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Admission Date: [2145-4-9] Discharge Date: [2145-4-9] Service: NEUROLOGY Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 8747] Chief Complaint: intracranial hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: Pt. is an 83 y/o with recently elevated BP but no formally diagnosed HTN who is transferred from OSH ED with a large R frontoparietal ICH. History is per son, who accompanies her, and EMS and ED records as pt. is intubated and sedated. Son reports that pt. had been in her USOH today. She had visited the doctor earlier in the day, who noted that her blood pressure was elevated (as it had been on her last visit). He said that if it continued to be elevated they might consider an anti-hypertensive in the future. He gave her a cortisone injection in her R knee for some arthritis, but otherwise pronounced her to be in good health. Her son went out in the evening and came back to the house with a friend. Pt. came downstairs at around 10:30 and he gave her a hamburger that he'd brought her. She was her normal self at that time. She went to the other room and he called his daughter on the phone. He reports that he and his daughter had an argument and that his mother called into the room, and was upset that he was yelling. Then, at around 11:10 he heard her fall. He came into her bedroom and found her laying on the side of the bed. The left side of her face was drooping and her speech was quite slurred, to the point where he couldn't understand anything she said. He immediately called EMS. Per EMS report they arrived at 11:30. They note that she had a L facial droop and L sided weakness and L sided drift. Her speech was slurred. She had a FS of 137. She vomited 3 times in the ambulance. They transported her to an OSH ED for evaluation. She arrived at [Hospital3 15402] at MN. On her initial exam she was awake, verbally responsive, and said her name. She had a L facial droop and no movement of her left arm or leg. Her BP was 240/120. Head CT was performed at 12:15, and read as a large (10.2 x 5.5 cm) R frontoparietal hemorrhage with effacement of the latreal ventricle, 1.2 cm of midline shift, and effacement of the supersellar cistern suggestive of uncal herniation. Her level of arousal had declined by the time she returned from the scanner, so at 12:30 she was intubated. She was hyperventilated and given 25 mg IV mannitol at 1:00. She was given Hydralazine 15 mg IV total and Labetalol 20 mg IV total, which brought her BP down to 157/72. She was transferred to [Hospital1 18] for further evaluation. Here she was evaluated by Neurosurgery, who reviewed her imaging and felt that she would not benefit from surgical intervention given the size of her hemorrhage. Past Medical History: HTN- recent, not yet being treated Stroke 3 years ago, with some L facial droop and dysarthria Social History: Lives with son and his girlfriend, retired, widowed Family History: + for HTN in son and several other family members, no FH of stroke that son is aware of Physical Exam: At 5:30 AM, off propofol for 10 min prior to exam T- 98.0 BP- 134/51 HR- 90 RR- 26 O2Sat- 99% on RA Gen: Lying in bed, eyes closed, intubated CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally in ant lung fields aBd: +BS soft, nontender ext: R knee wrapped in ACE bandage. 1+ non-pitting edema bilat LE to mid-calf. Neurologic examination: Mental status: intubated and sedated, does not open eyes to voice or sternal rub or answer any questions Cranial Nerves: Pupils irregular, reactive to light, 3 to 2 mm bilaterally. No EOM with Dolls or cold calorics on either side. No corneals bilaterally. L facial droop. + Gag with deep suction. Motor: Decreased bulk throughout. Tone increased in both LE. No observed myoclonus or tremor. Extensor posturing to pain LUE, triple flexion to pain RLE. Withdraws purposefully to pain RUE and RLE. Sensation: Grimaces to pain all 4 extremities Reflexes: +3 and symmetric throughout. Toes upgoing bilaterally Pertinent Results: pH 7.36 pCO2 45 pO2 360 HCO3 26 141 106 22 ------------< 175 4.0 23 0.9 Ca: 9.6 Mg: 2.1 ALT: 13 AP: 74 Tbili: 0.5 Alb: 4.0 AST: 26 [Doctor First Name ]: 71 WBC 11.7 Hgb 12.5 Plt 249 Hct 38.3 MCV 90 PT: 11.7 PTT: 26.9 INR: 1.0 Color Straw Appear Clr SpecGr 1.020 pH 7.0 Urobil Neg Bili Neg Leuk Neg Bld Tr Nitr Pos Prot Tr Glu Tr Ket Neg RBC <1 WBC 0-2 Bact Many Yeast None Epi [4-12] Imaging OSH Head CT, radiology report: Large (10.2 x 5.5 cm) R frontoparietal hemorrhage with effacement of the latreal ventricle, 1.2 cm of midline shift, and effacement of hte supersellar cistern suggestive of uncal herniation HCT: FINDINGS: There is a large area of intraparenchymal hemorrhage involving the white and [Doctor Last Name 352] matter of the right frontal, parietal, and temporal lobes. There is moderate surrounding edema resulting in mass effect on the right lateral ventricle and there is 11 mm leftward subfalcine shift. There is trapping of the left lateral ventricle and a mild amount of intraventricular hemorrhage layering within the atria of the left ventricle. Blood is seen within the sulci of the right frontal, parietal, and temporal lobes consistent with subarachnoid hemorrhage. The basilar cisterns are patent without evidence of uncal herniation. The osseous structures are unremarkable. There is mild mucosal thickening of the maxillary sinuses. IMPRESSION: 1. Large intraparenchymal hemorrhage involving the [Doctor Last Name 352] and white matter of the right frontal, parietal, and temporal lobes. Differential diagnosis includes hemorrhage secondary to amyloid, and hypertension. Underlying neoplasm cannot be excluded. Significant surrounding edema resulting in mass effect on the right lateral ventricle and trapping of the left lateral ventricle. 2. Small amount of intraventricular hemorrhage layering within the left atria. PCXR: IMPRESSION: 1. Nasogastric tube proximal port at GE junction and could be advanced 2 cm. 2. Mild pulmonary edema. EKG: Sinus rhythm. Left ventricular hypertrophy. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 78 182 88 [Telephone/Fax (2) 71751] 64 Brief Hospital Course: Pt. is an 83 y/o with a recent history of hypertension who presents with a large left frontoparietal hemorrhage (about 80 cc). On exam her pupils are 3 mm and reactive and she has a gag, but no EOM with dolls or cold calorics and no corneals. She has extensor posturing of L arm and leg with pain and withdrawal of the R side. Given the location of her hemorrhage and her SBP 240/120 on arrival to OSH most likely etiology is a hypertensive hemorrhage. Cannot exclude amyloid angiopathy (especially given her age) or underlying mass or AVM. Patient was admitted to NeuroICU, with Q1H neurochecks, Labetalol IV and Hydralazine IV PRN for goal MAP < 130, Mannitol 25 g IV Q6H. Repeat Head CT was performed that showed large right hemispheric bleed with significant surrounding edema resulting in mass effect on the right lateral ventricle and trapping of the left lateral ventricle. Patient was kept normothermia, Tylenol PRN and normoglycemia, FS QID and RISS PRN. Ventilation was managed per SICU team. Patient was DNR per previously stated wishes. The following morning, family meeting was held. [Name (NI) ] son [Name (NI) 382] stated that patient would not to be debilitated from a stroke and patient was made comfort measures only. Patient passed away from respiratory failure and family decline autopsy on [2145-4-9]. Medications on Admission: ASA 81 Alleve PRN Discharge Disposition: Expired Discharge Diagnosis: Large intraparenchymal hemorrhage involving the [Doctor Last Name 352] and white matter of the right frontal, parietal, and temporal lobes likely secondary to amyloid angiopathy. Discharge Condition: Deceased Completed by:[2145-4-15]	[ "4019" ]
Admission Date: [2196-3-20] Discharge Date: [2196-3-24] Date of Birth: [2139-4-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5119] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: esophagogastroduodenoscopy colonoscopy History of Present Illness: Mr [Known lastname ] is a 56M w HTN, HL, Lymphoplasmacytic Lymphoma (c/b GI bleed in [2186] s/p small bowel resection), Atrial Fibrillation on coumadin who presents from home with complaint of melena x 2 days. Patient states episode begain with one dark melanotic stool on friday night, no BRBPR. He then had 4 episodes on saturday and 3-4 episodes of very loose melanotic stools today. +intermittent RLQ pain, [4-19] which last for only seconds. Denies Nausea, Vomiting, fevers, chills, chest pain, cough, SOB. He does report two episodes of LH within the past two days when standing, no syncope. . In the ED, initial vs were: T 97.9, HR 90, BP 121/62, R 18 100% RA. Patient was given Vit K 10mg IV x 1, FFP x 1, 2L IVF, Pantoprazole 40mg IV x 1. 2 18g IVs placed and patient sent to the ICU for monitoring overnight with GI planning for scope in the AM. +black guaiac positive stool in the ED Past Medical History: Atrial Fibrillation on Coumadin Hypertension Hypertriglyceridemia Cervical radiculitis Lymphoplasmacytic Lymphoma ? DM II Peripheral Neuropathy GI bleed [2186] s/p Small bowel resection Social History: Retired State Trooper. +EtOH 6-7 beers 4-5x/week. Denies tobacco or illicit drug use. Marrtied for 30years. Family History: Denies hx of IBD. No history of colon Ca. Physical Exam: Vitals: T: 98.4 BP: 143/62 P: 92 R: 14 96% RA 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 Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: . HEMATOLOGY: [2196-3-20] 07:30PM BLOOD WBC-12.2# RBC-3.20# Hgb-10.5# Hct-28.5# MCV-89 MCH-32.9* MCHC-36.9* RDW-14.5 Plt Ct-260# (on admission) . [2196-3-21] 12:43AM BLOOD Hct-22.8* [2196-3-21] 08:50AM BLOOD Hct-26.0* [2196-3-21] 05:15PM BLOOD Hct-27.2* [2196-3-22] 12:42AM BLOOD Hct-28.2* [2196-3-22] 12:28PM BLOOD Hct-34.6* [2196-3-22] 08:01PM BLOOD Hct-33.6* [2196-3-23] 04:14AM BLOOD WBC-6.0 RBC-3.62* Hgb-11.8* Hct-31.8* MCV-88 MCH-32.4* MCHC-36.9* RDW-16.0* Plt Ct-143* [2196-3-23] 10:15AM BLOOD Hct-32.9* . [2196-3-20] 07:30PM BLOOD PT-20.8* PTT-25.4 INR(PT)-2.0* [2196-3-23] 04:14AM BLOOD PT-14.9* PTT-33.6 INR(PT)-1.3* [2196-3-20] 07:30PM BLOOD Glucose-232* UreaN-39* Creat-1.0 Na-139 K-4.3 Cl-104 HCO3-23 AnGap-16 [2196-3-20] 07:30PM BLOOD cTropnT-<0.01 [2196-3-21] 04:37AM BLOOD CK-MB-2 cTropnT-<0.01 [2196-3-21] 05:15PM BLOOD CK-MB-2 cTropnT-<0.01 [2196-3-20] 07:30PM BLOOD CK(CPK)-52 [2196-3-21] 04:37AM BLOOD CK(CPK)-329* [2196-3-21] 05:15PM BLOOD CK(CPK)-156 [2196-3-21] 12:43AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9 [2196-3-20] 07:30PM BLOOD Digoxin-1.0 . RADIOLOGY: . CXR ([3-20]): CONCLUSION: No acute cardiopulmonary process. . CARDIOLOGY: EKG ([3-20]): Atrial fibrillation. ST-T wave changes in leads I, II, III, aVF and V4-V6. Compared to the previous tracing of [2192-11-8] the ventricular response to atrial fibrillation has slowed from 136 to 87 beats per minute. The ST-T wave changes in leads V4-V6 are prominent and are new, possibly secondary changes due to left ventricular hypertrophy. . TTE ([3-23]): Conclusions The left atrium is dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. The RV may be slightly dilated/hypokinetic. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. Dilated ascending aorta. . . GI: EGD ([3-21]): IMPRESSION: - non-obstructive Schatzki's ring - Medium hiatal hernia - Ulcer in the stomach body on the greater curvature. Findings may account for the recent bleeding. - Erosion in the stomach body compatible with erosive gastritis - Erosions in the first part of the duodenum compatible with mild duodenitis - There was evidence of a submucosal lesion in the gastric antrum. - Otherwise normal EGD to second part of the duodenum . COLONOSCOPY ([3-23]): Normal mucosa in the cecum and terminal ileum Otherwise normal colonoscopy to cecum and terminal ileum . . Capsule Endoscopy ([3-23]): pending Brief Hospital Course: In brief, Mr [Known lastname ] is a 56M with hx of HTN, Hypertriglyceridemia, Lymphoplasmacytic Lymphoma (s/p short bowel resection), Atrial Fibrillation on coumadin who presented from home with melena and anemia, was found to have likely UGIB [3-14] gastritis/duodenitis, now hemodynamically stable. . # GI Bleed: Likely gastritis/duodenitis in the setting of anticoagulation. Mr. [Known lastname ] presents with complaint of melena and acute anemia with HCT drop from 40.4 ([2195-12-12]) --> 28.5 (on admission) ---> 22 (MICU). INR reversed w vitamin K and FFP. Pt received 6 blood transfusions total. Hct stabilized at ~32. GI consulted in the ED, performed EGD/colonoscopy/capsule study. EGD revealed gastritis/duodenitis/?ulcers, which could be the source of bleeding. Colonoscopy was unremarkable. Capsule endoscopy study is pending. Pt on pantoprazole 40mg [Hospital1 ], held coumadin on discharge. Outpatient follow-up scheduled w PCP (Dr [Known lastname ] - discuss capsule endoscopy results, consider H. pylori, monitor Hct, consider restarting coumadin. . # Chronic Atrial Fibrillation: Patient has hx of A-fib and is on Coumadin (CHADS2=1). INR reversed in the ED. Rate-control meds were held on admission, but restarted once Hct stabilized. Coumadin was held for the entire admission. Pt discharged on metoprolol succinate 200mg daily and digoxin 375mcg daily. Discussed anticoagulation w cardiologist (Dr [Last Name (STitle) ], who recommends restarting coumadin as outpatient once GI irritation improved/healed. . # ECG changes: Patient with new ECG changes likely in setting of strain with acute anemia. Denies CP, SOB. unlikely ACS. ROMI. . # HTN: Metoprolol and Cozaar held on admission, restarted on the floor. . # Hypertriglyceridemia: Tricor continued. . # Peripheral Neuropathy: Lyrica continued on discharge. . Medications on Admission: Warfarin 5mg M/W/F, 7.5mg Sun/T/Th/Sat Digoxin 375mcg daily Fenofibrate (Tricor) 145mg daily Losartan (Cozaar) 25mg daily Metoprolol succinate (Toprol XL) 200mg daily Pregabalin (Lyrica) 200mg TID Tizanidine (Zanaflex) 2mg 1-2tabs qHS PRN - muscle relaxant Viagra PRN Ambien 10mg qHS PRN Discharge Medications: 1. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Digoxin 125 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 5. 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 6. Losartan 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 8. Tizanidine 2 mg Capsule Sig: [2-12] Capsules PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: gastrointestinal bleeding likely secondary to gastritis/duodenitis . hypertension hypertriglyceridemia chronic atrial fibrillation lymphoplasmacytic lymphoma Discharge Condition: hemodynamically stable, Hct ~32 for >48 hours Discharge Instructions: You were admitted to the hospital with dark stools. We think that they were caused by bleeding from your stomach (gastritis/duodenitis/ulcer). We evaluated you with endoscopy (EGD and colonoscopy). We treated you with blood transfusions and supportive measures. . We changed your medications as follows: 1. stopped your coumadin for now, please follow up with your primary care physician and plan to restart 2. started you on pantoprazole 40mg twice daily . Should you have dizziness, lightheadedness, chest pain, black stools, bleeding, or any other concerning symptoms, please call your physician [Name Initial (PRE) 2227]. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 647], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2196-4-5] 9:00 Provider: [First Name11 (Name Pattern1) ] [Known lastname 14839], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2196-4-14] 9:40 [First Name7 (NamePattern1) 1569] [Initial (NamePattern1) ] [Name8 (MD) ] MD [MD Number(2) 5122] Completed by:[2196-3-24]	[ "2851", "V5861", "42731", "2724", "25000" ]
Admission Date: [2155-9-21] Discharge Date: [2155-9-27] Date of Birth: [2121-12-20] Sex: F Service: MEDICINE Allergies: Cefaclor / Morphine Sulfate / Cephalosporins / Penicillins / Carbapenem Attending:[First Name3 (LF) 943] Chief Complaint: 1. Transfer from OSH with acute hepatitis. 2. Presentation to OSH with nausea, vomiting, abdominal pain, and malaise. Major Surgical or Invasive Procedure: 1. Left Internal Jugular Central Line Placement. 2. Endoscopic Gastroduodenoscopy. History of Present Illness: 33F s/p [2137] renal transplant [2-13] HSP, [2146] R nephrectomy for renal CA, chronic immunosuppression, recurrent pancreatitis, gallstone disease, pancreas divisum, and hypertension, who is transferred from MICU following admission for acute hepatic failure. Ms. [Known lastname ] initially presented to an OSH on [2155-9-19] with nausea, vomiting, abdominal pain, and malaise. Symptoms began with sore throat and malaise and progressed to RUQ pain associated with nausea and vomiting. Noted to have transaminitis with AST 1478 and ALT 350 (83 and 31 on [9-8]). The following day AST was [Numeric Identifier ] with ALT 2470. INR was elevated to 6.4. Laboratories also noted for metabolic acidosis (non AG, bicarb 17) and elevated creatinine (2.1, baseline 1.3) The patient was fluid resuscitated and given vitamin K for reversal of coagulopathy. Imaging of abdomen consistent with necrotic changes concerning for liver failure (report unavailable). Pt had been on trazodone and effexor which was held out of concern for liver toxicity. . The patient reports she has taken Tylenol almost every day for 10 years because of headaches. She says she has been taking less of this lately. She also denies recent alcohol use but says she previously used to drink quite a bit of alcohol a few months ago. She denies any sick contacts. Had never been tested for HIV, not currently sexually active. Denies any kind of mushroom ingestion. Main complaints were RUQ pain. No fevers, denies abd swelling, pruritus, no increased confusion. Past Medical History: 1) S/p Cadaveric renal transplant in [2137] for renal failure secondary to Henoch-Schonlein Purpura. Had R nephrectomy after developing renal cancer in [2146], L nephrectomy in [2149] prophylactically. Baseline Cr 1.2-1.3, on Imuran, Cyclosporine, and Prednisone since [2146]. 2) Recurrent pancreatitis, last attack in [7-/2155], common bile duct stone seen at that time, not confirmed by ERCP. Attack resolved with fluids and pain control. 3) Pancreas divisum 4) Hypertension 5) Headaches, has taken Tylenol 6) Depression 7) Anxiety Medications Social History: Used to drink heavily a few months ago, pt could not quantify). Denies tobacco and illicit drug use. Single, works as secretary. Not currently in relationship, not sexually active. Family History: Notable for diabetes in both sides of family. No known renal, liver, or autoimmune disease. Physical Exam: T: 97.7 P: 77 BP: 124/79 RR: 18 O2: 94% 2L NC Gen: WD, obese female Caucasian, anxious but NAD HEENT: Scleral and sublingual icterus, PERRL, EOMI, dry MM, no lesions Neck: No LAD appreciated. No TM, trachea midline. Chest: Lungs with decreased breath sounds at bases, otherwise CTAB. Heart: RR, S1S2, no murmur, rub or gallop Abd: Obese, tender in RUQ, epigastric region, periumbilical region. No rebound or guarding. Graft site without tenderness or erythema. Liver edge palpable 2cm below costal margin Ext: No edema, 1+ distal pulses Neuro: A&Ox3, no asterixis Pertinent Results: EGD [2155-9-25] Impression: Erythema and congestion in the antrum (biopsy) Otherwise normal EGD to second part of the duodenum. . CT abdomen with contrast [2155-9-24]: IMPRESSION: 1) Likely focal fat within the peripheral aspect of segment [Doctor First Name ]/B of the liver; if warranted it cvould be definitively characterized by MRI. No other focal hepatic abnormalities or CT findings to explain the patient's acute hepatic failure. 2) Bibasilar atelectasis. 3) Normal appearing right lower quadrant transplant kidney. . . Cardiac ECHO [2155-9-23]: Conclusions: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. LABS: [2155-9-21] 02:37PM BLOOD WBC-8.4 RBC-3.10* Hgb-10.5* Hct-30.5* MCV-98 MCH-34.0* MCHC-34.5 RDW-13.9 Plt Ct-148* [2155-9-27] 07:40AM BLOOD WBC-5.5 RBC-2.96* Hgb-10.1* Hct-30.2* MCV-102* MCH-34.2* MCHC-33.6 RDW-15.0 Plt Ct-234 . [2155-9-21] 02:37PM BLOOD PT-20.6* PTT-22.2 INR(PT)-2.0* [2155-9-27] 07:40AM BLOOD PT-13.3* PTT-22.0 INR(PT)-1.2* . [2155-9-21] 02:37PM BLOOD Glucose-214* UreaN-18 Creat-1.3* Na-139 K-2.9* Cl-101 HCO3-24 AnGap-17 [2155-9-27] 07:40AM BLOOD Glucose-93 UreaN-19 Creat-1.2* Na-139 K-3.7 Cl-107 HCO3-24 AnGap-12 . [2155-9-21] 02:37PM BLOOD ALT-[2085]* AST-3942* LD(LDH)-824* AlkPhos-105 Amylase-79 TotBili-5.2* [2155-9-27] 07:40AM BLOOD ALT-214* AST-58* AlkPhos-111 Amylase-94 TotBili-2.3* . [2155-9-21] 02:37PM BLOOD Lipase-198* [2155-9-27] 07:40AM BLOOD Lipase-103* Brief Hospital Course: In the MICU, Ms. [Known lastname ] was supported medically. IV fentanyl and anzemet were given for pain and nausea management, respectively. She was started on prophylactic Levofloxacin and given lactulose to prevent hepatic encephalopathy. RUQ U/S was done, which confirmed increased liver echogeneity, but saw no focal lesions, and found normal flow patterns. Viral hepatitis panel was negative for HCV Ab, HBSAg, and HBCAb. EBV was IgG positive, IgM negative. HIV Ab test drawn, pending at time of transfer. Neuro exam and FS were frequently monitored. She was followed by transplant surgery and liver team. Imuran was d/c'ed due to possible hepatotoxic effects. During MICU stay, LFTs and INR consistently trended down. She did experience some ARF on CRI, with creatinine peak 2.1 from baseline 1.3. back to 1.4 at time of transfer. She was transferred to the [Doctor Last Name 3271]-[Doctor Last Name 679] service for further management. . While on the [Doctor Last Name 3271]-[Doctor Last Name 679] service the patient continued to have biochemical resolution of her hepatitis, renal insufficiency and a brief elevation of pancreatic enzymes. The patient did continue to to have abdominal pain for which a diagnositc evaluation was performed, consisting of a CT-scan and an EGD. Neither of these tests revealed a definitive etiology. The patient's symptoms spontaneously resolved and she was discharged with follow up with her gastorenterologist in [Location (un) ]. Medications on Admission: Cyclosporine 175 twice daily Imuran 100 mg daily Prednisone 50 mg every other day Procardia XL 60 daily Effexor XR 225 daily Trazodone 50 mg qHS Ativan 0.5 mg [Hospital1 ] prn anxiety prn Tylenol Pancrease Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) as directed Injection ASDIR (AS DIRECTED): as directed. 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule, Delayed Release(E.C.) Sig: ASDIR Cap PO QIDWMHS (4 times a day (with meals and at bedtime)): Please take this medication as originally prescribed. . 5. Cyclosporine 100 mg Capsule Sig: 1.75 Capsules PO Q12H (every 12 hours) as needed for Renal transplant. 6. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:10 Tablet(s) Refills:0 7. Prednisone 20 mg Tablet Sig: 2.5 Tablets PO EVERY OTHER DAY (Every Other Day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Please note that this is a narcotic and addiction is a risk of this medication. Try to limit use. . Disp:30 Tablet(s) Refills:0 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: Please discuss the utility of this medication with your gastroenterologist. . Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 10. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3) Capsule, Sust. Release 24HR PO DAILY (Daily). 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Please take for stool softening while on percocet for pain management, as needed for constipation. Disp:60 Capsule(s) Refills:2 14. Cyclosporine 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) as needed for Renal transplant: Please take with 25mg capsule to total 125mg twice daily. Disp:10 Capsule(s) Refills:0 15. Cyclosporine 25 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours: Please take with 100mg capsule to total 125mg twice daily. Disp:10 Capsule(s) Refills:0 16. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Disp:12 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Hepatititis of indeterminant etiology. . Secondary Diagnosis: 2. S/P Kidney Transplant. 3. Pancreas Divisum 4. Hypertension 5. Headaches 6. Depression. 7. Anxiety. Discharge Condition: Stable. Pain well controlled on percocet. Hepatic transaminases are trending down, nearly normalized. Ambulating without difficulty. Discharge Instructions: Please return to the hospital if you have nausea, vomiting, especially if there is blood in your vomit, fevers, chills, abdominal pain, diarrhea, especially if there is blood in your stool or if your stool is black and tarry. Also please return if you notice that the white's of your eyes are turning yellow. Please take your medications as prescribed. Please note that your blood pressure was stabilized while in the hospital on a medication that was different than what you were taking before you came in. We would like you to continue on the Amlodipine and to discontinue the Procardia (nifedipine). Please note that we will be sending you home with narcotics (Percocet - oxycodone/acetaminophen)to treat your pain. There is a risk of addiction to this medication so please to try to limit the use as much as possible. Followup Instructions: Please follow up with your gastroenterologist, Dr [Last Name (STitle) 12262] in [Location (un) ]. Please call on monday morning ([2155-9-29]) to schedule an appointment to see him within the next week. Please inform him of the decrease in dose of your Imuran to 50mg daily. Completed by:[2155-9-28]	[ "5849", "4019" ]
Admission Date: [2135-8-15] Discharge Date: [2135-8-30] Date of Birth: [2055-11-4] Sex: M Service: VSU CHIEF COMPLAINT: 1. Peripheral vascular disease with claudication right greater than left and right foot rest pain. 2. Asymptomatic carotid disease with internal carotid artery 80 to 90% left common carotid 68 to 69%, right internal carotid artery 70 to 79% with a left subclavian steel. Patient was recently hospitalized in [Month (only) 116] for respiratory failure and was discharged in [2135-4-25] and spent 2 months in rehab. He was discharged from rehab on [2135-6-20] to home. He returns now for carotid endarterectomy and revascularization of the right extremity. REVIEW OF SYSTEMS: Is positive for claudication, right greater than left x4 years, now with right foot pain which has increased since discharge. He denies any syncope, seizure, amaurosis or hemiparesis, seizures. Denies any chest pain, paroxysmal nocturnal dyspnea, orthopnea, edema, palpitations. He denies prostatism, melena or bloody stools. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Included Norvasc 10 mg daily, Toprol XL 100 mg daily, Nexium 20 mg daily, Captopril 25 mg t.i.d., Glipizide 10 mg q A.M. and Lipitor 10 mg q.d. ILLNESSES: Included enuresis, status post cystoscopy with cystometrics in [2131-3-26]. History of coronary artery disease with myocardial infarction x3 with a failed right coronary angioplasty stenting complicated by right coronary dissection requiring intra-aortic balloon support in [2121]. Peripheral vascular disease. Left hip and pelvic fracture secondary to fall in [2132-2-23]. Left upper lobe cancer, status post right upper lobectomy with chest wall resection, mediastinal node dissection. Bronchoscopy and mediastinoscopy and scalene node biopsy in [2132-2-23]. History of hypertension. History of type 2 diabetes mellitus on oral agents. History of chronic obstructive pulmonary disease. History of VRE. History of ventral hernia. History of non- Hodgkin's lymphoma by scalene node biopsy. History of ventilator-induced pseudomonas pneumonia. History of congestive heart failure, compensated. SOCIAL HISTORY: The patient is married x57 years. Lives with his spouse. [Name (NI) ] is retired. He ambulates. He is limited secondary to his foot pain. Patient's cardiologist is Dr. [Last Name (STitle) ]. The patient admits to tobacco use, 200 pack-years of smoking. He has not smoked since his lung resection in [2132-2-23]. PHYSICAL EXAMINATION: He is alert, oriented, in no acute distress. HEENT examination: No jugular venous distension. Carotids are palpable bilaterally 1+ with bruits bilaterally. Lungs are clear to auscultation. Heart is regular rate and rhythm without murmur, gallop or rub. Abdominal examination is soft, nontender. There are no bruits or masses. No aortic prominence. Peripheral vascular examination shows the right first and fifth toe with dry gangrenous changes. The right heel area with a superficial ulceration. The feet are pale bilaterally but warm. The right toes is with ruborous changes. Pulse examination: There is a left femoral bruit. The radial arteries are palpable 1+, femoral arteries: On the right Dopplerable. On the left 2+ palpable. Popliteals are Dopplerable bilaterally. The right dorsalis pedis is absent. The right posterior tibialis is a Dopplerable signal only. The left DP and PT are Dopplerable. Neurological exam: He is oriented x3, nonfocal. HOSPITAL COURSE: The patient was admitted to the vascular service. He was prepared for a right carotid endarterectomy. He underwent this on [2135-8-16]. He tolerated the procedure well. He was transferred to the post anesthesia care unit neurologically intact and stable. He required Neo- Synephrine drip for low urinary output. Patient's postoperative hematocrit was 31.7, BUN 16, creatinine 0.9. Patient continued to do well. Postoperative day 1 his Neo- Synephrine was weaned. His diet was advanced as tolerated. He did have episodes of supraventricular tachycardia but they were nonsustained and his Neo-Synephrine dose was decreased. He was restarted on his home medications and the Neo was weaned. Patient remained in the VICU. He was preopped for potential right leg revascularization with a femoral-femoral bypass but developed florid flash pulmonary edema and required admission to the SICU. He was intubated for respiratory insufficiency and his oxygenation improved. He continued on his Neo and Unasyn for his foot. He was transfused for his hematocrit of 28.5. He remained in the SICU. He was followed by his cardiologist, Dr. [Last Name (STitle) ]. Patient was aggressively diuresed and metoprolol was used for his supraventricular tachycardia. Patient was extubated on postoperative day 3. He continued to do well and he was transferred to the VICU for continued monitoring and care. His hematocrit remained stable post transfusion. His creatinine was remained stable with diuresis. His diet was advanced from clears to as tolerated on postoperative day 4. Ambulation was begun on postoperative day 4. Neck staples were discontinued on postoperative day 5. Patient continued to do well. Patient had an episode of nonsustained ventricular tachycardia. He was asymptomatic. He was sleeping in a chair. Postoperative day 6 his blood pressure was 70/50 after being placed back in bed but 15 minutes later his blood pressure was 122/50. His O2 saturation was 96% on 2 liters by nasal cannula. An electrocardiogram was obtained which showed no acute changes. He was continued to be monitored. Enzymes were sent. Those were unremarkable. Electrolytes were checked and those were stable and did not require any repletion. Because of this episode cardiology was requested to see the patient to determine whether he would be okay to undergo a major surgical procedure given his cardiac status. An echocardiogram was obtained. This demonstrated left atrial enlargement. The left ventricular cavity was mildly dilated. Overall left ventricular systolic function was moderately depressed with inferior and lateral akinesis with anterior and septal hypokinesis. The aortic valve was mildly thickened with three leaflets. The mitral valve was mildly thickened. There was mild mitral regurgitation. Compared to a previous study done in [Month (only) 116] of this year the left ventricular function had decreased. The patient underwent a stress test in which he had no anginal symptoms or electrocardiographic changes from baseline. A nuclear study demonstrated left ventricular cavity size was mildly enlarged. The resting and stress perfusion images revealed severe fixed inferior and lateral wall defect. There was also a moderate reversible apical defect with a calculated ejection fraction of 25%. These findings were reviewed with his cardiologist. After a long discussion the cardiologist, Dr. [Last Name (STitle) 1391] and the patient determined that he was at very high risk for a perioperative event. The patient elected to proceed to have surgery on his right leg for his ischemic right rest pain, even with significant increased risk. Patient underwent on [2135-8-26] a right common femoral artery endarterectomy with saphenous vein angioplasty, angiogram of the aorta and right iliac arteries. Patient tolerated the procedure well and was transferred to the post anesthesia care unit stable with Dopplerable DP and PT on the right and the foot was pink with 2 to 3 second capillary refill. Postoperatively the patient remained hemodynamically stable and was transferred to the VICU for continued monitoring and care. Postoperative day #1 there were no overnight events. The patient's diet was advanced as tolerated. His fluids were hep-locked. He was gently diuresed with Lasix and ambulation to a chair was begun. Cardiology continued to follow the patient. He continued on his beta blockers. Spirolactone was added daily for blood pressure and diuresis. Patient's Foley was discontinued on [2135-8-28]. He was continued on Augmentin perioperatively. Patient continued to progress. He was continued on all his preadmission medications. He was to be evaluated by physical therapy on postoperative day 4 of his right leg bypass to determine whether or not he would be safe to be discharged to home. Pending this evaluation patient will be discharged when medically stable either to rehabilitation or to home. DISCHARGE MEDICATIONS: Captopril 25 mg t.i.d., albuterol proprium aerosol 1 to 2 puffs q 4 hours p.r.n., Protonix 40 mg daily, albuterol actuation aerosol inhaler 1 to 2 puffs q 6 hours p.r.n., arvestatin 20 mg daily, aspirin 325 mg daily, Colace 100 mg b.i.d., Senna tabs 8.6 mg tablets 1 b.i.d. as needed, oxycodone/acetaminophen 5/325 tablets 1 to 2 q 6 hours p.r.n., amoxicillin 500/125 mg tablets q 8 hours for a total of 1 week, Lopressor extended release 100 mg daily. DISCHARGE INSTRUCTIONS: Patient should call us if his leg wounds become red, swollen or drain. He may ambulate essential distances and progress if tolerated. He should weigh himself daily and if he gains more than 2 pounds to call his cardiologist. He should limit his salt intake to no added salt to meals or in food preparation. To continue all medications as directed. He should continue his antibiotics until all the pills are gone. No driving until seen in follow up. To continue stool softeners while he is on pain medication. DISCHARGE DIAGNOSES: 1. Right carotid stenosis. 2. Arterial insufficiency with right foot pain. 3. History of coronary artery disease, status post myocardial infarction x3. 4. Status post failed angioplasty of the right coronary artery with right coronary artery dissection, intra- aortic balloon support in [2121]. 5. History of left hip and pelvic fracture secondary to fall. 6. History of right upper lung cancer, status post right upper lobe resection with chest wall resection, mediastinal node dissection, bronchoscopy, mediastinoscopy and scalene node biopsy. 7. History of postoperative congestive heart failure. 8. Compensated history of postoperative blood loss anemia, transfused. Patient should follow up with Dr. [Last Name (STitle) 1391] in 2 weeks at [Location (un) 5028]. He should call for an appointment at [Telephone/Fax (1) 5029]. MAJOR SURGICAL PROCEDURE: Right carotid endarterectomy with Dacron patch on [2135-8-16]. Right common femoral endarterectomy with vein patch angioplasty, intraoperative angiogram of the aorta and right iliac arteries on [2135-8-26]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2135-8-30] 11:00:06 T: [2135-8-30] 12:46:15 Job#: [Job Number 5030]	[ "4280", "41401", "25000" ]
Admission Date: [2131-2-19] Discharge Date: [2131-4-30] Date of Birth: [2060-5-10] Sex: F Service: SURGERY Allergies: Augmentin / Oxycodone Attending:[First Name3 (LF) 2777] Chief Complaint: Fever, swelling, pain and drainage from L BKA stump Major Surgical or Invasive Procedure: [2131-2-20] OPERATION PERFORMED: 1. Ultrasound-guided puncture of right common femoral artery. 2. Contralateral second-order catheterization of left external iliac artery. 3. Abdominal aortogram. 4. Serial arteriogram of the left lower extremity. 5. Debridement of massive soft tissue infection of the left lower extremity. [2131-3-2] Right Heart Catheterization/ Left Heart Catheterization/ Coronary Catheterization. [2131-3-13] PROCEDURE: Re-exploration of below-knee amputation and above- knee amputation. History of Present Illness: Patient is a 70F with severe PVD s/p left BKA [4-23] by Dr. [Last Name (STitle) ] with pain, redness, and discharge in left stump since Sunday. Fever to 101F. Pt was in usual state of health until saturday when the 1 cm ulcer that appears intermeittently on the bottom of her otherwise well-healed stump opened up and began to drain purulent fluid. On Sunday the stump became firey red and warm to touch which prompted her to present to the ED Today. No n/v/c/d. All other ROS negative. Past Medical History: PMH: vascular history as below, CAD s/p angioplasty 92, HTN, high lipids, s/p appy, s/p colon resection, s/p lumpectomy, GI bleed Vascular Procedures: [4-19]: L BKA [4-15]: Angio - Occlusion of the L [Doctor Last Name ] and peroneal art, unable to reenter the distal limb [4-11]: Left second toe amputation [4-7]: Angio - Dx abd aortogram & L lower extrem arteriogram, PTA of the tibioperoneal, [Doctor Last Name ] and SFA and stenting of the tibioperoneal BK-[Doctor Last Name ] and AK-[Doctor Last Name ] art for residual stenosis. Social History: neg drinker neg smoker Family History: unknown Physical Exam: PE: 96.8 74 128/42 18 100%RA Pain [6-25] Gen: NAD, appears comfortable Pulm: CTAB Chest: RRR. no murmurs Abd: Soft, NT/ND LLE: Purulent discharge along medial well healed incision of BKA stump; significant TTP from stump to proximal knee; significant blanching circumferential erythema from stump to proximal knee; pain with active and passive ROM of knee; no significant edema appreciated RLE: 3+ pitting edema to knee pulses fem [Doctor Last Name ] dp pt r 1+ d d d l 1+ d - - Pertinent Results: [2131-2-19] 07:00PM BLOOD WBC-25.0# RBC-3.58 Hgb-11.1* Hct-32.8* MCV-91 MCH-30.8 MCHC-33.7 RDW-18.9* Plt Ct-358 [2131-2-21] 03:05AM BLOOD WBC-12.7* RBC-3.18* Hgb-9.8* Hct-27.6* MCV-87 MCH-31.0 MCHC-35.7* RDW-18.1* Plt Ct-174 [2131-2-22] 03:27AM BLOOD WBC-10.0 RBC-2.84* Hgb-8.7* Hct-24.8* MCV-87 MCH-30.5 MCHC-34.9 RDW-18.1* Plt Ct-113* [2131-2-23] 03:30AM BLOOD WBC-13.0* RBC-4.33# Hgb-12.9# Hct-38.4# MCV-89 MCH-29.7 MCHC-33.5 RDW-17.5* Plt Ct-107* [2131-3-13] 07:26PM BLOOD WBC-30.1# RBC-2.85 Hgb-8.6* Hct-25.9* MCV-91 MCH-30.1 MCHC-33.2 RDW-17.5* Plt Ct-341 [2131-3-14] 04:20AM BLOOD WBC-16.3* RBC-3.44* Hgb-10.4* Hct-29.8* MCV-86 MCH-30.3 MCHC-35.0 RDW-17.5* Plt Ct-259 [2131-3-15] 04:07AM BLOOD WBC-11.8* RBC-3.54* Hgb-10.4* Hct-30.3* MCV-85 MCH-29.5 MCHC-34.5 RDW-17.0* Plt Ct-217 [2131-2-20] 08:10AM BLOOD PT-15.0* PTT-47.7* INR(PT)-1.3* [2131-3-11] 06:50AM BLOOD PT-11.9 PTT-30.6 INR(PT)-1.0 [2131-2-19] 07:00PM BLOOD Glucose-183* UreaN-44* Creat-1.4* Na-135 K-5.0 Cl-102 HCO3-18* AnGap-20 [2131-2-20] 06:56PM BLOOD Glucose-194* UreaN-26* Creat-0.8 Na-144 K-3.8 Cl-120* HCO3-17* AnGap-11 [2131-2-22] 03:27AM BLOOD Glucose-96 UreaN-18 Creat-0.6 Na-143 K-3.7 Cl-114* HCO3-23 AnGap-10 [2131-3-14] 04:20AM BLOOD Glucose-85 UreaN-13 Creat-0.5 Na-138 K-4.0 Cl-108 HCO3-24 AnGap-10 [2131-3-15] 04:07AM BLOOD Glucose-79 UreaN-14 Creat-0.4 Na-140 K-3.6 Cl-109* HCO3-27 AnGap-8 [2131-2-21] 03:05AM BLOOD ALT-9 AST-23 AlkPhos-51 Amylase-200* TotBili-0.8 [2131-3-14] 04:20AM BLOOD ALT-4 AST-18 AlkPhos-62 TotBili-1.0 [2131-2-20] 06:56PM BLOOD CK-MB-7 cTropnT-0.02* [2131-2-26] 10:49PM BLOOD CK-MB-NotDone cTropnT-0.08* [2131-2-27] 03:35AM BLOOD CK-MB-NotDone cTropnT-0.10* [2131-2-27] 10:38AM BLOOD CK-MB-NotDone cTropnT-0.13* [2131-2-27] 06:12PM BLOOD CK-MB-NotDone cTropnT-0.09* [2131-3-14] 04:20AM BLOOD cTropnT-0.02* Portable TEE (Complete) Done [2131-3-13] at 2:33:04 PM The left atrium is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. Brief Hospital Course: [2131-2-19] Admitted from home to Vascular Surgery, fever, pain w/ L below knee amputaion stump erythema and drainage. X-ray showed-likely a deep ulcer extending to the cortical surface of the remnant tibial stump. Started broad spectrum antibiotics. Remained febrile 101.5. Pre-oped for exploration and drainage of infected L BKA stump. NPO post MN and IV hydration. [2131-2-20] Remained febrile T 102- blood cultures sent. Triggered for hypotension SBP down to 60's and desaturation down to 88%. Given NS boluses, responded briefly but continued to become hypotensive. Transferred to the VICU, more fluid boluses given, given O2/NC 4l- O2 sats came up to 98-100%. Persistently hypotensive. Foley inserted, additional preipheral IV access, central line, a-line placed. Started on Dopamin to keep SBP>90's. Taken to OR for exploration and drainage of infected L BKA stump. Post-operatively, remained intubated and sedate, transferred to CVICU. Presumed to have necrotizing fascitis- started on Meropenem, Clindamycin and Gentamycin. Post-operatively the ID team was consulted who recommended continuing therapy with clindamycin and meropenem, vancomycin was added in addition. Cultures taken from the operating room were followed. Daily wound care was performed with wet->dry dressings TID. [2-21] Dopmaine was required to maintain adquate SBP's. [2-22] Pressors were weaned off, 1 U PRBC transfused and a plastic surgery consult was obtained. [2-23] The patient was weaned from mechanical ventilation, transitioned from AC to CPAP, a wound VAC was placed over the left BKA stump. [2-24] The patient was extubated without incident, began spiking fevers, c-diff was sent along with blood cultures. [2-25] Wound cultures from the OR were positive for beta-hemolytic strep and MSSA. [2-27] pt with increasing SOB, desaturations, CXR consistent w/volume overload, diuersis initiated. T-wave inversions noted on EKG [3-2] Persistently increasing troponins, Cardiac cath, negative for significant flow limiting coronary lesions. Pt transfered to VICU [3-3] - [3-7] The patient was progressively diuresed, nutrition recommendations were obtained and implemented, TTE was repeated showing improved systolic function (50-55%) [3-9] Pt cleared by cardiology to return to OR for completion AKA [3-13] Pt returned to operating room for above knee amputation with primary closure. The procedure was without complication. Chronic pain service continued to follow [3-14] 2 Units PRBC were transfused for a drop in Hct, no obvious source of bleeding aside from oozing at the amputation site. Enzymes were cycled to r/o for MI, negative x3. Antibiotics were continued [3-15] The dressing was taken down, amputation site appeared in good condition, meropenem was discontinued. [3-16] Pt was deemed fit for discharge. At the time of discharge pain was well controlled with oral medications, pt was voiding without difficulty, tolerating a regular diet and working with physical therapy. [3-18] CVL d/c'd Physical therapy continued to work with patient for transitioning to chair. Medial aspect of left AKA wound slightly opened in multiple subcentimeter areas with no evidence of infection or necrosis, pt kept in house for wound monitoring. Incision closing appropriately with dry dressing changes. No sign of infection. Medications on Admission: atenolol 25', folic acid 1', lasix 20', vicodin prn, lisinopril 10', methotrexate 17.5 mg q week, methyprednisolone 4', omeprazole 20', opium tincture 10mg/ml 2 drops [Hospital1 ], simvastatin 20', MVI, calcium 500", imodium 80' Discharge Medications: 1. Methylprednisolone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for distension. 5. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Methotrexate Sodium 2.5 mg Tablet Sig: Four (4) Tablet PO 1X/WEEK (FR). 15. Methotrexate Sodium 2.5 mg Tablet Sig: Three (3) Tablet PO 1X/WEEK (SA). 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 17. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 18. Opium Tincture 10 mg/mL Tincture Sig: Two (2) Drop PO BID (2 times a day) as needed for Diarrhea. Discharge Disposition: Extended Care Facility: [Location (un) ] Discharge Diagnosis: Infected L BKA stump Sepsis Hypotension Non STEMI CHF- Left ventricular systolic dysfunction, EF 30% Discharge Condition: Improved Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION . This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. . ACTIVITY: . There are restrictions on activity. On the side of your amputation you are non weight bearing until cleared by your Surgeon. You should keep this amputation site elevated when ever possible. . You may use the other leg to assist in transferring and pivots. But try not to exert to much pressure on the amputation site when transferring and or pivoting. Please keep knee immobilizer on at all times to help keep the amputation site straight. . No driving until cleared by your Surgeon. . PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: . Redness in or drainage from your leg wound(s) . . Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. . Exercise: . Limit strenuous activity for 6 weeks. . Do not drive a car unless cleared by your Surgeon. . Try to keep leg elevated when able. . BATHING/SHOWERING: . You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. . WOUND CARE: . Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. . When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. . MEDICATIONS: . Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. . CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . Avoid pressure to your amputation site. . No strenuous activity for 6 weeks after surgery. . DIET : . There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. . For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. . If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. . If you have diabetes and would like additional guidance, you may request a referral from your doctor. . FOLLOW-UP APPOINTMENT: . Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. . PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [12-19] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [1-17] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [Telephone/Fax (1) 1237]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2131-3-30] 11:00 Provider: [Name10 (NameIs) ], [Name8 (MD) ] MD (Vascular Surgery):([Telephone/Fax (1) 44777] [2131-4-5] - 11:00 AM [Last Name (un) 2577] Building [Location (un) 442]	[ "41071", "5990", "5849", "5070", "4280", "41401", "2875" ]
Admission Date: [2193-10-1] Discharge Date: [2193-10-10] Date of Birth: [2193-10-1] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname ] was born to a 30 year old gravida 4, para 3 to 4 mom with prenatal laboratories B positive, antibody screen negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune, unknown Group B Streptococcus status whose pregnancy was complicated by preterm labor with a Cerclage placed. She was on bedrest as well. She received a full course of Betamethasone. She had early labor leading to spontaneous vaginal delivery, rupture of membranes was one hour prior to delivery. There was no fever or clinical signs of chorioamnionitis. Her Apgars were 9 and 9 and her birthweight was 2280 gm. She was transferred to the Newborn Intensive Care Unit secondary to prematurity. PHYSICAL EXAMINATION: Her admission physical examination revealed a very well appearing infant with an examination consistent with 34 weeks gestation. Her birth weight was 2280 gm, her head circumference 30 cm and her length was 33.25 cm. Head and neck examination was normal. Chest, she had good breath sounds bilaterally with no crackles. Her cardiovascular examination revealed a regular rate and rhythm, no murmurs and normal femoral pulses. Her abdomen was benign. Her neurologic examination was normal. HOSPITAL COURSE: Respiratory - She has been on room air throughout her hospital stay. She has had mild apnea and bradycardia. Her last apneic spell with mild desaturation was on the evening of [10-7], at 11 PM. Cardiovascular - She was noted to have a very mild murmur on day of life No. 1 but had normal forelimb extremity blood pressures, electrocardiogram and hyperoxia test as well as a chest x-ray which did not show any cardiomegaly and clear lung fields. Her murmur persisted and on day of life No. 2, Cardiology was consulted who asked that we follow the murmur for a few more days and reconsult them once her pulmonary pressures had dropped, if the murmur had not changed. She had a murmur on day of life No. 6 which revealed a small muscular ventricular septal defect, otherwise normal anatomy. She will be followed up by Cardiology at one months time after discharge. No intervention is thought to be needed given the very small size of this muscular wall defect as well as the likelihood that it would close on its own as she grows. Fluids, electrolytes and nutrition - She was about to p.o. feed ad lib immediately after birth but was slow to take an adequate volume, so she required gavage feeding which she is still receiving. She is also supplementing with breastfeeding and is taking about one-half to three-quarters per volume orally. She has had normal urine output and stools. She had normal glucoses. He most recent weight on the day of interim summary was 2195 gm. Gastrointestinal - She has had no history of feeding intolerance, spits or abdominal distention. She had a bilirubin check on day of life No. 2 that was 6.8. We followed this up on one on day of life No. 3 which was 8.2. Her jaundice did not worsen and we followed it clinically thereafter. Hematology - She had an admission hematocrit which was 43.1 percent. Infectious disease - She had an initial blood culture sent as well as a complete blood count which showed a white count of 10.5, hematocrit 43.1, 314,000 platelets and differential at 41 neutrophils, 3 bands and 45 lymphocytes. No antibiotics were started. Sensory - She has not had a hearing screening as of this interim summary. She received hepatitis B vaccination on [10-5]. PRIMARY CARE PEDIATRICIAN: Her primary pediatrician is Dr. [Last Name (STitle) ], [Location (un) ] [State 350]. DISCHARGE DIAGNOSIS: Prematurity at 34 2/7 weeks. Mild apnea of prematurity. Immature feeding. Small muscular ventricular septal defect. Hyperbilirubinemia. dr.[First Name (STitle) ],[First Name3 (LF) ] 50-ABP Dictated By:[Last Name (NamePattern1) 56887] MEDQUIST36 D: [2193-10-10] 16:58:37 T: [2193-10-10] 19:24:45 Job#: [Job Number ]	[ "7742", "V290", "V053" ]
Admission Date: [2174-1-21] Discharge Date: [2174-1-26] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: CC:[CC Contact Info 46956] Major Surgical or Invasive Procedure: Pacemaker placement DDD History of Present Illness: HPI: 84 year old female with HTN, hypercholesterolemia, dementia presents from nursing home after they noted that her heart rate was in the 30's. She was noted to be in complete heart block, on arrival to hospital, sbp decreased to 80's systolic and she was started on Dopamine gtt at 13 cc/hr. Past Medical History: HTN Hypercholesterolemia dementia with agitation Hypothyroidism depression syncope Social History: Soc Hx: lives in nursing home. (+) Tobacco 1ppd x 50 yrs, quit > 15 [Last Name (un) ] Family History: FAMILY HISTORY: Sister CVA in her 60s. Father CVA in his 70s. Physical Exam: Phys Exam: 98.1F HR 60 BP 151/64 RR 14 100%/intubated Gen: sedated, intubated, responsive to pain HEENT: PERRL, intubated CV: distant S1, S2, ?systolic murmur Chest: external pacer in place with dsg C/D/I Pulm: diffuse rhonchi and occasional wheeze bilaterally Abd: (+) BS, soft, obese, nontender Ext: WWP, faint DP pulses b/l, 2+ pitting LE edema b/l Pertinent Results: [2174-1-21] 09:36PM BLOOD WBC-13.5# RBC-3.89 Hgb-11.3* Hct-32.5* MCV-84 MCH-29.1 MCHC-34.8 RDW-15.6* Plt Ct-222 [2174-1-26] 07:35AM BLOOD WBC-10.4 RBC-3.81* Hgb-11.4* Hct-31.7* MCV-83 MCH-30.0 MCHC-36.0* RDW-15.6* Plt Ct-222 [2174-1-23] 05:18AM BLOOD Neuts-79.2* Lymphs-14.0* Monos-3.0 Eos-3.7 Baso-0.1 [2174-1-21] 09:36PM BLOOD PT-12.6 PTT-24.9 INR(PT)-1.1 [2174-1-22] 05:42AM BLOOD PT-13.3 PTT-27.2 INR(PT)-1.2 [2174-1-24] 07:15AM BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1 [2174-1-21] 09:36PM BLOOD Glucose-148* UreaN-22* Creat-1.0 Na-136 K-4.5 Cl-101 HCO3-24 AnGap-16 [2174-1-26] 07:35AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-136 K-4.2 Cl-100 HCO3-27 AnGap-13 [2174-1-21] 09:36PM BLOOD ALT-28 AST-28 CK(CPK)-57 AlkPhos-77 TotBili-1.0 [2174-1-22] 05:42AM BLOOD CK-MB-NotDone cTropnT-0.04* [2174-1-22] 05:42AM BLOOD TSH-6.6* [2174-1-22] 05:42AM BLOOD Free T4-0.8* [2174-1-21] 09:41PM BLOOD Type-ART pO2-428* pCO2-38 pH-7.43 calHCO3-26 Base XS-1 [2174-1-22] 12:13PM BLOOD Type-ART Temp-37.2 FiO2-40 pO2-94 pCO2-36 pH-7.48* calHCO3-28 Base XS-3 Intubat-NOT INTUBA Echo [2173-1-24] 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 normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is moderate aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification with a moderate inflow gradient (in part due to significant regurgitation). Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. chest X ray: [2173-1-21] Chest: A single semi-upright AP view at 9:30 p.m. is compared to previous examination earlier from the same day. Since the previous exam the interstitial edema has decreased. There is an endotracheal tube with the tip approximately 4.5 cm proximal to the carina. There is a new single lead pacemaker with the lead overlying the right ventricle. There is no evidence of pneumothorax. There are probable pleural calcifications in left lower lung. There is focal opacity in right upper lobe which may represent pneumonia. Brief Hospital Course: A/P: 84 year old female with HTN, hyperlipidemia, recently diagnosed pneumonia treated with antibiotics, found by nursing home to have HR 30's, found to be in complete heart block. . 1. CV: Rhythm: Patient was taken to the cath lab, intubated for agitation, and a external screw-in pacemaker was placed. Unclear source of complete heart block, given she r/o for ischemia, more likely worsening conduction system with age. A permanent DDD pacemaker was placed on [2173-1-25] with no complications. Patient should have a follow up appointment with device clinic in 1 week. Pump: Patient on admission appeared volume overloaded, and her lasix dose was increased from 40 po day to 40 IV q day. Patient responded well, and later on was transitioned back to her home dose40 PO/day ECho on Echo on [1-24].EF >55%Mod AS, MOd MR [First Name (Titles) ] [Last Name (Titles) ] and severe pulmonary artery systolic HTN on ECHO. Ischemia: Patient rule out for MI, enzymes negative. BP: patient was initially hypotensive on admission, and was started on Dopamine. After procedure, she was transfer to CCU and Dopamine was weaned off over the following 12 hours. CAD: Patient was continued on Aspirin, Statin, and Ace was re-started once patient was transfer to the floor. 2. Pulm: patient was extubated succesfully in the morning of [2173-1-24]. Patient did well after extubation. . 3. ID: Pneumonia, was treated at NH with Erythromycin. Chest X ray on admission compatible with Right upper lobe pneumonia. Patient was switched to Azytromycin- Ceftriaxone. Sputum final showed sparse oropharingeal flora. Per ID recomendation, and given good clinical conditions, antibiotics were stopped on [2173-1-25]. Per electrophisiology recs, she received Vancomycin for 48 hours after procedure, since patient will be d/c after 24h, she will receive 1 more day of keflex. . 4. Hypothyroidism: Patient with high tsh and low free t4 on admission. levothyroxine dose was increased from 75 to 100mcg/day. . 5. Dementia: Continue Namenda. . 6. FEN: Cardiac heart diet monitor electrolytes and replete prn. . Medications on Admission: Lipitor 20 qhs Lasix 40 po qday lisinopril 2.5 po qday MVI Os-Cal 500mg qday ASA 81 qday Namenda 10 qday Levoxyl 75 mcg qday tylenol prn Erythromycin 333 TID (for PNA) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever. 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO qday (). 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-17] Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 8. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 1 days. 9. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 10. Os-Cal 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital 11851] Healthcare - [Location (un) 620] Discharge Diagnosis: Compleat Heart Block Community Acquired Pneumonia Hypothyroidism Discharge Condition: good Discharge Instructions: Please take your medications as prescribed. Please follow up your appointments as schedule. A pacemaker device was implanted durint this hospitalization. Your levothyroxine dose was increased during your hospital stay. If shortness of breath, chest pain, or any other symptoms that may concern you please call your pcp or come to the Emergency department. Followup Instructions: Please call your PCP for [Name Initial (PRE) ] follow up appointment in about 2 weeks. Please call Pacemaker and Device clinic at ([Telephone/Fax (1) 2361] to make an appointment in 1 week. Please recheck TSh in 1 month. Completed by:[2174-1-26]	[ "486", "4240", "2449", "4168", "2720", "4019" ]
Unit No: [Numeric Identifier 62241] Admission Date: [2186-9-29] Date of Birth: [2186-9-29] Date of Discharge: [2186-12-11] Sex: F Service: Neonatology IDENTIFICATION: Baby Girl ([Known lastname 18488]) [Known lastname ] is a 73 day old former 31 [4-22] wk twin (twin #2) who is being discharged from the [Hospital1 18] NICU. HISTORY: Baby Girl [Known lastname ] was a 1.010 kg product of a 31-5/7 week twin gestation born to a 33 year-old gravida I, para 0-II mother. Pregnancy was conceived via in [Last Name (un) 5153] fertilization. Prenatal laboratories: blood type is O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune, GBS unknown. Pregnancy was notable for intrauterine growth restriction in twin #2 and a 2-vessel cord in twin #2. Worsening growth restriction and decreasd amniotic fluid volume for twin #2 eventually led to c-section delivery. This infant emerged from breech presentation vigorous with a good cry. Apgars were 8 and 8 and she was admitted to the Neonatal Intensive Care Unit for prematurity. PHYSICAL EXAMINATION: Weight was 1010 gm, less than 5th percentile. Length was 36 cm, less than 5th percentile and the head circumference was 25.5 cm, also less than 5th percentile. Anterior fontanelle was flat. Palate was intact. Coarse breath sounds with fair aeration. Heart was regular rate and rhythm, no murmur. Abdomen is soft, nondistended, good bowel sounds, with 2-vessel umbilical cord. Skin pink and well perfused. Extremities: Left foot is noted to have shortened digits #1 through 4 with a normal fifth toe. Anus is patent. Normal female genitalia. The baby was admitted with the diagnoses of symmetric intrauterine growth restriction,, prematurity, 2 vessel umbilical cord and amniotic band syndrome of the left foot. HOSPITAL COURSE: RESPIRATORY: The patient was stable in room air at birth and never required oxygen supplementation. Mild to moderate work of breathing and tachypea were evident after birth, and gradually improved over first several days of life. Infant subsequently developed notable upper airway congestion, requiring periodic suctioning of the nares. Viral panel was negative. The congestion has persisted to the time of discharge, although it has not appeared to affect work of breathing or feeding ability, and may have improved somewhat after treatment for reflux was initiated (see below). The infant was treated with caffeine for apnea of prematurity from day of life 3 to day of life 19. Periodic desaturations and spells were noted subsequently, mostly related to feeds. The infant was prepared for discharge on [12-5], when in the context of having received 2 month immunizations and having a low-grade fever, infant had several desaturation and bradycardic spells while at rest. Infant was overall well-appearing, and was monitored. By the time of discharge, infant has been stable without any desaturations or spells for over 5 days. CARDIOVASCULAR: Infant was hemodynamically stable on admission, without need for blood pressure support. ECHOs performed over first 2 weeks of life secondary to murmur revealed a PDA that subsequently closed without treatment and a secundum ASD. Of note, ECHO on [10-9] revealed a 1 mm x 3 mm mass on the superior surface of the left atrium, consistent with a thrombus. This had not been seen on earlier ECHO on [10-3], and was thought to be most consistent with a line-related thrombus; at the time, the patient did have UVC in place which initially had crossed into the left atrium. The thrombus was followed with serial ECHOs and remained stable. An abdominal ultrasound on [10-9] revealed a small clot in the portal vein but no thrombus in the IVC or aorta. Hematology and cardiology were consulted, and as the [Name Prefix (Prefixes) ] [Last Name (Prefixes) 2966] was remaining stable, no treatment was initiated. Last ECHO on [11-28] revealed [Name Prefix (Prefixes) ] [Last Name (Prefixes) 2966] to be unchaged in size or appearance, and repeat abdominal ultrasound on [12-1] showed portal vein thrombus had resolved. Of note, ECHO on [11-28] did also show a small PDA with high-velocity L to R flow; the PDA had been closed on several earlier ECHOs. Over the last several weeks of hospitalization, mild elevations in blood pressures were noted, to approximately 90/40s with MAPs 50-60s consistently. These were considered high-normal to mildly elevated, but not needing treatment. EKG was normal. An extensive renal evaluation (see below) was negative without concerns for renal dysfunction. The renal service was consulted, and will follow the infant as an outpatient. The patient will be followed as an outpatient with cardiology to monitor the thrombus and the ASD. Follow-up can be arranged with Dr. [Last Name (STitle) 62242], who can be reached at [Telephone/Fax (1) 37115], for 2 to 3 months after discharge. GASTROINTESTINAL: The infant was initially maintained on IVF and IV nutrition, with introduction of enteral feeds on day of life 4. These were advanced without difficulty, to maximum intake of 150 cc/kg/day of PE 30 calories/oz formula. With adequate weight gain, calories were decreased, and by the time of discharge, the infant is taking Enfamil 28 calories/oz formula on an ad lib PO basis, taking approximately 150 cc/kg/day. Formula is Enfamil 24 with additional 4 calories/oz corn oil. During the hospitalization, clinical concerns for reflux became evident, and infant was begun on zantac 2 mg/kg q8 hrs with improvement. This is continued at the time of discharge. Discharge weight is 2.905 kg. HEMATOLOGY: Hematology service was consulted regarding the thrombus described above. Given that the thrombus was likely line associated, an evaluation for pro-thrombotic disorders was not undertaken. PT and PTT were measured, and were normal. If follow-up with hematology is required, referral can be made to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 62243] at the [Hospital3 328], phone [Telephone/Fax (1) 62244] and pager [Telephone/Fax (1) 47802]. Hematocrit was followed periodically during admission, with last value of 34.9 with retic count of 5.4% on [11-28]. Infant did not receive any transfusions, and is being discharged on iron supplementation. The patient had a maximum bilirubin of 7.2 and 0.3 and she received phototherapy from day of life 2 to 10. Normal rebound values were obtained. RENAL: Secondary to the 2 vessel cord, renal ultrasound was obtained on [10-9], which, other than the portal vein thrombus described above, was normal. Due to the elevated blood pressures noted over the last several weeks of hospitalization, renal evaluation was undertaken including urinalysis, BUN/Cr measurement, and repeat renal ultrasound. All were normal including the ultrasound on [12-1]. Renal service was consulted, and recommended a MAG-3 scan, which was performed on [12-8] and was aalso normal. By the time of discharge, blood pressures were stable at approximately 90/40-50; infant never required treatment for hypertension. Renal service will follow the infant as an outpatient, through the fellow [First Name8 (NamePattern2) 62245] [Last Name (NamePattern1) 51466] who can be reached at [Telephone/Fax (1) 50498]. ORTHOPEDICS: Orthopedics was consulted due to the amniotic band syndrome of the left foot. She has partial amputation of the first 4 toes and a normal fifth toe. Their impression was that if surgery was necessary it would not happen before 6 to 12 months of age and they would follow her in our clinic 2 to 3 months after discharge. Orthopedic doctor is Dr. [First Name (STitle) 2920] and he can be reached at [Telephone/Fax (1) 38453]. NEUROLOGY: Head ultrasounds were performed. due to low gestational age. First HUS on [10-9] revealed mildly dilated ventricles, with follow-up HUS on [10-11] being normal. Subsequently ultrasounds on [10-24] and [10-31] were notable for an echogenic area anterior to the left caudothalamic groove. This was read as a possible focal hemorrhage or infarction. Neurology was consulted, and after reviewing the images, believed the findings were consistent with a left germinal matrix hemorrhage, not clinically significant. No particular follow-up other than routine monitoring of development was recommended. The infant did undergo eye examinations, with immature retinas in zone III seen on [10-16], and mature retinas without ROP seen on [10-30]. PSYCHOSOCIAL: [Hospital1 69] social work was involved with the family. The contact social worker can be reached at [Telephone/Fax (1) 8717]. CONDITION AT DISCHARGE: Stable. DISPOSITION: To home. NAME OF PRIMARY CARE PHYSICIAN: [Last Name (NamePattern4) ]. [Last Name (STitle) ] at [Hospital ] Pediatrics. His phone number is [Telephone/Fax (1) 45985]. FEEDINGS AT DISCHARGE: Enfamil 28 calorie which is Enfamil 24 calorie with corn oil supplemented at 4 calories per ounces. DISCHARGE WEIGHT: 2.905 kg. MEDICATIONS: 1. Ferrous sulfate 25 mg/mL 0.5 mL po qd. 2. Zantac 2 mg per kilo per dose given q 8 hours. RHCM: Car seat test was passed. State newborn screen was normal on the [10-2] and [10-13]. Hearing screen was passed on [11-28]. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine [11-6]. On [12-4] Pediarix and hemophilus influenza B, Prevnar on [12-5] and Synagis on [12-4]. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1) Born at less at 32 weeks, 2) born at between 32 and 35 weeks with 2 of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, or 3) with chronic lung disease. 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. FOLLOW UP: Infant will follow-up with Pediatrician and VNA within 1 week of discharge. In addition, follow-up with renal, cardiology, and orthopedics should be arranged as described above. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Intrauterine growth restriction, symmetric. 3. Two vessel umbilical cord. 4. Hyperbilirubinemia, status post phototherapy. 5. Amniotic band syndrome left foot, toes 1 though 4. 6. PDA, self resolved. 7. Left atrial thrombus secondary to a high UVC. 8. Elevated blood pressures. 9. Apnea of prematurity requiring caffeine. 10. Left germinal matrix hemorrhage. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (NamePattern1) 62246] MEDQUIST36 D: [2186-12-5] 16:27:08 T: [2186-12-5] 18:54:46 Job#: [Job Number 62247]	[ "7742", "53081", "V053", "V290" ]
