU, patient appears comfortable. He notes 3-4 days of fatigue, wanting to do nothing besides sleep. He denies any fevers, chills, nightsweats, myalgias, SOB, chest pain, nausea, vomiting, diarrhea, or constipation. He does note pain at his AVG site but otherwise denies pain. He notes increased urination yesterday with ~ [4-23] voids. He typically makes minimal urine. He denies dysuria. He notes chronic cough productive of clear phlegm but denies any recent change in this. Patient also reports that in Surgery clinic today, there was concern that his AVG was infected and he was called in a prescription for keflex 250 mg [Hospital1 ]. Past Medical History: # restrictive/interstitial lung disease on 2L NC at home # ESRD on HD, initiated [8-26], T/Th/Sat at [Location (un) ] HD # Hypertension # Hypothyroidism # CLL -diagnosed [2131], BL WBC 90s-100s in last 2 years - partially treated with rituximab, initiated [9-26] after admission for CHF # hypogammaglobulinemia - likely [2-20] rituximab # RCC s/p R nephrectomy [2131] # Bladder CA x 2 - s/p chemo [2134] # prostate cancer in situ - s/p XRT [2132] - s/p transurethral resection [5-/2140] # Recurrent diverticulitis # Depression # irritable bowel syndrome # s/p ccy # s/p appendectomy Social History: Lives in [Location ], MA alone. Divorced. 2 children. Has girlfriend. Retired buyer at Staples office supply. Occ EtOH. Quit smoking cigarettes 30 years ago, but smoked 2 pks/day x 15 years. Smokes marijuana, no other illicit drugs. No IVDU Family History: Grandmother - breast CA age <50, Mother - died at 85 from stroke, Father - died at 75 from encephalitis, Brother - died at 31 from suicide Physical Exam: Initial Physical Exam AF, 135/81, 74, 22, 91% 45% ventimask Cannot appreciate JVP R IJ tunnelled line CDI RRR. III/VI sys murmur Crackles at bases distended abd. soft, NT LUE fistula with palpable thrill, TTP inferior to AVG site. No overlying erythema or drainage 1+ LE edema B. Full distal pulses Pertinent Results: [2141-1-13] 01:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-NORMAL NEUTS-3* BANDS-0 LYMPHS-94* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 WBC-98.5* RBC-3.23* HGB-10.1* HCT-30.1* MCV-93 MCH-31.3 MCHC-33.6 RDW-17.7* PLT COUNT-126* TSH-2.8 CK-MB-NotDone cTropnT-0.06* CK(CPK)-22* GLUCOSE-103 UREA N-32* CREAT-5.1# SODIUM-136 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-28 ANION GAP-11 LACTATE-0.7 [2141-1-13] 04:39PM PT-15.1 PTT-32.2 INR(PT)-1.3* IgG-298* ALBUMIN-4.1 cTropnT-0.06* ALT(SGPT)-8 AST(SGOT)-21 LD(LDH)-233 CK(CPK)-19* ALK PHOS-134* TOT BILI-0.6 CHEST (PORTABLE AP) Study Date of [2141-1-13] 1:38 PM IMPRESSION: Mild congestive heart failure. CHEST (PORTABLE AP) Study Date of [2141-1-13] 6:38 PM IMPRESSION: Previously seen pulmonary edema has improved. UNILAT UP EXT VEINS US LEFT PORT Study Date of [2141-1-13] 9:11 PM IMPRESSION: Son[Name (NI) 493] characteristics of the 1.9 cm subcutaneous fluid collection are more consistent with postoperative seroma than abscess, though infection cannot be completely excluded. Brief Hospital Course: 79 yo gentleman with a history of ESRD on HD, restrictive/interstitial lung disease on home 2LNC, untreated CLL, RCC s/p nephrectomy, prostate cancer, bladder cancer who was sent to the ED from outpatient follow up appointment for hypoxia. . # Hypoxia/Pulmonary Edema: Felt to be due to volume overload with change in HD schedule +/- dietary indiscretion. Pt had no symptoms of cardiac ischemia and No fever or other symptoms to suggest infectious etiology. No symptoms to suggest flu. He underwent HD with removal of ~4L of fluid with a prompt response in oxygenation and improvement on repeat chest x-ray. . # fatigue: Felt to be due to hypoxia on presentation. TSH was normal and blood cultures were without growth at the time of discharge. Over his brief hospital course, the patient's fatigue mildly improved and the patient reported being near his baseline. . # ESRD: As above, the patient underwent a session of HD during his hospitalization and was scheduled of a repeat session as an outpaient on Monday [1-16]. # AV Fistula: The patient had a right AV graft which was noted to be swollen. An ultrasound was obtained which was suggestive of a seroma but abcess could not be ruled out. The patient was given several doses of vancomycin for concern of infection, but it was learned that he was already prescribed a course of cephalexin for his graft as an outpatient. His home antibiotic regimen was reinitiated and the patient was discharged with instructions to complete his previously intended course. # Hypertension: Blood pressure medications were initally held on admission but reinitiated prior to discharge. # CLL/Hypogammaglobulinemia: WBC 96k on admission and IgG of 298, both of which were consistant with previously documented results. No interventions were made and the patient should follow-up with his hematologist as previously planned. # Hypothyroidism: The patient was continued on his home levothyroxine. . # Depression: The patient was continued on citalopram. . # IBS: Continued dicyclomine. Medications on Admission: ALBUTEROL 2 puffs every six hours as needed for wheezing ALLOPURINOL 100 mg each day AMLODIPINE 5 mg once a day NEPHROCAPS once a day BUDESONIDE 2 puffs inhaled [Hospital1 ] CITALOPRAM 40 mg daily DICYCLOMINE 10 mg QID EPOETIN ALFA LEVOTHYROXINE 88 mcg daily OMEPRAZOLE 20 mg daily TERAZOSIN 10 mg qhs TIOTROPIUM BROMIDE 18 mcg daily ERGOCALCIFEROL IRON Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 5. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 7 days. 6. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation q6hours:PRN. 12. Budesonide 180 mcg/Inhalation Aerosol Powdr Breath Activated Sig: Two (2) Inhalation twice a day. 13. Epoetin Alfa Injection 14. Ergocalciferol (Vitamin D2) Oral Discharge Disposition: Home Discharge Diagnosis: Pulmonary Edema HD dependent End stage renal disease Discharge Condition: The patient was hemodynamically stable, afebrile and without pain at the time of discharge. Discharge Instructions: You were admitted for evaluation and treatment of shortness of breath. It is felt that your symptoms were due to the recent change in your dialysis schedule. Durining this hospitalization, you underwent dialysis and your symptoms improved. You should attend an outpatient dialysis session tomorrow at your normal dialysis center. No changes were made to you medications. Please continue to take all previously prescribed medications (Including your recent antibiotic) as directed. Please call your doctor or seek medical attention if you develop worsening shortness of breath, cough, fevers, chills, nausea, vomiting, pain or redness over your fisula/gaft site or any other symptoms of concern. Followup Instructions: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2141-2-14] 9:40 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 3688] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2141-2-14] 10:00 Completed by:[2141-1-16]	[ "40391", "2449" ]
Admission Date: [2145-3-18] Discharge Date: [2145-3-23] Service: NEUROLOGY CHIEF COMPLAINT: Right-sided weakness and inability to speak. HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old, right-handed man, with a history of atrial fibrillation, hypertension, and history of Barrett's esophagitis in [2142], who came home late from work today and was with his wife eating supper when at 7:15 p.m., he suddenly stood up and stumbled. She noted that his right face was drooping. He was unable to talk and had a right-sided weakness. She immediately called 911, and he was brought to the [Hospital6 1760] Emergency Department. PAST MEDICAL HISTORY: 1. Atrial fibrillation on Coumadin. 2. Hypertension. 3. Barrett's esophagitis in [2142]. 4. Right hemicolectomy in [2141] for a large edematous polyp. 5. Hemorrhoids with guaiac positive stool. 6. Prostate cancer status post radiation therapy 5-7 years ago. REVIEW OF SYSTEMS: There were no recent illnesses per family. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Norvasc, Atenolol, Protonix, Cozaar. SOCIAL HISTORY: The patient's smokes four cigars a week. He does not drink alcohol or use drugs. He is married and owns a construction firm. FAMILY HISTORY: Brother with atrial fibrillation. PHYSICAL EXAMINATION: Vital signs: The patient was afebrile, blood pressure 161/97, pulse 70-80. General: He was an aphasic man with right hemiplegia. Neck: Supple. Without carotid bruits. Cardiovascular: Irregular, irregular rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. Extremities: No edema or rashes. Neurological: He was awake and alert. He was globally aphasic with no verbal output. He has a right hemifacial neglect. He localized with pain on the left but not on the right. He followed no commands. On cranial nerve exam his disk were flat and sharp. There were no hemorrhages on funduscopic exam. He blinked to threat bilaterally. Pupils equal, round and reactive to light. He had a fixed left gaze. He was unable to bring the eyes past midline. He had a right upper motor neuron pattern facial droop. Tongue was symmetric. Palate elevated symmetrically. On motor exam he moved the left side with good strength but followed no commands. His right side was completely immobile, but the tone was elevated in the right leg. On sensory exam he localized to pain on the left. With nail bed pressure on the right, he winces and then looked for a source on his left. On reflex exam, he was 2 out of 4 in the triceps, biceps, and patellar reflexes bilaterally. He was 1 out of 4 in the brachial, radialis and Achilles reflex bilaterally. Toes were upgoing on the left, downgoing on the right. Coordination and gait exam could not be tested. LABORATORY DATA: On admission stool was guaiac positive. Sodium 140, potassium 4.1, chloride 105, bicarb 27, BUN 23, creatinine 1.3, glucose 178, CK 154, MB 8, troponin less than 0.01, calcium 10.2, magnesium 1.9, phosphate 2.7; ALT 34, alkaline phosphatase 145, total bilirubin 0.9, albumin 4.3, AST 30, LDH 261, amylase 68, lipase 41, osmolality 300; white count 5.7, hematocrit 42.6, platelet count 185; INR 1.2, PTT 28.1, PT 13.7. Noncontrast head CT showed no hemorrhage or mass affect. There was a left MCA hyperdense sign with a bright spot that may represent initial emboli. HOSPITAL COURSE: 1. Neurology: Right MCA CVA status post TPA: The patient received intra-arterial TPA and was then admitted to the Intensive Care Unit for monitoring. After administration of TPA, he regained full strength on the right side of his body; however, he remained globally aphasic with minimal comprehension to things such as, "what is your name." He was had decreased verbal output and was able to write one-word lines. He also regained the ability to have full extraocular eye movements with more attention to his right side. He was then put on Heparin and Coumadin for an INR of [1-12]. Although his lipid panel was normal with a cholesterol of 163, triglyceride of 117, and HDL of 61, and LDL of 79, he was started on low-dose statin. Echocardiogram of the heart was done showing no evidence of clot or PFO, but there was a mildly dilated left atrium. Carotid ultrasounds were done showing no stenosis in the carotid arteries bilaterally. During the hospital course, he was also put on a regular Insulin sliding scale to prevent any hyperglycemia that may be toxic to injured neurons. 2. Cardiovascular/atrial fibrillation: Given his atrial fibrillation, he was put on low-dose beta-blocker to control his rate. He was also then anticoagulated given his history of atrial fibrillation and now a stroke. 3. Rheumatology/gout: He had some pain of the right first metatarsal and right ankle. The family reported that he has a history of gout and has taken Colchicine in the past. Uric acid was checked and found to be elevated at 8.8, so he was started on Colchicine for pain. DISCHARGE DIAGNOSIS: 1. Right MCA cerebrovascular infarction, status post TPA administration. 2. Atrial fibrillation. 3. Gout. DISCHARGE MEDICATIONS: Heparin drip to be discontinued after INR reaches 2, Coumadin 2.5 mg p.o. q.h.s., Lipitor 10 mg p.o. q.d., Lopressor 25 mg p.o. t.i.d., Colchicine 0.6 mg p.o. b.i.d. x 3 days, Prevacid 30 mg p.o. q.d. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To a rehabilitation center. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 12114] Dictated By:[Last Name (NamePattern1) 4270] MEDQUIST36 D: [2145-3-22] 20:15 T: [2145-3-22] 20:19 JOB#: [Job Number 105726]	[ "42731", "4019" ]
Admission Date: [2146-12-6] Discharge Date: [2146-12-10] Date of Birth: [2068-9-23] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1899] Chief Complaint: Cardiogenic shock Major Surgical or Invasive Procedure: -proctocolectomy -Tracheal intubation -cardiac catheterization [2146-12-6]: thrombotic LAD stent with no flow, and thrombotic Cx stent with TIMI 3 flow. Received Export to LAD and CX and POBA to both. RFA Perclose History of Present Illness: Mr. [Known lastname ] is a 78 year-old man with CAD s/p PCI w/ BMS to LAD and LCx on [2146-11-4] with a recent diagnosis of colorectal cancer with plan for bowel resection today. However, he developed cardiac arrest during surgery requiring defibrillation and subsequently found to have ST elevations on EKG. Patient had apparently stopped both plavix and aspirin on [11-30] prior to his surgery today. Per report, patient became hypotensive on pressors with MAP in 40s and tachycardic to 120s after prone jackknife positioning. Rhythm was identified as ventricular tachycardia. He was flipped back supine and got CPR for ~10 minutes, including Epi, Vasopressin, Atropine, a shock for transient VF, and a femoral CVL, with return of pulse and pressure. ABG immediately after was 7.24/36/391/16 w/lactate 7.2. He was transferred to [Hospital Unit Name 153] where TEE showed global LV hypokinesis and a normal RV, while the rhythm strip showed large ST elevations anteriorly. Troponins were greater than recordable. He was put on a heparin gtt and amiodarone bolus and was brought to the cath lab emergently on afternoon of [2146-12-6]. . In cath lab was found to have thrombotic LAD stent with no flow, and thrombotic Cx stent with TIMI 3 flow. Received Export to LAD and CX and POBA to both. RFA Perclose. He received a Heparin bolus and Plavix load in the cath lab and a Swan-Ganz was placed. His heparin ggt was turned off and he returned to the OR to complete proctocoletomy with open perineum and diverting ileostomy. He was transferred to the trauma SICU post-operatively and was cooled via Artic Sun protocol, and has since been rewarmed. Also has received 2 units PRCs on [2146-12-7] for HCT of 29, and 1 dose of vanc/zosyn for post-op ppx. . Today he was noted to be dropping his pressures, so returned to cath lab to have balloon pump placed and angiogram which confirmed patency of vessels. Upon transfer to ICU, he is on levophed ggt, neo ggt, milrinone and vasopressin ggt. He is also on fentanyl/versed ggt's for sedation. He is anuric with a Cr of 2.7 (baseline 0.9). Renal is following. Past Medical History: 1. CARDIAC RISK FACTORS: Hyperlipidemia 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: -[2146-11-4]: Cath revealing two vessel coronary artery disease. With successful PTCA/stenting of the mid LAD with BMS and the proximal LCx with BMS -[2146-12-6]: Cath revealing thrombosis of both stents s/p export with POBA - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -GERD -Colorectal Cancer- s/p chemo Xrt in [2146-7-20] Social History: He lives in [Location 620] with is partner who is [Name8 (MD) ] RN. He is a former smoker and smoked one pack per week for approximately [9-7] years. This calculates out to a four-pack-year smoking history. He has formerly drunk a few cocktails a day but has cut back to one glass of wine at night. He is independent in his activities of daily living and has no difficulties with walking. He formerly owned a small construction business and retired within the last year. Family History: He has three brothers and a sister, all of whom are healthy. His brother is status post a CABG. Physical Exam: GENERAL: Intubated/sedated. Responding to command by squeezing fingers HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVP elevated to ear lobe lying flat 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: On vent, coarse BS anteriorly ABDOMEN: Soft, Laparoscopic incisions c/d/i. Bowel in ostomy looks brown today. No output right now. No tenderness illicited Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Cool extremeties. 1+ DP/PT pulses. Right groin catheter site c/d/i SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ADMISSION LABS: . [2146-12-6] 12:52PM BLOOD WBC-10.8# RBC-3.23* Hgb-10.9* Hct-33.3* MCV-103* MCH-33.9* MCHC-32.8 RDW-13.3 Plt Ct-199 [2146-12-6] 06:40PM BLOOD PT-14.9* PTT-77.0* INR(PT)-1.3* [2146-12-6] 12:52PM BLOOD Glucose-261* UreaN-18 Creat-1.4* Na-138 K-5.1 Cl-105 HCO3-19* AnGap-19 [2146-12-7] 03:19PM BLOOD ALT-3942* AST-5276* LD(LDH)-5784* CK(CPK)-7255* AlkPhos-46 TotBili-1.5 [2146-12-6] 12:52PM BLOOD Calcium-8.4 Phos-6.7* Mg-2.4 . CARDIAC ENZYMES . [2146-12-7] 03:19PM BLOOD CK-MB-GREATER TH cTropnT-GREATER TH [2146-12-8] 05:47AM BLOOD CK-MB-305* MB Indx-7.6* cTropnT-GREATER TH [2146-12-8] 10:52AM BLOOD CK-MB-184* MB Indx-5.5 [2146-12-8] 03:55PM BLOOD CK-MB-137* MB Indx-5.3 [2146-12-9] 04:53AM BLOOD CK-MB-58* MB Indx-4.9 [2146-12-10] 05:00AM BLOOD CK-MB-17* MB Indx-3.7 cTropnT-GREATER TH . STUDIES: . CARDIAC CATH [12-6]: COMMENTS: 1. Stent thrombosis of CX and LAD stents. 2. Successful 2 vessel thrombectomy and balloon only angioplasty. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Primary angioplasty to LAD and Cx. . ECHO [12-6]: LEFT ATRIUM: Mild LA enlargement. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severely depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function. Cannot assess regional RV systolic function. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Aortic valve not well seen. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed with near global LV severe hypokinesis/akinesis; the basal septum and basal lateral wall have relatively preserved function (overall LVEF= ~15-20 %). Right ventricular chamber size is normal with grossly normal free wall contractility. The mitral valve leaflets are mildly thickened. The aortic valve is not well visualized. EKG [12-6]: Probable sinus rhythm at upper limits of normal rate. P-R interval prolongation. Fusion of the P wave with the prior T wave. There is a single wide complex beat, probably ventricular. Low limb lead voltage. There is an intraventricular conduction delay of left bundle-branch block type with prominent inferior and lateral ST segment elevation. Since the previous tracing of [2146-11-5] the rate is faster. The axis is more vertical. QRS complex is wider. ST-T wave abnormalities are new. Clinical correlation is suggested. . ECHO [12-8]: Overall left ventricular systolic function is severely depressed (LVEF= 20 %). There is focal hypokinesis of the apical free wall of the right ventricle. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion Brief Hospital Course: 78 yo male with CAD s/p LAD/LCx BMS in [10/2146] presenting with STEMI in setting of stopping asa/plavix prior to colorectal surgery, s/p cardiac arrest on table, on IABP, pressors, CVVH. Of note, the patient had no meaningful improvement and serial family meetings were held. Aware of the poor prognosis and believing that the current maximal supportive care including pressors, mechanical intubation, and IABP would not meet the patient's wishes, family decided to withdraw support and pt was taken of pressors, balloon pump, and was extubated. He expired shortly there after at 16:03 on [12-10] . # STEMI: Pt initially presenting for elective proctocolectomy for locally invasive colorectal cancer. Pt noted to go into Vtach on the operating table and subsequently found to have STEMI. Of note, pt undwerwent successful PTCA/stenting of the mid LAD with BMS and the proximal LCx with BMS in [2146-11-4], now presenting with thrombosis of the stents likely in the setting of stopping his asa/plavix prior to colorectal surgery. Underwent successful 2 vessel thrombectomy and balloon only angioplasty. Echo showing EF 15-20% with severely depressed LV function. IABP placed to augment coronary filling. ECG showing q waves and low voltages indicating extensive non-recoverable myocardial injury. He was maintained on asa, plavix and heparin ggt which was changed to argatroban for conern of HIT. Despite interventions, pt continued to be cardiogenic shock as below. . # Shock: Pt with echo showing severely depressed LV systolic function with EF 15-20% in setting of STEMI. Pt initially on milrinone, neo, levophed, and vasopressin. He was weaned off levophed, but continued on milrinone, neosynephrine, and vasopressin throughout admission. He was also started on vanc/zosyn for possible septic component. He was in multiorgan failure with LFTs in the 5000s and Cr peaking at 5.1. He was started on CVVH, but pt was unable to be weaned successfuly from pressors or the balloon pump, and prognosis was discussed with family who understood that recovery was unlikely. The decision was eventually made to wean the pressors, d/c the balloon pump, and extubate on [12-10]. Pt expired shortly after at 16:03. . # Ectopy: Pt noted to have frequent multifocal PVCs on tele overnight [12-6] and was subsequently started on amio ggt. Continued to have ectopy throughout admission and was continued on amio until support was weaned . # [Last Name (un) ]: Cr peaking at 5.1 and actually improved to 3.4 in setting of CVVH. However continued to be in multiorgan failure unable to wean from pressors. Likely [Last Name (un) ] from cardiogenic shock # Transaminitis: LFTs peaking in the 3000-5000 range, likely shock liver. They started to downtrend throughout admission. . # Anemia: Pt received a total of 7 U PRBC over admission including intraoperatively with a goal ~30. He continued to ooze from his perineum surgical site likely explaining his anemia. DIC was considered but ruled out with fibrinogen and FDPs. . # S/p Colectomy for colorectal surgery: Pt s/p proctocolectomy with open perineum and diverting ileostomy. Standard post-op care was maintained. Of note, pt with significant oozing from open perineum likely contributing to anemia Medications on Admission: Ferrous sulfate 325 mg p.o. b.i.d. Plavix 75mg Ranitidine 300mg Nitroglycerin 0.4mg Simvastatin 20mg Aspirin Discharge Medications: EXPIRED Discharge Disposition: Expired Discharge Diagnosis: EXPIRED Discharge Condition: EXPIRED Discharge Instructions: EXPIRED Followup Instructions: EXPIRED [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 1905]	[ "41071", "5845", "9971", "4280", "41401", "V4582", "2875", "2724", "53081", "2859" ]
Admission Date: [2175-6-8] Discharge Date: [2175-6-20] Date of Birth: [2103-2-19] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: fall Major Surgical or Invasive Procedure: Craniotomy with evacuation of SDH History of Present Illness: HPI: Mr. [Known lastname ] is a 72 y/o [Location 7979] male with a past medical history significant for hypertension who presents with left sided weakness. The patient speaks no english, but his daughter ([Name (NI) 36547]) acted as a translator. Over the last week the patient has noticed progressive left lower extremity weakness. This was significantly worse early this morning resulting in gait difficulty. He is now completely unable to walk without leaning on furniture. His left arm was also weak for the first time this morning. The patient's daughter also felt that there was a subtle new assymtry to the patient's face. The patient also reported that over the last two weeks he has fallen twice. He also fell 2 months ago out of bed - striking his head. Only during the event 2 months ago did he suffer head trauma. They did not go to the hospital after this event. The daughter noted he has been less interactive over the past 2 months. Head CT in [Hospital1 18] ED shows 2 cm right frontal-parietal chronic subdural hematoma with approximately 12 mm of midline shift. Past Medical History: Hypertension Peripheral neuropathy/persistent burning of his feet especially at night. GERD Low Back Pain Cataracts bilaterally Social History: Returned from [Country 3587] 3 weeks ago. Lives with wife and daughter. Retired [Name2 (NI) 36548]. Has 6 children. Non-smoker. No ETOH. No Drugs. Family History: non-contributory Physical Exam: Physical Exam(On admission): Vitals: T:97.5 P:62 R:16 BP:158/80 SaO2:100%RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [2-6] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-10] throughout except 4+/5 left deltoid and 4+/5 left iliopsoas. Profound left pronator drift present Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: Head CT Pre-op([6-8] 1:11am): There is a large right extra-axial collection along the right cerebral convexity with mixed attenuation. There are mixed hyper and hypoattenuated components. Effacement of the subjacent sulci is noted with the greatest width measuring 2.2 cm. There is 1.3 cm leftward midline shift and minor effacement of the ipsilateral perimesencephalic cistern is concerning for early uncal herniation. The extracalvarial soft tissues are within normal limits. No fractures are detected in the osseous structures. The visualized paranasal sinuses and mastoid air cells are clear. Head CT post-surgery([6-9] 9:43am): Patient is status post right frontoparietal craniotomy with evacuation of a right subdural hematoma. Pneumocephalus tracts within the bifrontal extra-axial spaces and along the right cerebral convexity with a small amount in the right middle cranial fossa. There is decrease in size of the right extra-axial collection, currently measuring 1.7 cm in greatest width. Decreased mass effect is present on the lateral ventricles with approximately 1.1 cm leftward midline shift. Decreased effacement is noted within the ipsilateral perimesencephalic cistern. Focal region of neumatized hyperattenuation is present within the right extra-axial subdural collection to a lesser degree than previous. The visualized paranasal sinuses and mastoid air cells are clear. A small amount of air and scalp hematoma present in the region of the craniotomy site. Head CT [6-12], 7:52am Status post evacuation of right frontoparietal subdural hematoma, persistent pneumocephalus, slightly smaller in comparison with a prior study, there is also evidence of decrease of the midline shifting, approximately 9.4mm of deviation is demonstrated. Effacement of the sulci and subdural collection is again noted in the right frontoparietal convexity, apparently unchanged since the prior study. Stable surgical changes consistent with right frontoparietal craniotomy. There is no evidence of ischemic changes. EKG([6-7]): Sinus rhythm. Normal tracing. Compared to the previous tracing of [2174-9-8] mild repolarization abnormalities persist. CXR PA/LAT([6-7]): The cardiomediastinal silhouette is normal. The lungs are clear. No effusion or pneumothorax is detected. The hilar structures are within normal limits. Labs On Admission: [2175-6-7] 10:35PM BLOOD WBC-5.2 RBC-3.90* Hgb-11.7* Hct-34.3* MCV-88 MCH-30.0 MCHC-34.1 RDW-12.7 Plt Ct-251 [2175-6-7] 10:35PM BLOOD Neuts-50.6 Lymphs-42.2* Monos-3.8 Eos-2.7 Baso-0.7 [2175-6-7] 10:35PM BLOOD PT-13.7* PTT-25.1 INR(PT)-1.2* [2175-6-7] 10:35PM BLOOD Glucose-181* UreaN-19 Creat-1.4* Na-138 K-4.0 Cl-104 HCO3-27 AnGap-11 [2175-6-7] 10:35PM BLOOD cTropnT-<0.01 [2175-6-7] 10:35PM BLOOD Calcium-9.5 Phos-3.5 Mg-2.0 Labs on Discharge: Brief Hospital Course: Pt was admitted to the neurosurgery service in SICU where he was monitored closely. He was pre-oped for the OR. On [2175-6-8] he was taken to the OR where under general anesthesia he underwent craniotomy with evacuation of SDH. He tolerated this procedure well, was extubated, and transferred to PACU in stable condition. His post op CT showed status post craniotomy, decreased mass effect. He was transferred to the floor. Diet and activity were advanced. Foley was removed. He was evaluated by PT who saw him daily until [6-19]. At that time they felt he was safe to be discharged to home with outpatient physical therapy. Neuro exam prior to discharge: Patient was alert and oriented x 3, following commands appropriately. CNs II-XII were intact to direct testing. Motor was [4-10] throughout, sensation intact distally. Reflexes were 2+ and symmetric throughout. The patient needed to get his prescription at the Free Care Pharmacy which was closed by the time he was deemed safe to leave on [6-19]. As a result he was discharged on [6-20]. Medications on Admission: AMITRIPTYLINE 25 mg--1 tablet(s) by mouth at bedtime ARTIFICIAL TEARS --One drop topical qid ou preservative free tears or gel, purite preserv. ok; theratears, genteal,refresh plus,systane, generic w/o preserv. ok. each day, let warm water fall on closed lids... ENALAPRIL MALEATE 20 mg--1 tablet(s) by mouth daily HYDROCHLOROTHIAZIDE 25 mg--1 tablet(s) by mouth daily METOPROLOL TARTRATE 25 mg--1 tablet(s) by mouth twice a day PROTONIX 40 mg--1 tablet(s) by mouth daily Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:1 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Outpatient Medication Please take all of your regular outpatient medications as prescribed by your doctor. 8. Outpatient Physical Therapy Please allow this patient to have outpatient physical therapy. Discharge Disposition: Home Discharge Diagnosis: chronic SDH Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures have been removed ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) ] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST Completed by:[2175-6-20]	[ "4019", "53081" ]