Admission Date: [2144-3-10] Discharge Date: [2144-3-17] Date of Birth: [2078-3-18] Sex: M Service: MEDICINE Allergies: Amitriptyline / Norvasc Attending:[Last Name (NamePattern1) 1167] Chief Complaint: Cough and shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 65 y/o M with PMHx of CAD s/p stenting, Afib/flutter, DM with neuropathy and tobacco dependance who presents with productive cough and SOB for 3 days. Pt reports upper respiratory congestion and cough with yellow sputum but denies fever & chills. Pt describes PND, orthopnea and new nocturia but has minimal exertion capacity and denies DOE. He also reports approx 1 wk of difficulty swallowing, coughing with thin liquids though no prior history of aspiration. Pt has poor dentition and difficulty chewing solid foods. He initially presented to his PCP on [Name9 (PRE) 766] morning and was discharged with prescription of Azithro and plan for outpt CXR. However, his shortness of breath worsened overnight and he presented to the ED early tuesday morning. . VS on arrival to the ED were: T 97.6 BP 148/104 HR 122 RR 28 Sats 100% on RA. CXR revealed LLL infiltrate and pt received Ceftriaxone 1gram, Azithromycin 500mg, Prednisone 60mg, Duonebs and 3L of NS IVF. Pt was given diltiazem 20mg IV for HR of 130 and was noted to have increasing O2 requirement. Pt was unable to wean from NRB and was started on diltiazem gtt for rate control. Repeat CXR showed worsening pulm edema and LLL consolidation. . On arrival to CCU, pt was feeling better, still c/o cough and mild SOB. Denies any fevers/chills, CP/palpitations, abd pain, nausea/vomiting or diarrhea. Past Medical History: # CAD s/p PCI x 2 with a history of MI and angioplasty 12 years ago. His most recent cardiac catheterization was in [Month (only) 216] of [2140] at [Hospital6 1708] which revealed non-flow limiting three-vessel disease and no intervention was performed at that time. # Atrial flutter/atrial tachycardia status post ablation in [2140-9-5] with breakthrough atrial tachycardia and atrial flutter # Atrial fibrillation- baseline HR 100-120 outpatient # DM type II - on NPH, recent A1C 6.6 # Neuropathy-[3-9] DMII wheelchair bound w/ caregiver # PVD followed by Dr. [First Name (STitle) ] # [First Name (STitle) ] Ca -- s/p partial colectomy [2125], no radiation or chemo # Neuropathy -- progressing to R arm now; legs unchanged, uses # Spinal Stenosis -- MRI done [5-/2141], no emergent issues, but some retrolisthesis of L4-5. # Anemia--Longstanding normocytic, unclear etiology # Alcoholism- Likely Active # Retinopathy- # Intracranial bleed-[2143-1-5]- fainted after dose of Amytripile and had intracranial bleed by rt inner ear. Social History: Lives at [Hospital1 1426]/[Location (un) ] with friend/partner [Name (NI) 61893] [Name (NI) ] ([Telephone/Fax (1) 61891]); this is also his HCP. Retired, disabled, wheelchair bound. Alcohol: Reports [3-10] drinks/day everyday for years. Denies problems with alcohol, but concern for abuse per previous notes. No h/o WD, DT's, seizure. Tobacco: 1.5 PPD x 40 yrs Drugs: Remote marijuana only. Family History: no family hx of heart disease. Both parents died at 92 of "old age." Physical Exam: Vitals: T: 97.5 BP: 127/82 P: 127 R: 24 O2: 93% on NRB General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated approx 3cm below angle of the jaw Lungs: No appreciable wheezes, occaisional rhonchi and inspiratory crackles at L>R base, clear with coughing. CV: Irreg/Irreg & tachycardic, diff to apprec murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding Ext: Warm, 2+ pulses, no edema Pertinent Results: [2144-3-10] 07:56AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.012 [2144-3-10] 07:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2144-3-10] 07:56AM URINE RBC-5* WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 [2144-3-10] 07:56AM URINE MUCOUS-RARE [2144-3-10] 04:56AM LACTATE-1.7 [2144-3-10] 04:15AM GLUCOSE-81 UREA N-13 CREAT-0.4* SODIUM-138 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12 [2144-3-10] 04:15AM estGFR-Using this [2144-3-10] 04:15AM WBC-7.3 RBC-3.64* HGB-10.4* HCT-30.8* MCV-85 MCH-28.7 MCHC-33.8 RDW-16.1* [2144-3-10] 04:15AM NEUTS-57.0 LYMPHS-35.2 MONOS-4.8 EOS-2.2 BASOS-0.8 [2144-3-10] 04:15AM PLT COUNT-393 [3-10] ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([2-7]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2142-12-13], tricuspid regurgittaion is now more prominent and estimated pulmonary artery systolic pressure is now higher. Left ventricular and right ventricular systolic function is less vigorous. [3-10] CXR COMPARISON: Chest radiograph from [2144-3-10] obtained of 04:16 a.m. and chest radiograph from [2143-11-8]. The left lower lobe consolidation accompanied by pleural effusion is unchanged but there is overall progression of perihilar vascular engorgement continuing towards the right lower lung with small right pleural effusion present. The radiological picture is consistent with mild-to-moderate pulmonary edema with the abnormality at the left lung being either a separate entity such as a pneumonia and parapneumonic effusion or potentially can be due to asymmetric pulmonary edema. There is no pneumothorax. The cardiomediastinal silhouette is unchanged. ADDENDUM: Findings were discussed with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] over the phone by Dr. [Last Name (STitle) ] approximately at 8:55 a.m. on [3-10], [2144]. [3-11] CXR 1. Increase in consolidation at the left lung base with slight increase in pleural effusion is concerning for pneumonia. 2. CHF with new mild-to-moderate pulmonary edema is unchanged. Brief Hospital Course: 65 year-old male with coronary artery disease, atrial fibrillation, diabetes mellitus type with neuropathy and tobacco dependance admitted [2144-3-10] with productive cough and SOB for 3 days. Patient was initially admitted to MICU, then medicine service, and finally to cardiology service prior to discharge. Hospital course was as follows. 1. Hypoxia: Etiology likely multifactorial. On initial presentation, patient was with adequate O2 saturation on RA and became progressively hypoxic with IVF resuscitation and Afib with [Month/Day/Year 5509]. Lobar pneumonia treated with good response with ceftriaxone (ten day course with 3 days of cefpodoxime prescribed at discharge) and azithromycin (5 day course). Pt became fluid overloaded intermittently with shortness of breath, which responded well to 20mg IV furosemide. Pt also experienced great symptomatic relief with brochodilators suggesting a brochospasm component to his dyspnea. After several days of gentle diuresis, antibiotics and nebulizer treatments, patient was saturating 95% on room and breathing comfortably. Discharged on continued antibiotics, furosemide, and albuterol. 2. Chronic diastolic heart failure: TTE on [2144-3-10] revealed EF 50-55% with minimal decrease in systolic function from prior TTE. Evidence of pulmonary hypertension. On cardiology service, patient experienced tachypnea at night which appeared consistent with PND. He was given Lasix with good response. 3. Atrial fibrillation with [Date Range 5509]: Patient has known atrial fibrillation and is status-post failed ablation. Suspect current worsening precipitated by CAP, hypoxia & long standing smoking history. Patient not anti-coagulated per Dr. [Last Name (STitle) ] given history of IVH from multiple falls. He was treated with increased doses of metoprolol and continued to enter A-Fib with [Last Name (STitle) 5509] to the 140's. For a short time his Toprol XL dose was doubled. On discharge, his heart rate was well-controlled with diltiazem SR 240mg PO daily and metoprolol succinate 100mg PO daily. 4. Coronary artery disease: Patient was without chest pain during episodes of atrial fibrillation with [Last Name (STitle) 5509]. EKGs essentially unchanged though low voltage in limb leads. He was continued on aspirin, Plavix, beta-blocker, and statin per his home regimen. 5. Diabetes mellitus, type II: Blood sugars poorly controlled, in the 300-400 despite excellent outpatient control with A1C of 6.6. This was likely due to prednisone treatment in the ED and the stress of his illness. [Last Name (un) ] was involved in management and guided daily insulin regimen changes. Patient's diabetes mellitus is complicated by neuropathy; he was continued on gabapentin 300mg PO TID per home regimen. 6. Alcohol use: Patient has been known to have significant alcohol intake. His alcohol level was elevated on admission. He was counseled on alcohol cessation. He was monitored on CIWA protocol and showed no signs of withdrawal. He was also started on a MVI, folic acid, and thiamine. 7. Hypertension: Well-controlled throughout hospitalization with metoprolol and diltiazem as above. 8. Anemia: Hematocrit remained at baseline (~30). Normocytic with labs consistent with iron deficiency. Patient with known history of [Last Name (un) 499] cancer s/p partial colectomy. Continued iron 325mg PO daily, and recommend to patient that he have a repeat colonoscopy as an outpatient. 9. ?COPD: No PFTs in our system. Unclear where how this diagnosis came about. Continued ipratropium prn, and discontinued albuterol given episodes of tachycardia. 10. Pulmonary hypertension: Moderate based on recent TTE. Source unclear, but may be related to left heart failure +/- acute illness. Patient recommended to have pulmonary follow-up as an outpatient. 11. Nutrition: He was evaluated by speech and swallow given presumed aspiration pneumonia, as described as above.He was recommended for a nectar prethickened liquid diet. Communication: [First Name8 (NamePattern2) 61893] [Last Name (NamePattern1) ], PCA ([Telephone/Fax (1) 61894] Medications on Admission: Lipitor 40mg daily Plavix 75mg daily Novolog 70/30 14units qam and 4units qpm Cymbalta 30mg daily Aspirin 325mg daily MIV daily Diltiazem SR 120mg daily Albuterol inhaler q4hr prn Azithromycin 500mg x 1, 250mg x 4 (started [2144-3-9*]) Gabapentin 300mg TID Folic Acid 1mg daily Toprol XL 100mg daily 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 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:2 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) inhalations Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 month supply Refills:0 14. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 3 days. Disp:5 Tablet(s) Refills:0 15. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous In the morning. Disp:30 day supply Refills:2 16. Novolog 100 unit/mL Solution Sig: As per attached sliding scale algorithm Subcutaneous four times a day. 17. Insulin Syringes (Disposable) 1 mL Syringe Sig: As per Lantus prescription Miscellaneous once a day. Disp:10 syringes Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: - Lobar Pneumonia, community acquired pneumonia vs. aspiration pneumonia - Atrial fibrillation with rapid ventricular rate - Acute on chronic systolic heart failure Secondary: - Diabetes mellitus type II complicated by retinopathy and neuropathy - History of [Month/Day/Year 499] cancer - Iron-deficient anemia Discharge Condition: Hemodynamically stable. Uses wheelchair for mobility (baseline). Discharge Instructions: You were admitted to the hospital because of difficulties breathing and a fast heart rate. You were found to have pneumonia and extra fluid in your lungs which was making it hard to breath. During your hospital stay, you were given antibiotics for your pneumonia and your heart rate was controlled by increasing some of your medications. We also gave you a medication to keep fluid off of your lungs. We also discovered you had a low blood count due to an iron deficiency. This may mean you have another problem in your [Month/Day/Year 499], and it may be necessary to have another colonoscopy in the future. Please discuss this with your doctor. Your medication regimen has changed. Please review your medication list closely. Please attend all the follow up appointments indicated below. If you have any of the following problems or any symptoms that are concerning to you, please return to the emergency department or call your physician: [Name Initial (NameIs) ] Difficulty breathing, - Fever, - Fast heart rate, - Confusion, - Inability to eat, or - Pain or pressure in your chest. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 131], MD (Primary care) Phone:[Telephone/Fax (1) 133] Date/Time: [2144-3-23] 2:30PM Provider: [Last Name (NamePattern5) 7224], NP (Cardiology) Phone:[Telephone/Fax (1) 62] Date/Time: [2144-3-31] 8:00AM, [Hospital Ward Name 23] 7 Please follow-up with Dr. [Last Name (STitle) 4379] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9485] at [Last Name (un) ] within one week. Completed by:[2144-4-6]	[ "486", "42731", "4280", "41401", "V4582", "412", "3051", "V5867", "4019", "2720" ]
Admission Date: [2151-8-17] Discharge Date: [2151-9-4] Date of Birth: [2079-6-23] Sex: F Service: MEDICINE Allergies: Macrodantin Attending:[First Name3 (LF) 6578] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: AKA History of Present Illness: 72 F non-ambulatory NH resident presented c L leg gangrene; underwent L AKA on [8-19]. Post-op had melena c 8 point HCT drop. Also developed respiratory compromise thought [3-11] PNA vs. overload, required 50 % FM O2 and received abx and furosemide. Decause of increasing O2 requirement, pt. transfered to ICU for initiation of BiPAP. . In MICU, pt did not require BiPAP; maintained O2 sat in 90s on FM 40%. Treated c vanco/levo/flagyl, broadened to vanco/zosyn. Flagyl stopped on [8-21]. On transfer from MICU, ctx data remained unrevealing and pt. on vanco/levo. Underwent u/s eval for possible thoracentesis to drain ? hemothorax but not felt to be suitable candidate at bedside. CHF thought less likely related to O2 req in MICU. Treated c free H20 boluses to address hypernatremia. MS improved; reversible causes of MS decline excluded. GI bleeding noted; pt received 4 u pRBC with stable HCT on d/c. Past Medical History: Peripheral vascular disease Atrial fibrillation Type 2 diabetes mellitus Neuropathy Chronic renal insufficiency Hypothyroidism Osteoarthritis H/O CVA S/P lumpectomy Social History: No etOH. Pt smoked for "a long time". Lives in [Location (un) 66758] [Street Address(2) 66759], [Location 9583] MA Family History: NC Physical Exam: VS- 96.5, 89, 110/58, 24, 94% Cool Neb 0.4% HEENT- OP clear, MMM LUNGS- Decreased BS at R base, CTA at other sites HEART- RRR, S1, S2, no rmg ABD- soft, NT, ND, BS+ EXT- L AKA noted; no erythema, purulence at surgical site. 1+ pitting edema over upper extremities. 2+ DP pulse R foot NEURO- AO3 Pertinent Results: [2151-8-17] 06:07PM GLUCOSE-167* UREA N-25* CREAT-0.8 SODIUM-137 POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-26 ANION GAP-16 [2151-8-17] 06:07PM CALCIUM-10.7* PHOSPHATE-2.5* MAGNESIUM-1.8 [2151-8-17] 06:07PM WBC-18.0# RBC-4.23 HGB-11.2 HCT-33.1* MCV-78* MCH-26.5* MCHC-33.9 RDW-16.0* [2151-8-17] 06:07PM PLT COUNT-405# [2151-8-17] 06:07PM PT-13.6* PTT-21.4* INR(PT)-1.2* CTA of chest w/contrast: IMPRESSION: 1. No pulmonary embolism. 2. There is soft tissue thickening in the right lower lobar bronchus. Additionally, there is some density within the bronchus at that level. Several scattered pulmonary nodules are seen in the right lower lobe. This appearance may reflect changes from local inflammation/pneumonia and mucoid impaction within the bronchus, though a primary malignant etiology cannot be excluded. Follow-up evaluation should be obtained to evaluate for resolution of these findings. . CXR [8-27]: The tip of the right internal jugular line is at the level of cavoatrial junction. The heart size is mildly enlarged, but stable. There is increase in bilateral perihilar opacities, representing mild pulmonary edema, as well as there is significant increase in right pleural effusion. Underlying consolidation in the right lower lobe cannot be excluded. There is no sizable pleural effusion on the left. There is a questionable small apical right pneumothorax, which is retrospectively demonstrated on the previous view, grossly [Month/Year (2) 1506]. IMPRESSION: 1. Increased right pleural effusion with possible underlying consolidation. 2. Suspected apical pneumothorax on the right. 3. Mild pulmonary edema . [2151-8-20] Blood - negative [2151-8-22] Sputum - negative [2151-8-22] Stool - c diff negative [2151-8-25] Urine - negative Brief Hospital Course: 72 y.o. female DM, CRI, s/p AKA had respiratory distress now c improving mental status. . 1. Hypoxia - Thought [3-11] aspiration PNA c R pleural effusion. CXR from [8-30] [Month/Year (2) 1506]. Cx data unrevealing. Patient had initially a Temp of 100.2 and elevated WBC, but WBC was trending down again later during her hospital course. Pt triggered on [9-1] in the afternoon b/o RR >30. The attending was informed. Pt seemed fluid overloaded on lung exam and 10 mg IV Lasix was given. The pt responded rapidly and urine output was adequate. Ipratroprium and Albuterol nebs were added. A VBG was obtained which indicated respiratory Alkalosis. The patient stabilized thereafter. The attending Dr. [First Name (STitle) ] informed the team on [9-2] that the nephew [Name (NI) 382] only wants [Name (NI) 3225] to be done for the patient at this point. All medications were stopped and only a Morphine drip and rectal Tylenol were started for pain control. No blood draws were perforemd anymore at this point. The patient passed away around 4pm on [2151-9-4] after aspiration. The event went very quickly. Her family was notified, the attending notified, and a death certificate was completed. Her family had a chance to see the patient before her death. . 2. Mental Status - MS [First Name (Titles) 17222] [Last Name (Titles) 1506] after initial improvement. Pt. remained somewhat withdrawn, speaking in whispers. There was limited evidence for metabolic, infectious etiologies of MS change. Reversible causes of MS [First Name (Titles) ] [Last Name (Titles) 20003] out. Her mental status was thought to be due to severe dementia, but was stable until her death. . 3. GI Bleed - HCT dropped initially from a baseline of 29-31 to 27.3. Transfused 1 U PRBC in AM of [8-29], followed by 1x IV Lasix 10 mg. Hct stable around 29-30 since then, but dropped once to 27.5, Possibly related to more frequent blood draws the day before. Pt was [Date Range 3225] since [9-2] and no more blood draws or actions were taken until her death. .. 4. DM - On Glargine for inpatient Glc control. Started with 8 U on [8-29], increased to 10 U on [9-1]. D/C'ed Metformin and Glyburide on [8-29] after starting Glargine. Possible causes for difficult Glc control were tube feeding and Abilify (known to cause hyperglycemia). Pt was [Month/Year (2) 3225] since [9-2] and no more blood draws or actions were taken until her death. 5. Afib - remained stable. Dig levels were checked on [8-30] and were wnl. Pt was [Month/Year (2) 3225] since [9-2] and no more blood draws or actions were taken until her death. . 6. Wounds - L AKA stable post-op. Wound remained nontender and nonerythematous until her death. . 7. Hosp FEN - Patient was continued on tube feeds (Dobhoff) until the decision was made by her nephew [Name (NI) 382] to be [Name (NI) 3225]. The tube was then pulled. Prophylaxis - SQ Heparin. No prophylaxis after the patient was [Name (NI) 3225]. Access - PIVs; central line. Code Status was DNR/DNI until her death. Medications on Admission: abilify 5mg asa 325 digoxin 0.125mg last level = 0.9 on [2151-8-16] paroxetine 15 mg MOM colace synthroid 150 mcg MVI metformin 1000/500 glyburide 1.25 mg [Hospital1 ], vicodin lipitor captopril 50 mg lopressor 25 mg [Hospital1 ]' amoxicillin prior to dental surgery Discharge Medications: None. Patient passed away. Discharge Disposition: Extended Care Discharge Diagnosis: - Discharge Condition: - Discharge Instructions: - Followup Instructions: -	[ "5070", "2760", "40391", "42731" ]
Admission Date: [2130-7-18] Discharge Date: [2130-7-21] Date of Birth: [2070-7-15] Sex: M Service: MEDICINE Allergies: Cefepime Attending:[First Name3 (LF) 613] Chief Complaint: Bradycardia, chest pain Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Mr [Known lastname 7203] is a 60 year old spanish speaking man with Diabetes, hypertenion, hyperlipideamia, history of ESRD on HD (Tues, Thurs, Sat), presenting with chest pain radiating to the left arm. Patient reports his symptoms started yesterday, at rest while sitting. He describes the pain as localized over the left chest, dull pressure with radiation to the back mid scapular area. No palpitations, diaphoresis or nausea. Patient took nitroglycerin at home without improvement in symptoms. Patient has been taking all medications as prescribed and has not skipped any dialysis sessions. He does report difficulty breathing starting with above symptoms. EMS gave patient ASA, Atropine 1mg and Nitro Spray x 1. In the ED, vital signs Temp 97.1 BP 150/36 RR 24 O2 Sat: 99% RA Patient was found to be hyperkalemic, bradycardic (junctional rhythm per report). Patient underwent CTA chest/abdomen and pelvis without evidence of dissection or PE. Per ED report a "small amount of contrast extravasated" on the right hand. Right IJ line was attempted but not successful, left subclavian line was placed. Patient did not receive any aspirin, plavix or heparin. Renal, cardiology and EP teams were made consulted. Patient was given Morphine, Atropine (0.5mg x 2), 10 units of IV insulin with 1 amp of dextrose, Kayexalate and 2gm of calcium Gluconate. Past Medical History: 1. Coronary Artery Disease - s/p CABG [2-28] LIMA-> LAD, SVG -> RCA/PDA, SVG -> OM1 - s/p PTCA and DES to proximal LAD with DES, POBA rescue of the D1 ([2129-9-26]) - s/p PTCA and DES sent to LM/LCx ([2129-9-2]) 2. DM 3. Dyslipidemia 4. Hypertension 5. Congestive heart failure (LVEF 60%, 1+ MR (eccentric), [12-28]+ TR, Mod PA HTN) 6. Peripheral [Month/Day (2) 1106] disease: s/p stent to bilateral CIAs (Genesis) and stent to [Female First Name (un) 7195], s/p POBA and atherectomy of L SFA [2126-7-17] bilateral iliac artery stenting and atherectomy of the left SFA in [2125] and [2130-6-28]. 7. End-stage renal disease: [1-28] Diabetic Nephropathy - on HD T/Th/Sat 8. COPD 9. Tracheomalacia 10. h/o c.diff colitis 11. h/o UGI bleed : EGD ([2-2]) showed non-bleeding [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear, gastropathy, and gastritis 12. Pulmonary Fibrosis: PET scan [2129-4-27], no areas of abnormal FDG uptake. Cannot rule out broncheoalveolar carcinoma. 13. AV fistula in left arm 14. Retinopathy 15. Neuropathy Social History: Patient is originally from [Location (un) 7225], [Country 7192]. His wife and family are still there. Patient currently lives alone, but his brother is nearby. He is on disability. His sister-in law works @ [Hospital1 18] in housekeeping. Family History: # Mother, died 71: DM2 # Father, died 97: HTN Physical Exam: VS: T 95.9 HR:51 BP: 95/47 O2 Sat: 95% 2L NC GEN: Ill appearing man, uncomfortable but in good spirits. HEENT: PERRL, sclera anicteric, conjunctiva non injected. Dry Mucous membranes. CV: Regular rate, loud early peaking systolic crescend murmur at RUSB Lungs: Clear to auscultation bilaterally, no rales/rhonchi/wheezes Abdomen: Soft, non tender non distended, normoactive bowel sounds. No guarding, no hepato/splenomegaly Extremities: Cold, Right hand edematous, non pitting, with impaired finger flexion and cyanotic decoloration. Pulses present on doppler. Pertinent Results: ================== ADMISISON LABS ================== WBC-7.4 RBC-3.10* Hgb-10.1# Hct-31.9 MCV-103* MCH-32.6* MCHC-31.7 RDW-15.0 Plt Ct-177 Neuts-70.1* Lymphs-20.0 Monos-6.0 Eos-3.0 Baso-0.9 PT-13.0 PTT-36.4* INR(PT)-1.1 Glucose-80 UreaN-60* Creat-8.3# Na-140 K-6.3 Cl-113* HCO3-15* AnGap-18 cTropnT-0.04* CK-MB-4 Calcium-6.8* Phos-4.6* Mg-2.5 Glucose-122* Lactate-1.5 Na-136 K-9.0* Cl-103 calHCO3-22 ECG: ([7-17] @2200)Bradycardic at 44, likely junctional escape rhythm (narrow QRS, no P waves, regular without variation. Right bundleoid pattern, deep Q waves on lead III and Deep S wave on lead I, no T wave inversion on lead III. Peaked T waves with lateral T-wave flattening . ECG: (on arrival) Regular rate, likely sinus bradycardia although varying P wave morphology. Peaked T waves, prolonged QTc (478), Unchanged inferior Q wave in III and TWI in I. ECHO The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function Brief Hospital Course: 60 year old man with complicated medical history, relevant for diabetes, end stage renal disease on HD, PVD / CAD s/p CABG and repeated stenting, presenting with chest pain, hyperkalemia, bradycardia. #. Chest Pain: Acute onset of pain at rest was very concerning for unstable angina. Patient with TIMI risk score of 5 (Known stenosis, greater than 3 CAD risk factors, Aspirin use, recurring angina in 24 hrs and positive troponins). Nonetheless, it is possible that this event constituted demand ischemia from metabolic disturbance or new valvular disease (loud murmur) leading to increase in demand. Degree of known CAD however severely limits interventions as pt is s/p CABG and stenting. Patient was closely monitored and dialysis started at the bedside. With correction of hyperkalemia, heart rate improved spontaneously and sinus rhythm was again noted. Chest pain improved significantly and remaining pain was easily reproducible to light palpation. Echocardiogram was obtained to evaluate for new wall motion abnormalities or new valvular disease. Results revealed preserved global systolic function and no new valvular process. With availabe information, it appears symptoms at presentation were related to bradycardia and do not warrant further workup at this time. Patient no longer complaining of chest pain or shortness of breath on walking at discharge. #. Right Hand Contrast Infiltration: Per report this ocurred in ED at time of CTA chest/abdomen/pelvis. Hand was very edematous, tight and painful, concerning for compartment syndrome. Hand surgery team was [Month/Year (2) 653] and hand was elevated and splinted. Patient will need follow up with hand surgery clinic. #. Hyperkalemia: Unclear etiology, as pt has been complient with dietary restrictions and has not missed dialysis sessions. This quickly resolved with adequate dialysis, raising concerns for sub-optimal dialysis as an outpatient. Per renal team, no evidence of fistula disfunction at this time. Patient to resume dialysis per outpatient regimen. #. Bradycardia / Junctional escape rythm: Although well documented in medical record to correspond to hyperkalemia, we considered beta blocker toxicity in differential. After dialysis, rhythm spontaneouly returned to sinus and no more bradycardia was observed. There is no evidence of beta blocker toxicity. #. ESRD: Received dialysis, resume outpatient schedule of tues, Thurs, Sat. Medications on Admission: ATORVASTATIN [LIPITOR] - 80 mg Tablet B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule CLOPIDOGREL [PLAVIX] - 75 mg Tablet daily ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 20 mg daily LISINOPRIL - 2.5 mg Tablet daily METOPROLOL SUCCINATE [TOPROL XL] daily NITROGLYCERIN - 0.3 mg Tablet, Sublingual PRN OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet PRN PREGABALIN [LYRICA] - 25 mg Capsule - [12-28] Capsule(s) daily RANITIDINE HCL [ZANTAC] - 150 mg Tablet - daily [Month/Day (2) ] HCL [RENAGEL] - 1 Tablet(s) by mouth three times a day ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) SENNA - 8.6 mg Capsule - 1 Capsule(s) by mouth [Hospital1 ] prn Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for Chest pain. 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. [Hospital1 7222] HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary 1. junctional bradycardia secondary to hyperkalemia 2. Contrast Extravasation in R. Hand Secondary 1. Coronary Artery Disease 2. chronic kidney disease, stage V, on HD 3. peripheral [Hospital1 1106] disease Discharge Condition: Ambulating without any shortness of breath, stable, no complaints, eating, drinking well, R. Arm strength 5/5 with good range of motion. Discharge Instructions: You were admitted for chest pain and during a scan, you had contrast extravasation which caused your hand/arm pain. You also had an incident where some of the chemicals in your blood increased to high levels (the potassium in your blood went up too high) -- as a result, we had to give you some medicatiosn to remove those chemicals along with your dialysis. You have several scheduled appointments listed below - please go to them all, and attend dialysis as scheduled. If you have any more chest pain, severe shortness of breath, severe back pain, please return back to the emergency room. Followup Instructions: 1. Provider: [Name10 (NameIs) ] CLINIC Phone:[Telephone/Fax (1) 3009] Date/Time:[2130-8-29] 10:30 2. Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2130-9-6] 9:40 3. Provider: [First Name8 (NamePattern2) 1409] [Last Name (NamePattern1) ], [MD Number(3) 1240]:[Telephone/Fax (1) 250] Date/Time:[2130-8-25] 9:00 4. Dr. [Last Name (STitle) ] [2133-9-20]:30 AM [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2130-7-23]	[ "42789", "40391", "2767", "2724", "4280", "496", "V4581", "V4582" ]
Admission Date: [2189-12-3] Discharge Date: [2189-12-7] Date of Birth: [2189-12-3] Sex: M Service: NEONATOLOG HISTORY OF PRESENT ILLNESS: This 1900 g, IVF, male triplet #2, was born at 33, +5 weeks gestation by cesarean section for maternal indications to a 39-year-old, gravida 1, now para 3. Pregnancy was complicated by pregnancy-induced hypertension from 29 weeks gestation. The mother had pregnancy-induced hypertension prompted cesarean section on the day of delivery. PRENATAL LABS: Mother was [Name2 (NI) ] group B+, antibody negative, hepatitis C surface antigen negative, rubella immune, RPR nonresponsive. blow-by oxygen. Apgar scores were 8 at one minute and 8 at five minutes. PHYSICAL EXAMINATION: Weight 1900 g, 50th percentile, length 40%, less than 50th percentile, head circumference 31.25 cm, 50th percentile. Of note on physical exam, the infant was tachypneic with expiratory grunting, nasal flaring, and retractions which worsened when time the infant arrived on the NICU. HOSPITAL COURSE: Respiratory: On arrival to the NICU, the infant was placed on nasal CPAP for mild to moderate respiratory distress. Chest x-ray showed ground-glass appearance consistent with surfactant deficiency. The infant was intubated and given surfactant times one in view of worsening respiratory distress. He was weaned onto nasal cannula oxygen within 24 hours of life and has been on room air since exam this morning. He remained intermittently tachypneic with respirations ranging from 50-70/min with mild retractions. He has had one apnea of prematurity over the preceding 24 hours, and his heart rate dropped to 30/min. He responded with moderate stimulation. Cardiovascular: The infant had some initial hypotension and required one bolus of normal saline. He has had no [Name2 (NI) ] pressure issues since then. He does not have cardiac murmur. FLUIDS/ELECTROLYTES/NUTRITION: His admission weight was 1900 g. His discharge weight is 1770 g. He was initially NPO on 80 cc/kg D10W. He was commenced on feeds on day #1 of life following extubation. He has advanced well with his feeding. He is currently taking 120 cc/kg of breast milk 22 or PE22, and he is able to take some bottles by mouth. He has had no reported GI intolerance. GI: He developed hyperbilirubinemia of prematurity and has required phototherapy from [2189-12-6]. His maximum bilirubin was 10.7, with a direct of 0.3 on [2189-12-6]. He is currently under phototherapy with a plan to discontinue phototherapy tomorrow and recheck rebound bilirubin. Hematology: His initial hematocrit on admission was 51.3. He has not required any [Year (4 digits) ] transfusions. Infectious disease: In view of his prematurity and respiratory distress, he underwent initial sepsis evaluation. His CBC was unremarkable. He had no left shift. [Year (4 digits) ] cultures were negative after 48 hours. Antibiotics were discontinued at 48 hours. Sensory: Audiology: He requires a hearing test prior to discharge from the hospital. Social: Parents were updated on his progressive regular intervals. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Transfer to [Hospital ] Hospital. PRIMARY PEDIATRICIAN: Undetermined at this time. CARE RECOMMENDATIONS: Feeds at discharge: Breast milk 22 or PE22. Advance calories as tolerated to maintain optimal weight gain. DISCHARGE MEDICATIONS: None. STATE NEWBORN SCREENING: Sent on [2189-12-7]. IMMUNIZATION RECOMMENDATION: He has not received hepatitis B at our hospital. Immunizations per AP guidelines. FOLLOW-UP: None scheduled at [Hospital6 2018]. DISCHARGE DIAGNOSIS: 1. Preterm triplets, infant #2. 2. Respiratory distress syndrome requiring surfactant times one. 3. Hypotension requiring saline bolus times one. 4. Sepsis evaluation. 5. Hyperbilirubinemia of prematurity requiring phototherapy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 35940], M.D. [MD Number(1) 35941] Dictated By:[Last Name (un) 46908] MEDQUIST36 D: [2189-12-7] 14:51 T: [2189-12-7] 18:54 JOB#: [Job Number ]	[ "V290" ]
Admission Date: [2174-11-7] Discharge Date: [2174-11-16] Service: SURGERY Allergies: Sulfonamides / Mevacor / Dicloxacillin Attending:[First Name3 (LF) 1234] Chief Complaint: Failed graft Major Surgical or Invasive Procedure: Pelvic angiography with left lower extremity run off. This corresponds with CPT [Numeric Identifier 7534], [Numeric Identifier 4238], and [Numeric Identifier 8881]. PROCEDURES: 1. Thrombectomy of left femoral-to-popliteal bypass graft. 2. Resection of left vein graft aneurysm. 3. Left femoral-to-peroneal bypass graft with arm vein. 4. Harvest of left arm basilic vein. 5. Angioscopy, vein inspection and valve lysis. History of Present Illness: The patient is a [Age over 90 ]-year-old female with a history of bilateral bypass grafts. The one on her index leg has been patent since [2161]. She presented somewhat acutely with a cold, blue foot. She was heparinized and taken to the angio suite which showed, as expected, occlusion of whole bypass graft and, unfortunately, only reconstitution was a peroneal artery that was not in continuity with the ankle. There was a collateral that then fed into the anterior tibial artery. There was no percutaneous treatment that could be performed. Lysis or an AngioJet of the vein graft was not realistic given the size of the graft and the size of the clot as well as the age of the patient. The patient underwent vein mapping and, unfortunately, only had one segment of basilic vein. The decision was made to try to thrombectomize the graft and do a revision down to the peroneal artery as the only chance. The family and the patient were told that the likelihood of success was moderate at best and if it did not work that there would be no further treatment possible. Past Medical History: Peripheral vascular disease s/p multiple bypass surgeries. CAD s/p MI in [2163] (last echo in [7-12]. Trace AR, MR, TR, significant pulmonary regurgitation) Atrial fibrillation status post pacemaker placement. GERD. Dysphagia with food impaction Osteoarthritis. Osteoporosis. Diverticulitis. Hypothyroidism. Depression. Lower extremity ulcers with positive MRSA in the past. Social History: Pt presents from home, where she has close care. No tobacco, no alcohol, no drugs. The patient was an exercise instructor. She is widowed. She has no children. Family History: NC Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [Doctor Last Name ], pt, dp lle - palp fem, [Doctor Last Name ], pt, dp Pertinent Results: [2174-11-16] WBC-12.0* RBC-3.49* Hgb-11.4* Hct-32.4* MCV-93 MCH-32.5* MCHC-35.1* RDW-14.1 Plt Ct-301 [2174-11-16] PT-18.8* PTT-39.9* INR(PT)-2.5 [2174-11-16] Glucose-103 UreaN-9 Creat-0.3* Na-132* K-3.9 Cl-97 HCO3-26 AnGap-13 [2174-11-16] Calcium-8.2* Phos-2.2* Mg-1.7 [2174-11-9] freeCa-1.13 [2174-11-7] URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG URINE RBC-0-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 URINE Hours-RANDOM Creat-54 Na-70 [2174-11-11] EKG Sinus rhythm. Atrial sensing and ventricular pacing. Compared to the previous tracing no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 84 0 128 366/[Telephone/Fax (2) 107428] ECHO Study Date of [2174-11-9] MEASUREMENTS: Left Atrium - Long Axis Dimension: 4.4 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.9 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.3 cm Left Ventricle - Fractional Shortening: 0.45 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Aorta - Ascending: 4.1 cm (nl <= 3.4 cm) Aorta - Arch: 2.9 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 2.1 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 17 mm Hg Aortic Valve - Mean Gradient: 9 mm Hg Aortic Valve - LVOT Peak Vel: 1.00 m/sec Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A Ratio: 0.82 Mitral Valve - E Wave Deceleration Time: 175 msec TR Gradient (+ RA = PASP): 40 mm Hg (nl <= 25 mm Hg) INTERPRETATION: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the basal septum. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Moderately thickened aortic valve leaflets. Minimally increased gradient c/w minimal AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate [[12-12]+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [2169-7-17], the degree of pulmonary hypertension detected has increased. Otherwise, no change. [2174-11-9] 9:38 PM CHEST (PORTABLE AP) INDICATION: Ischemic foot, central line attempted, eval for pneumothorax. There is moderate/severe new onset congestive heart failure with new bilateral pleural effusions, right greater than left. Pneumothorax is present, no central line is present. The cardiac silhouette and mediastinal contours are stable. There is some perihilar haze. Dual leads of pacemaker overlie their projected path. Skin staples identified at the left axilla extending down the left extremity. The thoracic aorta is calcified. Degenerative disease of the spine. IMPRESSION: New moderate CHF with new bilateral pleural effusions. No pneumothorax. Brief Hospital Course: Pt admitted [2174-11-7] [2174-11-8] Pt underwent a angiogram. She tolerated the procedure well there were no complications. No intervention could be done. The sheath was pulled in the usual fashion. There were no complications. Pt had vein mapping. Conduit inadequate to do BPG. It was decided to undergo thrombectomies of her graft site. Pt pre-oped oin the usual fashion. Pt cleared for surgery. [2174-11-8] Pt underwent a: 1. Thrombectomy of left femoral-to-popliteal bypass graft. 2. Resection of left vein graft aneurysm. 3. Left femoral-to-peroneal bypass graft with arm vein. 4. Harvest of left arm basilic vein. 5. Angioscopy, vein inspection and valve lysis. She tolerated the procedure well. There were no complications. Pt transfered to the PACU in stable condition. [2174-11-10] - [2174-11-12] Pt recieves PRBC's. Failed graft / pt started on heparin IV / restarted on coumadin. Coags followed. [2174-11-13] Mild rest pain Coags followed. INR 4 - vit K given Pt recieves PRBC's Incision ok. PT evaluation. [2174-11-14] PT INR 1.7 Heparin stopped. HCT stable after transfusion. [2174-11-15] Nutrition consult / REHAB screen Foley [Name (NI) 1788] pt urinates at time of void. [2174-11-16] Pt stable for DC to rehab On Dc taking PO / OOB with asst to chair / pos BM / pos urination INR at appropriate level. Medications on Admission: coumadin 4/4/6' over 3d, paxil 10', sacutra 20", digoxin 0.125' x2d, 0.25' 3rd day, levoxyl 75', sinemet CR 25/100 qhs, metoprolol 25"', nexium 20", enalapril 20', lorazepam 0.5 qhs, oscal 500+D", MVI', timolol 0.5% 1gtt os", artificial tears, ASA 81', benefiber"', colace 100" Discharge Medications: 1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY THIRD DAY (). 4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO bid (). 13. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day). 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BREAKFAST (Breakfast). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 20. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO once a day. 21. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 22. Os-Cal 500 + D 500-125 mg-unit Tablet Sig: One (1) Tablet PO once a day. 23. Benefiber 1 g Tablet Sig: One (1) Tablet PO three times a day. 24. GenTeal 0.3 % Drops Sig: One (1) Ophthalmic once a day: ou. 25. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO qhs prn. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Ischemic left foot and failed femoral-popliteal bypass graft. Discharge Condition: Stable Discharge Instructions: FOLLOW INR GOAL TO [1-13] DISCHARGE INSTRUCTIONS FOLLOWING LEG BYPASS / THROMBECTOMY SURGERY . This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. . ACTIVITY: . There are no specific restrictions on activity. You should be as active as is comfortable. Some fatigue is expected for the first several weeks. Leg swelling is typical following this type of surgery and can be controlled by elevating your leg above the level of your heart when you are not walking. Resume driving when you are comfortable without the need for pain medication. . PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: . Redness in or drainage from your leg wound(s). . New pain, numbness or discoloration of your foot or toes. . Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. . Exercise: . Limit strenuous activity for 4 weeks. . No heavy lifting greater than 20 pounds for the next 7 days. . Resume driving when you are comfortable without the need for pain medication . BATHING/SHOWERING: . You shower immediately upon coming home. No bathing. A clear dressing may cover your leg incision and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. Dissolving sutures, which do not have to be removed, were probably used. . If you have staples these will be removed on your follow-up appointment. . WOUND CARE: . Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for removal.). . When the sutures / staples are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . Avoid taking a tub bath, swimming, or soaking in a hot tub for two weeks after surgery. . MEDICATIONS: . Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. . CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . Avoid bending for 4-6 weeks. . No strenuous activity for 4-6 weeks after surgery. . DIET : . There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. . For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. . If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. . If you have diabetes and would like additional guidance, you may request a referral from your doctor. . FOLLOW-UP APPOINTMENT: . Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. . PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: Call and make an appointment with Dr [Last Name (STitle) ]. He can be reached at [Telephone/Fax (1) 1241]. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2174-12-28] 1:00 Provider: [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 126], M.D. Phone:[Telephone/Fax (1) 127] Date/Time:[2174-12-28] 1:30 Completed by:[2174-11-16]	[ "4280", "42731" ]
Admission Date: [2128-3-24] Discharge Date: [2128-3-27] Date of Birth: [2076-2-20] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5123] Chief Complaint: asthma exacerbation Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 52 yoF w/ a h/o severe asthma, presenting "feeling unwell" with progressive SOB x 3-5 days which felt like her asthma. She had a cough which was minimally productive, no hemoptysis. Her SOB was at rest and she has stable 2 pillow orthopnea, no PND or leg swelling / weight gain. At baseline she can walk across a room prior to becoming short of breath, currently she is short of breath at rest. She has chills but no fevers measured, + sore throat x day, global HA, and nasal congestion. She had intermittent chest pressure lasting about 20 minutes since the start of her SOB. No baseline exertional angina. . She is post menapausal, no vaginal bleeding, no blood in her stool or melena, no hematuria, no N/V or upper abd pain, has lower abd pain which has in the past been attributed to fibroids. No other urinary symptoms, no diarrhea or constipation. . In the ED, initial VS: T 99.3 HR 97 BP 116/68 RR 22 100% on RA. She was noted to have inspiratory and expiratory wheezes and working hard to breathe. She rec'd solumedrol 125mg x 1, nebs, azithromycin, and magnesium. EKG was noted to be sinus without ischemic changes, CXR was prelim clear. Guaiac negative in the ER. Prior to transport to the floor her VS were: HR 92, BP 115/92 RR 18 and 97% on RA. Her symptoms improved in the ER with therapy. . In the MICU, patient was observed and remained stable on room air. She was switched to prednisone and was ruled out for acute MI. She was transferred to the floor. . On the floor the patient reports feeling improved although not yet at her baseline. Her chest discomfort has resolved. Past Medical History: HIV- CD4 460, VL 106,000 -dx: [5-11] -RF: h/o sex with male partner who used IV drugs -nadir: 198 [1-18] -OIs: thrush in setting of inhaled steroids -ARV hx: recently started [2128-3-12] asthma- diagnosed at age 23, severe persistent -required hospitalization and intubation -normal peak flow ~250 per her report -spirometry [2128-2-11] FEV1/FVC 51 (68% pred), FEV1 1.5 (69% pred), DSB (HB) 13.98 (69% pred)- mild obstructive ventilatory defect with a mild gas exchange defect (asthma / COPD) hypertension dyslipidemia obesity Chest pain s/p neg stress [8-15] (limited exercise capacity) sleep-disordered breathing s/p sleep study- sleep apnea on CPAP anxiety bilateral knee OA GERD allergic rhinitis trichomoniasis [3-/2116] s/p bilateral tubal ligation Social History: No tobacco currently, quit 2 years ago, 20 pk year history. Drinks 1-3 beers per week (wine coolers), no illicit drug use. Lives with her daughter and three grandchildren, no pets. Family History: significant for mother with HTN/ESRD, CHF, several Aunts with DM. Physical Exam: Vitals - T: 97.2 BP: 126/74 HR: 75 RR: 18 02 sat: 97% RA. Peak flow 250. GENERAL: NAD, AOX3 HEENT: MMM, OP clear, JVP 8cm CARDIAC: RR, nl rate, soft heart sounds, no m/r/g LUNG: decreased air movement, sporadic/rare wheezes, no accessory muscule use, transmitted upper experiatory wheeze ABDOMEN: obese, soft, NT, ND, no masses or organomegaly EXT: WWP, no c/c/e NEURO: grossly normal Pertinent Results: [2128-3-24] 12:50PM WBC-7.3 RBC-2.78 HGB-7.2* HCT-22.6* MCV-81* MCH-26.0* MCHC-32.0 [2128-3-24] 12:50PM NEUTS-46.0* LYMPHS-48.2* MONOS-4.2 EOS-1.1 BASOS-0.5 [2128-3-24] 12:50PM GLUCOSE-111* UREA N-16 CREAT-1.2* SODIUM-133 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-26 ANION GAP-13 [2128-3-24] 12:50PM CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-1.7 [2128-3-24] 12:50PM CK(CPK)-41 [2128-3-24] 12:50PM CK-MB-NotDone cTropnT-<0.01 [2128-3-24] CHEST, PA AND LATERAL: The lungs are clear without consolidation or edema. There is persistent bibasilar atelectasis. There are no pleural effusions or pneumothorax. Again noted is bilateral diaphragmatic eventration. The cardiac size is normal, with a tortuous and calcified aorta. IMPRESSION: No acute cardiopulmonary process. [2128-3-24] EKG: Sinus rhythm with baseline artifact. Compared to the previous tracing of [2128-1-18] there is no diagnostic change. Brief Hospital Course: 52-year-old female with a history of asthma and HIV who present with 3-5 days of wheezing and shortness of breath. # Dyspnea: The patient likely has an asthma exacerbation. Her chest x-ray was clear making pneumonia or heart failure less likely. She had audible wheezes. She was satuating well on room air and had a peak flow of 270 (baseline of 250) in the emergency department. She was started on prednisone, standing nebulizers and antibiotics. She was admitted to the ICU for fear of decompensation. She remained saturating well on room air overnight and was sent to the floor. On the floor the patient felt much better. Her nebulizers were spread to q6hours and she stated she was at her baseline. The patient had an ambulatory O2 sat which was normal on room air. She was discharged on a 10 day steroid taper, 5 day course of azithromycin, spiriva, advair, albuterol nebs, ipratropium nebs. She will follow up with her primary care physician and pulmonologist in the future. # Anemia: The patient likely has iron deficiency anemia. She remained stable. Stools were guaiac negative. She will need to be follow by her primary care physician. [Name10 (NameIs) ] may require a colonoscopy. # Chest pressure: The patient was ruled out for MI with EKG and cardiac enzymes. The pressure was likely secondary to her respiratory status. # HIV: Recent CD4 of 460. She was continued on atripla. She has an appointment with her ID doctor int he future. # OSA: Continued on CPAP at night. # Hypercholesterolemia: Continued simvastatin. Medications on Admission: Albuterol inhaler and nebs prn Tiotropium 18mcg daily Advair 500/50 [Hospital1 ] Singulair 10mg po daily Celexa 20mg daily Atripla po daily Flonase [Hospital1 ] HCTZ 25mg po daily Lisinopril 30mg po daily Ativan 1mg po bid prn Simvastatin 40mg po daily Detrol LA 4mg po daily Ambien 10mg po qhs with CPAP Loratadine 10mg po daily Prilosec 40mg daily Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Albuterol Sulfate 2.5 mg/0.5 mL Solution for Nebulization Sig: One (1) Inhalation three times a day. 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 4. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ATRIPLA [Telephone/Fax (3) 567] mg Tablet Sig: One (1) Tablet PO once a day. 8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Nasal once a day. 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 10. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for anxiety. 12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day. 15. Loratadine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO once a day. 16. Calcium Carbonate-Vitamin D3 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 17. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:2 Tablet(s) Refills:0 18. Prednisone 20 mg Tablet Sig: As directed Tablet PO once a day for 7 days: Please take 3 tabs for the next 1 day, then take 2 tabs for the next 3 days, then 1 tabs for the next 3 days, then you are done. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: 1. Asthma exacerbation Secondary Diagnosis: 1. HIV Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted with an asthma exacerbation. You were treated with steroids, antibiotics and breathing treatments. You did well with these. Your ambulatory oxygen and peak flow meter were near your baseline. You felt well and were discharged home. You will need to continue your antibiotic for 2 more days and your steroids for 7 more days. Your red blood cell count was a little low. You should follow up for this with your primary care physician. [Name10 (NameIs) 2172] calcium level was slightly elevated. You should have follow up labs with your primary care physician to ensure this resolves. You will need to follow up with your primary care physician and pulmonologist. The following changes were made to your medications: 1. START Azithromycin 250mg by mouth for 2 more days 2. START Prednisone Taper for 7 more days. Please take as directed. Followup Instructions: Provider: [Name10 (NameIs) 39063] [Last Name (NamePattern4) 39064], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2128-4-9] 1:45 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2128-4-15] 7:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 456], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2128-4-23] 10:30 MD: Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4507] Specialty: Pulmonary Date/ Time: [5-19] at 9am for a Pulmonary Function test and then 9:45am for an appt with Dr [Last Name (STitle) 4507] Location: Phone number: [Telephone/Fax (1) 513] Special instructions for patient: This appt was already scheduled for you in [Month (only) ]. Please keep this appt.	[ "2720", "32723", "53081" ]
Admission Date: [2154-11-12] Discharge Date: [2154-11-16] Date of Birth: [2096-9-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 330] Chief Complaint: thrombocytopenia, vaginal bleeding, pancreatitis, diabetes Major Surgical or Invasive Procedure: none History of Present Illness: This is a 58 year-old woman with a history of hypertension transferred to [Hospital1 18] from [Hospital3 ] with pancreatitis for further management. Patient was admitted to [Hospital1 46] on [2154-11-10] with one week of polydipsia and one day of increased lethargy, confusion. On questioning now patient gives 2 week history of decreased appetite, early satiety, intermittent RUQ abdominal "discomfort" with eating. No history of gallstones. Significant polyuria, polydipsia of 1 week duration, no constant abdominal pain. No fevers, chills, wieght change or nightsweats. Rare alcohol. Also reports poor PO intake--small meals. On admission to [Hospital1 46] she was found to have a blood glucose of 1590, ketones in urine without gap, amylase of 491 and lipase of 7561. Vital signs at that time were stable and in the normal range--BP's 150's and HR 90's, afebrile. She was admitted to the ICU, vigoroisly hydrated, started on insulin drip. CT demonstrated acute pancreatitis, possible gallstones and a 19 x 17cm soft tissue density in the pelvis felt likely to be a fibroid, although patient is s/p hysterectomy. Creatinine on admission was 2 and increased to 5.3 with oliguria. Baseline creatinine of 0.8. Amylase and lipase peaked on [11-11] at 1,027 and [Numeric Identifier ] and on [11-12] trended down to 813 and 6228 respectively. Platelets on admission were 338,000 and fell to 55,000 on [11-12]. With normalization of blood glucose on [11-11], serum sodiu to 157. Hydrated with D5water. MRCP done on [11-11] but no results reported. .. At this time patient also noticed vaginal bleeding--has not menstruated for two years. Past Medical History: Past Medical History:hypertension s/p hysterectomy by records but patient denies Had 3 normal vaginal deliveries. Social History: Social History: No smoking, rare alcohol, no drug use. Lives with her children. Family History: Family History: Mother died from breast cancer in 70's, father died of MI at 46. Physical Exam: Physical Exam on Admission: VS: Temp: 98 BP: 137 /47 HR:90 RR:20 99%rm airO2sat general: pleasant, comfortable, NAD, obese, oriented x3 (although does not know [8-12]--"in teens" HEENT: PERLLA, EOMI, anicteric, no sinus tenderness, MMdry, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules, lungs: CTA b/l with good air movement throughout heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: distended, +b/s, diffuse tenderness especially in area of large abdominal mass from umbilicus to left upper quadrant to epigastrum, no Grey-[Doctor Last Name 27210] or Cullens extremities: no edema, non-tender, cold feet but warm lower exremities neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps skin: patient has blistering over both shoulder regions, mottling on lower extremities below knee bilaterally, no jaundice, splinters .. Pertinent Results: ADMISSION LABS WBC-17.6* RBC-3.86* Hgb-12.5 Hct-37.5 MCV-97 MCH-32.5* MCHC-33.4 RDW-13.7 Plt Ct-46 Diff: Neuts-83.7* Lymphs-11.2* Monos-4.1 Eos-0.9 Baso-0.1 Coags: PT-14.7* PTT-24.9 INR(PT)-1.5 DIC labs: Fibrinogen-363 D-Dimer->[Numeric Identifier 961]* Chemistries: Glucose-247* UreaN-71* Creat-3.5* Na-147* K-4.0 Cl-107 HCO3-25, Albumin-3.3* Calcium-7.8* Phos-1.7* Mg-1.5* Liver functions: ALT-31 AST-56* LD(LDH)-661* AlkPhos-80 Amylase-132* TotBili-0.7, Lipase-157* Cardiac enzymes: CK-MB-4 cTropnT-<0.01 Cholesterol: 123, tg-191-->119, hdl-25, ldl-74 Others: Haptoglobin-379* TSH-0.40 Urine electrolyte:CREAT-102 SODIUM-LESS THAN URIC ACID-A, OSMOLAL-420 AU/A: SP [Last Name (un) 155]-1.016, BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG, RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2, URIC ACID-OCC Pelvic ultrasound: An enlarged fibroid uterus measuring 19 x 12.1 x 15.4 cm is present. Multiple large fibroids are seen, 1 located at the fundus on the right measuring 6.3 x 6.4 x 7.6 cm. Another located towards the left measures 5.7 x 5.8 x 5.9 cm. Other fibroids are also present. Fibroids distort the endometrium, and the endometrium cannot be assessed. Neither ovary is visible. There are no adnexal masses. EKG:Rate about 90, nsr, nl axis, borderline LVH and left atrial abnormality, borderline prolonged QT of 472. U waves. Skin biopsy: Brief Hospital Course: Pancreatitis: Diff dx: gallstones, alcohol, triglycerides, hypercalcemia, infection, meds, vascular. Triglycerides were elevated at OSH. Triglycerides and calcium within normal limits at [Hospital1 ]. No medication changes since [Month (only) 404]. Possible gallstones seen at outside hospital CT. Gives no gallstone history but possible biliary colic in 2 weeks preceding admission. Never had elevation of bili or alk phos, only very minimal transaminitis. Also, ? abd mass causing compression leading to pancreatitis-- This is a very curious picture as amylase and lipase extremely elevated at OSH but here relatively modestly elevated--last lipase there of 6228 and here 157. She was treated with IVFs and made NPO. Initially she was treated with levofloxacin and flagyl, but these were discontinued after a couple of days. Gastroenterology was consulted and they felt that it was likely triglyceridemia that caused her pancreatitis. Patient improved with aggressive hydration although noted to be in DIC and to have severe pancreatitis by [Last Name (un) 5063] criteria. Patient stabilized by [6-16] and planned transfer to floor. Abdominal/Pelvic mass: Gynecology consulted. She had a pelvic ultrasound that revealed fibroids. Plan was for outpatient follow-up. Endocrine: DKA vs. HONK at outside hospital with serum glucose 1500 and ketones but no anion gap. She was treated with an insulin drip and then tarnsitioned to long-acting insulin. [Last Name (un) ] was consulted. Stable by [6-16]. Oliguric renal failure: Likely pre-renal due to improvement with IVFs. Hypernatremia: likely from extreme dehydration. Treated with IVFs. Thrombocytopenia/Platelet drop: HIT antibody negative. Likely from DIC. Hematology consulted. Improving. Mouth and vaginal bleeding: due to DIC/thrombocytopenia. Improving by [6-16]. Skin papules: Possible xanthomas. Dermatology consulted and lesion biopsed. The patient's pancreatitis was improving and her diabetes was under control by hospital day #4. Plan was to transfer out of the intensive care unit but early on the morning of [2154-11-16] the patient had a PEA arrest. The patient got up out of bed to go to the bathroom with assistance of nursing and nusrsing saw the patient gasp and then syncopize. Upon arrival the patient was unconscious and PEA. Patient underwent attempts at rescucitation for approximately 35 minutes which was unsuccessful. Patient declared dead at 5:37AM. Autopsy scheduled. No obvious cause of PEA arrest. Thrombolysis attempted approximately 20 minutes into code given possibility of PE. Medications on Admission: Medications outpatient:hydrochlorothiazide 25 mg daily, lisinopril 10mg daily, atenolol 25 mg daily, norvasc 2.5 mg daily, indapamide 2.5 mg daily, aspirin 81 mg daily Medications on admit: ISS, metoprolol 2.5 mg IV q6h, morphine, nystatin, protonix, levo 250 mg daily, flagyl 500 q8h Allergies: NKDA Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: pancreatitis DIC Hyperglycemia DKA Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A	[ "5849", "2875", "4019" ]
Admission Date: [2172-5-26] Discharge Date: [2172-5-28] Date of Birth: [2118-7-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7223] Chief Complaint: vfib/vtach arrest Major Surgical or Invasive Procedure: Atrial fibrillation and PVI/ablation Coronary Artery Catheterization Cardiac Arrest History of Present Illness: This is a 53 year old gentleman with hypertension and history of atrial fibrillation. He was rate controlled and started on anticoagulation therapy. He underwent a successful cardioversion in [2171-7-5] but reverted to atrial fibrillation within four days. He found when he was in regular rhythm he had more energy, an increased exercise tolerance and a reduction in his dyspnea. He was started on Propafenone and underwent another cardioversion but sinus rhythm was not successfully restored. The patient was seen in consultation with Dr. [Last Name (STitle) 3321] for his arrhythmia and ablation was discussed as an alternative to other medications. He has elected to undergo the procedure. . He reports in addition to dyspnea, fatigue and a decreased exercise tolerance he has associated palpitations,lightheadedness and profuse sweating. He reports episodes have awaken him from sleep. . His afib ablation was successful until the end of the procedure when he went into vtach arrest. Reportedly, he received an asynchronous emergency shock which put him into vfib which was refractory to 3 360J external shocks and required an internal defibrillation for restoration of sinus rhythm. His total time in VT and VF was 2 minutes 26 seconds. He was put on a neo and epi drip for BP support. The cause of his vtach was thought to be from triggered activity from the catecholamines he was on for the procedure. His neo, epi and dopamine was stopped and he was maintained in sinus rhythm with amio and lidocaine drip. His coronaries were imaged and there was no thrombus. Echo showed no tamponade, no gross wall motion abnormality, and mildly depressed RV function. He was then transferred to the ICU intubated. Reportedly, he recovered consciousness and was appropriate before being sedated again. . ROS: Unable to obtain ROS because patient is intubated and sedated. Past Medical History: PMH: Atrial fib Colon polyps Umbilical hernia . Cardiac History: CABG: none Percutaneous coronary intervention: none Pacemaker/ICD placed: none Social History: He is married, has five children and works as a lineman for NSTAR as well as runs a horse ranch. He does not smoke and drinks 2-3 alcoholic beverages daily. Family History: N/A Physical Exam: VITALS: 96.3, 107/64, 79, 99% 100%FiO2, AC 700x18, PEEP 8 Ht: 6 ft 3 in Wt: 275 lbs Admission GEN: intubated and sedated HEENT: intubated NECK: obese, unable to assess JVP CV: RRR, no M/G/R PULM: Coarse respirator sounds, no w/r/r ABD: Obese, soft, NT, ND, +BS EXT: No peripheral edema PULSES: 1+ DP and PT pulses bilaterally . Discharge VITALS: 98.3, 126/64, 79, 100% RA GEN: Aox3, in NAD HEENT: benign OP NECK: obese, unable to assess JVP CV: RRR, no M/G/R PULM: CTAB, no labored breathing ABD: Obese, soft, NT, ND, +BS EXT: No peripheral edema, right thigh numbness across anterior-lateral thigh from hip to just above the knee, strength [6-8], warm distal extremeties, distal sensation intact; mild bruising at right groin but no hematoma or bruit; left groin without hematoma, bruising or bruit PULSES: 1+ DP and PT pulses bilaterally Pertinent Results: 2D-ECHOCARDIOGRAM: [2172-5-26]: Overall left ventricular systolic function is low normal (LVEF 50-55%). There is depressed right ventricular free wall contractility. There is no pericardial effusion. . CXR In comparison with study of [5-20], there are lower lung volumes. This plus the AP technique may account for much of the increased prominence of the cardiac silhouette and fullness of the mediastinum. No gross evidence of pulmonary edema. Some atelectatic changes are seen at the left base. Although this certainly could well represent something on the patient, the possibility of a foreign body must be excluded. Endotracheal tube tip is in place with the tip at the upper clavicular level, approximately 6.5 cm above the carina. . CBC [2172-5-26] 07:15AM BLOOD WBC-4.8 RBC-5.09 Hgb-16.7 Hct-45.8 MCV-90 MCH-32.9* MCHC-36.5* RDW-13.2 Plt Ct-162 [2172-5-26] 05:32PM BLOOD WBC-10.3# RBC-4.37* Hgb-14.4 Hct-40.1 MCV-92 MCH-32.9* MCHC-35.8* RDW-13.4 Plt Ct-159 [2172-5-26] 10:30PM BLOOD WBC-9.6 RBC-4.35* Hgb-14.4 Hct-39.9* MCV-92 MCH-33.2* MCHC-36.2* RDW-13.5 Plt Ct-163 [2172-5-27] 04:14AM BLOOD WBC-9.1 RBC-4.25* Hgb-13.7* Hct-39.4* MCV-93 MCH-32.3* MCHC-34.8 RDW-13.7 Plt Ct-159 [2172-5-28] 06:05AM BLOOD WBC-5.5 RBC-3.86* Hgb-12.7* Hct-36.1* MCV-93 MCH-32.8* MCHC-35.1* RDW-13.6 Plt Ct-131* . Coag [2172-5-26] 05:32PM BLOOD PT-17.9* PTT-73.4* INR(PT)-1.6* [2172-5-26] 10:30PM BLOOD PT-15.4* PTT-23.0 INR(PT)-1.4* [2172-5-27] 06:00AM BLOOD PT-16.4* PTT-62.4* INR(PT)-1.5* [2172-5-28] 06:05AM BLOOD PT-17.2* PTT-26.1 INR(PT)-1.6* [2172-5-28] 06:05AM BLOOD Plt Ct-131* . Chem 7 [2172-5-26] 07:15AM BLOOD Glucose-99 UreaN-21* Creat-0.9 Na-140 K-4.5 Cl-105 HCO3-25 AnGap-15 [2172-5-26] 05:32PM BLOOD Glucose-162* UreaN-20 Creat-1.1 Na-138 K-4.9 Cl-106 HCO3-23 AnGap-14 [2172-5-26] 10:30PM BLOOD Glucose-151* UreaN-18 Creat-1.0 Na-140 K-4.8 Cl-107 HCO3-23 AnGap-15 [2172-5-27] 04:14AM BLOOD Glucose-151* UreaN-17 Creat-1.0 Na-142 K-4.7 Cl-108 HCO3-22 AnGap-17 [2172-5-28] 06:05AM BLOOD Glucose-94 UreaN-16 Creat-1.0 Na-139 K-4.7 Cl-102 HCO3-30 AnGap-12 Brief Hospital Course: 53 M with hypertension and afib s/p 2 failed DCCV admitted for elective PVI complicated by post-procedural vtach/vfib arrest now stablized in the CCU. . # Vtach/Vfib arrest: Vtach occured at the end of Afib PVI after isoproterenol administration. It was likely triggered activity from catacholemines. After Vtach/Vfib arrest he underwent cardiac cath which showed no coronary lesions. Peri-code echo ruled out tamponade. CTA of the chest performed after the procedure ruled out PE. Head CT was negative for acute stroke or bleeding. He received amiodarone and lidocaine drip during the code. These were sequentially discontinued with no recurrance of Vtach. Atenolol was restarted. Digoxin was permanently discontinued. He was monitored on telemetry when in the CCU and on the floor and remained in NSR. He was discharged with a [Doctor Last Name ]-of-hearts with close EP follow up. Per EP, he will need a cardiac MRI in one month. . # Afib: Afib s/p PVI. The patient remained in NSR after he was transfered to the CCU. Coumadin with lovenox bridging was intiated. He was also start on ASA 325mg. He was discharged with a KOH monitor with EP f/u in 2 weeks. Per EP, he will need a cardiac MRI in one month. . # Ant/Lateral right leg numbness: The morning after his proceedure he complained of right thigh numbness, w/o distal numbness, no weakness. On physical exam, his leg numbness was localized to the L3/4 dermatone with purely sensory deficity, distal ext with strength 5/5, good sensation and DP 2+ consistent with lateral cutaneous femoral nerve compression (meralgia parastetica). It is unclear exactly why he developed these symptoms but it most likely due to nerve compression while lying on his right side overnight. Alternatively, he had had a mild rt femoral arterial groin bleed with resolved with pressure to the groin; however, right groin U/S showed no hemamatoma or pseudoaneurysm. MRI L-spine showed no nerve compression. . # Pleuritic CP: Pt only has CP when taking a deep breath, EKG w/o ischemic changes. CXR nl w/o. Peri-code echo r/o tamponade. CP is likely MSK [3-7] to chest compressions during code and mild pericarditis [3-7] to procedure. He was started on Ibuprofen 600mg q 8hrs for two weeks. . # Incidental lymphadenopathy on CT: A large right hilar lymph node was seen on CTA performed for PE. The patient and [Month/Day (2) 3390]'s office was informed of this finding. The patient was scheduled for a repeat CT in 3 months although it might be valuable to perform at PET scan as an outpt prior to that. This decision was defered to his [Month/Day (2) 3390]. . # Communication: wife home [Telephone/Fax (1) 77957], cell [Telephone/Fax (1) 77958] Medications on Admission: Atenolol 25 mg 1 tab daily Coumadin 2 mg 1 day alternating with 4 mg every other day LD [2172-5-22] Digoxin 0.125 mg 1 tab daily Lovenox 120 mg x 3 doses Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. 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 3. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous [Hospital1 ] (2 times a day) for 7 days. Disp:14 injections Refills:0 4. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO once a day: 2mg alternating with 4mg every other day. 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: take on [2172-5-28],[2172-5-29] and [2172-5-30] and then switch to your regular coumadin dosing. Disp:3 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation Vtach/ Vfib arrest Meralgia Parasthetica Discharge Condition: improved Labs: INR 1.6 Discharge Instructions: Post atrial fibrillation ablation wound, activity and medication guidelines. Please report chest pain, shortness of breath, groin concerns (bleeding, redness, swelling) to Dr. [Last Name (STitle) 2232]. You will also be sent home with a heart monitor. In addition, you will need to restart coumadin; your coumadin level (INR) is currently low. Until your INR is 2.0, you will need to inject lovenox to prevent stroke. You will need to arrange to have your INR followed by your coumadin clinic. You should have your INR drawn on [2172-6-1]. . On your CT scan of your chest, there was an enlarged lymph node. This may not be abnormal. You will need a repeat CT scan of your chest in 3 weeks to see if this changes. Please see instructions below. . The following changes have been made your your medications: 1. Coumadin was restarted. You should take coumadin 5mg for the next 3 days, then start taking your usual dose of 4mg alternating with 2mg or as directed by your coumadin clinic. 2. You should take aspirin 325mg daily. 3. You will need to take lovenox 60mg twice a day until your INR is 2.0. 4. You should stop taking digoxin. 5. You can take Ibuprofen 600mg three times a day for two weeks. Then as needed for chest pain. Followup Instructions: You will need your INR checked frequently. Please have your INR draw on [2172-6-1]. . You will need a cardiac MRI in one month and then a follow up appointment with Dr. [Last Name (STitle) 2232]. Dr.[Name (NI) 11369] office will call you with the appointment for the cardiac MRI. . Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], [First Name3 (LF) 3947]. Phone:[Telephone/Fax (1) 62] Date/Time: [2172-7-1] 11:00 Provider: [Name10 (NameIs) 3390] [Name11 (NameIs) ],[Name12 (NameIs) ] [Name Initial (PRE) ]. [Telephone/Fax (1) 13254] on [2172-6-12] 11:45. He will need to follow up in the a repeat chest CT in 3 months. He may also consider sending you for PET scan. On your CT scan of your chest, there were some enlarged lymph. Please get a repeat CT scan of chest at 10:30am on [2172-8-27] located on [Location (un) 861] of the [Hospital Ward Name 23] Building. You should talk about these results with your [Hospital Ward Name 3390]. [Name10 (NameIs) 357] call [Telephone/Fax (1) 327] if you need to reschedule.	[ "42731", "9971", "V4581", "4019" ]
Admission Date: [2170-6-28] Discharge Date: [2170-7-11] Service: MEDICINE Allergies: Erythromycin Base / Sulfamethoxazole / Sulfa(Sulfonamide Antibiotics) / azithromycin Attending:[First Name3 (LF) 50171] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: This is a [Age over 90 ] year old female with a PMH notable for atrial fibrillation, sick sinus syndrome s/p pacemaker, annulocalcific mitral valve disease, chronic kidney disease with recent creatinine of 1.78 ([2170-6-6]) who is transferred from OSH for management of fluid status and possible aspiration pneumonia. Patient was transferred from [Hospital6 28728] Center. She initially presented to OSH on [2170-6-17] with hematuria in the setting of supratherapeutic INR (5). Urology was consulted who recommended holding her coumadin briefly (later bridged with IV heparin) with IV ceftriaxone X 3 days and her hematuria resolved. She underwent cystoscopy on [6-22] which demonstrated diffuse cystitis without active bleeding. She was found to have a citrobacter UTI with sensitivity to zosyn and patient completed a course of zosyn X 7 days (finished [6-26]). She was transfused one unit prbcs. Cardiology was consulted on [2170-6-27] (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Houzen) due to intermittent episodes of dyspnea thought to be multifactorial from acute on chronic diastolic congestive heart failure superimposed on a aspiration vs. hospital acquired pneumonia/pneumonitis. A CT scan was suggestive of aspiration pneumonia as well as a 5x6mm nodular filling defect within the trachea at the carina level. In addition to IV solumedrol and lengthening of zosyn course to 10 days for possible pneumonia, patient had received multiple doses of IV lasix (anywhere from 40-80mg IV boluses) due to vascular congestion. Her weight on admission was 131 lbs which dropped to 128.6 with diuresis (weight was 125lbs on [2170-6-6] office visit). In the setting of her diuresis, her creatinine has risen to 2.5 from a baseline of 1.8-2.0. Of note, she has chronic lower extremity edema at baseline. Her lisinopril, metformin, and glipizide were on hold in the setting of renal failure. On the floor, patient reports that she continues to feel short of breath and is complaining of a nonproductive cough with associated fits. She denies fevers, chills, nausea or vomtiing, She denies pain or problems with swallowing. She has a foley in place and denies any problems moving her bowels. She is compliang of some right sided chest pain that is located under her breast which has been hurting since a fall prior to her previous admission. Past Medical History: Diastolic dysfunction - Chronic kidney disease with recent creatinine 1.8-2.0 - Atrial fibrillation on coumadin - Prior left bundle branch block - Sick sinus syndrome s/p dual chamber pacemaker - Annulocalcific mitral valve disease - HTN - Diabetes mellitus - Hyperlipidemia - Squamous cell skin cancer - History of gallstones - History of osteopenia - Adenomatous polyps - History of TIA - History of breast cancer - Hematuria Social History: Widowed, prior telephone operator, retired. Lives with daughter, [Name (NI) ] [Last Name (NamePattern1) ] (who is HCP) [Name (NI) ] two other sons who live locally and are invovled. Independent to perform chores. Denies any history of alcohol, tobacco (but did have significant second hand smoke), or substance abuse. At baseline she walks around her house with a walker Family History: Non-contributory to presenting illness Physical Exam: Physical Exam on Admission Vitals- T: 98.3, 132/62, 72, 20, 97% 4L. General- Alert, oriented, no acute distress HEENT- Sclera anicteric, dry mmm, oropharynx clear Neck- supple, JVP elevated at 13, no LAD Lungs- Diffuse inspiratory crackles wet sounding to [2-5] way up. Musical expiratory wheezing throughout the lungs CV- Irregular rhythm, regular rate, with systolic murmu at the LUSB, and blowing mumur at the Apex radiating to the axilla. no tenderness to palpation of the right chest caudal to the breast 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, left anteior shin abrasion of 1cm in diameter, no surounding erythema or fluctuance. 2+DP pulses bilaterally no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal . Physical Exam on Discharge: Pulseless, no spontaneous respirations, no pupillary or corneal reflexes Patient expired. Pertinent Results: Admission Labs: [2170-6-28] 09:32PM BLOOD WBC-7.4 RBC-3.37* Hgb-10.1* Hct-31.7* MCV-94 MCH-29.8 MCHC-31.8 RDW-17.2* Plt Ct-203 [2170-6-28] 09:32PM BLOOD Neuts-65.7 Lymphs-20.8 Monos-5.8 Eos-6.6* Baso-1.1 [2170-6-28] 09:32PM BLOOD PT-24.5* PTT-39.0* INR(PT)-2.3* [2170-6-28] 09:32PM BLOOD Glucose-278* UreaN-62* Creat-2.5* Na-137 K-4.0 Cl-94* HCO3-30 AnGap-17 [2170-6-28] 09:32PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.4 [2170-6-29] 05:20AM BLOOD Digoxin-1.1 Urine: [2170-7-1] 12:00PM URINE Color-RED Appear-Cloudy Sp [Last Name (un) ]-1.016 [2170-7-1] 12:00PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2170-7-1] 12:00PM URINE RBC->182* WBC->182* Bacteri-NONE Yeast-MANY Epi-0 Microbiology: Blood cultures: all NGTD Imaging: Radiology Report CHEST (PORTABLE AP) Study Date of [2170-6-30] 1:37 AM FINDINGS: Comparison is made to the prior study from [2167-4-20]. There is a left-sided pacemaker with distal lead tips in the right atrium and right ventricle. There is unchanged cardiomegaly. There is prominence of the pulmonary interstitial markings suggestive of mild fluid overload. This is within a background of baseline interstitial lung disease. No confluent areas of opacity are seen. There are no pneumothoraces. Radiology Report RIB UNILAT, W/ AP CHEST RIGHT Study Date of [2170-6-30] 1:20 PM FINDINGS: Comparison is made to previous study from [6-30] at 1:43 a.m. Heart size is enlarged but stable. There is a dual-lead left-sided pacemaker with the distal lead tips in the right atrium and right ventricle which have intact leads. There are again seen airspace opacities throughout both lung fields which may represent an element of fluid overload. Underlying infection is not excluded. Markers have been placement at the right lower ribcage. At this location, there are no displaced rib fractures. CHEST X-RAY ([2170-7-2]): There is a dual-lead left-sided pacemaker with lead tips in the right atrium and right ventricle, unchanged. There is stable cardiomegaly. There is improved aeration and improvement of the airspace opacities throughout both lung fields. There remains some coarsening of the bronchovascular markings bilaterally, mostly in the perihilar region and at the lung bases, likely represent some fluid overload. CT CHEST WITHOUT CONTRAST ([2170-7-2]): 1. Bilateral patchy airspace opacities with prominent with interlobular septal thickening may be related to congestive heart failure versus a multifocal pneumonia. Clinical correlation is recommended. No definite evidence for interstitial lung disease is identified. 2. Calcification along the pleura suggests prior granulomatous disease. 3. Emphysematous changes in both lungs. (TTE) ECHO: [2170-7-3]: The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is dilated with normal free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. 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 moderately thickened. There is a minimally increased gradient consistent with trivial mitral stenosis. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Patient was a [Age over 90 ] yo F w/ PMH of diastolic heart failure, afib and sick sinus syndrome s/p pacemaker placement and recent hematuria in the setting of an elevated INR who developed a possible aspiration pneumonia/pneumonitis and decompensated diastolic heart failure. She underwent lasix diuresis to euvolemia and received antibiotics. Speech and swallow eval revealed persistent aspiration which was unavoidable with oral intake. The family decided to allow the patient to eat despite this finding to make the patient comfortable. ACUTE CARE ISSUES ADDRESSED THIS STAY: #Aspiration pneumonia- the patient had a suspected aspiration pneumonia at the outside hospital which presented with worsening shortness of breath and cough. She had a CT scan which showed some opacities which were consistent with an aspiration event. On further review of her history it was learned that she had undergone a barium swallow during which she had aspirated and it quite likely that the CT scan was showing this barium as the aspiration. She came in on a [8-14] day course of IV Zosyn, and completed this regimen during her stay. She was afebrile with no leukocytosis during her hospital stay. #Decompensated chronic diastolic heart failure- the patient had become volume overloaded at the outside hospital and had been agressively diuresed. Her home regimen included 10mg po lasix qday. She was diuresed gently while at [Hospital1 18] given her acute on chronic renal failure. #Acute on chronic renal failure- patient has a baseline creatinine of 1.8 at the beginning of [2170-6-5] and was 2.5 on admission to [Hospital1 18]. This was likely [3-8] her diuresis at the outside hospital. Nephrotoxic medications were held during her hospital stay, including her metformin, glipizide and losartan. #Diabetes mellitus- the patient had elevated blood sugars in the setting of her pneumonia. Her oral agents were held and she was started on ISS during her hospital stay. #Sick-sinus syndrome/Atrial fibrillation- the patient was in Afib during this admission without any episodes of RVR or bradycardia while on monitor. ====================== MICU COURSE: On HD #3, patient developed increased respiratory distress on the floor with RR 40s (although satting in mid 90s on 3L NC). She was started on Vanco + Levoquin to treat possible new HCAP and IV Solumedrol (presumably due to increased wheezing on exam) and transferred to the MICU for BiPAP and more intensive nursing care. In the MICU, Solumedrol was tapered to 25mg IV BID, and once patient more alert and taking POs was tapered to 40mg daily on [7-4] (to complete one week taper). Vanco was DC'd on [7-4] due to low suspicion for MRSA pneumonia. Levoquin was continued (last day [2170-7-7]). CT chest was performed which showed BL patchy airspace opacities c/w pulm edema vs. multifocal pneumonia, and granular pleural opacities suggestive of prior granulomatous disease. TTE was also performed which showed severe (3+ TR), LVEF >55%, pulm HTN, all unchanged from prior. Patient remained hemodynamically stable, except for an episode of confusion/delirium overnight on [7-2] during which she desatted (likely secondary to anxiety). Sats improved significantly with Zydis 2.5mg PO x1. She was transferred back to the floor on [2170-7-4] at which point she continued to express discomfort in respect to her dyspnea. She remarked on numerous occasions about how miserable she was and how she did not understand the point of all of the tests or medications she was receiving as she was just going to get sick again. On [2170-7-6], a palliative care meeting was held, and the patient's family made the decision to change her goals of care to comfort measures only. ======================== She expired with family at bedside on [2170-7-11] @ 1200. Autopsy was declined. Medications on Admission: Medications confirmed with patient - aspirin 81mg PO daily - digoxin 0.125mg PO daily - losartan 12.5mg PO daily - lasix 10mg PO daily - simvastatin 20mg PO daily - glipizide 10mg PO daily - metformin 1000mg PO daily - albuterol inhaler PRN - warfarin 1mg PO daily - vitamins PO daily - calcium - vitamin D - tylenol 325mg PO daily Medications on Transfer: - Aspirin 81mg PO daily - Caltrate plus D 1tablet PO BID - Coumadin 1mg PO daily - Folic acid PO daily - Lasix 40mg PO daily - Digoxin 0.125mg PO daily - Multivitamin 1 tablet PO daily - Simvastatin 10mg PO daily - Vitamin B12 1 tablet PO daily - insulin sliding scale - Zosyn 2.25mg TID for 3 more days...... - Mucomyst 10% four ml nebs TID - Duonebs - Tylenol 650mg PO q4h - Lidoderm patch at RUQ daily 12 hours on - Desenex powder Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Immediate cause of death: pneumonia Antecedent cause of death: chronic renal insufficiency Discharge Condition: Expired. Discharge Instructions: Patient expired. Autopsy declined by family. Followup Instructions: Patient expired. Autopsy declined by family. Completed by:[2170-7-11]	[ "5070", "5849", "486", "42731", "4280", "40390", "25000", "5859", "2859", "V5861" ]
Admission Date: [2111-11-21] Discharge Date: [2111-12-5] Date of Birth: [2111-11-21] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: [Known lastname ] [Known lastname 50715] is a former 2.005 kg product of a 33-5/7 week gestation pregnancy born to a 37 G4 P0-1 Caucasian woman. Prenatal screens: Blood type A positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group B Strep unknown. The pregnancy was notable for decreased fetal movement three days prior to deliver. The mother was evaluated at [Hospital6 2561]. A biophysical profile was [9-18]. Again, she presented on the day of delivery with repeat concerned for decreased fetal movement. A repeat scan had a biophysical profile of 0/8 and a sinusoidal fetal heart rate pattern. The mother was transferred from [Hospital6 2561] to [Hospital1 1444]. On fetal scan, there was noted to be increased velocity in the middle cerebral artery suggesting possible anemia. Mother was taken to STAT cesarean section. The infant emerged extremely pale and floppy. She received stimulation, bulb suctioning, and blow-by O2. Apgars were five at one minute and seven at five minutes. She was admitted to the Neonatal Intensive Care Unit for treatment of prematurity and her apparent anemia. PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 2.005 kg. Length 42 cm. Head circumference 29.5 cm. General: Pale, poorly perfused preterm female. Skin: Extremely pale, no rashes or lesions. Head, eyes, ears, nose, and throat: Anterior fontanel open and flat, bilateral red reflex present. Palate intact. Symmetric facial features. Chest: Inspiratory crackles, mild grunting and flaring, retracting. Cardiovascular: Normal S1, S2, no murmur. Pulses thready. Abdomen is soft, no hepatosplenomegaly and no masses. Three vessel umbilical cord. GU: Normal preterm female. Anus patent. Spine and trunk straight, normal sacrum. Extremities: Hips stable, moving all extremities. Neurological: Slightly decreased tone, otherwise consistent with gestational age. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: Initially, [Known lastname ] was in nasal cannula O2. She had increasing respiratory distress, and was treated with continuous positive airway pressure. There was no significant improvement, and she was electively intubated, and given one dose of surfactant. Within 3-4 hours after her first dose of surfactant, she had difficulty oxygenating and was placed on the high frequency oscillatory ventilator with a mean airway pressure of 18. She weaned rapidly over the next 12 to 16 hours, and was changed back to the conventional ventilator. She was extubated on day of life #1 to nasal cannula O2. She weaned to room air on day life #4 and remained in room air until discharge. At the time of discharge, her respirations are comfortable in the 30s to 50s. Oxygen saturations were greater than 95%. 2. Cardiovascular: Initial blood pressure mean was 52. [Known lastname ] has maintained normal heart rates and blood pressures. No murmurs have been noted during admission. 3. Fluids, electrolytes, and nutrition: [Known lastname ] was initially NPO and maintained on intravenous fluids. Enteral feeds and breast feeding were started on day of life #2. At the time of discharge, mother is almost exclusively breast feeding with occasional after feed offering of a bottle of Enfamil. Discharge weight is 1.93 kg with a length of 44 cm and a head circumference of 29.5 cm. Serial electrolytes were checked in the first week of life and except for one high serum sodium, were within normal limits. Repeat serum sodium was within normal limits. 4. Infectious disease: Due to her respiratory distress and prematurity and unknown group B Strep status, [Known lastname ] was evaluated for sepsis. White blood cell count was 10,000 with a differential of 21% polys, 1% bands. A blood culture obtained prior to starting antibiotics was no growth at 48 hours and the antibiotics were discontinued. 5. Hematological: As noted, [Known lastname ] was extremely anemic at birth. Her hematocrit drawn shortly after admission to the Neonatal Intensive Care Unit was 9.7%. She was transfused with 30 cc/kg of O negative packed red cells. Interim hematocrit was 28%, and she received an additional 20 cc/kg of packed cells for a total of 50 cc/kg. Her post-transfusion hematocrit on day of life two was 50.2%. Her initial platelet count was 135,000. After the initial transfusions, her platelet count was found to be 31,000. It slowly rose without any treatment, and on day of life two was 108,000. [Known lastname ] is blood type O positive, direct Coomb's negative. A Kleihauer-Betke test was sent on the mother, and was found to be positive with 12.8% fetal hemoglobin. This is diagnostic for a fetal maternal hemorrhage, which is the etiology of the fetal anemia. 6. Gastrointestinal: [Known lastname ] required treatment for unconjugated hyperbilirubinemia with phototherapy. Her peak serum bilirubin occurred on day of life number two with a total of 13.1 mg/dl, total over 0.4 mg/day direct. She was treated with phototherapy for approximately 48 hours. Her rebound bilirubin on day of life six was 8.6 total mg/dl over 0.3 mg/dl direct. 7. Neurology: [Known lastname ] has maintained a normal neurological examination during admission and there are no neurological concerns at the time of discharge. No neuroimaging was performed. 8. Hearing screening was performed with automated auditory brain stem responses. [Known lastname ] passed in both ears. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 24861], Pediatric Group, [Street Address(2) 3375], [Location (un) ], [Numeric Identifier 50716], phone number [Telephone/Fax (1) 50717], fax number [Telephone/Fax (1) 50718]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Ad lib breast feeding with post-feeding offering of formula. 2. No medications. 3. Car seat position screening was performed. [Known lastname ] was observed for 90 minutes without oxygen or heart rate drop. 4. State Newborn Screens were sent on [11-24] and [2111-12-5] with no notification of abnormal results to date. 5. Immunizations received: Hepatitis B vaccine on [2111-12-4], and Synagis on [2111-12-4]. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. 7. Follow-up appointments: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 24861] on [2111-12-7]. DISCHARGE DIAGNOSES: 1. Prematurity at 33-5/7 week gestation. 2. Respiratory distress syndrome. 3. Suspicion for sepsis ruled out. 4. Severe anemia due to fetal maternal hemorrhage. 5. Physiologic unconjugated hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Covering for [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],MD. Dictated By:[Last Name (Titles) 37548] MEDQUIST36 D: [2111-12-5] 04:06 T: [2111-12-5] 05:48 JOB#: [Job Number 50719]	[ "7742", "V290", "V053" ]
Admission Date: [2163-1-5] Discharge Date: [2163-1-11] Date of Birth: [2087-9-22] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Trazamine / Percocet / Vicodin Attending:[First Name3 (LF) 922] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2163-1-6] Coronary Artery Bypass Graft x 5 (Left internal mammary artery to Left anterior descending, Saphenous vein graft to Diagonal, Saphenous vein graft to Ramus, Saphenous vein graft to Obtuse Marginal, Saphenous vein graft to Right coronary artery) History of Present Illness: 75 y/o female with extensive past medical history who developed acute onset chest pain and dyspnea at the end of [Month (only) 321]. The symptoms progressively worsened and EMS brought patient to outside hospital. Underwent cardiac cath which revealed severe three vessel coronary artery disease and was transferred to [Hospital1 18] for surgical revascularization. Past Medical History: Diabetes Mellitus, Hypertension, Hypercholesterolemia, Congestive Heart Failure, Diabetic Retinopathy, Hypothyroidism, Carpal tunnel syndrome s/p bilateral surgery, s/p Hysterectomy, Obesity, Recurrent Urinary Tract Infections, s/p Appendectomy, s/p Tonsillectomy, s/p bilateral cataract surgery, s/p Thyroidectomy Social History: Patient lives with her son, smoked 1ppd for 20 years before quitting 30 years ago, drinks socially, no illicit/IVDU. Family History: Positive for [Name (NI) 2320], mother died of CAD Physical Exam: At discharge: VS: 99.2 97BPM 96/51 20 96% 4L NC Gen: Pleasant, answers questions appropriately HEENT: PERRLA Neck: supple, tender to palpation along sternocleidomastoid, worse when coughing Chest: Decreased lung sounds at left base. Serous drainage from distal pole of sternal incision. Sternum stable with cough. Heart: Bradycardic rate, distant heart sounds with normal S1S2 Abd: obese, normoactive bowel sounds. Soft and nontender without rebound/guarding Ext: warm with 1+ edema to mid shins Neuro: intact Pertinent Results: [1-5] ChestCT: 1. Mild calcifications of the aortic annulus and anterior ascending aorta extending to the level of the right pulmonary artery. 2. Pulmonary arterial hypertension. 3. Mediastinal lymph nodes likely reactive. [1-6] Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60-70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened and display slightly reduced systolic excusion. However, frank aortic stenosis is NOT present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2162-4-29], no major change is evident. [2163-1-6] Carotid U/S: 1. 40-59% stenosis of the right internal carotid artery. 2. Less than 40% stenosis of the left internal carotid artery. [2163-1-9] 06:45AM BLOOD WBC-8.7 RBC-3.10* Hgb-9.2* Hct-25.5* MCV-82 MCH-29.6 MCHC-36.1* RDW-15.4 Plt Ct-120* [2163-1-5] 07:24PM BLOOD WBC-8.0 RBC-4.26 Hgb-12.0 Hct-34.4* MCV-81* MCH-28.1 MCHC-34.8 RDW-15.0 Plt Ct-219 [2163-1-6] 06:57PM BLOOD PT-14.9* PTT-34.8 INR(PT)-1.3* [2163-1-5] 07:24PM BLOOD PT-13.6* PTT-24.6 INR(PT)-1.2* [2163-1-10] 05:19AM BLOOD Glucose-130* UreaN-37* Creat-1.6* Na-135 K-5.1 Cl-101 HCO3-26 AnGap-13 [2163-1-9] 06:45AM BLOOD Glucose-118* UreaN-33* Creat-1.3* Na-136 K-4.3 Cl-102 HCO3-21* AnGap-17 [2163-1-8] 06:03AM BLOOD Glucose-111* UreaN-26* Creat-1.2* Na-136 K-4.5 Cl-103 HCO3-24 AnGap-14 [2163-1-5] 07:24PM BLOOD Glucose-255* UreaN-20 Creat-0.9 Na-138 K-3.9 Cl-102 HCO3-28 AnGap-12 [2163-1-9] 06:45AM BLOOD Mg-2.5 [2163-1-7] 02:00AM BLOOD Mg-2.3 [2163-1-5] 07:24PM BLOOD %HbA1c-7.4* Brief Hospital Course: As mentioned in the HPI, Mrs. [Known lastname 4886] was transferred from OSH for cardiac surgery. She was appropriately worked-up and brought to the operating room on [1-6] where she underwent a coronary artery bypass graft x 5. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. She was gently diuresed with IV lasix towards her pre-operative weight. On POD 4 she had a slight increase in her BUN/CR and her lasix was changed to [Hospital1 ]. Physical therapy was consulted to work on strength and balance and felt that she would be best served by a short stay at a rehab facility. There was serous drainage from the distal pole of her sternal incision and she was started on a 5 day course of Keflex. On POD 4 she was screened and received a bed and was discharged to rehab. Medications on Admission: Carvedilol 12.5mg [Hospital1 ], Lasix 40mg qd, KCL, Aspirin 325mg qd, Lisinopril 2.5mg qd, Amlodipine 10mg qd, Levothyroxine 125mg qd, Simvastatin 80mg qd, Insulin Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP < 90, HR < 50. Disp:30 Tablet(s) Refills:0 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:5 Tab Sust.Rel. Particle/Crystal(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:qs Tablet(s) Refills:0 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:qs ML(s) Refills:0 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:5 Suppository(s) Refills:0 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): until patient is ambulatory and out of bed on a consistent basis. Disp:qs qs Refills:2 10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 14. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin Pen Sig: One (1) Subcutaneous three times a day: Patient to receive 20 units at breakfast, 10 units at lunch, and 25 units at dinner. Disp:qs qs Refills:2 15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:qs ML(s) Refills:0 16. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 5 days. Disp:30 Capsule(s) Refills:0 17. Furosemide 40 mg IV BID 18. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 PMH: Diabetes Mellitus, Hypertension, Hypercholesterolemia, Congestive Heart Failure, Diabetic Retinopathy, Hypothyroidism, Carpal tunnel syndrome s/p bilateral surgery, s/p Hysterectomy, Obesity, Recurrent Urinary Tract Infections, s/p Appendectomy, s/p Tonsillectomy, s/p bilateral cataract surgery, s/p Thyroidectomy 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 Dr. [Last Name (STitle) 5717] in [2-3] weeks Dr. [First Name (STitle) ] in [3-7] weeks Completed by:[2163-1-10]	[ "41401", "4280", "42789", "4019", "2720", "2449" ]
Admission Date: [2110-3-3] Discharge Date: [2110-3-11] Date of Birth: [2044-4-9] Sex: F Service: Cardiac surgery HISTORY OF PRESENT ILLNESS: This is a 65 female with known cardiac disease, status post percutaneous stents times two. Patient had recent increase in symptoms. Catheterization today revealed disease in stented and native coronary artery disease of three vessels and an ejection fraction of 67 percent. She is referred to cardiac surgery for coronary artery bypass graft. PAST MEDICAL HISTORY: Patient has a past medical history of papillary thyroid cancer, status post thyroidectomy, increased cholesterol, hypertension, former tobacco user, type 2 diabetes and sarcoid. Patient's medicines at home are as follows: 1) Levoxyl 137 mg q day, 2) nifedipine 60 mg q day, 3) atenolol 50 mg q day and 4) lisinopril 10 mg q day, 5) Imdur 60 mg q day, 6) enteric coated aspirin 81 mg q day, 7) Crestor 10 mg q day, 8) hydrochlorothiazide 25 mg q day, 9) NPH insulin 12 units b.i.d., 10) regular insulin 6 units b.i.d. and 11) Plavix 75 q day and 12) multivitamin. Patient has an allergy to Ceclor. LABORATORY VALUES: Patient had a white count of 7.1 and hematocrit of 32.2 and a platelet count of 210. Patient's urinalysis was negative. Chest x-ray showed no acute cardiopulmonary disease. Sodium was 137, potassium was 4.3, chloride was 101, bicarb was 29, BUN was 33, creatinine was 1.2, glucose was 122. Patient's INR was 1.1. Liver function tests were all within normal limits. Carotid arteries were within normal limits. REVIEW OF SYSTEMS: Were significant for positive transient ischemic attacks seven to eight years ago, right sided weakness with a negative work up. No seizure disorders, no asthma. Occasional cough with no sputum. Positive for sarcoid. No nausea, vomiting or diarrhea. No frequent constipation. No claudications. PHYSICAL EXAMINATION: The patient was a well appearing, well developed female in no acute distress. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm with normal S1 and S2. Abdomen was soft and flat, nontender to palpation. There was no hepatosplenomegaly. Extremities were warm, well perfused with no edema. Neurologic examination was grossly intact. HOSPITAL COURSE: This is a 65 year-old female with three vessel coronary artery disease who is seen for coronary artery bypass graft by Dr. [Last Name (STitle) ]. On [2110-3-4] the patient underwent coronary artery bypass grafts times four. The patient had LIMA graft to LAD, saphenous vein graft to diagonal, saphenous vein graft to OM, saphenous vein graft to PDA. Patient tolerated the procedure well and was transferred to the CSRU in stable condition on a Neo-Synephrine drip and propofol drip. Patient was intubated with chest tubes and wires. On postoperative day one patient was weaned and extubated, was placed on 3 liters by nasal cannula with saturations 96 percent or greater. Patient had a strong cough raising sputum. The Neo-Synephrine drip was weaned off. Patient had an insulin drip running. Patient was afebrile. Vital signs were stable. Patient was in normal sinus rhythm. Postoperatively patient had a white count of 21.1 and a hematocrit of 35.3. Otherwise laboratory values were stable. Patient was started on Lasix postoperatively and Lopressor. Postoperative day two patient was seen by physical therapy. Patient was out of bed to chair. Patient was afebrile with stable vital signs. Patient was placed on aspirin and Lopressor. Insulin drip was weaned off. Patient remained in sinus rhythm without any further complications. Patient was transferred to the floor on postoperative day number three. Patient was confused on transfer to the floor. Patient was given no Haldol or Ativan but had all of her pain medications held and seemed to return to baseline mental status. On postoperative day number four patient was given Tylenol #3 for pain. Patient had maximum temperature of 99.4, otherwise was in stable condition. Patient's laboratory values revealed a white count of 18.5 down from 21 and hematocrit of 28.8. Otherwise laboratory values were within normal limits. Patient had wires which were removed. The central line was removed. Patient's metoprolol was increased to 25 b.i.d. Patient was seen by Jocelin who is managing her insulin. Patient was seen by physical therapy. On postoperative day five patient was out of bed. There were no events. Patient's wires had been removed. She tolerated it quite well. Patient had chest x-ray which showed no acute cardiopulmonary processes. Patient's metoprolol was increased to 25 t.i.d. Patient's white count was 15.9. Patient's hematocrit was 27.2 and platelet count was 154. Otherwise laboratory values were normal. Patient was continued to be followed by Jocelin. Physical therapy - patient was able to ambulate without assistance. Patient was seen at the bedside with her daughter. On postoperative day six patient had been complaining of ear pain. Ears were examined. Patient had chronic history of ear infections that were treated by Amoxicillin. Patient was started on Amoxicillin 500 mg t.i.d. Patient was afebrile with stable vital signs. Laboratory values showed a white count of 12.2 down from 15 and a hematocrit of 25.3. Otherwise patient's laboratory values were all within normal limits. Patient was out of bed with physical therapy with PT level of 4 to 5. Postoperative day number seven patient saying she had resolution of her ear pain and patient's white count was 11, hematocrit was 25.9. Other laboratory values were within normal limits. Patient was following up with Jocelin. Postoperative day 8 patient was continued on Amoxicillin, was afebrile with stable vital signs and ambulating on her own, tolerating a regular diet. Patient was discharged to home in stable condition with VNA care. DISCHARGE DIAGNOSIS: 1. Status post coronary artery bypass graft times four. 2. Hypertension. 3. Diabetes mellitus. 4. Hypothyroidism. 5. Dyslipidemia. DISCHARGE MEDICATIONS: 1. Colace 100 mg tablet 1 tablet p.o. b.i.d. 2. Aspirin 325 1 tablet p.o. q day. 3. Levoxyl 137 mcg 1 tablet p.o. q day. 4. Plavix 75 mg 1 tablet p.o. q day. 5. Metoprolol 15 mg tablet [11-22] tablet p.o. t.i.d. 6. Amoxicillin 500 mg tablet 1 tablet t.i.d. for seven days. 7. Insulin Glargine 16 units q 24 hours. 8. Insulin regular sliding scale. Patient will follow up with Dr. [First Name11 (Name Pattern1) 1312] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [2110-3-25] at 11. Patient will follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Patient will call to schedule an appointment in one month. Patient will be seen by VNA for hemodynamic monitoring and wound evaluation. Patient is discharged home in stable condition tolerating a regular diet ambulating on her own. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 10638] MEDQUIST36 D: [2110-3-11] 09:12 T: [2110-3-11] 11:23 JOB#: [Job Number 15368]	[ "41401", "25000", "4019", "2724" ]
Admission Date: [2161-2-9] Discharge Date: [2161-2-25] Date of Birth: [2100-6-14] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3276] Chief Complaint: Dysphagia and weight loss Major Surgical or Invasive Procedure: pericardiocentesis gastric feeding tube placement by interventional radiology History of Present Illness: 60 yo F with newly diagnosed metastatic NSCLC was admiteed from clinic for worsening dyphagia, dehydration, neutropenia, and ARF. Mrs. [Known lastname 99102] presented to clinic today for an unscheduled urgent visit due to an inability to swallow and extreme fatigue. She has chronic low-back pain and was also unable to take her Percocet today. Her nutrition has been worse over the last couple of days and her husband fears she has lost even more weight (98 lbs 10 days ago). Otherwise, she has had no fevers at home, no chills or night sweats. Constipation remains an issue as she has not had a bowel movement in about 3 days. Past Medical History: 1. Smoked until 2 weeks ago, on nicotine patch until [9-6]. 2. Rheumatoid Arthritis 3. PCI to LAD in [2152] (95% LAD, 40%RCA, 50% PDA) 4. Hypercholesterolemia 5. HTN Social History: Lives w/ her husband of 38 [Name2 (NI) 1686]. Has daughter and son. Smoked 1ppd for 40 [Name2 (NI) 1686], quit 3 weeks ago. Drinks about 10 drinks per week. Works for her sons asphalt company doing office work. Family History: CAD in brother/sister [Name (NI) ] brother w/ prostate cancer Physical Exam: Vital signs: Temperature 96.6, blood pressure 142/86, pulse 102, oxygen saturation 96% on room air, weight is 90 pounds, height is 61 inches. ECOG performance status is 2. In general, Ms. [Known lastname 99102] is a thin, pleasant 60- year-old woman in no acute distress. HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Neck is supple with approximate 1-cm bilateral cervical lymph nodes. Heart: Tachycardic rate, regular rhythm with no appreciable murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally with no wheezes or crackles. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities: There is no edema, clubbing, or cyanosis. Pertinent Results: [2161-2-9] 11:53AM UREA N-77* CREAT-2.8# SODIUM-131 POTASSIUM-3.8 CHLORIDE-91* TOTAL CO2-30* ANION GAP-14 [2161-2-9] 11:53AM ALT(SGPT)-32 AST(SGOT)-31 LD(LDH)-300* ALK PHOS-77 TOT BILI-0.5 DIR BILI-0.1 INDIR BIL-0.4 [2161-2-9] 11:53AM ALBUMIN-4.1 CALCIUM-9.6 [2161-2-9] 11:53AM CEA-5107* [2161-2-9] 11:53AM WBC-1.4# RBC-3.96 HGB-13.1 HCT-36.8 MCV-93 MCH-33.0* MCHC-35.5* RDW-12.2 [2161-2-9] 11:53AM NEUTS-8* BANDS-1 LYMPHS-52* MONOS-31* EOS-3 BASOS-0 ATYPS-5* METAS-0 MYELOS-0 [2161-2-9] 11:53AM PLT SMR-LOW PLT COUNT-85# ECHO [2161-2-20] Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a large, circumfirential pericardial effusion with pericardial thickening (2.0-3.0 cm anteriorly from subcostal view). There is respiratory variation in the mitral and tricuspid inflow that is non-diagnostic. There is right atrial and right ventricular early diastolic invagination without definite collapse. There appears to be occasional, prolonged RV free wall diastolic invagination (respiratory change?) that likely represents early tamponade. IMPRESSION: Large circumfirential pericardial effusion with probable early tamponade. ECHO [2161-2-25] Conclusions: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is a small pericardial effusion subtending primarily the right atrial and right ventricular free wall. There are no echocardiographic signs of tamponade. No right atrial diastolic collapse is seen. No right ventricular diastolic collapse is seen. Compared with the findings of the prior report (tape unavailable for review) of [2161-2-23], the pericardial effusion is smaller. Brief Hospital Course: # Dysphagia: Pt with known significant LAD compressing the esophagus. This has caused substantial weight loss and is likely contributing significantly to her weakness as she was unable to take PO's. GI was consulted for placement of PEG tube for initiation of tube feeds. They performed EGD however were unable to pass the scope past the upper esophagus due to stricture likely from external source. IR was then called and they placed PEG tube under flouroscopy. Attempted to start using the PEG tube 24 hours after placement with 4 boluses per day of nutritional supplement. With this method pt had residuals of 100 and was requesting use of pump. She was then started on cycling which was adjusted until she was able to tolerate with minimal residuals. She was also started on reglan and erythromycin for enhamced GI motility. Pt continued to have problems with nausea and phlegm production. GI was reconsulted in reagrds to possible esophageal stent for comfort measures. Pt decided against esophageal stent and patient was discharged home on cycling tube feeds, tolerating it well with reglan. . # Pericardial effusion: Pt had a small pericardial effusion seen on recent CT scan. She developed progressive SOB in the setting of aggressive hydration for her ARF due to dehydration. CXR showed small bilateral effusion with pulmonary edema. At this point she was diuresed with minimal effect. Her SOB and O2 requirement continued to worsen. Repeat CXR now showed moderate szized effusion on the left with increase size of silhoutte of heart. Pulsus was 15 at this time. She was then sent for ECHO which demonstrated large pericardial effusion with tamponade physiology. Pt was tachycardic but BP stable at this time. Cardiology was consulted and patient was sent to the west for urgernt pericardiocentesis. They drained the effusion and performed a balloon pericardiotomy. After the drainiage her heart rate decreased and patient clinicallyy improved however still required O2. After the procedure she was monitored in the CCU for 1 day then on the floors by cardiology for 2 more days. Follow up ECHOs showed no evidence of reacculmulation 5 days later. . # Volume status: Pt was very dry at admission & labs c/w prerenal. Rec'd aggressive IV hydration. Now with pleural effusion in the setting of pericardial effusion. Pleural effusion was present on discharge. Disucussed possibility of thoracentesis, pt refused and wanted to go home. . # ARF: Pt presented with creatinine of 2.8 and BUN of 77. Her baseline creatinine was 0.8. Her FENA at this time was <1% and renal failure felt to be secondary to dehydration. She was aggressively hydrated with gradual improvement in her renal function. After several days creatinine had returned to baseline. . # Hypoxia: Pt with bilateral effusion left greater then right. Also likely has lymphangetic spread of the tumor. Disucussed possibility of tapping the effusion but the pt refused. Also not sure if tapping would help with hypoxia anyway given lymphangetic spread. Pt sent home with O2 for comfort. . # CAD: No chest pain during stay. Was on BB for most part. Had stop for for short period when pt was hypotensive. Did not restart statin as would have no benefit to patient in short term. . # Hyponatremia: Was likely due to volume depletion, this resolved with IVF. . # Non-small-cell lung ca: Did not actively treat as inpatient. However started on Tarceva prior to discharge. . # [Name (NI) 25933] Pt had isolated fever on [2161-2-21] after pericardiocentesis. She was emipirically started on Levo/vanco. Blood cultures and UA thus far negaitve. Since pt had been afebrile otherwise we stopped the abx. . # Dispo- Discharged home with VNA services and likely transition to hospice. Medications on Admission: Inderal, Benicar, Lipitor, Percocet one tablet q.6h. p.r.n. Discharge Medications: 1. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:10 Patch 72HR(s)* Refills:2 2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-14] Sprays Nasal QID (4 times a day) as needed. Disp:QS Refills:2 3. Lidocaine-Diphenhyd-[Doctor Last Name ]-Mag-[Doctor Last Name ] 200-25-400-40 mg/30 mL Mouthwash Sig: 15-30 ml Mucous membrane every four (4) hours as needed for mouth pain. Disp:QS Refills:2 4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea/anxiety: Please take 0.5mg qhs and then use q6hr prn otherwise. Disp:120 Tablet(s) Refills:1 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-20 MLs PO Q6H (every 6 hours) as needed. Disp:QS ML(s) Refills:2 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 10. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) mL PO BID (2 times a day). Disp:900 mL Refills:2 11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [4-21] MLs PO Q6H (every 6 hours) as needed. Disp:QS ML(s) Refills:2 12. Oxygen Pt requires 4L of continuous oxygen via NC 13. Probalance Liquid Sig: Four (4) cans PO once a day. Disp:120 8 oz Cans Refills:2 14. Tube feed supplies Pt will need a tube feed pump, pole, and G tube supplies(tubing, bag for tube feeds, etc.) Discharge Disposition: Home With Service Facility: Healthcare [Hospital 94111] Hospice Discharge Diagnosis: non-small cell lung cancer dehydration dysphagia due to lymphadenopathy pericardial effusion with tamponade Discharge Condition: stable, tolerating tubefeeds and small amounts of POs, breathing comfortably Discharge Instructions: Take all medications as instructed. Please contact Dr. [Last Name (STitle) 3274] if you develop fever/chills, worsening shortness of breath, worsening pain, or other concerning symptoms. Followup Instructions: You will need to follow-up with Dr. [Last Name (STitle) 3274] and Dr. [First Name (STitle) ] please call their office at [Telephone/Fax (1) 15512] to set up an appointment for next Thursday. [First Name8 (NamePattern2) 251] [Name8 (MD) ] MD [MD Number(1) 3282]	[ "5849", "2761" ]
Admission Date: [2144-5-8] Discharge Date: [2144-5-16] Date of Birth: [2071-8-27] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1] Chief Complaint: Hematochezia Major Surgical or Invasive Procedure: Colonoscopy [2144-5-6] Sigmoid colectomy [2144-5-12] History of Present Illness: 72M with a past medical history of hypertension, dyslipidemia presents with 2 days of hematochezia. Patient had colonoscopy 2 days ago during which he had 4 polypectomies (polyps ranged from 6 mm to 9 mm one each at ascending colon and hepatic flexure and 2 in descending colon). He was also found to have a fungating and ulcerated circumferential bleeding 7 cm malignant appearing mass in the mid-sigmoid colon. This colonoscopy was obtained due to weight loss and sporadic hematochezia over 1 year. Yesterday he had 2 episodes of bright red blood per rectum, not mixed with stool, associated with 1/10 crampy abdominal pain. Today he has 3 episodes of BRBPR mixed with stool. He denied chest pain, dyspnea, dizziness, palpitations and syncope. In the ED, patient was seen by GI who advised MICU admission. His hct was 37.8 and he was hemodynamically stable. Guaiac was grossly positive with red blood. 2 IVs were obtained. EKG was normal. On transfer, VS were 97.7, 60, [12/2096], 14, 94 RA. In the ICU, patient reports no pain and feels well. Past Medical History: -HTN -Hyperlipidemia -Insomnia -Constipation -Appendectomy in [2104] Social History: Lives with son in [Name (NI) 1110]. Immigrated from [Country 651] in [Month (only) 956] [2143]. - Tobacco: Former smoker (quit [2131], 30 year history of less than 1 ppd) - Alcohol: Less than once per year - Illicits: None Family History: Sister (lung cancer), No [Name (NI) 40342], heart disease, CVA or DM Physical Exam: Vitals: T: 98.1 BP: 112/70 P: 65 R: 12 O2: 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission: [2144-5-8] 01:55PM PLT COUNT-255 [2144-5-8] 01:55PM PT-11.8 PTT-42.5* INR(PT)-1.0 [2144-5-8] 01:55PM WBC-6.6 RBC-4.18* HGB-12.3* HCT-37.8* MCV-90 MCH-29.3 MCHC-32.5 RDW-13.6 [2144-5-8] 01:55PM NEUTS-64.9 LYMPHS-28.4 MONOS-5.0 EOS-1.4 BASOS-0.3 [2144-5-8] 01:55PM CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-2.2 [2144-5-8] 01:55PM GLUCOSE-89 UREA N-17 CREAT-0.9 SODIUM-140 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [2144-5-8] 02:04PM HGB-13.6* calcHCT-41 [2144-5-8] 02:04PM K+-4.2 [2144-5-8] 06:48PM PT-12.5 PTT-40.0* INR(PT)-1.1 [2144-5-8] 06:48PM HCT-36.8* Colonoscopy impression, [2144-5-6] (prior to admission): - Polyp in the proximal ascending colon (polypectomy) - Polyp in the hepatic flexure (polypectomy) - Polyps in the descending colon (polypectomy) - Mass in the mid-sigmoid colon at 26cm (biopsy, injection) - Otherwise normal colonoscopy to cecum Brief Hospital Course: 72 yo M with a past medical history of hypertension and dyslipidemia, with recent colonoscopy with multiple polypectomy and large fungating bleeding mass, now presents with 2 days of hematochezia. Admitted to the ICU over concern for hemodynamic instability. # GI Bleed: Given findings of recent colonoscopy, the patient's symptoms were felt likely related to the fungating mass in the sigmoid colon or post-polypectomy bleed. He did not develop hemodynamic compromise and Hct remained stable in mid 30s. He was seen by the gastroenterology service and general surgery, and it was decided that pt should undergo.... which he tolerated.... Pathology showed.... # Tick bite. [Name (NI) ] son reported that a tick was removed from his father's groin 2 days prior to admission. There was a 1x1 cm patch of erythema on the right upper inner thigh on admission, which developed a small pustule (pimple-like) the following morning. Although the tick was not available to verify as Ixodes species, the patient received a one-time prophylactic dose of doxycycline for Lyme disease prevention. # elevated PTT: noted incidentally. could consider outpatient mixing study. # Hypertension: Norvasc was held in the setting of GI bleed. # Dyslipidemia: Continued on home statin # Insominia: Ambien held during this admission. # Communication: Patient, Son [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 83143] . The surgical team was consulted for surgical resection of this bleeding sigmoid mass. He was taken to the operating room on [2144-5-12] and underwent a successful open sigmoidectomy with primary anastomosis. Post-operatively he did very well. He was given a PCA for pain control initially. He was started on clear liquids which he tolerated well. He continued to have a very flat and nontender abdomen. His diet was advanced to a regular house diet and he began to pass flatus. He was then converted to oral pain medications which he tolerated. He voided and ambualted without difficulty. Communication was through a Chinese interpreter. Medications on Admission: Norvasc 5 mg daily Omeprazole 20 mg daily Simvistatin 40 mg daily Ambien 5 mg daily Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:30 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(s) Refills:0 6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. Discharge Disposition: Home Discharge Diagnosis: carcinoma of the sigmoid colon Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call if you experience: - fever > 101 - chills - persistent nausea or vomiting - inability to eat or drink - abdominal distension or no bowel movement or flatus - bright red blood from your rectum, some bleeding is normal after this operation - increasing abdominal pain not relieved by your medication - increasing redness around or drainage from your incision . Medications: - continue taking all of your home medications - you may take tylenol or motrin as needed for pain - you will be given a prescription for narcotic pain medicine but only take this if you need to - take a stool softener as needed to prevent constipation . Incision: - you may shower - no tub baths for 3 weeks - call if you develop redness around your incision or drainage from your incision Followup Instructions: Call Dr.[Name (NI) 10946] office to schedule a follow up appointment in [2-8] weeks. Hif office number is ([Telephone/Fax (1) 9011].	[ "2760", "25000", "2859", "4019", "2724" ]
Admission Date: [2173-7-2] Discharge Date: [2173-7-10] Date of Birth: [2113-11-21] Sex: F Service: CARDIOTHORACIC Allergies: Ativan / Erythromycin Base / Statins-Hmg-Coa Reductase Inhibitors / [Female First Name (un) 504] Type Anesthetics Attending:[First Name3 (LF) 5790] Chief Complaint: Shortness of breath, cough - from tracheobronchomalacia Major Surgical or Invasive Procedure: Right thoracotomy and tracheoplasty with mesh, bronchoplasty of the bronchus intermedius and right main stem bronchus with mesh; left main stem bronchoplasty with mesh; bronchoscopy with bronchoalveolar lavage History of Present Illness: 59 yo female with h/o of persistent and disabling cough found to have TBM. Symptoms began in [2152] after exposure to chemical fumes--and anaphylactic shock to chemical fumes. In [4-/2173] dyspnea/cough have been ongoing and disabling--antibiotics/steroids not helpful. Bronch [5-/2173] showed 80% proximal trachea, 100% occlusion (distal bronchi); Y-stent trial yielded improvement (placed [6-8] and removed [6-14]) with some granulation tissue; pH Bravo study showed GERD/distal reflux. Past Medical History: TBM, CAD (LAD w/ < 30% stenosis), migraines, colonovaginal fistula, vaginitis, PSH: cesarean sections x 3, left lumpectomy Social History: Denies tobacco, ethanol and drug use. Has exposure to cleaning agents. Works for an electrical company. She is married and lives with family Family History: Mother pancreas ca Father Siblings ovarian ca Offspring Other lung ca Physical Exam: VS: Temp 97.2 HR 108 BP 110/60 RR 18 O2 sat 98% on 3L O2 via N/C PE: Gen: NAD, A&O x 3 Lungs: CTAB, decreased breath sounds L>R, no w/c/r, L thoracotomy incisions s/d/i w/ serosang drainage CV: RRR Pertinent Results: [2173-7-2]: CK(CPK)-1237 GLUCOSE-203 UREA N-13 CREAT-0.6 SODIUM-140 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-21 ANION GAP-15 CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.4 WBC-10.1 HGB-11.8 HCT-35.2 PLT COUNT-289 ABG: PO2-215* PCO2-37 PH-7.33* TOTAL CO2-20* BASE XS--5 Brief Hospital Course: [2173-7-2]: Admitted to thoracic surgery service after tracheobrochoplasty for tracheobronchomalacia. Was slightly tachycardic in the PACU to 105, but asymptomatic and BP normal. Admitted to ICU for respiratory status monitoring. Thoracic epidural function declined, likely paramedian. Epidural split to bupivicaine with dilaudid PCA. [2173-7-3]: Improved pain control with addition of Toradol. Epidural with minimal effect. Patient stable and out of bed to chair. No acute events. Right chest tube removed. [2173-7-4]: No acute events, tolerating clears, epidural removed, PCA dilaudid switched to intermittent IV dilaudid as patient was highly sedated and had questionable respiratory drive. [2173-7-5]: Foley catheter removed and IV fluids were stopped. Tolerated full liquid diet. Given oxycontin for pain. Begun on toradol for a 3 day period. Dilaudid PCA restarted, and lidocaine patch over the incision site was applied. Given lasix for diuresis, recent CXR showed mild fluid overload with a small left sided pleural effusion. [2173-7-6]: Continue diruesis given >3L positive yesterday -> lasix 20mg x1. Transferred from the ICU to the floor. Begun on a regular diet, which she tolerated well. [2173-7-7]: Has not taken topiramate during this admission. Developed nausea after going down for a CXR. Upon questioning, pt sts she is somewhat dizzy and that this exact same problem occured on her previous post surgical admission. Likely withdrawal from topiramate. Begun on standing topiramate. Morphine PCA stopped and oral morphine begun, with better pain control. [2173-7-8]: Mild pleuritic pain, O2 sat's stable, tolerating PO's well, and pain is well controlled. Was made NPO and placed on IVF in preparation for bronchoscopy on [2173-7-9]. [2173-7-9] - Patient underwent flexible bronchoscopy, which was within normal limits. She is alert, oriented, and ambulating independently. [2173-7-10]- Patient was afebrile, saturating 98% on room air, and normotensive. Pain was well controlled and she was ambulating independently. Cough was productive and clearing mucous effectively. Patient was discharged home. Medications on Admission: Albuterol inhaler Singulair 10 mg daily Topiramate 100 mg PO qHS Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for migraine. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) Inhalation Q4H (every 4 hours) as needed for wheezing/sob. 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for Indigestion. 5. Morphine 15 mg Tablet Sig: One (2) Tablets PO Q4H (every 4 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) scoop PO DAILY (Daily). Disp:1 can Refills:2 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain: take with food and water. Disp:90 Tablet(s) Refills:0 9. 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 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): cut in [12-19] place either side of incision. Disp:15 Adhesive Patch, Medicated(s) Refills:2 11. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:30 Tablet(s) Refills:0 12. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). Disp:40 Troche(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Tracheobronchomalacia. CAD (LAD w/ < 30% stenosis), Migraines Colonovaginal fistula vaginitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if you experience: -Fever > 101 or chills -Increased shortness of breath, cough or stridor -Chest pain -Incision develops drainage. -No driving while taking narcotics. Take stool softners with narcotics -Walk 4-5 times a day for 10-15 minutes to a goal of 30 minutes Followup Instructions: Follow-up with Dr. [Last Name (STitle) 24620] [Telephone/Fax (1) 3020] Date/Time:[2173-7-27] 9:30 in the [Hospital Ward Name 121] Building [Location (un) 591], [Hospital1 ] I Chest X-Ray [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiology 30 minutes before your appointment Provider: [Name10 (NameIs) 1532] [Last Name (NamePattern4) 8786], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2173-7-27] 9:30 Completed by:[2173-7-10]	[ "5119", "41401", "53081", "V4582" ]
Admission Date: [2149-3-17] Discharge Date: [2149-3-26] Date of Birth: [2080-1-24] Sex: F Service: ADMISSION DIAGNOSES: 1. Aortic valve stenosis. 2. Aortic insufficiency. 3. Mitral regurgitation. DISCHARGE DIAGNOSES: 1. Aortic valve stenosis. 2. Aortic insufficiency. 3. Mitral regurgitation. 4. Status post aortic valve replacement, mitral valve replacement, left atrial MAZE procedure. HI[Last Name (STitle) 2710]OF PRESENT ILLNESS: The patient is a 69-year-old retired nurse who was seen by Dr. [Last Name (Prefixes) ] in the office. She has had cardiac catheterization in the past showing aortic stenosis with an aortic valve area of 0.7 sq cm. Cardiac catheterization also demonstrated some aortic insufficiency as well as moderate mitral regurgitation. The patient does report increasing dyspnea on exertion over the past six months. No history of syncope. She does have occasional palpitations and a history of atrial fibrillation. PAST MEDICAL HISTORY: 1. Rheumatic fever at age 18. 2. Hypertension. 3. Palpitations. MEDICATIONS: 1. Protonix. 2. Hydrochlorothiazide. 3. Digoxin. 4. Toprol. 5. Verapamil. 6. History of Coumadin, currently on Lovenox. ALLERGIES: Keflex. PAST SURGICAL HISTORY: 1. Fracture of tibia and fibula on the right. 2. Vaginal hysterectomy for prolapse. PHYSICAL EXAMINATION: On admission in general the patient was an elderly woman in no acute distress. Vital signs were stable, afebrile. HEENT: Atraumatic, normocephalic, extraocular movements intact, pupils were equal, round, and reactive to light, anicteric. Neck: Supple, midline, without masses or lymphadenopathy. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm with a 2-3/6 systolic ejection murmur. Abdomen: Soft, nontender, nondistended, without masses or organomegaly. Extremities: Warm, noncyanotic, nonedematous x 4. Neurological: Grossly intact. LABORATORY DATA: [2149-3-10] complete blood count was 7.1/11.8/34.2/238. INR 1.2. Urinalysis was negative. Chemistries were 140/4.0/100/30/16/0.9/144. ALT 57, AST 31, alkaline phosphatase 56, total bilirubin 0.7, albumin 3.6. Type and screen was performed. HOSPITAL COURSE: The patient was admitted for replacement of her atrial and mitral valves. She has a history of atrial fibrillation and a MAZE procedure was planned at the same time. On [2149-3-17] the patient was taken to the operating room for aortic valve replacement, mitral valve replacement, left atrial MAZE performed with 23 and 27 mm [Last Name (un) 3843]-[Doctor Last Name ] valves respectively. The patient tolerated the procedure well and without complication. The patient was taken to the CSRU postoperatively for closer monitoring. On postoperative day zero the patient was extubated without incident. The patient did have a burst of supraventricular tachycardia and went into atrial fibrillation. The patient was attempted to be cardioverted electrically but failed. The patient was transferred to the floor later on postoperative day number two. On postoperative day three the patient's pacing wires were removed and the patient began anticoagulation for underlying atrial fibrillation. The remainder of her hospital stay was largely unremarkable with the exception of a short nine-beat run of ventricular tachycardia which occurred on the evening of postoperative day four. The EP service was consulted who recommended only beginning amiodarone 400 mg q.d. and anticoagulation. They also recommended sending the patient home on [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts Holter monitor, probable electric cardioversion in one month's time. From that point on, the patient had an unremarkable hospital stay where she remained in atrial fibrillation but was asymptomatic. She was awaiting therapeutic anticoagulation. Ultimately, the patient was discharged on postoperative day number nine, status post her aortic valve replacement, mitral valve replacement and MAZE procedure, tolerating a regular diet with adequate pain control and p.o. pain medications and with a therapeutic INR of 2.0. The patient remained in atrial fibrillation. DISCHARGE CONDITION: Good. DISPOSITION: To home. DIET: Cardiac. MEDICATIONS: 1. Coumadin 3 mg q.d. 2. Percocet 5/325 1-2 tablets q. four hours p.r.n. 3. Colace 100 mg b.i.d. 4. Peri-Colace 30/100 mg b.i.d. p.r.n. 5. Aspirin 325 mg q.d. 6. Amiodarone 400 mg q.d. 7. Lasix 20 mg b.i.d. x 7 days. 8. Potassium chloride 20 mEq q.d. x 7 days. 9. Lopressor 50 mg b.i.d. FO[Last Name (STitle) 996]P: The patient is to continue following up with her primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16004] for weekly INR checks. He is her primary care physician and should adjust her Coumadin appropriately for a goal INR of between 2 and 3. The patient will be sent home with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts Holter monitor with transmissions to Dr. [Last Name (STitle) ] for follow up. The patient will have a probable cardioversion attempt in one month. The patient should follow up within 1-2 weeks with her cardiologist and address the need for diuretics as well as adjusting her cardiac medications at that time. The patient should follow up with Dr. [Last Name (Prefixes) ] in approximately four weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 5745] MEDQUIST36 D: [2149-3-26] 13:35 T: [2149-3-26] 13:45 JOB#: [Job Number 46546]	[ "9971", "42731", "4019" ]
Admission Date: [2129-9-28] Discharge Date: [2129-9-30] Date of Birth: [2066-4-4] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2071] Chief Complaint: bradycardia Major Surgical or Invasive Procedure: none History of Present Illness: 63 yo female with history of DM2, Htn, COPD, question of CRI who originally presented to PCP c/o severe dizziness and found to be bradycardic (HR 30's) with associated junction escape rhythm, subsequently transferred to [Hospital1 18] and admitted to the CCU for close monitoring. Per report, Pt was experiencing severe fatigue and LH while at community center accompanied by SSCP and SOB that resolved on its own over several minutes. At PCP's office this afternoon was found to be bradycardic with HR in 30's and an ECG with a junctional rhythm and no sinus activity. In the ED recieved atropine twice and calcium gluconate without effect. Several ECGs obtained which showed evidence of a sinus rhythm in 20-40s with a narrow junctional escape and intermittent AV conduction. Per EP, bradycardic agents were held and Pt transferred to CCU for further evaluation. Past Medical History: DM2 Htn ?Asthma/COPD GERD depression s/p CCY ARF ([4-22]) diabetic neuropathy/retinopathy chronic pain HA Social History: 60-80 pack/year history, no EtOH. Lives alone with assistance Family History: NC Physical Exam: VS: 96.1, 36, 108/44, 18 99% PE: mildly obese, sitting upright in bed PERRL, EOMI, MMM, OP wnl Supple, 2+ carotids, no bruit, JVP at 10cm brady, nl S1/S2, no M/R/G scattered wheezes and bibasilar rales obese, soft, NT, ND, NABS trace edema, 2+ DPs A&O, CN roughly intact, non-focal neuro exam Pertinent Results: [2129-9-28] 12:25PM BLOOD WBC-13.9* RBC-4.31 Hgb-12.5 Hct-37.7 MCV-87 MCH-29.1 MCHC-33.2 RDW-12.6 Plt Ct-318 [2129-9-29] 06:00AM BLOOD WBC-11.0 RBC-3.78* Hgb-11.2* Hct-32.3* MCV-86 MCH-29.6 MCHC-34.7 RDW-12.7 Plt Ct-264 [2129-9-30] 06:40AM BLOOD WBC-8.1 RBC-3.91* Hgb-11.9* Hct-33.5* MCV-86 MCH-30.4 MCHC-35.4* RDW-12.6 Plt Ct-258 [2129-9-28] 12:25PM BLOOD PT-13.2 PTT-23.0 INR(PT)-1.1 [2129-9-28] 12:25PM BLOOD Plt Ct-318 [2129-9-30] 06:40AM BLOOD Plt Ct-258 [2129-9-28] 12:25PM BLOOD Glucose-270* UreaN-33* Creat-1.7* Na-141 K-6.6* Cl-109* HCO3-19* AnGap-20 [2129-9-28] 03:12PM BLOOD Glucose-162* UreaN-32* Creat-1.6* Na-144 K-5.7* Cl-112* HCO3-23 AnGap-15 [2129-9-29] 06:00AM BLOOD Glucose-46* UreaN-32* Creat-1.3* Na-146* K-3.6 Cl-113* HCO3-25 AnGap-12 [2129-9-30] 06:40AM BLOOD Glucose-60* UreaN-20 Creat-1.0 Na-147* K-3.7 Cl-110* HCO3-28 AnGap-13 [2129-9-28] 12:25PM BLOOD CK(CPK)-96 [2129-9-28] 10:00PM BLOOD CK(CPK)-52 [2129-9-29] 06:00AM BLOOD CK(CPK)-52 [2129-9-28] 12:25PM BLOOD cTropnT-<0.01 [2129-9-28] 10:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2129-9-29] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2129-9-28] 12:25PM BLOOD Calcium-9.1 Phos-3.7 Mg-2.2 [2129-9-29] 06:00AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9 [2129-9-30] 06:40AM BLOOD Calcium-9.6 Phos-3.8 Mg-1.8 CXR FINDINGS: Cardiac, mediastinal, and hilar contours are within normal limits. There is perivascular haze and increased prominence of the interstitial markings, consistent with CHF. There are no pleural effusions. Osseous structures are unremarkable. IMPRESSION: Mild CHF pattern Brief Hospital Course: 63 yo female with h/o multiple CV risk factors including DM2, HTn as well as CRI and COPD admitted to CCU for symptomatic bradycardia. 1) Rhythm: In both the PCPs office and [Name (NI) ], Pt found to be in sinus brady with junctional escape and intermittent AV conduction thought to be secondary to blockade from her regimen of BB and CCB. Those medications were held and Pt received atropine times two with no effect. EP cosulted who recommended admission to CCU for close monitoring. Given Pt's slow native sinus rhythm and no evidence of AV conduction block, it was not necessary for a temporary pacer wire to be placed. Overnight Pt reverted to a faster NSR at rate in the 80's. Pt hemodynamically stable and without further complaint of dizziness or fatigue. Given response, above agents continued to be held and HCTZ slowly added for BP control. 2) CAD: Pt with multiple risk factors but no known heart disease. ECG without ischemic changes and cardiac enzymes remained flat. History of modified [Doctor First Name ] protocol stopped after 4 minutes secondary to fatigue with no obvious ischemic changes. Pt educated and instructed to stop smoking. 3) Pump: Pt with eMIBI ([5-22]) with estimated LVEF to be 75%. Pt with history of HTn controlled in past with BB, CCB and ACEi. On admission BB/CCB held for bradycardia and ACEi held initial for h/o CRI while awaiting lab results. For BP control, Pt started initially on low dose HCTZ and titrated to 25mg daily for which she will be discharged home on. For addition control especially given history of DM, felt it was important to restart Pt's ACEi. However given Pt's admission hyperkalemia, it was initially held. The follow up K+ were normal and Cr normal. So Pt restarted on lisinopril at 2.5 mg daily, less than her preadmission regimen of 5mg daily. Pt should be followed up closely by PCP who will titrate her antihypertensives and increase her ACE as tolerated by BP and K+. 4) Hyperkalemia: On presentation to the ED had a K+ of 6.6 and 5.7 for which she received kayexelate twice. Repeat K= 3.9 and remained normal remaining of hospitalization. Because of hyperkalemia, lisinopril was added on at low dose of 2.5 mg daily with plans for outpatient titration. 5) CRI: Pt with h/o CRI and reported baseline Cr 1.5 and on admission was found to 1.7. Pt lightly hydrated overnight and Cr in AM improved to 1.2. Pt remained stable with good UOP. Given Cr 1.0-1.2 felt it was appropriate to restart Pt's lisinopril. 6) COPD: Pt with h/o COPD treated as an outpt with Advair and Combivent. This regmen was continued, however felt to be a bit more wheezy and thus increased her frequency of treatment. Pt did well and remained stable titrateing off her O2 supplementation. Pt to be discharged home on her pre-admission regimen. Medications on Admission: ADVAIR DISKUS 250-50MCG--One puff twice a day ASPIRIN E.C. 325 MG--One by mouth every day CARDIZEM CD 360MG--One by mouth every day COMBIVENT 103-18MCG--2 puffs four times a day as needed for for shortness of breath DIPROLENE 0.05%--Apply to scalp at bedtime FLUOXETINE HCL 20MG--One by mouth every day for depression LANTUS 100 U/ML--40 units every day LISINOPRIL 5 MG--One by mouth at bedtime for blood pressure MIDRIN 65-325-100--One by mouth as needed for headache (max 2/day) NEURONTIN 300MG--One by mouth three times a day for neuropathy PROTONIX 40MG--One by mouth every day as needed for acid reflux TOPROL XL 100MG--One by mouth every day for blood pressure TRAZODONE 100MG--One by mouth at bedtime as needed for insomnia Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 6. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H () as needed. 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home with Service Discharge Diagnosis: bradycardia; sinus node dysfunction Discharge Condition: good Discharge Instructions: please make all follow-up appointments, if you are unable please reschedule as soon as possible. please take all medications as prescribed. please call PCP or return to ED if experiencing dizziness, profound fatigue, severe chest pain, shortness of breath, persistent fever >101.4, productive cough. Followup Instructions: please follow up with your PCP Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 1144]) Wed [10-5] at 2:00 PM. Provider: [Name10 (NameIs) ],[Name11 (NameIs) 9119] [Name12 (NameIs) 9120] MEDICINE (PRIVATE) Where: ADULT MEDICINE UNIT [Hospital3 ] HEALTHCARE - 1000 [Location (un) ] - [Location (un) 2352], [Numeric Identifier 9121] Phone:[Pager number ] Date/Time:[2129-12-23] 9:00 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 2073]	[ "42789", "496", "4019", "25000", "311", "53081" ]
Admission Date: [2146-2-13] Discharge Date: [2146-2-15] Date of Birth: [2071-10-9] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 5790] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: [2146-2-14] 7.0 [Last Name (un) 295] adjustable tracheostomy tube and PEG tube placement. [2146-2-15] Bronchoscopy History of Present Illness: The patient is a 74-year-old woman with respiratory insufficiency who presents from rehab for elective tracheostomy tube and peg placement Past Medical History: Past Medical History: Appendectomy DM2 Hyperlipidemia HTN Cholecystectomy Hernia Repair H/o melanoma TAH/BSO Carpal tunnel OA Vitamin D deficiency Hypothyroid Restrictive lung disease [2-10] obesity Social History: Lives with husband, at rehab Family History: Noncontributory Physical Exam: Tcurrent: 36.6 ??????C (97.8 ??????F) HR: 83 BP: 116/49(63) RR: 22 SpO2: 97% General: laying with eyes closed, drowsy HEENT: dry MM, EOMI Neck: obese CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: good breath sounds BL, scattered rhonchi at bases Abdomen: soft, NT, obese, +BS, fecal tube with liquid stool, no rebound/guarding GU: foley Ext: warm, well perfused, 3+ edema of all extremities, non-warm firm erythema of BL lower extremities c/w chronic venous stasis, does not look cellulitic Skin: cherry hemangiomas and sebarrheic keratosis Neuro: CNIII-XII intact, moving all extremities spontaneously, normal DTRs Pertinent Results: [2146-2-13] 06:31PM WBC-7.4 RBC-3.66* HGB-8.7* HCT-30.8* MCV-84 MCH-23.9* MCHC-28.4* RDW-19.8* [2146-2-13] 06:31PM PLT COUNT-226 [2146-2-13] 06:31PM CALCIUM-9.8 PHOSPHATE-2.7 MAGNESIUM-2.1 [2146-2-13] 06:31PM GLUCOSE-114* UREA N-24* CREAT-0.7 SODIUM-145 POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-44* ANION GAP-8 [2146-2-14] CXR : Moderately severe pulmonary edema has worsened, and severe cardiomegaly and moderate right and small left pleural effusion persists. Tracheostomy tube is canted anteriorly and has a relatively short vertical excursion. There is no pneumothorax or mediastinal widening Brief Hospital Course: Mrs. [Known lastname 1001] was admitted to the ICU for full evaluation prior to undergoing elective tracheostomy and PEG tube placement. She was taken to the Operating Room on [2146-2-14] for the above mentioned procedures and tolerated it well. She returned to the ICU sedated on Propofol and on full mechanical ventilation. Her vent settings and mode was adjusted on multiple occasions due to hypercarbia and she alternated between MMV and A/C. Her most recent ABG revealed a Ph of 7.33 PO2 59 PCO2 90 and HCO3 16. Her chest Xray this morning was more opacified on the right side and an bronchoscopy was done which showed but there was no significant plugging. A post bronch cehst xray showed better aeration with the same right effusion. The Nutrition service recommended replete w/ fiber at a goal of 45 cc/hr w/ 42 Gm beneprotein daily. These feeding can be started after she arrives at rehab. Currently she is on no sedation and is responding to voice and commands. She received a dose of Lasix 20 mg this AM for possible fluid overload in light of her xray and diamox was also started. From a surgical standpoint she is doing well. Her trach flange sutures can be removed on [2146-2-24]. If there are any questions or concerns regarding the trach or PEG please call Dr. [Last Name (STitle) ] at 6[Telephone/Fax (1) 21905]. Medications on Admission: 2. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 6. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. 7. fenofibrate 150 mg Capsule Sig: One (1) Capsule PO once a day. 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. 11. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. 13. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 14. Humalog 100 unit/mL Solution Sig: Per sliding scale . Subcutaneous . 15. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily). 6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. Morphine Sulfate 2-4 mg IV Q2H:PRN pain 10. 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. 11. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. AcetaZOLamide 250 mg IV Q12H Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Hypercarbic respiratory 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 transferred to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1675] for placement of a feeding tube and a tracheostomy tube to help with breathing. * You have recovered well and are now ready to transfer back to your rehab. * The feeding tube can be used starting today. * If you develop any redness or drainage around the PEG tube or the trach tube please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2348]. Followup Instructions: Call Dr.[Name (NI) 2347] office at [Telephone/Fax (1) 2348] if follow up is needed. Completed by:[2146-2-15]	[ "4168", "25000", "2724", "4019", "2449", "32723" ]