Admission Date: [2147-4-30] Discharge Date: [2147-5-9] Date of Birth: [2096-10-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3151] Chief Complaint: Hypoxia and Hypotension. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [Known lastname ] is a 50 year old female with paraplegia secondary to traumatic injury with recurrent infections, noted by her husband to be lethargic and hypoxic to 70s on RA at home. In the ED, her vitals were T 98.6, HR 109, BP 113/79, RR 26, 79% on 2lNC. She was given vancomycin and zosyn. SHe was given a combivent neb as well. She was given lovenox for empiric treatment of PE. A CTA was unable to be obtained due to lack of peripheral IV. In the ED, her BP fell to to 79/39. She was given 1LNS. Upon arrival to the MICU, patient denies shortness of breath. She reports cough productive of green sputum. She denies fevers at home. She denies chest pain, nausea, vomiting, diarrhea, headache, neck stiffness or any other complaints. She denies bladder pressure, dysuria, or urinary frequency. Per her husband, her mental status is at 80%. Of note, she had been recently discharged from [Hospital1 18] for UTI, treated with irtapenem. Of note, patient hospitalized [Date range (1) 104917] for PNA and was treated with 7 day course of levaquin. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. 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: 1. T1-T2 paraplegia following MVC [1-5] 2. Recurrent UTIs 3. HCV, viral load suppressed after 3 months of therapy 4. H/o recurrent PNAs 5. Anxiety 6. DVT in [2142] -IVC filter placed in [2142] 7. Pulmonary nodules 8. Hypothyroidism 9. Chronic pain 10. Chronic gastritis 11. H/o obstructive lung disease 12. Anemia of chronic disease Social History: The patient currently lives at home wiht her husband and 2 children, ages 15 and 22. Former 35 packyear smoker. Denies current tobacco or alcohol use. Family History: Non-contributory. Physical Exam: On admission: Vitals: T 100.2, HR 99, BP 135/60, RR 24, 100% on 6LNC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: decreased breath sounds at right base, scattered wheezes, CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, + b/l LE edema w/o erythema Pertinent Results: Labs on admission: [2147-4-30] 12:20PM BLOOD WBC-20.3# RBC-4.19# Hgb-12.5# Hct-36.5# MCV-87 MCH-29.8 MCHC-34.2 RDW-16.0* Plt Ct-171 [2147-4-30] 12:20PM BLOOD Neuts-92* Bands-0 Lymphs-6* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2147-4-30] 01:45PM BLOOD PT-15.9* PTT-35.1* INR(PT)-1.4* [2147-4-30] 01:45PM BLOOD Glucose-105 UreaN-14 Creat-0.4 Na-137 K-4.5 Cl-98 HCO3-31 AnGap-13 [2147-4-30] 01:45PM BLOOD CK(CPK)-36 [2147-4-30] 01:45PM BLOOD cTropnT-<0.01 [2147-5-1] 03:30AM BLOOD Calcium-7.7* Phos-1.9* Mg-1.8 [2147-4-30] 12:39PM BLOOD pO2-43* pCO2-53* pH-7.41 calTCO2-35* Base XS-6 [2147-4-30] 02:08PM BLOOD Lactate-0.8 Chest x-ray [2147-4-30]: Persistent opacity obscuring the right hemidiaphragm, could reflect pleural effusion, consolidation or atelectasis. Chest x-ray [2147-5-1]: Minimal change in the cardiomegaly, bibasilar opacities, and small right pleural effusion. Brief Hospital Course: This is a 50 year old female with paraplegia secondonary to MVA in [2142], history of recurrent resistant infections, here with pneumonia and hypotension. # pneumonia/sepsis: patient presented with hypotension and radiographic evidence of bilateral pneumonia. She required levophed for blood pressure support for a few days for SBP 70-90 range. She was given broad spectrum antibiotics for vancomycin and zosyn. She was also worked up for other sources with a negative urinalysis and culture, negative legionella urinary antigen and two sputum cultures which were oral flora only. She did come in with a PICC line in place and there was thought this might be a source of infection but blood cultures remained negative and the site was clean. In addition, the PICC was only in for 10 days on admission. She completed a 7 day course of antibiotics for healthcare associated pneumonia. She had aggressive chest PT and incentive spirometry use. She is being discharged on 2L NC oxygen as her oxygen saturation declined to the mid 80's on room air with activity. Of note she has required oxygen at home on and off prior to this admission. # Anemia: Baseline HCT 30-35. In the hospital she was stable at about 27-25 range. Prior studies have shown anemia of chronic disease. Her HCT was closely monitored. # Delirium: She was very anxious and delirius in the ICU and a psychiatric consult was obtained. She likely was delirius from being in the ICU and for polypharmacy and from her illness. Her medication regimen was optimized and cut down to help prevent delirium. She was offered an appointment with psychopharmacology to further help with this, but she refused. She was provided with the number at discharge if she changes her mind. # Chronic pain: She was given her home methadone, baclofen, and lyrica. The doses were lowered while she was delirius and then increased to her home dose at discharge. She complained of significant chronic pain not controlled since [2147-1-2]. She was encouraged to follow up with the psychopharmacologist for this which she refused and also with her PCP and SW as we explained that pain can be affected by many things including depression. # Hypothyroidism: She was maintained on Levothyroxine. # Depression: Home Citalopram 40 mg was continued. Psychiatry and social work consults were following along. # Constipation: She was on an aggressive bowel regimen to maintain her as regular. # Access: PICC line which was removed prior to discharge. Medications on Admission: Tylenol PRN Oxycodone 5 mg prn Pregabalin 150, 75, 150 mg Calcium carbonate 500 mg [Hospital1 ] Baclofen 20, 10, 20 mg Clonazepam 2 mg QID prn Oxybutynin 10, 5, 10 Trazodone 100 mg qhs prn Methadone 5 mg TID Omeprazole 20 mg daily Citalopram 40 mg Levothyroxine 75 mcg daily Nicotine 14 mg/24 hr daily Ipratropium-Albuterol prn Sucralfate 1 gram QID Polyethylene Glycol 17 grams daily Docusate Sodium 100 mg PO BID Senna 8.6 mg [Hospital1 ] Ertapenem 1 gram daily completed [2147-4-27] Discharge Medications: 1. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for muscle spasms. 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. Pregabalin 75 mg Capsule Sig: [2-3] Capsules PO TID (3 times a day): Please take 150mg in the morning and at night. Please take 75mg in the afternoon. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). 11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: pneumonia sepsis anxiety anemia of chronic disease chronic pain paraplegia Discharge Condition: stable with resting oxygen saturation of 93% on RA but ambulatory saturation of 86% on RA and 96% on 2L NC. Discharge Instructions: You were admitted with severe pneumonia causing sepsis (or low blood pressure). You were treated with antibiotics and completed the course. Your stay was complicated by delirium and anxiety and a psychiatric consult helped us care for you. You still require oxygen by nasal cannual at home. Please keep 2L on at all times. You should continue aggressive chest physical therapy three times a day. Continue to use your incentive spirometer and get out of bed to a chair as much as possible to help your lungs expand. You should take your medications as prescribed. We recommend that you keep all of your appointments as written below. We also recommend that you see a psychopharmacologist. This appointment was not made because you did not want it, but the number is provided below if you change your mind. This is recommended to help you develop a working medical regimen to help control your pain and also keep you thinking clearly and without side effects. You should call your doctor or go to the emergency room if you have fevers over 102, chills, chest pain, trouble breathing, bleeding or any other symptoms which is concerning to you. Followup Instructions: Social work: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 23482], LICSW Phone:[Telephone/Fax (1) 250] Date/Time:[2147-5-12] 12:00 [Hospital Ward Name 23] building [Location (un) ] [Hospital1 18] [Hospital Ward Name ] Hepatology: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2147-5-12] 1:20 Primary care: [First Name8 (NamePattern2) 1409] [Last Name (NamePattern1) ], [MD Number(3) 1240]:[Telephone/Fax (1) 250] Date/Time:[2147-6-6] 1:20 [Hospital1 18] [Hospital Ward Name 23] building [Location (un) ] Psychopharmacology: [Telephone/Fax (1) 1387] We recommend you call and schedule an appointment. Completed by:[2147-5-10]	[ "0389", "486", "78552", "5990", "496", "99592", "2449", "V1582" ]
Admission Date: [2110-2-28] Discharge Date: [2110-3-6] Date of Birth: [2092-3-18] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1481] Chief Complaint: wound infection, intra-abdominal abscess Major Surgical or Invasive Procedure: CT guided drainage of abscess with pigtail drain placement History of Present Illness: 17 M s/p appendectomy at [Hospital3 2737] on [2-17] for perforated appendicitis. The patient recovered well and had an initial improvement in his symptoms and leukocytosis. On POD2 the patient started experiencing worsening abdominal pain, nausea and vomiting and was transferred to the OSH ICU where a CT was obtained showing postoperative changes and continued inflammation but no clear abscess. He was taken to the operating room for a exploratory laporotomy on [2-21] where, per report, an enterotomy or perforation was identified in the terminal ileum. An ileal resection was performed and an end ileostomy was placed, and the patient was taken to the ICU for further recovery. Following the procedure the patient continued to have abdominal pain and increasing leukocytosis up to [Numeric Identifier 3301]. His midline laparotomy wound was opened [1-22] wound infection. The patient had been receiving Zosyn and Flagyl and was then switched to Imipenem per ID recommendation. A repeat CT was obtained on [2-27] and demonstrated multiple fluid collections and the patient was transferred to [Hospital1 18] for further management. Past Medical History: PMH: Hypogammaglobulinemia PSH: Appendectomy [2110-2-17], ex-lap LOA, end ileostomy [2110-2-21] Social History: senior in high school, no ETOH, tobacco or drugs, active football player Family History: no immunodeficiencies, 2 siblings - one with ? diagnosis of SLE, other healthy Physical Exam: On Discharge: AVSS GEN: resting comfortably, NAD CV: RRR Lungs: CTAB ABD: Open midline abdominal wound with wet/dry dressing in place. Appropriately tender around the wound. Ostomy pink/viable. EXT: warm, well perfused Pertinent Results: [2110-2-28] 04:05AM BLOOD WBC-18.0* RBC-3.82* Hgb-11.3* Hct-34.3* MCV-90 MCH-29.7 MCHC-33.0 RDW-13.9 Plt Ct-543* [2110-3-4] 06:35AM BLOOD WBC-8.6 RBC-3.59* Hgb-10.6* Hct-32.2* MCV-90 MCH-29.6 MCHC-33.0 RDW-13.9 Plt Ct-642* [2110-2-28] 04:05AM BLOOD Glucose-106 UreaN-11 Creat-0.9 Na-137 K-5.1 Cl-101 HCO3-27 AnGap-14 [2110-3-4] 06:35AM BLOOD Glucose-86 UreaN-9 Creat-0.7 Na-139 K-4.8 Cl-102 HCO3-28 AnGap-14 CT abd/pel ([3-5]): IMPRESSION: 1. Two discrete collections are again visualized throughout the abdomen and pelvis. The previously aspirated, but not drained collection along the right paracolic gutter appears relatively unchanged with a focus of air consistent with prior instrumentation. The right lower quadrant collection with extension to pelvis which was aspirated and had a drain placed appears smaller with resolution of the lateral and superficial portion of the collection anterior to the right psoas muscle. 2. Moderate left pleural effusion, which is increased in size in comparison to prior study with adjacent atelectasis. Small right pleural effusion with adjacent atelectasis. Brief Hospital Course: Mr. [Known lastname 89930] was transferred to our trauma surgical intensive care unit from [Hospital3 ] early in the AM of [2110-2-28]. He was seen by Dr [Last Name (STitle) ] and his team, and based on the fluid collections seen on OSH CT scan, he was sent to IR for percutaneous drainage. The IR team aspirated the right paracolic gutter collection and left a drain in the pelvic collection. This fluid was sent for culture. The patient was initially tachycardic upon admission to the ICU, but was otherwise hemodynamically stable. He was transferred to the floor on HD4 in good condition. Neuro: His pain was initially well controlled on intermittent IV dilaudid. When tolerating po intake, the patient was switched to vicodin, which was well tolerated. CV: He arrived tachycardic with stable blood pressure. This improved quickly during his hospital stay, and he had no other issues. Resp: He had significant oxygen demand upon arrival and CXR showed bilateral effusions and atelectasis. Sputum cultures were drawn that were insufficient. Patient was concurrently being treated with vancomycin and meropenem for his intra-abdominal abscesses, which was determined to be sufficient for presumed pneumonia as well. The patient was also given intermittent lasix to improve his respiratory status as his lungs looked fluid overloaded. These effusions were followed with serial CXRs and improved throughout his stay. He was weaned off of oxygen on the floor and his breathing remained comfortable. GI/GU/FEN: The patient was initially NPO/IVF upon admission. His diet was advanced to regular by HD3 and this was well tolerated. Ostomy output was nearly 2 liters the first 24 hours of admission. The output remained high the first few days of his hospital stay, but then decreased on its own to an appropriate level without medical intervention. His electrolytes and fluid status were closely monitored and patient was repleted as needed. His open abdominal wound was treated with wet/dry dressing changes TID, and showed continued healing and improvement during his stay. ID: He was seen by our ID team upon arrival who recommended switching imipenem to meropenem. He was also started on vancomycin at arrival for presumed PNA. His abdominal wound was packed with wet to dry dressings. Abdominal fluid collections showed vanc sensitive enterococcus and [Female First Name (un) ], so fluconazole was added as well. The patient was kept on this antibiotic regimen during his hospital stay. PICC line was placed on [3-3] to continue atbx as an outpatient. Repeat CT scan was performed on [3-5] that showed persistent abscesses in the pelvis and R pericolic gutter. However, after patient's drain was adequately flushed, the drain began to put out purulent material. Radiology felt the drain was in good position and did not need to be re-adjusted. The patient was sent home on meropenem, vancomycin, and fluconazole per ID's recommendations. Prophylaxis: Patient was started on SQH and encouraged to ambulate often. Dispo: Patient received ostomy teaching, Picc line teaching, and wound care teaching. He understood all of this and agreed with the plan. He was given discharge instructions and told to keep all follow up appointments as scheduled. Medications on Admission: zyrtec Discharge Medications: 1. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 3. vancomycin 500 mg Recon Soln Sig: 1.5g Recon Solns Intravenous Q 8H (Every 8 Hours): Through [3-8]. Disp:12 Grams Refills:0 4. meropenem 500 mg Recon Soln Sig: 500mg Recon Solns Intravenous Q6H (every 6 hours): Through [3-17]. Disp:23 grams Refills:0 5. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day: Through [3-17]. Disp:22 Tablet(s) Refills:0 6. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Disp:30 syringes Refills:0 7. Normal Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection PRN as needed for drain or PICC line flush. Disp:100 Refills:0 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:30 Tablet(s) Refills:0 9. loperamide 2 mg Capsule Sig: [12-22] Capsules PO With meals and at bedtime as needed for ostomy output greater than 1200cc/day. Disp:30 Capsule(s) Refills:0 10. Outpatient Lab Work LAB TESTS: CBC, Bun, Crea, LFTs, ESR, CRP FREQUENCY: Qweekly All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 1353] Discharge Disposition: Home With Service Facility: [Telephone/Fax (1) 269] of Southeastern Mass. Discharge Diagnosis: wound infection, intra-abdominal abscesses Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: New chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-29] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please do not engage in any strenous activity until instructed to do so by your surgeon. . Wound Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the wound site. No showering, tub baths, or swimming until cleared by Dr. [Last Name (STitle) ] at your follow-up appointment. You may sponge bath until then. Please perform wet-to-dry dressing changes three times daily. You will have a visiting nurse come to help assist you with dressing changes, and they will teach you how to perform these dressing changes yourself. . Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [Last Name (STitle) 269] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output daily. Keep the insertion site clean and dry otherwise. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . Monitoring ostomy output/Prevention of Dehydration: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. If ostomy output is greater than 1200mL in one day, please use Immodium to slow down the output: 2-4mg with meals and at bedtime, as needed. Do not exceed 16mg/24 hours. . PICC Line Care: Please monitor the site regularly, and [Name6 (MD) 138] your MD, nurse practitioner, or [Name6 (MD) 269] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [Name6 (MD) ] your MD [First Name (Titles) ] [Last Name (Titles) 10836] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES. Please keep the dressing clean and dry. Contact your [Name2 (NI) 269] Nurse if the dressing comes undone or is significantly soiled for further instructions. . Antibiotic Instructions: You will be receiving IV antibiotic therapy through your PICC line. Per Infectious Disease recommendations, you will be on the following regimen: Vancomycin 1.5g IV every 8 hrs Start date: [2110-2-28] Stop date: [2110-3-8] Meropenem 500mg IV every 6 hrs Start date: [2110-2-27] Stop date: [2110-3-17] Fluconazole 400mg PO daily Start date: [2110-2-27] Stop date: [2110-3-17] Required laboratory monitoring while on IV antibiotics: LAB TESTS: CBC, Bun, Crea, LFTs, ESR, CRP FREQUENCY: Weekly All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 1353] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 1354] or to on [Name8 (MD) 138] MD in when clinic is closed. Followup Instructions: 1. Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2110-3-20]. Please come to Dr.[Name (NI) 1482] clinic at 8:15am to receive the contrast for your scan. You will then have the CAT scan at 9:30am. 2. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 2359] Date/Time:[2110-3-20] 10:45am. You will see Dr. [Last Name (STitle) ] after your CAT scan to go over the results. 3. Provider: [First Name4 (NamePattern1) 2482] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2110-3-25] 9:30am Completed by:[2110-3-7]	[ "486", "5119", "49390" ]
Admission Date: [2168-3-23] Discharge Date: [2168-3-27] Date of Birth: [2089-7-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: NSTEMI and Left hip fracture Major Surgical or Invasive Procedure: Cardiac Catheterization Treatment left intertrochanteric hip fracture with intramedullary nail. History of Present Illness: Mrs. [Known lastname 80797] is a 78 y o f with no known past medical history who presented to an OSH on [3-18] after fall/hip fracture, and was also diagnosed with an NSTEMI. She was transferred to [Hospital1 18] for cath, was initially admitted to [Hospital Ward Name 121] 3, but had atrial fibrillation with rapid ventricular rate and delerium which resulted in transfer to the CCU. The patient initially presented to [Hospital3 ] on [2168-3-18] after a mechanical fall which resulted in a left-sided hip fracture. The patient was sitting at a bench and tried sliding off to get up, but the bench was shorter then anticipated, and she fell to the floor. The husband says she had not complainted of any chest pain, LH, shortness of breath prior to the fall. no bowel or bladder incontinence. On admission to OSH, patient had troponin I of 0.21 initially thought secondary to sinus tachycardia (HR 100s). Subsequent troponins continued to rise with peak at 1.99 at which point she was started on asa, plavix, beta blocker, statin, and lovenox. Cardiology was consulted and patient was transferred to the OSH ICU. serial cardiac enzymes trended down (last 1.53). Her EKG did not show any ST elevation but did have T wave inversions inferolaterally that deepened throughout her admission. She was diagnosed with a non-st elevation MI and was transferred to [Hospital1 18] for cardiac catherization. At the OSH ICU, she developed atrial fibrillation with RVR and was treated with IV lopressor persistent RVR. She had a CXR that showed mild diffuse interstitial edema suggestive of congestive heart failure with a normal sized heart. A TTE showed LV dilation, apical, septal, inferior and anterior akinesis, mild MR, and PA pressure of 38mmHg with LVEF 20%. She received some fluids and had a 5 point Hct drop (32->27) that was thought to be dilutional. She was treated with one unit of pRBCs. Because NSTEMI and afib, hip surgery was deferred for now. The patient was transferred here for cardiac catherization around noon today. Per report the patient recieved dilauded, morphine and ativan the night before transfer and had been delerious since. When she got the the floor, she was delerious, in a fib with rvr with rates >150. She had a 5second pauses x2 and was transferred to the CCU for further management of her cardiac issues. On arrival to the CCU, she was a&o x2-3, complaining only of pain in her hip, [8-8]. She denied chest pain, shortness of breath, lightheadedness or any other symptoms. Her family were at the bedside and report that her mental status was improved since this morning, but far from baseline. Past Medical History: None known Social History: Patient is retired. She lives with her husband in [Location (un) 686], MA. Until recently had been the primary care taker of her [Age over 90 ] yo mother who now resides in a nursing home. She smokes [1-1] ppd. Drinks < 1 drink per month. Denies the use of any illicit drugs or medications. Family History: Noncontributory Physical Exam: VS: 102 rectal, hr 112, bp 145/64, RR 27, 97% 3L GENERAL: NAD, foggy, but no longer fankly delerious. Oriented x3 with some prompting. answere questions appropriately. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: tachycardic, irregular. no murmurs, rubs. LUNGS: mild bibasilar crackles, otherwise clear ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs [2168-3-23] 06:04PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.018 [2168-3-23] 06:04PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [2168-3-23] 06:04PM URINE RBC-[6-8]* WBC-[3-3] BACTERIA-FEW YEAST-NONE EPI-0-2 [2168-3-23] 06:04PM URINE GRANULAR-0-2 HYALINE-0-2 WBCCAST-<1 [2168-3-23] 06:04PM URINE MUCOUS-MOD [2168-3-23] 02:45PM TYPE-ART PO2-75* PCO2-34* PH-7.51* TOTAL CO2-28 BASE XS-3 INTUBATED-NOT INTUBA [2168-3-23] 02:45PM LACTATE-1.4 K+-3.7 [2168-3-23] 02:45PM O2 SAT-95 [2168-3-23] 12:50PM GLUCOSE-106* UREA N-21* CREAT-0.6 SODIUM-140 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16 [2168-3-23] 12:50PM estGFR-Using this [2168-3-23] 12:50PM ALT(SGPT)-14 AST(SGOT)-22 CK(CPK)-261* ALK PHOS-90 TOT BILI-0.6 [2168-3-23] 12:50PM CK-MB-5 cTropnT-0.27* [2168-3-23] 12:50PM CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-2.0 CHOLEST-133 [2168-3-23] 12:50PM TRIGLYCER-114 HDL CHOL-48 CHOL/HDL-2.8 LDL(CALC)-62 [2168-3-23] 12:50PM WBC-11.6* RBC-3.96* HGB-10.5* HCT-32.0* MCV-81* MCH-26.6* MCHC-32.9 RDW-13.8 [2168-3-23] 12:50PM PLT COUNT-175 [2168-3-23] 12:50PM PT-14.7* INR(PT)-1.3* Interval/Discharge Labs [2168-3-24] 06:02PM BLOOD Hct-27.5* [2168-3-25] 10:47AM BLOOD WBC-12.6# RBC-3.74 Hgb-10.4* Hct-31.0* MCV-83 MCH-27.8 MCHC-33.5 RDW-13.8 Plt Ct-200 [2168-3-27] 07:00AM BLOOD WBC-10.9 RBC-4.04* Hgb-11.4* Hct-33.0* MCV-82 MCH-28.2 MCHC-34.5 RDW-14.1 Plt Ct-234 [2168-3-27] 07:00AM BLOOD PT-24.2* PTT-34.4 INR(PT)-2.4* [2168-3-27] 07:00AM BLOOD Glucose-92 UreaN-27* Creat-0.4 Na-142 K-3.8 Cl-107 HCO3-24 AnGap-15 [2168-3-23] 12:50PM BLOOD ALT-14 AST-22 CK(CPK)-261* AlkPhos-90 TotBili-0.6 [2168-3-24] 03:28AM BLOOD ALT-16 AST-28 LD(LDH)-302* AlkPhos-74 TotBili-0.6 [2168-3-24] 03:28AM BLOOD Albumin-3.1* Calcium-8.2* Phos-2.9 Mg-2.6 [2168-3-23] 12:50PM BLOOD Triglyc-114 HDL-48 CHOL/HD-2.8 LDLcalc-62 [2168-3-24] 03:28AM BLOOD TSH-<0.02* [2168-3-24] 03:28AM BLOOD Free T4-2.5* [2168-3-25] 04:24AM BLOOD Anti-Tg-PND Thyrogl-PND antiTPO-PND [2168-3-25] 04:24AM BLOOD THYROID STIMULATING IMMUNOGLOBULIN (TSI)-PND Micro: Urine cx: negative Blood cx: pending x2 C diff: pending x1 [3-23] Head CT No acute intracranial hemorrhage. MR [Name13 (STitle) 430] is more sensitive for subtle lesions or small acut einfarcts. Study limited due to motion. [3-24] Cardiac Cath Selective coronary angiography of this right dominant system revealed no obstructive coronary artery disease. The LMCA had no significant disease. The LAD had no significant disease, with the distal LAD barely reaching the apex. The LCX consisted of a branching intermediate vessel without an AV groove CX, and had no significant disease. The RCA was a large dominant vessel, with a proximal 20-30% hazy stenosis and a 40-50% stenosis in the mid portion. [3-24] Echo: The left atrium is normal in size. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with anterior and septal apical hypokinesis (LVEF 40-45%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. L hip Xrays: reads pending Brief Hospital Course: 1. NSTEMI: Patient ruled in for NSTEMI with elevated troponin 1.99 at OSH and .27 here with diffuse t wave inversions on ECG and EF 20% on OSH echo. She was given aspirin 325, plavix 75, metoprolol IV as needed for HR as below and started on heparin IV for ACS and monitored on telemetry. Repeat Echo showed mild left regional systolic dysfunction with distal anterior, septal and apical hypokinesis c/w CAD as well as mild mitral regurgitation. EF 40%. Cardiac cath showed no focal occlusions and there was no intervention performed. Etiology of ECG changes and elevated biomarkers thought to be NSTEMI with either autolysis of clot or ischemia related to spasm, or Takotsubo's related to stress associated with fall and hip fx. She was continued on ASA 81, beta blocker, statin, and started on low dose ACE upon discharge. Plavix was not continued due to no stenting. 2. Atrial Fibrillation: In am of admission had RVR as fast as 160s. On the floor she was given 5mg iv lopressor and had 5 sec conversion pause. She had 2 more episodes in CCU but no further episodes after PO beta blocker was uptitrated and she subsequently remained in sinus rhythm. Amiodarone was started for rhythm control but discontinued when TSH found to be abnormal. Anticoagulation was started with coumadin, and INR was up to 2.4 after one dose at 2mg, so this was held for one day and decreased to 1mg daily. She will need close INR monitoring as outpatient. 3. Left hip fracture: Patient had pinning of left hip yesterday, tolerated well. Treating pain with acetaminophen, and occasional tramadol. Regarding DVT prophylaxis, patient has a therapeutic INR on warfarin. Will follow up in 2 weeks with orthopedics. 4. Hyperthyroidism: By labs prior to starting amiodarone. Further testing for thyroid antibodies is pending. Patient to follow up with endocrine as an outpatient. 5. Systolic CHF: Acuity is unclear. [Name2 (NI) ] of 20% is low for a first NSTEMI. Repeat echo shows improvement of EF to 40-45%, which may represent Takutsubo??????s, stress related cardiomyopathy. Patient did not appear hypervolemic and was not started on diuretics. 6. Delirium: Patient was A+O x3 prior to getting dilaudid/morphine/ativan the night prior to transfer to [Hospital1 18]. After these medications, she became delirious, with disorientation and agitation. Her head CT weas negative and her mental status returned to baseline by later the following day. Narcotics were avoided. 7. Diarrhea: Patient had 7 brown watery stools during her final two days in the hospital. This was guaiac negative x1, the patient had no fevers or leykocytosis, and no abdominal pain. A C diff toxin was sent and is pending at discharge. Please call the [Hospital1 18] lab at [Telephone/Fax (1) 66600] to follow up this result. 8. Code: Was changed during admission, with final decision to be DNR, although okay to intubate. Medications on Admission: NONE Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 2. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain: Try tylenol first. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold for SBP < 100. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please hold for SBP < 100 and/or HR < 60. 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Discharge Disposition: Extended Care Facility: [Hospital 38] Rehabilitation Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. NSTEMI 2. Left Hip Fracture 3. Atrial Fibrillation 4. Hyperthyroidism Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for treatment of your hip and your heart. For your heart, you likely had a small heart attack. You had a cardiac catheterization performed and there was no significant heart disease found. You were started on several new medications listed below. For treatment of your broken hip, you had surgery with placement of a nail to stabilize the fracture. We started the following medications: - Aspirin, lisinopril, metoprolol, and atorvastatin for your heart and blood pressure. - Warfarin to thin the blood due to atrial fibrillation, an abnormal heart rhythm you had while in the hospital. Please go to all follow up appointments, including regular blood testing of your INR, which helps calculate the proper dose of your warfarin. Please seek immediate medical attention if you develop worsened hip pain, chest pain, shortness of breath, back pain, light-headedness, dizziness, passing out, fevers, shaking chills, or night sweats. Followup Instructions: You will follow up with a new primary care physician, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. We will try to schedule an appointment; please call [Telephone/Fax (1) 250] next week to verify an appointment. Your new cardiologists will be Drs. [Last Name (STitle) 171] and [Name5 (PTitle) ]. Again, we will try to schedule you an appointment. Please call their office next week at [Telephone/Fax (1) ] to verify. Please follow-up with Dr. [Last Name (STitle) ] with orthopedic surgery in 2 weeks. Please call the office to schedule an appt. Phone: [Telephone/Fax (1) 1228] His address is: [Location (un) ], [Hospital Ward Name 23] 2 Clinical Center, park in the garage under the building. Endocrinology: Dr. [Last Name (STitle) ] [5-13] at 3:00pm. Phone: ([Telephone/Fax (1) 9072] [Location (un) 436] [Hospital Ward Name 23] Clinical Center, [Location (un) ], [Hospital Ward Name 516], [Hospital1 69] Completed by:[2168-3-27]	[ "41071", "42731", "4280", "2859" ]