Unit No: [Numeric Identifier 96276] Admission Date: [2192-4-11] Discharge Date: [2192-4-19] Date of Birth: [2144-9-11] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 47 year old female with a history of intravenous drug abuse who has been treated for multiple episodes of endocarditis in the past with her most recent episode in [2182]. At that time she had been informed that she has tricuspid regurgitation and recommended a repair of her tricuspid valve which she declined. Over the last several years she is becoming more symptomatic complaining of fatigue, dyspnea on exertion, palpitations and chest tightness and Dr. [Last Name (STitle) ], her cardiologist, referred her for surgical evaluation. She currently describes dyspnea on exertion with chest tightness and stabbing pain which will resolve spontaneously. She has a history of varicose veins and has bled from the varicose veins requiring transfusions but otherwise no new symptoms are noted. PAST MEDICAL HISTORY: Significant for asthma, hepatitis C with active titers, fibromyalgia, Raynaud's, chronic fatigue syndrome, bipolar disorder, endocarditis times five, history of intravenous drug abuse, varicose veins, renal calculi, ectopic pregnancy. PAST SURGICAL HISTORY: Is significant for a right thoracotomy secondary to emphysema in [2182] and right carpal tunnel release. MEDICATIONS ON ADMISSION: Include Ultram 60 mg q 4 hours p.r.n., methadone 40 mg daily, OxyContin 5 mg as needed, Ventolin 3 puffs daily, meclozine as needed. ALLERGIES: Are to penicillin which is anaphylaxis. Codeine which is gastrointestinal upset. Last dental examination was on [2192-3-24], she had several extractions and was cleared for surgery by Dr. [First Name (STitle) ]. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is currently not working. She lives with her mother. She smokes one pack a day, just has an occasional drink with meals. Denies any current intravenous drug use. PHYSICAL EXAMINATION: Preoperatively her examination includes she is 5 foot 1 inches tall, weight is 147, heart rate is 87, regular, blood pressure of 146/78. She is anxious appearing. The neck is supple with no jugular venous distension. The heart is regular with a IV/VI systolic ejection murmur, a II/VI diastolic murmur. The lungs are clear. The abdomen is soft, nontender. Lower extremities have bilateral varicosities. She has 2+ distal lower extremity pulses. PREOPERATIVE LABORATORY DATA: Included hematocrit of 37.2, platelets of 128, INR of 1.3. Urinalysis significant for 25 red cells, 2 white cells, less than 1 epithelial. BUN and creatinine of 12 and 0.7. Hemoglobin A1C of 5.3. Echocardiogram from [2192-2-24] showed an ejection of 60 to 65 percent, 4+ tricuspid regurgitation, mild left atrial enlargement, moderately dilated right atrium and moderate pulmonary artery systolic hypertension. Cardiac catheterization on [2192-3-16] demonstrated severe tricuspid regurgitation, normal coronaries. HOSPITAL COURSE: The day of admission the patient was taken to the operating room where she underwent a tricuspid valve replacement with a 29 mm pericardial valve. Intraoperatively she tolerated the procedure well but there was an episode of complete heart block and by the end of the case this had evolved to block with junctional escape rhythm. Due to the dysrhythmia a permanent epicardial pacing wire was placed at the end of the case and its lead remained in the subcutaneous tissue of the abdomen. The typical electrocardial wires were placed as well. She was transported to the Cardiac Intensive Care Unit stable and intubated with a little bit of pressor support. Over the next day she was extubated, pressor support weaned and pain service and the electrophysiological service were consulted. She remained hemodynamically stable by postoperative day one. She remained in a first degree AV block. Her beta blocker was dosed initially but then was stopped due to worry that this might precipitate complete heart block. She was transferred to the floor on postoperative day #2 and since then on postoperative day #3 had a temperature spike. She was pancultured, started on empiric levofloxacin. There have been no positive cultures to date but she is continued on a full course of antibiotics and she has defervesced. She has received physical therapy and at this current time has completed level 4 with the plan of completing a level 5 prior to discharge. She had a postoperative anemia which was treated with iron sulfate and vitamin C. Initially she was on a Dilaudid PCA and the acute pain service has helped manage her pain regimen and has evolved down back to the pre-hospitalization regimen. On postoperative day six her epicardial wires were removed. She has remained hemodynamically stable in a sinus rhythm with a first degree block and the EP service is continuing to follow. The pain service will continue to follow her as an outpatient as before. She is now currently stable and ready for discharge to home. DISCHARGE DIAGNOSES: 1. Severe tricuspid regurgitation, status post tricuspid valve replacement with a porcine valve. 2. Hepatitis C. 3. Prior intravenous drug abuse. 4. History of edema. 5. Varicose veins. 6. Raynaud's. 7. Fibromyalgia. 8. Bipolar. 9. Chronic fatigue syndrome. 10. Renal calculi. MEDICATIONS ON DISCHARGE: Lasix 20 mg p.o. daily for two weeks, potassium chloride 20 mEq p.o. daily for two weeks, aspirin 81 mg p.o. daily, Colace 100 mg p.o. b.i.d., methadone 40 mg p.o. in the morning and methadone 10 mg p.o. in the evening, albuterol activation aerosol 1 to 2 puffs q 6 hours as needed, vitamin C 500 mg p.o. b.i.d. for one month, ferous sulfate 325 mg p.o. daily for one month, Neofloxacin 500 mg p.o. daily for seven days. She will follow up with the [Hospital 409] Clinic in two weeks, Dr. [Last Name (STitle) ] in four weeks. She will follow up with Dr. [Last Name (STitle) 770] in the urology clinic for the hematuria that she has had. DISCHARGE CONDITION: Good. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1714], [MD Number(1) 1715] Dictated By:[Last Name (NamePattern1) 8958] MEDQUIST36 D: [2192-4-18] 21:13:59 T: [2192-4-18] 21:52:45 Job#: [Job Number 96277]	[ "4280", "5180", "2851" ]
Admission Date: [2190-5-23] Discharge Date: [2190-5-26] Service: MEDICINE Allergies: Iodine; Iodine Containing / Penicillins Attending:[First Name3 (LF) 3984] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 89 yo F, h/o recent admission for PNA/sepsis/UTI, h/o COPD/asthma,CHF,AF,DM presents from [Hospital 100] Rehab with report of hypoxia to the 70's and a R lung 'white out' on CXR. In ambulance bay on arrival had wide complex tachycardia. Pt noted to be having recent diarrhea and ? c.diff, is on Abx. Pt is [Name (NI) 595] speaking with baseline alzheimer's dementia. Per the daughter the patient has had chronic abdominal pain since her PEG procedure from the last admission. At baseline she is communicative, but since the last admission, the daughter describes increased confusion and difficulty communicating. . Of note, the patient was recently hospitalized from [3-15] to [4-5] with sepsis, PNA (MRSA and klebsiella), UTI, course c/b afib with RVR. Trach, PEG, PICC were performed during that admission. . ED Course: Pt was found to be in SVT vs. VT and loaded with amio and put on an amio gtt. She was then in AF. Cardiology was consulted. A CXR was done that shows worsened pulmonary edema since her last admission, though a focal consolidation could not be ruled out, so she was covered with levo/vanco for ?PNA. She was also given xopenex and atrovent nebs for wheezing. Labs were significant for tnt of 0.04 (all <0.01 in past), Cr of 1.3 (baseline 1.0), WBC 10.9 (baseline range 5-10), lactate 1.4, and a pos UA. other labs as below. vitals on transfer 99, 100 AF, 137/56, 20, 97%RA Past Medical History: HTN hypercholesterolemia diastolic CHF EF 60% COPD/asthma paroxysmal afib sick sinus syndrome s/p pacemaker Diabetes Mellitus (when she was in former rehab hospital) DVT ?CAD Nephrolithiasis cataracts CRI w/ baseline Cr 1.3 on [10-16] (per H&P from [8-2] Heb Reb baseline 2) dementia CVA [92] yrs ago, periods of confusion since then poor balance with frequent falls (coumadin stopped) urinary incontinence s/p left mastectomy for breast ca anemia (unknown baseline) Past Surgical History: Left radical mastectomy appendectomy. Social History: Non-smoker, no EtOH. Former nurse. Lives at [Hospital 100] Rehab. Family History: Noncontributory Physical Exam: PE: T98.8,P88,BP149/78,RR26,O2Sat 99% V, AC: fiO2 0.5, PEEP 10, RR 20, Tv 425 GEN: non-communicative, alert but looking uncomfortable in bed NEURO: CN II-XII intact, PERRL, MAE, alert HEENT: NCAT, OP clear, TM clear, NECK: supple, no LA, normal thyroid RESP: on vent, diffuse rhonchi b/l R>L, mild crackles at bases CV: RRR, no M/R/G ABD: NL BS, mild distended with general TTP, nonfocal, not peritoneal GU:NL EXT: no edema SKIN: no rash Pertinent Results: [2190-5-23] 09:20PM TYPE-ART PO2-343* PCO2-56* PH-7.36 TOTAL CO2-33* BASE XS-4 [2190-5-23] 08:39PM LACTATE-1.4 [2190-5-23] 08:35PM GLUCOSE-138* UREA N-44* CREAT-1.3* SODIUM-141 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-31 ANION GAP-12 [2190-5-23] 08:35PM estGFR-Using this [2190-5-23] 08:35PM CK(CPK)-24* [2190-5-23] 08:35PM cTropnT-0.04* [2190-5-23] 08:35PM CK-MB-NotDone [2190-5-23] 08:35PM CALCIUM-9.2 PHOSPHATE-3.6 MAGNESIUM-2.4 [2190-5-23] 08:35PM WBC-10.7 RBC-3.88# HGB-11.5# HCT-35.5# MCV-91 MCH-29.5 MCHC-32.3 RDW-15.2 [2190-5-23] 08:35PM NEUTS-57.3 BANDS-0 LYMPHS-33.9 MONOS-3.7 EOS-4.7 BASOS-0.5 [2190-5-23] 08:35PM PLT SMR-LOW PLT COUNT-97# [2190-5-23] 08:35PM PT-20.6 PTT-31.5 INR(PT)-1.9* [2190-5-23] 08:35PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.018 [2190-5-23] 08:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2190-5-23] 08:35PM URINE RBC-[7-6]* WBC->50 BACTERIA-MANY YEAST-RARE EPI-0-2 . [2190-5-23] URINE URINE CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S)} INPATIENT [2190-5-23] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2190-5-23] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] . CXR: 4/27IMPRESSION: Limited study, with: 1. Pulmonary edema, worse since [2190-4-1]. 2. Tracheostomy and gastrostomy tubes, dual-chamber pacemaker and right subclavian PICC, as before. . Cardiology Report ECG Study Date of [2190-5-23] 9:02:46 PM Atrial fibrillation with an average ventricular rate of 101 beats per minute. Left bundle-branch block. Low QRS voltage in the limb leads. Non-specific ST-T wave changes. Compared to the previous tracing ventricular tachycardia is no longer present. TRACING #3 . abd xray [5-24] :IMPRESSION: No bowel dilatation to suggest toxic megacolon. No evidence of obstruction. . cxr [5-25] FINDINGS: In comparison with the study of [5-23], the various devices remain in place. Diffuse haziness of both hemithoraces with preservation of pulmonary markings is consistent with substantial pleural effusions. Ill-defined vessels are consistent with the clinical impression of pulmonary edema. The possibility of a focal pneumonia is impossible to exclude, especially in the absence of a lateral view. Brief Hospital Course: A/P: 89 yo [Date Range 595] speaking woman with multiple medical problems including COPD/CHF/AF and recent admit PNA/sepsis and is s/p trach/peg at last admission. Also, in wide complex tachycardia on arrival, she was loaded with amio and then amio gtt,reverted to afib afterwards. . # Hypoxia: Pt has a h/o COPD and asthma and was noted to be wheezing on exam. XR was revealing for pulm edema, which seemed to be corroborated on physical exam, but also may have shown a consolidation c/w pna. On the vent, patient is now sating well and had good O2 sats while in the ED. WBC not elevated with no L shift and afebrile on this. DDx: PNA, CHF, COPD, PE. Likely hypoxia is secondary to heart failure. Abx for HAP, including coverage MRSA/Klebsiella pna :Levo/Vanc. Pt received doses in ED. Pt was not specifically treated for PnA during the hospital stay as she was no displaying signs of pna. Hypoxia thought secondary to vol overload. Sats improved after diuresis. Pt was placed on standing nebs prn. Pt was not given any steroids as they were not deemed necessary. PT was given lasix with prn IV boluses for diuresis. Pt will be going to rehab where her vent settings can be further titrated/weaned prn. . #ID-Pt has h.o C.diff from [Hospital 100] Rehab, continued on her PO vanco. UTI was being treated with Vanco (h/o MRSA UTI in the past) and cipro. Holding off for treating for a PNA at this point. Pt reportedly had one positive blood culture at [Hospital 100] Rehab for enterococcus, which may be a contaminant but would likely be covered by the vancomycin she is receiving for her UTI. Also, the line tip cultured at the time and was negative. PT is on vanco for ?+bcx and h/o MRSA UTI. . # COPD/Asthma: She was continued on her home dose inhalers. . # Elevated CE: all previous CE were <0.01 and her admission Troponin was 0.3, which is mildly elevated. Pt seemed to be having more abd pain, but being a woman/diabetic atypical presentations common, so she had three sets of cardiac biomarkers to rule out MI. Pt ruled out for MI. EKG showed signs of atrial fib. Pt was continued on her ASA, BB, statin. . # CHF: intact systolic EF, h/o diastolic dysfunction but not assessed due to poor study on most previous echo. Has evidence of worsening failure on CXR. diuresis with goal net neg 1L on the day of admission, O2 sats improved after receiving extra IV lasix (40mg) and diuresing. . # Tachycardia: Pt was in a wide complex tachycardia on arrival to the ED which was felt to be SVT vs. VT. Pt was stable, maintaning BP and mentating. HR while [Doctor First Name ] the MICU was irreg in AF after initiation of amiodarone. Insighting events may include hypoxia, infection, pain Cardiology was consulted and recommended d/c amio gtt, starting diltiazem 30mg po daily and uptitrating PRN. Would suggest dilt gtt instead of amio as needed for rate control. She did not require diltiazem gtt, and her beta blocker was increased from 25mg po tid to 37.5mg po tid . # AF: Has been paroxysmal and is anticoagulated with warfarin. After tachycardia broke, still in AF. - con't anticoagulation with goal INR [2-28] - qd INR checks . # SSS s/p pacemaker: pt is intermittantly paced, on EKG but it is inconsistant and ? pacer functionality. Pt has maintained BP's throughout in the rapid tacycardia and now in AF . # HTN: pt's BP appropriate, will continue on outpatient BB, lasix . # Hyperlipidemia: con't statin . # thrombocytopenia: stable -cont to trend . # Abdominal pain/distention: As per the daughter and notes, patient has experienced chronic abdominal pain ever since the trach and peg, and has required chronic pain control. She is mildly distended, but does not have an elevated WBC/F and lactate normal. Pt has required zofran prn at the nursing home for this issue on chronic basis. DDx: C.diff colitis, gatroenteritis, gastrtitis, SBO, chronic abd pain KUB: "No bowel dilatation to suggest toxic megacolon. No evidence of obstruction." LFTs, alk phos, amylase/lipase-were wnl serial abdominal exams were unchanged continue pt's chronic pain regimen w/ liquid oxycodone . # C.diff colitis: [Name6 (MD) ] the MD note, pt was dx w/ c.diff colitis and has been on PO vancomycin. There is no documentation of a + c.diff. - c.diff toxin - con't PO vancomycin . # DM: con't SSI and baseline lantus. will do 1/2 dose lantus while NPO . # CRI: past note states baseline at 1.3, but previous labs show baseline 0.9-1.1. . # UTI: Pt had UTI on prior admission as well, and cleared, now with + UA and Cx pending. - Cipro/Vanco to cover urine as she has had MRSA urine tract infections-14 day course . # FEN: NPO, replete prn # PPx: sch, warfarin, PPI, bowel # ACCESS: midline # CODE: DNR (confirm w/ daughter) # COMM: Pt's daughter [Name (NI) 23], is HCP. (h)[Telephone/Fax (1) 93241], (w)[0-0-], (c)[Telephone/Fax (1) 93242] Medications on Admission: Aspirin 81 mg qd Metoprolol 25 mg TID Simvastatin 20 mg qd Warfarin 5.5 mg qd lasix 20mg qd Albuterol/Ipratropium 2 puffs q6h Mucomyst neb 200mg/2ml [Hospital1 ] Insulin lantus 10U qhs Insulin Regular QID SSI Omeprazole 20 mg qd Oxycodone 15mg q8h Vancomycin 1g qd (started [5-20]) Vancomycin 250 mg qid PO (started [5-19]) Chlorhexidine Gluconate Fe [Hospital1 ], KCL 20mg qd Simethicone 80 mg q8h Trazodone 75mg qhs artificial tears miconazole cream tid prn bisacodyl, lactulose, senna viscus lidocaine in mouth ativan 0.5mg q6h prn Zofran 4mg q8h prn oxycodone 10mg Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Hospital1 ]: One (1) Intravenous Q48H (every 48 hours): to complete 14 day course. 1st day [5-24]. 2. Pantoprazole 40 mg IV Q24H 3. Cipro I.V. 400 mg/40 mL Solution [Month/Year (2) ]: One (1) Intravenous once a day for 14 days: to complete 14 day course for UTI tx. 1st day [5-24]. 4. Chlorhexidine Gluconate 0.12 % Mouthwash [Month/Year (2) ]: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed. 7. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 8. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 9. Vancomycin 250 mg Capsule [Hospital1 ]: One (1) Capsule PO Q6H (every 6 hours) for 12 days. 10. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 11. Simvastatin 10 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 12. Warfarin 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 13. Furosemide 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 14. Oxycodone 5 mg/5 mL Solution [Hospital1 ]: One (1) PO Q 8H (Every 8 Hours). 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [1-27] Drops Ophthalmic PRN (as needed). 16. Miconazole Nitrate 2 % Cream [Month/Day (2) ]: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 17. Oxycodone 5 mg/5 mL Solution [Hospital1 ]: One (1) PO Q4H (every 4 hours) as needed for breakthrough pain. 18. Albuterol 90 mcg/Actuation Aerosol [Hospital1 ]: Six (6) Puff Inhalation Q4H (every 4 hours). 19. Ipratropium Bromide 17 mcg/Actuation Aerosol [Hospital1 ]: Six (6) Puff Inhalation QID (4 times a day). 20. Diltiazem HCl 30 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 21. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: 1.5 Tablets PO TID (3 times a day). 22. insulin sliding scale see attached sheet Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: hypoxia secondary to CHF/volume overload acute on chronic diastolic congestive heart failure urinary tract infection COPD ------------------ hypertension hypercholesterolemia Discharge Condition: vitals stable. Discharge Instructions: You were admitted after you were found to have a low oxygen saturation, in addition you had chest x ray findings that were concerning for volume overload. While in the ambulance you had an abnormal rhythm that was likely your underlying heart rhythm. You were given a medication for this and your heart rate and rhythm are now back to your usual. You were found to have a urinary tract infection for which you are being treated with vancomycin and ciprofloxacin. Your low oxygen was felt to be due to fluid in your lungs. Your oxygenation status improved. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: You should follow up with your physician as determined by the rehab physicians. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2190-6-15]	[ "5990", "4280", "40390", "5859", "42731", "2720" ]
Admission Date: [2185-2-3] Discharge Date: [2185-2-8] Date of Birth: [2117-2-27] Sex: F Service: [Location (un) ] Medicine Firm HISTORY OF PRESENT ILLNESS: This is a 67-year-old Russian speaking female a history of chronic renal insufficiency, type 2 diabetes, obesity, presenting with a 7 pound weight gain, increase in BUN and creatinine, BUN 157, creatinine 3.5 from her baseline creatinine bearing between [2-22], a bicarbonate of 13, and an acidemia with a pH of 7.1, pCO2 40, pO2 114. The patient was noted to be hypothermic to 94.3 F, hypotensive in the Emergency Department with a blood pressure of 94/40. Patient received approximately 2 liters of normal saline in the ED, 1 liter of Lactated Ringers and 1 liter of D5 with bicarbonate. CT of the abdomen was remarkable for 4.5 x 2.3 cm Staghorn calculus in the right renal collecting system. There is no evidence of hydronephrosis, however, the kidneys were atrophic bilaterally. Chest x-ray was unrevealing. Patient was initially transferred to the MICU and entered in the MUST protocol. She was empirically treated with Levaquin, however, there was no clear source of infection. In the MICU, the working diagnosis was prerenal azotemia versus ATN. Patient did receive aggressive IV fluid hydration, bicarbonate with improvement in her renal function and overall urine output. The Renal service was following the patient while in the MICU, and felt that there was no indication for dialysis. Upon transfer to the floor, the patient was feeling well, denying any acute complaints. She was tolerating p.o., breathing comfortably, and hemodynamically stable. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Chronic renal insufficiency with a baseline creatinine varying between [2-22]. 3. Paroxysmal atrial fibrillation. 4. Status post pacemaker for bradyarrhythmia. 5. Hypertension. 6. Hypercholesterolemia. 7. History of right upper extremity DVT. 8. Anemia. 9. Peptic ulcer disease. 10. History of nephrolithiasis. 11. History of right Staghorn calculus. 12. Status post TMA in [2184-9-20]. 13. Status post left [Doctor Last Name ]-tib bypass. ALLERGIES: Sulfa causes hives. MEDICATIONS ON ADMISSION: 1. Ambien. 2. Lipitor 10 mg q.d. 3. Glipizide 5 mg q.d. 4. Hydralazine 50 mg p.o. q.i.d. 5. Hydrochlorothiazide 12.5 mg p.o. q.d. 6. Isosorbide dinitrate 20 mg t.i.d. 7. Lopressor 100 mg t.i.d. 8. Zantac 150 mg p.o. b.i.d. 9. Zoloft 50 mg p.o. q.d. 10. Coumadin 5 mg p.o. q.h.s. SOCIAL HISTORY: No alcohol or drug abuse. Denies smoking history. Is a retired music teacher. PHYSICAL EXAM FROM ADMISSION: Temperature 94.3, heart rate 60, blood pressure 94/40, respiratory rate 12, and 96% on room air. Generally, the patient is an alert, oriented, obese female. HEENT was notable for dry mucous membranes. Cardiac examination unremarkable. Lung exam normal. Abdominal examination normal. Extremity examination: 2+ pitting edema up to the thighs bilaterally. No CVA tenderness. No asterixis. Her left foot was wrapped status post the TMA surgery in [2184-10-20]. There is no evidence of infection upon changing of the dressing. LABORATORY STUDIES FROM ADMISSION: White blood cell count 6.3, hematocrit 30.8, platelets 230. INR 2.4. Sodium 131, BUN 157, creatinine 3.5, bicarbonate 13, calcium 7, phosphorus 12.7, anion gap 19, calcium/phosphorus product 88.9. LFTs within normal limits. Urinalysis notable for moderate blood, 500 protein, negative nitrites, glucose and ketones, small leukocyte esterase. ABG: pH 7.12, pCO2 40, pO2 114, lactate 0.6. CT of the pelvis: 4.5 x 2.3 cm Staghorn calculus in right renal collecting system, no hydronephrosis. Bilateral atrophic kidneys. Multiple gallstones within the gallbladder without any evidence of inflammation. Chest x-ray: No effusions or infiltrates. Renal ultrasound from the [11-4]: Right kidney measuring 9.8 cm, left kidney 12.9 cm, multiple cysts in the right kidney one with septations. EKG: A-V paced. Previous EKG A-V paced with fusion beats. HOSPITAL COURSE BY PROBLEM: 1. Renal: Renal consult followed the patient while in-house. The patient's creatinine and BUN improved dramatically post IV fluid hydration likely secondary to prerenal azotemia versus ATN. However, there was no evidence of an inciting infection or medications which could have caused ATN. Patient was intermittently hypotensive, therefore possible hypoperfusion may have been the cause. Other possibilities included patient's longstanding history of diabetes as well as hypertension. Patient's acidemia resolved, and she did not need any further repletion of bicarbonate during her hospital course. 2. Hypotension: Patient's hypotension resolved post IV fluid hydration. Antihypertensive regimen was restarted gently upon discharge. Nephrotoxic agents such as hydrochlorothiazide was held in the interim. 3. Infectious disease: There was no evidence of sepsis, although the patient was intermittently hypotensive upon presentation as well as hypothermic. Both of these had resolved upon transfer to the floor. Cultures were negative. Patient was treated empirically with levofloxacin for presumed UTI. 4. Cardiac: Patient ruled out for a myocardial infarction on presentation. She was maintained on aspirin, statin, and beta blocker. Pump: Repeat echocardiogram was unchanged. IV fluids were held while patient was transferred to the floor, however, in the MICU the patient received several liters of IV fluids. Rhythm: Patient was A-V paced. Coumadin was restarted. Patient's INR was therapeutic. 5. GI/Heme: Patient received total 1 unit of packed red blood cells. There is no evidence of an acute bleed. Thought this may have been related to hemodilution versus renal failure. Her hematocrit responded appropriately, and patient was maintained on a proton-pump inhibitor. 6. Type 2 diabetes: Patient was maintained on Glipizide, Humalog sliding scale. Her left foot wound was postoperatively checked without any evidence of infection. Vascular Surgery staff were consulted to evaluate the patient's wound to ensure proper healing. 7. Code status: The patient was confirmed to be a full code during this hospitalization. DISCHARGE DIAGNOSES: 1. Acute renal failure secondary to acute tubular necrosis. 2. Chronic renal insufficiency. 3. Atrial fibrillation status post biventricular pacer. 4. Hypertension. 5. Hypercholesterolemia. 6. Peptic ulcer disease. 7. Anemia. 8. Status post left transmetatarsal amputation in [2184-9-20]. 9. Type 2 diabetes. RECOMMENDED FOLLOWUP: The patient is instructed to followup with Dr. [Last Name (STitle) 1366] and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] within one month of discharge. MAJOR SURGICAL OR INVASIVE PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: Patient had a central venous line placed in the MICU, which was discontinued upon discharge. DISCHARGE CONDITION: Patient is going to go home with Physical Therapy. DISCHARGE MEDICATIONS: 1. Atorvastatin 10 mg p.o. q.d. 2. Sertraline 50 mg p.o. q.d. 3. Ambien 1-2 tablets p.o. q.d. prn. 4. Hydralazine 50 mg p.o. q.6h. 5. Metoprolol 100 mg p.o. t.i.d. 6. Warfarin 5 mg p.o. q.d. 7. Glipizide 5 mg p.o. b.i.d. 8. Ranitidine 150 mg p.o. q.d. 9. Becaplermin 0.01% gel applied topically to surgical site. 10. Calcium carbonate 500 mg two tablets p.o. t.i.d. with meals. 11. Amlodipine 5 mg p.o. q.d. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (NamePattern1) 1600] MEDQUIST36 D: [2185-3-2] 17:24 T: [2185-3-3] 06:19 JOB#: [Job Number ]	[ "5845", "40391", "4280", "42731", "2762", "2720" ]
Admission Date: [2145-1-27] Discharge Date: [2145-1-31] Date of Birth: [2145-1-27] Sex: M Service: Neonatology HISTORY: Baby [Name (NI) ] [Known lastname ] is a 38-week male, who the NICU team was called to evaluate in the Newborn Nursery following an episode of circumoral cyanosis. At the time of evaluation, baby was six hours old and was born by spontaneous vaginal delivery after pitocin induction for maternal anxiety, previous 38 week IUFD to a 39-year-old G3 P2 (1) -3 woman with prenatal screens O positive, antibody negative, rubella immune, RPR nonreactive. Hepatitis B surface antigen GBS antigen negative. No sepsis risk factors. Rapid second stage of labor. Apgars eight at one minute and eight at five minutes. PREVIOUS OB HISTORY: Significant for 38 week IUFD in [2140] and full term spontaneous vaginal delivery in [2142]. Infant alive and well. MATERNAL PAST MEDICAL HISTORY: 1. Depression. 2. Bulimia. 3. Alcohol abuse. 4. Posttraumatic stress disorder. 5. Self mutilization. The patient is seen weekly by Dr. [Last Name (STitle) 16471], Psychiatry at [Hospital1 69]. CURRENT MEDICATIONS: 1. Effexor. 2. Zyprexa. ADMISSION BIRTH WEIGHT: 3660 grams 90th percentile. LENGTH: 19-3/4 inches. HEAD CIRCUMFERENCE: 34 cm. PHYSICAL EXAM ON ADMISSION: Vigorous, nondysmorphic term male infant. Anterior fontanel is soft and flat. Sutures approximated. Positive bilateral red reflex. Palate intact. Neck is supple without masses. Respirations unlabored. Lungs are clear and equal. Heart: Regular, rate, and rhythm, no murmur, pink and well perfused. Femoral pulses 2+ and equal. Liver edge at right costal margin. Abdomen is soft and nontender, active bowel sounds. Spine straight without dimples. Stable hip examination. Normal digits and creases. Symmetric tone and reflexes. REVIEW OF HOSPITAL COURSE BY SYSTEM: Baby initially had oxygen saturations greater than 95 and then demonstrated some desaturations down to the 88 with feeds, required nasal cannula O2 maximum of 200 cc, 50%, and demonstrated some shallow breathing. He also was noted to be slightly jittery at that time with his D-sticks greater than 60-70. He transitioned to room air on 10 pm on [1-29], and had remained on room air for greater than 48 hours prior to discharge. Bilateral breath sounds clear and equal. No further desaturations. His respiratory distress was thought to be related to retained fetal lung fluid and probable transient tachypnea as a newborn. Cardiovascular: Baby's heart rate was 140's with stable blood pressure. He did not require any pressor support. Did not demonstrate any apnea, bradycardia, or desaturations. His blood pressure was stable with means in the 40's-50's. He has no murmur. Fluids, electrolytes, and nutrition: Baby initially was eating adlib Enfamil 20 with iron and continues to feed well. Baby is voiding and stooling with D-sticks greater than 60. Some of his jitteriness was thought perhaps to be related to maternal psychiatric medications. Discharge weight of 3440 grams. GI: The baby did not have a bilirubin drawn. Did not look jaundiced, and did not require phototherapy. Hematology: Baby did not require blood products during this admission. Infectious Disease: Initially had a blood culture and a complete blood count sent because of presentation. Had a white count of 13.1, 57 polys, 2 bands, platelet count of 352,000, and hematocrit of 52.4. Was started on ampicillin and gentamicin. At 48 hours, he was clinically well and improving with negative cultures and antibiotics were discontinued. Neurology: Baby is appropriate for gestational age with perhaps a slight transient increase in his tone with some jitteriness as described above. Baby did not have a head ultrasound based on gestational age of greater than 32 weeks and clinical course. Sensory: Audiology screening was passed prior to discharge. Ophthalmology examination not indicated based on gestational age. Psychosocial: Parents have been visiting daily. Mother has her 15 month old baby at home, who she cares for full time and will continue to do so the same with this baby. She and her husband are currently staying with the patient's mother as they are having renovations at her house. Maternal grandparents are caring for the 15 month old during this hospitalization and are supportive. Husband will be taking some time off after baby is discharged. Parents are loving and looking forward to transition home. CONDITION ON DISCHARGE: Stable. DISPOSITION: Home with family. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] at [Hospital ] Pediatrics CARE RECOMMENDATIONS: Continue adlib feeding Enfamil 20 with iron. No medications. State newborn screen was seen on [1-30] prior to discharge on the 16th. IMMUNIZATIONS RECEIVED: Hepatitis B [1-31]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with plans for daycare during RSV season, with a smoker in the household, or with preschool siblings, or 3) with chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOW-UP APPOINTMENT: Primary pediatrician per routine. DISCHARGE DIAGNOSES: 1. Former 38 week male status post transitional tachypnea as a newborn. 2. Mild respiratory distress. 3. Status post rule out sepsis with antibiotics. Reviewed By: [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36250] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2145-1-31] 17:01 T: [2145-2-1] 06:07 JOB#: [Job Number 49267]	[ "V290", "V053" ]
Admission Date: [2111-4-30] Discharge Date: [2111-5-5] Date of Birth: [2074-6-6] Sex: F Service: SURGERY Allergies: Lisinopril / Entocort EC Attending:[First Name3 (LF) 1390] Chief Complaint: Trauma: pedestrian struck by car Major Surgical or Invasive Procedure: [2111-5-1]: bilateral ORIF tib/fib fx History of Present Illness: Patient is a 36 y.o. female s/p pedestrian struck with positive LOC at the scene and transient hypotension to the 60s. She was transported to [Hospital1 18] for further management. On arrival to ED she was neurologically intact and complained of pain to her right shoulder, left knee, and left upper quadrant of her abdomen. A head CT showed traumatic SAH and neurosurgery consulted for further management. No nausea or vomiting, denies weakness or paresthesia Past Medical History: PMH: HTN, GERD, right breast cancer, Crohn's disease, endometriosis, iron deficiency anemia, depression, chronic pain & generalized fibromyalgia-like aching PSH: Exploratory laparoscopy, laparoscopic appendectomy [2107] Dr. [First Name (STitle) 2819] Laparoscopic left salpingo-oophorectomy, left ureterolysis, lysis of adhesions, cystoscopy and biopsy of right bladder flap [2109] Port-A-Cath placement [2109] Sentinel node mapping and biopsy right axilla, partial mastectomy with wire localization right breast cancer [2109] Dr. [Last Name (STitle) ] Removal of Port-A-Cath [2110] Dr. [Last Name (STitle) 853] MEDS AT HOME: wellbutrin SR 150'', cymbalta 120', gabapentin 600' qhs, ambien 10' qhs, lorazepam 0.5' qhs, omeprazole 40'', acyclovir 800 ''' prn, tums prn, cholecalciferol (vitamin D3) 1,000', asacol 2400'', coenzyme Q10 10', flonase 50 mcg/actuation Nasal Spray Nasal 2 Spray prn, BOSWELIA', iron ER 325 mg (65 mg iron)', prochlorperazine maleate 5mg prn, probiotic'' Social History: Social Work Note: This writer makes +contact with pt's father, [Name (NI) ], pt's step-mother, [Name (NI) ] and pt's cousin. [Name (NI) ] arrive to ED and SW connects family to pt at bedside. ED Resident, [Name8 (MD) ] RN and Ortho team also support pt and pt's family at bedside with information. Pt will be admitted to TSICU for further management and this is explained to pt and pt's family and info is received w/o issue. Additionally, during this brief SW contact with the pt and pt's family, they describe pt as a strong, determined and motivated woman who has battled cancer and is a survivor. Pt is obviously in pain at this time and is overwhelmed by the severity of this traumatic event but pt appears to be coping appropriately, accepting information and is future-oriented. Family History: NC Physical Exam: PHYSICAL EXAMINATION: upon admission: [2111-4-30] HR: 92 BP: 105/89 Resp: 17 O(2)Sat: 100 Normal Constitutional: Moderate distress HEENT: No facial tendenress to palpation. No jaw malocclusion. Laceration over the left eye. Abrasion over the right flank. Blood in the right nare. No hemotypanum. Chest: Airway clear with equal breath sounds bilaterally. Chest with no subcutaneous air. Chest nontender to compression. Old scar on the left shoulder Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Left upper quadrant and left lower quadrant tendernes to palpation. GU/Flank: Pelvis nontender to compression. Extr/Back: Upper and lower extremities with equal length. Skin: Right flank abrasion. Neuro: Speech fluent. Alert and oriented x 3. Responding appropriately to questions Psych: Normal mood, Normal mentation Physical examination upon discharge: [2111-5-5] General: Awake, conversant CV: Ns1, s2, -s3, -s4 LUNGS: clear ABDOMEN: soft, non-tender, no guarding EXT: knee immobilizers bil., dsd to bil. patellas, feet warm, pink, + dp bil. NEURO: alert and oriented x 3, speech clear, no tremors, EOM's full, st. upper ext. +4/+5, lower ext. right +3/+5, left +4/+5,+ radial pulses bil SKIN: Abrasions face, well healed laceration chin and left brow, ecchymosis around eyes bil. Pertinent Results: [2111-5-5] 06:15AM BLOOD WBC-5.2 RBC-2.89* Hgb-7.8* Hct-25.6* MCV-89 MCH-27.1 MCHC-30.6* RDW-15.2 Plt Ct-229# [2111-5-4] 05:11AM BLOOD WBC-6.1 RBC-2.62* Hgb-7.5* Hct-23.0* MCV-88 MCH-28.5 MCHC-32.5 RDW-15.2 Plt Ct-140* [2111-4-30] 02:40PM BLOOD WBC-6.5 RBC-4.55 Hgb-12.7 Hct-39.2 MCV-86 MCH-27.8 MCHC-32.3 RDW-14.5 Plt Ct-200 [2111-5-5] 06:15AM BLOOD Plt Ct-229# [2111-5-3] 04:30AM BLOOD PT-11.7 PTT-25.1 INR(PT)-1.1 [2111-4-30] 02:40PM BLOOD Fibrino-285 [2111-5-4] 05:11AM BLOOD Glucose-114* UreaN-5* Creat-0.4 Na-138 K-3.7 Cl-104 HCO3-30 AnGap-8 [2111-5-3] 04:30AM BLOOD Glucose-110* UreaN-3* Creat-0.4 Na-140 K-3.7 Cl-104 HCO3-30 AnGap-10 [2111-4-30] 02:40PM BLOOD Lipase-71* [2111-5-4] 05:11AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.7 [2111-5-2] 01:03AM BLOOD Phenyto-9.4* [2111-5-1] 01:48AM BLOOD Phenyto-11.7 [2111-4-30] 02:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2111-4-30] 02:47PM BLOOD Glucose-118* Na-140 K-3.6 Cl-105 calHCO3-27 [2111-4-30]: chest x-ray: No acute traumatic injury identified within the chest [2111-4-30]: cat scan of the head: 1. Nondepressed fracture of right sphenoid bone involving the greater [Doctor First Name 362] and orbital surface, which extends into the parietal bone. Non-displaced fracture of the right zygomatic process. Non-displaced fracture of the lateral wall of the right maxillary sinus with air-blood level within right maxillary sinus. 2. Possible nondisplaced right orbital floor fracture without entrapment of the inferior rectus muscle or orbital fat. 3. Subarachnoid blood within left frontal and temporal sulci. [2111-4-30]: cat scan of abdomen and pelvis: 1. Segmental right superior pubic ramus fracture and minimally displaced right inferior pubic ramus fracture. Nondisplaced right sacral fracture and nondisplaced right lateral fifth rib fracture. 2. No evidence of vascular or solid abdominal organ injury. 3. Right lower outer breast fluid collection with adjacent coarse calcifications and metallic clips, compatible with prior lumpectomy. The collection is likely related to a seroma, but correlation with prior studies is recommended; if no such studies are available, then a breast ultrasound can be performed for futher evaluation. 4. 9-mm hypodense hepatic lesion, too small to further characterize. A metastatic lesion cannot be excluded and MR should be obtained. 5. Right middle lobe anterior parenchymal opacities, compatible with prior radiation therapy. [2111-4-30]: cat scan of cervical spine: IMPRESSION: No fracture, acute alignment abnormality, or prevertebral soft tissue abnormality. [2111-4-30]: x-ray of right shoulder: IMPRESSION: No acute fracture or dislocation. Calcific tendinopathy of the rotator cuff. [2111-4-30]: x-ray of ankles bilateral: IMPRESSION: Comminuted bilateral proximal tibial and fibular fractures. Lipohemarthrosis noted within the left knee. [2111-4-30]: bilateral tib/fib. fracture: IMPRESSION: Comminuted bilateral proximal tibial and fibular fractures. Lipohemarthrosis noted within the left knee. [2111-4-30]: left elbow x-ray: IMPRESSION: No evidence of fracture or dislocation [2111-4-30]: cat scan of sinus, mandible, maxilla: IMPRESSION: 1. Fractures of the right zygoma, right greater [Doctor First Name 362] of the sphenoid, and the lateral wall of the right maxillary sinus. Equivocal fracture of the right orbital floor along the infraorbital canal as described above. 2. Blood noted within the right maxillary sinus. 3. Laceration in the left forehead. [2111-4-30]: cat scan of lower ext.: IMPRESSION: LEFT KNEE: Comminuted intra-articular fracture of the proximal metadiaphysis of the tibia that extends into the lateral condyle with 4-5 mm depression of lateral condyle as described above. Comminuted intra-articular fracture of the proximal fibula as described above. RIGHT KNEE: Comminuted fracture of the proximal metadiaphysis of the tibia as described above. Possible impaction fracture of the posterior medial tibial plateau. Comminuted extra-articular fracture of the proximal fibula as described above. [2111-4-30]: cat scan of the head: IMPRESSION: 1. Stable amount of subarachnoid hemorrhage in the left frontal and temporal sulci. 2 Stable right subgaleal hematoma 3. Incomplete visualization of known facial and skullbase fractures. [2111-4-30]: cat scan of the head: IMPRESSION: 1. Diffuse subarachnoid hemorrhage, evolving on the left and slightly increased on the right. 2. Persistent tiny left subdural hematoma. 3. Nondisplaced right facial/calvarial fractures [2111-5-1]: lower ext. fluro: FINDINGS/IMPRESSION: Again are seen fractures through the proximal tibial and fibular diaphyses. The tibial fracture has been restored to near anatomic alignment after plate and screw fixation. The intra-articular fracture and depressed fragment are more apparent on prior study. For more details, please see the operative note. [2111-5-1]: x-ray of the right tib/fib: FINDINGS/IMPRESSION: Again are seen fractures through the proximal tibial diaphysis as well as through the fibular head, now status post plate and screw fixation restoring the tibial fracture to near-anatomical alignment. For more details, please see the operative note. [2111-5-2]: head cat scan: In comparison to study obtained one day prior, there is no significant change in subarachnoid hemorrhage. A small subdural collection layering along the left tentorium cerebelli is more conspicuous since prior. Subgaleal hematoma of the right frontotemporal region has slightly decreased in size since prior. There is stable appearance of a nondisplaced fracture involving the right frontal, sphenoid, and the zygomatic arch. Brief Hospital Course: The patient was admitted to the hospital after being struck by a car. Initially, she was reported to be alert, but was hypotensive requiring intravenous fluids. Upon admission, she was made NPO, maintained on intravenous fluids, and underwent radiographic imaging. She sustained facial fractures, SAH, pubic rami fracture, sacral fracture, right 5th rib fracture, and bilateral tibia/fibula fractures. In addition, to the above injuries, she sustained left sided facial lacerations and abrasions. The laceration was sutured. Because of her injuries, several services were consulted. She was evaluated by Plastic surgery and after evaluation, they determined that non-operative intervention was needed with follow-up in the clinic for re-examination of her facial fractures. She was placed on sinus precautions. On HD #2, she was taken to the operating room for ORIF of bilateral tibia/fibula fractures. During her operative course, she required blood pressure support with neosynephrine. She was extubated after the procedure and transported to the intensive care unit for monitoring. Her pelvic fractures were deemed non-operative. Her cervical spine showed no fractures and the cervical collar was removed on HD #2. Her neurological status was closely monitored by clinical examination and by repeat head cat scans. The head cat scans were stable showing improving SAH. She continued on her 10 day course of dilantin for seizure prophalaxis. After her vital signs stabilized, she was transferred to the surgical floor on HD #3. She was maintained on a diluadid PCA for pain management. After starting clear liquids, she was transitioned to oral analgesia which provided pain control. She quickly progressed to a regular diet. Her foley catheter was removed on HD # 5 and she has been voiding without difficulty. Her facial sutures were removed on HD #19. During her hospitalization, she was evaluated by physical therapy and because of her limitations, recommendations made for discharge to a rehabilitative facilitly where she can further regain her strength and mobility. They have provided her with ROM exercises to her lower extremities. Social services have been an active participant in her discharge care, providing her and her family with support. Her vital signs have been stable and she has been afebrile. Her hematocrit has stabilized at 26. She is tolerating a regular diet and voiding without difficulty. She is preparing for discharge with instructions to follow-up in the acute care clinic, orthopedic clinic, plastic clinic and with neuro-surgery. Cognitive evaluation was recommended at rehabilitation facility. Of note: cat scan of abdomen pelvis: [4-30] showed: 9-mm hepatic hypodense lesion (601b:20) is too small to further characterize and if there is a history of malignancy, cannot exclude metastatic lesion and MR should be obtained. Will need to follow-up with primary care provider upon discharge from rehab. The patient was informed of the finding as well as Dr. [Last Name (STitle) 3649] and Dr. [Last Name (STitle) ]. Medications on Admission: MEDS AT HOME: wellbutrin SR 150'', cymbalta 120', gabapentin 600' qhs, ambien 10' qhs, lorazepam 0.5' qhs, omeprazole 40'', acyclovir 800 ''' prn, tums prn, cholecalciferol (vitamin D3) 1,000', asacol 2400'', coenzyme Q10 10', flonase 50 mcg/actuation Nasal Spray Nasal 2 Spray prn, BOSWELIA', iron ER 325 mg (65 mg iron)', prochlorperazine maleate 5mg prn, probiotic'' Discharge Medications: 1. Acetaminophen 1000 mg PO Q 8H 2. Bisacodyl 10 mg PO/PR DAILY 3. Docusate Sodium 100 mg PO BID 4. Duloxetine 120 mg PO DAILY 5. Gabapentin 600 mg PO HS 6. Heparin 5000 UNIT SC TID 7. BuPROPion (Sustained Release) 150 mg PO BID 8. Senna 1 TAB PO BID 9. Sarna Lotion 1 Appl TP QID:PRN itching 10. TraMADOL (Ultram) 50 mg PO QID 11. Zolpidem Tartrate 10 mg PO HS insomnia 12. Phenytoin Infatab 100 mg PO TID stop date [5-9] after last dose administered. 13. Mesalamine DR 2400 mg PO BID 14. OxycoDONE (Immediate Release) 5-15 mg PO Q3H:PRN pain 15. Omeprazole 40 mg PO BID 16. Acyclovir 800 mg PO Q8H prn 17. Lorazepam 0.5 mg PO HS:PRN insomnia Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit at [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: Trauma: pedestrian struck: Right temporal bone and sphenoid fracture Left frontal SAH Right zygoma fracture and lateral maxillary wall Right 5th rib fracture Right comminuted superior and inferior pubic rami fracture Right non-displaced sacral fracture Right tibia/fibula fracture Left tibia/fibula +plateau fracture L facial lac ([4-30]-) + abrasions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after you were struck by a car. You underwent a cat scan of your head, neck, and abdomen. You were found to have a small bleed in your head, facial fractures, a pelvic fracture, rib fractures, a fractured right arm, and fractures to your legs. You were takenn to the operating room where you had surgical repair of your lower extremities. You are slowly recovering from your injuries. You have been seen by Physical therapy and recommendations made for discharge to a rehabiliatation facililty where you can regain your strenght and mobility. Followup Instructions: Department: DIV. OF PLASTIC SURGERY When: TUESDAY [2111-5-19] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 16921], MD [Telephone/Fax (1) 4649] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: ORTHOPEDICS When: THURSDAY [2111-5-21] at 1:20 PM 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: THURSDAY [2111-5-21] at 1:40 PM 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: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2111-5-28] at 1:15 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Notes: You will need a chest x-ray prior to this appointment. Please go to [Hospital1 7768], [Hospital Ward Name 517] Clinical Center, [Location (un) 3202] Radiology 30 minutes prior to your appointment. Department: RADIOLOGY When: MONDAY [2111-6-8] at 10:15 AM With: CAT SCAN [Telephone/Fax (1) 590] Building: CC [Location (un) 591] [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Notes: Nothing to eat or drink for 3 hours prior to this test. Department: NEUROSURGERY When: MONDAY [2111-6-8] at 10:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 43708], MD [Telephone/Fax (1) 2731] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2111-5-5]	[ "4019", "53081", "42789" ]
Admission Date: [2168-1-10] Discharge Date: [2168-1-13] Date of Birth: [2123-8-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1055] Chief Complaint: urosepsos; bradycardia Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 44 yo M with h/o htn, ? prior strokes, transfer from prison for syncope. Prior to syncopal event, reports SSCP x 15 min, no radiation, but diaphoretic with nausea. Pt. then noticed his hearing going before blacking out. Pt. recently had his atenolol increased from 50 to 100mg qd. Pt. also reports having dysuria 4-5 days ago, 1 week of a L sided headache, mild photophobia, and 3 days of fatigue, but no fevers. Around the same time, noticed hand numbness when getting into bed. Brought to [Hospital 46] Hosp. There, pt. had bradycardic arrest, asystolic x 12 sec, got epi and atropine. HR increased from 25 to 160, thought to be in SVT, received adenosine(6mg, then 12mg). Then, hypotensive, started on dopamine. CT head/chest/abd negative. Transferred to [Hospital1 18]. On transfer, temp of 102F, sbp in 80s, lactate 3.2. After 3 L, sbp still in 80s. Code sepsis called. Sepsis line placed. Fluid CVP came up to [10-19]. Started on levophed. Pt. received unasyn and vanc. EKG without abnormalities, but troponin came back at 0.70. ABG - 7.43/32/295. Lactate decreased from 3.2 to 1.1. U/A grossly positive. Labs also notable for elevated Cr. (baseline unknown). Received vanc and Unasyn in ED. Patient admitted to MICU, IVF resuscitated and weaned off of levophed, and subsequently transferred to 12R. Past Medical History: PMH: htn, ? past strokes, h/o cocaine use;; patient reports h/o CAD (no records available) Social History: SH: Incarcerated x 1 mo. + tob use. Prior ETOH, none recently. Injected cocaine 1-2 months ago. Last sexually active 1 mo. ago - partner is female, not known to have STDs Family History: Non-contributory Physical Exam: PE: 97.5, tmax-102, 78, 132/70, 18, 94%RA gen - NAD HEENT - MM dry, PERRLA - no photophobia neck - supple, some post. midline tenderness c/v - RRR, no m/g/r abd - s/nt/nd, NABS rectal - boggy prostate, tender to palp (per OMR) groin - R inguinal tenderness without LAD - no hernia palpated lungs - b/basilar crackles back - paraspinal and midline lumbar tenderness extr - no c/c/e neuro - A+Ox3, mild facial weakness (baseline per patient), MAE Pertinent Results: [2168-1-10] 11:31PM URINE HOURS-RANDOM CREAT-89 SODIUM-66 [2168-1-10] 11:31PM URINE RBC-[3-12]* WBC->50 BACTERIA-FEW YEAST-NONE EPI-0-2 [2168-1-10] 11:19PM LACTATE-1.1 [2168-1-10] 09:00PM PT-14.3* PTT-54.5* INR(PT)-1.3 [2168-1-10] 08:13PM freeCa-1.11* [2168-1-10] 07:50PM GLUCOSE-115* UREA N-30* CREAT-2.3* SODIUM-137 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 [2168-1-10] 07:50PM ALT(SGPT)-19 AST(SGOT)-12 CK(CPK)-55 ALK PHOS-99 AMYLASE-79 TOT BILI-0.5 [2168-1-10] 07:50PM LIPASE-38 [2168-1-10] 07:50PM cTropnT-0.70* [2168-1-10] 07:50PM CORTISOL-47.6* [2168-1-10] 07:50PM CALCIUM-8.6 MAGNESIUM-1.8 [2168-1-10] 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2168-1-10] 07:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2168-1-10] 07:50PM WBC-11.3* RBC-3.66* HGB-13.3* HCT-37.3* MCV-102* MCH-36.4* MCHC-35.7* RDW-12.7 [2168-1-10] 07:50PM NEUTS-90.6* BANDS-0 LYMPHS-5.9* MONOS-3.3 EOS-0.1 BASOS-0.1 [2168-1-10] 07:50PM PLT SMR-NORMAL PLT COUNT-255 CXR: no acute process EKG:NSR ar 90bpm, nlaxis/nl int twi AvL Nuclear stress test-normal perfussion and wall motion. EF> 55% Brief Hospital Course: A/P 44 yo M with h/o htn p/w with new chest pain, syncope, hypotension, in setting of prostatitis c/b urosepsis and same day change in beta-blocker dose. The stress of infection in addition to bradycardia from increased atenolol likely led to unstable angina and syncope. . #hypotension - the cause of patient's arrest was never clear. Our theory was that he was becoming septic from a urinary tract pathogen, possibly related to prostatitis. Pt likely had a bradycardic arrest in the setting of this septic picture plus the recent increased dose of his beta blocker. Pt's blood pressure was high-normal at discharge and he was able to tolerate the equivalent of 50 [Hospital1 ] of lopressor. We felt this was a better drug than atenolol for this pt in light of his renal dysfunction (mild arf at presentation that cleared up with hydration). #urosepsis/prostatitis - positive U/A, likely related to prostatitis - STD ruled out by urethral swab. Pt probably became septic with foley insertion. Less likely from renal stone given nl CT abd. Will rx with 500 mg po levaquin for 4 weeks total for acute prostatitis. Abd/Pelvis CT negative for prostatic abscess. #bradycardia - probably has been going on for days as the patient has been feeling very fatigued x 3d. Brady likely from combination of increased atenolol plus vasovagal from the pain of the prostatitis. . #troponin leak -Pt had + troponin but negative CK at presentation which subsequently improved. It is unclear if related to the bradycardia or if from epinephrine during brady arrest or from CPR given in ER. No evidence of new coronary event on EKG. Pt. denies cocaine use, none seen in tox screen. Pt was seen by cardiology and had a negative stress mibi which also revealed normal ejection fraction. . #ARF - no known h/o renal failure. This was related to arrest vs hypotension of sepsis and dehydration. No hydronephrosis or perinephric abscess seen on abd/pelvic CT scan. Pt's renal fx improved with hydration. Medications on Admission: ASA ciprofloxacin 500mg [Hospital1 ] Discharge Disposition: Home Discharge Diagnosis: Sepsis-no pathogen found. Bradycardia related to medication side-effect. Prostatitis. Coronary Artery Disease Discharge Condition: Good Discharge Instructions: You have been evaluated for possible prostatitis and chest pain. Please take all your medications as prescribed. We have ruled out a heart attack as the cause of your low blood pressure and feel that you likely had an infection that caused your symptoms. Please page Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 8717] for questions you or your doctor may have about your care during this hospitalization. Please talk to your doctor if you develop chest pain, fevers or other problems. Followup Instructions: You should be evaluated by a doctor in [2-12] days to check your vital signs and perform orthostatic blood pressure checks. Please follow-up with a cardiologist in [4-13] weeks.	[ "0389", "99592", "78552", "42789", "5849", "4019", "41401" ]
Admission Date: [2185-2-25] Discharge Date: [2185-3-5] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8104] Chief Complaint: slurred speech Major Surgical or Invasive Procedure: PICC placement History of Present Illness: The patient is an 89F w/ HTN, vascular dementia who presents with slurred speech and weakness. She has reportedly experienced over the period of a couple days to a week worsening generalized fatigue, some dysarthria, swelling of lips, hands, and feet. She had a CT head as an outpatient that did not see anything acute but was limited by extensive chronic small vessel disease. She was scheduled for an MRI today but she had a mechanical fall (she says she tripped over the table) and so was sent to the ED. She did not have loss of consciousness. In the ED her vitals were 96.6, 54, 141/76, 17, 100%. A repeat CT head showed no evidence of acute stroke. Neuro was consulted and said there were no focal neuro symptoms so stroke is unlikely. She has chronic right shoulder and arm weakness that is unchanged. CXR was unremarkable, UA was negative. She appeared dehydrated and was given a 500cc bolus of IVF. BNP was 498. Her baseline is reportedly not far off her baseline per her family. ROS: -Constitutional: []WNL []Weight loss [x]Fatigue/Malaise []Fever []Chills/Rigors []Nightsweats []Anorexia -Eyes: []WNL [x]Blurry Vision []Diplopia []Loss of Vision []Photophobia -ENT: []WNL [x]Dry Mouth []Oral ulcers []Bleeding gums/nose []Tinnitus []Sinus pain []Sore throat -Cardiac: [x]WNL []Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: [x]WNL []SOB []Pleuritic pain []Hemoptysis []Cough -Gastrointestinal: [x]WNL []Nausea []Vomiting []Abdominal pain []Abdominal Swelling []Diarrhea []Constipation []Hematemesis []Hematochezia []Melena -Heme/Lymph: [x]WNL []Bleeding []Bruising []Lymphadenopathy -GU: [x]WNL []Incontinence/Retention []Dysuria []Hematuria []Discharge []Menorrhagia -Skin: [x]WNL []Rash []Pruritus -Endocrine: [x]WNL []Change in skin/hair []Loss of energy []Heat/Cold intolerance -Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain -Neurological: []Numbness of extremities []Weakness of extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion []Headache -Psychiatric: [x]WNL []Depression []Suicidal Ideation -Allergy/Immunological: [x] WNL []Seasonal Allergies Past Medical History: # Syncope since [2179]: per neuro note [5-3], these occur while sitting in church, at a funeral, and eating. -- [10-29]: Holter with frequent atrial ectopic beats and short bursts of atrial tachy. -- [10-29]: Echo: mild symmetric LVH. EF normal. No AS, mild MR -- [10-31]: EEG: No focal, lateralizing, or epileptiform features were seen. -- [12-31]: MRI: Extensive roughly symmetric T2 hyperintensity in the cerebral white matter and pons with extension into the temporal horns # HTN # ? Hyperlipidemia # Vascular dementia: seen by neuro here, subcortical white matter disease # Ptosis - initially right sided, more recently left sided. No evidence for myasthenia based on negative antibodies, normal EMG, no systemic signs. Seen by Dr. [Last Name (STitle) ] of neurology who couldn't fully exclude ocular myasthenia (unlikely though). Has had repair bilaterally by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7363] of ophthalmology for dermatochalsis of the upper lids Social History: Lives alone in [Location (un) 448] apt, her elderly sister, niece, and grand nephew live upstairs. Gets VNA twice a week, Meals on Wheels Denies tobacco, alcohol, drugs Family History: nc Physical Exam: Physical Exam: Appearance: NAD Vitals: T: 94.6 (axillary) BP: 104/60 HR: 60 RR: 18 O2: 100% RA Eyes: EOMI, PERRL, conjunctiva clear, mildly injected bilaterally, anicteric, no exudate, ptosis right>left ENT: Dry MM Neck: No JVD, no LAD, no thyromegaly, no carotid bruits Cardiovascular: RRR, nl S1/S2, no m/r/g Respiratory: CTA bilaterally, comfortable, no wheezing, no ronchi, no rales Gastrointestinal: soft, non-tender, non-distended, no hepatosplenomegaly, normal bowel sounds Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint swelling, trace edema in the bilateral extremities Neurological: Alert and oriented x3, dysarthric speech but fluent, sensation WNL, CNII-XII intact except for right nasolabial fold flattening and right ptosis greater than left; unable to fully cooperate with strength exam despite redirection but has 4-5/5 strength in all extremities with 4-/5 in right upper extremity Integument: warm, no rash, no ulcer Psychiatric: appropriate, pleasant Hematological/Lymphatic: No cervical, supraclavicular, axillary, or inguinal lymphadenopathy GU: normal genitalia, catheter present Pertinent Results: [2185-2-25] 02:00PM GLUCOSE-91 UREA N-32* CREAT-0.8 SODIUM-136 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-29 ANION GAP-11 [2185-2-25] 02:00PM ALT(SGPT)-32 AST(SGOT)-59* ALK PHOS-118* TOT BILI-0.3 [2185-2-25] 02:00PM LIPASE-107* [2185-2-25] 02:00PM proBNP-498 [2185-2-25] 02:00PM ALBUMIN-3.7 [2185-2-25] 02:00PM WBC-3.9* RBC-4.28 HGB-14.0 HCT-39.7 MCV-93 MCH-32.8* MCHC-35.4* RDW-13.5 [2185-2-25] 02:00PM NEUTS-81.4* LYMPHS-13.0* MONOS-4.3 EOS-0.5 BASOS-0.7 [2185-2-25] 02:00PM PLT COUNT-149# [2185-2-25] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG CXR [2-25]: No acute cardiopulmonary abnormality. Head CT [2-25]: IMPRESSION: No intracranial hemorrhage. MR [Name13 (STitle) ] [2-27]: 1. No acute infarction. 2. Extensor FLAIR hyperintense areas, in the brain parenchyma likely related to ischemic changes, grossly unchanged. 3. Multilevel degenerative changes in the cervical spine, causing mild-to- moderate canal stenosis at C5-C6 level not completely evaluated on the present study. 4. Patent major intracranial arteries, with ectasia of the distal vertebral, basilar and cavernous carotid segments as before. No flow-limiting stenosis or occlusion or focal aneurysm, more than 3 mm elsewhere, other than the ectatic segments, within the resolution of MRA. 5. New paranasal sinus disease -fluid versus mucosal thickening in the ethmoid, sphenoid and the left side of the frontal sinus. CSF:Hematology ANALYSIS WBC RBC Polys Lymphs Monos Macroph [2185-3-1] 02:17PM 2 4 5 52 0 43 TUBE#4 Chemistry CHEMISTRY TotProt Glucose [2185-3-1] 02:17PM 32 54 Source: LP; TUBE#2 HSV:lHerpes Simplex Virus [1-28] Detection and Diff, PCR HSV 1 DNA Not Detected Not Detected HSV 2 DNA Not Detected Not Detected Brief Hospital Course: [Hospital Unit Name 153] course [2-26] - : 89F w/ HTN, vascular dementia admitted with weakness and dysarthria, transferred to [Hospital Unit Name 153] with altered mental status. # Sepsis: The patient's WBC increased to 21.0 the day after transfer to the [Hospital Unit Name 153] from 9.4. The night after transfer she required vasopressor support after running a SBP in the 60s-70 with no response to IVF. Her decline overnight was rapid, around 1900 showed signs of somonelence and apnea, she was then noted to be hypotensive requiring at first peripheral Dopamine. Her antihypertensives were discontinued. During that time she also showed no [Location (un) 1131] on rectal temperature and was started on a Bair hugger. Concern stemmed from her progression of AMS to sepsis, given this data there was a large concern for bacterial meningitis. She was initally started on Ceftriaxone and Vancomycin empirically [2-26] and an LP was deferred given that she was hemodynamically unstable. She was also started on Ampicillin for Listeria coverage. An LP was attempted on [2-27] at the beside, but was unsuccessful. DIC labs were checked and were negative. Brain MRI was negative for acute ischemia. An IR guided LP was performed. All culture data was negative at time of discharge, but given patient's presentation and lack of alternative diagnosis, neurology recommended complete treatment for meningitis. # AMS/seizure: On the evening of [2-26] she was noted to be somnolent with episodes of apnea, due to concerns for airway protection and she was intubated and transferred to ICU. On the day after transfer she had a witnessed left focal hemibody clonic seizure that lasted for about 60 s and left her in apost-ictal state with unresponsiveness to voice or sternal rub. Since admission she has not been responsive, given the witnessed episode of tonic clonic seizure, it was hypothesized that Ms. [Known lastname 34601] underwent a seizure on the floor and was post-ictal upon assessment. Neurology were consulted and recommended loading with Keppra continuing 500mg Keppra IV BID. CT head performed yesterday showed no acute ICP, MRI was negative for acute ischemia or mass, though did reveal extensive vascular disease. She was subsequently extubated without complication. Her keppra dose was uptitrated to 1000mg [Hospital1 ]. She had no other witnessed seizures and her mental status improved during this hospitalization. # NSTEMI: No ECG changes, no complaint of chest pain, however elvated CKs Suspect likely demand ischemia in setting of acute illness. TT was performed and showed ## lip swelling and tongue enlargement: unclear etiology, no new meds, diff dx includes drug, allergy, infection, autoimmune disorder. Her respiratory status was stable. She was seen by the allergy service who agreed with plan to discontinue asa and continue antihistaminefor now. Diagnostic tests were sent. She has follow-up in allergy clinic. #vascular dementia: -Was continued on ASA and statin. Given angioedema plan was to hold ASA and start Plavix. Plavis was not given as patient had gross hematuria at discharge, but this could be restarted when resolved. ## hypertension: normotensive on arrival c/b hypotension. --outpatient HCTZ still held at discharge ## ptosis: followed by Dr. [First Name (STitle) 7363] of ophtho, s/p bilateraly lid repair -- eye drops continued ## Nutrition: please see page 1 #Addendum: Patient was discharged to [Last Name (un) 2299] house, but since written confirmation of PICC line placement was not in paperwork, patient was sent back to [Hospital1 18]. Confirmation was received and patient was then discharged [3-5] to [Last Name (un) 2299]. Of note, patient's hematuria was resolved, so Plavix can likely be restarted. Medications on Admission: Os-Cal 500 + D 500mg (1,250 mg)-200 unit tab travatan Z 0.004% eye drops ASA 81mg qd MVI Tylenol 325mg qd Timoptic-XE 0.5% eye gel 1 drop [Hospital1 ] qam HCTZ 12.5mg qd Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 4. Timolol Maleate 0.5 % Drops [Hospital1 ]: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 6. Latanoprost 0.005 % Drops [Hospital1 ]: One (1) Drop Ophthalmic HS (at bedtime). 7. Simvastatin 40 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Last Name (STitle) ]: [1-28] Drops Ophthalmic PRN (as needed) as needed for dryness. 10. Fexofenadine 60 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 11. Keppra 100 mg/mL Solution [Month/Day (2) ]: Ten (10) ml PO twice a day. 12. 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. 13. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback [Month/Day (2) ]: One (1) Intravenous Q12H (every 12 hours) for 7 days. 14. Vancomycin 1000 mg IV Q 24H 15. Ampicillin Sodium 2 gram Recon Soln [Month/Day (2) ]: One (1) Recon Soln Injection Q6H (every 6 hours) for 10 days. 16. Acyclovir Sodium 500 mg Recon Soln [Month/Day (2) ]: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 10 days. 17. 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. 18. Plavix 75 mg Tablet [Month/Day (2) ]: One (1) Tablet PO once a day: ****** PLEASE NOTE THAT THIS WAS HELD AT DISCHARGE GIVEN HEMATURIA******. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: 1) Angioedema 2) Seizure d/o 3) Possible meninigitis Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with angioedema. You also had a seizure and an infection. Please return to the hospital should you develop fevers, chills, worsening mental status or other concerning symptoms. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 9316] Date/Time:[2185-3-9] 8:00 Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 252], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2185-3-22**] 9:45	[ "0389", "41071", "51881", "99592", "2724" ]