Admission Date: [2171-2-3] Discharge Date: [2171-2-19] Date of Birth: [2095-3-28] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 11040] Chief Complaint: urinary tract infection, respiratory distress Major Surgical or Invasive Procedure: Intubation CVL placement History of Present Illness: Mr [Known lastname ] is a 75 y.o. Male w/ h.o. end stage Alzheimers dementia (non-verbal at baseline), HTN, COPD BIBA to ED after being found unresponsive, febrile in [Hospital3 2558]. . Per ED signout and review of [Hospital3 ] notes over the past few years pt's baseline has been non-verbal due to his end stage Alzheimers dementia, per family he will nod or shake his head to yes or no questions. The pt was reported to be 'normal' during the 7pm-11pm shift at his nursing home. This AM he was noted to be 'unresponsive' by the nurses, febrile to 103.6, he was also noted to be in respiratory distress with use of accessory muscles. Nursing home called 911 and the pt was brought into the ED . In the ED, initial vs were: T103.6, P125, BP 148/78, R 16, O2 sat 90% on RA, poor effort. He was noted to be in respiratory distress with accessory muscle use, he was thus immediately intubated with Etomidate and Succinylcholine. He was sent for a CT head which showed no acute intracranial pathologic process, severe global atrophy, with moderate chronic microvascular ischemic disease. A chest xray was also obtained which showed no consolidation but did show ETT tube placement 3cm from bifurcation point. His initial labwork was notable for a neutrophillic leukocytosis of 15.6. Troponin set was negative x 1. Chem panel was notable for Na 146, BUN/Creatinine 39/1.8 and phos 2.6. Lactate level was 3.4, U/A was remarkable for pyuria, moderate blood, small leuks, many bacteria. Following intubation an ABG showed pH 7.40, pCO2 35, pO2 449, HCO3 23. He had a right IJ placed in the ED. Although his U/A was suspicious for infection the ED were concerned for an additional source of infection; he underwent an LP with a CSF analysis showing 1 WBC only. He was started empirically on Zosyn, Vanc, Ceftriaxone. He was also hypotensive to the high 70s/80s and was given 4L NS, he was also started on low dose Levophed, prior to transfer the Levophed was running 0.08. He was started on Midazolam for sedation. . Of note he was last hospitalized [2170-7-4] for fever and right nsided weakness. Per discharge summary, a fever workup revealed no clear source although diverticulitis was suspected based on radiological evaluation. . Unable to obtain ROS as pt is intubated. Past Medical History: -Alzheimer's disease -GERD -HTN -COPD -Incarcerated inguinal hernia status-post repair Social History: - resident of [Hospital3 ] - married, children (daughter is HCP) - remote tobacco use, at least 40 pack year history - no etoh or drugs Family History: Non-contributory. Physical Exam: General: Elderly Asian Male laying down in bed intubated, appears comfortable HEENT: Sclera anicteric, dry mucous membranes. OD 2mm reactive, OS 1mm sluggish Neck: Supple, JVP not elevated Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, tympanetic to percussion, no facial grimacing or tachycardia with deep palpation of the abdomen. Ext: Warm, 2+ pulses, no edema Pertinent Results: [2171-2-3] 06:11PM GLUCOSE-161* UREA N-28* CREAT-1.2 SODIUM-144 POTASSIUM-3.6 CHLORIDE-114* TOTAL CO2-22 ANION GAP-12 [2171-2-3] 06:11PM CALCIUM-7.4* PHOSPHATE-2.1* MAGNESIUM-1.8 [2171-2-3] 01:33PM CEREBROSPINAL FLUID (CSF) PROTEIN-23 GLUCOSE-100 [2171-2-3] 01:33PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-0 LYMPHS-50 MONOS-50 [2171-2-3] 10:49AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.025 [2171-2-3] 10:49AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2171-2-3] 10:49AM URINE RBC-[2-23]* WBC-[5-31]* BACTERIA-MANY YEAST-FEW EPI-0 [2171-2-3] 09:52AM proBNP-959* [2171-2-3] 09:52AM cTropnT-LESS THAN [2171-2-3] 09:52AM WBC-15.6* RBC-4.69 HGB-15.3 HCT-44.9 MCV-96 MCH-32.7* MCHC-34.2 RDW-13.0 [2171-2-3] 09:52AM NEUTS-92* BANDS-2 LYMPHS-5* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2171-2-4] 8:31 pm SPUTUM Source: Endotracheal. FINAL REPORT [2171-2-7] GRAM STAIN (Final [2171-2-4]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2171-2-7]): Commensal Respiratory Flora Absent. MORAXELLA CATARRHALIS. RARE GROWTH. [2171-2-3] 10:30 am SPUTUM ENDOTRACHEAL. FINAL REPORT [2171-2-7] GRAM STAIN (Final [2171-2-3]): [10-15] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2171-2-6]): MODERATE GROWTH Commensal Respiratory Flora. MORAXELLA CATARRHALIS. MODERATE GROWTH. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. [2171-2-3] 10:49 am URINE Source: Catheter. FINAL REPORT [2171-2-8] URINE CULTURE (Final [2171-2-8]): THIS IS A CORRECTED REPORT [2171-2-7] 10:05AM. REPORTED BY PHONE TO DR. [Last Name (STitle) ] [2171-2-7] 10:24AM. PROTEUS MIRABILIS. QUANTITATION NOT AVAILABLE ( <10,000 organisms/ml ). PRESUMPTIVE IDENTIFICATION. PREVIOUSLY REPORTED AS [2171-2-4]. >100,000 ORGANISMS/ML.. PLEASE DISREGARD PREVIOUS SENSITIVITIES. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ESCHERICHIA COLI \| \| AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 8 S 8 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S [2171-2-3] 10:02 am BLOOD CULTURE TRAUMA. FINAL REPORT [2171-2-9] Blood Culture, Routine (Final [2171-2-9]): NO GROWTH. [2171-2-3] 9:52 am BLOOD CULTURE TRAUMA. FINAL REPORT [2171-2-9] Blood Culture, Routine (Final [2171-2-9]): NO GROWTH. Brief Hospital Course: In brief, this is a 75 year old male with end stage dementia (nonverbal) brought in on [2171-2-3] after being found unresponsive, febrile, and in respiratory distress at [Hospital ]. Brief Hosptial Course by Problem: . # Respiratory distress: In the ED, initial vs were: T103.6, P125, BP 148/78, R 16, O2 sat 90% on RA, poor effort. He was noted to be in respiratory distress with accessory muscle use, he was thus immediately intubated with Etomidate and Succinylcholine. He was sent for a CT head which showed no acute intracranial pathologic process, severe global atrophy, with moderate chronic microvascular ischemic disease. A chest xray was also obtained which showed no consolidation but did show ETT tube placement 3cm from bifurcation point. The patient remained intubated in the MICU until [2171-2-7]. After extubation, the pt had high O2 saturation with only minimal O2 supplementation. He was stable off oxygen for a short period of time, then seemed to have an aspiration event on the floor and was admitted to the MICU where he ws intubated. He was difficult to wean from the ventilator despite treatment with broad antibiotics. He was termintally extubated and passes away a few hours after the ET tube was removed after discussions with the family about goals of care. . # Urosepsis/and second pneumonia sepsis: On presentation, the patient qualified for SIRs criteria given initial temp, leukocytosis, qualifies as septic shock given the hypotension requiring pressors. Troponin set was negative x 1. Chem panel was notable for Na 146, BUN/Creatinine 39/1.8 and phos 2.6. Lactate level was 3.4, U/A was remarkable for pyuria, moderate blood, small leuks, many bacteria. Following intubation an ABG showed pH 7.40, pCO2 35, pO2 449, HCO3 23. He had a right IJ placed in the ED. Although his U/A was suspicious for infection the ED were concerned for an additional source of infection; he underwent an LP with a CSF analysis showing 1 WBC only. He was started empirically on Zosyn, Vanc, Ceftriaxone. He was also hypotensive to the high 70s/80s and was given 4L NS, he was also started on low dose Levophed. The patient was afebrile during hospitalization. Antibiotics were weaned to ceftriaxone given pyuria, but negative CXR and LP. He was diuresed with lasix 20 IV to ~1L negative during MICU stay. Urine culture grew two strains of E. coli (>100,000) and proteus <10,000. Again, after he aspirated, he was hypotensive and briefly on pressors due to pneumonia. He was treated with vanco/cefepime and then broaden to vanco/[Last Name (un) 2830]. No organism was isolated. He was then made comfort measures only and the ET tube was removed. . # Acute Kidney Injury: Pt on admission noted to have a Creatinine of 1.8, acutely elevated given a prior baseline of 0.5-0.7. This was thought to be pre-renal in origin given his increased insensible losses from fevers and poor PO intake. It initially improved, but then after his second sepsis event, worsened again. He was fluid resuccitated. At one point, attempted diuresis was attempted to see if we could improve his vent settings. He did not tolerate diuresis due to low blood pressures. As above, he was made comfort measures and the ET tube was removed. His kidney function was no longer monitored. . ## Alzheimers dementia: Pt has history of AD per prior discharge summary, per ED report pt is non-verbal at baseline but does apparently nod yes or no to responses. His mental status remained at his baseline. He was non-communicative his whole admission. . Medications on Admission: Simvastatin 40mg daily Vitamin D 50,000u qweek Senna 8.6mg daily PRN Colace 100mg [Hospital1 ] Bisacodyl 10mg daily PRN Discharge Medications: n/a expired Discharge Disposition: Expired Discharge Diagnosis: Urosepsis Pneumonia Discharge Condition: n/a expired Discharge Instructions: You were hospitalized for respiratory distress and fever. Your difficulty breathing required that you be intubated with a breathing tube. You had no problems with breathing after the breathing tube was removed. Urine culture showed infection of your urinary tract. This was treated with the antibiotic ceftriaxone while you were in the hospital. Unfortunately, your breathing worsened again after you developed pneumonia and were unable to survive the pneumonia. Followup Instructions: n/a expired Completed by:[2171-2-21]	[ "78552", "5070", "5990", "5849", "2762", "99592", "42789", "4019", "496", "53081" ]
Admission Date: [2149-6-12] Discharge Date: [2149-6-16] Date of Birth: [2080-5-6] Sex: M Service: CARDIOTHORACIC Allergies: Gluten Attending:[First Name3 (LF) 922] Chief Complaint: mild DOE/occasional palpitations Major Surgical or Invasive Procedure: AVR (Magna pericardial tissue) [6-12] History of Present Illness: 68 yo M with hepatocellular ca diagnosed 6 months ago. Echo for transplant workup showed AS, referred for AVR. Past Medical History: hepatitis C hepatocellular cancer severe aortic stenosis celiac disease prostate cancer -treated with hormone therapy and radiation R leg skin lesion -biopsied at [Hospital1 2177] last week, results unknown Social History: Lives alone, h/o tobacco (quit) and alcohol use (last alcohol 7 months ago), h/o drug use (quit) Family History: nc Physical Exam: HR 76 BP 132/64 Anxious, NAD Several echymotic areas on arms Lungs CTAB 4/6 SEM t/o precordium radiating to carotids Abdomen benign Extrem warm, no edema Pertinent Results: [2149-6-15] 04:20AM BLOOD WBC-7.0 RBC-2.59* Hgb-8.4* Hct-24.4* MCV-94 MCH-32.5* MCHC-34.5 RDW-16.6* Plt Ct-123* [2149-6-14] 04:00AM BLOOD WBC-9.2# RBC-2.80* Hgb-9.2* Hct-25.7* MCV-92 MCH-32.8* MCHC-35.7* RDW-16.3* Plt Ct-106* [2149-6-13] 04:56PM BLOOD Hct-27.9* [2149-6-14] 04:00AM BLOOD PT-17.3* PTT-39.4* INR(PT)-1.6* [2149-6-13] 03:23AM BLOOD PT-14.8* PTT-32.9 INR(PT)-1.3* [2149-6-16] 04:24AM BLOOD Glucose-103 UreaN-17 Creat-0.6 Na-135 K-3.8 Cl-100 HCO3-30 AnGap-9 Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [2149-6-14] 7:11 AM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2149-6-14] SCHED CHEST PORT. LINE PLACEMENT Clip # [Clip Number (Radiology) 33193] Reason: ? tlc placement change over wire, CT removal ? ptx [Hospital 93] MEDICAL CONDITION: 69 year old man with s/p avr REASON FOR THIS EXAMINATION: ? tlc placement change over wire, CT removal ? ptx Final Report CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [2149-6-12]. FINDINGS: The right central venous access line has been exchanged. The new line projects with its tip over the right atrium and could be retracted by 2 to 3 cm. The nasogastric tube and the endotracheal tube have been removed. There is a decrease in lung volumes, with newly appeared bilateral small pleural effusions and moderate retrocardiac atelectasis seen together with slightly enlarged cardiac silhouette. Additional perihilar haziness suggests moderate overhydration. There are no focal parenchymal opacity suggestive of pneumonia. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 33194], [Known firstname ] [Hospital1 18] [Numeric Identifier 33195] (Complete) Done [2149-6-12] at 10:02:32 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] C. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2080-5-6] Age (years): 69 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Chest pain. Shortness of breath. ICD-9 Codes: 402.90, 786.05, 786.51, 440.0, 424.1 Test Information Date/Time: [2149-6-12] at 10:02 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5209], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW3-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 50% to 60% >= 55% Aorta - Ascending: 3.4 cm <= 3.4 cm Aortic Valve - Peak Velocity: 5.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 94 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 58 mm Hg Aortic Valve - Valve Area: 1.1 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Mildly dilated ascending aorta. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Moderate-severe AS (area 0.8-1.0cm2). Mild to moderate ([12-11]+) AR. [Due to acoustic shadowing, AR may be significantly UNDERestimated.] MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild to moderate ([12-11]+) aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [Last Name (STitle) 33196] was notified in person of the results. POST-CPB: On infusion of phenylephrine. Well-seated bioprosthetic valve in the aortic position. No paravulvular leak seen. Initial [Male First Name (un) ] improved with neo, esmolol and iv fluid administration. Preserved biventricular function. Aortic contour intact post decannulation Brief Hospital Course: He was taken to the operating room on [2149-6-12] where he underwent an AVR. He was transferred to the ICU in stable condition. He had significant bleeding post op and required multiple blood products. He was extubated on POD #1. He was transferred to the floor on POD #2. He did well postoperatively and was ready for discharge to rehab on POD #4. Medications on Admission: Clotimazole 10''''', Trazodone 50' Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: then reassess need for diuresis. 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): with lasix . 10. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital ] - [Location (un) ] Discharge Diagnosis: AS s/p AVR acute post op blood loss anemia PMH: Hepatitis C cirrhosis, HCC, hx IV drugs, Basal cell Ca, celiac disease, prostate Ca s/p seed implant, portan HTN, R knee arthroscopy Discharge Condition: Stable. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incision. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [Last Name (STitle) ], [First Name3 (LF) ] G. [Telephone/Fax (1) 6951] Dr. [Last Name (STitle) 914] 4 weeks Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2149-7-16] 2:20 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2149-8-15] 11:00 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2149-8-22] 9:30 Completed by:[2149-6-16]	[ "4241", "2851" ]
Admission Date: [2107-5-2] Discharge Date: [2107-5-27] Date of Birth: [2037-10-1] Sex: F Service: NEUROLOGY Allergies: Depakote / Iodine; Iodine Containing / Erythromycin Base / Tegretol / Demerol / Morphine Attending:[First Name3 (LF) 11291] Chief Complaint: Increased seizure frequency to [5-2] sz/day with increased coughing episodes Major Surgical or Invasive Procedure: Right temporal lobe cyst fenestration to the posterior fossa and placement of Rickham reservoir with catheter in the cyst cavity History of Present Illness: The pt is a 69yo F, who has PMH of seizure, who presented with the CC of cough and increasing frequency of seizure. She was in her USOH until [2105-12-26] when she cought a cold, which progressed to bronchitis. Her cold got better in a week, leaving the cough with yellow sputum. She lost her voice for a month, and was diagnosed with fungal infection of esophagus and vocal cord. Her cough once got better (though it did not disappear) in summer [2106], with the anti-fungus medication, which she took from [2106-8-27] to [2107-3-27]. Her cough exacerbated in [2107-2-27]. Lying back makes this dry cough worse and does wake her up at night. It gets worse from morning towards afternoon, but it is basically consistant for all the day. It is alleviated by albuterol nebs, but comes back after a while. The pt also complained of the increasing frequency of seizure, from once/year to 4-6times/day since last month. Her husband described that it starts in Lt side getting stiff, and then the Rt side gets stiff. It is resolved by Rameron in few minutes but repeats 4-6 times in 4 hours. Pt and her husband stated that she can hear but cannot respond, and that the is tired but not confused after the seizures. The cough and seizure are associated with 8/10 bitemporal throbbing HA, which is alleviated by tylenol. ROS found pain in leg and fall from her bed 2-3 weeks ago, which made a bruise on her leg. Denied weight change, fever, chills, sweats, night sweats, chest pain, abd pain, diarrhea or change in urination. Past Medical History: 1) Seizure d/o s/p R temporal lobectomy with multiple admissions for sz 2) [Doctor Last Name 1193]-Chiari malformation s/p tonsillectomy [2087] 3) R temporal lobectomy 4) CAD with MI s/p PTCA [2085] 5) Asthma 6) Hemorrhoids 7) Fibromyalgia 8) Depression ) S/P cholecystectomy ) S/P TAH Social History: Pt lives with her husband and brother. She smoked 2ppd x 20yrs and quit 18yrs ago. No etoh. Family History: Mother died of MI at 72. Father died of interstitial fibrosis at 80. Physical Exam: Exam: T 97.9 BP 119/64 HR 85 RR 18 O2Sat 97%(RA) Gen: Lying in bed, NAD HEENT: NC/AT, conjunctivae pink, sclerae non icteric, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit, thyroid mass(assymetric to Rt) CV: RRR, nl. S1 and S2, no S3 or S4, no murmurs/gallops/rubs Lung: B/l coarse crackles worse in Rt aBd: +BS soft, nontender, distended, no bruit, no masses, no organomegaly ext: nl. turgor, pitting edema in both legs, no cyanosis/clubbing, good peripheral pulses at radial and dorsalis pedis Neurologic examination: MS: General: alert, awake, normal affect, co-operative Orientation: oriented to person, place, date Attention: follows simple/complex commands. Speech/[Doctor Last Name ]: fluent, but has difficulty speaking with the cough Memory: Registers [3-29] and Recalls [3-29] at 5 min Calculations: 14+38=52 L/R confusion: Touches left thumb to right ear CN: I: not tested II,III: VFF to confrontation, PERRL 4mm to 2mm, fundi normal III,IV,VI: EOMI, no ptosis, end-gazed nystagmus on Rt V: sensation intact V1-V3 to LT VII: asymmetrical face, weak on Lt, orbicular oculi / , orbicularis oris / VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [Doctor First Name 81]: SCM/trapezeii [5-31] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk and tone; resting tremor in Rt hand, asterixis or myoclonus. No pronator drift. Delt [Hospital1 ] Tri WE FE Grip IO IP Quad Hamst DF [Last Name (un) 938] PF C5 C6 C7 C6 C7 C8/T1 T1 L2 L3 L4-S1 L4 L5 S1/S2 L 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 Reflex: No clonus, no pathological reflexes(Babinski, [Last Name (un) 9301], Hoffmans) [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 1 1 1 0 0 Flexor R 1 1 1 0 0 Flexor Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS. Coordination: finger-nose-finger normal, heel to shin normal, RAMs normal. Gait: Narrow based, steady. Romberg: Negative Pertinent Results: [2107-5-2] 03:58PM URINE HOURS-RANDOM [2107-5-2] 03:58PM URINE GR HOLD-HOLD [2107-5-2] 03:40PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.006 [2107-5-2] 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2107-5-2] 12:50PM GLUCOSE-90 UREA N-11 CREAT-1.2* SODIUM-136 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-22 ANION GAP-14 [2107-5-2] 12:50PM estGFR-Using this [2107-5-2] 12:50PM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-2.3 [2107-5-2] 12:50PM WBC-6.4 RBC-4.08* HGB-13.7 HCT-39.6 MCV-97 MCH-33.6* MCHC-34.7 RDW-13.5 [2107-5-2] 12:50PM NEUTS-71.1* LYMPHS-18.5 MONOS-6.4 EOS-3.0 BASOS-1.0 [2107-5-2] 12:50PM PLT COUNT-270 Brief Hospital Course: 69 y/o RHF with R Temporal Epilepsy s/p R temporal lobectomy, [Doctor Last Name 1193] Chiari s/p tonsillectomy who presented with increasing cough. She was on EEEG-LTM. The coughs were associated with R temporal spikes in EEG. She was also having seizures which consisted of left side stiffening and shaking. Patient underwent drainage of right temporal cystic area & placement of reservoir in R temporal lobe on [5-13]. Seizures accociated with cough decreased significantly. She continues to have seizures 1-2 per day whose semiology can be partial complex with left sided jerks or episodes in which she would "freeze". Patient was febrile for 5 days after surgery; CSF collected from shunt from reservoir showed WBC 800 RBC 2800 with 82% eosinophils. Eosinophilia and fever prompted a broad infectious work-up as per ID recommendation. Patient was started empirically on vancomycin, ceftazidine which were stopped on [2107-5-26] as patient was afebrile and cultures were negative. Serologies for toxoplasma, RPR, cryptococcal were negative. EBV PCR, TB PCR from CSF. [Location (un) ], cysticercosis, trichinella, LCMV antibodies are pending. In summary: SEIZURES: Patient has a baseline [5-1] seizures per day. Semiology can be cough, left side jerks or "freezing episodes". Coushing seizures improved significantly after neurosurgical procedure as above SEIZURES SHOULD BE TREATED WITH ATIVAN 1-2MG AT REHAB IF THEY LAST LONGER THAN 5 MINUTES OR SHE HAS MORE THAN 2 SEIZURES WITHIN ONE HOUR. Continue AEM as per prescriptions including topamax , lamictal, gabapentin. ID: Patient has been afebrile for more than 72 hours; off antibiotics since [2107-5-26]. She should have Serologies for toxoplasma, RPR, cryptococcal were negative. EBV PCR, TB PCR from CSF. [Location (un) ], cysticercosis, trichinella, LCMV antibodies are pending and should be followed-up in next appointment. The fever etiology is mostly likely non-infectious but a reaction to the neurosurgical procedure: placement of Rickham reservoir with catheter in the cyst cavity. Medications on Admission: Fosamax 70mg 1tab weekly Lamictal 200mg 3tab daily Nevrontin 300mg 4tab daily Lipitor 10mg 1tab daily Remeron 30mg 1/2tab daily Topamax 25mg 4tab daily Lasix 20mg 1tab daily Rasperadal 3mg 1/2tab daily Dulcolax stool softener 100mg 4 daily Slow Fe Iron 2 daily Multi Vitamin 1 daily Lorazepam 1mg 2tab daily Albuterol nebs Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every Wednesday). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Risperidone 0.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for cough and comfort. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q5 MIN PRN () as needed for seizures. 11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. Lamotrigine 100 mg Tablet Sig: 3.5 Tablets PO BID (2 times a day). 13. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). 14. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 15. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 16. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 17. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for fever. 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 20. Docusate Sodium 100 mg Capsule Sig: [1-28] Capsules PO TID (3 times a day). 21. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6 (): Taper 0.5mg/per every 3 days until patient takes 2mg daily. 23. Topiramate 50 mg Tablet Sig: 2 and 1/2tab Tablets PO BID (2 times a day). 24. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 25. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for for SBP>160. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Epilepsy Right Tempotal Lobectomy -now s/p Right temporal lobe cyst fenestration to the posterior fossa and placement of Rickham reservoir with catheter in the cyst cavity Discharge Condition: Stable; patient still has [1-28] seizures per day after procedure. Neuro exam: alert and oriented, speech is fluent, comphehension is intact, mild left sided weakness UMN pattern Discharge Instructions: You were admitted with increasing seizure frequency, left sided jerking and cough, some of which was found to be seizures. You had a brain surgery to decompress the cystic area that was in the temporal side of your brain. The coughing seizures improved significantly; although you still have some of the other seizures. You should continue to take your seizures medications as per the prescriptions. If you have more seizures than what you usually have, you should contact your doctor. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 5285] Date/Time:[2107-8-25] 1:00 DO NOT HESITATE TO CALL IF THE APPOITMENT IS NEEDED EARLIER THAN THAT Completed by:[2107-5-27**]	[ "51881", "41401", "V4582", "311", "53081", "49390", "4019" ]
Admission Date: [2112-9-18] Discharge Date: [2112-10-4] Service: MEDICINE Allergies: Zosyn Attending:[First Name3 (LF) 10682] Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: intubation extubation ERCP with biliary stent placement Percutaneous cholecystostomy tube placement by IR History of Present Illness: [Age over 90 ]M with CHF, HTN, CKD recently hospitalized for CHF exacerbation who had been at rehab until recently who developed RUQ abdominal pain 3 days PTA when discharged home and developed N/V and worsening abdominal pain last couple days. . At OSH, labs were significant for elevated transaminase, bili, and lactate. RUQ U/S revealed distended GB, CBD 8mm, no pericholecystic fluid or thickened wall. He was given Dilaudid, Unasyn, Cipro, Flagyl, and Gentamycin and sent to [Hospital1 18] for possible ERCP vs surgical management of presumed biliary obstruction. . In the ED, initial vs were: 99.2 121 129/76 26 95%. He received 2L NS. SBPs dropped to 80s as well as HR 80s. He received an additional 500cc with improvement in BP to 94/46. Labs significant for lactate 7.2, WBC 5K with 33% bands, T bili 6.3, ALT 220, AST 167, AP 310. He was seen by surgery and ERCP with recommendation for ERCP in am. At transfer: T 97.1 BP 94/46 HR 88 97%4L. . On the floor, he reports pain is [9-11] in severity. Past Medical History: CHF (recent exacerbation) Hypercholesterolemia Renal disease Gait disturbance HTN Anemia GERD Bradycardia Social History: Lives with wife although was recently at rehab until day of admission. Has 14 grandchildren. Formerly worked odd jobs and as a grocer. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: not relevant to this admission. Physical Exam: on ICU admission: General: Somnolent but arousable, oriented x 3, appears to be in pain HEENT: Sclera icteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased BS in bases with faint crackles. No wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Slightly distended. Tender in RUQ and RLQ, positive [Doctor Last Name 515]. Involuntary guarding, no rebound. Absent BS. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [2112-9-18] 04:13AM BLOOD WBC-12.2# RBC-3.15 Hgb-9.2* Hct-28.4* MCV-90 MCH-29.2 MCHC-32.4 RDW-13.5 Plt Ct-122* [2112-9-30] 06:40AM BLOOD WBC-4.6 RBC-3.17* Hgb-8.8* Hct-27.4* MCV-87 MCH-27.7 MCHC-32.0 RDW-13.5 Plt Ct-453# [2112-9-17] 11:00PM BLOOD Glucose-134 UreaN-56* Creat-2.5* Na-142 K-4.5 Cl-106 HCO3-18* AnGap-23* [2112-9-19] 05:27AM BLOOD Glucose-128* UreaN-71* Creat-3.5* Na-139 K-5.0 Cl-108 HCO3-21* AnGap-15 [2112-9-30] 06:40AM BLOOD Glucose-118* UreaN-33* Creat-1.5* Na-135 K-4.4 Cl-106 HCO3-22 AnGap-11 [2112-9-17] 11:00PM BLOOD ALT-220* AST-167* AlkPhos-310* TotBili-6.3* DirBili-5.6* IndBili-0.7 [2112-9-26] 06:50AM BLOOD ALT-31 AST-15 LD(LDH)-237 AlkPhos-111 TotBili-0.6 [2112-9-17] 11:00PM BLOOD Lipase-198* [2112-9-22] 03:49AM BLOOD Lipase-21 [2112-9-18] 09:45PM BLOOD CK-MB-49* MB Indx-2.7 cTropnT-0.27* [2112-9-19] 03:09PM BLOOD CK-MB-20* MB Indx-2.2 cTropnT-0.32* [2112-9-22] 03:49AM BLOOD CK-MB-4 cTropnT-0.31* [2112-9-30] 06:40AM BLOOD Phos-3.9 Mg-1.6 [2112-9-23] 06:00AM BLOOD %HbA1c-6.2* eAG-131* [2112-9-17] 11:08PM BLOOD Lactate-7.4* [2112-9-20] 09:53PM BLOOD Lactate-1.1 Discharge labs, [9-30]: 135 106 33 ----------------< 118 4.4 22 1.5 Mg 1.6, Phos 3.9 4.6>-----<453 27.4 Micro: [2112-9-25] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- + CLOSTRIDIUM DIFFICILE URINE CULTURE-Negative Blood Culture, Routine-Negative x7 [2112-9-20] Bile FLUID CULTURE- ESCHERICHIA COLI, pan-sensitive [2112-9-18] MRSA SCREEN MRSA SCREEN- No MRSA isolated Cardiac Echo Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). There is mild (non-obstructive) focal hypertrophy of the basal septum. There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild calcific aortic stenosis. Mild mitral and moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Renal Ultrasound IMPRESSION: No evidence of hydronephrosis, masses, or stones. Echogenic kidneys with evidence of chronic renal disease. Limited doppler examination shows patent renal arteries and renal veins bilaterally. Doppler waveforms indicate increased bilateral resistance to diastolic flow. UNILAT UP EXT VEINS US Study Date of [2112-10-3] IMPRESSION: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Superficial thrombus noted in the left cephalic vein, below the level of the left antecubital fossa. 3. Subcutaneous edema in the region of the left antecubital fossa ________________________________________________ ERCP Procedures: A 9cm by 10FR Cotton [Doctor Last Name ] biliary stent was placed successfully in the main duct due to the high suspicion for cholangitis. No [Known firstname ] pus was seen exiting the papilla following stent placement. Impression: Successful biliary cannulation. Normal biliary tree and anatomy. Normal size CBD given patient's age. No pus seen exiting the papilla. No evidence of extrinsic compression, no ductal abnormalities, and no filling defects. Cystic duct slowly filled with contrast and the gallbladder was partially visualized. Successful placement of 9cm x 10F Cotton [Doctor Last Name ] biliary stent due to the high LFTs, clinical suspicion for cholangitis, and possibility of a small stone being missed on cholangiogram contributing to symptoms. Otherwise normal ercp to third part of the duodenum. Recommendations: Please call Dr.[Name (NI) 2798] office at [Telephone/Fax (1) 2799] with any further questions or concerns. Please call the on call ERCP fellow at [Telephone/Fax (1) 2756] with any immediate concerns such as fever, abdominal pain, bleeding, following your procedure. Return in 4 weeks for repeat ERCP with Dr. [Last Name (STitle) ] for stent pull and re-assessment of the duct. ____________________________________________ Brief Hospital Course: [Age over 90 ]M with CHF, CKD, and HTN trasnferred from OSH with N/V, hyperbilirubinemia, and bandemia consistent with biliary sepsis s/p ERCP with stent placement s/p percutaneous drain placement. . # Septic shock from cholangitis: Patient presenting with sepsis (elevated bands and tachycardia in setting of likely infection) and cholestatic pattern of elevated LFTs as well as RUQ U/S with distended GB consistent with biliary obstruction. Underwent successful ERCP [9-19] with stent placement and his LFTs have been trending down. IR drain placed [9-20]. In terms of his sepsis, lactates have trended down to normal, and no longer with a pressor requirement. Vancomycin was added to zosyn on [9-19] for broader coverage. Bile culture grew pan sensitive e.coli an antibiotics were tailored to cipro/flagyl to complete a 2 week course. Given his ongoing pain, a cholecystostomy tube was placed by Interventional Radiology. The cholecystostomy tube will need to remain in place for at least 3 weeks, per Surgery. Pt will f/u with ACS [Doctor First Name ] Service Clinic after discharge. He had no abdominal pain upon discharge. . #Aspiration pneumonitis: Patient developed an evolving right lower lobe infiltrate on CXR. Afebrile with nl WBC. Pt with diffuse rhonchi on [9-24] and therefore vanco/zosyn continued. However, pt rapidly improved and antibiotics were changed to cipro/flagyl as above. There was no further evidence of pneumonia. . #C.diff colitis: Pt developed loose stools on [9-25]. His stools were tested and were found to be C.diff toxin positive. He was continued on flagyl however he continued to have ongoing frequent stooling. Due to the lack of significant improvement in the frequency of his stools, oral vancomycin was added to his regimen. This was discussed with Infectious Disease, and the pt meets criteria for severe c. diff based on frequency of BM and age, and therefore warrants addition of po vancomycin. Pt's BM's frequency is improving on dual therapy. Patient is to continue flagyl as per above through [10-13] (14 day course from the addition of vanc) and continue po vanc 125 mg po Q6hr through [10-13] (14 day course). . # Acute renal failure on CKD: Pt presenting with elevated Cr with baseline 1.4. most likely ATN in setting of sepsis with prolonged hypotension. Urine lytes checked and Fena is 1.2% with 12 granular casts on sediment arguing for intrinsic renal pathology likely in setting of prolonged hypotension, likely ATN. His renal function continued to improve throughout the hospitalization. . # chronic diastolic congestive heart failure: Pt was recently hospitalized with CHF exacerbation. Echo: EF 55-60%. His fluid balance was carefully monitored throughout the hospitalization. . # Elevated Cardiac enzymes: Elevated enzymes likely demand ischemia and renal failure. EKG did not show changes concerning for MI. . # Hypertension: His blood pressure medications were initially held in the setting of hypotension, and his amlodipine was added back as his blood pressure rose. His hydrochlorothiazide remains held at this time, as the patient is at risk for dehydration considering his frequent stooling from c-diff infection. Please consider adding back his hydrochlorothiazide 25 mg po q day once his diarrhea has resolved. . # Hypercholesterolemia: his statin was initially held in the setting of elevated LFT's. His simvastatin was resumed once his LFT's normalized. . # Superficial venous thrombosis of L upper extremity: Pt was noted to have LUE swelling on [10-3]. No DVT on ultrasound. No indication for anticoagulation. Keep elevated. . #DVT Prophylaxis: Heparin 5000 units TID #COMMUNICATION: wife [Name (NI) 22362] [Telephone/Fax (1) 87794] Medications on Admission: Updated [9-23] based on fax from PCP. [Name Initial (NameIs) 87795] 2.5-0.025 tablet. 1-2 tabs po QID prn diarrhea Roxicet 5-325 mg tab. One tab po q 8 hr prn. HCTZ 25 mg po q day Sulindac 150 mg po BID B12 injection 1000 mcg q month MVI 1 tab po q day omeprazole 20 mg po q day simvastatin 20 mg po q HS amlodipine 10 mg po q day Discharge Medications: 1. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One (1) inj Injection once a month. 6. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. 7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day): for DVT prophylaxis given decreased mobility. 10. insulin lispro 100 unit/mL Solution Sig: 2-10 units Subcutaneous ASDIR (AS DIRECTED). 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital ] Rehabilitation & Nursing Center - [Location (un) ] Discharge Diagnosis: sepsis due to biliary obstruction C.diff diarrhea aspiration 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 with an infection in your gallbladder. You had a drain placed in your gallbladder and were given antibiotics and your symptoms improved. You also had an infection in your stool and were given antibiotics for this as well. . Medication changes 1.ciprofloxacin 2. flagyl 3. oral vancomycin . Discontinued: 1. hydrochlorothiazide (until follow up with PCP) Please follow up with the appointments below and take your medications as prescribed. Followup Instructions: Name: Dr [First Name4 (NamePattern1) 518] [Last Name (NamePattern1) 519], General Surgeon Location: [Hospital Ward Name 516], [Hospital Ward Name 23] Bldg, [Location (un) 470] Phone: [Telephone/Fax (1) 6554] Appt: [10-10] at 9:30am Return in 4 weeks for repeat ERCP with Dr. [Last Name (STitle) ] for stent pull and re-assessment of the duct. Please follow up with your primary care physician after discharge from rehab.	[ "0389", "51881", "78552", "5070", "5845", "2762", "99592", "4280", "40390", "2720", "25000", "53081", "4168" ]
Admission Date: [2130-11-14] Discharge Date: [2130-11-27] Date of Birth: [2058-9-27] Sex: F Service: SURGERY Allergies: Latex / Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 4691] Chief Complaint: Abdominal pain; BRBPR Major Surgical or Invasive Procedure: Hartmann's resection of the sigmoid colon, end colostomy with Hartmann's pouch History of Present Illness: 72F with history of rheumatoid arthritis on steroids presents with severe abdominal pain of one day duration. Patient reports long standing trouble with gastric ulcers due to her immunosuppressive therapy, however her medication was stopped due to intolerance. She had not had episodes of abdominal pain in the past. Her current pain is not accompanied by nausea, vomiting, or diarrhea. She has not been passing flatus since her pain started. She has normal bowel movements and reports a normal recent colonoscopy. She denies fevers, chills, and malaise. Her main health problems at this time are related to her RA which is severe and has recently required citoxan therapy for which a tunneled L SCV line was placed about 6 weeks ago. Her last dose of citoxan was 5 weeks ago. She was recently admitted at [Hospital3 ] for management of MRSA cellulitis from her chronic vasculitic LE leg wounds. At outside hospital, received meropenem and flagyl. Of note, her plavix has been held for the last 4 days. Past Medical History: PMH: LE vasculitis, MRSA from leg wound, htn, R stroke with minor weakness of LUE, diabetes, rhematoid arthritis, vasculitis, CAD, bronchiectasis with pigeon chest, diastolic CHF, corpus calosum, osteoperosis, anemia, anxiety PSH: Cervical fusion, R shoulder, b/l wrist, b/l THR, b/l knee replacement, b/l ankle Social History: SH: Accompanied by her sons, came from rehab facility. Denies tobacco use, occasional alcohol use. Family History: FH: No known GI cancers Physical Exam: On exam: VS:97.6 100 140/85 18 98% Gen: Appears comfortable, NAD CV: RRR Resp: CTAB, anterior protrusion of chest wall Abd: Distended, tympanitic, very tender to percussion and palption, + guarding, no rebound Ext: 2 deep wounds (1.5 cm area) over lateral surface of RLE and posterior calf of her LLE, chronic from vasculitis. Multiple healing ulcers. Palpable pulses b/l. Warm, no edema. Pertinent Results: [2130-11-14] 10:30PM BLOOD WBC-25.4* RBC-3.88* Hgb-11.1* Hct-34.0* MCV-88 MCH-28.7 MCHC-32.8 RDW-18.3* Plt Ct-249 [2130-11-14] Neuts-96.0* Lymphs-2.2* Monos-1.4* Eos-0.2 Baso-0.1 PT-12.8 PTT-23.5 INR(PT)-1.1 Glucose-98 UreaN-20 Creat-0.7 Na-138 K-4.1 Cl-106 HCO3-20* AnGap-16 [2130-11-14] 11:17PM BLOOD Lactate-1.7 [2130-11-16] 02:47AM BLOOD freeCa-1.23 [2130-11-18] 04:56AM BLOOD WBC-10.0 RBC-3.73* Hgb-10.0* Hct-33.1* MCV-89 MCH-26.7* MCHC-30.1* RDW-18.2* Plt Ct-282 Calcium-8.3* Phos-3.0 Mg-2.0 Glucose-108* UreaN-20 Creat-0.4 Na-142 K-4.2 Cl-114* HCO3-19* AnGap-13 [2130-11-14]: Rapid irregularly irregular narrow complex rhythm is present consistent with atrial fibrillation. A single monomorphic ventricular premature beat is present. Non-specific ST-T wave changes are present. The development of atrial fibrillation is new compared with the previous tracing of [2113] Echo [9-7] at [Hospital3 ]: LVEF 65%, 3+ MR, 1+ TR, mild pHTN, mild [Name Prefix (Prefixes) ] [Last Name (Prefixes) 1915], LVID 5.2 diastolic, 3.5 systolic Brief Hospital Course: The patient was transferred from an OSH after an Abd CT scan revealed free air and fluid within her pelvis without a clear source of perforation. She was initially admitted to the trauma ICU, but was taken emergently to the operating room on [11-14], [2130] where she underwent a Hartmann's resection of the sigmoid colon and end colostomy with Hartmann's pouch; please see operative report for further details. Postoperatively, the patient was transferred to the ICU. She was extubated and transitionted to IV dilaudid for pain control with continued intravenous metronidazole and meropenem. Her NGT was discontinued and po medications were initiated. Given hemodynamic stability, she was transferred to the general surgical [Hospital1 ] on [Month (only) 359] POD2 for further management. Neuro: The patient was alert and oriented throughout her hospitalization; post-extubation, pain was initially managed with intravenous hydromorphone. This was transitioned to oral oxycodone and acetaminophen on POD5 with well controlled pain. Of note, the patient did occasionally require intravenous morphine for breakthrough pain control. CV: Upon transfer from the OSH, the patient was noted to be in a fib with intermittent RVR. Oral metoprolol was resumed on POD1 and a cardiology consult was obtained on POD4 with recommendations for anticoagulation with either heparin gtt or lovenox bridged to oral warfarin or to begin anticoagulation with dabigatran. [Month (only) 4692], possible cardioversion either as an in/outpatient was suggested; anticoagulation not resumed at this time as per surgeon due to very high risk for falls. The patient remained asymptomatic and hemodynamically stable, therefore, inpatient cardioversion was not attempted. She will follow-up with her primary care provider upon discharge for ongoing management of these issues. She was not started on anticoagulation, outside of subcutaneous heparin, because of fall risk and the thought that her irregular heart rate was a post-surgical response. This will be reassessed when she follows up in [Hospital 2536] clinic and with her PCP. [Name10 (NameIs) 4692], the patient presented with a tunneled line in place for outpatient citoxan, which was noted to be out of position on POD2, requiring IR removal and replacement. Pulmonary: The patient remained intubated post-operatively due to difficulty with initial intubation for surgery. Given respiratory stability she was extubated on POD1. She remained stable until POD6 when she developed acute SOB. A CXR was obtained and suggested 'unchanged left lower lung collapse and improved bilateral pleural effusions'. The event did not recur and the patient remained stable throughout the remainder of her hospitalization; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. Patient has history of diastolic heart failure, chronic, that was monitored throughout this hospitalization and she ahd no acute issues realted to her heart failure. GI/GU/FEN: Bowel function returned by POD3 as noted by gas/ stool within the ostomy appliance. The patient received teaching regarding ostomy care including emptying pouch and changing the appliance from the Ostomy RN. However, her ability to perform these tasks was limited by her hand deformities. Occupational therapy was consulted for further assistance and will continue at the rehab facility. She was initially NPO, but was advanced sequentially following return of bowel function to diabetic diet, which was well tolerated. Nutrition was consulted due to multiple bilateral chronic lower extremity ulcerations; recommendations included high protein supplements and food choices. Patient's intake and output were closely monitored with electrolyte repletion prn. She was taking adequate food and had gppd output through her ostomy. ID: Intravenous metronidazole and meropenem were initiated and continued through POD2 & POD7, respectively. On POD 7, the patient's WBC began trending upward, therefore, blood cultures were sent and an CT Torso was obtained and her antibiotics were switched to vancomycin, zosyn, and fluconazole; results from CT scan showed small amount of free fluid in the pelvis but no signs of abscess and otherwise normal CT. On POD 8, the WBC began trending downward and on POD 9 patient was kept on only diflucan with a planned 5 day course for what appeared per derm and rheum to be a yeast infection on her back. She was discharged on no antibioics as she had finished her course of diflucan and her back rash was much improved. At time of discharge her blood cultures had no growth to date. She has a JP drain on her left side that has been draining minimal amout of serous fluid but will be left in until follow-up appointment. She also has staples in her abdominal wound that will be left in until her follow-up appointment with [Hospital 2536] clinic. Rheum: No acute change in managment of RA while inpatient, patient will follow up with her outpatient rheumatologist Dr [Last Name (STitle) 1492]. Daily predinsone, at home dosage, was continued while in-house. [Last Name (STitle) 4692], on POD8, a large rash was noted on the patients back. Rheumatology felt this was fungal in nature and recommended topical antifungal treatment with derm consultation who also agreed with antifungal treatment. Prophylaxis: The patient received subcutaneous heparin during this stay; she was encouraged to get out of bed as ealry as possible. Rehab: The patient was seen by physical therapy for in-patient evaluation and treatment. PT recommended transfer to rehab upon discharge due to the level of assistance required in addition to pt living at home alone; see evaluation for details. At the time of discharge to rehab, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a diabetic diet, ambulating with assistance and use of a rolling walker. She was voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Folic acid 1g daily Plavix 75 mg daily Vitamin B12 1000 mcg daily Lasix 20 mg daily Metoprolol 50 mg daily Spironolactone 125 mg daily Neurontin 100 mg [Hospital1 ] Prednisone 10 mg daily Iron 325 mg daily MVI 1 tablet daily Maalox 30 mg prn Discharge Medications: 1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for pain. 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:30 Tablet(s) Refills:0 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. spironolactone 25 mg Tablet Sig: Five (5) Tablet PO once a day. 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) ] of [Location (un) 4693] Discharge Diagnosis: Sigmoid diverticulitis with ruptured pelvic abscess and peritonitis Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [Hospital1 18] from an outside hospital after experiencing abdominal pain associated with bright red blood per rectum. An abdominal CT scan revealed free air within the abdominal cavity due to perforation. Therefore, you underwent an emergent operation to repair a ruptured pelvic abscess. You have recovered from surgery in the hospital and have also worked with occupational therapy, physical therapy and the ostomy care RN and are now preparing for discharge to a rehab facility for ongoing recovery. Followup Instructions: Please call for an Acute Care Service appointment at [Telephone/Fax (1) 600]. You should schedule this appointment for [8-6] days from discharge with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. At this appointment you will possibly have your drain removed and your staples taken out. Please follow-up with Dr. [First Name11 (Name Pattern1) 1494] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1492], your PCP, [Last Name (NamePattern4) ] [0-0-] in the next 2 weeks. This would be regarding this hospitalization if cardiology referral is needed for further follow-up of the mitral regurgitation found on your Echo. You should also discusss the possibility of a repeat Echo. Completed by:[2130-11-27]	[ "5119", "4280", "25000", "42731", "4019" ]
Admission Date: [2127-1-17] Discharge Date: [2127-1-27] Date of Birth: [2072-4-23] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: chest pressure on exertion Major Surgical or Invasive Procedure: [2127-1-23] Coronary Artery Bypass Graft x 2(LIMA-LAD,SVG-OM) left heart catheterization, coronary angiogram History of Present Illness: This 54 year old man with recent onset chest pain who has a past medical history significant for hypertension, hyperlipidemia and family history of coronary artery disease. A stress test was performed which was positive with severe anterior ischemia. He was subsequently referred for cardiac catheterization which showed a high grade left main stenosis and a proximal left anterior descending artery stenosis. Given the severity of his disease, he was referred for surgical revascularization this admission. Past Medical History: Hypertension Hyperlipidemia asthma obesity right neck nerve division ( in childhood for asthma study) s/p inguinal herniorrhaphy s/p vasectomy Social History: Race:Caucasian Last Dental Exam:[11-16] Lives with: Wife Contact: [Name (NI) ] [Known lastname 92057] Phone # cell [Telephone/Fax (1) 92058] Occupation:sales Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use:one cigar per week, last 2 months ago ETOH: < 1 drink/week [] [2-11] drinks/week [] >8 drinks/week [x] Illicit drug use-none Family History: Family History: +Premature coronary artery disease Father MI < 55 [] Mother < 65 [x]CABG at 64 Physical Exam: Pulse: Resp: O2 sat: B/P Right: Left: Height: 5'8" Weight:190# General:NAD, no pain, resting comfortably Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X]anicteric sclera;OP unremarkable Neck: Supple [X] Full ROM [X]healed incision R neck Chest: Lungs clear bilaterally [X]healed lac. R ant-lat chest Heart: RRR [X] Irregular [] Murmur [] grade ______ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema [] _none____ Varicosities: None [X]lying down Neuro: Grossly intact [X]MAE [5-10] strengths, nonfocal exam Pulses: Femoral Right: cath drsg.1+ Left:2+ DP Right: 2+ Left:2+ PT [Name (NI) 167]: NP Left:NP Radial Right: 2+ Left:2+ Carotid Bruit Right: none Left: none Pertinent Results: [2127-1-26] 05:03AM BLOOD WBC-8.8 RBC-2.88* Hgb-9.1* Hct-25.3* MCV-88 MCH-31.5 MCHC-35.8* RDW-12.0 Plt Ct-196 [2127-1-25] 04:06AM BLOOD WBC-9.0 RBC-3.03* Hgb-9.7* Hct-26.4* MCV-87 MCH-31.9 MCHC-36.7* RDW-12.0 Plt Ct-179 [2127-1-24] 02:04AM BLOOD WBC-9.5 RBC-3.31* Hgb-10.5* Hct-28.2* MCV-85 MCH-31.7 MCHC-37.1* RDW-11.9 Plt Ct-177 [2127-1-26] 05:03AM BLOOD Na-141 K-4.1 Cl-106 [2127-1-25] 04:06AM BLOOD Glucose-109* UreaN-10 Creat-0.9 Na-141 K-4.3 Cl-107 HCO3-28 AnGap-10 [2127-1-24] 02:04AM BLOOD Glucose-133* UreaN-9 Creat-0.7 Na-133 K-4.2 Cl-107 HCO3-22 AnGap-8 [2127-1-23] 01:30PM BLOOD UreaN-13 Creat-0.7 Na-141 K-4.3 Cl-117* HCO3-21* AnGap-7* TTE [2127-1-20] (preop) The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). 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 stenosis or aortic regurgitation. 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: Normal study. No structural heart disease or pathologic flow identified. [2127-1-27] 05:15AM BLOOD WBC-7.3 RBC-2.92* Hgb-9.2* Hct-25.9* MCV-89 MCH-31.5 MCHC-35.4* RDW-12.1 Plt Ct-235 [2127-1-27] 05:15AM BLOOD Glucose-112* UreaN-12 Creat-1.0 Na-142 K-4.5 Cl-104 HCO3-29 AnGap-14 Brief Hospital Course: After an inpatient Plavix washout he was taken to the Operating Room on [2127-1-23] where he underwent coronary artery bypass graft x 2. He tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward his preoperative weight. The patient was transferred to the telemetry floor for further recovery. Beta blockers were titrated for rate and blood pressure control. Chest tubes and pacing wires were discontinued without complication. He did have a temperature to 101.1 on POD3. He was cultured,but there was no growth to date at the time of discharge. His CXR showed no signs of infiltrate and he was afebrile with a normal white blood cell count at the time of discharge. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating independently, the wound was healing well, he was tolerating a full oral diet and pain was controlled with oral analgesics. The patient was discharged home with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: Aspirin 325 mg daily Atenolol 25 mg daily Docusate Sodium 100 mg [Hospital1 ] Maalox 30 ml q4hrs PRN Milk of magnesia 30 mg daily PRN nitroglycerin 0.3mg SL q5min for 3 doses prn chest pain pravastatin sodium 40 mg qHS prochlorperazine 10 mg q6hrs PRN (25 mg q12 hrs PRN rectally) Temazepam 15 mg qHS PRN insomina Tylenol 650 mg q6hrs PRN Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease\ns/p coronary artery bypass grafts Hypertension Hyperlipidemia asthma obesity s/p herniorraphy Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. 1+ Edema Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. 1+ Edema Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Right - 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 [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [2127-2-26] at 1:15 PM Cardiologist: Dr. [Last Name (STitle) 5686] ([Telephone/Fax (1) 11554]) on [2127-2-19] at 2:15pm [Hospital 409] clinic at Cardiac Surgery office on [2127-2-4] at 10:30am Please call to schedule appointments with: Primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [4-10] weeks ([Telephone/Fax (1) 3183]) 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:[2127-1-27]	[ "41401", "4019", "2724", "49390", "2859" ]
Admission Date: [2193-2-21] Discharge Date: [2193-3-5] Date of Birth: [2131-11-17] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Pentothal / Codeine / Wellbutrin / Zosyn / Meropenem Attending:[Doctor First Name 5188] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Total Abdominal Colectomy and end ileostomy [2193-2-24] History of Present Illness: 61 morbidly obese female with multiple medical problems including DM, HTN, dCHF, COPD. Was recently discharged on [2-17] after admission for hypoxic and hypercarbic respiratory failure after being found unresponsive at home by her husband, treated for [Name (NI) 16630] with Vanco/Levo/Zosyn, s/p trach after prolonged wean, course c/b ARF and drug fever, transferred to [Hospital1 ] on [2193-2-17]. Readmitted yesterday after she was complaining of diffuse abdominal pain and had low grade fevers to 100.9. At [Hospital1 ] on the morning of [2-20], she had altered mental status, and was more difficult to arouse. On exam she seemed to have significant right sided abdominal/flank pain. She was started on levoflox 250mg Q48h when she began to spike fevers to 103 with a dirty U/A no culture was sent. Blood Cx post for staph and vanco Iv was started yesterday. Flagyl IV Started yesterday after CT abd/pelvis which showed diffuse colitis (unchanged from previous exam. C. Diff cultures came back positive today and Medical tem was concerend that abdominla exam had changed overnight to include rebound tenderness. The patient has remianed hemodynamically stable throughout this admission thus far. Past Medical History: Past Medical History: relative immobility, spends a lot of time in bed Hypertension Diabetes Obesity COPD on home O2 2-3L at all times Currently Tobacco use Obstructive Sleep Apnea on home CPAP Obesity hypoventilation syndrome diastolic CHF (by c.cath [1-/2192]) Social History: Social history is significant for the current tobacco use (40-50 pk yr). There is no history of alcohol abuse, only occasional wine She lives at home with her husband. Family History: There is family history of premature coronary artery disease- her father died in his 40s of an MI. Physical Exam: PE: 103.7 104 136/55 25 95% AC 500x14 PEEP 5 Fluids NaCL 200/hr UOP >100/hr AbX IV vanc/levo/flagyl started last night Obese female Mod distress NCAT trach in place mottled skin with drug rash diffuse bilateral ronchi tachycardia gastrostomy tube in place Abd obese TTP diffusely R>L with no tap tenderness but with gaurding and rebound stool guiac neg Pertinent Results: 12.7>-----<294 28.4 149 112 57 ---I---I---<153 4.2 25 3.4 CT [2-21]: Interval worsening of colitis extending from the ascending colon to the splenic flexure, with new area of involvement within the sigmoid colon. Stool Cx C.Diff pos Brief Hospital Course: The patient was initially admitted to the MICU service. General Surgery consulted for C.Diff colitis. She was treated conservatively. However, over the next 48 hours her abdominal become worrisome and she developed ARF and essentially became anuric. A KUB at this time demonstrated free air. The patient was then taken to the operating room where she underwent a total abdominal colectomy with end ileostomy. She was noted to have 2.5 Liters of purulent material in the abdomen in the OR. POST-OP: The patient was transferred to the SICU for further resuscitation. Neuro: pain was controlled and sedation minimized . CV: At this point her hemodynamics had begun to improve. She was quickly weaned off of pressors and required minimal fluid resuscitation. . Pulm: She was eventually able to wean to minimal vent settings, but only tolerated trach collar for a few hours at a time. This is likely due to her pre-existing condition as well as severe illness she was recovering from. . GI/FEN: She was placed on trophic tube feeds and advanced to goal which she tolerated. Her stoma was functioning well at the time of discharge. . Renal: Renal was consulted for her ARF. She began CVVHD after a HD line was placed. This was continued for about a week until enought volume had been taken off to adequately wean her vent settings. The CVVHD was stopped and she began making more urine, about 50-100cc per hour. Her electrolytes and Creatinine remained stable. Renal recommended holding off on further dialysis for now. She did receive a few doses of lasix and seems to respond well to this. . Heme: her Hct was stable but slowly drifted down to 22 by discharge, she received one unit of PRBC for this. . ID: she was initially treated with Cipro/Flagyl/Vanco. The IV vanco was for a coag neg blood Cx. The flagyl was for the C.Diff, and the cipro was continued for 7 days for coverage due to gross abdominal contamination. . Endo: blood sugars controlled with sliding scale insulin. Medications on Admission: Benadryl 50mg IV q6,Triamcinolone cream TID,Sarna,Insulin SS Bisacodyl,Colace,Levofloxacin 250mg q48,Vancomycin x 1,Albuterol Ipratropium,Fluticasone,TF's Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 2. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical TID (3 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 6-8 Puffs Inhalation Q4H (every 4 hours). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [Hospital1 ] (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection [Hospital1 ] (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Insulin Regular Human 100 unit/mL Solution Sig: insulin sliding scale Injection ASDIR (AS DIRECTED). 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 12. Famotidine(PF) in [Doctor First Name ] (Iso-os) 20 mg/50 mL Piggyback Sig: One (1) dose Intravenous Q24H (every 24 hours). 13. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [Location (un) 32674] - [Location (un) ] Discharge Diagnosis: Clostridium Difficile Colitis Sepsis Acute renal failure Respiratory Failure Discharge Condition: Hemodynamics stable, still requiring some vent support but tolerating periods of trach collar. Acute renal failure appears to be resolving. Tolerating tube feeds. Wound healing well with wound VAC dressing. Discharge Instructions: DIET: patient should continue on tube feeds for now. [Month (only) 116] try POs if passes swallow evaluation, off ventilator, and tolerating PMV ACTIVITY: OOB as much as possible, aggressive PT WOUND: abdominal wound with large wound vac. Wound appears healthy, should be changed every 3-4 days. OSTOMY: stoma healthy, putting out adequate stool, continue current management. ANTIBIOTICS: flagyl should continue for a total of 14 days from day of surgery (end on [3-10]) Followup Instructions: Please follow up with Dr. [Last Name (STitle) 5182] in 2 weeks [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190]	[ "5845", "5990", "2760", "496", "4280", "40390", "5859", "32723", "25000", "3051" ]
Admission Date: [2123-11-21] Discharge Date: [2123-11-25] Date of Birth: [2087-6-4] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Abilify / Cymbalta / Trileptal Attending:[First Name3 (LF) 2145] Chief Complaint: Overdose Major Surgical or Invasive Procedure: None History of Present Illness: 36F h/o bipolar d/o who took approx 100 tabs of 325mg aspirin and 25 tabs of excedrin pm at 1400 [2123-11-21]. She told her brother what she had done and subsequently presented to [Hospital ] Medical Center, where around 1730 her tylenol level was 46 and her aspirin level was 34. She was given NAC 9gm, 60g activated charcoal, and 3 amps of bicarb in 1L D5W. Urine pH was 6.5, ABG 7.41/26/92. She was tachy to 140's-150's. She was transferred to [Hospital1 18] for further management. . On arrival in the ED, VS: T 97.6, BP 115/87, HR 162, RR 25, Sat 98% RA. Initial ABG 7.53/27/189. She was given ativan 2mg iv. She had a foley catheter placed with 900cc UOP. . She states that her intention was not to harm herself with her overdose, she 'just wanted to sleep.' She notes one past suicide attempt 3 years prior with psych hospitalization and does not want further inpatient psych treatment. She notes her father being in the hospital as a current stressor. . ROS: Increased stress recently related to father being in the hospital, parent's anniversary would be this month (mother deceased 6 years ago). She notes dry mouth, feeling thirsty, abdominal discomfort (gas?). She denies HA, visual changes, tinnitus/hearing changes, sore throat, cough, SOB, CP, palpitations, nausea, vomitting, diarrhea, constipation, melena, BRBPR, dysuria, weakness, extremity pain, tingling, numbness, confussion. Past Medical History: Bipolar D/O: H/O suicide attempt with psychiatric hospitalization 3 years ago; followed by therapist Chartial, psychiatrist Mufti (both in [Location (un) 5503]) -H/O tachycardia, has had holter monitor, TTE in the past (? normal) recent TSH reportedly normal, reports negative stress 1 year ago, cardiologist in [Location 21487] [Location 47010] Social History: Divorced, no children, lives alone in [Location (un) 5503]. Denies etoh, tobacco, illicit drug use. Family History: Father with hypertension, CAD; mother deceased [3-19] breast cancer, brother/sister healthy. Physical Exam: VS: T: 98.0 HR: 149 BP: 102/67 RR: 21 Sat: 95% on RA Gen: Anxious, thin, slightly unkempt appearing woman HEENT: NCAT, PERRL but 9mm, sclera anicteric, OP clear, mm very dry, hair coarse in texture Neck: Supple, no LAD, no JVD CV: regular rhythm, tachycardic, no m/r/g Resp: CTAB, no w/r/r Abdomen: soft, NT, ND, +BS, no HSM or organomegally Ext: No c/c/e. DP pulses/radial 2+ bilaterally Neuro: A + O x 3, motor [6-19] UE/LE, sensation intact to light touch UE/LE; DTR's 2+ at biceps, triceps, brachioradialis, patellar bilaterally; [Doctor First Name ] smooth and well coordinated Skin: dry, warm, no rashes Pertinent Results: [2123-11-21] 10:58PM TYPE-ART PO2-99 PCO2-25* PH-7.55* TOTAL CO2-23 BASE XS-0 [2123-11-21] 10:58PM LACTATE-2.0 [2123-11-21] 10:58PM freeCa-1.04* [2123-11-21] 10:55PM TYPE-[Last Name (un) ] PO2-37* PCO2-29* PH-7.53* TOTAL CO2-25 BASE XS-2 [2123-11-21] 10:38PM GLUCOSE-127* UREA N-7 CREAT-0.9 SODIUM-150* POTASSIUM-3.3 CHLORIDE-112* TOTAL CO2-22 ANION GAP-19 [2123-11-21] 10:38PM ALT(SGPT)-9 AST(SGOT)-13 LD(LDH)-107 ALK PHOS-52 TOT BILI-0.1 [2123-11-21] 10:38PM ALBUMIN-4.4 CALCIUM-8.9 PHOSPHATE-1.9* MAGNESIUM-2.0 [2123-11-21] 10:38PM TSH-1.2 [2123-11-21] 10:38PM ASA-54* ACETMNPHN-9.6 [2123-11-21] 10:38PM WBC-8.2 RBC-4.52 HGB-14.5 HCT-39.5 MCV-87 MCH-32.0 MCHC-36.6* RDW-14.0 [2123-11-21] 10:38PM NEUTS-66.7 LYMPHS-27.5 MONOS-5.1 EOS-0.5 BASOS-0.2 [2123-11-21] 10:38PM PLT COUNT-269 [2123-11-21] 10:38PM PT-13.9* PTT-25.2 INR(PT)-1.2* [2123-11-21] 08:22PM TYPE-[Last Name (un) ] PO2-189* PCO2-27* PH-7.53* TOTAL CO2-23 BASE XS-1 COMMENTS-GREEN TOP [2123-11-21] 08:22PM K+-3.3* [2123-11-21] 08:16PM GLUCOSE-246* UREA N-7 CREAT-0.9 SODIUM-148* POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-23* [2123-11-21] 08:16PM estGFR-Using this [2123-11-21] 08:16PM ALT(SGPT)-11 AST(SGOT)-18 ALK PHOS-55 AMYLASE-55 TOT BILI-0.2 [2123-11-21] 08:16PM LIPASE-36 [2123-11-21] 08:16PM ALBUMIN-4.7 CALCIUM-9.5 PHOSPHATE-1.7* MAGNESIUM-2.1 [2123-11-21] 08:16PM ASA-53* ETHANOL-NEG ACETMNPHN-20.5 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2123-11-21] 08:16PM URINE HOURS-RANDOM [2123-11-21] 08:16PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2123-11-21] 08:16PM WBC-6.8 RBC-4.72 HGB-15.0 HCT-42.7 MCV-90 MCH-31.7 MCHC-35.1* RDW-13.4 [2123-11-21] 08:16PM PT-12.6 PTT-24.3 INR(PT)-1.1 [2123-11-21] 08:16PM PLT COUNT-282 [2123-11-21] 08:16PM FIBRINOGE-242 [2123-11-21] 08:16PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.008 [2123-11-21] 08:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG Brief Hospital Course: 36F, transferred to [Hospital1 18] by [Location (un) ] following ingestion of 100 tabs of 325mg ASA at 2:50 on day of admission. Also took tylenol pm. PTA in ED patient was given 50 grams of charcoal, 9 grams of mucomyst, and 3 grams of bicarb. In addition, pt received PO and IV potassium In the [Name (NI) ], pt was tachycardic to the 160s. Pt was seen in the ED by renal and no HD was indicated at that time. Pt was admitted to the MICU for further management of her issues. At 3.5 hour aspirin level 34, noted to be slightly elevated, It was expected to climb over the next several hours reaching a toxic level. Pt was monitored closely for fever, tinnitus, nausea, vomiting, pulmonary edema, hypotension, tachycardia. Her urine was alkalinized with goal pH 7.50-7.59 (to prevent salicylate from crossing BBB, promote urinary excretion) Pt received fluid rehydration and potassium repletion with a goal of maximizing renal excretion. Per recs from toxicology, pt received q2hr asa levels with a goal of discontinuing bicarb at levels less than 20. By 2:42 AM on [2123-11-23], pt had negative aspirin level. In addition to aspirin toxicity pt was also exposed to Diphehydramine. She was monitored for hyperthermia, erythema, anhidrosis, mydriasis, delerium, hallucinations, urniary retention, psychomotor aggitation, and seizures. Her QTc was monitored for prolongation with EKG. Pt remained clinically stable from this perspective. In addition to aspirin and diphenhydramine exposure, pt also was exposed to acetaminophen. It was decided, per nomogram, that she would most likely not have hepatic injury from acute acetominophen toxicity. However, her LFT's were monitored as well as her acetaminophen level. She received NAC at 70mg/kg q 4hours for 24 hours. LFT's did not reflect acute injury. At presentation, pt was noted to be hypernatremic which was likely secondary to free-water deficit in the setting of OD, poor po intake. Pt was repleted with D5W and provided with ample free water and allowed her to drink to her thirst. At the time of discharge her sodium had trended downwards to 140. In addition, at presentation, pt was noted to be tachycardic(sinus) with a rate of 165. At baseline patient is known to have sinus tachycardia and she has seen both her PCP and cardiologist for this in past, is on calcium channel blocker. However, it was believed that there was an element of reactive tachcardia from anxiety, diphehydramine toxicity, or dehydration. She was monitored on tele and provided with diltiazem for rate control. On day 2 of her floor admission, her diltiazem was increased to 60 QID and her heart rate was better controlled. For the patient's bipolar disorder we held her home regimen. Psych was consulted for further help with management and she will go to inpatient psych after discharge. For the patient's suicide attempt, psych was consulted. Pt was provided with a 1:1 sitter. Pending clinical improvement and stabilization, pt was transferred to psych for further evaluation and management. Medications on Admission: Patient states not taking these for about 2 weeks: zoloft 200mg daily haldol 5mg [Hospital1 ] (?) klonapin 1mg qid cartia 240mg daily simvastatin 20mg daily prednisone 1mg prn itching-last week . Allergies: Sulfa --> Nausea. Discharge Medications: 1. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Klonopin 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. Discharge Disposition: Extended Care Facility: [Hospital1 69] - [Location (un) 86] Discharge Diagnosis: Suicide attempt with aspirin, acetaminophen and diphenhydramine Metabolic acidosis Depression Sinus tachycardia Discharge Condition: stable, medically cleared for further evaluation and treatment by psychiatry. Discharge Instructions: Please return for further evaluation with fevers, chills, nausea, vomiting, diarrhea, chest pain, shortness of breath. Followup Instructions: You are being transferred to psychiatry for further evaluation and management. You should follow up with your primary care doctor in [2-16] weeks. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "2762", "42789" ]