Admission Date: [2135-8-29] Discharge Date: [2135-9-27] Date of Birth: [2066-11-25] Sex: M Service: MEDICINE Allergies: Vidaza / vancomycin Attending:[First Name3 (LF) 38616] Chief Complaint: Admitted electively for chemotherapy for MDS in transformation to AML Major Surgical or Invasive Procedure: cardiac cath thoracentesis History of Present Illness: Patient is admitted for Cycle 2 of Decitabine. He has been doing relatively well at home since his most recent two hospital admissions: [Date range (1) 73068] admitted with progressive weakness due to pneumonia and UTI and [Date range (1) 73067] with fever and found to have a pansensitive E. coli bacteremia, Vancomycin sensitive enterococcal bacteremia, and [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 563] blood stream infection. That hospitalization included marked LFT abnormalities, and a question of a cholecystitis versus possible drug reaction. Last had chemotherapy with Cycle 1 Decitabine on [2135-6-6] after a drug challenge with lower doses which he tolerated well. The drug challenge was performed because he had a severe reaction to Azacitadine with multiple skin complications including neutrophilic dermatoses and ischemic bowel. He was transferred to the CCU after developing CP while on the oncology service on the evening of [9-5]. He developed sudden onset SSCP which then radiated to the back, described as a throbbing sensation, not similar to chronic back pain. He received 0.4 SL Nitro x 3 and 10 mg IV morphine with some resolution. There was a thought there may be some ST depressions in V4-V5, which resolved after the above. BP was symmetric in BUE at that time. A bedside echo was performed by the cardiology fellow with new inferolateral hypokinesis so he was transferred urgently for cath, lab was activated overnight. Cath revealed single vessel right dominant disease with 70% stenosis of the RCA. No stent was placed in order to minimize the risk of interruption of chemotherapy. His CP was attributed to demand ischemia and troponin peaked at 0.07 before trending down. . Upon arrival to the CCU, pt. was noted to have temp of 104 without localizing symptoms for infection. He was already on Vancomycin, Cefepime, Fluconazole and Acyclovir at time of transfer to the CCU (Vanc and Cefepime added just prior to cath). Vancomycin was changed to Daptomycin today given concern for allergy. UA showed trace leuks, few bacteria and CXR showed no evidence of pneumonia. Blood and urine cultures show NGTD. He also developed asymptomatic hypotension in the CCU with systolics in the 80s, responsive to fluid. He was afebrile otherwise throughout CCU stay. He was given 1L NS total with improvement to the 90s systolic. He had a few hours of [Last Name (un) ], transient hypoxia with SaO2 88 on RA which resolved with 2L nasal O2. He was transferred to the floor on [9-7] without any complications. On ROS he reports that he is still fatigued, ambulating with a walker, and has a poor appetite. He denies fevers, rigors, chills, new pain, cough, dysuria or focal symptoms of infection. He also denies chest pain, nausea, vomiting, shortness of breath. All other ROS are negative. . Past Medical History: MDS RAEB type 1, 7% blasts with extensive myelofibrosis, 7q-, transfusion dependent, s/p azacitadine complicated by ischemic bowel perforation and multiple ulcers (pyoderma gangrenosum). Right colectomy [9-/2134], for ischemic bowel with slow healing midline abdominal wound. Decubitus ulcers. Neutrophilic dermatosis (pyoderma gangrenosum and Sweets syndrome). Carpal tunnel syndrome. COPD. Left knee surgery. Back surgery. Demand ischemia with 70% stenosis of RCA on cath [9-5], elected to treat with medical therapy alone Social History: Retired, used to work for a chemical company. History of asbestos and other chemical exposure. He has a history of significant alcohol use, which he stopped approximately seven years ago. 60 pack year history of tobacco use. Family History: Sister - died of scleroderma; Another sister - died of unclear etiology; Brother - died of EtOH abuse; Daughter with Marfan's; Two brothers are alive and well; Mother - died of lung cancer; Father - died in an MVC. Physical Exam: VS: T: 99 BP:94/52 P:92 RR:18 in O2Sat: 98 % on 2L GENERAL: thin appearing, in no apparent distress Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: Mucous membranes moist,without ulcers or exudates, good dentition Neck: supple, no JVD or carotid bruits appreciated Respiratory: CTA bilaterally without rhonci, without wheezes Cardiovascular: RRR, S1S2, II/VI systolic murmur on LUSB, no rubs, no gallops Gastrointestinal: soft, NT/ND, no rebound, no guarding, normoactive bowel sounds, no masses or organomegaly noted. Skin: warm, dry, two right sided abdominal ulcers that are pink and perfused well, appear to be healing and uninfected, unstageable sacral decub Extremities: without cyanosis, without clubbing, mild bilateral LE edema, without joint swelling Neurologic: -mental status: Alert, oriented x 3. Normal attention. Able to relate history without difficulty. Fluent speech. Psychiatric: calm, appropriate. . Pertinent Results: [2135-8-29] 12:15PM UREA N-30* CREAT-1.2 SODIUM-133 POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-29 ANION GAP-10 [2135-8-29] 12:15PM ALT(SGPT)-13 AST(SGOT)-25 LD(LDH)-311* ALK PHOS-160* TOT BILI-0.5 [2135-8-29] 12:15PM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.7 [2135-8-29] 12:15PM WBC-3.6* RBC-2.71* HGB-8.0* HCT-22.7* MCV-84 MCH-29.4 MCHC-35.1* RDW-16.0* [2135-8-29] 12:15PM NEUTS-31* BANDS-4 LYMPHS-28 MONOS-11 EOS-2 BASOS-3* ATYPS-2* METAS-3* MYELOS-2* BLASTS-14* [2135-8-29] 12:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [2135-8-29] 12:15PM PLT SMR-VERY LOW PLT COUNT-25* . [2135-9-7] 04:01PM BLOOD WBC-1.2* RBC-3.20* Hgb-9.5* Hct-27.3* MCV-85 MCH-29.6 MCHC-34.8 RDW-16.2* Plt Ct-17* [2135-9-7] 04:01PM BLOOD WBC-1.2* RBC-3.20* Hgb-9.5* Hct-27.3* MCV-85 MCH-29.6 MCHC-34.8 RDW-16.2* Plt Ct-17* [2135-9-7] 05:59AM BLOOD Neuts-36* Bands-2 Lymphs-33 Monos-4 Eos-3 Baso-1 Atyps-0 Metas-9* Myelos-7* Blasts-5* [2135-9-7] 04:01PM BLOOD Plt Ct-17* [2135-9-6] 06:02AM BLOOD PT-16.2* PTT-33.7 INR(PT)-1.4* [2135-9-7] 04:01PM BLOOD Glucose-99 UreaN-38* Creat-1.1 Na-135 K-4.1 Cl-102 HCO3-22 AnGap-15 [2135-9-6] 06:02AM BLOOD ALT-11 AST-18 CK(CPK)-20* AlkPhos-77 TotBili-0.3 [2135-9-7] 04:01PM BLOOD Calcium-8.6 Phos-4.3 Mg-2.5 Trend for [Last Name (un) ]: [2135-9-24] 07:10AM BLOOD Glucose-100 UreaN-48* Creat-1.6* Na-136 K-4.3 Cl-104 HCO3-25 AnGap-11 [2135-9-25] 04:43AM BLOOD Glucose-88 UreaN-53* Creat-2.3* Na-137 K-5.0 Cl-106 HCO3-22 AnGap-14 [2135-9-26] 06:35AM BLOOD Glucose-106* UreaN-65* Creat-3.0* Na-135 K-5.6* Cl-105 HCO3-21* AnGap-15 Hypercalcemia: PARATHYROID HORMONE RELATED PROTEIN Test Result Reference Range/Units PTH-RP 15 14-27 pg/mL VITAMIN D [1-11] DIHYDROXY Test Result Reference Range/Units VITAMIN D, 1,25 (OH)2, TOTAL <8 L 18-72 pg/mL VITAMIN D3, 1,25 (OH)2 <8 VITAMIN D2, 1,25 (OH)2 <8 VITAMIN D 25 HYDROXY Test Result Reference Range/Units VITAMIN D, 25 OH, TOTAL 22 L 30-100 ng/mL VITAMIN D, 25 OH, D3 16 ng/mL VITAMIN D, 25 OH, D2 6 ng/mL Pleural Fluid: [2135-9-19] 08:22AM BLOOD freeCa-1.43* [2135-9-9] 05:17PM PLEURAL WBC-144* RBC-4625* Polys-45* Lymphs-35* Monos-1* Eos-18* Meso-1* Other-0 [2135-9-9] 05:17PM PLEURAL TotProt-2.3 Glucose-139 LD(LDH)-91 Albumin-1.5 pH=7.42 NO MALIGNANT CELLS [2135-9-5] Cardiac catheterization COMMENTS: 1) Selective coronary angiography of this right-dominant system demonstrated single vessel CAD, with a 70% non-obstructive ostial lesion of the large RCA. The LMCA and LAD were large-caliber and patent vessels; the LCx was diminutive and patent. 2) Ventriculography revealed an estimated EF of 55% with mild inferior hypokinesis and mild mitral regurgitation. 3) Limited resting hemodynamics revealed systemic arterial hypotension, with a central aortic pressure of 80/38 mmHg. There was no systolic pressure gradient between the aorta and the left ventricle, upon careful pullback of the pigtailed catheter. 4) Given the patient's acute leukemia, thrombocytopenia, and plan to continue with chemotherapy in the setting of being chest pain-free, we opted to treat the RCA stenosis medically for now until we have a detailed discussion with the oncology team. The patient as well favored this approach, understanding that an intervention may interfere with his chemotherapeutic plan. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Mild mitral regurgitation. 3. Mild systolic ventricular dysfunction. [2135-9-5] Echo Very limited views obtained. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function appears grossly preserved (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. [2135-9-5] CXR FINDINGS: As compared to the previous radiograph, the pleural effusions have resolved. Lung volumes have minimally increased, potentially suggesting improved ventilation. Moderate cardiomegaly, unchanged evidence of mild-to-moderate interstitial fluid overload. No evidence of pneumonia. [9-25] Head CT: No acute process [9-25] CT Abdomen and Pelvis: 1. No evidence for hematoma. 2. Persistent increased bilateral pleural effusions. 3. Marked splenomegaly. 4. Gallstones. 5. Suspected chronic avascular necrosis involving each femoral head, with more prominent findings on the right than left side. Microbio: [2135-09-23] 4:38 pm SPUTUM Source: Expectorated. FINAL REPORT [2135-10-7] GRAM STAIN (Final [2135-9-24]): [10-11] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [2135-9-28]): SPARSE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. AZTREONAM Sensitivity testing per DR [Last Name (STitle) 73069] ([Numeric Identifier 73070]). SENSITIVE TO COLISTIN sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. RESISTANT TO AZTREONAM AT >=32 MCG/ML sensitivity testing performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| AMIKACIN-------------- 16 S CEFEPIME-------------- =>64 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ =>16 R FUNGAL CULTURE (Final [2135-10-7]): YEAST. BLOOD Cultures all negative Brief Hospital Course: The patient is a 68-year-old gentleman with a history of MDS evolving to AML with increasing transfusion requirement and severe pancytopenia. Several prolonged and complicated hospital admissions in last 3 months following his first cycle of Decitabine as noted above in HPI. His post-treatment course was complicated by fever, LFT abnormalities, and a question of a cholecystitis. He is admitted for his second full cycle of chemotherapy with Decitabine today with the plan to use a 10 day regimen. Of note, treatment Vidaza (a drug from the same class)resulted in a prolonged and complicated course in the past. # MDS and pancytopenia: Pt's current cycle 2 of decitabine stopped after 8 days. Pt w/ unstable angina found to have fixed stenotic lesion of the RCA, thought by cards to be causing demand ischemia and favored medical mgmt. Overall, pt failed azacitidine and two cycles of decitabine. He required near daily transfusions with platelets and pRBC and failed to increase counts appropriately. Pt had a drop in HCT, which along with his abdominal pain was concerning for an intraabdominal bleed--CT did not demonstrate hemmorrhage. Towards the end of patient's care, numerous conversations took place between patient, patient's family, and medical team. Given poor performance status, significant medical comorbidities including obtundation, virulent drug resistant pneumonia, and ARF, and the patient's goals of care, the patient was made CMO before his death a few days later. # Pneumonia and infection: Pt had fever in late [Month (only) ] to 104 while on fluconazole, flagyl, cipro. Pt then completed abx course of greater than 2 weeks with linezolid and cefepime. A source of infection failed to be identified. Per ID, on [9-22] abx were stopped. The next day pt spiked to 104.3, coughing up green sputum and became increasingly confused and then obtunded. Pt started on linezolid, meropenem, and acyclovir. Blood cultures were negative, but sputum culture came back positive for pan-resistant (except Amikacin) pseudomonal pneumonia. Given pt's renal failure and goals of care, the infection was not treated. Medications were withdrawn with the exception of those to keep the patient comfortable. # ARF: Toward the end of his life, pt developed ARF, obtundation, and low blood pressure w/ pseudomonas lung infection. Blood cultures were negative. The pt's decline in mental status was most likely [1-19] to sepsis and uremia from ARF which may have been precipitated by sepsis as well as IV acyclovir. The patient also developed a pericardial friction rub correlating with his ARF. Given goals of care and patient's performance status, pt did not undergo dialysis. #CAD: The pt developed chest pain during the course of this hospital stay. EKG showed ST depressions in V4-V5 that resolved with sublingual nitroglycerin and morphine. An echo was performed with showed new infererolateral hypokinesis. The pt was taken urgently to cardiac catheterization where a 70% osteal right coronary artery disease was discovered. The decision was made not to place a stent due to ongoing chemotherapy and his likely need for further platelet transfusions. Stent placement would require the initiation of anti-platelet therapy in order to maintain stent patency. Medical management was started with atorvastatin 20mg not the usual 80mg due to medication interactions and low dose metoprolol. He was observed in the CCU for approximately 24 hrs where his blood pressures remained stable and he remained chest pain free. He was then transfered back to the [Hospital Unit Name 153] for further management. In the [Hospital Unit Name 153] he remained pain free, hemodynamically stable. Pt was continued on low dose statin and metoprolol. Did not start aspirin given platelets and risk of bleeding. # Lytes: Hypokalemia/Hypercalcemia/Hypomagnesemia. Pt had hypercalcemia which improved with fluids and pamidronate x 1. Pt had low PTH, Vitamin D, Calcitriol, and PTHrP. Pt's hypokal and hypomag were aggressively repleted with termination of premature ventricular beats. Pt passed away the morning of [2135-9-27]. Medications on Admission: acyclovir 400 mg Tablet Q8hr ciprofloxacin 500 mg Q12hr fluconazole 400 mg Q24hr metronidazole 500mg Q8hr MS Contin 30 mg Q8hr omeprazole 20 mg daily oxycodone 5mg Q4HR:PRN pain Zofran ODT 8mg Q8HR prochlorperazine maleate 5mg Q6HR:PRN nausea ascorbic acid 500mg Q12HR docusate sodium 100mg [Hospital1 ] multivitamin one daily sennosides [senna] one [Hospital1 ]:PRN constipation Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Myelodysplasia with evolution to AML Sepsis from pseudomonas penumonia ARF Pancytopenia Decubitus and abdominal ulcers Chronic back pain Diabetes Unstable angina CAD multilobar pneumonia Insomnia Hearing loss Discharge Condition: N/A Discharge Instructions: N/A [Name6 (MD) 11021] [Name8 (MD) 11022] MD [MD Number(2) 38620] Completed by:[2135-10-17]	[ "486", "25000", "4019", "496", "41401" ]
Admission Date: [2166-7-7] Discharge Date: [2166-7-9] Date of Birth: [2088-8-25] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 2704] Chief Complaint: S/p Carotid Stent Major Surgical or Invasive Procedure: Angiography with placement of carotid stent History of Present Illness: Mr. [Known lastname ] is a pleasant 77yo gentleman with h/o HTN, DM, and hyperlipidemia who was incidentally found to have a carotid bruit on routine examination by his PCP. [Name10 (NameIs) ] [Name11 (NameIs) 8019] revealed total occlusion of his left proximal ICA and severe stenosis of right proximal ICA. CTA neck confirmed these findings. The patient denies any symptoms of transient weakness, dysarthria, or numbness. He does note a chronic weakness in his left hand that has been present x years. . Mr. [Known lastname ] [Last Name (Titles) 1834] stenting of his Right ICA earlier today. He received benadryl 25 IV, pepcid 20mg IV, solumedrol 60mg IV prior to his procedure given his history of allergy to IV contrast dye. He is currently feeling well and without complaints. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative except as noted above. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Hypertension--borderline, recently diagnosed at Dr.[Name (NI) 3101] office, not on any meds. Hyperlipidemia. Diabetes--no A1C available Spinal stenosis status post repair with chronic back pain History of bladder cancer. History of appendectomy. Peripheral [Name (NI) 1106] disease, asymptomatic carotid artery disease. Aortic stenosis, mild. . Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension . Cardiac History: CABG: none . Percutaneous coronary intervention: none . Pacemaker/ICD: none Social History: Social history is significant for the absence of current tobacco use; he admits to smoking in the distant past. There is no history of alcohol abuse. He lives with his wife of 58 years and his 21yo grandson. Family History: There is a questionable family history of premature coronary artery disease or sudden death; reports his mother had heart trouble, though she passed away in her 70s. Physical Exam: VS: T 98.5 81 165/80->131/66 19 96% RA Gen: Pleasant elderly man in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of [5-13] cm. No carotid bruits. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. +Systolic murmur at base. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Neuro: Language intact, appropriate. EOMI, face symmetric, tongue midline. Strength 5/5 in UE proximally but distal UE strength is mildly diminished (4+/5 in LUE) as compared with 5/5 in RUE. Has muscle wasting of his left hand. Distal strength intact in LE b/l. Sensation intact in UE and LE b/l. Pertinent Results: [2166-7-8] 04:55AM BLOOD Glucose-209* UreaN-24* Creat-1.5* Na-133 K-4.6 Cl-95* HCO3-26 AnGap-17 [2166-7-9] 06:30AM BLOOD Glucose-163* UreaN-31* Creat-1.7* Na-137 K-4.5 Cl-99 HCO3-30 AnGap-13 [2166-7-8] 01:00AM BLOOD CK(CPK)-47 [2166-7-8] 04:55AM BLOOD CK(CPK)-53 ECG ([2166-7-7]) Sinus rhythm. Non-specific lateral ST-T wave changes. Compared to the previous tracing of [2162-7-19] there is ST-T wave flattening in lead I and biphasic T wave in lead aVL. Otherwise, no diagnostic interim change. Carotid Cath ([2166-7-7]) COMMENTS: 1. Access: Retro RFA with catheter selective in RCCA 2. Aorta: Aortography revealed a Type 1 arch with anomalous take-off of the RSCA (posterior). 3. Carotid/vertebrals: The left CCA is patent. The [Doctor First Name 3098] is occluded. The RCCA is normal. The [Country ] has an eccentric 90% lesion. The [Country ] fills the ipsilateral ACA and MCA with noted cross filling of the contralateral ACA and MCA. 4. Successful PTA/stent of right ICA with a 6-8mm Protege RX stent and posted with a 4.0mm balloon. Excellent result with normal flow down vessel and no residual stenosis. No neurological symptoms during procedure. Patient left cathlab in stable condition. FINAL DIAGNOSIS: 1. Severe 90% stenosis of right ICA. 2. Successful PTA/stent of right ICA with a 6-8mm self-expandable stent posted with a 4.5mm balloon. Brief Hospital Course: 77yo man incidentally found to have severe carotid atherosclerosis admitted following elective stenting of his right ICA. 1. Carotid atherosclerosis: Pt tolerated the procedure well. His ASA (increased to 325 mg), plavix, and statin (atorvastatin used in-house) were continued. He was started on a low dose beta blocker and ACE I, and his blood pressure was maintained at a goal of SBP 100-160. Neuro checks throughout hospital course were unremarkable, and pt remained asymptomatic. 2. Diabetes [Name (NI) ] Pt reports poor compliance with oral hypoglycemics at baseline. He was given 2 doses of solumedrol, once before and once after the procedure, for his dye allergy. The following morning, his fingerstick glucoses spiked into the 400s. Insulin by IV was given and sliding scale tightened with substantial improvement in his FSGs by evening. He was kept overnight for monitoring with subsequent FSGs in the 100s. Pt to resume oral hypoglycemics on [2166-7-10], 48 hours after the dye load. 3. Chronic renal insufficiency. Pt has a baseline Cr of 1.4, increased after dye load. He reported good urine output during hospital stay and will have f/u labs done at his next PCP appointment to check his renal function. Medications on Admission: Admits to poor compliance with his meds: Plavix 75mg daily Ultram 50mg PRN Lescol 40mg daily Protonix 40mg daily Glipizide 5mg daily (rarely taking) Metformin 500mg [Hospital1 ] (often taking daily) ASA 81mg daily Robaxin 400mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ultram Oral 3. Lescol 40 mg Capsule Sig: One (1) Capsule PO once a day. 4. 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 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Robaxin Oral 7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day: *Please do not start again until Thursday, [7-10]. 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 11. Outpatient Lab Work Please draw patient's potassium, BUN, and creatinine at his office visit with Dr. [Last Name (STitle) 17025] on [2166-7-16]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Carotid atherosclerosis Secondary Diagnoses: Hypertension, diabetes [Date Range ], chronic renal insufficiency, iodine allergy Discharge Condition: Vital signs stable with appropriate follow-up arranged. Discharge Instructions: You were admitted for an elective placement of a stent to keep open one of the arteries to your head. You tolerated the procedure well. 1. Please take all medications as prescribed. Note that the following medication changes were made during your stay: - you were started on lisinopril 5mg daily - you were started on metoprolol succinate 25mg daily - we gave you a prescription for aspirin 325mg daily - you should not take your metformin or glipizide until Thursday morning, [7-10] 2. Please attend all follow-up appointments listed below. 3. Please call your doctor or return to the hospital if you develop chest pain, shortness of breath, sudden weakness or numbness or difficulty speaking, lightheadedness, fevers, or any other concerning symptom. Followup Instructions: We scheduled you an appointment to see Dr. [Last Name (STitle) 17025] on Wednesday, [7-16] at 2:15pm. Be sure to bring your medications with you. You should also bring the prescription for lab work with you so that Dr. [Last Name (STitle) 17025] knows to draw your blood to check your kidney function and potassium levels. We also scheduled you to see Dr.[Name (NI) 3101] nurse practitioner on [2166-7-22] at 11am. [Hospital Ward Name 23] building, [Location (un) 436]. Call [Telephone/Fax (1) 62] with questions. Please be sure to attend all previously scheduled appointments: Provider: [Name10 (NameIs) ] STUDY Phone:[Telephone/Fax (1) 327] Date/Time:[2166-9-2] 9:30 Provider: [Last Name (NamePattern5) 7224], [MD Number(3) 1240]:[Telephone/Fax (1) 62] Date/Time:[2166-9-2] 10:30 *This is Dr.[Name (NI) 3101] nurse practitioner	[ "25000", "40390", "5859", "4241", "2724", "53081" ]
Admission Date: [2151-3-21] Discharge Date: [2151-3-25] Date of Birth: [2112-11-25] Sex: F Service: MEDICINE Allergies: Nsaids Attending:[First Name3 (LF) 613] Chief Complaint: DOE, progressive fatigue Major Surgical or Invasive Procedure: Right sided central line placement. History of Present Illness: 38 y/o female with a 12 year h/o Crohn's Disease, Psoriasis, and recent diagnosis of vasculitis by right leg biopsy presented to [Hospital3 26615] Hospital with one month of worsening malaise, dark urine, yellow skin, progressive DOE, and fever for ten days to 103 max. Found to have a hematocrit of 9.6, Tbili 4.7, Dbili 0.4, macrocytosis, elev WBC, elev d-dimer 648, direct Coombs+. Unable to get PRBC's because of difficult crossmatch, treated with IV solumedrol 125mg, and transfered for blood transfusion and workup by Hematologist. She was recently on prednisone taper for vasculitis of LE that was diagnosed by biopsy in [2150-10-29]. She had not been having any chest pain, but was complaining of severe headache. She denied abd pain, recent BRBPR or increased menstrual bleeding. her mother had a hemolytic anemia as a child and her mother's step brother died of a hemolytic anemia. The patient is blood type AB negative. . [Hospital Unit Name 153] course notable for stress dose steroids leading to deveolopent of psychosis, and 6 PRBC transfusions with imprvement in Hct to 26. Past Medical History: Crohn's disease- diagnosed S/P laparotomy revealing malrotation & duodenunal mesenteric adenitis Vasculitis [9-2] (multiple prednisone tapers; last started [12-4], ending one week ago, also treated with cellcept ending one week ago) Psoriasis Basal Cell Ca of Leg Osgood-Schlatter (osteochondritis of the tibial tuberosity) Social History: Denies etoh, tob, or drug use. Family History: Mother with hemolytic anemia at 6mth of age, Uncle with hemolytic anemia in infancy causing his demise. No family h/o SLE or Crohn's. Physical Exam: Tc 99.4 BP 128/58 HR 120 RR 28 Sat 96% 4L NC Gen: pale, jaundiced, tired appearing caucasian woman HEENT: pale conjuncivae, +scleral icterus, pale tongue, dry MM, +subungal jaundice Neck: supple, no JVD CV: tachy, no murmur or rub appreciable, no gallop Lungs: CTAB Abd: mildly obese, soft, nt, nd, no palpable spleen or liver margin, no r/g, nl BS Rectal: guaiac neg per OSH Ext: no edema, strong DP/PT pulses Neuro: A+Ox0 Brief Hospital Course: 38 y/o female with history of autoimmune diseases (Crohn's vasculitis, psoriasis) with autoimmune hemolytic anemia following fever. . 1. Autoimmune Hemolytic Anemia: Etiology includes acquired post infectious autoimmune process, reactive autoimmune process after tappering steroids. Presented febrile. WBC was elevated in the setting of hemolysis and elevated bone marow turnover. Fevers could have been due to vasculitis, infection (unclear source). She received 6 units of PRBC's. She was treated initially with IV solumedrol, to which she had some psychosis. She was later changed to Prednisone 80 mg PO QD. Her hemolysis labs slowly improved. Her HCT was stable in the mid 20's. She was treated with B12 and folate. Hematology will follow her as an outpatient. Would recommend watching for fevers once off steroids. . 2. Non Gap Metabolic Acidosis: Likely lactic acidosis from cell lysis, as LDH was elevated. She was treated with IV fluids- Lactated Ringers. . 3. Elevated Blood Sugars: Likely due to steroids. She was covered with insulin based on a sliding scale. . 4. Vasculitis: Much improved per patient with prednisone. Unclear [Name2 (NI) 99777]. Diagnosed and followed at B&W Hospital. . 5. Crohn's: Stable. . 6. Psoriasis: Stable. . FULL CODE Medications on Admission: prednisone 10 mg QD Percocet prn Xanax 0.5 mg prn Prilosec Cipro 500 mg [Hospital1 ] Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Folic Acid 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 3. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO once a day for 1 months. Disp:120 Tablet(s) Refills:0 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Autoimmune Hemolytic Anemia Discharge Condition: Stable, with improved exercise capacity, stable hematocrit, decreasing hemolysis labs. Discharge Instructions: Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], your primary care doctor, if you have any concerns. If you notice increased shortness of breath, increased yellow skin color, darkening of your urine, please return to the emergency room for evaluation. Please follow up with the hematologist. Followup Instructions: Primary care physician-[Name10 (NameIs) 11937],[Name11 (NameIs) ] [Telephone/Fax (1) 65735] Has slightly higher blood pressures while on steroids, which needs to be watched, and has anxiety on prednisone for which we started klonopin. Hematology-Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9561], M.D. Phone:[Telephone/Fax (1) 457] Date/Time:[2151-3-31] 2:00 at [Last Name (NamePattern1) 439] Basement G. Needs to continue Prednisone at 80 mg PO QD for two weeks, then start slow taper. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2151-3-27]	[ "2762" ]
Admission Date: [2172-6-16] Discharge Date: [2172-7-21] Date of Birth: [2149-7-26] Sex: F Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: Ms. [Known firstname ] [Known lastname ] is a 22-year-old female who is status post a motor vehicle accident where she was a pedestrian struck by another oncoming vehicle on [2172-6-15]. She suffered a traumatic crush injury of the bilateral lower extremities with an open fracture of her right tibial plateau and right fibula associated with popliteal artery occlusion and severe ischemia of the right lower extremity, as well as an open fracture of her left femoral condyle. On [2172-6-15], the patient presented as a pedestrian struck by an oncoming vehicle with open bilateral tibia/fibula fractures and wounds. She was hemodynamically stable at the scene. There was no report of loss of consciousness. Upon arrival to the [Hospital1 69] Emergency Department, initial vital signs revealed heart rate was 130 and blood pressure was 118/palpation. The patient was complaining of right leg which was initially noted to have a cool dusky appearance. PAST MEDICAL HISTORY: The patient's brief past medical history included a newly diagnosis factor V Leiden deficiency. PAST SURGICAL HISTORY: Past surgical history on the day of arrival was none. MEDICATIONS ON DISCHARGE: Medications on admission were birth control pills. ALLERGIES: Allergies included AMOXICILLIN. PHYSICAL EXAMINATION ON PRESENTATION: Her physical examination in the trauma bay revealed temperature was 97.1, heart rate was 100 to 115 (sinus rhythm), and blood pressure was 118/palpation. The patient was alert and oriented on the day of her admission. Neurologically, her head was normocephalic and atraumatic. Her pupils were equal, round, and reactive to light and accommodation. Her [Location (un) 2611] Coma Scale was 15. There were no obvious deficits. The patient did have decreased motor activity in her right lower extremity. Cardiovascular examination revealed a regular rate and rhythm. Pulmonary examination revealed bilateral breath sounds which were clear to auscultation. Abdominal examination revealed the abdomen was soft, nontender, and nondistended. Her pelvis was stable. Her extremity examination revealed her right lower extremity to be cool and modeled without a palpable dorsalis pedis, popliteal, or posterior tibialis pulse, and an open tibial wound with exposed bone and muscle was present. On the left lower extremity and open tibial wound was present. However, on the left lower extremity, the foot was warm and the dorsalis pedis pulse and posterior tibialis pulses were palpable. Neck examination revealed the neck was nontender. The trachea was midline. The back examination revealed no tenderness and without any deformities or stepoff. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory values on the day of admission revealed white blood cell count was 11.9, hematocrit was 30.4, and platelets were 362. Coagulation studies revealed prothrombin time was 13.4, partial thromboplastin time was 20.9, and INR was 1.2. Toxicology screen was negative. PERTINENT RADIOLOGY/IMAGING: A chest x-ray was negative for a pneumothorax. A pelvic x-ray was negative for any fractures. The right lower extremity x-ray revealed a tibial plateau fracture as well as fibular fracture. A left lower extremity x-ray showed a possible posterior knee dislocation and a femur evulsion fracture. A computed tomography of the abdomen was negative for any acute injury. The patient received thoracic spine and lumbar spine films to assess for a spinal injury. Her thoracic spine and lumbar spine films revealed no fractures. These films were dated [2172-6-17]. The patient also received a computed tomography scan of her cervical spine without contrast on [2172-6-15] to rule out a cervical injury. There was no fracture or abnormality. The impression was a negative computed tomography of the cervical spine. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted with a diagnosis of probable ischemic right lower extremity due to a right tibia/fibula fracture as well as a left open fracture of the tibia. Angiograms were immediately and emergently performed on both lower extremities and a Vascular Surgery consultation was obtained as well as an Orthopaedic Surgery consultation. The angiograms which were performed did reveal a total occlusion of the right popliteal artery. However, the left arteriogram showed an intact vascular supply to the left lower extremity. The patient was heparinized at this time with an intravenous heparin drip and kept anticoagulated from this time on during her entire hospital stay with the exception of her multiple debridements and washout procedures. The patient was taken emergently to the operating room on [6-16] where the following procedure was performed; an exploration of the distal right popliteal space with a thromboembolectomy of the right popliteal artery as well as reversed saphenous vein interposition graft from the popliteal artery at the knee region to the tibial peroneal trunk of the right leg. Upon completion of this procedure and placement of the vein graft, distal flow to the right lower extremity was appreciated, and it returned to pink in color over the next immediate period of time was noted. Pulses were then dopplerable and eventually palpable. As previously mentioned, the patient's major orthopaedic injuries included a right tibial plateau fracture and midshaft fibular fracture on the right side, as well as x-rays which showed a fracture of the left femoral condyle. The patient received several consultations including that of Orthopaedic Surgery, Plastic Surgery, Vascular Surgery, Infectious Disease and remained on the Trauma Service during this entire period. The following is a list of the procedures performed during the [Hospital 228] hospital stay. As previously mentioned, on [6-16], the exploration of the distal right popliteal space with thromboembolectomy of the right popliteal artery and reversed saphenous vein interposition graft from the popliteal artery at the knee to the tibial peroneal trunk of the right leg. The patient underwent multiple debridements of the bilateral lower extremity wounds including dressing changes and wound Hemovac sponge changes of the right tibia and left knee. Orthopaedic Surgery also performed open reduction/external fixation on the right lower extremity placing an external fixator on the right lower extremity. Subsequently to this procedure, the patient underwent several more washout and debridement procedures of the bilateral lower extremities as well as a split-thickness skin graft on the left and right lower extremity from Plastic Surgery. On [2172-6-18] procedure performed by Dr. [First Name8 (NamePattern2) ] [Name (STitle) 9694] which included a debridement of the skin, muscle, and bone of the right leg wound as well as operative treatment with the application of an external fixator to the right leg and application of a vacuum-assisted closure dressing. Other pertinent laboratory data included a culture from the tissue of the wound on the right lower extremity which revealed Pseudomonas species growing out from this culture which was pan-sensitive to all the antibiotics listed. Infectious Disease was consulted and recommended 4-week to 6-week treatment with a combination of gentamicin and cefepime antibiotics. These were begun approximately on [6-27]. The patient also received a Psychiatry consultation which diagnosed the patient with acute stress disorder and possible episodic delirium secondary to narcotics. The patient remained hemodynamically stable throughout her hospital course despite several episodes of spiking fevers; as mentioned previously, when Infectious Disease was consulted, and the patient was placed on antibiotics. Otherwise, the patient advanced with her diet. She remained anticoagulated during her entire hospital stay, as previously mentioned and returned to the operating room multiple times for washouts and debridement of her lower extremity wounds. The patient's external fixator on the right lower extremity remained intact and in place, and her pulses remained palpable bilaterally throughout her hospital stay. Eventually, she was advanced to a regular diet, and her medications were switched to oral medications. The patient's heparin drip was kept, and her coagulation studies were checked every day. During the last several days of her hospital stay she was started on oral Coumadin therapy, and her INR was followed until it became therapeutic for interposition vein graft on the right lower extremity. During her hospital course, the patient also was seen in consultation by Physical Therapy and Occupational Therapy who began her on a rehabilitation program as well as an exercise regimen to allow her to start regaining her previous function. Her medications while in house included the following: Colace, Ativan, Dilaudid through patient-controlled analgesia (for pain control), Vioxx, nortriptyline (for sleep), guaifenesin, gentamicin, cefepime, heparin, and Coumadin. It should also be noted that before the patient was to be discharged, there remains one final wound vac in the patient's right lower extremity which will be followed up on by Plastic Surgery and needs to removed at a later date to be determined by them (Plastic Surgery). Also, the patient's external fixator located in the right lower extremity was to be maintained for a total of six weeks postoperatively (according to her orthopaedic surgery team). The patient may also be scheduled for a future left knee repair once the external fixator has been removed, or once the Orthopaedic team decided it is time to proceed with that surgery. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE STATUS: The patient's discharge status was to an inpatient rehabilitation facility. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient had a peripherally inserted central catheter line placed to allow her to receive her intravenous medications as necessary while staying at the inpatient rehabilitation facility. 2. The patient has been anticoagulated on Coumadin. Her most recent coagulation studies taken on [2172-7-21] (which is today) were the following: Prothrombin time was 18.6 and INR was 2.3. 3. The patient was to follow up with the listed specialists. The patient was to contact the below listed specialists (including Plastic Surgery, Orthopaedic Surgery, and Vascular Surgery) at the telephone numbers listed below to insure proper followup on her previous surgeries and her future care. (a) Dr. [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) 5385] from Plastic Surgery (office telephone number [0-0-]); office location is 85 [Location (un) ] through [Hospital1 69]. (b) Dr. [First Name (STitle) ] [Name (STitle) ] (office telephone number [Telephone/Fax (1) 20278]); office location is E-CC7, Division of Plastic Surgery at [Hospital1 1444]. (c) Dr. [First Name8 (NamePattern2) ] [Name (STitle) 9694] from Orthopaedic Surgery (office telephone number [Telephone/Fax (1) 4301]); office location is [Street Address(2) 49136], the Division of Orthopaedic Surgery through [Hospital1 69]. (d) Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1476] (office telephone number is [Telephone/Fax (1) 20413]), the Division of Vascular Surgery; office location is W/LMOB-5B through the [Hospital1 190]. (e) Dr. [First Name4 (NamePattern1) 518] [Last Name (NamePattern1) 519] from Trauma and General Surgery Division (office telephone number is [Telephone/Fax (1) 6554]) through the [Hospital1 69]. DISCHARGE DISPOSITION: The patient received approval through Case Management to be transferred to [Hospital3 245] in [Location (un) 246], [State 350] as a rehabilitation inpatient (telephone number is [Telephone/Fax (1) 49137]; fax number is [Telephone/Fax (1) 49138]). Please insure that this facility receives a copy of the Discharge Summary. DISCHARGE DIAGNOSES: (The patient's discharge diagnoses included the following) 1. A right grade IIIC tibial plateau fracture. 2. A left grade III femoral condyle fracture. 3. Multiple wound debridements and washouts of the bilateral lower extremities. 4. Factor V Leiden (as previously diagnosed). 5. Right popliteal interposition vein graft (which requires chronic anticoagulation). MEDICATIONS ON DISCHARGE: (Discharge medications included the following) 1. Coumadin 3 mg to 5 mg p.o. once per day (as will be prescribed). 2. Ibuprofen 400 mg to 600 mg p.o. q.8h. as needed (for pain). 3. Ferrous sulfate 325 mg p.o. once per day. 4. Bisacodyl 10 mg p.r. q.p.m. as needed (for constipation). 5. Cefepime 2 g intravenously q.12h. 6. Gentamicin 100 mg intravenously q.8h. (please check levels after the third dose). 7. Vioxx 25 mg p.o. once per day. 8. Sarna lotion one application four times per day as needed. 9. Docusate sodium 100 mg p.o. twice per day. 10. Acetaminophen 325 mg to 650 mg p.o. q.4-6h. as needed (for pain). 11. Milk of Magnesia 30 mL p.o. q.6h. as needed (for constipation). [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Name8 (MD) 5541] MEDQUIST36 D: [2172-7-21] 15:46 T: [2172-7-21] 16:45 JOB#: [Job Number 49139] cc:[Telephone/Fax (1) 49140]	[ "2851" ]
Admission Date: [2159-12-26] Discharge Date: [2160-1-9] Date of Birth: [2082-8-17] Sex: F Service: SURGERY Allergies: Iodine / Penicillins / Morphine Sulfate Attending:[First Name3 (LF) 1481] Chief Complaint: Transferred from rehabilitation facility for decreased hematocrit Major Surgical or Invasive Procedure: [12-28] Colonoscopy [12-28] EGD [1-2] Octreotide scan History of Present Illness: 77 yo F with h/o hypertension, tachy-brady syndrome s/p pacer, CAD s/p NSTEMI in [2157], s/p recent admission for cholecystitis s/p percutaneous biliary drain placement and recent dx of mesenteric mass (?carcinoid tumor) who presents from rehab with maroon stool. Pt was admitted in [11/2159] with cholecystitis. She had a perc drain placed which ultimately fell out, and plan was to follow up with Dr. [Last Name (STitle) ] for CCY. She was also recently diagnosed with mesenteric mass on CT, which was felt to possibly be carcinoid tumor. She was discharged to rehab on [2159-12-19] and on [2159-12-26] per nursing notes, she had a small amount of BRBPR and hct drop to 22.7 (bl 33). She had a negative lavage in ED. She was hemodynamically stable, with SBP 100-110's, with maroon stool on ED rectal exam. A sublclavian line was placed for access and she was transfused 2 units of PRBC. She complains of some abdominal pain, in RUQ, RLQ and epigastrium. She did not notice the color of her stools. She denies CP, SOB, dysuria, diarrhea, history of GIB, dizzyness. She does note DOE, night sweats, fatigue, and zoster rash on buttocks. Past Medical History: Past Medical History; HTN Tachy-brady syndrome '[57] NSTEMI CAD GERD '[41] [First Name9 (NamePattern2) 8751] [Last Name (un) 8061] Shingles Past Surgical History: [12-22] Coronary catheterization '[51] Pacemaker Colectomy Left lumpectomy Umbilical hernia repair Social History: Married, came in from rehab after recetn admission, prior to that lived with husband, they were functional and still working for a used car facility, delivering cars, She quit smoking 40+ years ago, about 15 pack yr history, no alcohol use Family History: Father and mother both deceased from CAD Physical Exam: 98.8, 134/61, 104, 20, 95%2L NC GENL: pleasant female in NAD HEENT: OP dry, no LAD, no elev JVP, EOMI, PERL CV: RRR no MRG Lungs: CTAB Abd: soft, tender to palp in RLQ, mild tenderness to palp in RUQ and epigastrium, brown stool guaiac pos, no rebound, slight guarding Ext: no edema, 2+ pedal pulses Neuro: EOMI, PERL Pertinent Results: Cardiology Report ECG Study Date of [2159-12-26] 5:45:28 PM Technically difficult study Sinus tachycardia Marked left axis deviation Intraventricular conduction delay Lateral ST-T wave changes V2-3 R wave reversal Since previous tracing, no significant change Intervals Axes Rate PR QRS QT/QTc P QRS T 102 0 138 374/[Telephone/Fax (2) 64699] Chest X-Ray [12-30]: IMPRESSION: No change in size and appearance of moderate left pleural effusion with adjacent atelectasis/consolidation and small right pleural effusion, given difference in techniques. Operative note: Carcinoid tumor of the small bowel and cholecystitis. PROCEDURE: Laparotomy, lysis of adhesions, small bowel resection, cholecystectomy. Octreotide scan [1-2]: IMPRESSION: 1. No abnormal focus of tracer uptake to indicate somatostatin receptor avid tumor. 2. Markedly distended gallbladder with mild wall thickening. Correlate clinically and with ultrasound if indicated. Admission labs: [2159-12-26] 04:25PM BLOOD WBC-14.6* RBC-2.47* Hgb-7.8* Hct-23.2* MCV-94 MCH-31.7 MCHC-33.7 RDW-15.1 Plt Ct-782* [2159-12-26] 04:25PM BLOOD Neuts-85.1* Bands-0 Lymphs-7.7* Monos-5.5 Eos-1.4 Baso-0.1 [2159-12-26] 04:25PM BLOOD Plt Smr-VERY HIGH Plt Ct-782* [2159-12-26] 07:32PM BLOOD PT-14.6* PTT-28.5 INR(PT)-1.3* [2159-12-26] 04:25PM BLOOD Glucose-118* UreaN-24* Creat-0.9 Na-130* K-4.7 Cl-95* HCO3-26 AnGap-14 [2159-12-26] 04:25PM BLOOD ALT-11 AST-19 AlkPhos-63 Amylase-44 TotBili-0.3 [2159-12-26] 04:25PM BLOOD Lipase-23 [2159-12-26] 04:25PM BLOOD Albumin-2.8* Phos-3.2 Mg-2.3 [2159-12-26] 06:10PM BLOOD Lactate-2.3* Discharge labs: [2160-1-7] 04:33AM BLOOD WBC-8.3# RBC-2.85* Hgb-8.8* Hct-26.5* MCV-93 MCH-30.9 MCHC-33.3 RDW-15.2 Plt Ct-287 [2160-1-7] 04:33AM BLOOD Plt Ct-287 [2160-1-7] 10:03AM BLOOD Glucose-90 UreaN-13 Creat-0.5 Na-139 K-3.5 Cl-105 HCO3-25 AnGap-13 [2160-1-7] 10:03AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.7 Brief Hospital Course: 77 yo F with h/o htn, CAD, recent hosp for cholecystitis s/p percutaneous drain that has since fallen out, mesenteric mass felt to be carcinoid who presents from rehab with BRBPR/maroon stool. . #) GIB: Likley lower source given BRBPR. She was transfused a total of 4U prbcs for a goal of >28 and her hct has since remained. She had no evidence of continued bleeding while in the [Hospital Unit Name 153]. GI was consulted and upon preparation for EGD/colonoscopy there was no evidence of bright blood/active bleed, rather just old blood. Although poorly prepped, colonoscopy was normal and her EGD showed atrophic gastritis in the antrum. H. Pylori studies were sent and should be followed up as an outpatient. She will need a repeat colonoscopy in 6 months which can be set up by her PCP. [Name10 (NameIs) ] she to have recurrent bleeding, small bowel follow through and capsule endoscopy would be the next steps per GI. . #) Cholecystitis: She was continued on her course of levofloxacin/Flagyl which she is to complete on [2159-12-29]. She had no abdominal pain during her stay. She should follow up with surgery upon discharge regarding cholecystectomy. . #) Mesenteric mass: Radiographically was c/w carcinoid. She has had some flushing that would be consistent with dx, but denies diarrhea. Chromogranin A was found to be elevated while 5HIAA was normal. This will need further evaluation as well for octreotide scan. . #) CAD: No signs of ischemia on EKG but paced rhythm. She was restarted on her home dose metoprolol. ASA was held in the setting of her bleed. Restarting this will need to be readdressed upon outpatient follow up given her known h/o of CAD. Her ACEI was held on admission in the setting of her GI bleed and was restarted as her blood pressure tolerated. . #) Hypertension: Antihypertensives were held originally in the setting of GIB. Metoprolol was added back for persistent tachycardia (h/o tachy-brady). ACEI and Lasix can be added back as blood pressure and fluid status tolerates. On HD 6, she was transferred to the surgical service for planned surgical intervention of her known mesenteric mass; she was afebrile, hemodynamically stable with a hematocrit of 34, ambulating with a walker, tolerating Ensure supplementation, and had moderate right upper quadrant pain controlled with Vicodin. On HD 7 and 8, she underwent an Octreotide scan, which demonstrated no abnormal focus of tracer uptake to indicate somatostatin receptor avid tumor. On HD 10 she underwent an exploratory laparotomy, lysis of adhesions, small bowel resection, and cholecystectomy; intra-operatively she was found to have large bulky disease, consistent with carcinoid with nodules which had a tremendous sclerotic reaction which basically enveloped substantial portions of the small intestine, she had no complications. Post-operatively she was NPO with intravenous hydration, Morphine PCA, nasogastric tube, foley catheter, and was continued on telemetry monitoring while receiving intravenous beta-blockade. On POD 4, she had +flatus and a bowel movement, her diet was advanced, her pain was well controlled with Vicodin, her oral medications were resumed, she remained afebrile, and was voiding without difficulty. She had been followed by physical therapy during her hospitalization course with recommendations of transfer to a rehab facility for continued therapy. She was discharged on [1-9] to Life Care Center of the [Hospital3 ] rehabilitation facility in good condition. She was to follow-up with Dr. [Last Name (STitle) ] in [12-18] weeks. Medications on Admission: Ezetimibe 10 mg Daily Buspirone 15 mg PO BID Nortriptyline 75 mg HS Alprazolam 1 mg TID Pantoprazole 40 mg Q24H Metoprolol Tartrate 50 mg PO BID Fexofenadine 60 mg [Hospital1 ] Aspirin 325 mg Daily Hydrocodone-Acetaminophen 5-500 mg 1-2 Tablets PO Q4-6H PRN Levofloxacin 250 mg PO Q24H Last Dose 1/13 Metronidazole 500 mg PO TID Last dose pm [12-29]. Ipratropium Inhalation Q6H as needed for wheezing. Albuterol Inhalation Q6H as needed for wheezing. Docusate Sodium 100 mg PO BID Lactulose 30 ML PO DAILY Lasix 20 mg PO BID Quinapril 10 mg daily Zovirax apply to affected area [Hospital1 ] Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 5X/D (5 times a day). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. BusPIRone 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): Hold for HR < 60 Hold for SBP < 100. 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day: While on Lasix. 14. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: Life Care Center of the [Hospital3 ] - [Location (un) 3493] Discharge Diagnosis: Lower gastrointestinal bleed Cholecystitis Carcinoid tumor of small bowel Discharge Condition: Stable Discharge Instructions: Notify MD or return to the emergency department if you experience: Increased or persistent pain not relieved by pain medication Fever > 101.5 Nausea, vomiting, diarrhea, or abdominal distention Inability to pass gas, stool, or urine If incision appears red or if there is drainage Bleeding from any part of the body Shortness of breath or chest pain Any other symptoms concerning to you You may shower and wash incision with soap and water, pat dry No swimming or tub baths for 2 weeks Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in [12-18] weeks, call [Telephone/Fax (1) 2981] for an appointment Completed by:[2160-1-9]	[ "5119", "41401", "4019", "53081", "2859", "412" ]
Admission Date: [2178-4-29] Discharge Date: [2178-5-1] Date of Birth: [2178-4-29] Sex: M Service: NEONATOLOGY HISTORY OF THE PRESENT ILLNESS: Baby boy [Known lastname 48422] is a 3,175 gram product of a 38 week gestation born via a stat cesarean section on [2178-4-29]. The pregnancy in this 42-year-old apparently healthy woman was notable for ultrasound notation of complete atrioventricular canal with minimal atrioventricular regurgitation and limited visualization of the aorta. No other anomalies were noted. The pregnancy was also noted for anti D antibody present on antibody screen after RhoGAM administration. Karyotype was normal 46 XY. The mother's prenatal screens were notable for A negative blood type, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, group beta strep negative with antibody screen as noted above. Spontaneous rupture of membranes greater than 24 hours prior to delivery. There were no other sepsis risk factors. The mother did not receive intrapartum antibiotics. PHYSICAL EXAMINATION: Vital signs: Temperature 99.4, heart rate 162, respiratory rate 44, blood pressure 59/31 with a mean arterial pressure of 42. Oxygen saturations 92-95% in room air. Weight 3,175 grams. Head circumference 32.5 cm, length 50.5 cm. At delivery, the patient emerged vigorous, pink, active, nondysmorphic infant. The skin was without lesions. The lungs were clear. The heart revealed normal S1, S2, without murmurs. Abdomen was benign. Genitalia revealed normal male. Testes descended bilaterally. Spine intact. Hips normal. Neurological examination nonfocal and age appropriate. HEENT: Within normal limits. HOSPITAL COURSE: RESPIRATORY: The infant was in room air for his entire NICU stay. Oxygen saturations consistently greater than 95% and breath sounds clear and equal, comfortable respiratory pattern. No desaturations or increased work of breathing noted. CARDIOVASCULAR: The infant's blood pressure was stable throughout his NICU admission. No normal saline boluses required or pressor support required. An echocardiogram was performed on the date of birth and showed a complete AV canal with a large atrial defect, moderate sized ventricular component, a small PDA with bidirectional flow, possible left SVC to coronary sinus, and possibility of coronary sinus being unroofed. The infant remained pink and well perfused throughout his NICU admission. FLUIDS, ELECTROLYTES, AND NUTRITION: The infant was started on ad lib demand breast feeds on the date of delivery. He has consistently breast fed well and also tolerated feeds of 20 calorie Enfamil ad lib. He is voiding and stooling without difficulty. Weight at the time of transfer to the Newborn Nursery was 3,110 grams. GASTROINTESTINAL: The bilirubin at six hours of age was 2.8/0.4. Phototherapy was not indicated during his NICU admission. HEMATOLOGY: The infant did not receive any blood products during his NICU admission. His blood type is A positive, direct Coombs' negative. The hematocrit upon admission to the NICU was 45.5. INFECTIOUS DISEASE: Upon admission to the NICU, a CBC with differential and blood culture was drawn. White count 16.6000, hematocrit 45, platelet count 345,000 with 56% polys, 1% bands. A blood culture was drawn as well and was negative at 48 hours of age. He did not require any antibiotics. NEUROLOGY: The infant has had a normal neurologic examination throughout his NICU stay. SENSORY: A hearing screen is pending. His hearing will be tested prior to discharge at [Hospital6 2018]. OPHTHALMOLOGY: Eye examination not indicated. PSYCHOSOCIAL: [Hospital6 256] social work is involved with the family. Contact social worker can be reached at [Telephone/Fax (1) ]. CONDITION AT THE TIME OF TRANSFER: Stable, feeding well, stable cardiovascular condition. DISCHARGE DISPOSITION: To Newborn Nursery. PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 2257] in Glaucester, phone number [Telephone/Fax (1) 37897]. CARE RECOMMENDATIONS: Feeds at the time of transfer were ad lib demand breast or bottle feeding. MEDICATIONS: None. CAR SEAT POSITION SCREENING: Not indicated. STATE NEWBORN SCREENING: To be done at 72 hours of age. IMMUNIZATIONS RECEIVED: None at the time of transfer to Newborn Nursery. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following criteria: 1) Born at less than 32 weeks. 2) Born between 32 and 35 weeks with plans for Day Care during RSV season, with a smoker in the household, or with preschool siblings. 3) With chronic lung disease. 4) infants with congenital heart disease. Influenzae immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenzae to protect the infant. FOLLOW-UP: A follow-up appointment has been scheduled with Cardiology at [Hospital3 1810], Dr. [First Name (STitle) 2856], phone number [Telephone/Fax (1) 37115], appointment on [2178-5-14] at 2:00 p.m. DISCHARGE DIAGNOSIS: 1. Complete AV canal. 2. Rule out sepsis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Name8 (MD) 35942] MEDQUIST36 D: [2178-5-2] 04:26 T: [2178-5-2] 07:28 JOB#: [Job Number 48423]	[ "V290", "V053" ]
Admission Date: [2169-12-20] Discharge Date: [2169-12-27] Date of Birth: [2101-6-26] Sex: F Service: MEDICINE Allergies: Prednisone / Aspirin / Codeine / Sulfa (Sulfonamides) / Ivp Dye, Iodine Containing / Bactrim / Procardia Attending:[Last Name (NamePattern4) 290] Chief Complaint: Transfer from [Hospital 1727] Medical Center for IP intervention Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: Ms. [Known lastname 66188] is a 66 year old woman with history of COPD and tracheobronchomalacia s/p Y stent, now transferred to [Hospital1 18] from [Hospital 1727] Medical Center for interventional pulmonary intervention. She initially presented to [Hospital 66189] Hospital on [2169-11-18] with dyspnea, sputum, and increased secretions, and was diagnosed with community-acquired pneumonia as an outpatient, which she subsequently failed. Sputum grew MRSA, and she was then transferred to MMC for furhter evaluation and management. . Her hospital course at MMC was notable for the following problems: . 1. Respiratory failure/MRSA pneumonia. Transferred to MMC on vancomycin, which was changed to linezolid when blood cultures grew VRE. At MMC, she was difficult to ventilate, given problems with auto-PEEP; she did well on CPAP 20/12. . 2. Hypotension. In setting of MRSA pneumonia and VRE bacteremia. On phenylephrine . 3. Tracheal bleeding. Had acute bleeding from tracheostomy; bronchoscopy demonstrated friable granulation tissue. No other bleeding episodes. . 4. VRE bacteremia. Culture on ??? grew VRE (drawn from PICC). PICC pulled, CVL placed, surveillance cultures negative to date. Linezolid to finish 7-day course on [12-21]. . 5. History of DVT/Pulmonary Embolism in [2167]. She had been on coumadin since [2167] for treatment; coumadin was held, and she was transitioned to heparin on [12-20] for IP procedure. . 6. Agitation. Agitation during the hospitalization controlled with scheduled phenobarbital and PRN pushes. . Per the discharge summary, at the time of discharge, her chest x-ray demonstrated "stable appearance of multiple patchy opacities persistent in the left lung with volume loss in the left lung and slight shift of the mediastinum to the left, unchanged from prior, as well as persistant left pleural effusion". . On arrival to the floor, an A-line was placed and chest x-ray was performed. Chest X-ray showed complete white out of the left lung, consistent with complete collapse. Tidal volume was immediately decreased, the patient received deep sedation, and IP was called in for emergent bronchoscopy (the ICU bronchoscope did not fit in her tracheostomy tube). Bronch demonstrated granulation tissue on both arms of the Y-stent (L>R) and increased mucus in left main bronchus, which was suctioned. Past Medical History: - COPD on home oxygen - Tracheomalacia s/p Y stent in fall [2168] - Obstructive sleep apnea - Hypertension - Recurrent DVTs on anticoagulation - Anemia - Recurrent MRSA and Klebsiella pneumnonias - Steroid-induced myopathy - Chronic anemia - History of fibromyalgia Social History: Lived with husband in [Name (NI) 1727]. >40 pack-year history of smokign. Rare EtOH use. Denies drug use Family History: Noncontributory Physical Exam: VITALS: T98.3F, BP 122/69, HR 87, RR 25, SaO2 100% VENT: TV 400, RR 25 (breathing ~40), FiO2 100%, PEEP 12 GENERAL: Sedated, breathing over vent, mild respiratory distress HEENT: Pupils sluggish bilaterally but reactive NECK: Unable to appreciate JVD CARD: RRR normal S1/S2, no m/r/g appreciated RESP: Vent sounds bilaterally R>L, rhonchi at left lung base ABD: Soft, midline scar, healing G-tube site, non-tender, non-distended, + bowel sounds EXT: 2+ DP pulses bilaterally, warm, well perfused; clubbing present; no cyanosis or edema NEURO: Sedated Pertinent Results: 7.46/38/155/28 on FiO2 100%, TV 450, RR 18 . Na 131 K 4.3 Cl 95 HCO3 25 BUN 16 Creat 1.0 Gluc 105Ca: 8.4 Mg: 2.3 P: 4.1 . CK: 15 MB: Notdone Trop-T: <0.01 . ALT: 35 AST: 39 AP: 124 Tbili: 0.5 Alb: 2.5 LDH: 280 . WBC 24.8 N:88.8 L:8.1 M:2.7 E:0.3 Bas:0.1 Hgb 9.0 Hct 27.4 Plt 822 . PT: 21.4 PTT: 59.7 INR: 2.0 Fibrinogen: 614 . STUDIES: . CXR [12-20]: Leftward shift of mediastinum with complete opacification of the left lung field new compared to previous exams. S/p trach and Y stent. NG in good position. Right CVL line probably in good position. Right lung grossly clear. Brief Hospital Course: 68yF with history of COPD, tracheomalacia s/p Y-stent, tracheostomy, recurrent MRSA pneumonia, transferred from OSH for IP intervention and found to have collapsed left lung. Patient was evaluated by interventional pulmonology. Her Y-stent was stenosed and subsequently removed. The patient underwent debridement. She was thought to have no meaningful recovery from a pulmonary stand-point and continued to require significant sedation to allow her to tolerate the ventilator. A CT of the chest was performed to evaluate for underlying malignancy but did not show clear malignant cause of her respiratory failure. On [12-27] the family decided to provide comfort measures only and mechanical ventilation was discontinued and a few hours later, at 21:17, the patient expired. Primary cause of death was cardiopulmonary arrest, immediate cause was chronic respiratory failure. The family was present. Medications on Admission: Heparin gtt on protocol Linezolid 600mg IV q12h (through [12-21]) Paroxetine 40mg PO daily Methadone 10mg PO Q8H Phenobarbital 65mg IV Q12H with 65mg IV Q1H pushes PRN Omeprazole suspension 20mg PO Q24H Albuterol INH Q6H Ipratropium INH Q6H Colace Senna Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary arrest Discharge Condition: deceased Discharge Instructions: Expired Followup Instructions: deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "5180", "5990", "496", "32723", "V5861", "4019" ]
Admission Date: [2146-2-19] Discharge Date: [2146-3-3] Date of Birth: [2097-10-29] Sex: M Service: MEDICINE Allergies: Penicillins / Abacavir Attending:[First Name3 (LF) 9598] Chief Complaint: febrile neutropenia Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: 48 y/o M with AIDS-related Burkitt's lymphoma who was recently hospitalized [2146-2-7] to [2146-2-13] for chemotherapy with R-IVAC (rituximab, ifosfamide/mesna, etoposide,ara-C, and intrathecal methotrexate). He presented to the [Hospital 478] clinic today and was found to have fever and neutropenia. In clinic, his VS were BP 140/92; HR 105; T 99.1; RR 18; O2 Saturation 99. Lab work was drawn and was significant for an ANC 0 and an H&H of 9.5 and 24.8. He was given 1 units of PRBCs and 650 mg of neupogen. After the blood transfusion, he was noted to spike a temperature to 100.4. Blood cultures were drawn, and the patient was referred to the OMED service for admission and further management. . On arrival to the floor, the patient's VS were T 99.8; BP 140/90; HS 95; RR 20; SaO2 97% on RA. He states that, since his discharge, he has not been feeling well. He has been experiencing malaise, nausea, and decreased appetite. He reports that he has not had a fever until today. He also reported a left-sided temporal headache that has continued since his prior hospitalization. He reports that he has some light sensitivity but denies any neck stiffness. He reports diarrhea that has been continuing since the start of his therapy, but denies any blood in his stools. . Review of Systems: (+) Per HPI. He also reports some sensitivity to smells. (-) Denies chills, night sweats. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath. Denied vomiting. No recent change in bowel or bladder habits. No dysuria. Past Medical History: [Known firstname ] was diagnosed with HIV infection in [2144-10-5]. At the time CD4 was 311, viral load 96,934 range ([2144-10-22]). Atripla was started. In [2145-10-5], [Known firstname ] noted tightness and pressure across his left chest associated with a new mass. This was subsequently biopsied on [2145-11-4], which confirmed Burkitts lymphoma (c-myc positive). At or about the same time, he was seen by oral surgery for swelling on upper and lower gums. This too showed the same lymphoma. PET-CT scan (see full note on OMR) was floridly positive. . He started chemotherapy with Cyclophosphamide, Doxorubicin, Rituximab. The external mass resolved 100% within two days. At no point did patient develop tumor lysis syndrome. Ommaya reservoir was placed. Course was complicated by peri-orbital cellulitis in the setting of grade 4 neutropenia. He was treated successful with cipro, flagyl and vancomycin. . He then received high-dose methotrexate with leucovorin rescue. He did well though did develop perianal mucositis. . PET/CT done after 2 cycles of therapy showed resolution of his disease. . Other past medical history: 1) HIV infection as above; medication-related diarrhea, typically twice a day 2) Depression since [2144] 3) Hypertension since [2143] 4) Dental extractions 5) Left humerus spiral fracture in [2136] after falling down flight of stairs Social History: Single gay man, not currently in a relationship, not currently sexually active. Currently not working. Patient is still smoking cigarettes, 1/2-1 ppd. Drinks 1 bottle of wine a week. He smokes marijuana occasionally for relief of nausea and poor appetite. Family History: Father died in [2135] of AML, Mother is alive in her 70s and is well. Three brothers and three sisters; all alive and well. One sister had hysterectomy for endometriosis. No children. He is closest to sister [Name (NI) 1022] in [Name (NI) 7349]. Physical Exam: GEN: Alert; NAD; Somewhat toxic appearance. Vitals: T 99.8; BP 140/90; HS 95; RR 20; SaO2 97% on RA HEENT: EOMI, PERRL, OP clear and non-erythematous without evidence of mucositis. NECK: Supple LUNGS: CTA bilaterally CARDIOVASCULAR: RRR; No murmurs, rubs, or gallops appreciated ABDOMEN: BS present; S/NT/ND NEURO: Alert; NAD; No focal neurologic deficits noted. Pertinent Results: [2146-2-18] 08:45AM BLOOD WBC-0.1# RBC-3.00 Hgb-9.7* Hct-26.5* MCV-88 MCH-32.3* MCHC-36.6* RDW-16.7* Plt Ct-16* [2146-2-20] 06:00AM BLOOD Neuts-0* Bands-0 Lymphs-80* Monos-0 Eos-20* Baso-0 Atyps-0 Metas-0 Myelos-0 [2146-2-21] 06:35AM BLOOD Gran Ct-0* [2146-2-23] 07:45AM BLOOD Gran Ct-64* [2146-2-24] 06:15AM BLOOD Gran Ct-152* [2146-2-25] 06:30AM BLOOD Gran Ct-399* [2146-2-26] 05:35AM BLOOD Gran Ct-350* [2146-2-27] 12:50AM BLOOD Gran Ct-571* [2146-2-28] 06:45AM BLOOD Gran Ct-870* [2146-3-1] 08:35AM BLOOD Gran Ct-1080* [2146-3-2] 07:10AM BLOOD Gran Ct-1420* [2146-3-3] 07:40AM BLOOD Gran Ct-2380 [2146-2-19] 05:20PM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-138 K-3.2* Cl-103 HCO3-26 AnGap-12 [2146-2-19] 05:20PM BLOOD ALT-12 AST-13 LD(LDH)-110 AlkPhos-106 TotBili-1.0 [2146-2-21] 08:11PM BLOOD Hapto-238* [2146-2-23] 07:45AM BLOOD IgG-1035 CRYPTOCOCCAL ANTIGEN (Final [2146-2-22]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. Respiratory Viral Antigen Screen (Final [2146-2-22]): Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to Respiratory Virus Identification for further information. REPORTED BY PHONE TO [First Name8 (NamePattern2) 10561] [Last Name (NamePattern1) 2113] @ 2137 ON [2-22] - [Numeric Identifier 10562]. Respiratory Virus Identification (Final [2146-2-22]): POSITIVE FOR RESPIRATORY SYNCYTIAL VIRUS (RSV). Viral antigen identified by immunofluorescence. CMV Viral Load (Final [2146-3-2]): CMV DNA detected, less than 600 copies/mL. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. FOR RESEARCH USE ONLY.. NOT FOR USE IN DIAGNOSTIC PROCEDURES. This test has been validated by the Microbiology laboratory at [Hospital1 18]. CXR: IMPRESSION: No evidence of acute cardiopulmonary process. CT head [2-20]: 1. Stable appearance to right frontal approach ventriculostomy catheter. Stable ventricle size. 2. No acute findings in the brain, no enhancing masses. Mild ethmoid, and sphenoid sinus mucosal thickening. . MR head: 1. Pansinusitis is a potential explanation for the patient's headaches and fevers. 2. Stable appearance of the Ommaya catheter without abnormal intracranial enhancement or other acute findings. Bihemispheric white matter changes may relate to the patient's underlying AIDS versus treatment related. Brief Hospital Course: # neutropenic fever - Patient presented with ANC 0 and fevers to 103 and was started on vancomycin/cefepime empirically. Blood cultures, urine cultures showed no growth. The patient began to complain of severe headaches during the hospitalization, which raised the concern of meningitis. The patient had no mental status changes (although did have increased irritability), no meningeal signs. As there was concern that the patient's antibiotic regimen was insufficiently covering CNS infections, he was transferred to the [Hospital Unit Name 153] for an LP to be performed as well as the meropenem desensitization protocol (patient with anaphylaxis to PCN, ~1% chance of crossreactivity with meropenem). The patient tolerated desensitization well but the LP failed. The patient is known to be a difficult tap, and had an Ommaya placed by NSGY previously for intrathecal MTX drug delivery during his chemotherapy regimen. After returning to the floor from the [Hospital Unit Name 153], patient continued to have persistent fevers and now began to complain of nasal/chest congestion. Microbiology testing revealed positive viral DFA for RSV. As the patient's IgG was WNL, ID opted against giving IVIG or any other treatment. At this point, it was felt that his fevers may be drug-induced, and vancomycin was discontinued and meropenem continued as single [Doctor Last Name 360]. The patient's frequency of fevers decreased but he continued to have severe HA. Given his continued severe symptoms, even in the setting of an ANC which had now risen to >1000, an MRI brain was performed, which showed evidence of severe pansinusitis. The patient was switched to levofloxacin to provide superior atypical coverage. He showed significant improvement on this regimen and defervesced completely with improved headaches. Per ID, he is to continue on a 21-day course of levofloxacin. After that time period, his symptoms should be reassessed by a physician; if they have resolved, the levofloxacin should be discontinued at that time. # [Name (NI) 10563] Lymphoma - Pt is s/p recent hospitalization for chemotherapy with R-IVAC. Per primary oncologist (Dr. [Last Name (STitle) ], pt has completed all chemotherapy. . # HIV - Most recent CD4 count was 479 and VL was less than 48 copies/mL in 10/[2145]. Per ID, patient could potentially have abacavir hypersensitivity given that blood bank testing indicated he was HLA-B5701 positive. He was switched to Atripla for his HAART regimen. Additionally, the patient received INH pentamidine for PCP prophylaxis as well as acyclovir prophylaxis. . # anemia / thrombocytopenia - The patient had severe anemia and thrombocytopenia during his hospitalization thought [3-8] myelosuppresion. He received several transfusions of both pRBCs and platelets. Medications on Admission: ABACAVIR-LAMIVUDINE [EPZICOM] - 600 mg-300 mg Tablet - one Tablet(s) by mouth once daily ACYCLOVIR - 400 mg Tablet - one Tablet(s) by mouth twice daily CIPROFLOXACIN [CIPRO] - 500 mg Tablet - one Tablet(s) by mouth twice daily CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth once daily EFAVIRENZ [SUSTIVA] - 600 mg Tablet - one Tablet(s) by mouth once nightly LORAZEPAM - 1 mg Tablet - 1-2 mg Tablet(s) by mouth twice daily as needed for nausea ONDANSETRON HCL - 8 mg Tablet - one Tablet(s) by mouth two to three times per day PROCHLORPERAZINE [COMPAZINE] - 10 mg Tablet - one Tablet(s) by mouth three times a day as needed for nausea ZOLPIDEM - 10 mg Tablet - [2-5] to 1 Tablet(s) by mouth once nightly as needed for insomnia DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider; Pt reports recently starting.) - Dosage uncertain ??Pentamidine 300mg Recon soln once monthly (due) Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 4. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [2-5] Sprays Nasal QID (4 times a day) as needed for congestion. Disp:1 inhaler Refills:2 8. Ibuprofen 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 18 days: please take until you run out of pills. Disp:18 Tablet(s) Refills:0 10. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety, nausea. 12. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:60 Tablet(s) Refills:0 13. ATRIPLA [Telephone/Fax (3) 567] mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary: RSV infection, sinusitis, febrile neutropenia, Burkitt's lymphoma . Secondary: HIV Discharge Condition: Activity Status:Ambulatory - Independent Level of Consciousness:Alert and interactive Mental Status:Clear and coherent Discharge Instructions: You were admitted for fevers and low blood counts. Your blood cultures were negative, but you were found to have a viral infection called RSV which causes colds and flu like illnesses. This virus is generally self limited. You were also found to have sinusitis, which is being treated with an antibiotic called levofloxacin. Finally, we changed your HIV meds to make them easier to take. You improved and are being discharged to home with close follow up with your doctors. . Please continue to take you medications as ordered. We have made the following changes: 1. STOP taking Epzicom and Sustiva for HIV 2. START taking Atripla 1 tablet at bedtime for HIV 3. Take Levofloxacin 500mg daily until [2146-3-21] 4. Use a saline nasal spray to help treat your sinusitis 5. We have adjusted your pain medications and are discharging you on Percocet, [2-5] pills four times daily 6. Please take senna and colace while taking pain medications to decrease constipation as a side effect 7. Please take ibuprofen 200mg twice daily to decrease pain and inflammation . Please attend your follow up appointments. . Followup Instructions: Monday, [2146-3-7] at 1:00pm with Dr. [Last Name (STitle) ] [Name6 (MD) ] [Last Name (NamePattern4) 9601] MD, [MD Number(3) 9602] Completed by:[2146-3-5]	[ "2761", "311", "4019", "3051", "2859", "2875" ]
Admission Date: [2147-10-25] Discharge Date: [2147-11-22] Service: SURGERY Allergies: Penicillins / Ambien / Hydralazine Attending:[First Name3 (LF) 1481] Chief Complaint: Dysphasia Major Surgical or Invasive Procedure: Neck wound exploration, hematomoa drainage G tube placement History of Present Illness: 89 yo F s/p repair of Zenker's diverticulm on [10-17]. Had a post-op hematoma at the site which was not impairing her breathing and was left to resolve on its own. However, she returns with dysphasia to solids > liquids and a 10 Lb weighty loss. Past Medical History: 1)coronary artery disease, status post myocardial infarction in [2135], recent cardiac catheterization in [2144-6-20], revealed a 90% stenosis of the left anterior descending artery, 40% of the circumflex, 40% of OM1 and 100% stenosis of the right coronary artery. 2) Diabetes. 3) Hypertension. 4) Hypercholesterolemia. 5) Gastroesophageal reflux disease. 6) Peptic ulcer disease. 7) Status post right hip fracture. 8) Iron deficiency anemia. Social History: Has been in rehab since surgery. Used [Year (4 digits) ] from age 16 to age 76 (one pk q 2-3 days). ETOH 2 shots of vodka every night with dinner. Family History: Non-contributory Physical Exam: NAD AAO x 3 Moist mucus membranes L neck incision C/D/I Echymoses along left neck and chest Heart RRR Lungs CTAB Abd soft, NT Ext WWP, no edema Pertinent Results: [2147-10-25] 04:45PM BLOOD WBC-7.4# RBC-3.28* Hgb-9.3* Hct-30.1* MCV-92 MCH-28.4 MCHC-31.0 RDW-17.0* Plt Ct-234 [2147-10-25] 04:45PM BLOOD Neuts-80.2* Lymphs-13.5* Monos-6.0 Eos-0.2 Baso-0.1 [2147-10-25] 04:45PM BLOOD PT-13.4* PTT-26.0 INR(PT)-1.2 [2147-10-25] 04:45PM BLOOD Glucose-252* UreaN-15 Creat-0.8 Na-143 K-3.9 Cl-102 HCO3-25 AnGap-20 [2147-10-26] 05:30AM BLOOD Calcium-8.9 Phos-2.4# Mg-1.6 [2147-11-9] 05:48AM BLOOD calTIBC-272 Ferritn-143 TRF-209 [2147-11-9] 05:48AM BLOOD Triglyc-94 [2147-11-9] 03:49PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2147-10-25] Blood Cx - Strep Viridans [2147-10-27] Wound Cx - C/w skin flora [2147-10-30] Blood Cx - Neg x 2 [2147-11-3] Wound Cx - MRSA [2147-11-10] Urine Cx - Neg Brief Hospital Course: 89F with Zenker's diverticulum, s/p myotomy [10-17], returns with inability to swallow and 10 lb weight loss. Patient was taken to the OR on [2147-10-27] for exploration neck wound, hematoma evacuated, perforation confirmed, JP placed, CVL placed. Postoperatively, the patient had a brief episode of A-fib on [10-29], was converted with lopressor and ruled out for MI x 3. Blood cultures (1 set) grew strep viridans. The patient completed a 6 week course of antibiotics. An echo obtained showed mild LVH, LV wall motion abnormalities (new since last echo [7-25]), EF=35%, mild AR, mod MR, but no vegetations. Wound cultures grew MRSA, covered by Vancomycin. On [11-10], the patient returned to the OR for open G-tube placement and tube feeds were initiated. The patient had volatile blood sugar readings which were eventually controlled. The rest of her hospital course was uneventful and she was deemed fit for discharge [Hospital ] rehabilitation. Medications on Admission: ASA EC 325', calciumcarbonate 650', FA 1', glyburide 5', imdur 15', iron, lasix 20' (mo/wed/fri), lisinorpil 10am 15pm, carvedilol 6.25", plavix 75', prilosec 30', simvastatin 10' Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: Malnutrition and esophageal fistula with central venous line malfunction. Discharge Condition: Stable Discharge Instructions: Restart your medications as usual. You may resume activity as tolerated. Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Other symptoms concerning to you Followup Instructions: Please see Dr. [Last Name (STitle) ] in 2 weeks, [Telephone/Fax (1) 2981]. Completed by:[2147-11-20]	[ "5070", "4240", "42731", "4280", "V5867", "41401", "412", "4019", "53081" ]
Admission Date: [2198-4-9] Discharge Date: [2198-4-14] Date of Birth: [2144-5-1] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 943] Chief Complaint: Dark stools Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [Known lastname ] is a 53F with h/o chronic EtOH use and HCV cirrhosis c/b varices s/p banding in [2190], portal hypertensive gastropathy, PUD, and multiple GIB who p/w dark stools x1d. She has had multiple recent admissions for sequelae of HCV cirrhosis and chronic EtOH use: Most recently, she was hospitalized from [Date range (1) 80820] with coffee ground emesis and anemia requiring 2u pRBC and attributed to portal gastropathy after EGD demonstrated chronic grade I varices, portal gastropathy, and known PUD without e/o of active bleed. She was subsequently hospitalized from [Date range (1) 82049] with symptomatic ascites negative for SBP and anemia requiring 2u pRBC and attributed to portal gastropathy and PUD in the absence of active bleed on abdominal CT. Since the time of her last admission, she has undergone therapeutic LVP x2 on [3-28] and [4-3]. Previous w/u in the setting of GIB notable for colonoscopy with diverticulosis and AVMs in the cecum and terminal ileum in [11-15]. She reports non-bloody diarrhea, followed by "dark" stools x2 on the evening PTA. She denies f/c/s, lightheadedness, n/v, hematemesis, CP, SOB, or abdominal pain. In the ED, initial VS were 97.4 106 128/92 16 100% RA. Her Hct was noted to be 27, c/w baseline, and she was found to be guiac positive. She received ceftriaxone, octreotide, and protonix. Hepatology was consulted in the ED and advised MICU admission for HD monitoring; emergent EGD deferred unless fall in Hct or e/o active bleed. In the MICU, repeat Hct was found to be 20.1 6h after initial CBC, and 2u pRBC and FFP were transfused, with plans for intubation and emergent EGD. Past Medical History: - Hepatitis C c/b by varices s/p banding in [5-15] - Portal gastropathy - Peptic ulcer disease - [Date Range ] deficiency anemia - GERD - Hypertension Social History: She lives alone and works in marketing. Her family lives in NJ. Denies tobacco. Endorses 2 glasses of red wine per weekend with dinner, most recently on the evening PTA. No illicit/IVDU. Family History: Per [Name (NI) ], mother with h/o GIB of unknown source. Sisters with [Name2 (NI) ]-deficiency anemia. Physical Exam: Admission Exam: Vitals: 98.8 105 133/88 17 93% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Tensely distended, nontender GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, trace pitting edema bilaterally 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: [2198-4-9] 02:08PM BLOOD WBC-5.1 RBC-3.03* Hgb-8.8* Hct-27.4* MCV-90 MCH-29.0 MCHC-32.2 RDW-21.7* Plt Ct-199 [2198-4-9] 02:08PM BLOOD PT-20.5* PTT-36.6* INR(PT)-1.9* [2198-4-9] 02:08PM BLOOD Glucose-112* UreaN-9 Creat-0.6 Na-133 K-4.2 Cl-101 HCO3-24 AnGap-12 [2198-4-9] 02:08PM BLOOD ALT-38 AST-149* AlkPhos-85 TotBili-3.0* [2198-4-9] 02:08PM BLOOD Albumin-3.3* [2198-4-10] 12:55AM BLOOD Calcium-7.6* Phos-3.6 Mg-1.5* [2198-4-9] 08:12PM BLOOD ASA-NEG Ethanol-28* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2198-4-10] 01:02AM BLOOD Type-[Last Name (un) ] Temp-38.2 Rates-/18 Tidal V-400 PEEP-5 FiO2-50 pO2-101 pCO2-38 pH-7.43 calTCO2-26 Base XS-0 Intubat-INTUBATED [2198-4-10] 01:02AM BLOOD freeCa-1.04* [2198-4-10] 01:02AM BLOOD Lactate-1.5 EGD ([2198-3-11]): -Varices at the lower third of the esophagus -Blood in the stomach body -Varices at the cardia -Erythema, congestion and mosaic appearance in the antrum, stomach body and fundus compatible with portal hypertensive gastropathy -Polyp in the antrum -Otherwise normal EGD to third part of the duodenum MRI Abdomen ([2198-4-13]): 1. No focal lesions in the liver to suggest HCC. 2. Sequela of portal hypertension. 3. Cystic lesion in the pancreas. Given the size and age of the patient, a followup MRI should be obtained in 6 months to evaluate interval changes. Alternatively, the pancreas can be evaluated at the patient's next MRI evaluation of the liver. Brief Hospital Course: 53F h/o HCV cirrhosis c/b varices s/p banding in [2190], portal hypertensive gastropathy, PUD, and GIB p/w dark stools. . Active Problems: #GIB: The patient was admitted for melena and Hct 27.4 on admission, c/w baseline, followed by repeat Hct 20.1 6h later, with appropriate response in Hct 25.5-26.8 s/p 2u pRBC. She was intubated for airway protection and admitted to the MICU on a PPI gtt and Octreotide gtt. She underwent emergent EGD with banding of esophageal varix x1 on HD1 in the setting of low Hct after receiving Vitamin K 10 mg IV and FFP. She was extubated successfully on HD2. Home nadolol 20 mg PO qd was resumed and increased to 40 mg on HD4. She experienced minimally bloody large-volume emesis on HD1 and melenotic stools x2 on HD3, without significant change in Hct, hemodynamically stable. She was called out and transitioned to a [Hospital1 ] PPI, and had no further episodes of GI bleeding while in-house. #Cirrhosis: Largely stable LFTs, with the exception of AST (initially up from baseline, then downtrending 149 -> 88) and TBili (uptrending 3.0 -> 4.2-5.9). The patient had significant ascites and is scheduled for routine outpatient large volume therapeutic paracenteses, and had a therapeutic paracentesis witih removal of 5L ascitic fluid. She was discharged on her home furosemide and aldactone, which were reinitiated following her variceal banding. #Anemia: As above, likely [3-8] variceal bleed, with element of known [Month/Day (2) ] deficiency anemia. Hct remains stable s/p 2u pRBC and banding. #Chronic EtOH use: Given known h/o EtOH use and serum EtOH of 28 on admission, she received a banana bag on admission and was placed on a CIWA scale, with no triggering events. Transitional Issues: - f/u MRI results with outpatient hepatologist; will need repeat MRI in 6 months Medications on Admission: Pantoprazole EC 40 mg PO bid Folic acid 1 mg PO qd Thiamine HCl 100 mg PO qd MV PO qd Lasix 20 mg PO qd Spironolactone 50 mg PO qd Trazodone 25 mg PO qhs prn insomnia Sucralfate 1 g PO tid Fluticasone 50 mcg intranasal [2-5] sprays qd Nadolol 20 mg PO bid Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. spironolactone 50 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for Insomnia. 8. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. nadolol 20 mg Tablet Sig: One (1) Tablet PO twice a day. 10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Last day on [2198-4-15]. Disp:2 Tablet(s) Refills:0 11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Please titrate the number of times you take this medication on a daily basis so that you are having 3 soft bowel movements every day. Disp:2700 ML(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Esophageal variceal bleed, Portal hypertensive gastropathy. Secondary Diagnosis: Anemia, Hepatic cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you while you were at the [Hospital1 18]. You were admitted for having dark stools. You were taken to the Medical Intensive Care because you had a low level of hemoglobin. You were intubated and had an endoscopy which showed varices in the esophagus that had been recently bleeding. You were also given blood and your hemglobin levels returned to baseline. You have not had any further dark stools. You also had a paracentesis (tap) in which we removed 5L of fluid (ascites). The MRI of yoru liver that had been scheduled as an outpatient was performed while you were in the hospital. The following changes were made to your medications: - Ciprofloxacin was STARTED due to your GI bleed, to be taken until [2198-4-15] (two additional days at home) - Lactulose was STARTED; please take this at home every day and adjust the number of times you take the medication every day so that you are having 3 soft bowel movements daily (increased frequency for increased bowel movements) - spironolactone was INCREASED to 100mg daily - lasix was INCREASED to 40mg daily Followup Instructions: Department: RADIOLOGY CARE UNIT When: WEDNESDAY [2198-4-18] at 11:30 AM [Telephone/Fax (1) 446] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: RADIOLOGY When: WEDNESDAY [2198-4-18] at 1 PM [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: LIVER CENTER When: WEDNESDAY [2198-4-18] at 1:40 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 2261] Appointment: Thursday [2198-4-19] 10:50am. It is recommended that you have an EGD within the next 2 weeks. Please discuss with your PCP the best time to have this done.	[ "2851", "4019", "53081" ]
Admission Date: [2189-6-3] Discharge Date: [2189-6-30] Date of Birth: [2116-6-21] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 22401] Chief Complaint: Not talking or moving left side Major Surgical or Invasive Procedure: Extraction of tooth History of Present Illness: Pt is a 72yoF with h/o HTN and DM who is not currently getting regular medical care who is brought in today after being less responsive at home for 2 days. She was seen normal at 9:30 am on Monday. her husband then came home at 2:30 pm and she did not greet him as usual. Eventually, after he called multiple times, she came to the front door, but had her face covered with a napkin. She did not speak. When he asked what was wrong, she just stared at him, then walked back to the living room and lay down. She was walking well at that point. Since then, he reports she has not spoken at all. She also wouldn't eat or drink and according to the husband, she was not moving any of her extremities. The only movement she had was a tremor that comes in her right arm with stimulation which is suppressible. She was awake, but did not want to do anything. He tried to give her juice and water but was not very successful. On one attempt, she actually vomited with the juice. She was in bed this whole time and he would sit her up to try and feed her. She had no BMs and to urinate, he picked her up and put her on a bucket beside the bed. She had no incontinence. . He reports he would have brought her in sooner, but his friends told him to wait it out and she might get better. He got too worried today and called EMS at 11 am. She came here and had a stat head CT which shows a large hypodensity in the superior R MCA territory. She has a slight midline shift due to mild edema. She is minimally responsive. She was found to have a fever to 101 and a WBC ct of 18.2. She was also found to have a glucose of 459. The remainder of her labs are unremarkable. . In the field, her FS was 460. She is not talking and is minimally responsive. Again, at baseline, she is normal and independent of all ADLs. . ROS: Patient unable. Husband says no recent fever, infection, HA, dizziness, LH, CP/SOB. She has not had nausea, but did have some vomiting on Monday when the husband tried to feed her some [Name (NI) ]. Past Medical History: HTN-not on treatment DM-not on treatment Social History: Pt is originally from [Country 2045] and speaks Creole. She lives here with her husband. She is independent of her ADLs. No EtOH or smoking. Walks independently. Family History: She has 4 siblings and a father who are all deceased from complications of DM and HTN. Physical Exam: Exam:Vitals:98.2-->101, 173/65, 61, 20, 100% on 2L. Gen:Grimaces to sternal rub. Doesn't open eyes to voice. HEENT:MM dry. Sclera clear. OP clear Neck: No Carotid bruits CV: RRR, Nl S1 and S2. Lung: Clear to auscultation bilaterally Ext:No cyanosis/edema . Mental Status:Grimaces to sternal rub. Doesn't follow commands or have any verbal output. . CN: Pupils:PERRL, but sluggish. 3->2.5 bilat. Gag/Cough:+ cough Corneal Reflex:Brisk on right, minimal on left. OCRs:Eyes deviated rightward. Move only to ~ midline with head turning. Move back to right with turning head opposite way. The right eye passes midline more readily. . Motor:Occasional spont mov't of RUE and RLE. She does have an inducible tremor(with stimulation) of the right arm that is also suppressible with pressure. She withdraws both of these to painful stim. She also withdraws left side to painful stim, but much less than right. No tremor noted on left. Unable to formally test strength. Pt is moderately hypertonic in RUE and RLE and mildly hypertonic in LLE and LUE. . Toes:Downgoing on right, ? upgoing on left. . DTRs: [Name2 (NI) ] Tri Br Pa [Doctor First Name ] R 2 2 2 2 tr L 2 2 2 2 tr . Respiration:Pt is breathing spontaneously. Pertinent Results: [2189-6-3] 09:05PM ALT(SGPT)-15 AST(SGOT)-22 CK(CPK)-1056* ALK PHOS-144* AMYLASE-21 TOT BILI-0.3 [2189-6-3] 09:05PM LIPASE-16 [2189-6-3] 09:05PM CK-MB-11* MB INDX-1.0 cTropnT-<0.01 [2189-6-3] 09:05PM CHOLEST-164 [2189-6-3] 09:05PM VIT B12-382 [2189-6-3] 09:05PM TRIGLYCER-80 HDL CHOL-41 CHOL/HDL-4.0 LDL(CALC)-107 [2189-6-3] 09:05PM TSH-0.88 [2189-6-3] 07:44PM COMMENTS-GREEN TOP [2189-6-3] 07:44PM LACTATE-3.2* [2189-6-3] 04:44PM COMMENTS-GREEN TOP [2189-6-3] 04:44PM LACTATE-3.2* [2189-6-3] 03:00PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.032 [2189-6-3] 03:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2189-6-3] 03:00PM URINE RBC-0-2 WBC-0 BACTERIA-0 YEAST-NONE EPI-0 [2189-6-3] 01:53PM K+-4.3 [2189-6-3] 01:40PM GLUCOSE-459* UREA N-33* CREAT-1.2* SODIUM-145 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-23 ANION GAP-25 [2189-6-3] 01:40PM CK(CPK)-871* [2189-6-3] 01:40PM CK-MB-11* MB INDX-1.3 cTropnT-<0.01 [2189-6-3] 01:40PM WBC-18.2* RBC-5.72* HGB-14.0 HCT-43.2 MCV-76* MCH-24.5* MCHC-32.4 RDW-13.9 [2189-6-3] 01:40PM NEUTS-88* BANDS-0 LYMPHS-5* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2189-6-3] 01:40PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [2189-6-3] 01:40PM PLT SMR-NORMAL PLT COUNT-352 [2189-6-3] 01:40PM PT-13.5* PTT-18.1* INR(PT)-1.2* . . Radiologic Data CHEST (SINGLE VIEW) [2189-6-3] 6:39 PM AP UPRIGHT RADIOGRAPH OF THE CHEST: The apical regions are obscured by the patients head. The heart is normal in size. The mediastinal and hilar contours are unremarkable. The lungs are clear. There may be very mild left basilar atelectasis. No pleural effusions are seen. IMPRESSION: No evidence of pneumonia. . MRA BRAIN W/O CONTRAST [2189-6-3] 5:13 PM IMPRESSION: Large right cerebral infarction involving the brain parenchyma supplied by the anterior division of the middle cerebral artery. A small focus of signal abnormality within the left cerebellar hemisphere may represent a subacute infarct versus T2 artifact. MRA of the circle of [Location (un) 431] demonstrates marked attenuation within the anterior division MCA branches. No focal areas of hemorrhage are seen on gradient echo images. . CT HEAD W/O CONTRAST [2189-6-3] 1:49 PM IMPRESSION: Right middle cerebral arterial territory infarction, involving the superior division. . ECG [2189-6-3] 11:58:38 PM Sinus rhythm. Atrial premature beats. Non-specific ST-T wave changes. Compared to the previous tracing no significant change. . CAROTID SERIES COMPLETE [2189-6-4] 10:01 AM IMPRESSION: No evidence of carotid disease bilaterally. . ECHO (TTE) [2189-6-4] Conclusions: 1. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. . CHEST (PORTABLE AP) [2189-6-5] 11:42 AM Cardiac, mediastinal, hilar contours are normal. The lungs are essentially clear. An NG tube is seen with its tip terminating within the stomach. No other changes since the prior examination. . EEG [2189-6-6] IMPRESSION: This is an abnormal portable EEG obtained in wakefulness progressing to drowsiness due to the absence of the background rhythm in the right hemisphere. This finding suggests deep subcortical lesion projecting to the entire right hemisphere. There were no clear epileptiform discharges recorded. The slow and disorganized background rhythm represents a mild encephalopathy. Periods of EMG artifact obscured the EEG interpretation in this recording. . CT HEAD W/O CONTRAST [2189-6-7] 11:22 AM IMPRESSION: Significant increase in the territory of hypodensity in the right frontal, parietal, and temporal lobes consistent with an evolving right MCA infarction. No intracranial hemorrhage is identified. Stable mass effect on the adjacent right lateral ventricle and minimal shift of normally midline structures. . CHEST (PORTABLE AP) [2189-6-8] 8:00 AM IMPRESSION: AP chest compared to [6-3] and 12: Mild cardiomegaly and mediastinal and pulmonary vascular engorgement are stable accompanied by small bilateral pleural effusions increased slightly since [6-5]. Although there is no pulmonary edema, this suggests cardiac decompensation. Nasogastric tube passes into the stomach and out of view. No pneumothorax. . CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [2189-6-10] 9:02 PM IMPRESSION: 1. Bilateral pleural effusions, right greater than left with associated atelectatic changes. 2. 1.1 cm pretracheal lymph node of uncertain clinical significance. 3. Right upper lobe patchy opacity worrisome for pneumonia. 4. 2.7 x 1.5 cm splenic hypodensity which may represent a posttraumatic cyst but cannot be further characterized. 5. Right kidney hypodensity which may represent a cyst but cannot be further characterized. . CHEST (PORTABLE AP) [2189-6-10] 6:14 PM PORTABLE CHEST: A nasogastric tube is seen coursing below the diaphragm and terminating in the body/antrum. Bilateral pleural effusions are seen. The bowel gas pattern appears normal, although examination is limited by poor penetration. . PORTABLE ABDOMEN [2189-6-11] 7:28 PM COMPARISON: CT of the torso from [2189-6-10]. PORTABLE AP VIEW OF THE ABDOMEN: An NG tube tip is seen overlying the stomach. Contrast is seen throughout the colon, to the rectum, where there is a large amount of stool. No dilated loops of small or large bowel are identified. The osseous structures appear unremarkable. IMPRESSION: Nasogastric tube tip overlying the stomach. . EEG [2189-6-11] IMPRESSION: This is an abnormal routine EEG due to the presence of intermittent bifrontal slowing in the mixed theta and delta frequency range occasionally left side predominance. This finding suggests subcortical dysfunction in this region. There is no clear background rhythm seen throughout the recording but beta and occasionally theta frequency rhythm. There is no previous EEG recording to compare a change of EEG amplitude bilaterally. However, low voltage fast EEG patterns can be a normal finding in five percent of the population. There were no clear epileptiform or seizure activity recorded. . CHEST (PORTABLE AP) [2189-6-12] 8:51 PM IMPRESSION: Nasogastric tube in body of stomach. . CT HEAD W/O CONTRAST [2189-6-15] 4:19 PM IMPRESSION: Unchanged appearance of large right MCA infarct with associated edema, but without significant uncal herniation. . CHEST (PORTABLE AP) [2189-6-16] 9:40 AM IMPRESSION: AP chest compared to [6-10] and 19: There has been an increase in the volume of peribronchial infiltration in the right mid lung zone to accompany lower lobe pneumonia. Moderate cardiomegaly worsened. No pulmonary edema. Small right pleural effusion stable. . CXR [2189-6-29]: [Hospital 93] MEDICAL CONDITION: 72 year old woman w/R MCA stroke, with persistent fevers. Please eval for progression of RLL infiltrate, port cxr with worsening effusions, tachypnea REASON FOR THIS EXAMINATION: assess for change in effusions/infiltr 2 VIEW CHEST [2189-6-29]: COMPARISON: [2189-6-27]. INDICATION: Stroke. Fevers. There is marked cardiomegaly with increasing heart size compared to prior radiographs. There is vascular engorgement and bilateral perihilar haziness as well as asymmetrical perihilar consolidation in the right upper lobe. There has been interval improved aeration in the lung bases, particularly in the left lower lobe with residual opacities remaining as well as residual bilateral small to moderate pleural effusions. IMPRESSION: Likely worsening of asymmetrical pulmonary edema although underlying infection is not excluded . Hip x-ray: HISTORY: Bilateral hip pain. Three radiographs of the pelvis and right hip demonstrate no fracture. No joint space narrowing. Sacroiliac joints are normal. Pubic symphysis is unremarkable. Tiny sclerotic focus in the right femoral neck likely represents either a benign bone island or possibly tiny synovial herniation pit. When compared to [2189-6-22], there is no interval change. IMPRESSION: Unremarkable radiographs of the pelvis and right hip. Brief Hospital Course: Neuro: Patient was admitted with large right MCA stroke. She had a severe left hemiparesis and did not communicate verbally. Though she was unresponsive initially, she gained some function in the left arm, as she pulled out several NGT while her right arm was unrestrained and her left arm was free. She also slowly began to communicate with what sounded like mumbled Creole and wrote her name approximately two weeks into her admission. She responded to some simple commands and actually waved goodbye. She then became less communicative a few days later and seemed to be more apathetic/abulic. She waxed and waned from this point of view, but her left arm did stop functioning again. She had a repeat head CT which showed a moderate amount of edema that may be responsible for her symptoms and continued lethargy. She was also still having low grade fevers and an elevated WBC ct of unclear etiology that may be contributing. The fact that she wasn't talking was abnormal given a right MCA stroke in a right handed person, but it is possibl ethat she was born left handed and switched in school at a young age, putting her language in the right brain. She was stable from a neuro standpoint throughout, with no verbal output, a paretic left side, a left facial droop, and dysphagia. . CV: Patient had uncontrolled HTN on admission. Her SBPs ranged in the 130s-170s. She was started on Lopressor and Captopril, which had to be titrated up to control her HTN here. This was very difficult to control however and her doses were escalated. Given her acute renal failure, her captopril was discontinued. She was instead maintained on metoprolol, hydralazine, and ISDN. She was in the 130s-140s range on discharge. She had an echocardiogram which showed an EF 60%, with LVH. She was noted to have increased pulmonary edema on CXRs with repeat echocardiogram performed the day of discharge [2189-6-30]. The final read was pending on discharge. . ID: Patient had an unexplained leukocytosis on admission(and throughout) and low-grade fevers throughout hospital stay. She was found to have mild right lower lobe PNA on CXR and started on Levofloxacin and Flagyl. After a 7-day course, she continued to have low-grade fevers and elevated WBC. A subsequent CXR showed worsening of the PNA, so Vancomycin and Zosyn were started to cover for possible MRSA or pseudomonas. The other antibiotics were stopped. Blood and urine cultures were negative throughout. She also had a torso CT with contrast to look for evidence of an occult infection/abscess, but none was found. A TTE showed no abnormality. She was then found to have LFT elevations on Zosyn, which was discontinued. Progressive CXRs were concerning for continued aspiration pneumonia, so she was switched to levofloxacin/metronidazole and will need to complete a 14 day course. Repeat urine, blood, stool cultures were all negative. . Heme: Patient had unexplained leukocytosis on admission and then developed a thrombocytosis approximately two weeks into admission. It was not clear if the elevations were reactive (infection, s/p PEG). Patient had a torso CT to rule out underlying malignancy/infection as etiology. This was negative. . Endo: Patient, who had uncontrolled DM on admission, was followed by the [Hospital ] clinic staff and treated with Lantus and Humalog. She was initially on an insulin drip for a short time due to very high glucoses inthe 500 range on admission. Her blood sugars were initially difficult to control as patient would pull NGT and her medicines did not properly match with feedings. She then had a PEG placed, and sugars steadily improved. She was steadily in the 100s-200s range on discharge. She will need follow up with [Last Name (un) ] after discharge. . FEN/GI: Patient initially had tube feeds via NGT, which she pulled out several times. She then underwent PEG placement by GI successfully. Patient had some mild tenderness and discharge expressed from PEG site two days after PEG placement. Cultures were sent to rule out abscess. A CT abdomen also showed no evidence of problems/abscess. . Dental: Patient had poor dental hygiene, which posed a significant aspiration risk. She actually lost several teeth during her admission. Dental and oral surgery were consulted and the question of dental abscess was raised. She underwent successful bed-side extraction of a particularly loose tooth that was a possible source of infection. . LFT abnormalities: Patient had elevation in her LFTs. A RUQ ultrasound was performed to assess for cholecystitis and portal venous flow, and was normal. Hepatitis serologies were checked, and were positive for hepatitis A IgG antibody only. Hepatitis A IgM was pending on discharge. Hepatitis B and C were negative. An EBV, CMV, and antimitochondrial antibody were still pending at time of discharge. Her statin was discontinued due to concern for contribution to LFT abnormalities. She had stabilization of her LFTs, with downward trend by time of discharge. . Acute renal failure: Patient was noted to develop acute renal failure in setting of rapid uptitration of captopril. A renal ultrasound was negative, urine eosinopils were negative, and urine electrolytes were not consistent with prerenal azotemia. Patient's creatinine stabilized at 1.7 to 1.8 at time of discharge. . Social: Patient's family was minimally involved in care. Elder care services was involved for care of patient, given concern for neglect at home with a husband who appeared to have dementia. [Name (NI) ] nephew was assisting with decision making. Medications on Admission: None. Drinks ginger/cinnamon herbal tea when she has a cold. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-26] Drops Ophthalmic TID (3 times a day). 6. Ranitidine HCl 15 mg/mL Syrup Sig: One [Age over 90 1230]y (150) mg PO BID (2 times a day). 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed. 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 11. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed. 13. Insulin Per attached sliding scale. 14. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 16. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 10 days. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Right MCA infarct 2. Hypertension 3. Diabetes mellitus 4. Hyperlipidemia 5. Acute renal failure 6. Hepatitis A infection 7. LFT abnormalities Discharge Condition: Stable Discharge Instructions: You were diagnosed with a stroke. You will need extensive rehabilitation. If you develop worsening weakness, fever, chills, nausea, vomiting, or shortness of breath, you should call your primary care doctor or go to the emergency room. Followup Instructions: Patient will need blood pressure medication adjustment. Patient should follow up with neurology. The number to call is [Telephone/Fax (1) 16748]. Patient should follow up with a primary care doctor in [2-27] weeks. The number to call to make appointment is [Telephone/Fax (1) 250]. At that time, PCP should review liver abnormalities. Patient may need referral to gastroenterology. You will need careful monitoring of your liver function tests and your creatinine. Patient should follow up with [Last Name (un) ] Diabetes Center for management of your new diabetes. The number to call is [Telephone/Fax (1) 2378].	[ "5849", "486", "5070", "4019", "V5867", "2859" ]
Admission Date: [2122-6-5] Discharge Date: [2122-6-13] Date of Birth: [2061-3-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2698] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 61 yo male with h/o HTN, DM, OSA (BIPAP at home), no known CAD, who presented to OSH with 5 day h/o intermittent CP found to have ST changes, increase troponin c/w MI and transfered to [Hospital1 18] for cath. Pt was in usual good state of health until 5 days ago when he developed intermittent L sided chest pain at rest, radiating down L arm and back. Last ~ 1 hr. +diaphoresis. minimal relief with tylenol/advil at home. Went to hospital last night as CP associated with SOB/DOE. At [Hospital1 1474], O2 92% RA, tachypnic, [7-12] SSCP. pt given SL nitroX3, morphine(4mg IV), 325mg ASA, 40 IV lasix and then nitro ggt. Troponin 4.6, CK 85. In ED, no ST/T wave changes and CP relieved with nitro ggt. Admitted to CCU and then continued to have intermittent CP despite inc nitro ggt and inc ST elevation in II/AVF. Transfer for cath. . Cath results: LAD - 90% lesion after D1 LCX -90% proximal RCA - 50%mid, 70%postlat branch PCW - 40, PA 65/37 CI: 3.7 Intervention: s/p 3 stent to LAD and 1 stent to Lcx; balloon pump Of note, pt hypotensive on transfer to [Hospital1 18], but after stenting in cath lab, pressures improved. Intubated [2-4] agitation. Propofol started--> became hypotensive 50s--> balloon pump inserted--> started on dopamine and propofol changed to fentanyl/versed. .. Past Medical History: HTN, DM, OSA with home BIPAP, obesity Social History: hx: + tob 1.5 ppd X50 yrs Family History: nc Physical Exam: On admission: PE: T: 96.3 BP: 160/83 (SBP: 53-160) HR: 80-102 O2: 100% on AC control: TV: 650 X RR 20 X PEEP 5 XFIO2 1.00 GEN: pt obese male, intubated/sedated, NAD HEENT: pupils ~2mm equal, mmm/pink CHEST: equal breath sounds/chest mov't bilat; no crackles noted on ant exam; whooshing of balloon pump heard on ins/exp CARDIAC: rrr, no m/g/r ABD: protuberant, soft, nt EXT: cool/dry; bounding L DP pulse; very faint R DP pulse, but dopplerable; no femoral bruits appreciated; R femoral access - balloon pump Neuro: sedated Pertinent Results: Labs at OSH: glucose 312, creatinine - 0.8, k - 3.6, CK - 85, MB-2 troponin 4.6, wbc - 9, hct 40.4 ... EKG: OSH: [6-4] 6:36 PM: NSR @ 90, nml axis, flat T I/avL; jpoint --> 2mmSTE V2-V3 OSH: [6-5] 1:12am: nsr @80, nml axis, TWI 1, AVL [Hospital1 18] [6-5] after cath: nsr @80, nml asix, 2mm STE V3-V4 Brief Hospital Course: A/P: 61 yo male with h/o HTN, DMII, +tob, p/w USA s/p cardiac cath with PCI to LAD/LCx and evidence of R/L inc filling pressures. 1. CAD - Post MI care including ASA, plavix load - 300mg IV after cath, followed by 75mg daily X3months, and lipitor 80mg daily. He received integrilling X18hrs after cath. Mr [Known lastname 10083] was hyptotensive immediately after his cardiac cath and outpt antihypertensives were held. However, once abx were started and he was extubated, his hypotension resolved and carvedilol and ace-I were started. CPK was monitored during admission, but never bumped. Discussed smoking cessation with patient prior to discharge, to which he stated that this hospitalization was a wake up call to him to stop smoking. . 2. PUMP: Elevated r/l filling pressures values were obtained during the cardiac cath, and balloon pump initially put in for afterload reduction. Of note, adequate cardiac output/index values were obtained during the cath. PCWP was monitored via arterial line, with goal wedge pressure 15-20. He was given lasix to maintain goal wedge pressures. Mr. [Known lastname 10083] was initally hypotensive s/p intubation (SBP in 50s) - which was thought likely to be secondary to the propofol; blood pressures improved with dopamine and sedation medications were changed to versed/fentanyl, whic hthe patient tolerated well. Dopamine was eventually weaned, but took few days due to pneumonia. Echo [6-5]--> EF 40%, anterior/ distal septal AK and apical AK. Inital extubation failed, likely [2-4] fluid overload, and patient was subsequently diuresed and successfully extubated [6-10]. He was continued on lasix after extubation, and discharged on 40mg PO daily. THis can likely be weaned on f/u with cardiologist within few weeks of discharge. Given akenesis seen on echo [6-5], patient was started on coumadin 2mg qHS prior to d/c. Spoke with covering PCP in [Name9 (PRE) 1474], who agreed that Dr. [Name (NI) 3314], pts PCP, [Name10 (NameIs) ] follow INR. Will need repeat echo in 3 months, at which time, length of anticoagulation can be readressed. . 3. rhythm: nsr, bb for cad; goal HR 50-60 as BP tolerates . 4. Resp failure/PULM: Initially intubated during cath for pt safety. However, right sided infiltrate on CXR (liekly aspiration PNA based on r-sided dependent infiltrate) delayed extubation. Given infiltrate on CXR and spike, pt was initially started on broad spectrum abx with ceftriaxone and flagyl, which then were changed to meropenem and vanc as patient contiued to spike fevers, grew GNR in sputum, and was difficult to wean off vent. ULtimately, his sputum grew pan sensitive E.Coli and abx were changed to levofloxacin, which he will continue PO as an outpt to complete a 14 day course of abx. After extubation, pt remained on oxygen via NC throughout admission, with ambulatory O2 sats in low 80s. He was discharged on home O2 with VNA to help monitor respiratory status. He is to follow up with PCP for reevaluation of oxygen requirement on week of d/c. Pt . 5. DMII - H/o diabetes on metformin/glyburide as outpt. HgbA1c was checked during admission and found to be 11.9. Discussed importance of adhering to diabetic diet/wt loss for improved glycemic control. Patient was initially on insulin ggt while intubated and then restarted on glyburide(10mg [Hospital1 ])/metformin(500mg [Hospital1 ]). He is to follow up with PCP [Last Name (NamePattern4) ]: adjusting diabetic medications for improved control. 02 . 6. Hypernatremia - Pt with increased serum Na (147-149) while intubated. Resolved with free water bolus. . Medications on Admission: glyburide metformin antihypertensive meds no asa Discharge Medications: 1. oxygen - continuous 2-4 Liters oxygen continuous. Use as directed. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months: please continue this medication for 3 months. Disp:30 Tablet(s) Refills:2 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:3 Tablet(s) Refills:0 6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. 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 9. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): please have your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 3314], follow your coumadin levels and adjust the medication as appropriate. Disp:30 Tablet(s) Refills:2 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: please have your primary care doctor adjust this medication as necessary. Disp:30 Tablet(s) Refills:2 12. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 13. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 14. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:6 Tablet(s) Refills:0 15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. 16. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 17. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day for 3 days. Disp:12 Tablet(s) Refills:0 18. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. 19. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime for 3 days. Disp:3 Tablet(s) Refills:0 20. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Primary diagnosis: 1. Unstable angina s/p cardiac cathterization with PCI to LAD and LCx 2. Pneumonia Secondary Diagnosis: 1. Diabetes Mellitus 2. HTN Discharge Condition: stable Discharge Instructions: Please call your PCP or return to the emergency department if you develop chest pain, shortness of breath, bloody stools or other worrisome symptom. Please take all medications as prescribed. Please continue your antibiotics, levofloxacin, as prescribed until [2122-6-8] Followup Instructions: Please call your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 3314], at [Telephone/Fax (1) ] to schedule a follow up appointment within the next week. He should adjust your diabetes medications, follow your coumadin levels, and refer you to a cardiologist in your area. Please also have Dr. [Last Name (STitle) 3314] adjust your lasix dose as appropriate.	[ "41071", "41401", "0389", "99592", "51881", "5070", "2760", "4280", "3051", "25000", "V5867", "V5861" ]
Admission Date: [2103-6-19] Discharge Date: [2103-6-24] Date of Birth: [2019-8-6] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Quinolones Attending:[First Name3 (LF) 1406] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2103-6-19] Coronary bypass grafting times 4(left internal mammary artery to left anterior descending artery, reverse saphenous vein graft to right coronary artery,sequential reverse saphenous vein graft to first and second obtuse marginal arteries). Permanent left ventricular epicardial lead placement History of Present Illness: This 83 year old white male with complaints of dyspnea on exertion and abnormal stress echo was referred for cardiac catheterization. This revealed severe coronary artery disease and he was referred for surgical intervention. Past Medical History: Hypertension Hyperlipidemia s/p St. [Male First Name (un) 923] PPM for CHB [9-15] Arthritis Sleep apnea noted after administration of narcotics Diverticulitis s/p Left hemicolectomy [5-/2102] s/p Back surgery [2101] s/p Appendectomy s/p Tonsillectomy Social History: Race:Caucasian Last Dental Exam: Lives with:wife Occupation:Retired Tobacco:quit 23 years ago, smoked x 50 years ETOH:[12-9] pint of hard alcohol a day Family History: noncontributory Physical Exam: admission: Pulse:70 Resp:13 O2 sat:97% RA B/P Right:156/662 Left:160/64 Height:5'1" Weight:163 lbs General: NAD, sitting comfortably in chair 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-I/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +1 Left:+1 DP Right:+2 Left:+2 PT [Name (NI) 167]: +2 Left:+2 Radial Right:+2 Left:+2 Carotid Bruit Right: none Left:none Pertinent Results: [2103-6-21] 05:10AM BLOOD WBC-11.8* RBC-2.98* Hgb-9.6* Hct-28.1* MCV-94 MCH-32.1* MCHC-34.0 RDW-14.5 Plt Ct-157 [2103-6-19] 03:22PM BLOOD WBC-16.2# RBC-3.43 Hgb-11.3* Hct-31.7* MCV-92 MCH-32.9* MCHC-35.7* RDW-14.4 Plt Ct-216 [2103-6-19] 03:22PM BLOOD UreaN-12 Creat-0.8 Na-141 K-4.4 Cl-109* HCO3-24 AnGap-12 Brief Hospital Course: Mr. [Known lastname 14] was a same day admit who was taken to the Operating Room where he underwent coronary artery bypass graft x 4 and permanent left ventricular epicardial lead placement. Please see operative report 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. On post-op day one beta-blockers and diuretics were initiated and he was diuresed towards his pre-op weight. Also on this day he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. Physical Therapy worked with him for strength and mobility. Wounds were clean and healing well at discharge. discharge restrictions, precations, medications and follow up were discussed with him prior to discharge. He was cleared for discharge to home on POD#5 by Dr. [First Name (STitle) ]. He will receive VNA and has private care at home as well. Medications on Admission: Norvasc 5mg po daily Lipitor 10mg po daily ASA 81mg po daily Vitamin D3 Lactobacillus Rhamnosus 10 billion cells cap- 1 cap po daily MVI Fish Oil Preservision 1 cap po daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery bypass graft x 4 Hypertension Hyperlipidemia s/p St. [Male First Name (un) 923] permanent pacemaker [9-15] Arthritis Diverticulitis s/p Left hemicolectomy [5-/2102] s/p Back surgery [2101] s/p Appendectomy s/p Tonsillectomy Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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) ] Wednesday ([Telephone/Fax (1) 170]on [7-25] @ 1:00 PM Please call to schedule appointments with your Primary Care: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1407] ([Telephone/Fax (1) 1408]in [12-9] weeks Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [12-9] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2103-6-24]	[ "41401", "4019", "2724", "32723", "V1582" ]
Admission Date: [2177-6-7] Discharge Date: [2177-6-17] Date of Birth: [2103-1-20] Sex: F Service: CARDIOTHORACIC Allergies: Ativan Attending:[First Name3 (LF) 2969] Chief Complaint: Transfer from OSH w/ c/o increasing SOB and rapid Afib- found to have pericardial effusion -admitted for management /pericardial window. Major Surgical or Invasive Procedure: pericardial window [6-9], intubated [6-10], extubated [6-13]. History of Present Illness: : Ms. [Known lastname ] is a 74-year-old patient treated by Dr. [First Name4 (NamePattern1) 951] [Last Name (NamePattern1) 952] in the past, where she was found to have a right hilar carcinoma likely arising in the middle lobe. Evaluation revealed pleural carcinomatosis rendering her stage T4 (3B). She underwent talc pleurodesis and has been treated with systemic chemotherapy. She was transferred emergently from [Hospital3 ] over the weekend with dyspnea on exertion, shortness of breath, and new atrial fibrillation. She was found to have a new pericardial effusion which progressed to hemodynamic significance requiring pericardiocentesis. A pericardial window was planned for management. Past Medical History: Stage IV lung cancer ([11-23]) s/p TALC and chemo, htn, hyperlipid, COPD, CAD, s/p L CEA Social History: Lives w/ sister- [Name (NI) ] [Name (NI) 59451] 1-[Telephone/Fax (1) 59452]. Has home O2 and home hospice prior to this admit. Former smoker -1pk q 2 weeks -quit [2172]. no Etoh. Family History: Mother CVA, Sister Cervical Ca, Physical Exam: VS: 98.4, 108(irreg), 138/84, 27. 96% on 5L. General: Alert, SOB on 5 liter O2 NP, pleasant and [Doctor Last Name ]. Lungs: decrease BS on right base, occas rhonchi Heart: Irreg, irreg Abd: soft, ND, Right tenderness -no [Doctor Last Name ] sign. remanider of abd exam w/o tenderness, rebound, or guarding w/ +BS. Extrem: no C/C/E Neuro A+OX3 Pertinent Results: RENAL U.S. PORT [2177-6-11] 8:20 AM FINDINGS: The kidneys are normal in contour and echogenicity with no evidence of hydronephrosis, masses, or stones. The right kidney measures 11.5 cm and the left kidney measures 12 cm. The bladder was emptied during the study. There is a small amount of ascites and gallstones are noted. Cardiology Report ECHO Study Date of [2177-6-10] :Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are grossly normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. [2177-6-9] [-4/2337] PERICARDIAL FLUID :POSITIVE FOR MALIGNANT CELLS consistent with adenocarcinoma. LIVER OR GALLBLADDER US (SINGLE ORGAN) [2177-6-8] 12:13 AM:Transabdominal ultrasound examination of the right upper quadrant was performed. There is a 1.8 cm mobile gallstone. There is gallbladder wall thickening and a small amount of pericholecystic fluid. The common duct is not dilated and measures 3 mm. There is no intrahepatic biliary ductal dilatation. Limited images of the pancreas are grossly unremarkable. IMPRESSION: Findings worrisome for acute cholecystitis. If indicated, HIDA scan may be performed for further evaluation. Brief Hospital Course: Patient admitted to BICMC CCU [2177-6-7] from [Hospital 1562] HOspital after present to ED w/worsening shortness of breath, found to be in Afib@150. Echo showed ef 70%, moderate pericardial effusion, trace MR, mild pulm htn. Pt transferred for further management. Pt denied f/c, CP, SOB, abd pain, constipation, diarrhea. [2177-6-8]- HD#1--Cardiology and Surgery consult obtained, chest CT, CXRY, RUQ u/s to r/o cholycystitis done. HIDA scan scheduled Patient managed on diltiazem gtt, vanco and zosyn after pan culture, ivf. HD#2-12am- Increased SOB and confusion, ? ativan. Echo done STAT> partial collapse of RA, partial limited contraction of RV c/w early tamponade. Pericardialcentesis and drainage of 600cc done by Cardiology w/ local. Plan for pericardial window in am. Dilt gtt cont for Afib, digoxin load, autodiuresing w/ lytes repleated, vanco and zosyn. Left thoracotomy and pericardial window done; clot in atrial appendage> heparin to start. Chest tube and JP drain in place. Intubated, PA line placed, u/o low, somulent, CT drainage 170. Post-op admitted to SICU. HD#3/POD#1- Somulence, toradol and narcan given. Morphine, dilaudid, haldol d/c. Head CT done, then Heparin started @800/hr- goal PTT50-60. Diuresis w/ lasix. Neo started for MAP >60; cardiac enzymes and troponin neg, JP drain d/c; CPAP trial done; Renal consult done, renal u/s for increased Cr 2.5. POD#2- INtubated and sedated on CPAP; afib cont; wean pressor/NEO; zosyn and vanco d/c, levofloxacin started for UTI; good u/o- rnal u/s normal; TF started and held for residuals >300cc. POD#3- Family meeting, planned extubation after wean, tolerated well. Patient DNR/DNI. Plan for discharge to home w/ Hospice when stable. Planning started. Central line change, PA line d/c, triple lumen changed over wire for Neo. POD#4- Neo, dilt d/c; lopressor 25 [Hospital1 ]; CT to water seal. Transfer to floor, with some confusion- 1:1 sitter for safety of IV and CT. A&Ox2, OOB w/ assist. POD#5- Patient doing well, pain controlled, good po intake, ambulating. CT d/c, foley d/c, CXRAY s/p CT d/c wnl, no ptx.HR 100-12O afib, BP stable. Discharge planning for hospice cont. Plan for d/c in AM. POD#6- Central line d/c w/o complication. Patient ready for discharge to home w/ Hospice. Discharge instructions given and reviewed with patient and family by RN. Medications on Admission: Zoloft 50', Lipitor 40', Inderal 80' Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). 9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:20 Tablet(s) Refills:0 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 15. Lopressor 50 mg Tablet Sig: [12-22] Tablet PO twice a day. Disp:30 Tablet(s) Refills:2 16. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Stage IV Non small cell lung cancer. Pericardial effusion-s/p pericardial window Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 1816] office for: fever, chills, chest pain, or shortness of breath. [Telephone/Fax (1) 170]. YOu may resume your activity as you tolerate and is comfortable. No driving for 2 weeks. YOu may take motrin or tylenol or codeine for any pain or discomfort you might have. Refer to medication list. Followup Instructions: Call Dr.[Name (NI) 1816] office for a follow up appointment in [1-23] weeks. [Telephone/Fax (1) 170]. Completed by:[2177-6-17]	[ "42731", "496", "5990", "2724", "4019" ]
Admission Date: [2110-10-24] Discharge Date: [2110-10-31] Service: Medicine CHIEF COMPLAINT: Bright red blood per rectum and lightheadedness. HISTORY OF PRESENT ILLNESS: The patient is an 87 year old man in a rehabilitation facility, who was observed to have bright red blood per rectum. He was seen to have a large bowel movement with bright red blood as well as blood clots. The patient felt dizzy and his blood pressure was taken as 90/40. He was given 250 cc of normal saline and transferred to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ], where his hematocrit was found to be 19.9. His baseline hematocrit is around 29. PAST MEDICAL HISTORY: 1. Dementia. 2. Frequent falls. 3. Coronary artery disease, status post coronary artery bypass grafting in [2105] and myocardial infarction in [2093]. 4. Congestive heart failure with a left ventricular ejection fraction of 25% in [2104]. 5. Intermittent atrial fibrillation, not anticoagulated because of fall risk. 6. Anemia. 7. Type 2 diabetes mellitus. 8. Hypertension. 9. Hyperlipidemia. 10. Hypothyroidism. 11. Most recently admitted from [10-16] for diuresis for congestive heart failure exacerbation. MEDICATIONS ON ADMISSION: Digoxin 0.125 mg p.o.q. Monday, 0.25 mg p.o.q. Wednesday, Lasix 80 mg p.o.b.i.d., spironolactone 25 mg p.o.q.d., Cozaar 50 mg p.o.b.i.d., glyburide 5 mg p.o.b.i.d., aspirin 81 mg p.o.t.i.d., Isordil 40 mg p.o.t.i.d., Colace, metformin 1,000 mg p.o.b.i.d., iron sulfate 160 mg p.o.q.d., Lipitor 10 mg p.o.q.d., Casodex (bicalutamide) 50 mg p.o.q.d., Synthroid 0.15 mg p.o.q.d., ranitidine 150 mg p.o.q.d., Toprol XL 50 mg p.o.q.d., hydralazine [2119-11-22] mg p.o.q. a.m./afternoon/p.m. PHYSICAL EXAMINATION: On physical examination on admission, the patient was afebrile with a pulse of 72 to 80, blood pressure 116/34, respiratory rate 15 and oxygen saturation 100%. General: Pale elderly gentleman in no acute distress. Head, eyes, ears, nose and throat: Pupils equal, round, and reactive to light and accommodation, fundi with sharp disks, no hemorrhage, oropharynx without discharge, mucous membranes dry. Neck: Supple, no bruits. Chest: Clear to auscultation bilaterally, no wheezes, rales or rhonchi. Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmur. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Rectal: Normal tone, dark stool, guaiac positive. Musculoskeletal: 5/5 strength in upper and lower extremities. Neurologic examination: Alert and oriented times three, poor short term memory. Physical examination on discharge showed crackles to one-half way up lungs, left greater than right, and 1+ edema to mid-calves. Cardiovascular: Regular rate and rhythm. Nasogastric lavage: Negative for blood. LABORATORY DATA: Admission white blood cell count was 11.5 with 79.8 neutrophils, 0 bands, 12.6 lymphocytes, 5.9 monocytes, 1.1 eosinophils and 0.6 basophils, hemoglobin 6.7, hematocrit 19.9, platelet count 329,000, sodium 132, potassium 5, chloride 96, bicarbonate 29, BUN 63, creatinine 1.1, prothrombin time 12.9 and INR 1.1. Serial CK were 60, 45 and 24. [2110-10-31]: White blood cell count 14.2, hemoglobin 11.8, hematocrit 33.4. [2110-10-30]: White blood cell count 13, hemoglobin 11.3, hematocrit 33.9. [2110-10-29]: White blood cell count 12.4, hemoglobin 12.1, hematocrit 36.4. [2110-10-28]: White blood cell count 11.7, hemoglobin 12.1, hematocrit 35.4. [2110-10-27]: White blood cell count 14, hemoglobin 12.1, hematocrit 34.8. [2110-10-26]: White blood cell count 12.2, hemoglobin 9.8, hematocrit 28.3. [2110-10-31]: Sodium 138, potassium 3.9, chloride 103, bicarbonate 25, BUN 23, creatinine 1.1 and glucose 129. [2110-10-29]: Helicobacter pylori antibody positive. [2110-11-1]: Urinalysis (straight catheterization), greater than 50 red blood cells, greater than 50 white blood cells, few bacteria, no epithelial cells. RADIOLOGIC DATA: Tagged red blood cell scan, [2110-10-24]: Blood flow images show increased diffuse activity in the left side of the abdomen, delayed blood pool images obtained over one hour show no increased activity in the region of the gastrointestinal tract, delayed blood pool images obtained over a third half-hour show a brief focus of increased activity in the left mid-abdomen, the activity moves up into the left and diffuses out over one-half hour; impression, (1) increased diffuse activity over the left side of the abdomen could represent a region of hyperemia which can be seen with diverticulitis, (2) brief focus of activity over the left mid-upper quadrant of the abdomen could represent a small bleed which disperses in the bowel, its location is difficult to identify but could represent bleeding in the transverse colon. [2110-10-26] chest x-ray: Increased pulmonary vascularity with associated perihilar haziness in a bilateral lower lobe interstitial pattern; there are probably small pleural effusions bilaterally; impression, congestive heart failure with interstitial edema and probable small bilateral pleural effusions. [2110-10-31], chest x-ray (unofficial read): Left lower lobe infiltrate, small nodular opacity in the right lung at level between fifth and sixth ribs. [2110-10-28], small bowel follow-through: Several air filled loops with small and large bowel throughout the abdomen; the patient was given barium to drink and this reached the cecum over three to four hours; no intrinsic mass effect or filling defects are seen over 1 cm in size; the terminal ileum was normal in appearance; impression, no obvious mass or mass effect is identified. [2110-10-27], upper gastrointestinal endoscopy: Reducible small sized hiatal hernia in the esophagus, stomach with diffuse continuous erythema of the mucosa with no bleeding noted in the antrum; these findings are compatible with gastritis; duodenum, multiple cratered nonbleeding ulcers ranging in size from 2 to 5 mm were found in the duodenal bulb. HOSPITAL COURSE: The patient felt asymptomatic during his hospital stay. He himself did not complain of shortness of breath, weakness or dizziness, although he is a poor historian. He was admitted to the Medical Intensive Care Unit initially, where two large bore intravenous lines were placed. He received three times daily hematocrit checks and was transfused with four units of packed red blood cells, with appropriate hematocrit bump to 29. The patient was then transferred to the floor and given two more units. His hematocrit was 31.5 afterwards. He had no further transfusions and his hematocrit was 34.4 on discharge. His stool was guaiac negative on discharge. His antihypertensive medications, besides losartan, were held for most of the hospitalization because of the concern of risk for hypotension, especially given his likely recent bleed. He was restarted on Toprol XL 50 mg daily and Lasix 80 mg twice a day on [2110-10-30]. He had a systolic blood pressure of approximately 130 and pulse approximately 75 on these medications. He will be discharged with his baseline antihypertensive regimen, which includes Isordil 40 mg three times a day and hydralazine [2119-11-22] mg in the morning, noon and evening, with hold parameters applied. He usually had a regular rate and rhythm but occasionally was in atrial fibrillation. As evaluated on previous admission, the patient is a poor candidate for anticoagulation given that he has a history of frequent falls. On [2110-10-27], the patient underwent an upper gastrointestinal endoscopy which showed multiple, 2 to 5 mm, nonbleeding duodenal ulcers. Colonoscopy was attempted on [2110-10-27], but failed because the patient had too much residual stool despite having consumed one gallon of GoLYTELY. A colonoscopy was successfully performed after he drank another gallon. The colonoscopy revealed nonbleeding, grade II, internal hemorrhoids and diffuse continuous melanosis. Otherwise, he had a normal colonoscopy with no evidence of bleeding. A small bowel follow-through, performed on [2110-10-28], also was normal and did not yield a source of bleeding. The source of the patient's gastrointestinal bleed, therefore, was most likely his duodenal ulcers. He was found to be Helicobacter pylori positive and was started on triple therapy as well as a proton pump inhibitor twice a day for life. He had been receiving 81 mg of aspirin three times a day prior to admission. Because of his ulcers, yet his multiple cardiac risk factors, it was decided to continue him on aspirin but only on 81 mg per day. A chest x-ray on [2110-10-30] revealed a possible small nodule in the left lung at the level between the fifth and six ribs. This could potentially be followed up with an outpatient CT scan. However, given the patient's age and his co-morbidities, as well as his being an extremely poor candidate for chemotherapy or surgery, this workup may not be necessary. The chest x-ray also revealed a left lower lobe infiltrate. The patient had been afebrile and without cough during his hospitalization. He will be started on levofloxacin 250 mg per day for ten days. His urinalysis on [2110-10-30] showed a possible urinary tract infection, which levofloxacin would cover. He did have red blood cells in his urine and it is unclear whether this is due to trauma from catheter insertion. He should have a repeat urinalysis as an outpatient. CONDITION AT DISCHARGE: Guarded, owing to the patient's baseline health with multiple co-morbidities. DISCHARGE STATUS: Full code. DISCHARGE DIAGNOSES: Gastrointestinal bleed, likely from duodenal ulcers. Positive for Helicobacter pylori. DISCHARGE MEDICATIONS: Digoxin 0.125 mg p.o.q. Monday, 0.25 mg p.o.q. Wednesday. Lasix 80 mg p.o.b.i.d. Spironolactone 25 mg p.o.q.d. Cozaar 50 mg p.o.b.i.d. Glyburide 5 mg p.o.b.i.d. Aspirin 81 mg p.o.q.d. Isordil 40 mg p.o.t.i.d. Colace one to two tablets p.o.b.i.d.p.r.n. constipation. Metformin 1,000 mg p.o.b.i.d. Iron sulfate 160 mg p.o.q.d. Lipitor 10 mg p.o.q.d. Casodex (bicalutamide) 50 mg p.o.q.d. Synthroid 0.15 mg p.o.q.d. Omeprazole 30 mg p.o.b.i.d. Toprol XL 50 mg p.o.q.d. Hydralazine [2119-11-22] mg p.o.q. a.m./afternoon/p.m., hold for systolic blood pressure less than 100. Levofloxacin 250 mg p.o.q.d., last day [2110-11-9]. Clarithromycin 500 mg p.o.b.i.d., last day [2110-11-11]. Amoxicillin 1 gm p.o.b.i.d., last day [2110-11-11]. DISPOSITION: The patient was discharged to a rehabilitation facility for work on his ambulation. His wife should contact Dr. [First Name8 (NamePattern2) 1312] [Last Name (NamePattern1) 101490] to schedule a follow-up appointment in about three weeks. Dr. [Last Name (STitle) 101490] is at [Telephone/Fax (1) 101491]. Mrs. [Known lastname 62041] is at [Telephone/Fax (1) 101492]. [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Name8 (MD) 4123] MEDQUIST36 D: [2110-10-31] 15:25 T: [2110-11-3] 08:40 JOB#: [Job Number ]	[ "42731", "4280", "486", "5990", "25000", "2449", "4019", "V4581" ]
Admission Date: [2106-6-20] Discharge Date: [2106-6-23] Date of Birth: [2059-10-11] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 19193] Chief Complaint: Syncope Major Surgical or Invasive Procedure: EGD on [2103-6-22] History of Present Illness: Ms. [Known lastname 2643] is a 46 yo woman with a PMH significant for obesity s/p gastric bypass surgery ~10 years and chronic anemia who presented to [Hospital3 ] on [2106-6-20] after passing out. She reports that she was at work on the day of admission when she began to feel lightheaded, put her head down and then when she got up lost consciousness. . She awoke in an ambulance, and she was taken to [Hospital3 ], where her Hct was noted to be 15.7. She was not tachycardic, but her BP was 98/54. She was given pantoprazole, and a unit of blood was hung, and she was transferred to [Hospital1 18] for further management. . She reports worsening fatigue and dyspnea on exertion over the past few weeks, and had to stay home from work 2 days prior to admission [1-22]. . She has noted dark stools, but reports that this has been because of iron supplements. She reports blood on the toilet paper and sometimes scant amounts in the toilet bowl after bowel movements, but ascribes this to hemorrhoids. She denies hemoptysis, hematemesis, coffee-ground emesis, tarry, sticky stool or frank hematochezia. She denies abdominal pain. She denies darkening of her urine, yellowing of her eyes or skin. Of note, the patient did describe taking significant quantities of ibuprofen (up to 3 pills 3 times a day) for refractory headaches, in addition to aspirin and fioricet. . In the ED, her VSs were 99.1, 94, 96/55, 16, 100%RA. NG lavage was negative. A rectal exam revealed guaiac positive brown stool. She received pantoprazole and 1 unit pRBCs. . The patient spent the night in the ICU. She received an additional 2 U PRBC's. Her Hct climbed to 30. She remained hemodynamically stable. Immediately prior to transfer to the medicine floor, the patient underwent endoscopy revealing 2 clean based, non-bleeding ulcers at the site of her gastric bypass anastomosis. . Review of symptoms was positive only for headache. The pt denied recent unintended weight loss, fevers, night sweats, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: - TAH for fibroids - H/o obesity s/p gastric bypass surgery ~ 10 years ago at [Hospital1 336] - Anxiety - Depression - Tension headaches - Hypercholesterolemia Social History: Patient smokes 3 cigarettes per day, occasional alcohol, denies any illicit drugs Family History: Father died of "bone marrow cancer" at 66 yo. Physical Exam: Vitals: 98.5 76 108/70 18 100% RA Gen: Nervous, well-appearing. NAD. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Soft, nontender, nondistended. Ext: No edema Pertinent Results: Admission Labs: [2106-6-20] 07:27PM BLOOD WBC-5.4 RBC-1.89# Hgb-6.2# Hct-17.7# MCV-94# MCH-32.9# MCHC-35.1# RDW-16.7 Plt Ct-191 [2106-6-20] 07:27PM BLOOD Neuts-69.5 Lymphs-26.1 Monos-3.3 Eos-1.1 Baso-0.1 [2106-6-20] 07:27PM BLOOD Glucose-103 UreaN-19 Creat-0.5 Na-141 K-3.8 Cl-113* HCO3-21* AnGap-11 . Imaging/Studies: . ECG [2106-6-20]: Sinus rhythm, Borderline prolonged/upper limits of normal Q-Tc interval - is nonspecific and may be within normal limits, but clinical correlation is suggested, rate 88 . [2106-6-21] EGD: Normal mucosa in the esophagus 1. A small pouch of stomach leading into proximal jejenum was noted.This is from her gastric bypass surgery.There were two ulcers noted at the anastomotic area.The ulcers were not actively bleeding. Ulcers had clean base. Otherwise normal EGD to second part of the duodenum . Discharge Labs: [2106-6-23] 08:15AM BLOOD WBC-5.2 RBC-3.40* Hgb-10.9* Hct-31.5* MCV-93 MCH-32.0 MCHC-34.5 RDW-16.5* Plt Ct-217 [2106-6-23] 08:15AM BLOOD Glucose-95 UreaN-11 Creat-0.6 Na-143 K-4.2 Cl-110* HCO3-24 AnGap-13 [2106-6-23] 08:15AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3 Brief Hospital Course: # Anemia/Syncope. Likely secondary to GI bleed from ulcers at anastomotic site which was likely complication by extensive ibuprofen and aspirin use for headaches. After transfusion, the patient's hematocrit continued to remain stable. There was no active bleeding on EGD as above. In addition, GI recommended no colonoscopy at this time as the bleed was likely explained by the findings on EGD. Patient was placed on a proton pump inhibitor, and was discharged on carafate as well. . # Headache. Patient with complaints of severe headaches exacerbation by tension and stress. Patient was continued on topiramate and acetaminophen prn and was told to avoid ibuprofen. Would recommend outpatient follow up for progression of headaches (MRI/CT) . # Anxiety/depression. Continued clonazepam, sertraline. Medications on Admission: Sertraline 100 mg PO daily Ezetemibe/simvastatin [10-9] Vitamin B12 1000 Clonazepam 1 mg PO tid prn Topiramate 50 [Hospital1 ] Iron 64 mg PO bid MVI Discharge Medications: 1. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Vytorin [10-9] 10-20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: Take 30 minutes before breakfast and dinner. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 7. Carafate 100 mg/mL Suspension Sig: Two (2) gram PO twice a day. Disp:30 days Refills:0 8. Iron (Ferrous Sulfate) 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed Discharge Condition: Stable Discharge Instructions: You were admitted with an extensive gastrointestinal bleed that was likely from ulcers in your stomach. Your blood count was very decreased when you arrived, and you were given blood which improved your count considerably. While you were admitted, you had an upper GI scope (EGD) which showed that you had two ulcers in your stomach at the site of your gastric bypass surgery. As a result, we have put you on a medication (protonix) to decrease your chances of having another bleeding ulcer. You should take this twice daily, 30 minutes before breakfast and dinner until you see your gastroenterologist. In addition, we are sending you home on Carafate, which is another medication to protect your stomach lining. You should take this twice daily. You should avoid taking any non-steroidal anti-inflammatory medications (NSAIDS) which include advil, aleve, motrin, ibuprofen, as well as aspirin and many others. Please speak with your primary care doctor before starting new medications that may contain NSAIDS. If you develop any dizziness, lightheadedness, shortness of breath, chest pain, increasing black or tarry stools, increased bright red blood in your stools, or any other symptom that concerns you, please proceed to the nearest Emergency Department or contact your primary care doctor as soon as possible. Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 16258], within one week of discharge from the hospital. Please follow up with your gastroenterologist, Dr. [First Name (STitle) 679], within 2 weeks.	[ "2859", "3051", "2720" ]