Admission Date: [2158-3-18] Discharge Date: [2158-4-22] Date of Birth: [2096-1-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3913] Chief Complaint: Fever Major Surgical or Invasive Procedure: Thoracentesis Chest Tube Placement History of Present Illness: 62 year old male with a history of refractory biphenotypic leukemia, disseminated fusarium [First Name3 (LF) 2], on chemo and with neutropenia, recent enterococcal empyema finishing treatment with long course of vancomycin through PICC line, now presents with worsening [First Name3 (LF) ] and fevers to 102. Over the past 2 months he has been at home, able to walk many blocks without dyspnea; he has been eating and drinking well, without nausea, vomiting, diarrhea, chest pain, shortness of [First Name3 (LF) 1440], headache or malaise. Mild sore throat, but no [First Name3 (LF) ] or other URI symptoms. No myalgias or joint pain. On the evening of this admission, he developed chills and his wife took his temperature and found it to be 101, rising later to 102.5. He called his oncologist who recommended he go to the ED. He denied any other symptoms at this time. . He has a history of biphenotypic leukemia currently on dacogen (last administration on [3-17]) who continues to be transfusion dependent with blasts in periphery, neutropenia, and thrombocytopenia. He has also had multiple complications secondary to his leukemia including congestive heart failure, recurrent pleural and pericardial effusions, and infectious complications including disseminated fusarium which is currently controlled. His IV vancomycin course for enterococcal empyema was due to complete on [3-16]. . In the ED he received 2 L of fluid; his atrial fibrillation was at a rate of 100-120. He was initially on a non-rebreather but was quickly weaned off. Chest x-ray was obtained which revealed bibasilar opacities. He was transferred to the MICU for further management. Past Medical History: Hematologic History: 1) followed since [2154] for an autoimmune pancytopenia treated with steroids and IVIG. 2) In [3-/2157] his cytopenias worsened and he was noted to have about 90% blasts and he was transferred to [Hospital1 18]. Preliminary bone marrow biopsy was suspicious for a biphenotypic leukemia 3) therapy was initiated with hyperCVAD. His day 14 marrow showed persistent disease 4) Regimen was changed to 7+3. Day 14 and 2 subsequent marrows all continued to show persistent involvement with leukemia. 5) Further chemotherapy was held as MR. [Known lastname 1005] was found to have disseminated fusarium [Known lastname 2] in the setting of prolonged neutropenia and was treated with a prolonged course of AmBisome with voricoanzole before transitioning to voriconazole alone. 6) He has subsequently been treated with Dacogen with refractory disease; 7) He has had several admissions for pericardial effusions with tamponade physiology, treated medically; 8) He has had periodic pleural effusions requiring thoracentesis with transudative to exudative chemistries; cell blocks and flow cytometry have not been suggestive of leukemic infiltration, and work up for infectious causes including viral, fungal and AFB have remained unrevealing. 9) admission for VRE bacteremia presumed to be of line origin though line tip cultures were unrevealing and completed a prolonged course of linezolid. 9) admission in late [Month (only) 956] 2012for acute shortness of [Month (only) 1440], fevers and found to have an enterococcal empyema. 10) Prior HBV [Month (only) 2], on lamivudine prophylaxis. Other Medical History: 1. Biphenotypic leukemia CLL/AML (s/p hyper [Last Name (LF) ], [First Name3 (LF) ]/Ara, MEC, two cycles of Decitabine) 2. Autoimmune pancytopenia 3. Disseminated fusarium [First Name3 (LF) 2], treated with Ambisome and Voriconazole for four and half months. Ambisome was stopped on [10-20]. Last voriconazole level was 1.0 on [10-8] 4. HBV, on Lamivudine 5. VRE bacteremia/cellulitis 6. Pericardial effusion of unknown etiology 7. s/p appendectomy 8. s/p umbilical hernia repair 9. a-fib, MVR Social History: Currently on disability. Wife is a retired physician. [Name10 (NameIs) ] from [Country 5976]. Nonsmoker, no EtOH, no IVDU. Family History: One brother died of ALL. Denies DM, CAD, strokes, other CAs. Physical Exam: GEN: Cachectic appearing man in NAD [Country 4459]: [Country 3899], NCAT, temporal wasting, MMM, no mucositis or thrush Neck: Supple CV: Irreg/irreg, normal s1/s2, no s3/s4, no m/r/g PULM: Rales at the bases, diminished [Country 1440] sounds in dependent lung fields, no wheezes, no increased WOB, no accessory muscle use ABD: Flat, soft, NTND, NABS, no rigidity, rebound or guarding EXT: WWP, no c/c/e NEURO: A/O x3, CN II-XII intact, sensory and motor exam non focal Pertinent Results: Admission Labs: [2158-3-18] 01:30AM [Month/Day/Year 3143] WBC-5.4# RBC-3.17* Hgb-9.1* Hct-27.3* MCV-86 MCH-28.6 MCHC-33.3 RDW-13.9 Plt Ct-12* [2158-3-18] 01:30AM [Month/Day/Year 3143] Neuts-0* Bands-0 Lymphs-4* Monos-0* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Promyel-0 Blasts-96* [2158-3-18] 09:47AM [Month/Day/Year 3143] PT-18.8* PTT-34.4 INR(PT)-1.8* [2158-3-29] 12:00AM [Year/Month/Day 3143] Fibrino-384 [2158-3-26] 12:00AM [Year/Month/Day 3143] Gran Ct-140* [2158-3-18] 01:30AM [Month/Day/Year 3143] Glucose-120* UreaN-28* Creat-0.9 Na-138 K-4.8 Cl-103 HCO3-25 AnGap-15 [2158-3-18] 09:47AM [Month/Day/Year 3143] ALT-89* AST-122* LD(LDH)-330* AlkPhos-144* TotBili-0.5 [2158-3-18] 01:30AM [Month/Day/Year 3143] Calcium-8.6 Phos-3.6 Mg-1.8 [2158-3-18] 09:47AM [Month/Day/Year 3143] Cortsol-31.4* Discharge Labs: [2158-4-22] 12:00AM [Month/Day/Year 3143] WBC-0.4* RBC-2.27* Hgb-6.7* Hct-19.1* MCV-84 MCH-29.4 MCHC-35.0 RDW-13.7 Plt Ct-22* [2158-4-22] 12:00AM [Month/Day/Year 3143] Neuts-0 Bands-0 Lymphs-23 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-77* [2158-4-22] 12:00AM [Month/Day/Year 3143] PT-14.6* PTT-33.5 INR(PT)-1.4* [2158-4-22] 12:00AM [Month/Day/Year 3143] Plt Smr-VERY LOW Plt Ct-22* [2158-4-22] 12:00AM [Month/Day/Year 3143] Glucose-125* UreaN-17 Creat-0.7 Na-135 K-4.4 Cl-100 HCO3-28 AnGap-11 [2158-4-22] 12:00AM [Month/Day/Year 3143] ALT-32 AST-20 AlkPhos-110 TotBili-0.3 CXR [2158-4-20] Stable chest findings, there is no evidence of new pulmonary parenchymal infiltrates as can be excluded on this single AP portable chest view examination. [2158-3-28] CT CHEST 1. Multiloculated, bilateral, pleural effusion, with the largest individual collection in the right lower lung with enhancing visceral pleura which is concerning for empyema. This largest collection has decreased in size since [2158-3-20] and may be related to prior thoracocentesis (PER OMR). Second largest loculated collection on right side along the paramediastinal aspect has increased, while on the left side is overall unchanged, except in the left lung apex where it shows minimal interval decrease. 2. Right lower lung pneumonia. 3. Borderline sized and other smaller mediastinal lymph nodes, unchanged since [2158-3-20]. 4. Splenomegaly [2158-3-21] ECHO The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Primary Reason for Admission: 62 yo M with a history of biphenotypic leukemia, disseminated fusarium [Month/Day/Year 2], recent diagnosis of enterococcal empyema, admitted to MICU green with septic shock and GNR bacteremia growing E.Coli. Then transferred to BMT service. # Septic Shock ?????? [Month/Day/Year ] cultures grew E. coli on [3-18]. Initially was febrile and hypotensive requiring MICU admission. He was covered with broad spectrium antibiotics which were narrowed to meropenem. When pressures improved he was transferred to BMT service. He was continued on Linezolid (recent Enterococcal empyema, concern for VRE), Meropenem (E Coli sepsis) and Voriconazole (disseminated fusarium). Prior to discharge, he was given a single dose of Ertapenem. He will have VNA services at home and will continue [Last Name (un) ]/Erta/Vori for at least 2 weeks. He will follow up with [Hospital 3242] clinic [2158-4-24]. . # Pleural effusions - He had bilateral pleural effusions, with left greater than right as well as significant ascites. His left effusion was tapped by IP, and pleural fluid showed no growth. A chest tube was kept in place to allow for drainage until it stopped. Effusions remained but they were loculated and could not be drained further. He was aggressively diuresed with IV lasix, and his dyspnea improved significantly. He was then switched to maintenance dosing of PO lasix. He was switched from Vanc to Linezolid for treatment of known Enterococcal empyema due to concern for VRE. . # Biphenotypic Leukemia - His leukemia is treatment refractory, after receiving hyperCVAD, decitabine, MEC and dacogen. He remained pancytopenic requiring [Month/Day/Year ] and platelet transfusions nearly daily. His blast count began to climb, with WBC count up to 6000 with 60+% blasts. He was started on hydrea with improvement of blast counts. His dose was eventually lowered to 500mg daily where he was maintained. He was transfused 1U pRBC and 1U platelets the day of discharge. He will follow up with [Hospital 3242] clinic on [2158-4-24] for count check and PRN transfusions. . # Atrial fibrillation ?????? History of paroxysmal atrial fibrillation. Rate control difficult in ICU, with hypotension on beta blockade requiring pressors. On transfer to BMT he was kept on digoxin, metoprolol and diltiazem with a heart rate in the low 100s. His BP on the BMT service was 90s/50s, occasionally in the 80s while sleeping. However, he was never symptomatic from his hypotension. Pt requested 50mg Metoprolol Succinate [Hospital1 ] instead of 100mg po qday at time of discharge. . # Hepatitis B - Continued on Lamivudine . Transitional Issues: Pt spiked a fever to 100.4 the evening before discharge. However, the patient and his wife continued to express a clear desire to go home. Per pt and his wife, if his health deteriorates at home, they will initiate home hospice. Bridge to hospice was arranged. He will have counts check in [Hospital 3242] clinic on [2158-4-24]. Medications on Admission: ACYCLOVIR - (Dose adjustment - no new Rx) - 400 mg Tablet - 1 (One) Tablet(s) by mouth three times a day DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day DILTIAZEM HCL - 120 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) Solution - 1 Solution(s) inhaled every four (4) hours as needed for shortness of [Date Range 1440] or wheezing LAMIVUDINE [EPIVIR HBV] - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) LEVOFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth every twenty-four(24) hours LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth every four (4) hours as needed for nausea/anxiety/insomnia METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day OXYCODONE - 5 mg Tablet - [11-21] Tablet(s) by mouth every four (4) hours as needed for pain RAISED TOILET SEAT - - ICD9: 208.0 SHOWER RAIL - - ICD9: 208.0 SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth once a day VANCOMYCIN - (Prescribed by Other Provider) - 500 mg Recon Soln - 1 Recon(s) twice a day VORICONAZOLE - (Dose adjustment - no new Rx) - 200 mg Tablet - 1.5 (One and a half) Tablet(s) by mouth every twelve (12) hours Medications - OTC MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. oxygen 2-4L continuous, pulse dose for portability dx: VRE empyema and PNA 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every four (4) hours as needed for shortness of [Month/Day (2) 1440]. Disp:180 neb Refills:0 4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:0 5. DILT-XR 120 mg Capsule,Ext Release Degradable Sig: One (1) Capsule,Ext Release Degradable PO once a day. Disp:30 Capsule,Ext Release Degradable(s) Refills:0 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:0 10. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:0 11. ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection once a day. Disp:30 Recon Soln(s) Refills:0 12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. Disp:180 Tablet(s) Refills:0 13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:300 Tablet(s) Refills:0 14. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 15. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 16. 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 17. benzonatate 100 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:30 Capsule(s) Refills:0 18. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. Disp:180 Tablet(s) Refills:0 19. multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 20. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO twice a day. Disp:60 Tablet Extended Release 24 hr(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Praimry Diagnoses: E Coli Sepsis VRE Emypema [Hospital1 ]-Phenotypic Leukemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 1005], It was a pleasure caring for you at the [Hospital1 827]. You were admitted for a serious [Hospital1 2] in your [Hospital1 ]. We treated you with antibiotics and anti-fungal medications and you improved. In accordance with your wishes, you will return home with VNA care. During this admission, we made the following changes to your medications: STARTED Ertapenem STARTED Linezolid STARTED Hydroxyurea STARTED Omeprazole STARTED Benzonatate STARTED Zofran STOPPED Levofloxacin It will be important for you to keep your BMT appointment to have your [Hospital1 ] and platelets checked. Thank you for allowing us to participate in your care. Followup Instructions: Department: BMT/ONCOLOGY UNIT When: MONDAY [2158-4-24] at 10:00 AM [Telephone/Fax (1) 447] Building: Fd [Hospital Ward Name 1826] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3971] Campus: EAST Best Parking: Main Garage	[ "78552", "486", "5849", "5119", "2875", "99592", "42731", "4280" ]
Admission Date: [2197-2-28] Discharge Date: [2197-3-6] Date of Birth: [2111-9-21] Sex: F Service: NEUROSURGERY Allergies: Amoxicillin Attending:[First Name3 (LF) 1835] Chief Complaint: confusion Major Surgical or Invasive Procedure: [3-1]: diagnostic cerebral angiogram [3-2]: craniotomy and resection of mass History of Present Illness: 85yo woman known to the neurosurgery service since [2196-9-10] when she presented to the ED with pressure ulcers,rhabdomyolysis and renal failure after being found down in her bath tub. A head CT was performed which revealed a frontal parafalcine base avidly enhancing mass. Pt has been followed closely and recent imaging revealed interval increase in size. Past Medical History: DM type 2 CAD s/p stent and pacer defibrilaltor in [2194] Spondylolisthesis of lower back for which she bas never been operated on but that it causes her occasional numbness and weakness of her lower extermities. This has been since an injury in [2146] when she fell straight down. Social History: The patient is a lifelong non-smoker. She worked in internal accounting at Price Waterhouse. She admits to rare alcohol use. Family History: NC Physical Exam: PHYSICAL EXAM UPON DISCHARGE: awake, a+o to self, hospital & date PERRL, EOMI face symmetric, tongue midline MAE's with good strengths following all commands incision- dissolvable sutures, well healing Pertinent Results: [3-1] Head CT:IMPRESSION: 4.1 x 4.9 cm extra-axial dural based mass in the anterior cranial fossa with displacement of the anterior cerebral arteries. There is no shift of midline structures. [3-2] Head CT:IMPRESSION: Unchanged appearance of 4 x 5 cm extra-axial mass in the anterior cranial fossa- redemonstrated for planning for surgery. [3-4] Head CT:IMPRESSION: Redemonstration of postoperative changes status post right frontal craniotomy and resection of inferior frontal mass, with no evidence of postoperative hemorrhage, infarcts, or other complication. Brief Hospital Course: Pt presented electively on [2-28] for preop angiogram. Due to scheduling this was not able to be performed. She was admitted in anticipation of angiogram the following morning. On [3-1] she underwent a cerebral angiogram without embolization due to tortuosity of vessels and calcifications. Procedure was without complication. She was transferred to the PACU for close neurological monitoring post op. She returned to the floor for the evening of [3-1] and on the morning of [3-2] she went to the operating room for a craniotomy for resection of her meningioma. Surgery was without complication. She was extubated and transferred to the ICU. Post operative head CT revealed no hemorrhage and good resection. On [3-3] she remained neurologically stable and monitored closely in the ICU. on [3-4] she was cleared for transfer to the floor. Her foley was discontinued and meds were changed to PO. The patient had a fall and when examined she was noted to have a small amount of blood over her incision. A stat head CT was performed and negative for interval change. On [3-5] & [3-6] she worked with PT & OT who recommended discharge to rehab. urine output was closely monitored and labs were repleted as necessary. She was cleared for discharge pending bed availability. Medications on Admission: Lipitor, Plavix, eplerenone, furosemide, levothyroxine, lisinopril, Toprol [Last Name (LF) 8864], [First Name3 (LF) ] Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 7. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 11. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. heparin (porcine) 5,000 unit/mL Solution Sig: [11-27] Injection TID (3 times a day). 15. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8hrs () for 2 days. 16. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8hrs () for 2 days. 17. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q8hrs () for 2 days. 18. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12hrs () for 2 days. 19. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Qdays () for 1 days. 20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 21. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: skull base lesion likely representing a olfactory groove meningeoma 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: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: Follow-Up Appointment Instructions ??????You have an appointment in the Brain [Hospital 341] Clinic on [3-20] at 11:30 The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 9151], MD Phone:[Telephone/Fax (1) 1669] Date/Time:[2197-5-30] 10:45 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2197-5-30] 10:15 Completed by:[2197-3-6]	[ "25000", "2449", "V4582", "4280", "2724", "41401" ]
Admission Date: [2150-9-9] Discharge Date: [2150-9-15] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5129] Chief Complaint: Jaundice, Dilated CBD Major Surgical or Invasive Procedure: ERCP - [9-10] PICC placement by IR -- [9-11] History of Present Illness: 89 y/o F with DM, HTN and gout who initially presented to [Location (un) 21541] Hospital with painless jaundice that she says developed over the past day. She denied any associated abdominal pain, n/v/d, constipation, or blood in her stool. She does admit to drinking one small drink with vodka per day, but denies ever being told that she liver problems in the past. At [Hospital3 ] Hospital her labs were notable for a white count of 10.6, alk phos of 394, total bilirubin of 31.2, direct bilirubin of 28.7, Albumin of 2, AST of 102, ALT of 51, Cr of 2.95, bicarb of 14 and an INR of 7.0. An ultrasound of her abdomen showed a heterogenous liver with nodular edge suspicious for cirrhosis, patent portal vein, thickened gall bladder wall, CBD dilated to 20mm and medium amount of ascites. Given the concern for biliary obstruction she was transferred to [Hospital1 18] for ERCP, hepatology and surgery evaluations. She was also given 5mg of vitamin K and 1 pack of FFP before transfer. . In the ED, initial VS were: 98.7, 90, 126/57, 18, 100% RA. Labs here showed a t-bili of 36.6, d-bili of 29.1, AP of 379, Cr of 3.3, bicarb of 14, WBC of 12.6 (2 metas, 2 myelos) and an INR of 7.0. A repeat RUQ U/S again showed a likely cirrhotic liver with CBD dilatation to 1.5cm and moderate ascites. She was seen by surgery and discussed with hepatology and ERCP, the decision was made to attempt to reverse her coagulopathy and get an ERCP. She was given zosyn and vancomycin for possible cholangitis, although she has been afebrile. She was also given another 10mg of IV vitamin K. She also was found to be a difficult stick and developed a large hematoma on her right hand post an attempt at IV placement. . On arrival to the ICU initial VS were: 97.6, 92, 125/61, 16, 99% on RA. She currently is complaining of right hand pain at the site of her hematoma, and will also admit to about one week of easy bruising and ankle edema prior to admission. She denies any n/v/d, constipation, abdominal pain or fever/chills. Past Medical History: Atrial fibrillation on coumadin Diabetes on insulin Hypertension Gout GERD CKD (stage III, baseline 2.6 [3-6]) Social History: Married, lives in [Location 23723] on [Hospital3 ] with her Husband. [Name (NI) ] to do ADL, has hired help for IADL. Husband with poor mobility. Son is involved in care. Handles her own meds. - Tobacco: never - Alcohol: 1oz vodka with soda nightly - Illicits: Denies Family History: No FH autoimmune disease, liver disease, or GI disease, including IBD/UC. Mother with diabetes. Physical Exam: Admission Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge Physical Exam: Pertinent Results: Admission Labs: [2150-9-9] 06:50PM WBC-12.6* RBC-4.00* HGB-12.6 HCT-37.4 MCV-94 MCH-31.5 MCHC-33.7 RDW-17.8* [2150-9-9] 06:50PM NEUTS-74* BANDS-0 LYMPHS-11* MONOS-8 EOS-3 BASOS-0 ATYPS-0 METAS-2* MYELOS-2* [2150-9-9] 06:50PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-1+ TARGET-1+ [2150-9-9] 06:50PM PLT SMR-NORMAL PLT COUNT-322 [2150-9-9] 06:50PM PT-64.3* PTT-53.7* INR(PT)-7.1* [2150-9-9] 06:50PM GLUCOSE-60* UREA N-48* CREAT-3.3* SODIUM-137 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-14* ANION GAP-21* [2150-9-9] 06:50PM ALT(SGPT)-50* AST(SGOT)-93* ALK PHOS-379* TOT BILI-36.6* DIR BILI-29.1* INDIR BIL-7.5 [2150-9-9] 06:50PM LIPASE-7 [2150-9-9] 06:50PM ALBUMIN-2.7* CALCIUM-8.4 PHOSPHATE-4.5 MAGNESIUM-2.4 [2150-9-9] 06:50PM HBsAg-NEGATIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE [2150-9-9] 06:50PM HCV Ab-NEGATIVE [2150-9-9] 06:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2150-9-9] 07:21PM GLUCOSE-55* LACTATE-2.4* K+-3.6 . Microbiology: [2150-9-9] URINE CULTURE (Final [2150-9-11]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I 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 TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . blood culture ([9-9]): pending . Imaging: RUQ ultrasound ([9-9]): 1. No evidence of cholecystitis. Large amount of gallbladder sludge identified without evidence of stones. 2. The common bile duct demonstrates increasing dilatation towards the level of the pancreatic head, suggestive of obstruction. No common bile duct stone or pancreatic head mass definitely identified. Recommend ERCP for further evaluation. 3. Coarse echogenic liver texture suggestive of cirrhosis. 4. Moderate amount of ascites. 5. Low amplitude portal venous flow, could suggest impending reversal of flow. . XR hand ([9-9]): 1. Massive soft tissue swelling at dorsum of hand, tracking proximally. 2. Query erosive changes at dorsum of radius - is osteomyelitis a clinical concern. 3. No discrete fracture. 4. Chondrocalcinosis. 5. Degenerative changes of the wrist and hand as described above. 6. Possible CPPD involving the ulnocarpal joint. . TTE ([9-11]): 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. 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. There is no ventricular septal defect. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) 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. . ERCP ([9-10]): - Moderate diffuse biliary dilation . Likely common bile duct stricture. - Possible extravasation of contrast at level of tumor. Given possible extravasation of contrast and presentation with cholangitis, detailed cholangiogram was not obtained. - Likely distal pancreatic duct stricture - Sphincterotomy was performed - Cytology samples were obtained for histology using a brush. - Successful placement of a 7cm by 10 FR biliary stent - Successful placement of a 5cm by 5FR pancreatic stent - Otherwise normal ercp to third part of the duodenum Recommendations: - Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call - Consider CT abd to further evaluate pancreas once renal function improves. - Repeat ERCP in 2 months. . Renal ultrasound ([9-12]): pending IMPRESSION: Normal kidneys bilaterally, without obstruction COMMON BILE DUCT BRUSHINGS Procedure Date of [2150-9-10] Distal common bile duct brushing: POSITIVE FOR MALIGNANT CELLS, consistent with adenocarcinoma. Brief Hospital Course: 89 y/o F with a h/o HTN and DM who initially presented to [Location (un) 21541] Hospital complaining of one day of jaundice, found to have an obstructive pattern of jaundice on LFT's and imaging, likely a more chronic process given the degree of CBD dilatation seen on abdominal ultrasound. . #) Hyperbilirubinemia: On presentation the patient had a high bilirubin level (36.6) and was obviously jaundiced. She was treated with Zosyn for empiric coverage of cholangitis. ERCP was performed on [9-10] revealing obstruction at the distal main pancreatic duct. Brushing was performed for cytologic study, which revealed cancer cells. . . #) Acute Kidney Injury: On presentation the patient was found to have a Cr of 3.3. The patient denies any history of CKD, but her baseline Cr is unknown. Hydration did not improve her renal function, and she continued to have low urine output and her creatinine continued to rise. She was seen by Nephrology and dialysis was not felt to extend life and, on discussion with the patient with family was not pursued. She does not wish to have dialysis even when she develops symptoms of uremia. She is making no urine to speak and we are aware of this. # Communication:Son, [Name (NI) ] [Name (NI) ] ([Telephone/Fax (1) 91423]) # Code: DNR/DNI/CMO per discussion with the patient on [9-14] and [9-15]. Family is in agreement. # Disposition: Hospice at [Hospital1 1501]. Given the pancreatic/billiary cancer, endstage liver and kidney disease, her age, and poor prognosis, the patient wished to move forward with comfort measures only and hospice care. Family meetings were held which included her son [Name (NI) ], and everyone is in agreement. Medications on Admission: - Colchicine 0.6 mg daily PRN - Atenolol 50 mg [Hospital1 ] - Allopurinol 200mg daily - Omeprazole 20mg daily - Novolin 70/30 20u QAM - Novolin 70/30 6u QPM - Simvastatin 10 - Cardizem 240 mg Discharge Medications: 1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Five (5) mg PO Q2H (every 2 hours) as needed for pain. Discharge Disposition: Extended Care Facility: Eagle [Hospital ] Rehabilitation Center - [Location 23723] Discharge Diagnosis: Pancreatic cancer Renal failure 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 diagnosed with inoperable cancer of the bile ducts/pancreas. Your kidney function worsened and your kidneys shut down. You are no longer making urine, which can happen when the liver fails from bile duct/pancreatic cancer. You chose to not have continued aggressive care, and your treating team at the [Hospital1 ] as well as your family agreed that this is the best course of action given the poor prognosis associated with the kidney failure and the cancer. You decided on hospice care and comfort measures only. Followup Instructions: You will be followed by the physician at the skilled nusing facility where you will be receiving your hospice care.	[ "5849", "2762", "5990", "40390", "25000", "V5867", "42731", "V5861" ]
Admission Date: [2153-12-18] Discharge Date: [2153-12-21] Date of Birth: [2118-12-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: V fib arrest Major Surgical or Invasive Procedure: Cardiac Catheterization with drug eluting stent placement. History of Present Illness: 35yo man with history of htn and tobacco who presented to [Hospital ] after collapsing at a friend's house. CPR initiated by friend/nurse. [First Name (Titles) ] [Last Name (Titles) 71342] and found to be in VF, then shocked out of VF. At [Hospital3 15402], found to have anterior STE-MI. Given 1/2 dose reteplase, eptifibitide, plavix load and transferred to [Hospital1 18]. EKG in-transit showed resolution of STE. Cath at [Hospital1 18] showed lesion at mid-LAD and prior to D1, DES placed to LAD. On arrival to the CCU, he was confused, repeatedly asking what had happened and to call his workplace. Pt c/o mild chest pain at sternum otherwise had no complaints. Patient has limited memory of event, but denies preceding illness, chest pain, diaphoresis, SOB. Past Medical History: PMH: Anxiety panic attacks ptsd ?htn Social History: 2 drinks the night of arrest, 1ppd smoker (now 1/3ppd). Denies illicits but tox at OSH showed cannabis. Works at transitional house as cook. Reportedly lives in an apartment that he rents. Per friends' report pt does binge drink at least once per week, usually on weekends. Has a h/o crack/cocaine abuse, now clean x 1yr. No history of IVDU (per pt's psychiatrtist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3517] [Telephone/Fax (1) 71343] at [Location (un) 22870] Mental Health. on SSDI [1-25] psych issues. . Pt was born in [Country 6257]. Lived in the US in [Location (un) ]. Goes to [Country ] often. MSM. unknown HIV status. Former user of cocaine and heroin. . Patient has no family here. Has 1 aunt that he doesn't really talk to. Is closest to his friends: [Name (NI) ] [Last Name (NamePattern1) ] ([Hospital1 112] Cardiac nurse) H: [Numeric Identifier 71344] C: [Telephone/Fax (1) 71345] Family History: Unknown Physical Exam: PE: VS: BP 149/98 HR 71 RR 18 Gen: Pleasant wn/wd young man, anxious HEENT: pupils dilated, MMM CV: Nl s1/s2, rrr, no m/r/g Pul: CTA b/l Abd: Soft,NT Ext: DP 2+ b/l sheath in place Pertinent Results: Please call [Telephone/Fax (1) 2756] for cath report (not available at discharge). . Admission Labs: [2153-12-18] 03:51AM GLUCOSE-110* UREA N-14 CREAT-0.9 SODIUM-137 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-12 ALT(SGPT)-63* AST(SGOT)-98* LD(LDH)-283* CK(CPK)-475* CK-MB-36* MB INDX-7.6* cTropnT-1.32* MAGNESIUM-2.2 . ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . WBC-22.8* RBC-4.14* HGB-13.4* HCT-38.4* MCV-93 MCH-32.4* MCHC-34.9 RDW-13.8 Plts 429 NEUTS-90.9* LYMPHS-6.0* MONOS-2.8 EOS-0.3 BASOS-0.1 . PT-12.0 PTT-68.8* INR(PT)-1.0 . URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . [2153-12-20]: TSH 1.8, VitB12 230, Folate 5.9, RPR negative . [2153-12-19] Head CT: IMPRESSIONS: 1. No acute intracranial abnormality. 2. No specific evidence of anoxic brain injury, with normal appearance of the deep [Doctor Last Name 352] matter structures. If clinical suspicion persists, MR imaging would be more sensitive in this regard. . ECHO REPORT [2153-12-18]: PATIENT/TEST INFORMATION: Indication: Left ventricular function. Myocardial infarction. Height: (in) 70 Weight (lb): 150 BSA (m2): 1.85 m2 BP (mm Hg): 129/82 HR (bpm): 80 Status: Inpatient Date/Time: [2153-12-18] at 10:52 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W050-0:32 Test Location: West CCU Technical Quality: Adequate . MEASUREMENTS: Left Atrium - Long Axis Dimension: 2.6 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 3.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 3.9 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 30% (nl >=55%) Aorta - Valve Level: 3.9 cm (nl <= 3.6 cm) Aorta - Ascending: 3.5 cm (nl <= 3.4 cm) Aorta - Arch: 2.2 cm (nl <= 3.0 cm) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 1.14 Mitral Valve - E Wave Deceleration Time: 154 msec TR Gradient (+ RA = PASP): 8 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is normal in diameter with <50% decrease during respiration (estimated RAP 11-15mmHg). LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Cannot exclude LV mass/thrombus. Moderately depressed LVEF. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Focal apical hypokinesis of RV free wall. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal aortic arch diameter. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: ?# aortic valve leaflets. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal mitral valve supporting structures. Normal LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal tricuspid valve supporting structures. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. . Conclusions: The left atrium is normal in size. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. An apical left ventricular mass/thrombus cannot be excluded with certainty. Overall left ventricular systolic function is moderately-to-severely depressed (ejection fraction 30 percent) secondary to severe hypokinesis of the anterior septum and anterior free wall (with basal segment function relatively preserved) and extensive apical akinesis with focal dyskinesis. There is no ventricular septal defect. Right ventricular chamber size is normal. There is focal hypokinesis of the apical free wall of the right ventricle. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: A/P: 35M with h/o HTN, tobacco, admitted s/p VF arrest with anterior STEMI s/p PCI. . # STEMI: Patient had PCI with DES to mid LAD lesion. peak CK at [Hospital1 18] 509, peak MB 7.6. Patient was treated with Integrillin x 18hrs peri placement of the stent. We began medical management with Aspirin 325mg, Plavix 75, Toprolol XL 50mgQD, atorvastatin 80mg QD, Lisinopril 10mgQD. . #Cardiomyopathy/Pump: His post MI echo shows EF < 30% with akinetic apex and could not rule out LV thrombis. He was started on lisinopril and toprolol. He was started IV heparin and coumadin for ?LV thrombus and apical akinesis. He will be discharged on coumadin with lovenox bridge and scheduled INR/PTT/PT checks. He will need MRI, TWA, and signal avg EKGs in 4-6wks post dc for risk stratification and ICD implantation consideration. . #Rhythm: Normal sinus with rate of 60-70 with very rare PVCs. He will be discharged with a holter monitor and the results will be faxed to his cardiologist, Dr. [First Name (STitle) 1169]. . #Risk factors: Patient is a smoker, +etoh, +h/o crack/cocaine use. Lipids profile: Triglyc: 156 HDL: 36 CHOL/HD: 2.9 LDLcalc: 39. These can be falsely lowered in setting of acute event and patient will need retested as outpatient. He will continue atorvastatin 80mg for cardiac protection. We have given him a prescription for nicotine patches and have encouraged him to stop. . #Aspiration PNA/leukocytosis/fever: wbc of 22 on admission, no bands, likely in a setting of AMI. But wbc count bumped from 11 to 12 on hospital day 3, with low grade fever and with mild peribronchovascular opacity suggestive of early infiltrate. In the setting of v fib arrest and time down we will treat with Clindamycin x 7 days (last day [2152-12-26]) for aspiration pna (no levoflox b/c of long QT). After one day of treatment his WBC decreased, he defervesced and His urine cultures were negative . #Groin hematoma: This was likely from movement of leg. Initially treated with compression dressing. His hematoma is resolving and his hct was stable throughout. . #ST memory loss: Slowly improving. Per converstaion with the patient's psychiatrist, the patient has a h/o depressive sx, ? ptsd, panic attacks, [1-25] h/o of prior abusive relationships. CT head with no evidence of anoxic brain injury. No focal neurological symptoms. Improving memory and insight. Psychiatry was consulted. We tested for causes of early dementia (syphilis, folate, b12 and tsh), which was negative except a slightly low B12, for which he was started on supplements. . #psych: h/o depression, anxiety, panic attacks. on xanax, doxepin. sees oupt psych. has substance abuse issues with active etoh use and crack/cocaine use. Patient reports to be clean for 1yr. Initially on CIWA scale with valium, he was switched to xanax at home dose. . #Hematuria: Patient self reported small amounts of gross blood in urine, which was confirmed by dipstick. This was in setting of foley placement and discontinuation and heparin. We would recommend outpatient pcp/urology follow-up. . #FEN: cardiac diet . #FULL CODE . #Follow up plans: will need MRI, signal avg ekg, t-wave alterans upon discharge (4-6wks after) . PCP: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 71346]/[Last Name (un) ] ([Telephone/Fax (1) 71347] . Contacts: [Name2 (NI) ] has no family here. Has 1 aunt that he doesn't really talk to. Is closest to his friends: [Name (NI) ] [Last Name (NamePattern1) ] ([Hospital1 112] Cardiac nurse) H: [Numeric Identifier 71344] C: [Telephone/Fax (1) 71345]/1 . Psych: Dr. [Last Name (STitle) 3517], [Location (un) 22870] health [Telephone/Fax (1) 71343] Medications on Admission: Doxepin 300qhs Xanax 2mg TID:PRN 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): for a minimum duration of 1 year. Disp:30 Tablet(s) Refills:12 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:90 Tablet Sustained Release 24HR(s) Refills:2 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H (every 6 hours) for 6 days. Disp:72 Capsule(s) Refills:0 9. Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety. 10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) 60mg Subcutaneous twice a day for 7 days: Until coumadin/INR is therapeutic. Disp:14 syringes Refills:0 12. Lab work Sig: One (1) ONCE for 1 doses: Please draw PT/INR, ALT, AST, BUN and Cr on Sunday [2153-12-23] and have the results faxed to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1169] [Last Name (NamePattern1) 71348]fax [Telephone/Fax (1) 71349], phone [Telephone/Fax (1) 40420]. . Disp:1 1 Refills:0 13. Doxepin 25 mg Capsule Sig: Six (6) Capsule PO HS (at bedtime): Please only take 150mg QD until instructed otherwise. . Disp:QS Capsule(s) Refills:2 14. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily): Please readdress with your PCP at the next visit. . Disp:QS Patch 24HR(s) Refills:2 15. Xanax 2 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA [Location (un) 5503] Discharge Diagnosis: Primary ST elevation MI s/p ventricular fib arrest and defibrillation CHF with EF of <30% suspicion of LV thrombis apical akenesis h/o ?HTN Secondary hematuria . Discharge Condition: Stable Discharge Instructions: It is very important that you take your medications. . The most important medications are aspirin and plavix (also called clopidigrel). If you were to stop taking these you would have a high likelihood of having another major heart attack and possibly dying. . We have started you on several other medications that are important for your heart. They are all listed below. . You are on antibiotics for pneumonia. You will need to complete a seven day course. . Your dose of doxepin was decreased by half. Please take this until you see your psychiatrist and cardiologist. It was decreased for possible effects on your heart. . Please call your doctor or seek medical attention if you have increasing chest pain, palpitations, lightheadedness, difficulty breathing, weight gain, feet swelling. You will need to weigh yourself daily. Please contact your doctor if you gain more than 3 pounds a day. Please limit your sodium intake to 2 grams daily. . We have made you an appointment with a cardiologist. It is very important that you keep this appointment as you will need closely followed by a cardiologist from now on. Followup Instructions: You need to have VNA follow up for the next few weeks with medication checks, INR checks, weight checks. Please talk to your PCP about cardiac rehab. . You need to return your holter monitor to the [Hospital1 18] for analysis. . Please see your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 71346]/[Last Name (un) ] ([Telephone/Fax (1) 58547]), in the next 7-10 days. Have her follow up on medications, anticoagulation and hematuria. . You have an appointment with a cardiologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1169], on [2153-12-26] at 3:30. The office is at [Last Name (NamePattern1) ]. The phone number is [Telephone/Fax (1) 40420] ([First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]). [Patient prefers to follow up at [Hospital6 302]. The cardiologists all have private offices.] . Patient will need risk stratification including Signal Average EKG, cardiac MRI, TWA in 6 weeks and follow up with EP. . Please follow-up with your psychiatrist. This was a major event and your life will change. You will also need to address your medications.	[ "5070", "41401", "4019", "3051", "311" ]
Admission Date: [2112-11-16] Discharge Date: [2112-11-23] Date of Birth: [2053-3-26] Sex: M Service: MEDICINE Allergies: Morphine / Demerol / Macrodantin / Imuran Attending:[First Name3 (LF) 2297] Chief Complaint: Hypoxia, hypotension Major Surgical or Invasive Procedure: Intubation Central Line History of Present Illness: 59 yo white male with metastatic lung cancer, renal transplant on predisone, h/o CAD s/p CABG, and SVT s/p right hemi-arthroplasty being transferred to the MICU for hypoxia in the setting of recurrent atrial tachycardia. He was admitted [11-16] for a right hemi-arthroplasty for an impending pathological right femoral neck fracture, developed atrial tachycardia pre-operatively that was unresponsive to esmolol and amiodarone (it was controlled by dilt-gtt), and he was ,therefore, cardioverted in the OR ([2112-11-16]). His amiodarone dose has been increased (200-->300). He was transferred from the SICU to the medicine floor [2112-11-20]. He has been diuresed since [11-19] for volume overload (20mg iv lasix) with good response. Last night a trigger was called for pulse 140s-150s, that responded to IV metoprolol (5mg x2). Tonight another trigger was called for tachycardia to 150s and hypoxia (sats to 75% on 4l which he had required since extubation). He was treated with 5 mg metoprolol IV and developed hypotension (sbp to 80s). At the time of evaluation, he was tachypneic with R 30s up from 20, pulse down to 80s, and BP 100/58. Past Medical History: DM type I ESRD s/p kidney transplant x2 ('[88] & '[08]) Fungal meningitis '[96] CAD s/p CABG x3 '[98] PVD s/p bilat BKA L hip replacement Chronic AFIB/Flutter s/p mult cardioversions Glaucoma Hypothyroidism HTN HyperChol Autoimmune hemolytic anemia Social History: 60 pack-year smoker, quit in [2098] Family History: Non-contributory Physical Exam: T 100.8 (rectal) bp 114/27(88/50 once invasive monitoring obtained) hr 90 rr 30 O2 88% on 100% NRB genrl: in respiratory distress heent: perrla cv: rrr, no m/r/g pulm: bibasilar crackles w/o wheeze abd: decreased BS, soft, NT neuro: o x 3 Pertinent Results: [2112-11-23] 02:56AM BLOOD WBC-1.3# RBC-3.52 Hgb-10.8* Hct-31.7* MCV-90 MCH-30.5 MCHC-33.9 RDW-16.2* Plt Ct-86* [2112-11-23] 02:56AM BLOOD Plt Smr-LOW Plt Ct-86* [2112-11-23] 02:56AM BLOOD FDP-10-40 [2112-11-23] 02:56AM BLOOD Gran Ct-990* [2112-11-23] 02:56AM BLOOD Glucose-83 UreaN-45* Creat-2.1* Na-141 K-4.3 Cl-105 HCO3-23 AnGap-17 [2112-11-23] 12:00AM BLOOD ALT-21 AST-37 LD(LDH)-327* AlkPhos-102 Amylase-22 TotBili-3.3* [2112-11-23] 12:00AM BLOOD Lipase-9 [2112-11-23] 12:00AM BLOOD CK-MB-1 cTropnT-0.06* [2112-11-23] 02:56AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.9 [2112-11-18] 03:45AM BLOOD Vanco-13.5* [2112-11-23] 12:00AM BLOOD Digoxin-0.5* [2112-11-23] 02:44AM BLOOD Lactate-5.6* [2112-11-23] 01:11AM BLOOD Lactate-4.6* [2112-11-23] 02:44AM BLOOD Type-ART Temp-39.9 Rates-28/ Tidal V-450 PEEP-10 FiO2-100 pO2-183* pCO2-51* pH-7.29* calHCO3-26 Base XS--2 AADO2-492 REQ O2-82 -ASSIST/CON Intubat-INTUBATED [2112-11-23] 03:08AM BLOOD O2 Sat-68 [2112-11-19] 02:20AM BLOOD freeCa-1.23 [2112-11-16] 02:49PM BLOOD AMIODARONE AND DESETHYLAMIODARONE-Test Brief Hospital Course: Mr. [Known lastname 23952] is a 59 yo M w/ h/o metastatic lung cancer, s/p renal transplant on predisone, h/o CAD s/p CABG, and h/o SVT s/p CV this admission who was admitted [11-16] for right hemi-arthroplasty following a pathologic fracture. Patient was transferred to the MICU on the evening of [2112-11-22] for hypotension, tachycardia, and hypoxia. Patient was initially tried on BIPAP but upon return of worsening labs, poor improvement in oxygenation, and lack of response to lasix, patient was intubated for aggressive management of presumed sepsis. Following intubation, patient's sats continued to fall. Bronchoscopy was performed but minimal secretions were obtained, all airways were patent, and the ETT was confirmed to be in appropriate positioning. Following this intervention, patient's sats improved and repeat ABG w/ PaO2 64->183. However, patient was requiring high dose levo, neo, and vasopressin to maintain MAP 60. In addition, course c/b recurrent atrial tachycardia controlled w/ an esmolol gtt. Lab called re: blood cx positive for GNR from [11-21]. Patient's family arrived at this point and discussion was initiated re: clarification of code status (per NF and notes, patient documented to be full code). Wife clearly and deliberately stated patient wished to be DNR. When asked re: intubation, wife stated they had not discussed that. Family informed that Mr. [Known lastname 23952] was critically ill and pressor dependent and requiring high ventilatory support; if support d/c, patient would likely die. Family requested a moment and then approached me re: d/c of all support. ICU attending made aware of family's wishes. Patient's oncologist, Dr. [Last Name (STitle) ] also made aware and reiterated patient's short life expectancy (likely, months). Wife and sister at the bedside and were offered continued care to see how things go but that the decision was ultimately theirs to decide what [Doctor First Name ] would want. Wife and sister agreed [Name (NI) ] would not want continued ICU support to sustain his life. They requested all care be discontinued. Pressors and esmolol gtt d/c and ventilator adjusted to provide 23% FiO2 w/o PEEP or PS. Patient expired within 5 minutes. Family declined an autopsy. PCP, [Name10 (NameIs) 2085], and oncologist emailed. ICU and floor attending notified by page Discharge Medications: Patient Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA Completed by:[2112-12-14]	[ "0389", "4280", "42731", "4019", "2449" ]
Admission Date: [2154-6-24] Discharge Date: [2154-7-3] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3376] Chief Complaint: Lower Gastrointestinal Bleed Major Surgical or Invasive Procedure: s/p R colectomy [6-28] History of Present Illness: The patient is a 86 year-old male with a h/o of a sigmoid colectomy for 4-5cm bleeding rectosigmoid mass at 15 cm transferred from [Hospital ] Hospital after presenting with a lower gastrointestinal bleed requiring a total of 13 units of PRBC over the course of 8 days. His last transfusion occurred at 2:55AM on [2154-6-24] with his last hemotocrit of 28.5 at 9AM. Per the patient, he reports that his prior episode of gastrointestinal bleed occurred approxiamtely 10 years prior to presentation which required the sigmoid colectomy and does not remember any other episodes of BRBPR. He states that on [6-16], [2153], he had diffuse abdominal cramps and pain sometime in the next morning had a large bloody bowel movement. He immediately went to [Hospital ] Hospital. At [Hospital ] Hospital, he has had multiple tagged RBC scans which were all negative ([2154-6-16], [2154-6-18] and [2154-6-20]) until one on [2154-6-22] which reportedly showed a small accumulation of radiolabel in the right midabdomen, possibly a right colonic gastrointestinal bleeding source. He also underwent colonoscopy X 2 which showed diffuse colonic diverticulosis from the proximal ascending to the rectosigmoid anastomosis at 15cm with relative sparing of the splenic flexure. Upper endoscopy revealed normal stomach and duodenum. Following his positive tagged RBC scan, the decision for possible angiography or conservative management was decided and the decision to transfer to a facility with angiography capabilities was made. Currently he reports no pain and no bloody bowel movement for the previous three days. Past Medical History: Depression Social History: Lives alone. Denies tobacco, EtOH and rec. drug abuse. Family History: Noncontributory Physical Exam: On day of admission: O: T: HR:68 BP:130/67 RR:22 O2SAT:98% room air Gen: WD/WN, comfortable, NAD Neuro: Awake, alert, cooperative with exam, normal affect, oriented to person, place and date. HEENT: PERRLA, EOM intact Neck: Supple Lungs: CTA bilaterally Cardiac: RRR, S1/S2 Abd: Soft, ND, NT, BS+, well-healed low midline scar and right inguinal scar, no scar visualized in left inguinal region? Rectal: Normal tone, gross blood Extrem: Warm, well-perfused, palpable distal pulses in all distal extremities, well-healed left knee scar Pertinent Results: [2154-6-30] 06:20PM BLOOD WBC-12.1* RBC-3.18* Hgb-9.7* Hct-28.7* MCV-90 MCH-30.4 MCHC-33.8 RDW-15.3 Plt Ct-233 [2154-6-30] 08:45AM BLOOD WBC-14.5* RBC-3.31* Hgb-9.9* Hct-29.5* MCV-89 MCH-29.9 MCHC-33.5 RDW-15.7* Plt Ct-224 [2154-6-24] 11:01PM BLOOD Neuts-77.1* Lymphs-15.1* Monos-6.2 Eos-1.4 Baso-0.2 [2154-6-30] 06:20PM BLOOD Plt Ct-233 [2154-6-30] 06:20PM BLOOD PT-13.0 PTT-28.4 INR(PT)-1.1 [2154-6-30] 06:20PM BLOOD Glucose-113* UreaN-10 Creat-1.0 Na-138 K-3.9 Cl-104 HCO3-27 AnGap-11 [2154-7-1] 07:40AM BLOOD CK(CPK)-589* [2154-7-1] 07:40AM BLOOD CK-MB-7 [2154-6-30] 06:20PM BLOOD Calcium-7.8* Phos-2.4* Mg-2.0 [2154-6-24] 11:01PM BLOOD CEA-1.5 [2154-6-30] 04:00PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.008 [2154-6-26] 09:45PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.014 [2154-6-30] 04:00PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD [2154-6-26] 09:45PM URINE Blood-MOD Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [2154-6-30] 04:00PM URINE RBC-2 WBC-32* Bacteri-FEW Yeast-NONE Epi-<1 [2154-6-26] 09:45PM URINE RBC-27* WBC-125* Bacteri-FEW Yeast-NONE Epi-0 . URINE CULTURE (Final [2154-6-30]): ESCHERICHIA COLI. >100,000 ORGANISMS . MRSA SCREEN (Final [2154-6-27]): No MRSA isolated. . Capsule Endoscopy Report [6-26] Summary: 1. dark fluid in the small bowel precludes complete visualization of the entire small bowel mucosa 2. The capsule did not reach the cecum. The entire small bowel was not identified due to the lack of passage into the cecum. 3. No active bleeding seen in the small bowel to the limit of the examination Brief Hospital Course: Patient was transferred to [Hospital1 18] for further angiographic vs. surgical management. On transfer to [Hospital1 18] ICU, patient was hemodynamically stable. Patient was evaluated by surgery team which recommended close hemodynamic monitoring and further consultation by GI service. He has not received any blood transfusions at [Hospital1 18]. The patient reports feeling very well. He reports that prior to recent bleeding episode he had not had BRBPR in nearly 10 years. He is unaware of a previous cancer diagnosis, and explains the colectomy was performed due to diverticular bleeding. He is currently without fever, chills, nausea, vomiting, abdominal pain, diarrhea, constipation. His last bloody bowel movement was on [2154-6-22]. [6-24] - admitted to the ICU under care of the East surgical service, foley catheter in place, serial hematocrits obtained, started on octreotide infusion, protonix IV BID, NPO, IVF for hydration. [6-25] - octreotide and protonix discontinued, famotidine started, diet advanced to clear liquids, transferred to the surgical floor for continued monitoring. [6-26] - transfused one unit RBC for low hematocrit, capusle study was performed demonstrating dark fluid in the small bowel and no active bleeding seen in the small bowel to the limit of the examination. Temp spike, pan cultured with positive urine cultures, started on cipro. [6-28] - the patient was taken to the operating room for a right colectomy, he tolerated the procedure well, diet NPO, IVF for hydration, IV pain control, foley catheter in place. [6-29] - diet advanced to sips, maint IVF [6-30] - diet advanced to clears, foley catheter removed, patient became agitated pulling at lines, cultures were drawn (negative), EKG performed (negative), lab results within normal limits, given haldol and seroquel with good response. [7-1] - diet advanced to regular, continued ciprofloxacin d/c'd [7-2] PT was d/c'd on [7-3] home, he was cleared by PT. Medications on Admission: none Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:4 Tablet(s) Refills:0 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: lower gastrointestinal bleed Post-op A-fib Discharge Condition: stable. tolerating regular diet. pain well controlled with oral medications. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your 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. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * 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 ambulate several times per day. . Incision Care: -your staples will be removed at your follow up appointment. -Steri-strips will be applied and will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Followup Instructions: 1. Please call Dr.[Name (NI) 3377] office, [Telephone/Fax (1) 160], to make a follow up appointment in [12-7] weeks. NEITHER DICTATED NOR READ BY ME Completed by:[2154-7-3]	[ "5990", "9971", "42731", "V1582", "4168" ]
Admission Date: [2147-5-7] Discharge Date: [2147-5-11] Date of Birth: [2147-5-7] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname ] is the 1080-gram product of a 30-2/7 week gestation born to a 33-year-old gravida 1, para 0 mother. Prenatal screens revealed A negative, antibody negative, hepatitis B surface antigen negative, rapid plasma reagin nonreactive, and Rubella immune. Group B strep status unknown. This pregnancy was notable for dichorionic-diamniotic twins, maternal hypertension (managed on Procardia 30 mg p.o. every day), and IUFD of twin A at 29 weeks with severe oligohydramnios intrauterine growth restriction and hydrops. (Autopsy results of this baby are pending) Betamethasone complete on [2147-5-2]. On the day of delivery, mother with spontaneous labor. Given Pitocin to augment labor. Given fetal decelerations, decision to deliver by cesarean section. Mother placed under general anesthesia. Rupture of membranes at the time of delivery with Apgar scores of 8 and 9. PHYSICAL EXAMINATION ON PRESENTATION: Birth weight was 1080 (10th to 25th percentile), length was 37 cm (10th to 25th percentile), and head circumference was 27 cm (25th percentile). The infant was ruddy. Comfortable on room air. Anterior fontanel was soft and flat. Palate was intact with good suck. Lungs were clear to apex and equal. Cardiovascular examination revealed a regular rate and rhythm. No murmurs. Femoral pulses were 2+. The abdomen was soft. Minimal bowel sounds. Genitourinary revealed infant with hypospadias. Testes palpable, high in inguinal canal. Patent anus. No sacral anomalies. Extremities were pink and well perfused. Moved all extremities well. Skin revealed scattered bruising; lower lip, left wrist, left earlobe. Immature examination with creasless folds, minimal scrotal rugae, and flat nipples. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY ISSUES: [Known lastname ] has been stable on room air throughout his hospital course. He has had occasional apnea of bradycardia episodes but is not requiring methoxamine therapy at this time. 2. CARDIOVASCULAR SYSTEM: Initially, required normal saline bolus for management of hypotension which responded well to normal saline boluses. He is currently stable with heart rates in the 150s to 170s and blood pressure mean of 35 to 41. 3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: His birth weight was 1080. His discharge weight is 1 kilogram. He was initially started on 80 cc/kg of D-10-W. Parenteral nutrition was initiated on day of life one. Enteral feedings were initiated at day of life one. The infant is currently receiving 140 cc/kg per day total; 70 cc/kg per day of total fluid is consistent of parenteral nutrition, D-10-W with 2 mEq of sodium cholesterol, 1 mEq of potassium chloride. The other 70 cc is made up Premature Enfamil. The infant's blood sugars/Dstix have been stable; 74 and 54 today. Electrolytes most recently obtained on [5-10] had a sodium of 134, potassium was 6.6, chloride was 102, and bicarbonate was 19. These were noted to be slightly hemolyzed. 4. GASTROINTESTINAL ISSUES: Peak bilirubin was day of life two of 10.4/0.4. The infant was treated with triple phototherapy with a nice affect. His most recent bilirubin was 7.2/0.3. 5. GENITOURINARY ISSUES: The infant with hypospadias noted on admission. Good renal function at this time. Names of urologists were provided to the parents for followup after discharge. 6. HEMATOLOGIC ISSUES: His hematocrit on admission was 55.6%. His blood type is A negative and Coombs negative. He has not required any blood transfusions. 7. INFECTIOUS DISEASE ISSUES: A complete blood count and blood culture were obtained on admission. Complete blood count was benign. Blood cultures remained negative at 48 hours, and ampicillin and gentamicin were discontinued at that time. 8. NEUROLOGIC ISSUES: The infant has been appropriate for gestational age. Head ultrasound pending for days of life seven to ten. 9. SENSORY ISSUES: Audiology screening has not been performed. Ophthalmologic exam also has not yet been performed. 10. SOCIAL WORK ISSUES: A [Hospital1 188] social worker has been involved with the family. The contact social worker's name is [Name (NI) 4457] [Name (NI) 38331]. She can be reached at [Telephone/Fax (1) 8717]. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge disposition was transfer to [Hospital6 3622] - Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 26079] accepting neonatologist. PRIMARY PEDIATRICIAN: Name of primary pediatrician is not yet identified. CARE RECOMMENDATIONS: Continue advancing enteral feedings at 10 cc/kg per day to a maximum of 150 cc/kg per day as tolerated. MEDICATIONS: None at discharge - Fe to be initiated when baby achieves full feedings. IMMUNIZATIONS/SCREENING: State Newborn screen was sent at day of life three; results pending. Immunizations have not been provided for. DISCHARGE DIAGNOSES: 1. Former 30-2/7 weeker twin; now four days old. 2. Status post transient hypotension. 3. Hypospadias. 4. Status post rule out sepsis with antibiotics. 5. Ongoing issue of hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Name8 (MD) 40912] MEDQUIST36 D: [2147-5-11] 13:26 T: [2147-5-11] 13:28 JOB#: [Job Number 47907]	[ "7742", "V290" ]
Admission Date: [2165-5-14] Discharge Date: [2165-5-22] Date of Birth: [2130-11-24] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Erythromycin Base / Minocycline Attending:[First Name3 (LF) 1283] Chief Complaint: During EP procedure, ablation catheter got stuck in mitral valve. Major Surgical or Invasive Procedure: 1. Removal of foreign body from heart 2. ASD closure with patch History of Present Illness: 34M c known h/o paroxysmal AF, who presented to the EP service for ablation procedure. Ablation catheter became intertwined in the mitral valve apparatus during the procedure. He was stable throughout the procedure. Cardiac surgery consulted emergently for removal of foreign body. Past Medical History: 1. Paroxysmal atrial fibrillation 2. Hypertension 3. Mild MR Social History: Remote h/o smoking and EtOH. Family History: Father: AFib Physical Exam: Afebrile, VSS Intubated and sedated Heart: RRR Lung: CTAB Abd: soft, NT, ND Ext: no edema, percutaneous catheter in groin Pertinent Results: [2165-5-21] 06:00AM BLOOD WBC-9.9 RBC-3.32* Hgb-8.9* Hct-27.8* MCV-84 MCH-26.7* MCHC-31.8 RDW-13.8 Plt Ct-342# [2165-5-22] 05:15AM BLOOD PT-17.4* PTT-50.3* INR(PT)-2.0 [2165-5-21] 06:00AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-137 K-5.2* Cl-99 HCO3-28 AnGap-15 Brief Hospital Course: 34M c known h/o paroxysmal AF, who presented to the EP service for ablation procedure. Ablation catheter became intertwined in the mitral valve apparatus during the procedure. He was stable throughout the procedure. Cardiac surgery consulted emergently for removal of foreign body. Patient was evaluated in the EP lab and transferred emergently to the OR for removal of foreign body and incidental AS closure on [2165-5-14]. For more detailed account, please see operative report. Post-op, he was transferred to the CSRU where he was extubated on POD 0, received peri-op blood transfusion for low Hct although no bleeding source identified, chest tubes were removed on POD 3, started on amiodarone for transient rapid afib, pericardial wires were removed on POD 4. Transferred to the floor on POD 3. He had a significant amount of pain that may have contributed to his extended hospital stay. He was also anticoagulated on heparin gtt and coumadin. Discharged on POD 8. Medications on Admission: 1. Atenolol 75 mg po bid 2. Coumadin 5 mg po hs Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 1 weeks: After 1 week, then 400 mg once a day for 1 month. Disp:90 Tablet(s) Refills:0 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Atenolol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:5 Tablet(s) Refills:0 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 5 days. Disp:5 Capsule, Sustained Release(s) Refills:0 10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 976] VNA Inc Discharge Diagnosis: 1. Paroxysmal atrial fibrillation 2. HTN 3. Mild MR Discharge Condition: Good Discharge Instructions: 1. Medications as directed. 2. Follow up INR checks as before. 3. Call office or go to ER if fever/chills, drainage from sternal or thoracotomy wound, chest pain, shortness of breath. 4. Cardiac MRI in 1 month. Followup Instructions: PCP, 2 weeks, call for appointment. Dr. [Last Name (STitle) ], 4 weeks, call for appointment. Dr[Last Name (Prefixes) 4558], 4 weeks, call for appointment.	[ "42731", "2851", "2875", "4240" ]
Admission Date: [2132-1-25] Discharge Date: [2132-2-2] Date of Birth: [2074-5-8] Sex: M Service: MEDICINE Allergies: Tetracyclines / Carbamazepine / Levaquin Attending:[First Name3 (LF) 338] Chief Complaint: MRSA bacteremia, endocarditis Major Surgical or Invasive Procedure: None History of Present Illness: 57 yo male with ESRD on HD (via dialysis line) s/p 2 failed kidney transplants, HTN, WPW, PVD s/p PTCA of R proximal posterior tibialis artery [9-17], s/p left femoral anterior-tibial bypass 7/200, pelvic fx [2125] wheelchair-bound s/p left hip replacement who initially presented to [Hospital6 33] on [2132-1-14] with mental status change x 12 hours and generalized weakness x 24 hours. Except for chronic low back pain, a decubitus ulcer and a heel ulcer, ROS was negative. In the ED he was febrile. A CXR was clear and he does not make urine. He was found to be bacteremic with MRSA presumed to be dialysis line sepsis. His tunneled Dialysis line was removed in the OR on [1-14]. Line tip and 2 sets of blood cultures from [1-14] grew MRSA. He was treated with multiple antibiotics including ceftriaxone, zosyn, vancomycin, and gentamicin. Surveillance blood cultures following removal of the HD line grew MRSA. Subsequent TEE reportedly revealed three vegetations on the patient??????s mitral valve with 1+MR, LVEF 55%. He has been noted to have embolic phenomena involving L thumb biopsied and debrided (thought to be infected) and on the penis throught to be vascular in nature. Spine MRI reportedly negative for epidural abscess. Patient has been treated with vancomycin. Gentamicin not included in treatment regimen. Patient continues to be bacteremic thus far with blood cultures still positive as recently as [1-24]. He has been dialyzed with temporary catheters since still bacteremic. Before today, he was last successfully dialyzed Monday [1-21] due to inability to gain IV access. Today he had a temporary femoral line placement today [1-25] and was dialyzed prior to transfer for a K of 6.1 but reportedly not volume overloaded or acidotic. Other active issues have been his sacral decubitus ulcer which has been receiving aggressive wound care. He also has a necrotic, infected R heel ulcer that per vascular surgery consult at OSH, may require amputation (followed by Dr. [Last Name (STitle) ] at [Hospital1 18]). He has also has been delerious at the OSH with negative head CT which has been attributed to toxic metabolic encephalopathy. The patient did have a MICU course for hypotension/septic physiology during which the patient was briefly on pressors. The patient had been on the medical floor at the OSH for two days but was transferred to the MICU Tuesdsay [1-22] for closer monitoring for blood pressures in the 90s systolic. He was to be transferred to the medical floor today, [1-25] but a medical bed became available here at [Hospital1 18] and family requested transfer. Upon arrival to the medical floor at [Hospital1 18], patient continues to be disoriented. He is A+Ox1. His T was 99, BP 84/50, HR 120s, RR 20, O2 100% 2LNC. Given hypotension, he was given a 500 cc NS bolus and was transferred to the MICU. Upon arrival to the MICU, patient continues to be delerius but BPs improved to 100s. Past Medical History: PMH: # ESRD on HD since '[11] s/p failed transplant x2 ([2112], [2123]) # PVD s/p LT femoral a. tibial bypass, PTCA Rt prox post tibialis artery. # Hypertension # CAD - ETT MIBI [12-17]: partially rev. apical/inf wall defect # Hx fibrocystocytoma in the Lt axilla s/p removal in [2118] at [Hospital1 2025]-> treated with XRT # Depression # Back pain 2nd T11/12 wedge compression # Restless leg syndrome # Peripheral Neuropathy # Secondary hyperparathyroidism # Psoriatic arthritis # Hx [Doctor Last Name ] Parkinson white . PSH: # s/p L hip replacement # L fem-at bypass [2124] # R AT atherectomy and PTA [6-16] # RT PT PTA [2130-10-5] # failed renal tx x2 Social History: Per OSH records, has occasional EtOH use. Denies tobacco and other drugs. Married with 3 children. Family History: heart disease in father and brothers. Physical Exam: PE: T: 99.6 BP: 103/65 HR: 105 RR: 12 O2 100% 2LNC Gen: Laying in bed, comfortable. Falling asleep easily but arousable. HEENT: No conjunctival pallor. No icterus. MMM. Poor dentition NECK: Supple, No LAD. JVP low. CV: regular w/ early beats. tachycardic. [3-20] sys murmur. LUNGS: CTAB, good BS BL ABD: NABS. Soft, NT, ND. No HSM EXT: Chronic venous stasis in [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]. Mult scabbed skin breaks in legs. Contracture of digits in UEs w/ sclerosis of skin. R heel ulcer dressed. L thumb dressed. GU: necrotic penile tip w/o drainage. R femoral HD line intact SKIN: Multiple hypokeratotic circular lesions on upper and lower extremities. Stage 1-2 sacral decub. NEURO: A&Ox1 to self. Agitated but redirectable. CN 2-12 intact. Strength and sensory exam limited by patient cooperativeness but moving all extremities. Pertinent Results: ECG [1-25]: sinus tach @ 110 w/ PVCs. LAD. Borderline LBBB +/- LAFB. Borderline 1st degree AVB. QW in III. Poor RW progression. TWI in I, aVL, V4-6. Compared to ECG from [2132-1-14], PR interval is prolonged. OSH STUDIES: TEE: 1. L ventricle normal w/ mildly reduced sys function and mild global HK, more pronounced inferoseptal HK 2. mitral valve leaflets thickened, particularly anterior valve. 3 mobile, somewhat calcific echodensities seen under leaflets associatd with chordae c/w vegetation. Largest is 1 cm/0.6 cm. Mild MR. [First Name (Titles) ] [Last Name (Titles) 30646] are MV to suggest abscess. 3. Aortic valve trileaflet. Nodular calcification at base of leaflets. Mild AS w/ peak gradietnt 25 mmHg. No AI. No vegetation 4. No thrombus in [Name Prefix (Prefixes) ] [Last Name (Prefixes) 1916]. 5. No significant TR 6. interatrial septum is aneurysmal. No color flow abnormalitiy. A Chiari network is seen in R atrium w/ is normal embryologic remnant. 7. RV appears preserved in size and function 8. No pericardial effusion 9. Mild atherosclerotic plaque in descending thoracic aorta CT lumbar spine: 1. No evidence of discitis osteomyelitis. Destructive changes noted at L2/3 level are essentially unchanged when compared to MRI performed on [2131-5-9] and CT dated [2129]. These findings most likely represent dialysis-associated amyloid spondylarthropathy. 2. multilevel degenerative change as described resultant severe central canal stenosis at multiple levels as well as bilateral foraminal stenosis as described above. Byunching of the nerve root surrounding the conus is visualized likely reflecting severe central canal stenosis at more inferior levels. 3. The kidneys are atrophic and largely replaced by cysts consistent with the history of long standing renal failure and dialysis. TTE: 1. EF 50-55%. Concentric LVH. 1+ MR. 1+TR. PASP estimatd at 17 mmHg. CT head [1-23]: No acute intracranial process or significant change from [1-14]. Some central atrophy. Small basal gangioonic lacunar infarct as before. New inflammatory changes within the R mastoid air cells and R inner ear. CT head [1-14]: negative for ICH CXR [1-25]: small focu sof air space disease R medial chest base, slightly worse. L perihilar atelectasis. No evidence of CHF. Brief Hospital Course: This is a 57 yo male with ESRD on HD (via dialysis line) s/p 2 failed kidney transplants, HTN, WPW, PVD who was transferred from OSH w/ MRSA bacteremia and mitral valve endocarditis. Based on all of the issues below, the family decided on [2132-1-31] to make the patient comfort measures only. He was terminally extubated and pressors turned off on [2132-1-31] at 6:30pm. The patient passed away on [2132-2-2]. # ID - Patient with persistent MRSA bacteremia with evidence of vegetations on mitral valve with septic emboli to the hand and penis. Presumed source was infected HD line, which was removed at the OSH. A temporary right femoral HD line was placed on [1-23] prior to transfer to [Hospital1 18]. Continued to have persistent positive cultures depsite therapeutic treatment with vancomycin. ID was consulted upon admission to [Hospital1 18] and antibiotics were changed to Daptomycin and Gentamicin for synergistic effect. CT surgery was consulted regarding possibility of surgical intervention. At this time, they recommended following TTE q3 days and obtaining a TEE here to assess clot burden on the mitral valve. The patient also complained of left hip pain, over the area of prior hip replacement. Hip films were obtained as well as an ortho consult, who recommended IR-guided aspiration to assess for seeding of the prosthesis. A CT of the head was obtained to assess for septic emboli and was negative for any acute intracranial processes. A CTA of the head was ordered to assess the vasculature to r/o mycotic aneurysms. The patient was initially hypotensive upon admission, which resolved with IVF initially but then required pressors to keep his MAP>60. This was in the setting of the LGIB (see below). # UGIB - on [2132-1-30] the patient was found to be hypotensive with copious melena. He required pressors and received 6 units PRBC, 3 units FFP, DDAVP, and vitamin K. GI performed an urgent EGD and found a visible vessel on that they put 2 clips on. His hct continued to trend down. # Cardiac Arrest - Immediately following the patients UGIB, he was found to be in VFib and received shocks x 2. He coverted to NSR and was started on an amiodarone drip. # LGIB - on [2132-1-27], the patient developed an acute, sudden and significant BRBPR with hemodynamic instability (hypotension to the 80's systolica and tachycardia to the 110's). GI was consulted who recommended a tagged RBC scan, given the distal and active bleed. The scan demonstrated an active bleed in the recto-sigmoid area. Surgery was also consulted who evaluated the patient and determined the source to be a ?exposed vessel vs. fissure at the anus. The bleeding resolved with 1 suture to the exposed area. Angio was also consulted, however the patient did not require IR intervention. He received a total of 5 U PRBCs, 2 U FFP, and ddAVP between [Date range (1) 18370] with estimated loss of blood approximately 3 units. # ESRD on HD - currently only with temporary HD access given persistent bactermia at OSH. Renal has been following with plans for HD on M/W/F. Due to persistent bacteremia, the plan is to keep the current temp line in place for HD and avoid further lines if possible. Continued sevelamer and cinecalcet. # Delirium - patient presented with delirium upon arrival and at the OSH as well, with symptoms of confusion, hallucinations, disorientation, and mild agitation. CT head on admission did not demonstrate any intra-cranial pathology. Other ddx included uremia, drug-induced, ICU delirium. The patient's sinemet and comtan (taken for RLS) were d/c'd on [1-27] as they may potentially exacerbate his existing delirium. # Heel ulcer - patient has significant h/o peripheral vascular disease with chronic right heel ulcers. He had a vascular surgery evaluation at OSH and there was concern he may need an amputation electively. He is at high risk for peri-operative complications. Both vascular surgery and podiatry were consulted upon admission here and recommended NIAS prior to possible debridement of the right heel ulcer. Medications on Admission: HOME MEDS: renagel zonisamide 500 mg qhs xanax 0.25 mg TID flexeril 5 mg TID ativan 0.5 mg qhs sinemet (25mg/100 mg) 2 tabs TID comtan 200 mg TID MEDS ON TRANSFER: tylenol prn oxycodone 5 mg Q6H prn comtan 200 mg TID sinemet 25/100 mg 2 tabs TID sevelamer 2400 mg TID w/ meals hydroxyzine 25 mg qhs percocet 1 tab Q8H cinacalcet 60 mg daily aspirin 325 mg daily zonisamide 500 mg qhs xenaderm ointment to buttocks [Hospital1 ] amoxicillin 500 mg Qday ? vancomycin per HD (not on records) Discharge Medications: The patient expired on [2132-2-2]. Discharge Disposition: Expired Discharge Diagnosis: MRSA Endocarditis UGIB LGIB Cardiac Arrest ESRD Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "40391", "2851", "41401" ]
Admission Date: [2185-11-21] Discharge Date: [2185-12-3] Date of Birth: [2130-3-13] Sex: M Service: MEDICINE Allergies: Codeine / Penicillins / Cephalosporins Attending:[Male First Name (un) 5282] Chief Complaint: recurrent UGIB in cirrhotic patient Major Surgical or Invasive Procedure: EGD with banding of varicies. History of Present Illness: 55M with EtOH and Hep C cirrhosis, admitted [2185-11-12] to OSH with rectal bleeding and abdominal pain, now transferred to [Hospital1 18] with continued UGIB for TIPS evaluation. . He was admitted after presenting with (per the notes) 2 days of RUQ/epigastric pain and 2 episodes of large volume hematochezia. Patient recalls not much abdominal pain but does report 6 hours of BRBPR as well as some hematemesis. At admission HR 128 with BP 133/83 and Hct 34.9. Total bili 1.7 and INR 1.1 with platelets 49. At OSH, he subsequently developed hematemesis with Hct drop to 28.3. Emergent EGD showed bleeding grade III varices, which were sclerosed. He was treated also with protonix gtt and octreotide gtt. Received 4 units PRBCs and one unit platelets. Nadolol was started. He continued to have melena but was hemodynamically stable and was transferred to the floor. On [11-17] he again developed hematemesis (400 cc bright red blood). He went back to the MICU with hypotension to the 80s. Received 4 more units and fluids (Hct low 24.3). EGD at that time did not suggest bleeding of his varices but did show gastritis with hemorrhage. He received 2 more units PRBCs on [11-19] and [11-20]. On [11-20] he had 2 episodes of BRBPR with 6 point hematocrit drop. Colonoscopy was done today without evidence of a source. Following this, he "coughed up" 20 cc blood (patient does not recall this). He received one more unit PRBCs. Last hematocrit 31.2 at noon today (got one more unit after this). During his admission he was also treated with 5 days ertapenem for ?colitis on CT. No other major events during his hospital course. . Currently denies abdominal pain or nausea. Endorses mild lightheadedness. Does recall watery diarrhea from prep overnight but none recent. No noted jaundice or scleral icterus. Does endorse LE edema that he noted today as well as abdominal distension. Also notes he developed cough, mildly productive, since going outside for transfer today. . Review of systems: (+) Per HPI (-) Denies fever (though did have a 100.4 at hospital admission), chills, recent weight loss or gain (unsure of this). Denies headache. Denies shortness of breath, wheezing. Denies chest pain, chest pressure, palpitations. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - ESLD due to EtOH and HCV - EtOH abuse with history of DTs. - Hepatitis C - GERD - Cervical disc degeneration s/p surgical procedure Social History: - Tobacco: Current smoker of 1.5 PPD x 40 years. - Alcohol: 12-18 beers per day; occasionally hard alcohol. Family History: Mother died of throat cancer. Father died of MVA Physical Exam: ON ADMISSION: General: Chronically ill appearing. Alert, oriented, no acute distress HEENT: Sclera anicteric, PERRL (3->2), EOMs intact with few beats horizontal nystagmus, MM slightly dry, oropharynx clear. Neck: supple, JVD flat, no LAD Lungs: + bibasilar crackles R>L, clear almost entirely with cough. Few wheezes when coughing. CV: Regular rate and rhythm, normal S1 + S2, soft SM at apex. Abdomen: soft, non-tender, mild to moderate distension, hyperactive bowel sounds present, no rebound tenderness or guarding. mostly tympanic with some peripheral ?shifting dullness. Ext: warm, well perfused, 2+ LE edema. Neuro: alerted and oriented x 3, CN II-XII intact, strength 5/5 in distal UEs and LEs, no asterixis. ON DISCHARGE: Pertinent Results: On Admission: [2185-11-21] 05:12PM BLOOD WBC-10.2 RBC-3.43* Hgb-10.7* Hct-31.7* MCV-93 MCH-31.2 MCHC-33.7 RDW-17.3* [2185-11-22] 12:03AM BLOOD WBC-28.8# RBC-3.71 Hgb-12.1* Hct-34.0* MCV-92 MCH-32.5* MCHC-35.5* RDW-17.8* Plt Ct-83* [2185-11-21] 05:12PM BLOOD Glucose-110* UreaN-15 Creat-0.7 Na-138 K-3.9 Cl-110* HCO3-22 AnGap-10 [2185-11-21] 05:12PM BLOOD ALT-35 AST-40 LD(LDH)-185 AlkPhos-43 TotBili-2.6* CXR: FINDINGS: No prior comparisons films. Heart size is normal, although patient rotation limits evaluation of the right heart border. There is a large opacity/consolidation in the left mid and lower lung fields. Differential includes aspiration as well as infectious processes. No definite adenopathy is seen. Right lung is clear. NG tube tip lies well below the diaphragm, its distal end is not included on the film. No pneumothorax. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Mr [Known lastname ] was initially transferred to the ICU for management of his hematemesis. Hepatology was consulted and performed an EGD in the ICU which revealed bleeding varicies which were banded. IR was made aware in case he re-bled, the plan would be for urgent/emergent TIPS. He was started on Ciprofloxacin for SBP prophylaxis. He was continued on a PPI and octreotide drip in the ICU. He was then transferred to the floor but had recurrent episodes of bleeding and was sent back to the ICU where an emergent TIPS was eventually performed by IR. Patients hematocrit remained stable back on the floor. Lasix, Nadolol was restarted, and Mr [Known lastname 1226] bleeding did not recur. He did have an abnormal respiratory exam; a chest x-ray revealed a large consolidation while he was in the ICU and he completed a course of vancomycin and meropenem while in the unit; on the floor his respiratory status improved and was breathing normally on room air. He was not encephalopathic during his hospitalization. His end-stage liver disease was felt secondary to his hepatitis C history and alcohol history. He was not considered a transplant candidate since does have active drinking. Social work was consulted for his alcohol history. A nicotine patch was started for smoking cessation. He was discharged with liver follow up. Medications on Admission: Medications at home: None Medications at transfer: Octreotide 50 mcg/hr IV Protonix 8 mg/hr IV Trazodone 100 mg HS and 25 mg daily prn insomnia Nicotine patch 21mg daily Morphine 2 mg IV q3H prn pain (4 doses yest, one today) zofran 4 mg IV q4H prn nausea Magnesium 2 gram x 1 today Potassium phosphate 15 mmol x1 today Golytely yesterday Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:0 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Titrate to 3 bowel movements daily. Disp:2700 ML(s) Refills:2 5. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 7. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:45 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed secondary to varices HCV and alcoholic cirrhosis Alcohol abuse Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Patient has been hemodynamically Discharge Instructions: You were transferred to [Hospital1 18] because of bleeding from your esophagus and to be evaluated for further treatments. While at [Hospital1 18] you had an endoscopy which showed continued bleeding and some blood vessels were banded (tied off to stop the bleeding). You then had repeat bleeding and required a procedure to decompress your varices (TIPS). This should prevent bleeding from these swollen vessels in the future. You also developed a pneumonia that required IV antibiotics. This has resolved. You have not had any other signs of infection while you were here. You underwent a paracentesis which did not show any infection in the fluid in your abdomen. You had fluid in your abdomen (ascites) which was removed as well for comfort. You were also incidentally found to have a very small clot in one of the vessels in your abdomen (superior mesenteric vein). This should be followed by your outpatient doctor; however, nothing needs to be done at this time. You have been started on a number of new medications for your liver disease as noted below. Please take all of these medications as prescribed: 1. Spironolactone (for your ascites and swelling in your legs) - 150 mg daily 2. Lasix (also for swelling and ascites) - 60 mg daily 3. Protonix (for ulcer prevention) - 40 mg daily 4. Lactulose (to prevent confusion given your liver disease) - take 30 mL three times daily. You should titrate this (either take less or more) so that you are having 3 bowel movements every day 5. Rifaximin (to prevent confusion given your liver disease) - 400 mg three times daily 6. Multivitamin - you should take this to give you the vitamins and minerals you need daily 7. Nicotine patch - use this as needed to stop smoking You have been given a walker as you are a bit unsteady on your feet for now, likely from deconditioning since you have been in the hospital. Please use this to prevent falls. Followup Instructions: It is very important that you follow up with your primary care doctor as well as hepatology (Dr. [First Name8 (NamePattern2) 2943] [Name (STitle) 696]). Since it is the weekend, we cannot make an appointment for you, but we will have Dr.[Name (NI) 8653] office contact you next week with a follow up appointment. If you do not hear from his office by the middle of the week, please call to arrange an appointment. The number is [Telephone/Fax (1) 673]. In addition, it is very important that you continue to get alcohol relapse prevention and/or attend AA meetings.	[ "5070", "3051" ]
Admission Date: [2191-12-5] Discharge Date: [2191-12-9] Date of Birth: [2118-12-22] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [2191-12-5] Redo sternotomy and resection of proximal saphenous vein graft > right coronary artery pseudoaneurysm History of Present Illness: 72 year old male s/p CABG in [2176] who underwent angioplasty and stenting in [2189] who now presents for evaluation of mediastinal mass found on echocardiogram. The mass was originally discovered in [2189-5-3] and was noted to be 5.5cm. A CT scan suggested it may be a saphenous vein graft aneurysm while a PET scan showed no evidence of malignancy. A recent echo now shows the mass to measure 9.5cm. He was seen in clinic in [Month (only) ] and has since had an MRA which confirmed the diagnosis of a vein graft pseudoaneurym. He also underwent a cardiac catheterization which showed three vessel disease yet patent grafts. The vein grafts were aneurysmal with the SVG->RCA being markedly aneurysmal. He returns today for surgical planning. Past Medical History: Hypercholesterolemia Hypertension Coronary artery disease s/p CABGx3 and angioplasty/PCI [2189]-(DES to native LCX) Abdominal aortic aneurysm 4cm followed by Dr. [Last Name (STitle) ] Cholelithiasis, biliary duct dilatation- to have MRCP CRI - Creat 1.9 (Range 1.6-2.7) Chronic back pain with "pinched nerve" Osteoarthritis Chronic obstructive pulmonary disease Social History: Currently smokes [2-4] ppd, smoked for 40 years. Denies alcohol or drugs. Lives at home. Retired construction worker. Family History: Brother with heart disease, s/p CABG [92] years ago. Physical Exam: Pulse: 67 SR Resp: 14 97% RA Sat B/P Right: 130/76 Left: 142/86 Height: 68" Weight: 145 General: WDWN, tanned gentleman in NAD Skin: Dry [X] intact [X] No C/C/E. +Rhinophyma. Right wrist cyst vs lipoma. Left thigh lipoma. Sternal incision well healed. Bone is stable. HEENT: NCAT, PERRLA, EOMI, OP benign. Voice is hoarse. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Delayed expiration Heart: RRR, Nl S1-S2, No M/R/G Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema. Prominent right popliteal pulse. Varicosities: Right GSV surgically absent by open technique. Incision well healed. Left appears suitable. Mild area of dilatation of branches at mid lower leg below knee. Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 PT [Name (NI) 167]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Right: ? Faint bruit Left: None Pertinent Results: [2191-12-8] 09:20AM BLOOD WBC-11.5* RBC-3.31* Hgb-9.0* Hct-26.5* MCV-80* MCH-27.2 MCHC-33.9 RDW-17.3* Plt Ct-165 [2191-12-5] 11:42AM BLOOD PT-13.6* PTT-34.3 INR(PT)-1.2* [2191-12-9] 06:50AM BLOOD Glucose-81 UreaN-26* Creat-1.6* Na-138 K-4.3 Cl-101 HCO3-30 AnGap-11 [Known lastname 41097],[Known firstname ] H [Medical Record Number 41098] M 72 [2118-12-22] Radiology Report CHEST (PA & LAT) Study Date of [2191-12-8] 1:53 PM [Last Name (LF) ],[First Name3 (LF) ] R. CSURG FA6A [2191-12-8] 1:53 PM CHEST (PA & LAT) Clip # [Clip Number (Radiology) 41099] Reason: r/o inf, eff [Hospital 93] MEDICAL CONDITION: 72 year old man s/p cabg REASON FOR THIS EXAMINATION: r/o inf, eff Final Report INDICATION: A 72-year-old man status post CABG, rule out infection or effusion. COMPARISON: [2191-12-6]; [2191-12-5]; preoperative film of [12-1], [2191]. CHEST, TWO VIEWS: Stable appearance to median sternotomy wires, clips and cardiomediastinal contours. Left linear atelectasis. Small pleural effusions are more prominent. Together with prominent Kerley B lines, ovolume overload is suggested. No pneumothorax. Hyperexpansion with prominent retrosternal airspace suggests COPD. Linear streaks of gas in the retrosternal region is likely post- operative. Mild degenerative changes are seen in the spine. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Mr. [Known lastname ] was admitted on the same day of surgery and underwent redo sternotomy with resection of pseudoaneurysm from saphenous vein graft to right coronary artery. See operative report for further details. He received cefazolin for perioperative antibiotics and was transferred to the intensive care unit in stable condition for hemodynamic management. Within the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. He continued to progress and was transferred to the floor on postoperative day one. Chest tubes were removed on post-op day one. Physical therapy worked with him on strength and mobility. On post-op day four he appeared to be doing well and was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Avalide 300/12.5mg daily, Crestor 40mg daily, Plavix 75mg daily (stopped 1 week prior to surgery), Aspirin 81mg daily, Nifedical XL 60mg daily, Vicodin prn for back pain 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). Disp:60 Capsule(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 8. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:1 9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:30 Tablet Sustained Release(s) Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Hypercholesterolemia Hypertension Coronary artery disease s/p CABGx3 and angioplasty/PCI [2189]-(DES to native LCX) Abdominal aortic aneurysm 4cm followed by Dr. [Last Name (STitle) ] Cholelithiasis, biliary duct dilatation- to have MRCP CRI - Creat 1.9 (Range 1.6-2.7) Chronic back pain with "pinched nerve" Osteoarthritis Chronic obstructive pulmonary disease Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming Monitor wounds for infection and report any redness, warmth, swelling, tenderness or drainage Please take temperature each evening and Report any fever 100.5 or greater 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule appointments Surgeon Dr [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Primary Care/cardiologist Dr [Last Name (STitle) 14522] in [2-4] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2191-12-9]	[ "2720", "496", "3051", "5859", "53081", "2859", "V4582", "V4581" ]
Admission Date: [2176-4-5] Discharge Date: [2176-4-13] Date of Birth: [2093-8-24] Sex: F Service: MEDICINE Allergies: Levaquin Attending:[First Name3 (LF) 1828] Chief Complaint: decreased responsiveness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 77355] is an 82 year old female with history of remote breast CA, alcoholic cirrhosis, s/p AVR who was last seen in normal health at 7PM on the evenig prior to admission. On the morning of admission, the patient was found by her roommate slumped over, fully dressed in bed. The patient is reported by EMS records to have been supine in bed, awake, but unresponsive to verbal or painful stimuli, additionally noted to be incontinent of urine and feces. When EMS arrived patient's vitals were 110/64 86 100% RA, unclear RR. The patient was initially sent to [Hospital 8125] hospital where she was intubated for airway protection. ABG prior to intubation was 7.42/27/370 on a NRB. Per report the patient was vomiting prior to arrival and prior to intubation. The patient had a CT head which revealed no acute process and had a normal CXR. Given history of distant breast CA a CTA was performed which revealed no evidence of PE or metastatic disease but did reveal a cirrhotic appearing liver and small ascites on abdominal cuts. The patient had a tox screen which was normal. . Per discussion with the patient's family she has been generally in her usual state of health. She has had a few recent med changes including increase in her Xanax dosing from once daily to three times daily approximately 2-3 weeks ago. She has no known history of seizure disorder or large stroke although has had history of microvascular disease. She has not had episodes of hepatic encephalopathy previously, is not currently maintained on lactulose. . ED Course: The patient was maintained on Propofol, reported to be waking up off sedation. The patient was given Levo/Vanc, ceftriaxone for potential infectious etiologies. Past Medical History: #. Breast Cancer - s/p right mastectomy - no recurrent disease known to date #. Alcoholic Cirrhosis - quit ETOH > 10 years ago #. Aortic stenosis s/p AVR #. COPD #. MDS Social History: The patient currently lives in a home with a roommate in [Hospital ] [Location (un) 3320]. She is generally independent in ADL, walks with a walker/cane and has a home health aide once a week. Tobacco: Distant, unclear amount ETOH: Previous history of abuse, thought clean x 10 years per family Illicts: None Family History: Non-contributory Physical Exam: Vitals: T- 99.8 100/50 HR: 96 Vent: AC 1.0 16 (overbreathing 5) x 500 . HEENT: NCAT. Pupils equal and reactive to light. OP: limited view secondary to ET tube. NG tube with clear fluid with some brown debris, trace gastroccult + Neck: JVp visible to 6-7 cm Chest: s/p Right mastectomy. Generally clear to auscultation anterior and posterior without rales, rhonchi or wheezes Cor: RRR, normal S1/S2. No obvious murmurs, rubs or gallops Abd: mod distended, obese, + umbilical hernia. Soft, no guarding with palpation. ? fluid wave Rectal: Performed in ED, brown trace guaiac+ stool Ext: no edema. Feet cool but not cold. DP 2+ bilaterally Neuro: Limited secondary to recent sedation. Patient currently off sedation x 10 minutes. Patient does not respond to voice. Does not open eyes spontaneously or to painful stimuli. Withdraws feet bilaterally to pain, does not respond to painful stimuli to upper extremities. Plantar reflexes: Equivocal bilterally Pertinent Results: [2176-4-5] 04:38PM WBC-8.8 RBC-3.40* HGB-11.8* HCT-35.7* MCV-105* MCH-34.6* MCHC-32.9 RDW-16.0* [2176-4-5] 04:38PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2176-4-5] 04:38PM TSH-2.4 [2176-4-5] 04:38PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.9 [2176-4-5] 04:38PM ALT(SGPT)-23 AST(SGOT)-83* ALK PHOS-94 AMYLASE-28 TOT BILI-1.8* [2176-4-5] 04:38PM GLUCOSE-109* UREA N-19 CREAT-0.9 SODIUM-148* POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-26 ANION GAP-14 . Admission ECG: Normal sinus rhythm with right bundle-branch block and occasional premature ventricular contractions. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. . Admission Chest CT: CT OF THE CHEST WITH IV CONTRAST: An endotracheal tube is seen with the tip at 4.5 cm above the carina. An NG tube is also seen with the tip within the stomach. Breathing artifact degrades the quality of the study. The heart is enlarged. The pulmonary artery is normal in size. Ascending aortic graft is seen with no complication noted. There are no filling defects within the main pulmonary artery to the segmental and larger subsegmental branches to suggest pulmonary embolism. However, evaluation of the subsegmental branches is limited due to respiratory motion artifact. Atherosclerotic calcifications within the aorta. Small left- sided pleural effusion with associated compressive atelectasis. The patient is status post right mastectomy. There is suggestion of chronic sternal dehiscense. There is no mediastinal, hilar, or axillary lymphadenopathy. Small 12mm x 8mm focal density is within the central left breast. This study is not designed for the evaluation of the abdomen, however, the visualized portions of the upper abdomen demonstrate a cirrhotic liver, ascites, borderline enlarged spleen and collateral circulation. Tiny granuloma is seen within the spleen. BONE WINDOWS: No suspicious lytic or sclerotic lesions. IMPRESSION: 1. Limited study without evidence of central and segmental PE. 2. Small left-sided pleural effusion with associated atelectasis. 3. Cirrhotic liver, splenomegaly, and ascites, incompletely evaluated. 4. Small mass within the left breast, correlate with recent mammogram, if obtained. Else the pateint would need a formal diagnostic mamogram to evaluate this lesion further. . Admission MR [Name13 (STitle) 430]: TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were obtained before gadolinium. T1 axial, sagittal and coronal images were obtained following gadolinium. There are no prior examinations for comparison. FINDINGS: Diffusion images demonstrate subtle area of slow diffusion involving both thalami. No cortical infarcts are identified. Pre-gadolinium T1 images demonstrate hyperintensities involving the basal ganglia, predominantly the globus pallidus and putamen, but also involvement of the upper brainstem. Multiple small foci of T2 hyperintensity indicative of mild- to-moderate changes of small vessel disease also identified. Following gadolinium, no abnormal parenchymal, vascular, or meningeal enhancement seen. There is a fluid level in the left maxillary sinus. IMPRESSION: 1. Subtle slow diffusion identified in both thalami could be secondary to global hypoxic event. Clinical correlation recommended. If indicated, a followup examination can help for further assessment. 2. Increased T1 pre-gadolinium signal in basal ganglia could be secondary to hepatic insufficiency. 3. No enhancing brain lesions. 4. Mild-to-moderate changes of small vessel disease. Brief Hospital Course: Ms. [Known lastname 77355] is an 82 year old female admitted with decreased responsiveness ultimately attributed to non-convulsive status epilepticus. . #. Decreased Responsiveness: The exact cause of the pt's unresponsiveness and seizure activity remained unclear. There was some evidence on brain MR of changes associated with hypoxia. It was unclear whether these may have triggered the seizures or been a result of them; there was no obvious inciting event to cause respiratory failure. The pt was intubated at an outside hospital for airway protection and transferred to the MICU at [Hospital1 18]. A wide differential was considered however extensive laboratory testing was largely un revealing. The pt was seen and followed by the neurology service who made the diagnosis of non-convulsive status epilepticus via serial EEG. She was started on Dilantin. *At the time of discharge, it was advised that the pt should be transitioned from Dilantin to Keppra. Per the neurology service, this should happen as follows: Dilantin was being given at 100 mg TID at discharge. This should be weaned by 100 mg a day over the next three to four days. Thus, on Sunday, [2176-4-14], would advise 100 mg [Hospital1 ] of Dilantin. On the day of discharge, Keppra was started at 500 mg [Hospital1 ]. This should be increased by 500 mg daily over the next three to four days to a total dose of 1500 mg [Hospital1 ].* If the pt experiences an acute mental status change in the future, consideration should be given to repeat seizure. The pt also continues to be treated with lactulose in case hepatic encephalopathy was contributing her condition. It is expected that this can likely be discontinued in the next 1 to 2 weeks if the pt remains stable. . #. CHF: The pt is thought to carry a diagnosis of CHF based on her home medications, although there was limited data available in the [Hospital1 18] system. She was thought to be mildly volume up at admission and was started on low-dose Lasix; after this, she appeared clinically euvolemic throughout her course. The pt's home Coreg continued. Her home digoxin was held; this can likely be restarted in the near future. . #. Cirrhosis: The pt has a history of EtOH cirrhosis. Her most recent INR is 1.3. Her cirrhosis did not appear to be contributing to her clinical picture during her admission. . #. s/p AVR: Bioprosthetic, not on anticoagulation as outpatient. . # Contact: [Name (NI) ]: [Name (NI) ] [Name (NI) 1193] [Telephone/Fax (1) 77356] Daughter: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1193] [Telephone/Fax (1) 77357] Medications on Admission: Digoxin .125mg daily Coreg 3.125mg [Hospital1 ] Remeron 30mg qhs Duloxetine 30mg daily Xanax .25mg PO tid Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) 511] Siani, [Location (un) 86] Discharge Diagnosis: Primary: decreased responsiveness non-convulsive seizures . Secondary: history of breast cancer alcoholic cirrhosis COPD CHF Discharge Condition: Vital signs stable. Without seizure activity. Overall improved. Discharge Instructions: -You were admitted with decreased responsiveness and found to be having non-convulsive seizures. We have treated you with anti-seizure medications. You are now being transferred to a rehab hospital for further care. -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> Lactulose was started. --> Dilantin was started and is now being transitioned to Keppra. --> Lasix was started to help remove excess fluid from your body. --> Your Remeron and Xanax was held as these medications can cause sedation. Talk with your doctor about when or if to restart this. -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: Please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 36604] when you are discharged from rehab to schedule a follow-up appointment.	[ "51881", "2761", "4280", "496", "4019" ]