Admission Date: [2183-2-5] Discharge Date: [2183-2-10] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5827] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 88yo F resident of [Hospital3 2558] with CAD s/p CABG (last known EF 40%), CHF, DM who presents with progressive sob for one week. As per the daughter, the pt has been having progressive LE edema and orthopnea as well. The pt was treated for presumed pneumonia for the last 1 week at [Hospital3 2558]. Per records and daughter, pt never had fever but had light colored sputum production. She was treated with levofloxacin but did not improve. After few days without improvement in dyspnea, pt was given lasix diuresis. Ultimately renal function declined and she was given IVF. On the day of admission, she became increasingly dyspneic and lethargic and was subsequently transfered to the ED. EMS found the pt pale diaphoretic and tachypneic to 30s with SaO2 of 80% on 2L -> 100% on NRB. The pt was also found to have BP of 170/65, with HR of 80 on arrival to the ED. On exam, she was found to have elevated JVP, with [Month (only) ] BS at bases and crackles up halfway, he was also having abdominal breathing and was minimally responsive (although primarily Russian speaking). ABG at the time was 7.34/67/229. A foley catheter was placed and the pt was given lasix 40mg IV x1. A nitro gtt was started and the pt was placed on BiPAP. Due to difficult access, a right fem line was placed. Placed on BiPAP without improvement in CO2 or mental status. The pt eventually put out several hundred ml of urine and her respiratory status improved. Her nitro gtt was discontinued and she was eventually converted to NC. ABG improved to 7.41/61/89. BNP returned at [Numeric Identifier 104170]. She was also given ceftriaxone 1g IV x1 and transferred to the [Hospital Unit Name 153]. Past Medical History: 1. CAD s/p CABG in [2172]. TTE in [2175] demonstrated EF 40% with inferolateral hypokinesis. 2. Hypertension 3. Hypercholesterolemia 4. Diabetes Mellitus 5. Colorectal Cancer, s/p resetion in [2177] with positive nodes. Chose to be followed conservatively without chemotherapy. 6. s/p left hemispheric CVA. Pt had left internal capsule and left occipital infarcts. 7. Gait instability. Patient has had frequent falls due to instability secondary to knee and hip pain, DJD of spine and old CVA's (above) 8. s/p L ORIF ([6-14]) 9. GERD 10. Vitamin B12 deficiency. Patient receives monthly injections. Social History: The patient lives at [Hospital3 2558]. No history of tobacco or alcohol use ever. [Name (NI) ] grandson, [Name (NI) ], can be reached at [0-0-]. Patient's daughter, [Name (NI) 440], can be reached at [Telephone/Fax (1) 104171]. Family History: CAD. Physical Exam: VS in ED: T: 98.3, HR: 76, BP; 170/65, RR: 35, SaO2: 100% on NRB VS in [Hospital Unit Name 153]: HR: 66, BP: 111/33, RR: 12, SaO2: 100% on 2L NC GEN: Elderly female in NAD wearing NC, comfortably asleep. arousable with significant physical stimulus, no accessory muscle use. HEENT: EOMI, anicteric, mmm, op clear Neck: thick big neck, difficult to appreciate JVP Chest: [Month (only) ]. BS with crackles anteriorly and laterally CV: RRR, S1, S2, no m/r/g Abd: soft, NT, ND, BS+ Ext: 2+ bilateral pitting edema Pertinent Results: STUDIES: ECG [2183-2-5]: NSR at 80, nml-left [Hospital1 ] axis, wide QRS, Q in III, TWI in I and L, V4-v6. CXR [2183-2-5]: bilateral pleural effusions and pulmonary vascular congestion consistent with CHF. Evaluation of the underlying lung parenchyma is difficult with likely superimposed bibasilar compressive atelectasis or consolidation. The lung apices are better visualized on the current study and appear clear. The osseous structures are grossly unremarkable. . TTE [2-6]: The left atrium is mildly dilated. There is asymmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Impression: moderate-to-severe mitral regurgitation; asymmetric septal hypertrophy . [2183-2-5] 05:00PM BLOOD WBC-10.0 RBC-3.15* Hgb-9.4* Hct-28.4* MCV-90 MCH-29.8 MCHC-33.1 RDW-17.8* Plt Ct-288 [2183-2-7] 07:15AM BLOOD WBC-8.7 RBC-3.08* Hgb-8.8* Hct-27.4* MCV-89 MCH-28.8 MCHC-32.3 RDW-17.0* Plt Ct-242 [2183-2-5] 05:00PM BLOOD Neuts-92.0* Bands-0 Lymphs-6.6* Monos-1.3* Eos-0 Baso-0.1 [2183-2-5] 05:00PM BLOOD PT-13.0 PTT-23.6 INR(PT)-1.1 [2183-2-6] 04:01AM BLOOD PT-12.6 PTT-22.3 INR(PT)-1.1 [2183-2-5] 05:00PM BLOOD Glucose-306* UreaN-44* Creat-1.6* Na-140 K-4.5 Cl-97 HCO3-33* AnGap-15 [2183-2-7] 07:15AM BLOOD Glucose-138* UreaN-51* Creat-1.6* Na-142 K-3.8 Cl-93* HCO3-39* AnGap-14 [2183-2-5] 05:00PM BLOOD ALT-10 AST-18 CK(CPK)-26 AlkPhos-89 Amylase-56 [2183-2-5] 05:00PM BLOOD Lipase-19 [2183-2-5] 05:00PM BLOOD cTropnT-<0.01 proBNP-[Numeric Identifier 104170]* [2183-2-6] 10:11AM BLOOD CK-MB-2 cTropnT-<0.01 [2183-2-5] 05:00PM BLOOD Albumin-3.6 Calcium-10.8* Phos-3.5 Mg-2.0 [2183-2-7] 07:15AM BLOOD Calcium-9.7 Phos-3.3 Mg-1.7 [2183-2-6] 04:01AM BLOOD calTIBC-329 VitB12->[2177] Folate-GREATER TH Ferritn-85 TRF-253 [2183-2-7] 07:15AM BLOOD Hapto-301* [2183-2-6] 04:01AM BLOOD Triglyc-147 HDL-36 CHOL/HD-4.2 LDLcalc-86 [2183-2-6] 04:01AM BLOOD TSH-0.45 [2183-2-5] 05:08PM BLOOD Type-ART pO2-229* pCO2-67* pH-7.34* calHCO3-38* Base XS-7 [2183-2-5] 06:29PM BLOOD Type-ART pO2-58* pCO2-60* pH-7.38 calHCO3-37* Base XS-7 [2183-2-5] 06:53PM BLOOD Type-ART pO2-89 pCO2-61* pH-7.41 calHCO3-40* Base XS-10 [2183-2-6] 12:07AM BLOOD Type-ART pO2-89 pCO2-58* pH-7.43 calHCO3-40* Base XS-11 [2183-2-6] 12:24AM BLOOD Type-ART pO2-57* pCO2-53* pH-7.46* calHCO3-39* Base XS-11 [2183-2-5] 05:08PM BLOOD Glucose-323* Lactate-1.8 K-4.7 [2183-2-5] 06:29PM BLOOD Glucose-313* Lactate-1.8 K-4.7 [2183-2-5] 06:53PM BLOOD O2 Sat-96 COHgb-1 MetHgb-0 Brief Hospital Course: 88yo F with CAD s/p CABG, CHF with EF of 40% and DM presents with one week of progressive SOB. . Heart Failure: Mrs. [Known lastname ] was admitted for progressive shortness of breath and was thoroughly evaluated from a cardiopulmonary and hematologic standpoint. Her hematocrit was near baseline. A myocardial infarction was excluded with an ECG and three sets of cardiac enzymes. Her CXR had the distinctive appearance of CHF without evidence of pneumonia; a BNP level supported this diagnosis, as did both her history and physical. She was initially and briefly admitted to the MICU and treated with BiPAP; she responded well there to diurese and was soon transferred to the medical floor where diuresis continued without difficulty. Given renal insufficiency, her captopril was held and she was started on hydralazine and isosorbide mononitrate, as an ace-inhibitor equivalent. She was negative by ins/outs and her oxygen requirement improved to mid-90's on room air by the time of discharge. Her Echo showed and ef of 70% but mod-severe MR. She was put on a brief prednisone taper for a concern of exacerbation of an underlying reactive airways disease. . DM: For her DM, Mrs. [Known lastname ] was continued on NPH and regular insulin. Her Avandia was stopped given its propensity to increase fluid rentenion. Her blood sugars were well controlled on the insulin-only regimen. . UTI: The pt had UA suggestive of infection at time of admission. As the pt was recently on fluoroquinolones (levofloxacin until day of admission) and the culture came back for FQ-resistant E. coli and P. mirabilis, she was started on cefpodoxime, to which the bacteria was sensitive, for a three day course. She should have a repeat urinalysis/culture sent next week. She has had no symptoms, abdominal tenderness, fever, or leukocytosis while an inpatient. . Knee pain: Per the notes and family, this is a chronic problem for the patient. She was continued on her lidoderm knee patches and put on scheduled acetaminophen for pain relief. She should have PT as an outpatient. . Renal failure -- The patient came in above her baseline, with a creatinine of 1.6, up from her previous value of 1.0. This was felt to be due to CHF and improved slightly with diuresis. With further diuresis, her Cr increased to 1.8, likely from over-diuresis, so her furosemide dosing was scaled back to 40mg by mouth daily. It was felt that the overall picture was consistent with worsening renal function due to diabetes and hypertension, with an acute exacerbation in the setting of shifting renal function. Medications on Admission: 1. Lasix 20mg once daily 2. Aspirin 325mg once daily 3. Atenolol 50mg once daily 4. Gemfibrozil 600mg [Hospital1 ] 5. NPH 14units QAM and 4units QPM 6. Regular 4units QAM with NPH 7. Avandia 2mg [Hospital1 ] 8. Levoxyl 25mcg HS 9. Prednisone taper - currently on 50mg once daily 10. Duoneb PRN 11. Prozac 20mg once ddaily 12. Acetominophen PRN 13. Cyanocobalamin 1000mcg sub Q monthly (given [2183-2-3]) 14. Nortriptyline 10mg QHS 15. Lidoderm patch 5% to knees 16. Lactulose 30cc daily 17. Senna 18. Docusate 19. Bisacodyl 10mg suppository 20. Os-Cal TID 21. MOM PRN Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fourteen (14) u Subcutaneous q AM. 4. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four (4) u Subcutaneous q PM. 5. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Four (4) u Subcutaneous q AM w/ NPH. 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q24HOURS PRN (). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 17. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 18. Prednisone 10 mg Tablet Sig: Per below taper Tablet PO daily (): 30mg (3tabs) x 2 days, then 20mg (2tabs) x 2 days, then 10mg (1tab) x 2 days. 19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 21. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. 22. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. 23. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO at bedtime. 24. Prozac 20 mg Capsule Sig: One (1) Capsule PO once a day. 25. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. 26. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: congestive heart failure urinary tract infection Secondary: 1. CAD s/p CABG in [2172]. TTE in [2175] demonstrated EF 40% with inferolateral hypokinesis. 2. Hypertension 3. Hypercholesterolemia 4. Diabetes Mellitus 5. Colorectal Cancer, s/p resetion in [2177] with positive nodes. Chose to be followed conservatively without chemotherapy. 6. s/p left hemispheric CVA. Pt had left internal capsule and left occipital infarcts. 7. Gait instability. Patient has had frequent falls due to instability secondary to knee and hip pain, DJD of spine and old CVA's (above) 8. s/p L ORIF ([6-14]) 9. GERD 10. Vitamin B12 deficiency. Patient receives monthly injections. Discharge Condition: improved w/ good O2 saturation Discharge Instructions: Please return for further care if you have fever, chills, shortness of breath, chest pain, increased swelling in your legs, acute confusion, blood in your urine, difficulty with urination or any other symptoms that are concerning to you. . Weigh yourself everyday; if your weight increases by more than 2 pounds, please call you primary care doctor. . Please rigidly adhere to a two gram sodium diet. Followup Instructions: Please follow up with your primary care provider in the next week; call [Telephone/Fax (1) 608] to make an appointment.	[ "4280", "5990", "5849", "41401", "25000", "V4581", "4019", "2720", "53081" ]
Admission Date: [2124-6-14] Discharge Date: [2124-6-18] Date of Birth: [2042-4-2] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: - need for drain internalization Major Surgical or Invasive Procedure: [2124-6-14]: metal stents placed [2124-6-15]: cholangiogram -> metal stents found to be clogged, ballooned and extended, replaced external drains [2124-6-16]: cholangiogram -> History of Present Illness: 82 yo F who originally presented to [Hospital1 18] [2124-4-23] with 2 weeks of painless jaundice. Her work-up was significant for locally advanced gallbladder vs. biliary CA and is now s/p palliative external biliary drain placement and duodenal stenting. She presented to [Hospital1 18] to have her external biliary drain internalized by interventional radiology on the day of admission. Past Medical History: HTN, hypothyroidism Social History: Married, 4 children, from [Location (un) 3493], MA. Social alcohol, tobacco 20 pack-years, stopped 7 years ago. Family History: Non-contributory. Physical Exam: Discharge Physical Exam: AxOx3. NAD. RRR. CTAB. Abd soft, +BS, NTND, b/l drain sites clean, secure with no erythema, swelling. Ext WWP. Pertinent Results: [6-18] Na 128 [6-16] T.bil 1.1 Brief Hospital Course: The patient presented to [Hospital1 18] to have her external biliary drain internalized by interventional radiology. Post-operatively, upon arrival to PACU, the patient developed respiratory distress with HTN/tachycardia. She was given lasix 10mg IV and labetalol 10mg IV x2. Placed on BiPAP for 45 minutes with clinical improvement. Admitted to TSICU on 4LNC, hemodynamically stable for overnight monitoring of CHF exacerbation likely in setting of hyperdynamic response post-op. [2124-6-14] & [2124-6-15]: Pt's respiratory condition improved after diuresis in the PACU and SICU. Her oxygen requirements decreased from BIPAP to NC once lasix was given. Her cardiac markers were negative and a formal echo done showed mild aortic stenosis. The cardiology service saw the patient and reported that her pulmonary edema may have been due to diastolic dysfunction in the setting of hypertension and tachycardia. A formal echo done on [6-15] confirmed the presence of mild aortic stenosis. The pt was transfered from the the ICU to the from on HD 2 and IR attempted to cap the two externalized biliary drains in the patient. Fluoroscopic analysis of the pt's two stents revealed that both stents were clogged. IR placed dilated the two stents and placed two longer stents over the original stents. These were left draining on HD 2 with the plan of clamping them for 24 hrs and if no complications developed sending the pt home on HD 3. The right drain had moderate output and was clamped on HD 2. The left drain was not clamped until HD 3 [1-25] high ss fluid output. [2124-6-16]: Pt underwent another cholangiogram by IR and it was then decided to leave both drains clamped [2124-6-17]: LFTs were found to be stable on HD 4 w/ no e/o biliary obstruction after clamping the tube o/n. Both drains were left clamped during HD 4 and the patient tolerated a regular diet and did not develop constitutional sx's. The drains will be left for 7-10 days to ensure patency of her biliary tree and then removed by IR as an outpatient. Pt was kept in place for 7-10 days to ensure patency and remove it as an outpatient. Pt developed hyponatremia on HD4 to 124. She was given salt tabs and continued her regular diet and by evening her Na had risen to 128. [2124-6-18]: Pt's Na remained stable on HD5 and she was discharged to home w/ Na suppl and f/u to PCP in good condition. Medications on Admission: Atenolol 50mg daily, dicloxacillin 250 mg Q6H (do not restart), Levoxyl 75mcg daily, pantoprazole 40mg daily, colace 100 [Hospital1 ], valsartan 160mg daily Discharge Medications: 1. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Levothyroxine 75 mcg Capsule Sig: One (1) Capsule PO once a day. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. 6. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO every eight (8) hours for 2 days: Pls take 3 times per day . Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] vna Discharge Diagnosis: unresectable gallbladder vs biliary vs pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - with assistant. Discharge Instructions: Resume regular diet. Please resume all home medications unless specifically asked not to resume them. Take all new medications as prescribed. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-1] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: Please see Dr. [Last Name (STitle) ] in his clinic on [2124-7-7]. Please call his office at [Telephone/Fax (1) 1231] to schedule this appointment early next week. Completed by:[2124-6-18*]	[ "2761", "4280", "4019", "2449" ]
Admission Date: [2160-10-3] Discharge Date: [2160-10-7] Date of Birth: [2074-6-3] Sex: M Service: NEUROLOGY Allergies: Iodine-Iodine Containing Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Stroke in the setting of cardiac cath Major Surgical or Invasive Procedure: cardiac catheterization, failed angioplasty History of Present Illness: Mr. [Known lastname 34909] is an 86 year old man with a hx of CAD s/p CABG in [2143], PCI with DESx3 to SVG-OM in [2157] who was referred for urgent cardiac cath in the setting of increasing anginal symptoms. Per OMR, the patient has been experiencing chest and back pain for the past month occurring at rest and with exertion. He was seen by Dr. [Last Name (STitle) ] in early [Month (only) ] and his Imdur was increased to 120mg daily. Since then he has continued to have increasing chest pain at rest, including 2 episodes on [2160-10-2] requiring several nitroglycerin for relief. Dr. [Last Name (STitle) ] was notified and has recommended urgent urgent catheterization. Per the patient's family, he has otherwise been in his usual state of health lately. . In the cath lab, balloon angioplasty was performed to the OM2, an intervention was about to be performed on the OM1, but the patient suddenly woke up and was aphasic. Stroke team called, patient sent for CTA of the head, which showed no bleed or visible occlusion. In the cath lab, he was started on a bivalirudin drip, but transitioned to a heparin drip at the advice of the stroke team. Upon stroke consult, initial exam was remarkable for significantly impaired speech with some preserved repetition of short words but otherwise unintelligible. Also had R facial droop and some difficulty with fine movements of R hand but otherwise full strength throughout. CT head showed no acute intracranial process and CTA showed no major vessel occlusion. MRI performed [10-4] showed bilateral partial small middle cerebral artery territorial infarcts. Transferred to the neurology service for further management. Past Medical History: . CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: CABG [2143] at [Hospital1 1774], LIMA to LAD, SVg to D1 (known occluded), SVG to PDA (known occluded), SVg sequential to OM1-OM2 - PERCUTANEOUS CORONARY INTERVENTIONS: [12-11] s/p stenting of SVG to OM with 3 drug eluting stents 3. OTHER PAST MEDICAL HISTORY: atrial fibrillation - on Coumadin bph s/p turp x2 c/b post operative hemorrhage [9-/2147] TIA [2142] cholecystectomy [4-11] CT of chest: pleural changes c/w asbestos exposure inguinal hernia repair x 3 hard of hearing cataract surgery bilaterally CHF asbestosis s/p flu shot last week emergency appendectomy [2-15] in [State 108]; since then having some short term memory issues Social History: Lives with his wife, is a retired driver for the T. - Tobacco history: none - ETOH: wife denies - Illicit drugs: none Family History: son with ASD and stroke. father with a stroke in his 40s. Physical Exam: Admission Exam VS: T=96.1 BP=188/58 HR=70s RR18 O2 sat 97% on RA GENERAL: elderly male, NAD, well-nourished, cooperative HEENT: NCAT. EOMI. mild, right sided facial droop. CARDIAC: irregularly irregular, S1, S2. No murmurs appreciated LUNGS: CTAB anteriorly ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. right femoral cath site with no hematoma or bruit Neuro: moves all four extremities equally, normal tone, no pronator drift PULSES: DP pulses dopplerble b/l Exam upon neurology transfer: SBP 190 HR 90 RR 16 Sat 95% RA General: well nourished, well kept, calm, cooperative Heart: no murmurs heard Lungs clear Abd soft to palpation Neurological exam: MS: awake, alert Speech: anarthric Language: sounds, cannot comprehend. Follows commands crossing midline. cannot repeat. Can write basic things. CN: Pupils are 3 mm, round and reactive although surgical. Recognizes waiving hands bilaterally by pointing. Patient can track light source with preserved lateral gaze. R facial weakness. Tongue protrudes to the right. Motor: Strength is [5-8] in all four extremities (difficult to test the RLE due to femoral access). Tone is normal. No drift. DTRs symmetrical on biceps and knees [Last Name (un) ]: LT seems preserved, including face Coord:: No dysmetria on UEs Plantar responses flexor b/l GAIT: deferred Exam upon discharge: GENERAL: elderly male, NAD, very pleasant HEENT: NCAT. EOMI. +right sided facial droop. CARDIAC: irregularly irregular, S1, S2. No murmurs appreciated LUNGS: CTAB anteriorly ABDOMEN: Soft, NTND. +BS EXTREMITIES: No c/c/e. General: well nourished, well kept, calm, cooperative Heart: no murmurs heard Lungs clear Abd soft to palpation Neurological exam: Mental status: Alert and oriented x 3. Language significantly improving, able to produce some spontaneous words and short sentences. Still difficult to understand due to significant dysarthria. Comprehension and repetition intact. Follows commands well. CN: Pupils 3mm to 2mm bilaterally. EOMI, VFF. +R lower facial weakness. Tongue protrudes to the right. Motor: Strength is [5-8] throughout. Tone is normal. No drift. DTRs symmetrical on biceps and knees [Last Name (un) ]: intact to light touch Coord:: No dysmetria on UEs Plantar responses flexor b/l GAIT: ambulates steadily with assistance Pertinent Results: [2160-10-3] 10:20AM BLOOD WBC-7.6 RBC-4.63 Hgb-13.3* Hct-39.8* MCV-86 MCH-28.6 MCHC-33.3 RDW-15.0 Plt Ct-126* [2160-10-3] 10:20AM BLOOD Neuts-58.4 Lymphs-28.4 Monos-5.3 Eos-7.3* Baso-0.5 [2160-10-3] 10:20AM BLOOD PT-18.3* PTT-29.5 INR(PT)-1.6* [2160-10-3] 10:20AM BLOOD Glucose-104* UreaN-28* Creat-1.6* Na-142 K-4.5 Cl-105 HCO3-29 AnGap-13 [2160-10-3] 10:44PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1 CT/CTA [2160-10-3]: 1. Head CT shows no evidence of hemorrhage. No definite loss of [Doctor Last Name 352]-white matter differentiation seen. Small vessel disease and brain atrophy noted. 2. CT angiography of the neck demonstrates calcification in both carotid bifurcations, but no evidence of high-grade stenosis. The right vertebral artery is only faintly visualized. 3. CT angiography of the head demonstrates some evidence of decreased branching in the region of left middle and left sylvian fissure which could be secondary to an evolving infarct or slow flow in the region. Subsequent MRI can help for further assessment to exclude infarct in this location and clinical correlation is also recommended. There is no evidence of occlusion of main vascular structures seen. Calcification is seen in the left vertebral artery and mild atherosclerotic disease is seen in the basilar artery. Brain MRI [2160-10-4]: There are areas of restricted diffusion seen bilaterally in the frontal lobes in the distribution of the middle cerebral artery indicative of small bilateral partial middle cerebral artery territorial infarcts. There is no evidence of hemorrhage seen. There is brain atrophy seen. There is no midline shift. Soft tissue changes seen in the right maxillary sinus. TTE 10/3/1: IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild-moderate aortic regurgitation. Mild-moderate mitral regurgitation. Pulmonary artery hypertension. Dilated thoracic aorta. No definite cardiac source of embolism identified. Brief Hospital Course: Mr. [Known lastname 34909] was admitted on [10-3] and was brought to the cardiac cath lab for angioplasty to relieve anginal symptoms. In the cath lab, he developed difficulty speaking and the procedure was halted before the angioplasty was completed. The stroke service was consulted. Upon stroke consult, initial exam was remarkable for significantly impaired speech with some preserved repetition of short words but otherwise unintelligible. Also had R facial droop and some difficulty with fine movements of R hand but otherwise full strength throughout. CT head showed no acute intracranial process and CTA showed no major vessel occlusion. MRI performed [10-4] showed bilateral partial small middle cerebral artery territorial infarcts. Transferred to the neurology service for further management. He was started on a heparin drip due to the likely cardioembolic source for his stroke. His exam remained stable with some improvement of his aphasia during his stay. He continued to have a right facial droop but no significant strength deficits. TTE showed mild symmetric left ventricular hypertrophy with preserved systolic function with EF >55%. He was continued on pravastatin for his hyperlipidemia. HbA1c was 6.5%; he was maintainted on insulin sliding scale during his admission. Per discussion with his cardiologist he was transitioned from the heparin drip to Pradaxa 150mg [Hospital1 ]. He was continued on aspirin 81mg daily. He was seen by PT, OT, and speech therapy who recommended discharge to acute rehab. A video swallow study showed aspiration of thin liquids and he was started on a heart healthy diet with regular solids and nectar thick liquids. He was discharged on [2160-10-7] in good condition. He will follow up with his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] as well as Dr. [Last Name (STitle) ] in stroke clinic. Pharmacy recommended monitoring of his renal function on Pradaxa as his Cr was slightly high on admission. This has now resolved and we have advised him to have an electrolyte panel drawn at his follow-up visit with his PCP. Medications on Admission: FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth daily alternating with 60mg ISOSORBIDE MONONITRATE - - 120 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth qam LOSARTAN - 100 mg Tablet daily METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth twice a day MOM[Name (NI) ] [[Name2 (NI) ] TWISTHALER] - (Prescribed by Other Provider) - Dosage uncertain NITROGLYCERIN - (Prescribed by Other Provider) - Dosage uncertain OMEPRAZOLE - 20 mg Capsule, 1 Capsule(s) by mouth twice a day POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Extended Release - 1 Tablet(s) by mouth daily PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth qpm WARFARIN - 2 mg Tablet - 1 Tablet(s) by mouth daily last dose [10-1] ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth qam CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1000 mg monthly 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. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 12. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Bilateral middle cerebral artery strokes Discharge Condition: Condition: good Mental status: improving nonfluent aphasia, comprehension intact Ambulatory status: ambulates with assistance Discharge Instructions: Dear Mr. [Known lastname 34909], You were admitted to [Hospital1 69] on [2160-10-3] due to difficulty speaking after a heart procedure. You were found to have small strokes on both sides of your brain. The stroke on the left side is likely responsible for your speech difficulties. Your speech should improve with time and appropriate rehabilitation. We made the following changes to your medications: STARTED Pradaxa 150mg twice a day We held some of your blood pressure medications during your admission to help maintain good blood flow to your brain in light of your stroke. These may be slowly started back as per your primary care physician after your discharge. If you experience any of the below listed danger signs, please call your doctor or go to the nearest Emergency Department. It was a pleasure taking care of you during your hospital stay. Followup Instructions: You have an appointment with your primary care doctor Dr. [Last Name (STitle) ] on [10-16] at 11am. You need to have an electrolyte panel drawn at this appointment to check your kidney function. [Hospital 4038] clinic follow-up: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 2574] Date/Time:[2160-11-7] 2:00 You need to call the office prior to this appointment in order to update your information in the system	[ "41401", "42731", "40390", "2724", "25000", "V5861", "V4581", "5859", "4280" ]
Admission Date: [2170-3-7] Discharge Date: Date of Birth: [2170-3-7] Sex: F Service: NB DATE OF INTERIM SUMMARY: [2170-4-12]. HISTORY OF PRESENT ILLNESS: This patient's name is [Name (NI) 75262] [Name (NI) ]. The [Hospital 228] [Hospital3 ] medical record number is [Numeric Identifier 77825]. This is the former 3.72 kg product of a 39 and [1-29] week gestation pregnancy born to a 30 year-old, G2, P1 now 2 Asian woman. Prenatal screens: Blood type A positive, antibody negative, Rubella immune, RPR nonreactive. Hepatitis B surface antigen negative. GBS positive. The pregnancy was notable for the diagnosis of an atrioventricular canal by fetal echo in [Month (only) 404]. The parents declined amniocentesis. The mother had an elevated risk for trisomy 21 based on the nuchal translucency and an elevated quadruple screen blood sample. Estimated risk was 1:200 for trisomy 21. The mother underwent elective induction of labor for a planned vaginal birth after Cesarean section. Infant was born at 13:12 hours on [2170-3-7]. The mother received antibiotic prophylaxis greater than 4 hours prior to delivery. There was no clinical concern for chorioamnionitis. There was fetal tachycardia noted one hour prior to delivery. The infant had spontaneous respirations at birth, required suctioning and drying. Apgars were 8 at 1 minute and 9 at 5 minutes. In the delivery room, she was noted to have facial features consistent with trisomy 21. The infant was admitted to the NICU for evaluation of the cardiac defect and for evaluation for sepsis. Anthropometric measurements at the time of birth: Weight 3.72 kg, 75th percentile. Length 50.5 cm, 75th percentile. Head circumference 32.5 cm, 10th percentile. PHYSICAL EXAM AT INTERIM SUMMARY: Weight 3.565 kg, length 51.5 cm, head circumference 34 cm. General: Alert infant with facial features consistent with Down's syndrome, including flat nasal bridge, down slanting palpebral fissures, flat occiput, nuchal cord. Palate intact. Large tongue. Head, ears, eyes, nose and throat: Positive red reflex bilaterally. Anterior fontanel open and flat. Sutures apposed. Neck supple. Chest: Breath sounds clear and equal. Intermittent mild tachypnea with intercostal retractions. Cardiovascular: Grade II over VI harsh systolic murmur at the left lower sternal border. Normal S1; fixed split S2. Femoral pulses +2. Pale with stress. Abdomen soft, nontender, nondistended. No masses. No hepatosplenomegaly. Cord healed. Genitourinary: Normal female genitalia. Spine straight with normal sacrum. Hips stable. Neurologic: Low normal tone, consistent with diagnosis of trisomy 21. Moves all extremities. Positive suck, positive grasp. Weak complete Moro. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: Respiratory: This infant required nasal cannula oxygen for the first 48 hours of life to maintain saturations in the 80 to 90% range. She has continued in room air since that time with oxygen saturations consistently greater than 90%. Respirations are notable for intermittent tachypnea with mild intercostal retractions. Baseline heart rate is 40 to 70 breaths per minute. Cardiovascular: As previously noted, this infant had a prenatal diagnosis of a complete atrioventricular canal or endocardial tissue defect. This was confirmed by a post natal echo on the day of birth, showing a balanced complete AV canal, 2 to 3 mm primum atrioseptal defect and a 7 mm ventricular septal defect. There was a large PDA with primarily right to left flow, with good biventricular systolic function. The infant continued to have weekly echos due to concern for the potential arch obstruction with the closing of the patent ductus arteriosus. The PDA on the last echo, on [2170-3-21], showed a very small PDA with no arch obstruction identified, the previously identified atrioseptal and ventriculoseptal defect and the complete AV canal. The infant has been followed by the cardiology consult service at [Hospital3 1810]. The primary attending is Dr. [Last Name (STitle) 13959]. The infant is being evaluated for possible surgical treatment in lieu of her continual failure to thrive. At the recommendations of the cardiology consult service, Lasix at 1 mg per kg once daily was started on [2170-3-27]. Serum electrolytes remained within normal limits. Fluids, electrolytes and nutrition: This infant initially was able to p.o. ad lib feed and in the first week of life, was taking 120 to 160 ml/kg per day. Her ability to fully p.o. feed waned in the second week of life, when she started to require gavage feedings. She initially was on Enfamil formula that was gradually advanced to 30 calories per ounce due to the lack of weight gain. Her second day on the 30 cal Enfamil, she experienced explosive loose stools and was changed to Prosobee formula. After 4 days, she was switched to Nutramigen formula which is what she remains on at the time of this summary. She is currently on 28 calories per ounce by concentration. There is grave concern due to her inability to gain weight and she has, as yet, not regained her birth weight. Weight at the time of this interim summary is 3.565 kg. Serum electrolytes have remained normal. Most recently, on [2170-4-9], she had a sodium of 138, potassium of 6.3, which was slightly hemolyzed, a chloride of 102 and a total C02 of 21. Infectious disease: The mother had a fever of 102.5 degrees at the time of delivery, prompting a sepsis evaluation upon admission to the Neonatal Intensive Care Unit. A complete blood count was within normal limits. A blood culture was obtained prior to starting IV ampicillin and gentamycin. Blood culture was no growth at 48 hours and the antibiotics were discontinued. On [2170-3-28], shortly after starting on daily Lasix therapy, the infant spiked a temperature to 103 degrees rectally. Due to concern for sepsis, she received a CBC and blood culture and had a lumbar puncture performed. The white blood cell count was 5,200 with 60% polymorphonuclear cells, 8% band neutrophils. The lumbar puncture had 2 white cells, 500 red cells with normal glucose and protein. IV ampicillin and gentamycin were started. The blood and cerebrospinal cultures were negative at 48 hours and the antibiotics were discontinued. Hematology: Hematocrit at birth was 40.1%. Platelet count was 132,000. The most recent hematocrit was 33.9% on [2170-4-3]. Reticulocyte count was 1.5%. Platelets repeated on day of life 21 were 218,000. The infant did not receive any transfusions of blood products. Gastrointestinal: Peak serum bilirubin occurred on day of life #5 at 10.9 mg/dl to subsequent bilirubins being checked, the most recent on [2170-3-16] at 10.1 mg/dl. She never required treatment. Neurologic: This infant has maintained a fairly normal neurologic exam. She is very alert and interactive. Her muscle tone is slightly low normal limits, consistent with her diagnosis of trisomy 21. Genetics: A blood specimen for chromosomes and Fish-21 were sent on [2170-3-8]. The karyotype was confirmed as an isochromosome of the long arm of 21. The infant was evaluated by Dr. [First Name (STitle) 6164] of the Genetics Consult Team from [Hospital3 1810]. Endocrine: Due to the concern for possible hypothyroidism associated with the Down's syndrome, this infant thyroid function studies were confirmed as normal by state screen. Sensory: Audiology: Hearing screening has not yet been performed and is recommended prior to discharge. Psychosocial: This was a Mandarin-speaking Chinese family. Their other child lives in [Country 651] with the grandparents. After careful consideration, these parents decided that they could not care for [Country 75262] with her special needs and she was surrendered to the department of social services custody for adoption. The department of social service adoption worker is [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and her phone number is [Telephone/Fax (1) 77826]. [Hospital1 1444] social worker involved with this case is [Name (NI) 46381] [Doctor Last Name 36527] and she can be reached at [Telephone/Fax (1) 8717]. CONDITION AT INTERIM DISCHARGE SUMMARY: Fair. No primary pediatrician has yet been identified. CARE AND RECOMMENDATIONS: Feeding: 140 ml/kg per day of Nutramigen fortified to 28 calories per ounce by gavage or by mouth. Medications: Lasix 3.7 mg p.o. once daily. Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 i.u. (may be provided as a multi-vitamin preparation) daily until 12 months corrected age. Car seat position screening has not yet been performed. State newborn screens have been sent on [3-11] and [2170-3-21] with all results within normal limits. Immunizations: No immunizations have been administered thus far. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following four criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease or (4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. This infant has not received ROTA virus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age. DISCHARGE DIAGNOSES: 1. Appropriate for gestational age term female. 2. Balance complete AV canal with atrial and ventricular septal defect. 3. Down's syndrome with isochromosome 21 karyotype. 4. Rule out sepsis times 2 with negative cultures and antibiotic treatment. 5. Post natal growth failure. [Doctor First Name ] [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 62348] Dictated By:[Name8 (MD) 75740] MEDQUIST36 D: [2170-4-13] 00:21:13 T: [2170-4-13] 05:19:09 Job#: [Job Number 77827]	[ "4280", "V290" ]
Admission Date: [2159-11-21] Discharge Date: [2159-11-25] Date of Birth: [2111-4-30] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 2387] Chief Complaint: Transfer for cardiac catheterization Major Surgical or Invasive Procedure: 1. Cardiac catheterization s/p cypher stents x2 to PDA 2. Cardiac catheterization s/p 5 metal stents for RCA dissection History of Present Illness: The patient is a 48-year-old female with history of hyperlipidemia. She was in usual state of health, and on [2159-11-16], while at work, had the onset of substernal chest pain. She saw her outpt provider where an EKG demonstrated inferior ST segment elevations. The patient was admitted to NEBH. Laboratory studies demonstrated a peak troponin I of 1.27 (negative cks). Initially, the patient had no further chest pain with medical management. Because of recurrent chest pain with EKG changes and elevated troponin level, cardiac catheterization was advised. Cardiac cath at NEBH demonstrated approximately 90%-95% mid right PDA stenosis. The patient also had evidence of peripheral vascular disease with approximately 70% right iliac artery stenosis. EF was 61%. No intervention was performed. . Patient subsequently developed further chest pain and was thus transferred to [Hospital1 18] for PCI. Cardiac Catherization was performed on morning of [11-21] and stent was placed to PDA lesion. A small dissection ocurred proximal to the lesion. On arrival to the floor post-PCI, patient developed worsening chest pain and ST elevations. She was returned to cath lab which revealed that her stent thrombosed and was reopened and also a large dissection extending the length of the RCA was found. Six additional stents were placed. Patient remained hemodynamically stable and was transferred to CCU. On arrival to the floor she denied CP, SOB, N/V and was thirsty. However, she reported significant discomfort at her left groin site when it was pressed and some low back pain which she attributed to lying on the table for so long. Past Medical History: Hyperlipidemia H/O laparoscopic surgery for removal fibroids and ovarian cysts H/O lower extremity edema L>R Left shoulder rotator cuff tendinitis Goiter- cystic with normal thyroid function Ovarian cysts Social History: Works in medical records at NEBH Former smoker. Quit 20 yrs ago Drinks 2 glasses of wine a day Lives with mother in [Location ] Single, no children. Family History: Mother age 76, had an aortic dissection and hypertension. Father died at age 75 from lung cancer. He had a myocardial infarction at age 43. One brother age 43 is status post mitral valve replacement. One brother age 50, has had CAD and status post stent. One sister is status post renal artery bypass. One sister is alive and well. Physical Exam: Temp 97.0 BP 121/68 Pulse 88 Resp 21 O2 sat 100% 2 L NC Gen - Middle aged female lying flat in bed, alert, in no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist Neck - could not assess JVD as patient lying flat, no cervical lymphadenopathy, no carotid bruits, neck full Chest - Clear to auscultation bilaterally anteriorally CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Chest: 2x3 cm ecchymosis at medial left breast Abd - Soft, nontender, nondistended, with normoactive bowel sounds, mild tenderness as approach left groin site Back - could not assess as patient had to lie flat Extr - No clubbing, cyanosis, fingernails with nail polish, trace edema LLE no edems RLE, 1+ DP pulses b/l, 2+ DP pulses Neuro - Alert and oriented x 3, cranial nerves [2-10] intact, upper extremity strength 5/5 and equal b/l, [Last Name (un) 938] and gastroc [5-3] and equal b/l, sensation grossly intact Groin: large tender hematoma approximately 20 cm x 10 cm at left grain, right groin small non-tender 2x2 hematoma, no femoral bruits appreciated Skin - ecchymoses over groin site and medial left breast Pertinent Results: [2159-11-21] 11:53AM BLOOD Hct-35.8* Plt Ct-352 [2159-11-21] 04:09PM BLOOD WBC-15.0* RBC-3.48* Hgb-11.4* Hct-32.1* MCV-92 MCH-32.7* MCHC-35.4* RDW-13.5 Plt Ct-368 [2159-11-22] 04:13AM BLOOD WBC-15.4* RBC-3.34* Hgb-10.8* Hct-30.5* MCV-91 MCH-32.5* MCHC-35.5* RDW-13.9 Plt Ct-303 [2159-11-23] 05:59AM BLOOD WBC-11.5* RBC-2.90* Hgb-9.5* Hct-27.0* MCV-93 MCH-32.7* MCHC-35.0 RDW-14.0 Plt Ct-261 [2159-11-25] 06:19AM BLOOD WBC-11.1* RBC-3.03* Hgb-9.6* Hct-28.0* MCV-92 MCH-31.8 MCHC-34.5 RDW-14.4 Plt Ct-280 [2159-11-21] 11:53AM BLOOD Plt Ct-352 [2159-11-24] 03:30AM BLOOD Plt Ct-309 [2159-11-25] 06:19AM BLOOD Plt Ct-280 [2159-11-21] 04:09PM BLOOD Glucose-117* UreaN-12 Creat-0.6 Na-136 K-4.1 Cl-103 HCO3-19* AnGap-18 [2159-11-25] 06:19AM BLOOD Glucose-102 UreaN-11 Creat-0.7 Na-141 K-4.0 Cl-105 HCO3-25 AnGap-15 [2159-11-21] 04:09PM BLOOD CK-MB-38* MB Indx-8.9* cTropnT-0.97* [2159-11-21] 04:09PM BLOOD CK(CPK)-428* [2159-11-21] 04:09PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.7 [2159-11-25] 06:19AM BLOOD Calcium-8.8 Phos-4.0# Mg-1.8 . [2159-11-23] CT abdomen and pelvis: 1. Blood and extravasated contrast within the left groin, tracking along the iliopsoas muscle, but remaining extraperitoneal in location. There is no retroperitoneal extension or hematoma. No isolated fluid collection is identified. 2. Multiple low-density lesions within the liver. While some of these represent simple cysts, others are too small to adequately characterize and ultrasound or MRI is recommended for further evaluation. 3. Cholelithiasis. 4. Moderate sliding hiatal hernia. . [2159-11-21] Cardiac cath #1: The angiogram of the RCA showed a long mid PDA lesion with a maximum narrowing of 80%. We planned to perform POBA to this. A 6F JR 4 guide provided adequate support. An Asahi prowater wire crossed the lesion after several attempts. We then inflated a 2.0 X 15mm maverick balloon twice at 6 and 5 atm. There was a small dissection proximally in the lesion. We then deployed a 2.25 X 18mm Minivision stent at 10 atm to cover the dissection. The final angiogrm showed TIMI III flow with no residual stenosis or embolisation. The patient left the lab in a stable condtion. COMMENTS: Successful predilation using a 2.0 X 15 mm Maverick balloon and stenting using 2.25 X 18mm Minivision stent of the mid PDA with lesion reduction from 80% to 0%. The final angiogram showed TIMI III flow with no embolisation. (see PTCA report) FINAL DIAGNOSIS: Successful stenting of the mid PDA lesion. . [2159-11-21] Cardiac cath # 2: Left Heart Catheterization: was performed by percutaneous entry of the left femoral artery, using a 6 French right [Last Name (un) 2699] catheter, advanced to the ascending aorta through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French JR4 GUIDE, with manual contrast injections. Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). PTCA COMMENTS: The angiogram of the RCA showed a 80% lesion and a small dissection in the mid PDA, immediately prior to the previously deployed stent. There was TIMI II flow beyond the end of the prviously deployed stent. We planned to treat this lesion. Heparin and Integrillin were used prophylactically. Choice PT XS wire was used to cross in to the PDA with difficulty due to a distal RCA tortuosity prior to the origin of the PDA. During the procedure, there was a proximal /mid RCA dissection which progressed to include the distal vessels /RPL/RLV. The flow deteriorated to TIMI 0. We then inflated a 2.0 X 20mm Voyager balloon in the distal RCA several times between [8-8] atm, from distal to proximal. We then deployed two 3.5 X 33mm and one 3.5 X 28mm Cypher stents seqeuntially from distal to proximal RCA begining proximal to the crux. We then predilated the distal RCA using 2.5 X 20mm Cross sail and 2.5 X 30 mm Maverick balloons at 8 atm thrice from begining of the PLV 1 to the end of the distally placed RCA stent. We then deployed 3.0 X 18mm and 3.0 X 23mm Vision stents at 12 atm, in an overlapping manner, from the distal PLV to the distal RCA jailing the RLV branch without compromise in flow. We then post dilated the proximally placed stents using a 3.5 X 28mm Powersail balloon to 18 and 22 atm. At this stage the the flow restored to TIMI III in all the distal RCA vessels except the PDA. We then attempted to cross in to the PDA using a PTGI wire with only limited success. We used multiple doses of IC adenoine and diltiazem during the procedure. At the end of the procedure there was no flow visible in the two RV marginal branches which were jailed in the stenting. In the PDA there was a 70% proximal and a 80% lesion prior to the PDA stent with preserved flow. We elected to accept the achieved result at this stage and consider staged PCI of the PDA if she became symptomatic. The final angiogram showed TIMI III flow with no dissection or embolisation. There was no residual stenosis in the stented segments. The patient left the lab in a stable condition. COMMENTS: Acute extensive RCA dissection treated with predilation using cross sail 2.5X 30mm and maverick 2.5 X 30 mm balloons, stenting using two 3.5 X 33mm and one 3.5 X 28mm Cypher, 3.0 X 18mm and 3.0 X 23mm Vision stents and post dilation using 3.5 X 28 power sail balloon with lesion reduction from 100% to 0%. There was residual 70% PDA ostial and 80% mid PDA lesions with jailing and occlusion of the two RV marginal vessels with no hemodynamic compromise. The final angiogram showed TIMI III flow with no dissection or embolisation. There was no residual stenosis in the stented segments. (see PTCA comments) . [2159-11-21] Limited echocardiogram: Normal RV chamber size and free wall motion. Pericardial effusion. No echocardiographic signs of tamponade. . [2159-11-23] Echocardiogram: 1. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (EF 50%). Posterior hypokinesis is present. 2. Compared with the findings of the prior study (images reviewed) of [2159-1-21], the posterior hypokinesis may be new. Brief Hospital Course: 48 y/o female with STEMI, PCI of PDA with cypher stenting complicated by stent occlusion and repeat stenting complicated by dissection of RCA s/p 5 metal stents. . 1. STEMI/RCA dissection: EKG revealed ST elevations in II, III and aVF with STE's III>II and V4R with right sided leads. However, were CKs negative and peak trop I 1.27. PDA with 90-95% lesion on cath at OSH, originally no there was no intervention. Upon arrival to [Hospital1 18] she had a cardiac catheterization at which time a cypher stent was placed in the PDA. After, placement the patient again developed chest pain and had a second cardiac catheterization which revealed an 80% lesion and a small dissection in the mid PDA, immediately prior to the previously deployed stent. There was TIMI II flow beyond the end of the previously deployed stent. In an attempt to fix this lesion the RCA was dissected requiring the placement of an additional 5 stents. At the end of the procedure there was no flow visible in the two RV marginal branches which were jailed in the stenting. In the PDA there was a 70% proximal and a 80% lesion prior to the PDA stent with preserved flow. We elected to accept the achieved result at this stage and consider staged PCI of the PDA if she became symptomatic. The final angiogram showed TIMI III flow with no dissection or embolization. There was no residual stenosis in the stented segments. Patient was continued on ASA, Lipitor, Plavix, metoprolol and captopril and was on a Integrilin drip for 18 hours after the catheterization. The catheterization was further complicated by a left groin hematoma which is detailed below. Echocardiogram showed normal RV free wall motion and RV size and no pericardial effusion with EF 50% and possible new posterior hypokinesis. At discharge, the patient was chest pain free, her heart rate and blood pressure were well controlled on metoprolol 75 mg [Hospital1 ] and captopril. Her captopril was changed to lisinopril 5 mg po QD at discharge. She was continued on aspirin, Plavix, and Lipitor 80 mg po QD. She will follow up with Dr. [Last Name (STitle) 2912] as an outpatient with plans for an echocardiogram in 1 month, cardiac rehab and possible follow up catheterization in 6 weeks. 2. Groin Hematoma: This was secondary to catheterization and insetting of Integrilin drip. She required 2 units of packed RBCs as her hematocrit dropped from 32 to 27. Given that she also had some back pain, a CT scan was performed which reveled no evidence of RP bleed. She had no femoral bruits and maintained strong femoral and DP pulses. At discharge her hematocrit was stable and her hematoma was resolving. . 3. Hyperlipidemia: Last LDL in [Month (only) 956] of last year 145, at OSH HDL 61 but no LDL. she was continued on Lipitor 80 mg po QD. She will need her LFTs followed up in 1 month. . 4. Liver hypodensities: There were several small hypodensities in her liver found incidentally on CT scan. They were felt to likely be simple cysts, but some were too small to characterize. She will follow up with her PCP for ultrasound or MRI to further evaluate these lesions. Medications on Admission: OUTPT MEDS: birth control pills - recently stopped HCTZ 25 mg daily Tylenol Extra Strength p.r.n. . MEDS on TRANSFER: ASA 325 mg qd Plavix 75 mg qd HCTZ 25 mg qd Lipitor 20 mg qd Lopressor 75 mg [Hospital1 ] Protonix 40 mg qd Imdur 30 mg qd Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: 1. ST elevation MI s/p cypher stents x 2 to PDA 2. Right coronary artery dissection s/p 5 metal stents 3. Groin hematoma Secondary: 1. Hyperlipidemia 2. Hypertension Discharge Condition: Hemodynamically stable, afebrile, no chest pain. Discharge Instructions: If you have any chest pain, shortness of breath, dizziness, sweating, nausea or vomiting, bleeding, warmth, or pain at your groin site or any other concerning symptoms, call your doctor or come to the emergency room. Take all of your medications as directed. IT IS EXTREMELY IMPORTANT THAT YOU TAKE YOUR PLAVIX EVERYDAY. . Keep all of your follow up appointments. . The following changes/additions have been made to your medications: 1. You can stop taking your hydrochlorathiazide 2. Metoprolol 75 mg twice daily 3. Plavix 75 mg once daily 4. Lipitor 80 mg once daily 5. Aspirin 325 mg once daily 6. Lisinopril 5 mg once daily Followup Instructions: You should make a follow up appointment with Dr. [Last Name (STitle) 2912] [Telephone/Fax (1) 25832] in [12-31] weeks. At that time you should discuss having your liver function tests checked in 1 month as you are now on lipitor which can cause elevation in these enzymes. You should also have your electrolytes checked. You should also discuss getting a repeat echocardiogram in 1 month and possibly cardiac rehab. You may need an outpatient stress test and possibly a follow up catheterization in 6 weeks. You can discuss this with Dr. [Last Name (STitle) 2912]. . Please make an appointment with your primary doctor Dr. [Last Name (STitle) 5456] [Telephone/Fax (1) 25798] to follow up you hospitalization in [2-2] weeks.	[ "41401", "9971", "2724", "4019" ]
Admission Date: [2200-3-25] Discharge Date: [2200-3-28] Date of Birth: [2156-5-10] Sex: M Service: MEDICINE Allergies: Penicillins / fish / Ativan Attending:[First Name3 (LF) 1253] Chief Complaint: seizure Major Surgical or Invasive Procedure: Intubated History of Present Illness: 43M with reported PMH of TBI s/p craniotomy/VP shunt, seizure disorder, polysubstance abuse and depression, who was transferred here after intubation for seizures at [Hospital ] [Hospital 1459] Hospital. . History was as below from OSH record: Pt was found down/unresponsive in a motel, given narcan by EMS and he became more responsive, was following some commands and was taken by ambulance to an OSH. There, he had an EKG done, which showed afib with RVR with HR of 150. He was given IV diltiazem 25 mg with improvement in his HR. He was also given 5mg of IV haldol for agitation, and was then drowsy with mildly slurred speech. He was sent for a CT of head/neck, which was read as probable postop changes from his known TBI and R frontal craniotomy. After returning from the CT, he went to the bathroom, and was noted to have 1 GTC as he was returning from the bathroom. Unclear duration of seizure. He was given 2mg of IV ativan. He then had another GTC when he was back on his stretcher, and was given 2 mg more of IV ativan, intubated for airway protection with etomidate/succ at 2315, and was noted to have pinpoint pupils (unclear if this was the initial exam also), and sent to [Hospital1 18]. While at the OSH, he was noted to have a tab of dilantin in his pocket. . Of note, his tox screen were positive for opiates and alcohol, and lithium level was <0.2. He also had an elevated AST of 65, and an elevated CPK of 614, but were otherwise unremarkable. . In ED, initial vitals were: HR: 86, RR: 13, BP: 136/80, O2Sat: 99, on vent, Temp: 100.6 ??????F (38.1 ??????C). He was intubated and unsedated, and following most commands per neurology note. He was then put on propofol as he was trying to remove his ETT, and became more sedated, not following commands. He had a phenytoin level drawn which was <0.6. He also had an elevated lipase of 61 and a lactate of 3.8. . Prior to transfer to ICU, patient noted to have temp of 103F, neurosurgery consulted at that time to access VP shunt given concern for intracranial/CNS infection. BCx also sent. Started on vancomycin and ceftriaxone. . On arrival to the ICU, patient is unable to give further history or complete ROS as he is intubated and sedated. Past Medical History: Past Medical History (per OSH records): - depression - TBI s/p VP shunt - seizure disorder (no further info is available at this time) - EtOH and substance abuse - DJD - hepatitis C Social History: positive for EtOH, tobacco and illicits Family History: unable to obtain Physical Exam: ADMISSION EXAM: . General: intubated and sedated HEENT: Sclera anicteric, pinpoint pupils, unable to visualize oropharynx, ?dentures in place Neck: JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, no wheezes/rales/rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, quiet bowel sounds, no rebound tenderness or guarding, no organomegaly GU: +foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Left shoulder with erythematous abrasions, track mark along L forearm, scabs over left hip and left heel. shallow pink ulceration on medial aspect of right heel, clean base without drainage. . DISHCARGE EXAM: . AAOx3. Able to comprehend benefits of ongoing hospitalization, and risks of leaving the hospital against medical advice. Pt currently appears non-toxic. Linear thoughts, conversant. Pertinent Results: ADMISSION LABS: . [2200-3-25] 12:45AM BLOOD WBC-6.3 RBC-3.79* Hgb-11.9* Hct-35.7* MCV-94 MCH-31.5 MCHC-33.4 RDW-14.0 Plt Ct-162 [2200-3-25] 07:21AM BLOOD Neuts-53.0 Lymphs-36.9 Monos-4.4 Eos-5.2* Baso-0.6 [2200-3-25] 12:45AM BLOOD PT-11.5 PTT-30.3 INR(PT)-1.1 [2200-3-25] 12:45AM BLOOD Fibrino-222 [2200-3-25] 07:21AM BLOOD Glucose-73 UreaN-10 Creat-0.9 Na-143 K-4.1 Cl-109* HCO3-25 AnGap-13 [2200-3-25] 07:21AM BLOOD ALT-24 AST-56* LD(LDH)-247 CK(CPK)-822* AlkPhos-80 TotBili-0.9 [2200-3-25] 12:45AM BLOOD Lipase-61* [2200-3-25] 07:21AM BLOOD Albumin-3.4* Calcium-8.3* Phos-3.3 Mg-1.9 . DISCHARGE LABS: . Micro: [2200-3-25] Blood culture - pending [2200-3-25] Blood culture - pending [2200-3-25] CSF fluid - pending [2200-3-25] Urine culture - no growth [2200-3-25] Legionella antigen - no growth [2200-3-25] MRSA screen - negative [2200-3-25] Sputum culture - pending . Images: CT Head from OSH: [2200-3-25] CXR (per my read): small lung volumes, haziness throughout lung parenchyma concerning for pulmonary congestion. possible retrocardiac opacity as some of L hemidiaphragm is obscured. No other obvious consolidations. . [2200-3-25] CTA HEAD AND NECK W&W/OC & RECON: No acute intracranial hemorrhage or mass effect. Encephalomalacic changes in the right frontal and the right parietal lobe along with post-surgical changes with right-sided craniotomy and cranioplasty. Ventricular catheter is seen through the left frontal approach, ending in the right caudate head. Correlate clinically if this is desired position and with catheter function. Patent major arteries as described above, without focal flow-limiting stenosis, occlusion, or aneurysm more than 3 mm within the resolution of CT angiogram. CT angiogram of the head is somewhat suboptimal due to delayed arterial phase imaging. Paranasal sinus disease with mild mucosal thickening in the maxillary and the sphenoid and ethmoid air cells. Degenerative changes in the cervical spine, inadequately characterized. [2200-3-28] 06:40AM BLOOD WBC-3.3* RBC-4.17* Hgb-13.1* Hct-39.3* MCV-94 MCH-31.4 MCHC-33.2 RDW-14.2 Plt Ct-137* [2200-3-28] 06:40AM BLOOD Glucose-96 UreaN-7 Creat-0.7 Na-142 K-4.0 Cl-109* HCO3-25 AnGap-12 [2200-3-27] 04:39AM BLOOD ALT-27 AST-93* LD(LDH)-260* CK(CPK)-1049* AlkPhos-78 TotBili-1.2 [2200-3-28] 06:40AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.7 [2200-3-25] 07:21AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-NEGATIVE [2200-3-25] 12:45AM BLOOD Phenyto-<0.6* [2200-3-25] 12:45AM BLOOD ASA-NEG Ethanol-34* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2200-3-25] 07:21AM BLOOD HCV Ab-POSITIVE* [2200-3-25] 12:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [2200-3-25] 11:56 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [2200-3-26]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. STAPH AUREUS COAG +. MODERATE GROWTH. [2200-3-25] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2200-3-25] URINE Legionella Urinary Antigen -FINAL INPATIENT [2200-3-25] URINE URINE CULTURE-FINAL INPATIENT [2200-3-25] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL EMERGENCY [Hospital1 ] [2200-3-25] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2200-3-25] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT Brief Hospital Course: Assessment and Plan: 43M with reported PMH of TBI s/p craniotomy/VP shunt, seizure disorder, polysubstance abuse and depression, intubated for airway protection given 2 GTC at OSH and found to have temp to 103 in ED. # AMS/Seizures: unclear history, patient found down in a motel room, appears that his mental status initially improved with narcan administration which points to medication effect. However, given the temp to 103 and 2 episodes of seizures at OSH, concerning for CNS infection initially. Other etiologies for seizures could include substance abuse, etoh withdrawal, trauma, CNS bleed or medication noncompliance. Alcohol level of 49 here, less likely to have withdrawal seizures at this time, though concerning in the future. CT head/neck from OSH did not show acute abnormalities or intracranial bleed, which was reassuring. Unclear what medications he is on as an outpatient for his seizures. Pt found with Dilantin in his pocket, but his level is subtherapeutic. CSF obtained and was without evidence of infection. Vancomycin and Ceftriaxone was received in the ED and was not continued. CSF HSV PCR was also negative. He did require Haldol and Diazepam for intermittent agitation concerns; and we continued Keppra dosing per Neurology. # Fevers: concerning for infection vs. CNS fever given intracranial pathology vs. seizures vs. medication induced. Infection most concerning given unclear immune status (HIV or ?IVDU). Infection could be blood/endocarditis given concern for IVDU, aspiration pneumonia given alcohol use, or CNS infection given hardware. CSF with protein 43 and glucose of 73, not suggestive of bacterial meningitis but of high concern. CXR with ? aspiration pneumonia in a patient with unclear risk factors for MDR organism. Sputum, blood and urine cultures were unrevealing. Following clear CSF, his antibiotics were discontinued. Patient remained afebrile afterwards. # Intubation for Airway Protection: patient intubated for airway protection/after being given 4 mg IV of ativan at OSH. Started on propofol for sedation given attempts to self-extubate in the ED. Mental status appears close to baseline following extubation. # Polysubstance abuse: patient with OSH toxicology screen positive for oxycodone and alcohol. unable to give further history about substance abuse, however, etoh level found to be 34 in [Hospital1 18] ED. This was initially concerning for alcohol withdrawal and he was dosed Haldol and Diazepam with good effect. Social work was consulted for coping issues. # Transaminitis: likely from alcohol use, no corroborating data at [Hospital1 18] to see how significant his alcohol use and liver damage have been. Per [Hospital1 2025] record, patient has history of hepatitis C, which was confirmed by serology here. # Reported afib with RVR: patient with reported afib with RVR to 150-160s at OSH, improved with diltiazem. On tele, pt appears sinus at this time. Afib could have been triggered by infection, hypovolemia, or underlying heart disease. Repeat EKG was stable. . The morning following transfer from the ICU to the medical floor, pt chose to leave the hospital against medical advice. Pt was evaluated for capacity, and was determined to have capacity to decide to leave the hospital against medical advice. Pt set paperwork before physically leaving the hospital. Neurology, NeuroSurgery, and Social work notes were reviewed. Per Neurology consult recommendations, pt was provided a prescription for increased Keppra dose to 1000 mg po BID, to minimize the risk of further seizures. Medications on Admission: Medications (per OSH records, uncomfirmed with patient): - lithium - keppra - fioricet - prozac - ? dilantin, pt had a pill in pt's pocket Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 2. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Prozac 20 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: # SEIZURE, CONVULSIVE # HISTORY OF TRAUMATIC BRAIN INJURY # DRUG USE/DEPENDENCE, ALCOHOL Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized at [Hospital1 18] intubated for airway protection after a seizure. You were evaluated for infection. While it currently does not appear that you have an infection, lab results are not final yet. Your hospitalization is not yet complete, and we have discussed our concerns about your decision to leave the hospital against medical advice. As we discussed, there are many possible complications from your decision, which may include more seizures, falls, injuries, including head injuries, and possible death. You were able to understand these risks as well as the possible benefits of remaining in the hospital, and you have decided to leave the hospital against medical advice. During this hospitalization, Neurology has recommended increasing your Keppra to 1000 mg po BID. We have provided a prescription for this increased dose. Followup Instructions: You have chosen to leave the hospital against medical advice. We strongly encourage you to follow up closely with your primary care physician, [Name10 (NameIs) ] continue to address the issues of this hospitalization.	[ "51881", "311" ]