Admission Date: [2182-3-9] Discharge Date: [2182-3-24] Date of Birth: [2182-3-9] Sex: F HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 14966]-[Known lastname 3640] is a 34 week premature infant admitted to the Newborn Intensive Care Unit with prematurity. The infant was born on [2182-3-9] to a 37 year old Gravida 5, Para 1 to 2 mother at 34 weeks positive, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune and Group B Streptococcus unknown. Prenatal course is notable for the following: 1. Maternal hypertension, presumed secondary to a combination of chronic hypertension and preeclampsia. 2. History of poor fetal growth and maternal treatment with Betamethasone approximately three weeks prior to delivery secondary to and pain secondary to fibromyalgia treated with multiple medications including Lidocaine injections. 4. Development of oligohydramnios and subsequent plan for induction. 5. Positive maternal urine toxicology screen for cocaine, amphetamines and barbiturates. Previous maternal history notable for prior delivery of a 30 week premature infant in [2171]. [Hospital 37544] medical history as above, notable for severe migraines and fibromyalgia. Delivery occurred following induction secondary to oligohydramnios. Rupture of membranes occurred 13 hours prior to delivery and mother received antibiotics the first 15 hours prior to delivery. Infant was delivered vaginally with Apgar scores of 8 and 9. No significant resuscitation was needed. The patient was noted to have moderate work of breathing with a notable significant oxygen requirement upon arrival in the Neonatal Intensive Care Unit and was placed on CPAP. PHYSICAL EXAMINATION ON ADMISSION: Weight was 1785 gm or 10th to 25th percentile, head circumference 30.5 cm 25th to 50th percentile and length was 41 cm, 10th to 25th percentile. Vital signs were within normal limits with the patient on CPAP with oxygen requirement of 30 to 40%. The patient was active and vigorous. Fontanelles were flat, open and soft. Red reflex was present bilaterally. Palate was intact. Chest sounds were coarse but well aerated. Mild to moderate retractions were present. Cardiac was regular rate and rhythm without murmur. Abdomen was soft, nontender without hepatosplenomegaly. Umbilical cord revealed three vessels. Extremities were warm and well perfused. The left hand was somewhat swollen and bruised. The hips were stable. Lumbosacral area was normal. Genitalia were normal. Tone and activity were appropriate. HOSPITAL COURSE: Respiratory - The patient was maintained on CPAP approximately 48 hours following which time the patient was weaned to room air. Since day of life #2 the patient has been stable, breathing comfortably in room air without need for supplemental oxygen or notable respiratory distress. Cardiovascular - The patient has been hemodynamically stable throughout admission without the need for blood pressure support. No evidence of patent ductus arteriosus developed. Fluids, electrolytes and nutrition - The patient was is maintained on intravenous fluids with stable blood sugars. Enteral feeds were begun on day of life #2 and were taken orally from the start. The volumes of feedings were gradually advanced to full feeds. Subsequently the calories were increased to 26 cal/oz and supplemental iron was added. At the time of discharge, the patient has been taking Neosure 26 cal/oz formula orally with adequate volumes and as demonstrated appropriate weight gain. Weight on [2182-3-22], two days prior to discharge is 1770 gm, increasing steadily over the past several days. On [3-24] it was 1840. HC was 30.5 cm. Lth was 41.5 cm. Infectious disease - Initial complete blood count revealed a white count of 22 with a benign differential, hematocrit of 52% and platelets of 247. Blood culture was sent and subsequently has been negative. Ampicillin and gentamicin were given 48 hours pending negative cultures and benign clinical course. Gastrointestinal - The patient exhibited mild hyperbilirubinemia of prematurity and received phototherapy for several days. Neurological - The patient was noted to be somewhat jittery for the first several days of life. Urine toxicology screen on the infant revealed barbiturates which are consistent with maternal medication use. Absence scores were followed and in the first several days of life ranged between 3 and 8. On day of life #4 onwards the absence scores were basically 0 and the infant exhibited no further signs of withdrawal. Of note, no medications were administered for the early symptoms of mild withdrawal. Social - Social work was involved, given the maternal history in addition to the positive toxicology screens. DSS was involved and a 51A was filed. Social work and DSS worked actively with the family and at the time of discharge the DSS case is still open but the family maintains custody. Substantial supports have been arranged for the mother and the family. Sensory - Hearing screen was performed with automated auditory brain stem responses and passed bilaterally. DISCHARGE CONDITION: At the time of discharge he is cardiovascularly stable and breathing comfortably on room air. The infant is tolerating feeds of Neosure 26 cal/oz oral, substantial volumes with normal urine and stool output. The infant is gaining weight. DISCHARGE DISPOSITION: The infant is discharged to the care of the family. PRIMARY CARE PHYSICIAN: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 40226], phone [Telephone/Fax (1) 40227]. CARE RECOMMENDATIONS: 1. Feeds - Neosure 26 cal/oz. Neosure recommended to 6 to 9 months of record age. Calories may be adjusted based on the infant's growth. 2. Medications - Fer-In-[Male First Name (un) ], provide additional 2 mg/kg/day of iron. 3. Carseat - Test passed. 4. State newborn screening sent on [3-18], and again on [3-23], results pending at time of this dictation. 5. Immunizations the infant has received - Hepatitis B immunization #1. 6. Follow up appointments - He will follow up with primary pediatrician, Dr. [Last Name (STitle) 40226] two days following discharge. In addition to Early Interventional Referral and Visiting Nurse [First Name (Titles) ] [Last Name (Titles) 2176] have been arranged. In addition DSS social worker will follow up with the family as well. DISCHARGE DIAGNOSIS: 1. Prematurity 34 weeks 2. Mild hyperbilirubinemia of prematurity, resolved 3. Mild respiratory distress, resolved 4. Sepsis evaluation, resolved 5. Positive maternal urine toxicology screens 6. History of maternal drug use [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Name8 (MD) 38043] MEDQUIST36 D: [2182-3-24] 16:30 T: [2182-3-22] 20:57 JOB#: [Job Number 20130]	[ "7742", "V290" ]
Admission Date: [2140-4-17] Discharge Date: [2140-4-22] Date of Birth: [2101-4-14] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 371] Chief Complaint: Trauma: fall: left temporal bone fracture left temporal SAH / SDH left aspiration pneumonitis Major Surgical or Invasive Procedure: None History of Present Illness: 39F intoxicated who presents after falling approximately [7-17] feet and striking the back of her head. Loss of consciousness was noted and EMS was called. When EMS arrived she had evidence of emesis. Pt was moving all extremities purposefully but was reported to have agonal breathing and was bradycardia with a GCS 7. She was thus intubated in the field and medflighted to [Hospital1 18]. On arrival her exam was notable for 2 mm pupils bilaterally which were non-reactive and disconjugate with intact gag and cough reflexes. CT head revealed left temporal bone fracture and left SAH. CT chest revealed left aspiration pneumonitis. Mannitol was administered and her exam was noted to improve markedly as sedation concomitantly wore off. Per Neurosurgical evaluation, no EVD or other acute surgical intervention was required. INJURIES: -left temporal bone fracture -left SAH -left aspiration pneumonitis Past Medical History: -Hx concussion in college Social History: unknown Family History: NC Physical Exam: PHYSICAL EXAM: upon admission: [2140-4-18] Gen: intubated, sedated HEENT: Pupils: PERRL EOMs unable to assess Neck: c-collar in place, Supple. Lungs: Diminished on left, CTA on right Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: sedated Orientation: unable to assess Language: intubated Physical examination upon discharge: [2140-4-22] Vital signs: t=97.6, hr=60, rr=18, oxygen saturation 100% General: Resting comfortably in bed, NAD CV: Ns1, s2, -s3, -s4 LUNGS: Clear ABDOMEN: soft, non-tender EXT: + dp bil. no ankle edema bil., no calf tenderness NEURO: alert and oriented x 3, speech clear, no tremors, full EOM's, + hearing right > left, muscle st. upper ext. +5/+5 bil., lower ext. +5/+5 bil., tongue midline, no decreaseed sensation face, Pertinent Results: [2140-4-20] 05:30AM BLOOD WBC-8.8 RBC-3.34* Hgb-10.9* Hct-31.1* MCV-93 MCH-32.6* MCHC-35.0 RDW-12.4 Plt Ct-163 [2140-4-19] 12:46AM BLOOD WBC-15.4* RBC-3.64* Hgb-12.1 Hct-33.1* MCV-91 MCH-33.2* MCHC-36.5* RDW-12.6 Plt Ct-198 [2140-4-18] 01:43AM BLOOD WBC-14.8# RBC-3.89 Hgb-12.9 Hct-34.8* MCV-89 MCH-33.1* MCHC-37.0* RDW-12.2 Plt Ct-243 [2140-4-20] 05:30AM BLOOD Plt Ct-163 [2140-4-19] 12:46AM BLOOD Plt Ct-198 [2140-4-19] 12:46AM BLOOD PT-12.8* PTT-25.8 INR(PT)-1.2* [2140-4-20] 05:30AM BLOOD Glucose-95 UreaN-6 Creat-0.3* Na-140 K-3.7 Cl-104 HCO3-21* AnGap-19 [2140-4-19] 12:14PM BLOOD Glucose-122* UreaN-7 Creat-0.4 Na-139 K-3.9 Cl-106 HCO3-21* AnGap-16 [2140-4-19] 06:05AM BLOOD Na-140 K-3.8 Cl-107 [2140-4-19] 12:46AM BLOOD ALT-83* AST-85* AlkPhos-69 TotBili-1.0 [2140-4-18] 07:33AM BLOOD ALT-124* AST-192* AlkPhos-82 TotBili-0.7 [2140-4-18] 06:36AM BLOOD ALT-128* AST-208* AlkPhos-82 TotBili-0.6 [2140-4-17] 08:50PM BLOOD Lipase-64* [2140-4-18] 02:58PM BLOOD cTropnT-<0.01 [2140-4-20] 05:30AM BLOOD Calcium-8.3* Phos-1.8* Mg-1.9 [2140-4-19] 12:14PM BLOOD Calcium-7.8* Phos-2.1* Mg-2.1 [2140-4-19] 12:14PM BLOOD Osmolal-285 [2140-4-18] 02:58PM BLOOD Phenyto-19.8 [2140-4-17] 08:50PM BLOOD ASA-NEG Ethanol-262* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2140-4-18] 02:07AM BLOOD Type-ART pO2-244* pCO2-33* pH-7.39 calTCO2-21 Base XS--3 [2140-4-17] 09:01PM BLOOD freeCa-0.87* [2140-4-17]: chest x-ray: IMPRESSION: 1. Diffuse left lung opacity likely reflecting a mixture of aspiration pneumonitis, asymmetric edema, and /or pneumonia. 2. ET tube terminating 7 cm above the carina. [2140-4-17]: head cat scan: IMPRESSION: Small left temporal subarachnoid hematoma and small left cerebral subdural hematoma. Generalized loss of cerebral sulcal markings raises the suspicion for mild cerebral edema. No signs of herniation. Non-displaced left temporal bone fracture. [2140-4-17]: cat scan of the abdomen: IMPRESSION: 1. Left lung consolidation is concerning for a combination of aspiration pneumonitis and associated edema, atelectasis. 2. Markedly distended urinary bladder. [2140-4-17]: cat scan of the c-spine: IMPRESSION: 1. No acute fracture or traumatic malalignment of the cervical spine. 2. Severe left apical lung consolidation, likely reflecting aspiration - better assessed on concurrent CT torso. [2140-4-18]: cat scan of the head: IMPRESSION: 1. New hyperdense blood products seen along the left tentorial leaflet, right vertex, right aspect of the falx, and within the left frontal lobe. 2. Slightly increased blood products neighboring the focal left temporal bone fracture. Small amount of subarachnoid blood in the interpeduncular cistern. 3. No new mass effect. [2140-4-18]: chest x-ray: Cardiomediastinal contours are normal. There are low lung volumes, increasing opacities in the lower lobes are partially due to increasing atelectasis. There is continuous improvement of left upper lobe opacities, now almost completely resolved. There is no pneumothorax or pleural effusion [2140-4-21]: CTA head: IMPRESSION: 1. Increase in left frontal and temporal lobe hemorrhagic contusions. Mass effect of subjacent sulci and left lateral ventricle but no midline shift. 2. No evidence of dissection on CTA of the head. [2140-4-21]: CT tempora bone (orbits, sinuses): There is a fracture in the squamous portion of the temporal bone extending into the air cells. There is no extension of the fracture into the carotid canal. There is fluid (blood) in the middle ear cavity but the ossicles without evidence of injury. There is also fluid in the mastoid air cells. Brief Hospital Course: 39 year old female who fell backwards, hitting head on concrete with + LOC. She was intubated in the field related to agonal breathing and bracycardia. Upon admission, she underwent a cat scan of the head which showed a left temporal bone fracture, left temporal sub-arachnoid and sub-dural hematoma. On arrival her exam was notable for 2 mm pupils bilaterally which were non-reactive and disconjugate with intact gag and cough reflexes. She was given mannitol and lasix and her neurological status slowly improved. She continued on hourly neuro exams. Neurosurgery was consulted and recommended neurological monitoring in the intensive care unit and continuation of mannitol. She was sedated with propofol and fentanyl and started on dilantin. Repeat head cat scan on HD # 2 demonstrated a small new contusion in the left frontal region as well as a small increase in the bleed with no midline shift. On chest x-ray she was found to have a left lung consolidation concerning for a combination of aspiration pneumonitis. On HD #2 she was extubated and started on clear liquids. Her c-spine showed no acute fracture or traumatic mal-alignment of the cervical spine and her cervical collar was removed. Chest x-ray shows an improvment in the left upper lobe opacities and she continued with pulmonary toilet. She was transferred to the surgical floor on HD #3. Her vital signs are stable and she is afebrile. Her hematocrit is 31. She has reported pain in left ear and a headache. Her pain medication has been changed to codeine. ENT was consulted on HD #5 regarding her left temporal bone fracture and to address her left ear pain. She underwent a cat scan of the head which showed an increase in the temporal lobe contusion. Neurosurgery was consulted and no intervention warrented. She also underwent a cat scan of the temporal bone fracture and was found to have no extension of the fracture into the carotid canal. Fluid (blood) in the middle ear cavity was reported but there was no evidence of injury to the ossicles. Fluid was also seen in the mastoid air cells. Her vital signs are stable and she has been afebrile. She was reporting a headache along with decreased hearing in the left ear. She was started on fioricet which seemed to decrease the headache and alleviate the nausea. She is slowly progressing to a regular diet. She has ambulated with the assistance of physical therapy who evaluated her and made recommendations for discharge with 24 hour supervision. Her family was able to provide her with this care. She was also seen by the social worker who has provided her and her family with additional support. She has an out-pt audiogram scheduled on [4-25] with Dr. [Last Name (STitle) 3878]. Medications on Admission: None 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 for constipation. 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 4. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO Q 8H (Every 8 Hours) for 2 days: last dose 3/18. Disp:12 Tablet, Chewable(s) Refills:0 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:40 Tablet(s) Refills:0 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [2-8] Tablets PO Q6H (every 6 hours) as needed for headache: maximum 6 tablets daily. Disp:25 Tablet(s) Refills:0 8. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal ONCE (Once) for 1 doses. Discharge Disposition: Home Discharge Diagnosis: s/p fall: Injuries: 1. Left temporal bone fracture 2. Left subarachnoid hemorrhage 3. Left subdural hematoma 4. Left aspiration pneumonitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after suffering a fall. You sustained an injury to your brain and a fracture in a bone in your skull. You are recovering well and are now being discharged home with the following instructions: Take your pain medicine as prescribed. Exercise should be limited to walking; no lifting, straining, or excessive bending. Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (colace) while taking narcotic pain medication. Unless directed by your doctor, DO NOT take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen, etc. You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine. Take this medication as presribed for 4 more days until the prescription is complete. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: New onest of tremors or seizures. Any confusion, lethargy or changes in mental status. Any visual changes Any numbness, tingling, weakness in your extremities. Pain or headache that is continually increasing, or not relieved by pain medication. New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Department: Primary Care Name: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 33239] When: Wednesday [2140-4-27] at 1:45 PM Location: FAMILY MEDICAL ASSOCIATES Address: [State 92518], [Location (un) ],[Numeric Identifier 45899] Phone: [Telephone/Fax (1) 79431] Department: RADIOLOGY When: TUESDAY [2140-5-31] at 1:30 PM With: CAT SCAN [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: NEUROSURGERY When: TUESDAY [2140-5-31] at 2:15 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 9151], MD [Telephone/Fax (1) 1669] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2140-5-3] at 10:15 AM With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 853] in ACUTE CARE CLINIC Phone: [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [2140-5-5] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6403], MD [Telephone/Fax (1) 1690] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage You have an appointment for an Audiogram on [2140-4-25] with Dr. [Last Name (STitle) 3878] at [Location (un) 92519],( the KINKO-[Company ] building) [Location (un) 55], Mass. Your appointment is scheduled for 11:15 am. Please arrive at 10:45am. The telepone number is #[Telephone/Fax (1) 2349]. Completed by:[2140-4-22]	[ "5070", "42789" ]
Admission Date: [2104-1-5] Discharge Date: [2104-1-11] Service: [Doctor Last Name ] Medicine Firm HISTORY OF PRESENT ILLNESS: This is an 89-year-old female with COPD (requiring home oxygen and nebulizers) and a history of multiple exacerbations, found down in bathroom with a respiratory rate of 6. Per family, patient was noted to have progressive respiratory difficulty one week prior to admission. She responded well to a nebulizer at the time. Family members increased O2 requirement from 1-2 liters by nasal cannula and patient seemed to be doing well. On the day of admission, she was found down in the bathroom with a respiratory rate between [5-13]. EMS arrived and placed an oral airway and bagged the patient. Noted the entitle CO2 to be approximately 60 and the decision was made to intubate the patient. The patient received Versed and propofol for sedation; subsequently systolic blood pressure dropped to the 30s. She was treated at the time with an IV fluid bolus and dopamine, and responded well. At this time, her vitals were temperature of 97.0, blood pressure 130/40, respiratory rate of 20, and O2 saturation at 99%. In the ED, her temperature was 97.2, pulse of 84, blood pressure 140/30, respiratory rate of 12, and O2 saturation of 100%. Lungs were noted to be rhonchorous with crackles bilaterally. An ABG after starting ventilator showed a pH of 7.24, pO2 of 274 and a pCO2 of 74. Head CT showed no acute hemorrhage. Chest x-ray showed only emphysematous changes. Cardiac enzymes showed a troponin leak. EKG was unchanged from prior. Blood cultures and urine cultures were obtained. In the MICU, the patient was maintained on sustained mechanical ventilation, started on IV Solu-Medrol, ipratropium, and albuterol nebulizers, and levofloxacin. She failed several attempts of weaning off the ventilator, was successfully extubated on the day of transfer to ICU (ICU day #5). She was initially receiving tube feeds, but upon transfer was tolerating p.o. well. Given her history of SIADH, she was on free water restriction. Sodium initially was at 132, by transfer day, had increased to 136. Upon transfer to the [Doctor Last Name ] Medicine Firm, the patient denies any fevers, chills, nausea, vomiting, diarrhea, chest pain, shortness of breath, or abdominal pain. She states that her breathing is back to baseline and is tolerating p.o. well. PAST MEDICAL HISTORY: 1. COPD: Emphysema. Pulmonary function tests on [2103-1-7] show a FEV1 of 0.64 (52%), FVC 0.74 (37%). Chronic CO2 retainer, with a baseline pCO2 between 70-80. Requires home oxygen. 2. SIADH: Thought to be secondary to COPD. Usually treated with free water restriction. 3. Seizures secondary to hyponatremia. 4. Question of CAD: Multiple admissions for acute respiratory failure secondary to COPD, had shown troponin leaks. An echocardiogram in [2103-1-7] showed left ventricular systolic function is hyperdynamic with an ejection fraction of more than 75% with mild left atrial dilatation. Have never undergone a stress test. She is on medical management. 5. Hypertension. 6. Colon cancer status post resection in [2097]. 7. Dementia. 8. Degenerative joint disease. 9. Iron deficiency anemia. SOCIAL HISTORY: Patient lives at home with four children. Smoking history of 20 pack years, quit four years ago. Denies any alcohol use. Active second-hand [Year (4 digits) ] from her children. FAMILY HISTORY: Noncontributory. ALLERGIES: Doxycycline. MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Detrol 1 mg p.o. q.d. 3. Flovent prn. 4. Albuterol prn. 5. Combivent prn. 6. Multivitamins one tablet p.o. q.d. 7. Tums 500 mg p.o. b.i.d. 8. Vitamin D 400 units p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: In general, she is a female appearing her stated age, laying in bed comfortable in no apparent distress. Very cooperative. Vitals show a temperature of 97.1 with a pulse of 77 beats per minute and regular, blood pressure of 154/62 with a respiratory rate of 22, and O2 saturation of 92% on 3 liters nasal cannula. Her weight is 108 pounds. She is normocephalic, atraumatic with pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Red reflex is present, anicteric sclerae. Oropharynx is clear. Dry mucous membranes. Her neck is supple with no nodules, lymphadenopathy, or tenderness. Trachea was midline. No JVD. Carotid pulses were 2+ with no bruits. Thyroid was not palpable. Lungs show decreased breath sounds throughout with poor air movement. There is scattered inspiratory crackles throughout. No wheezes or rhonchi noted. Her heart was regular, rate, and rhythm with a normal S1, S2, no murmurs, rubs, or gallops. Her abdomen was soft, nondistended, and nontender with normoactive bowel sounds and no bruits. It was tympanic to percussion with no masses or ascites noted. Liver edge was palpable on inspiration, it was soft. Spleen tip was unpalpable. No costovertebral angle tenderness was noted. Her infraumbilical midline scar is well healed. Both lower extremities were cool to touch with no clubbing, cyanosis, or edema. Her dorsalis pedis pulse was 1+, PT pulse was unpalpable. She had no jaundice or rashes. Patient was alert and oriented to person, place, and time. Patient made good eye contact throughout the interview. Cranial nerves II through XII were intact. Had normal tone throughout. She had 3/5 strength and appropriate for age. Reflexes were 1+ at the knees and ankles. Her sensory examination was intact to vibration at hallux bilaterally. She had normal finger-to-nose testing, appropriate to age, and gait was not assessed. LABORATORY VALUES ON PRESENTATION: Sodium of 136, potassium 3.8, chloride 95, bicarb of 39, BUN of 12, creatinine of 0.3, glucose of 108. White count of 10.9, hemoglobin of 10.6, hematocrit of 33.2, and platelets of 268. Calcium was 7.9, magnesium was 1.8, and phosphate was 2.0. Blood cultures showed no growth to date. Urine cultures showing no growth to date. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. Acute respiratory failure secondary to COPD exacerbation: Upon presentation to the floor, the patient had been started on a prednisone taper at 40 mg taking her down to 0 in two weeks. She was receiving O2 via nasal cannula with an O2 saturation goal between 90-95% given her history of chronic CO2 retention. Her nebulizers were continued and spaced to q.4-6h. She was continued on levofloxacin for a total of 10 days. Upon discharge, the patient stated that she was returning back to baseline. 2. Question of coronary artery disease: The patient did have a positive troponin while in-house of 3.2. She was started on a beta blocker in the ICU. However, due to her severe chronic obstructive pulmonary disease and per PCP's recommendation, it was discontinued on hospital day #3. She was continued on aspirin and an ACE inhibitor. Because of her debilitated state and severe chronic obstructive pulmonary disease, she would not be a candidate for any cardiac intervention, so the plan was made to medically manage her to the best possibility as noted previously. 3. Syndrome of inappropriate secretion of antidiuretic hormone: The patient's sodium was followed while in-house. Fluid restrictions were maintained. Her sodium improved while in-house and was normal at the time of discharge. 4. Hypertension: The patient's hypertension was stable on ACE inhibitors throughout the hospitalization. 5. Dementia: Her dementia remained at baseline throughout her hospital stay. 6. Hyperglycemia: Likely secondary to steroid taper. She was started on regular insulin-sliding scale. At the time of discharge, her sugars have been well managed. 7. Anemia: Patient's hematocrit levels were followed and they remained stable throughout the hospitalization. 8. Prophylaxis: The patient received prophylaxis, subcutaneous Heparin for deep venous thrombosis, with ranitidine for gastrointestinal ulcer prophylaxis, and continued on calcium and vitamin D for steroid-induced osteoporosis prophylaxis. 9. Physical Therapy: Evaluated patient, ambulated well, desatting only to the high 80s. She was recommended to be discharged to home with visiting nurse services. Family expressed concern as they do not want her to go an extended care facility. 10. Fluids, electrolytes, and nutrition: The patient was fluid restricted. She tolerated a regular diet. Her electrolytes were repleted as needed. Speech and Swallow team was consulted. She has been evaluated in the past. They noted no aspiration risk. She was continued on house diet. DISCHARGE DISPOSITION: Given the patient's baseline clinical condition, the decision was made to discharge the patient to home. DISCHARGE STATUS: To home with visiting nurse services. DISCHARGE MEDICATIONS: 1. Lisinopril 2.5 mg p.o. q.d. 2. Levofloxacin 500 mg p.o. q.d. for a total of 10 days. 3. Prednisone taper from 40 mg down to 10 mg in two weeks as noted. 4. Albuterol one nebulizer treatment q.4h. as needed. 5. Ipratropium bromide one nebulizer treatment q.6h. as needed. 6. Zantac 150 mg p.o. b.i.d. DISCHARGE DIAGNOSES: 1. Acute respiratory failure secondary to acute exacerbation of chronic obstructive pulmonary disease. 2. Syndrome of inappropriate secretion of antidiuretic hormone. 3. Acute bronchitis. 4. Hypertension. CODE STATUS: Full. DISCHARGE FOLLOWUP: Patient is to followup with her primary care physician in two weeks or earlier if needed. [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Last Name (NamePattern1) 17681] MEDQUIST36 D: [2104-1-15] 14:15 T: [2104-1-17] 07:43 JOB#: [Job Number 19230]	[ "4019" ]
Admission Date: [2116-12-23] Discharge Date: [2116-12-27] Service: HISTORY OF PRESENT ILLNESS: Patient is an 82-year-old man without a past medical history except for longstanding asthma, who presents to the Emergency Department after having seen his primary care this morning, and noted to have a temperature of 103 F. Patient reports that he was in his usual state of health last evening, however, but he awoke this morning feeling generally unwell and subsequently had an episode of nausea and vomiting with subjective fevers. Patient denies chills. REVIEW OF SYSTEMS: Positive for chronic nonproductive cough. Negative for pleuritic chest pain, abdominal pain, dysuria, or frequency, diarrhea, or hematochezia. He denies sick contacts or travel history. He has had no hospitalizations since [2112] at which time he had resection of a distal pancreatic mass and splenectomy. In the Emergency Department, the patient's temperature was 101.6 with stable vital signs. PHYSICAL EXAM ON ADMISSION: Temperature 101.6, blood pressure 126/42, heart rate 67, respirations 18, and saturating 96% on room air. Generally, the patient was in no acute distress. HEENT exam was unremarkable. He had no lymphadenopathy in the cervical or axillary regions. Heart sounds were normal. Lung exam was significant for coarse breath sounds. Abdomen was benign. Extremities: He had trace to +1 edema bilaterally. LABORATORIES ON ADMISSION: White blood cell count 33.5 with 81% neutrophils, 12% bands, 6% lymphocytes, hematocrit 42.8, platelets 545. Chem-7 was unremarkable. Lactate was 4.4. Urinalysis was negative. Chest x-ray: Negative for consolidation or effusion. Blood cultures: Negative. BRIEF SUMMARY OF HOSPITAL COURSE: Patient was admitted to the Medical Intensive Care Unit according to the MUST sepsis protocol. No infectious source was found. Patient's white blood cell count continued to trend down on ceftriaxone, which he was continued on for five days after which point he was changed to oral Levaquin for a total of 14-day course. Despite the diagnosis of fever of unknown origin, suspicion for endocarditis was extremely low, and transthoracic echocardiogram was also negative for vegetation. Patient became afebrile two days after admission and continued to be afebrile throughout his hospital course. Lung nodule: CT torso was done to evaluate potential abscesses, which could be the source of the patient's fever. Incidentally, it was noted that patient had a spiculated noncalcified pulmonary nodule measuring 1 cm in diameter from the left lung apex. CT Surgery consulted during this admission, and recommended a repeat CT scan in one month with outpatient followup. Asthma/emphysema: Patient was continued on his Flovent and Serevent. He has no record of pulmonary function tests and this will be done as an outpatient. DISCHARGE DIAGNOSES: 1. Sepsis, fever of unknown origin. 2. Pulmonary nodule seen incidentally on CAT scan. FOLLOW-UP INSTRUCTIONS: Patient was instructed to followup with his primary care doctor, Dr. [Last Name (STitle) 2903] in one week. He was also instructed to have a repeat CAT scan on his chest in one month and this was scheduled for [2117-1-26]. He is also to followup with Dr. [Last Name (STitle) 175], Cardiothoracic Surgery after this CT scan. Lastly, he is to followup to get pulmonary function tests on [1-20]. DISCHARGE CONDITION: Stable. Patient was afebrile and clinically at his baseline. DISCHARGE MEDICATIONS: 1. Serevent 50 mcg one inhalation p.o. q.12h. 2. Flovent two puffs b.i.d. 3. Levofloxacin 500 mg one p.o. q.d. for eight days to complete a 14-day course. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[Last Name (NamePattern1) 2543] MEDQUIST36 D: [2117-2-2] 19:47 T: [2117-2-3] 05:43 JOB#: [Job Number 9903]	[ "0389", "49390" ]

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