Admission Date: [2130-2-17] Discharge Date: [2130-2-25] Date of Birth: [2067-3-21] Sex: M Service: CARDIOTHORACIC Allergies: Benadryl Attending:[First Name3 (LF) 1267] Chief Complaint: transfer from OSH for cath shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 62 year old man with DM2,HTN, OSA who presented to OSH on advice from PCP with worsening SOB and DOE [[2130-2-13]] found to have a new cardiomyopathy with an EF of 40% with diffuse hypokinesis, now being transferred for cardiac catherization. Pt describes DOE over several years durationbut progressively worse in last few months to point where he is now unable to walk across a standard room. No Sx c/w angina. Remaining compliants included LE edema. Otherwise denied F/C/S, cough, CP, abd pain, N/V/D. . OSH Course: Ruled out for MI by CEs. He was diuresed for 20lbs. FOund to have mild cellulitis of the left leg, which improved on Ancef. . Currently Pt feels better with improved SOB. He has no CP, N/V, abd pain. He reports his L leg pain and swelling are also improved. Past Medical History: DM2- new diagnosis, no current treatment HTN OSA- not currently on CPAP, scheduled for outpt sleep study no previously-known CAD Social History: Works as heavy machinery mechanic; married and lives with wife, 3 daughters; +[Name2 (NI) ]- 120pk-yr history, quit 13y ago; no EtOH/IVDU Family History: both mother and father died of MIs in their 50s Physical Exam: T 97.3, HR 98, BP 117/71, RR 18, O2sat 96%RA Gen: comfortable, speaking in full sentences, pleasant, lying in bed in NAD HEENT: R eye laterally deviated, sclerae anicteric, MMM, OP clear Neck: No LAD. Lying flat so unable to approximate JVD, no CB b/l CV: RRR, nl S1S2, no M/R/G Lungs: CTAB anteriorly, no wheeze or rales Abd: +BS, soft, obese, NT, ND, no fluid wave, no HSM Ext: trace LE edema to 1/4calf b/l, DP 2+ bilaterally, R groin cath site- c/d/i, no hematoma/ooze/bruit/tenderness Neuro: A&O x 3, appropriate, R eye laterally deviated, h/o R eye blindness Pertinent Results: Cardiology Report C.CATH Study Date of [2130-2-17] * Not Signed Out * BRIEF HISTORY: Patient is a 63 year old male who has not sought care for many years. He presented to [Hospital3 4107] last week with CHF. He was diuresed 20 pounds and diagnosed with having diabetes. EF was 40% on echo with mild LVH. He is now referred for cath for new diagnosis of cardiomyopathy. INDICATIONS FOR CATHETERIZATION: CHF, cardiomyopathy PROCEDURE: RIGHT HEART CATH- was performed via 8F sheath in Right Femoral Vein via a PA catheter. LEFT HEART CATH- was performed via a 5F sheath in Right Femoral Artery. Multiple projections of coronary arteries were performed with 5F JL4 and JR4. VENTRICULOGRAM was performed wia a 5F pigtail with 39 cc of contrast injected over 3 seconds. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.09 m2 HEMOGLOBIN: 10.9 gms % FICK PRESSURES RIGHT ATRIUM {a/v/m} 22/20/16 RIGHT VENTRICLE {s/ed} 54/20 PULMONARY ARTERY {s/d/m} 54/28/39 PULMONARY WEDGE {a/v/m} 33/35/31 LEFT VENTRICLE {s/ed} 102/35 AORTA {s/d/m} 102/67/82 CARDIAC OUTPUT HEART RATE {beats/min} 96 RHYTHM SINUS O2 CONS. IND {ml/min/m2} 125 CARD. OP/IND FICK {l/mn/m2} 4.4/2.1 RESISTANCES SYSTEMIC VASC. RESISTANCE 1200 PULMONARY VASC. RESISTANCE 146 % SATURATION DATA (NL) SVC LOW 53 PA MAIN 53 AO 93 ARTERIAL BLOOD GAS INSPIRED O2 CONCENTR'N 21 LEFT VENTRICULOGRAPHY: Volumetric data: LV ejection fraction (nl 50%-80%). 35 Qualitative wall motion: [Doctor Last Name ]: 1. Antero basal - hypokinetic 2. Antero lateral - hypokinetic 3. Apical - hypokinetic 4. Inferior - hypokinetic 5. Postero basal - hypokinetic Other findings: Mitral valve showed the following abnormalities. 1. Regurgitation 1+. Aortic valve was normal. ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM RIGHT CORONARY 1) PROXIMAL RCA DIFFUSELY DISEASED 2) MID RCA DISCRETE 95 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA DIFFUSELY DISEASED ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM LEFT CORONARY 5) LEFT MAIN DISCRETE 40 6) PROXIMAL LAD DISCRETE 90 6A) SEPTAL-1 NORMAL 7) MID-LAD NORMAL 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 10) DIAGONAL-2 NORMAL 11) INTERMEDIUS DIFFUSELY DISEASED 12) PROXIMAL CX DIFFUSELY DISEASED 13) MID CX DISCRETE 60 13A) DISTAL CX DISCRETE 95 14) OBTUSE MARGINAL-1 DISCRETE 80 15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 16) OBTUSE MARGINAL-3 DISCRETE 90 17) LEFT PDA NORMAL TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 36 minutes. Arterial time = 23 minutes. Fluoro time = 5 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 94 ml, Indications - Renal Premedications: ASA 325 mg P.O. Lasix and aldactone Anesthesia: 1% Lidocaine subq. Anticoagulation: Other medication: Fentanyl 25mcg IV Lasix 60mg IV Versed 1mg IV Cardiac Cath Supplies Used: 200CC MALLINCRODT, OPTIRAY 200CC 100CC MALLINCRODT, OPTIRAY 100CC COMMENTS: 1. Selective coronary angiography in this co-dominant patient revealed severe three vessel native coronary disease. The LMCA had a distal 40% stenosis. The LAD had a 90% long tubular stenosis proximally. The LCX system was diffusely diseased with 80% large OM1, small diffusely diseased OM2 and 90% large OM3. The mid LCX had a 60% lesion and the distal LCX had a 95% lesion before the last posterolateral. The ramus was small and diffusely diseased with a 95% mid lesion. It gave off a very small PDA. 2. Resting hemodynamics revealed severe elevation of right and left sided filling pressures with mean RA of 16mmHG and mean PCWP of 31mmHG. The LVEDP was also elevated at 35mmHG and there was moderate-severe elevation of pulmonary pressures with mean PA of 39mmHG. The cardiac index was depressed at 2.11. There was no gradient on aortic valve pullback. Systemic blood pressure was normal at 106/67 3. Ventriculogram revealed moderate global hypokinesis with a dilated ventricule. There was severe anteroapical hypokinesis. EF was about 35% with mild mitral regurgitation. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate systolic dysfunction 3. Severe diastolic dysfunction with elevated right and left filling pressures and reduced cardiac index. ATTENDING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. REFERRING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] CARDIOLOGY FELLOW: [Last Name (LF) 38290],[First Name3 (LF) ] M. ATTENDING STAFF: [Last Name (LF) ],[First Name3 (LF) ] E. Cardiology Report ECHO Study Date of [2130-2-20] PATIENT/TEST INFORMATION: Indication: Left ventricular function. Height: (in) 67 Weight (lb): 218 BSA (m2): 2.10 m2 BP (mm Hg): 105/58 HR (bpm): 86 Status: Inpatient Date/Time: [2130-2-20] at 11:49 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W002-0:49 Test Location: [Location 11648]/[Hospital Ward Name 121] 6 Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) *] MEASUREMENTS: Left Atrium - Long Axis Dimension: 4.7 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.6 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 5.4 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.9 cm Left Ventricle - Fractional Shortening: 0.24 (nl >= 0.29) Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%) Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A Ratio: 3.67 TR Gradient (+ RA = PASP): 28 mm Hg (nl <= 25 mm Hg) Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate global LV hypokinesis. No resting LVOT gradient. RIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. Mild global RV free wall hypokinesis. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate global left ventricular hypokinesis. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD on [2130-2-20] 14:00. [Location (un) ] PHYSICIAN: [Name10 (NameIs) ],[First Name3 (LF) ] Cardiology Report ECG Study Date of [2130-2-21] 3:48:38 PM Sinus rhythm Old anteroseptal infarct Low QRS voltages in precordial leads Nonspecific ST-T wave changes Since previous tracing, no significant change Read by: [Last Name (LF) ],[First Name3 (LF) ] J. Intervals Axes Rate PR QRS QT/QTc P QRS T 90 144 78 362/409.71 69 12 85 Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2130-2-17] for further management of his congestive heart failure. His catheterization at [Hospital1 18] revealed significant 3 vessel disease with a depressed LVEF. Please see catheterization report for details. Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. He was worked-up in the usual preoperative manner. On [2130-2-21] he successfully underwent CABGx3 (LIMA->LAD, SVG->OM, SVG->PDA). Afterward he was transferred to the Cardiac surgery recovery unit in stable condition and awakened neurologically intake. He was weaned from ventilator support, extubated, and pressors were weaned. On POD 2 he was then transferred to the Stepdown unit for further recovery. His chest tubes were removed without complication. He was gently diuresed to his preoperative weight, beta blockade and aspirin therapy were resumed, and physical therapy service was consulted to assist with his postoperative strength and mobility. Electrolytes were repleted as needed. On POD 3 his epicardial pacing wires were removed without complication, he continued to improve his ability to ambulate including climbing stairs without respiratory distress or chest pain. On POD 4 the [Last Name (un) ] diabetes clinic was consulted regarding diabetic teaching for Mr. [Known lastname ] newly diagnosed diabetes. Follow up for management of his diabetes will be done at the [Hospital1 1474] clininc. On POD 5 Mr. [Known lastname ] was 5kg his preop weight with good exercise tolerance, no SOB, or Chest pain. His blood pressure was stable. His sternotomy and leg incision were clean, dry, and intact without evidence of infection. He was discharged home on POD 5 with services in good condition, cardiac diet, sternal precautions, and instructed to follow up with his PCP/cardiologist in [1-16] weeks. He will follow up with Dr. [Last Name (STitle) ] in four weeks. Medications on Admission: MEDS outpatient: ASA 81mg qd MVI qd fish oil capsules . MEDS on transfer: lasix 80IV QD Metoprolol 25 [Hospital1 ] Lisinopril 10 qd Aldactone 25 QID ASA 81 ancef s/p pneumonocccal vaccine yesterday 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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. Disp:28 Tablet(s) Refills:0 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 14 days. Disp:56 Capsule, Sustained Release(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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Disp:30 Tablet(s) Refills:2 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day: follow SSI. Disp:qs 30 Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: CAD, HTN, Hyperlipidemia, DM type 2, right eye blindness Discharge Condition: Good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in four weeks [Telephone/Fax (1) 170] Follow up with Dr. [Last Name (STitle) 31187] in one to two weeks [Telephone/Fax (1) 64680] Completed by:[2130-2-25]	[ "41401", "4280", "2724", "4019", "25000" ]
Admission Date: [2165-5-2] Discharge Date: [2165-5-6] Service: MEDICINE Allergies: Penicillins / Meropenem Attending:[First Name3 (LF) 3326] Chief Complaint: Fever and MS changes with mild hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 81M with MMP including CRI, HTN, PVD, CABG, a left-sided above the knee amputation and a previous fem fem bypass and a right fem peroneal bypass, recently admitted for UTI/ pyelonephritis and ARF sent to nursing home, was found to have fever, decreased urine output, started with avelox and gent yesterday, still febrile today, sent to ED. In ED, found to be hypotensive 80/41, received levo and flagyl, and 3L NS, and BP improved, sent to [Hospital Unit Name 153]. In [Hospital Unit Name 153], BP around 80's/50's, pt found to be unresponsive to sternal rub, pin point pupil, fs 129, O2sat upper 90's, pt responded to 1.8mg Narcan, became awake and interactive. . In the [Hospital Unit Name 153], the patient required several more liters of fluid but never required pressors. His Ucx grew proteus and his antibiotics were changed from meropenem -> vanco/aztreonam -> aztreonam. He continued to have intermittant fever spikes but subsequent cultures have not grown anything to date. F/U ultrasound of his L kidney showed resolution of his previously noted hydronephrosis. His mental status improved after administration of narcan and he has remained lucid. Past Medical History: 1. Hypertension 2. Peripheral [Hospital Unit Name 1106] disease. 3. ? h/o cardiomyopathy with a history of alcohol abuse. 4. Left above knee amputation in [2161] at Veterans Administration Hospital. Left phantom limb and stump pain 5. Ischemic right foot/leg, s/p intraoperative arteriogram with Right femoral thrombectomy and femoral-femoral bypass([2164-7-23]). 6. S/p right femoral to peroneal bypass with non-reverse saphenous vein graft on ([2164-8-2]). 7. CKD with baseline creat 1.8 Social History: The patient lives with his wife. Uses a walker/wheelchair. He has a 70 pack-year history of smoking. He had heavy alcohol use up until 3 years ago. Family History: Non-contributory Physical Exam: GEN: not arousable by voice or painful stimuli, breathing comfortably, not using accessory mm. HEENT: pinpoint pupil minimally reactive to light, dry mucous membrane. CV: reg rate, s1 s2 Lung: CTAB ABD: soft, NT/ND, +bs EXT: BKA on left, moving all extremities. . Pertinent Results: ADMISSION LABS: [2165-5-2] 10:10AM BLOOD WBC-22.1# RBC-4.99 Hgb-12.4 Hct-38.4* MCV-77* MCH-25.0* MCHC-32.4 RDW-17.0* Plt Ct-240 [2165-5-2] 10:10AM BLOOD Neuts-93.4* Bands-0 Lymphs-3.0* Monos-2.9 Eos-0.6 Baso-0.1 [2165-5-2] 10:10AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [2165-5-2] 10:10AM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.2* [2165-5-2] 10:10AM BLOOD Plt Smr-NORMAL Plt Ct-240 [2165-5-2] 02:35PM BLOOD Ret Aut-1.4 [2165-5-2] 10:10AM BLOOD Glucose-135* UreaN-54* Creat-3.4# Na-136 K-4.3 Cl-106 HCO3-16 AnGap-18 [2165-5-2] 10:10AM BLOOD ALT-15 AST-45* AlkPhos-81 Amylase-130* TotBili-0.5 [2165-5-2] 10:10AM BLOOD Lipase-13 [2165-5-2] 02:35PM BLOOD Calcium-6.9* Phos-2.6* Mg-1.4* [2165-5-4] 03:53AM BLOOD calTIBC-122* Ferritn-361 TRF-94* [2165-5-2] 08:31PM BLOOD Ethanol-NEG Bnzodzp-NEG [2165-5-2] 02:23PM BLOOD Type-ART pO2-50* pCO2-30* pH-7.30* calHCO3-15* Base XS--9 Comment-QNS TO REP [2165-5-2] 10:16AM BLOOD Lactate-2.2* . IMAGING: CT abd [2165-3-7]: IMPRESSION: 1. New obstruction of the left kidney with hydronephrosis, hydroureter and perinephric stranding. Left ureter dilated to level of aortic bifurcation. The cause of obstruction is not identified and may be due to a ureteral stricture or mass. There is no obstructing stone 2. Multiple small stones in the gallbladder without evidence of acute cholecystitis. 3. Atherosclerotic disease with aneurysmal dilatation of the abdominal aorta, not significantly changed from prior. 4. Rounded structure arising from left mediastinum, possibly representing duplication cyst, not significantly changed from prior. . [5-3]: Renal U/S: Resolution of the previously seen left-sided hydronephrosis. Small simple-appearing cysts in both kidneys. . [5-3]: CXR: Left skin fold should not be mistaken for pneumothorax; there is none, nor any significant pleural effusion. Tip of a right internal jugular line projects over the upper third of the superior vena cava. Thoracic aorta is chronically enlarged and tortuous. The saccular aneurysm of the descending portion is obscured by the cardiac silhouette and mild left lower lobe atelectasis. . Brief Hospital Course: BRIEF OVERVIEW: 81M with MMP including CRI, HTN, PVD, CABG, presented with recurrent UTI, delta ms, and acute on chronic renal failure. He was resuscitated with IVF and treated with narcan for MS changes. Somnolence resolved, Utox was negative. BP normalized with fluids. Urine grew proteus [Last Name (un) 36] to cephalosporins, but pt has hx of anaphylaxis to PCN, therefore was treated with aztreonam. Foley was discontinued and Pt was transfered to the floor. . Course by Problem: . # ID/fevers- His Ucx grew proteus and the patient was treated with aztreonam for this microbe. His fever curve trended down on this medication and he was afebrile for >24hrs prior to d/c. He will be d/c to complete a 10d course of [Hospital1 ] aztreonam at his nursing home. . # delta MS: Was somnolent on admission - resolved with narcan. He was interactive throughout the rest of his admission but . #H/o Hydronephrosis: seen by urologist on [2165-4-24] for history of left-sided hydronephrosis and was thought most likely secondary to fibrosis from his peripheral [Date Range 1106] disease and graft placements. To ensure that there is no malignancy in the area of the mid ureter, pt was advised to have a cystoscopy and retrograde pyelogram on the left side with balloon dilatation and ureteral stent placement and was told to f/u with urology for this. . # acute on chronic renal failure- The patient's baseline creatinine appears to be 1.8, and was 3.1 on admission. It was assumed that this was [1-31] a pre-renal picture given his septic presentation and he trended to normal w/ hydration. U/S r/o obstruction and the patient w/ f/u with his outpatient urologist in 1mo. . # anemia: baseline 35-38 and iron studies c/w a mixed anemia of chronic dz and iron deficiency picture. He was started on iron supplementation and his Hct trended upwards throughout his admission. . # HTN: Outpt HTN meds were held on his admission given his hypotension. Once he was afebrile for a 24hr period his HCTZ was added back and his imdur and BBlocker should be readded as necessary at his rehab facility Medications on Admission: 1. Gabapentin 300 mg qd 2. Acetaminophen 325-650 mg PRN 3. Pantoprazole 40 mg qd 4. Aztreonam 1000 mg Q12H 5. Senna prn 6. Docusate Sodium 100 mg [Hospital1 ] Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Primary: Urosepsis, AMS, acute on chronic renal failure . Secondary: HTN, PVD, left AKA, Discharge Condition: Stable; tolerating PO and afebrile Discharge Instructions: Please take your medications as directed by your facility Return to the ER or call your PCP [Name Initial (PRE) ]: 1. fever to 101 2. chest pain 3. shortness of breath 4. other concerning symptoms Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D., PH.D. Date/Time:[2165-8-1] 3:00 Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2165-5-8] 2:15 Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3627] [Name12 (NameIs) 3628] [Name12 (NameIs) ] [Name12 (NameIs) 3628] (NHB) Date/Time:[2165-5-8] 1:00 . Please make an appointment to be seen by your PCP ([Last Name (LF) 63604],[First Name3 (LF) ] [Telephone/Fax (1) 14943] EXT. 376) within the next 2weeks Completed by:[2165-5-7]	[ "0389", "5990", "5849", "40391", "2762", "99592", "V4581" ]
Admission Date: [2149-10-10] Discharge Date: [2149-10-26] Date of Birth: [2104-10-19] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: This patient presented with sudden onset of nausea, vomiting, rightsided weakness, and loss of consciousness. Major Surgical or Invasive Procedure: Tracheostomy PEG placement Transespohageal Echocardiogram Cerebral angiography History of Present Illness: On [2149-10-10], Mr. [Known lastname 56767] was transferred to [Hospital1 18] from [Hospital 11560] [Hospital3 ] after having been hospitalized for the sudden onset of nausea, vomiting, right sided weakness, and loss of consciousness. This episode was witnessed and EMS was called immediately. Mr. [Known lastname 56767] was intubated upon their arrival, at which time he was noted to have decorticate posturing and was not protecting his airway. Upon arrival at [First Name4 (NamePattern1) 11560] [Last Name (NamePattern1) ], Mr. [Known lastname 56767] was given a lumbar puncture, which was negative, and blood cultures were taken. He was normotensive and afebrile. No seizure activity was noted and no sign of trauma. As a prophylactic measure, Mr. [Known lastname 56767] was loaded with dilantin in the emergency department. He was then sent to the ICU; MRA and CTA revealed a high grade basilar artery stenosis and left sided pontine infarct. He was started on IV heparin and transfered to [Hospital1 18] for cerebral angiography and possible basilar stenting. Past Medical History: Hypothyroidism Nephropathy as a child Social History: Lives at home with his mother. Non [Name2 (NI) 1818], occasional EtOH, no drugs. Family History: Mr. [Known lastname 56768] paternal grandfather had a stroke when he was between 70 and 80 years of age. There is no history of hypercoagulability in the family. Older brother with psychiatric problems. Physical Exam: T-97.4 BP-130/70 HR-88 RR-19 Gen: lying in bed in no apparent distress Heent: NCAT, oropharynx clear Neck: supple, no carotid bruits Chest: clear to auscultation b/l CV:regular rate, tachycardic Ext: no c/c/e, 2+ dorsalis pedis Neurologic Exam: MS: Oriented to person, place and time. Alert. Able to say days of week backwards. Severely dysarthirc but fluent speech, repetition, naming intact. Able to read from NIHSS stroke card. No apraxia, neglect, frontal signs. CN: Visual fields intact to confrontation to finger counting. Pupils normal round 4mm->2mm with light. Eomi without nystagmus. Normal facial sensation. Patient has facial diplegia, with right side involved more than left. Obicularis oculi weak b/l r>l. Hearing intact to finger rub. L side of palate does not elevate fully. Tongue deviated to right on protrusion. Motor: The patient has a flaccid hemiplegia on the right involving arm and leg. Tone and bulk are normal with 5/5 strength in the entire left hemibody. Reflexes: Reflexes are brisk in UE 2+/4. [2-13] patellar b/l. Ankle jerks present. No clonus appreciated. Plantar reflexes extensor on right, mute on left. Sensory: Intact to pinprick, vibration, proprioception and temperature throughout. No extinction to DSS. Coordination: Intact FTN on L. Gait:deferred Pertinent Results: CBC [2149-10-24] 04:17AM BLOOD WBC-12.0* RBC-4.03* Hgb-12.2* Hct-34.8* MCV-86 MCH-30.4 MCHC-35.1* RDW-12.4 Plt Ct-408 Differential [2149-10-16] 02:57AM BLOOD Neuts-62 Bands-16* Lymphs-10* Monos-10 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0 CHEMISTRY [2149-10-24] 04:17AM BLOOD Glucose-124* UreaN-15 Creat-0.7 Na-135 K-4.4 Cl-98 HCO3-31* AnGap-10 Calcium-8.8 Phos-3.9 Mg-2.0 LIPID PROFILE [2149-10-11] 12:25AM BLOOD Triglyc-118 HDL-36 CHOL/HD-4.1 LDLcalc-87 VANC LEVEL [2149-10-21] 01:13AM BLOOD Vanco-6.5* TOXICOLOGY SCREEN [2149-10-11] 12:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ARTERIAL BLOOD GAS [2149-10-22] 06:31PM BLOOD Type-ART pO2-111* pCO2-43 pH-7.46* calHCO3-32* Base XS-5 [2149-10-26] 04:20AM BLOOD WBC-7.3 RBC-3.89* Hgb-12.0* Hct-33.6* MCV-87 MCH-30.9 MCHC-35.7* RDW-12.5 Plt Ct-363 [2149-10-26] 04:20AM BLOOD Plt Ct-363 [2149-10-26] 04:20AM BLOOD PT-14.6* PTT-69.8* INR(PT)-1.3 [2149-10-11] 12:25AM BLOOD Triglyc-118 HDL-36 CHOL/HD-4.1 LDLcalc-87 [2149-10-25] 04:05AM BLOOD TSH-11* [2149-10-25] 01:09PM BLOOD HIV Ab-PND Brief Hospital Course: 44 yo with hx of hypothyroidism who p/w acute onset of nausea and vomiting followed by unresponsiveness-originally at OSH and found to have pontine infarcts L>R secondary to basilar occlusion of unknown etiology. [Month/Day/Year ] negative. Angio [10-14] showed open verts, mid basilar occlusion, PCAs filling via PCOMs bilaterally. No intervention. Post-angio, neuro exam unchanged. On heparin for basilar occlusion-goal PTT 40-60. Failed swallow eval. Had an aspiration event afternoon [10-15]->desat and very tachypneic; intubated [10-15] evening and transferred to ICU. He was admitted to the neuro ICU for workup of his bilateral pontine infarcts and basilar occlusion. 1. Neuro: -He was maintained on heparin with PTT goal 40-70 and started on Coumadin [10-22], goal INR 2.0-3.0. He will be switched to Lovenox at time of discharge. Lovenox should be continued until INR is therapeutic. -Underwent MRA and CTA which showed left>right pontine infarction and mid-basilar stenosis. -Etiology of basilar occlusion remains unclear: [Name2 (NI) ] was negative for cardioembolic source, hypercoag w/u was started at the OH-but still needs: homocysteine, lupus anticoagulant, factor VIII, fibrinogen, and cardiolipin Ab - which will be done as an outpatient; he had a CT of the chest/abd/pelvis to r/o occult malignancy/paraneoplastic process, he had an HIV test drawn [10-25]-results pending at time of discharge. -Cerebral angiogram [10-14] showed: Bilateral distal vertebral artery and proximal basilar artery thrombosis without evidence of recanalization or flow through the basilar artery on injection of the vertebral arteries bilaterally with a right vertebral artery ending in AICA and the left vertebral artery ending in PICA. Flow to the bilateral posterior cerebral arteries provided via the bilateral posterior communicating arteries. PLAN: --Continue heparin IVSS at 1100/hr until 6PM tonight. Stop the heparin at 6PM. Start Lovenox at 8PM. Continue Lovenox 70mg SC q 12h until INR is therapeutic. Target INR is 2.0-3.0. He will need Coumadin for the next six months. --Follow up in [Hospital 4038] Clinic after discharge from rehab (see follow-up instructions)for completion of hypercoagulabilty workup. 2. Pulm: Pt had difficulty handling oral secretions and required intubation and eventual tracheostomy. Sputum cx [10-14] with MRSA, on Vancomycin-needs 14 day course (will finish on [10-31]). He was trached on [10-22], doing well on 35% Trach mask. Needs aggressive pulmonary toilet. Maintain aspiration precautions. Fenestrated trach/passy muir attempted by speech tx. Patient tolerated well. 3. GI: -GJ tube placed -Started tube feeds, Impact -PPI/H2 blocker -Antiemetics -Has had diarrhea-likely antibiotic induced. C.diff neg and stool cx negative. 4. Heme: -Transfusion to keep hct>30, plts>100, INR<1.4 -Coumadin started [10-21], goal INR 2.0-3.0 -Continue heparin gtt with goal PTT 40-60 until coumadin therapeutic -Got 1 unit prbcs [10-17] for slight drop in hct, Hct stable since 5. ID: -Sputum with MRSA pneumonia, Vanco and should complete 14 day course-to end [10-31]. 6. Endocrine: -Levoxyl for hypothyroidism -Had elevated TSH, normal FT4-probably sick euthyroid. Needs repeat TFTs Medications on Admission: Levothyroxine 112 mcg po od Discharge Medications: Vancomycin 1500mg IV q12h(began on [2149-10-17] and should be continued until [2149-10-31]) 1. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Vancomycin HCl 500 mg Recon Soln Sig: 1500 (1500) mg Intravenous Q12H (every 12 hours). 7. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 8. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1100 (1100) units/hour Intravenous COntinuous: Stop at 6:00PM. 9. Lovenox 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous every twelve (12) hours: First dose at 8PM. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Pontine infarct caused by basilar artery stenosis Discharge Condition: Patient is stable and improved Discharge Instructions: Continue Physical Therapy. Take medications as directed. Heparin should be discontinued tonight at 6PM. Two hours later, at 8PM he should be started on Lovenox 60mg q12hours. COntinue lovenox until INR is therapeutic (2.0-3.0). Coumadin should be continued for 6 months. Follow up in stroke clinic for completion of hypercoagulability work up and continued care after d/c from rehab facility. Followup Instructions: Follow up in [Hospital 4038] Clinic with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in three months. Please call to set up appointment when discharged from rehab. Phone number: [Telephone/Fax (1) 1694]. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "5070", "51881", "2449" ]
Admission Date: [2115-9-18] Discharge Date: [2115-9-28] Date of Birth: [2056-8-4] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 59 year old female with past medical history significant for insulin dependent diabetes mellitus, end-stage renal disease on peritoneal dialysis, Methicillin resistant Staphylococcus aureus bacteremia diagnosed in [2115-3-12], hypertension, status post left hip fracture with left hip osteomyelitis in [2115-3-12], Stage III decubitus ulcer, delirium, transfusion dependent anemia and hypothyroidism. She is admitted for low systolic blood pressure of 260/40. Her baseline systolic blood pressure is around 80s to 90s. In the Emergency Department, the patient was given normal saline which has increased her blood pressure to her baseline. One unit of packed red blood cells were transfused. Nasogastric lavage revealed coffee ground aspirate and guaiac positive stool. The patient was admitted to the Medical Intensive Care Unit and then the patient was transferred to the Floor on [9-20], after being stabilized. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus. 2. End-stage renal disease on peritoneal dialysis. 3. Methicillin resistant Staphylococcus aureus bacteremia in [2115-3-12]. 4. Hypothyroidism. 5. Status post left hip fracture in [2114-6-11]. 6. Left hip osteomyelitis. 7. Stage III decubitus ulcer. 8. Urinary retention. 9. History of pneumonia. 10. History of delirium. 11. Transfusion dependent anemia. 12. Hypotension. ALLERGIES: To tetracycline, from which patient developed rash. SOCIAL HISTORY: The patient has chronic smoking history but had quit and has not been smoking. The patient denied any alcohol use. The patient has recently been widowed; her husband passed away in [Name (NI) 547] of this year and she has been living in the rehabilitation facility for the past three months. PHYSICAL EXAMINATION: On admission, vital signs were that the patient was afebrile; heart rate is 115; blood pressure is 79/47; 100% on room air. In general, the patient is chronically ill appearing, cachectic, lying in bed in no apparent distress. HEENT: Right eye is surgical; pale conjunctivae. Mucous membranes were moist. Heart tachycardic with a holosystolic murmur at the apex. Lungs: Decreased breath sounds at the bases bilaterally. Abdomen soft, nontender, nondistended. Positive bowel sounds. No organomegaly detected. Extremities positive for muscle wasting. No edema, no clubbing. Notable for obvious sacral decubitus ulcer that is covered by dressing. LABORATORY: On admission, the patient's white blood cell count is 9.1, hematocrit is 30.9, with baseline 32.9, platelets 256. Chem-10 is significant for creatinine of 2.9, and glucose of 469. HOSPITAL COURSE: 1. MENTAL STATUS CHANGE: The patient's mental status has been waxing and [Doctor Last Name 688]. It appeared to be delirium at times and clear at others. The patient had a CT scan done during her hospital stay that showed a new area of encephalomalacia involving the right frontal parietal region and the right occipital region consistent with areas of infarction; those are new since [2115-3-12]. An area of high attenuation within the infarcted area might represent residual brain parenchyma versus hemorrhaging to the infarction. Neurology was consulted and they recommended several tests as well, including lumbar puncture and other exams. The patient's family felt that they did not want to have invasive procedures for the patient, so a lumbar puncture was not done. 2. RIGHT FACIAL DROOP: Neurological was consulted and per their recommendations, it is likely to be felt as peripheral cranial nerve VII nerve palsy. Acyclovir was recommended, started on [9-22] and will continue for a 14 day course. 3. HYPOTENSION: At baseline, the patient's blood pressure is 80/60. The patient's blood pressure waxed and waned, but has been stabilized in the last few days and with rehydration and encouraging of p.o. intake, we will just keep on monitoring her and rehydrate her if necessary. The patient is on peritoneal dialysis and the fluid level has to be carefully monitored. 4. QUESTION OF INFECTION: The patient was started in Medical Intensive Care Unit on ....... and Ceftriaxone intravenously for potential sepsis. All cultures have been negative so far and her white blood cell count has been normal in the past few days and the patient remained afebrile. Will just continue monitoring the patient for any signs of infection given that she has open Grade III decubitus ulcer. 5. DECUBITUS ULCER: There was a question of osteomyelitis. Plastics was consulted and recommended dressing change from wet-to-dry three times a day. A CT scan of the pelvis revealed that there is no free air and no signs of osteomyelitis although there is a significant amount of fluid collection around the left hip joint. Orthopedics was consulted and they do not recommend drainage at this point. 6. PLEURAL EFFUSION SEEN ON CT SCAN: A chest CT scan was done and that showed a significant amount of pleural effusion on both sides. The patient is not symptomatic. The plan is to drain the fluid if patient becomes short of breath or desaturates. 7. ANOREXIA/DIFFICULTY SWALLOWING: Speech and Swallow was consulted and they stated that there are no signs of aspiration upon bedside swallow evaluation. They recommended a Gastrointestinal consultation. Dr. [First Name (STitle) 679] performed endoscopy on the patient on [9-25], and had the following findings: 1) He saw a grade 3 esophagitis in the gastroesophageal junction and lower third of the esophagus. Biopsy was done; 2) Ulcer in the stomach body greater curve as well as ulcer in the distal part. He also did a biopsy as well in the stomach antrum. Otherwise, it shows normal esophagogastroduodenoscopy to the second part of the duodenum. No stricture was seen. The patient's dose of Protonix as well as add Zantac to her daily treatment. The patient's difficulty to swallow might partly be attributed by the fact that she does not have teeth and she only had an upper denture which was not even with her during her hospital stay. The patient might need a new denture set as an outpatient. DISCHARGE DIAGNOSES: 1. Auto-immune disease, not elsewhere classified. DISCHARGE MEDICATIONS: 1. Timolol eye drop 0.25% drops, one drop in each eye twice a day. 2. Miconazole nitrate powder, apply three times a day as needed to affect the area. 3. Quetiapine fumarate 25 mg p.o. q. h.s. 4. Mirtazapine 15 mg q. h.s. 5. Docusate 100 mg p.o. twice a day. 6. Folic acid 1 mg p.o. q. day. 7. Clopidogrel 75 mg p.o. q. day. 8. Metoclopramide 10 mg p.o. four times a day before meals and at bedtime. 9. Levothyroxine 25 micrograms, 1.5 tablet p.o. q. day. 10. Polyphenol alcohol, 1.4% drop, two drops Ophthalmic four times a day. 11. Lanolin/mineral oil/petrolatum ointment: Apply to the right eye four times a day. 12. Folic acid, B vitamin complex, 1 mg p.o. q. day. 13. Nystatin 5 ml p.o. q. day swish and swallow. 14. Pantoprazole 40 mg p.o. twice a day. Take one before breakfast and take another one before dinner. 15. Acyclovir 150 mg intravenously q. day. The patient needs to take Acyclovir until [10-6]. 16. NPH insulin subcutaneously, 3 units twice a day. 17. Zantac 150 mg, take before bedtime once a day. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. [First Name8 (NamePattern2) 11595] [Last Name (NamePattern1) ], M.D. [MD Number(1) 17144] Dictated By:[Name8 (MD) 18513] MEDQUIST36 D: [2115-9-27] 16:20 T: [2115-9-27] 17:54 JOB#: [Job Number 110763]	[ "40391", "4280", "2859" ]
Admission Date: [2123-10-25] Discharge Date: [2123-11-4] Date of Birth: [2049-4-18] Sex: M Service: DR.[Last Name (STitle) ],[First Name3 (LF) ] J. 12-749 Dictated By:[Name8 (MD) 12984] MEDQUIST36 D: [2123-11-7] 12:22 T: [2123-11-7] 12:29 JOB#: [Job Number 12985]	[ "4280" ]
Admission Date: [2105-7-22] Discharge Date: [2105-8-9] Date of Birth: [2052-9-21] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 106] Chief Complaint: fever, chills Major Surgical or Invasive Procedure: Pacemaker explant Insertion of temporary external pacemaker PICC line placement R History of Present Illness: Mr. [Known firstname 487] [Initial (NamePattern1) ]. [Known lastname ] is a very nice 52 year-old gentleman with history of bicuspid aortic valve and ascending aortic aneurysm s/p mechanical [Hospital3 ] AVR on coumadin, h/o CHB s/p PPM who comes with malaise, HA and fever up to 102 with peripheral vision loss. He underwent surgery succesfuly in [1-21], which was complicated by recurrent pericardial effusion that was treated with a pericardial window. He was discharged home on [2105-2-21] and was doing well, able to play golf and purposely losing some weight. Six days ago he started noticing fever up to 102, chills, rigors, loss of apetite and night sweats. He almost had no symptoms during the day. He went and saw his PCP 3 days ago who did blood work and sent him home. His PCP labs included gluc 11, BUN 8, Creat 0.68, Na 136, K 4.1, Cl 102, CO2 26, Ca 8.8, Prot 6.4, Alb 3.4, AP 87, AST 38, ALT 34, Bil 0.7. UA negative for UTI, but with mild proteinuria and keytones. He got blood cultures drawn that came back positive 1/2 bottles (anaerobic) with GPCs in chains and was called to go to the ER. . At [Hospital ] Hospital his VS were stable. He received in Vancomycin 1 gm IV once morphine and zofran. WBC 9.7, HCT 25, PLT 191, no bands. He was transfered to our ER for further work up. . In our ER his initial VS were T 103.1 F, BP 124/70 BPM, HR 90 BPM, RR 18 X', SpO2 96% on RA. His initial exam showed normal JVP, clear lungs, no edema. He received gentamycin 120 mg IV, tylenol PO at 6 AM, 8 mg of morphine IV, 4 mg of zofran and 5 mg of IV Vit K. During his ED stay he reports loss of vision in the left upper visual field in his left eye. Stroke service was consulted. Repeat CT scan showed 15 mm lesion without any new lesions. Minimal perihemorrhagic edema. Reconstruction is pending to eval for mycotic aneurysm. Ophtalmology evaluated patient and saw no abnormalities after dilation. The differential includes TIA, compromised circulation to occipital area, embolic event is also possible. He is admitted to the CCU service. Her received 2 FFPs. His VS prior to transfer were VS: HR 85, RR 12, BP 109/68, 96% 2L. . Of note, he denies any recent dental procedures, skin infections, URI-symptoms, sick contacts, IVDU, changes in his medications (other than stopping Toprol XL and ranitidine). No recent travel. <br> On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. <br> Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: PPM, 2 leads in place. <br><b>PAST MEDICAL HISTORY: </b> Complete Heart Block(PPM) Postop DVT in LUE [2104-3-12] following lead extraction Hyperlipidemia s/p Dual chamber pacemaker placement in [2087] s/p replacement of PM generator [2096] s/p Lead extraction and reimplantation of PPM [3-/2104] Hernia repair as child s/p AVR(mechcanical)Ascending Aortic arch replacment on [2105-2-3] with 25-mm St. [Hospital 923] Medical Regent mechanical valve secondarily to bicuspid aortic valve diagnosed in 7th grade and progressing ascending aortic aneurysm of 5.4cm at time of surgery. Surgery was complicated by tamponade and required Subxiphoid pericardial window on [2105-2-18]. s/p CABG LIMA-LAD in [2105-2-3] h/o DVT Social History: He lives with his wife, daughter, son and son in law in [Name (NI) 1727]. He works in a shipyard, but denies any exposure to asbestos. He quit smoking 2 years ago and has history of 30-40 pack-year. He denies any current or past alcohol intake or illegal substance use. He plays golf as excercise. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Father had first MI in his 60s and died of emphysema. Mother died of a blood clot (unknown location). Physical Exam: VITAL SIGNS - Temp 97.8 F, BP 123/67 mmHg, HR 77 BPM, RR 26 X', O2-sat 98% 2 L NC GENERAL - well-appearing man in NAD, Oriented x3, comfortable, Mood, affect appropriate. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, mechanical S2. Mild SEM [1-17] RUSB radiating towards both carotids. No r/g. No thrills, lifts. No S3 or S4. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), No c/c/e. No femoral bruits. SKIN - no rashes or lesions. No stasis dermatitis, ulcers, scars, or xanthomas. No osler nodes or signs of embili. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [4-15] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait not evaluated, normal eye exam on confrontation and 20/20 bilateraly. Pertinent Results: [2105-7-22] 10:38AM BLOOD WBC-7.6 RBC-3.63* Hgb-10.1* Hct-29.9* MCV-82 MCH-27.7 MCHC-33.7 RDW-15.0 Plt Ct-166 [2105-7-23] 04:30AM BLOOD WBC-9.1 RBC-3.62* Hgb-9.9* Hct-30.7* MCV-85 MCH-27.2 MCHC-32.1 RDW-14.5 Plt Ct-173 [2105-7-24] 07:00AM BLOOD WBC-8.4 RBC-4.17* Hgb-11.6* Hct-35.0* MCV-84 MCH-27.8 MCHC-33.1 RDW-15.0 Plt Ct-251 [2105-8-4] 06:00AM BLOOD WBC-12.5* RBC-3.43* Hgb-9.4* Hct-28.3* MCV-83 MCH-27.4 MCHC-33.2 RDW-14.7 Plt Ct-374 [2105-8-5] 06:02AM BLOOD WBC-11.1* RBC-3.32* Hgb-9.3* Hct-27.0* MCV-81* MCH-28.2 MCHC-34.6 RDW-14.3 Plt Ct-356 [2105-7-22] 06:00AM BLOOD PT-46.6* PTT-38.9* INR(PT)-5.0* [2105-7-22] 10:38AM BLOOD PT-24.6* PTT-33.5 INR(PT)-2.4* [2105-7-22] 09:07PM BLOOD PT-14.9* PTT-27.3 INR(PT)-1.3* [2105-7-22] 10:38AM BLOOD ESR-45* [2105-7-22] 10:38AM BLOOD Ret Aut-0.9* [2105-7-22] 06:00AM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-136 K-4.4 Cl-102 HCO3-23 AnGap-15 [2105-7-23] 04:30AM BLOOD Glucose-113* UreaN-6 Creat-0.7 Na-133 K-4.2 Cl-100 HCO3-25 AnGap-12 [2105-7-24] 07:00AM BLOOD Glucose-101* UreaN-6 Creat-0.6 Na-136 K-4.3 Cl-97 HCO3-31 AnGap-12 [2105-8-4] 06:00AM BLOOD Glucose-113* UreaN-9 Creat-1.0 Na-129* K-4.4 Cl-96 HCO3-27 AnGap-10 [2105-8-5] 06:02AM BLOOD Glucose-121* UreaN-10 Creat-1.1 Na-131* K-4.1 Cl-96 HCO3-28 AnGap-11 [2105-7-22] 10:38AM BLOOD ALT-29 AST-36 LD(LDH)-364* AlkPhos-56 TotBili-0.4 [2105-7-27] 06:30AM BLOOD ALT-94* AST-60* LD(LDH)-406* AlkPhos-73 TotBili-0.3 [2105-7-28] 06:35AM BLOOD ALT-94* AST-57* LD(LDH)-414* AlkPhos-72 TotBili-0.3 [2105-8-5] 06:02AM BLOOD ALT-33 AST-18 LD(LDH)-329* CK(CPK)-28* AlkPhos-70 TotBili-0.3 [2105-7-22] 06:00AM BLOOD cTropnT-<0.01 [2105-7-22] 10:38AM BLOOD Albumin-3.2* Calcium-7.9* Phos-2.6* Mg-1.7 [2105-7-23] 04:30AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.9 [2105-8-5] 06:02AM BLOOD Albumin-3.0* Calcium-8.8 Phos-4.5 Mg-2.1 [2105-7-24] 09:20AM BLOOD Iron-22* [2105-7-24] 09:20AM BLOOD calTIBC-225* VitB12-1376* Folate-14.9 Ferritn-388 TRF-173* [2105-7-22] 10:38AM BLOOD RheuFac-13 CRP-215.5* [2-11] blood cultures drawn on the day of admission showed the same culture results. Blood Culture, Routine (Final [2105-7-24]): BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Sensitivity testing performed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP B \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>4 R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [2105-7-22]): GRAM POSITIVE COCCI IN CHAINS. REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] AT 1715 ON [2105-7-22]. Aerobic Bottle Gram Stain (Final [2105-7-23]): GRAM POSITIVE COCCI IN CHAINS. EKG [7-22]: Sinus rhythm with atrial sensed and ventricular paced rhythm. Since the previous tracing of [2105-2-18] there is no significant change. CTA Head: IMPRESSION: 1. Stable 15 mm right frontal parenchymal hematoma with slight increase of peripheral zone of edema; a small underlying mass cannot be entirely excluded. 2. No CT angiographic "spot sign" to suggest impending enlargement of hemorrhage. 3. No evidence of cerebral venous thrombosis. 4. No new focus of hemorrhage. 5. Patent anterior and posterior circulation vasculature without evidence of vascular malformation or aneurysm larger than 2 mm. TEE [7-23]: 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. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. A bileaflet aortic valve prosthesis is present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: No vegetations seen on mitral valve, tricuspid valve, pulmonic valve. There is small (3mm) relatively fixed echodensisty adjacent to the aortic root side of the mechanical aortic valve near the non-coronary cusp which was present in the immediate post operative TEE on [2105-2-3] and is likely a suture. Compared with the prior TEE study (images reviewed) of [2105-2-3] there are no significant changes. . TEE [7-30]: The left atrium is markedly dilated. The left atrium is elongated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage.There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is inferolateral and inferior wall hypokinesis but overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal with good free wall contractility.The aortic root is moderately dilated at the sinus level. A mechanical aortic valve prosthesis is present. The valve appears to be well-seated without perivalvular leaks, however, the individual prosthetic leaflets cannot be adequately assessed due to artifact. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Peak/mean gradients are 64/36 mmHg. Mild-moderate aortic regurgitation is seen. There is a mobile 7mm x 6 mm mass on the upstream surface of the aortic valve, most likely on the right cusp. This is also the area which shows the AI. It is consistent with a vegetation. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. . TTE [7-29]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal disc motion and transvalvular gradients. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior focused study (images reviewed) of [2105-2-20], the pericardial effusion has resolved. The absence of endocarditis on a transthoracic echo does not exclude the diagnosis if clinically suggested. If clinically suggested, a TEE may be more sensitive for identifying vegetations. . Cerbral angiography: IMPRESSION: No evidence of aneurysm, arteriovenous malformation, or active extravasation. In particular, no abnormality identified in the region of the right frontal parenchymal hemorrhage. . LENI [8-3]: [Doctor Last Name ]-scale and Doppler son[Name (NI) ] of bilateral common femoral, superficial femoral, and popliteal veins were performed. There is appropriate compressibility, flow, and augmentation. IMPRESSION: No evidence of DVT. . PICC: IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen PICC line placement via the right brachial venous approach. Final internal length is 37 cm, with the tip positioned in SVC. The line is ready to use. . LLE U/S: STUDY: Left lower extremity soft tissue ultrasound. FINDINGS: Multiple grayscale images of the left groin, left thigh and left calf demonstrate no fluid collection. IMPRESSION: No evidence for fluid collection. . CXR [8-5]: Lung volumes are normal. Lungs are clear without focal consolidations. Heart size is normal. Hilar and mediastinal silhouettes appear stable. No pulmonary edema, pleural effusions or pneumothoraces are identified. Pacemaker lead projects over right ventricle. Two radiopaque densities are seen projecting over right ventricle, which may represent fragmented leads, and are unchanged since [2105-1-23] study. Right PICC line tip is obscured by pacemaker lead, it is visible at upper to mid SVC. IMPRESSION: No acute cardiopulmonary process. . CT L-Spine 1. No evidence of epidural or paraspinal abscess in the lumbosacral spine. 2. Mild degenerative changes of the lumbar spine, worse at L4-L5 level, with discogenic disease and osteophytes causing thecal sac indentment and neural foraminal narrowing bilaterally. ATTENDING NOTE: Although CT without contrast is not sensitive to detect epidural disease, no obvious deformity of thecal sac seen to suggest abscess. Bilateral moderate foraminal narrowing seen at L4-5. Brief Hospital Course: Mr. [Known firstname 487] [Initial (NamePattern1) ]. [Known lastname ] is a very nice 52 year-old gentleman with history of bicuspid aortic valve and ascending aortic aneurysm s/p mechanical [Hospital3 ] AVR on coumadin, h/o CHB s/p PPM who comes with malaise, HA and fever up to 102 with peripheral vision loss and positive blood cultures for GPCs. # Endocarditis: The patient came from an outside hospital with positive blood cultures. He was immediately started on vancomycin and gentamicin. The vancomycin was then switched to ceftriaxone and he was continued on the gent. He had an initial TEE that showed no evidence of a thrombus or vegetation in the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] leads. CT surgery did not want to intervene at this time as he was stable. His first 3 blood cultures all returned positive for group B streptococcus that was sensitive to ceftriaxone. The patient had a CT head at an OSH that showed a frontal lobe hemorrhage, this was followed by CT and showed small interval change after the first. A cerebral angiogram was also obtained per neurology which showed no evidence of mycotic aneurysm, or other irregularities. Neurology recommended re-imaging only if there was change on physical exam, which there was not. The patient had repeated fevers spikes so a TTE was done which showed no evidence of vegetation. A repeat TEE was done which showed a 7mm x 6 mm vegetation on the aortic valve. CT surgery was reconsulted and again deferred intervention until he had a longer treatment with abx. The patient had his pacer and leads explanted with EP and a temporary external pacemaker was placed. CT A/P was obtained which showed no focus of infection in the abdomen. He developed intermittent back and left leg pain which ID was concerned for abscess/phlegmon. A CT L-spine showed no evidence of abscess, discitis, or osteomyelitis. U/S of the left thigh and DVT studies were obtained which showed no evidence of fluid collection or DVT. It was thought this pain was MSK and was managed with pain control and hot packs. The patient had a PICC line inserted under IR with no complications. His gentamicin was stopped in house after a 2 week course and he was to continue ceftriaxone for a total of 6 weeks. Follow-up was scheduled with Dr. [Last Name (STitle) ] on [8-27]. # Embolic Stroke - The patient had a head CT at an OSH that showed a frontal lobe hemorrhage. The patient's coumadin was held and he had a repeat CT head and CTA which showed a small interval increase in hemorrhage from previous. A cerebral angiogram showed no irregularities as above. Neurology recommendations were to hold his coumadin for 1 week and then start a heparin drip to bridge to a therapeutic INR. He was also started on aspirin 81mg daily. INR therapeutic at 2.3 on Coumadin 12mg daily on [8-9]. Pt discharged. . # Follow up: Pt requires CT abdomen for evaluation of abscesses [1-13] septic emboli from endocarditis as outpatient. Cardiology Device Clinic at [Hospital ] Hospital for evaluation of device within 1 week following discharge. ID f/u per appts. INR checks with f/u with PCP, [Name10 (NameIs) ] home INR machine and titrate medication based on PCP [Name Initial (PRE) 2742]. Cardiology f/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] per appt. CT surgery f/u [Doctor Last Name ] per appt. Medications on Admission: Aspirin 81 mg Daily Colace 100 mg PO BID Coumadin 10 mg 3 days per week and 11 mg 4 days per week Simvastain 40 mg, PCP switching to [Name9 (PRE) ] Discharge Medications: 1. Ceftriaxone 2 gram Recon Soln Sig: Two (2) gram Intravenous every twenty-four(24) hours for 27 days. Disp:qs 27 doses Refills:0 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 5. Warfarin 10 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [Hospital6 486] of Southern [State 1727] Discharge Diagnosis: Endocarditis - AV vegetation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you during your hospitalization. You were admitted for infection of your aortic valve and blood stream. You were started on antibiotics to treat the infection and it was decided by the cardiology and electrophysiology teams to remove your pacemaker as well since it was a potential focus of infection. A temporary pacemaker was placed in your neck until you finish your course of antibiotics and can have a new pacemaker replaced. You were also started on blood thinning medications called warfarin and IV heparin. You became therapeutic on wafarin on [8-9]. Dr. [Last Name (STitle) ] advised you to go rehab with your temporary pacemaker until surgical replacement of your pacer could occur after you finished the course of IV antibiotics. The reason for this is your heart rhythm is pacer dependent and if your pacer is disrupted, it could result in lifethreatening consequences. You declined discharge to long-term acute care and stated preference to be discharged to home. . We recommend that you get an abdominal CT scan to evaluate for possible abscess formation as an outpatient. Please schedule this through your PCP [Name Initial (PRE) 3726]. . The following changes were made to your medications: STARTED CeftriaXONE 2 gm IV Q24H Day 1 [2105-7-23] INCREASED Coumadin 12mg daily . Please follow up with your physicians at the appts states below: Followup Instructions: Department: CARDIAC SURGERY When: THURSDAY [2105-8-27] at 1:45 PM With: [Name6 (MD) ] [Name8 (MD) 6144], MD [Telephone/Fax (1) 170] Building: LM [Hospital Unit Name ] [Location (un) 551] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: CARDIAC SERVICES When: TUESDAY [2105-9-22] at 3:20 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Dr. [Last Name (STitle) ] wants pt to see device clinic 2 weeks post op according to [Doctor First Name ]( Dr.[Initials (NamePattern4) 1565] [Last Name (NamePattern4) ]) when she spoke to him. Department: INFECTIOUS DISEASE When: TUESDAY [2105-8-25] at 9:00 AM With: [Name6 (MD) 9462] FLASH, MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: TUESDAY [2105-9-8] at 10:30 AM With: [Name6 (MD) 9462] FLASH, MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Please follow up with your Cardiology Device Clini At [Hospital ] Hospital, call for appointment within 1 week of discharge. Call for appt: [Telephone/Fax (1) 83782] . INR checks on your warfarin medication: please check levels using your home INR machine. Follow up with your PCP who will titrate your medication appropriately.	[ "2724", "2859", "V4581", "V5861" ]
Admission Date: [2109-7-10] Discharge Date: [2109-7-23] Date of Birth: [2026-6-30] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: History of vomiting x 3 month Major Surgical or Invasive Procedure: [2109-7-16]: Classical Whipple with open cholecystectomy. History of Present Illness: This 83-year-old woman has been very healthy, but has developed anemia over the last few months. This has led ultimately to endoscopy which showed an ulcer in the duodenum which was treated with H. pylori. However, she has now developed gastric outlet obstruction, and she vomits semi digested food 3-4 times a week. Imaging suggested a mass in the pancreatic head region enveloping the outflow of the stomach at the duodenum as well. There was a high suspicion this was duodenal cancer. This looked entirely resectable by CT imaging. Past Medical History: PMH: HTN, hyperlipidemia PSH: Tosillectomy Social History: Tobacco-17 pack years, EtOH-4 drinks per week. Lives alone in FL during the [Doctor Last Name 6165]. Currently lives alone in [Location (un) ] Beach Family History: Father died of PNA, Mother died of Heart Failure. Pt denies any family history of cancer. Physical Exam: On Admission: PE:97.7/68/ 168/80 / 20/95% on RA Gen: Tan woman, not jaundice, AOx3, lying comfortably in bed, NGT in place from previous hospital Heart: RRR -m/b/g Lungs: CTAB Abdomen: nontender, nondistended, normal bowels sounds Extremities: WWP On Discharge: VS: GEN:NAD, A&OX3 CV:RRR, no m/r/r Lungs:CTAB ABD: +BS, appropriately tender around the surgical incision. Subcostal incision, steri-strips in place. Extr: warm, well perfused, no e/c/c Pertinent Results: [2109-7-11] 01:15AM BLOOD WBC-6.0 RBC-3.46* Hgb-9.6* Hct-30.2* MCV-87 MCH-27.9 MCHC-31.9 RDW-13.4 Plt Ct-206 [2109-7-11] 01:15AM BLOOD Glucose-100 UreaN-6 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-28 AnGap-12 [2109-7-11] 01:15AM BLOOD ALT-15 AST-21 LD(LDH)-188 AlkPhos-58 Amylase-37 TotBili-0.4 [2109-7-11] 01:15AM BLOOD Albumin-3.6 Calcium-8.8 Phos-2.3* Mg-1.6 [2109-7-20] 06:58AM BLOOD WBC-12.2* RBC-3.25* Hgb-9.3* Hct-28.3* MCV-87 MCH-28.5 MCHC-32.8 RDW-14.8 Plt Ct-330 [2109-7-20] 06:58AM BLOOD Glucose-107* UreaN-24* Creat-0.9 Na-141 K-4.3 Cl-108 HCO3-26 AnGap-11 [2109-7-20] 06:58AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.0 [2109-7-11] ABD CTA: IMPRESSION: 1. A 2.3 x 2.6-cm mass is present at the junction of the pancreatic head and its uncinate process. An adjacent pancreatic cystic lesion is noted, measuring approximately 1.1 x 1.9 cm. The former has direct mass effect on the adjacent duodenum. 2. The celiac trunk, superior mesenteric artery and its branches are patent. The portal vein, splenic and superior mesenteric veins are patent. 3. Prominent bilateral adrenal glands. 4. A hyperdense lesion located within the left liver lobe of the liver, most likely represents a hemangioma. Attention on followup study is advised. [2109-7-15] EKG: Sinus bradycardia with first degree A-V block. Left axis deviation. Intraventricular conduction defect. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 86889],[Known firstname ] O [2026-6-30] 83 Female [-9/3116] [Numeric Identifier 86890] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ]. SHABANI/cofc SPECIMEN SUBMITTED: gall bladder, JEJUNUM, WHIPPLE. Procedure date Tissue received Report Date Diagnosed by [2109-7-16] [2109-7-16] [2109-7-20] DR. [Last Name (STitle) ]. [Doctor Last Name ]/ttl DIAGNOSIS: I. Gallbladder: 1. Chronic cholecystitis. 2. One lymph node free of tumor (0/1). II. Jejunum: Segment of unremarkable small bowel. III. Pancreaticoduodenectomy specimen, Whipple procedure: 1. Adenocarcinoma of duodenum; see synoptic report. 2. Seventeen lymph nodes free of tumor (0/17). Small intestine: Polypectomy; Segmental Resection; Whipple procedure (Pancreaticoduodenectomy, partial or complete, with or without partial Gastrectomy Synopsis MACROSCOPIC Specimen Type: Whipple procedure. Tumor Site: Duodenum. Tumor configuration: Other (specify): Annular. Tumor Size Greatest dimension: 3.4 cm. Additional dimensions: 2.0 cm x 2.0 cm. Other organs Received: Jejunum, gallbladder. MICROSCOPIC Histologic Type: Adenocarcinoma (not otherwise characterized). Histologic Grade: G1: Well differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor invades through the muscularis propria into the subserosa of the nonperitonealized perimuscular tissue with extension of 2 cm or less; see comments. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 17. Number involved: 0. Distant metastasis: pMX: Cannot be assessed. Margins Proximal margin: Uninvolved by invasive carcinoma. Distal margin: Uninvolved by invasive carcinoma. Circumferential/radial (mesenteric or retroperitoneal) margin: Uninvolved by invasive carcinoma. Bile duct margin: Margin involved by invasive carcinoma. Pancreatic margin: Margin involved by invasive carcinoma. Distance of carcinoma from closest margin: 3 mm. Specified margin: Posterior retroperitoneal. Venous (Large vessel) invasion: Absent. Perineural invasion: Absent. Additional Pathologic Findings: None identified. Comments: The tumor invades pancreas but appears to invade less than 2 cm. Clinical: Pancreatic cancer. Brief Hospital Course: The patient was originally admitted for substernal fullness, vomiting on [2109-7-10]. Her workup led to a CT scan that showed two lesions in her pancreas (a 2.3 x 2.6-cm mass at the junction of the pancreatic head and its uncinate process; an adjacent pancreatic cystic lesion measuring approximately 1.1 x 1.9 cm with direct mass effect on the adjacent duodenum). The patient was admitted to the hospital and worked up for her pancreatic lesions. CT did not indicate any metastases. Her vomiting and fullness was attributed to gastric outlet obstruction from compression of the duodenum by one of the masses, and the patient was decompressed w/ an NG tube and scheduled for a Whipple procedure. On [2109-7-11] patient was started on TPN which she received until her scheduled procedure. On [7-16] the patient was taken to the OR for a Whipple procedure. This lasted approximately 9 hours and the patient tolerated the procedure without major complications. In order to achieve adequate margins, a pyloric sparing operation was unable to be performed. Please refer to the operative note for details. A #19 [Doctor Last Name 406] was left in [Location (un) ] pouch and the patient was taken to the PACU for further recovery. In the PACU the patient was noted to have low uop (5-10cc/hr) and respiratory depression. The patients UOP improved with resuscitation and her respiratory status improved on a Narcan drip. She was then transferred to the SICU for further management. In SICU patient's UOP improved with IV fluids, her creatinine became normal. Intermittent dilaudid and Fentanyl patch were d/c'd, patient received minimal dose of Dilaudid IV prn for pain control. The NGT was d/c'd. Patient was transferred to the floor in stable condition, NPO, on IV fluids, with a foley catheter and a JP drain in place, and intermittent dilaudid for pain control. The patient was hemodynamically stable. The rest of the [Hospital 228] hospital course was uneventful. Post-operative pain was initially well controlled with intermittent dilaudid, which was converted to oral pain medication when tolerating clear liquids. The foley catheter was discontinued at on POD#4. The patient subsequently voided without problems. The patient was started on sips of clears on POD#3, which was progressively advanced as tolerated to a regular diet by POD#6. JP amylase was sent in the evening of POD#5; the JP amylase was 146 and the JP drain was removed. During this hospitalization, the patient ambulated early and frequently with Physical Therapy assist, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly and insulin was administered when indicated. At the time of discharge on [2109-7-23], 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. Staples were removed, and steri-strips placed. The patient was discharged home. She received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Benicar 20mg daily (olmesaratn) cartia xt 240mg daily hctz 25mg daily simvastatin 20 mg qhs niacin 500mg daily Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:120 Tablet(s) Refills:2 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. 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 4. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 6. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours. 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: 1. Duodenal cancer. 2. Gastric outlet obstruction. 3. Acute renal failure 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 [4-22] 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 steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 1231] Date/Time:[2109-8-9] 10:15 [Hospital Ward Name 23] 3, [Hospital Ward Name ] Completed by:[2109-7-23]	[ "5849", "4019", "2724" ]
Admission Date: [2170-4-10] Discharge Date: Date of Birth: [2170-4-10] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname 66658] is the 2.44 kg product of a 36-week gestation born to a 24-year-old, G8, P2 now 3, mother. Prenatal screens: A+, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. This pregnancy was complicated by insulin-dependent gestational diabetes mellitus and oligohydramnios. On most recent assessment in ATU on [4-9], AFI was noted to be 5. Options for management were discussed by OB service with mother for twice weekly testing versus delivery, and mother chose delivery. Mother admitted in past on [2-21] for fetal decelerations and was made betamethasone complete at that time. Maternal past medical history significant for G6 PD deficiency, asthma, migraines and depression. Maternal past obstetric history notable for five SABs, primary c-section in [2161], and VBAC delivery in [2162]. Older child reportedly has cerebral palsy. No perinatal sepsis risk factors were identified. Scheduled repeat cesarean section. Intact membranes at time of delivery. GBS unknown. No maternal fetal or fetal tachycardia. Clear amniotic fluid. Infant emerged with good tone and color, however irregular respirations with apnea noted. Mother had received fentanyl prior to c-section, but infant's respiratory stauts gradually improved with stimulation. Otherwise, the infant was always with good color, tone and heart rate. Apgars were 8 and 9, and the infant admitted to the newborn intensive care unit for observation. PHYSICAL EXAMINATION ON ADMISSION: Weight was 2.44 kg, length was 47 cm, head circumference was 33.5 cm. EXAM ON DISCHARGE: A small, growing, near term infant, swaddled, pale pink, mildly jaundiced, well perfused in room air. Anterior fontanels open and flat, sutures approximated. Eyes clear. Nares parent. Chest clear, equal breath sound, comfortable. Cardiovascular with regular rate and rhythm, normal S1, split S2, no murmur, pulses 2+ equal. Abdomen: Soft, without hepatosplenomegaly, active bowel sounds. GU: Testes in scrotum. Extremities: Lean, moves all extremities. Neuro: Flexed posture, symmetric tone and reflexes. HISTORY OF HOSPITAL COURSE BY SYSTEM: RESPIRATORY: [Known lastname 4768] was admitted to the newborn intensive care unit and placed on nasal cannula oxygen for first 2-3 days of life. He subsequently weaned to room air, and has been stable in room air since that time. He did experience occasional desaturation episodes, primarily with feeding, that gradually resolved. By time of discharge, no desaturation spells had been noted for over 6 days. CARDIOVASCULAR: Infant remained hemodynamically stable throughout admission. FLUID AND ELECTROLYTES: Birth weight was 2.44 kg. Discharge weight is 2.695 kg. Infant was initially started on 60 cc/kg/day of D10W. Enteral feedings were initiated on day of life #2, and advanged to full feedings without difficulty. Enteral feedings were initially given PG, and gradually transitioned to PO. Infant is currently ad lib feeding Similac 24-calorie formula orally, taking in adequate amounts. GI: Infant received phototherapy for hyperbilirubinemia for approximately 2 days. Peak bilirubin was 10.9/0.4 on day of life 4. HEMATOLOGY: Hematocrit on admission was 53.8. His most recent hematocrit on [4-26] was 45.1 with a reticulocyte count of 1.6%. Of note, given maternal history of G6PD deficiency, testing at 4 months of age should be considered. INFECTIOUS DISEASE: CBC and blood culture obtained on admission. CBC was benign. Chest x-ray was concerning for pneumonia so the decision was made to treat for a total of 7 days. A lumbar puncture was performed which was within normal limits and ampicillin and gentamicin were discontinued at day of life #7. Infant presented on [4-25] with concerning exam, more lethargic than normal, requiring isolette to maintain temperature. Urine culture was obtained which was negative. CBC and blood culture were obtained and both were negative. He received 48-hours of vancomycin and gentamicin which were discontinued. Examination normalized. NEURO: Infant has been appropriate for gestational age. Sensory: Hearing scan was performed with automated auditory brainstem responses and the infant passed. PSYCHOSOCIAL: This family is known to the DSS system. Family lives in a homeless shelter. Over course of hospitalization, 51A applications were filed by shelter on behalf of the 8 yr-old sibling and by [Hospital1 18] on behalf of the newborn infant due to concerning behaviors of the parents while visiting. A court hearing was held at which DSS requested custody; custody was retained with the family, but parents were told that close monitoring by DSS would continue. DISCHARGE DISPOSITION: To parents' care. Name of primary pediatrician is Dr. [First Name4 (NamePattern1) 2411] [Last Name (NamePattern1) ], telephone number is ([Telephone/Fax (1) 72397]. FEEDS AT DISCHARGE: Continue ad lib feedings, Similac-24 calorie. MEDICATIONS: None. Car seat position screening was performed and the infant passed. State newborn screens have been sent per protocol and have been within normal limits. IMMUNIZATIONS: Infant received first hepatitis B vaccine on [2170-5-1]. DISCHARGE DIAGNOSES: Premature infant born at 36 weeks gestation, respiratory distress syndrome, infant of a diabetic mother, status post pneumonia, hyperbilirubinemia. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2170-5-1] 01:22:27 T: [2170-5-1] 09:16:12 Job#: [Job Number 72398]	[ "7742", "V290", "V053" ]
Admission Date: [2167-1-24] Discharge Date: [2167-1-27] Date of Birth: [2091-4-11] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2297] Chief Complaint: syncope, chills, nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: [2167-1-24] - Arterial line placement History of Present Illness: 75 yo M with metastatic gallbladder cancer on gemzar/cisplatinum (last dose [2167-1-16]), bladder cancer s/p cystectomy, recent admissions for partial SBO ([1-5] - [1-7]) and for biliary obstruction ([1-20] - [1-22]) now presenting with hypotension, nausea, vomiting. . The patient was admitted [Date range (1) 30498]/12 following ERCP, performed due to biliary obstruction. During the ERCP, diffuse ulceration was noted in the distal esophagus, at the GE junction, and in the body of the stomach. Cannulation of the biliary duct was initially difficult but was successful and deep after placement of a 5 mm x 5 FR pancreatic stent. A 12 mm long segment of severe narrowing was noted at the level of the hilum consistent with a stricture. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A WallFlex TM biliary RX uncovered 8 mm x 80 mm stent (REF: 7062, LOT: [Numeric Identifier 93920]) was placed successfully. The pancratic stent was removed after placement of the metal stent. . ERCP was complicated by nausea, vomiting, and elevated lipase. The patient was treated with bowel rest and IV fluids, and his diet was advanced prior to discharge on [2167-1-22]. Hospital course was also notable for new diagnosis of bilateral DVTs for which patient was started on lovenox treatment. . Yesterday, the patient developed weakness, nausea, and vomiting. He estimates that he had 10 episodes of non-bloody emesis. He also had some black diarrhea overnight last night. Then, at 3 a.m., the patient awoke with nausea and vomiting. He spent the next couple of hours sitting on a couch, during which time he experienced shaking chills and also syncopized for a couple of minutes. He regained consciousness and his family helped him to the toilet, at which point he had no BM had more syncope, and his family called EMS. When EMS arrived, initial BP was 70s/40s. . The patient also complains of cough and the sensation fo being unable to take a deep breath, which started during his recent admission. He has had hiccups for several weeks now, and has been taking baclofen twice daily for this. . In the ED, initial vitals signs were T 98.4 BP 73/37 HR 122 RR 16 Sat 93%. Exam was significant for AOx2, course breath sounds bilaterally. Patient was bolused with IVF. Labs were notable for WBC 6.9 (73N, 15bands), Hct 34 (27 at discharge), platelets 1000 (588 at discharge), Cr 1.4 (0.7 at discharge), ALT 16, AST 15, AP 675 (627 at discharge), Tbili 2.5 (2.2 at discharge), lactate 5.1, UA w 83 WBCs, positive nitrites, few bacteria. CXR demonstrated new L basilar infiltrate and bilateral pleural effusion. Patient was started on vanco/cefepime for presumed HCAP. LIJ was placed for fluid resuscitation. Patient remained hypotensive in SBP 80s, requiring initiation of levophed. ED course otherwise notable for patient reporting abdominal pain. CT abd/pelvis demonstrated known tumor, mildly distended stomach, with some fluid in the lower esophagus, could relate to partial gastric antral obstruction in the presence of symptoms. CT abd/pelvis also showed pleural effusion, ascites, improved left hydronephrosis. Repeat lactate returned 2.1. At time of transfer, patient had received 4L IVF and had a LIJ and two peripheral 18 gauge IVs. Vital signs on transfer were 98.5 HR119 BP85/50, RR34 98%3L. . On arrival to the ICU, the patient complained of heartburn and abdominal bloating. His nausea had resolved. He had the sensation of needing to defecate. However, he did not pass any stool. . Review of systems: No fever. +chills. +cough and dyspnea. No chest pain. +syncope. +abdominal discomfort and bloating, increased from baseline. Urine has been darker than usual. Has urinary ostomy. +hiccups. No rash. No focal weakness. +Chronic bilateral toe tingling L>R. No visual changes. Past Medical History: ONCOLOGY HISTORY - [2158] - cystoprostatectomy by Dr. [Last Name (STitle) 7391] revealed bladder TCC invading the lamina propria involving intravesicular portion of the left ureter - [2165] - resection for local recurrence. - [10/2166] - CT abdomen w hypodense liver lesion and mesenteric band-like nodularity in the right upper quadrant concerning for peritoneal carcinomatosis, pleural thickening along the ascending colon. - [11/2166] - colonoscopy w severe narrowing at the hepatic flexure [12-25] extrinsic compression, CT torso and MRCP demonstrated regular hypoenhancing mass centered within the gallbladder fossa and infiltrating portions of the right and left hepatic lobes, extending to hepatic flexure most c/w gallbladder cancer, also w loss of intervening fat plane between the extension of the tumor out of the liver and the hepatic flexure and duodenal bulb, intrahepatic bile duct dilation, extrinsic compression of the hepatic duct, and enhancing soft tissue nodules in the greater omentum consistent with peritoneal carcinomatosis. - [2166-12-30] - CT-guided liver biopsy carcinoma with clear cell features diffusely positive for cytokeratin cocktail and cytokeratin 7 and negative for Hep Par 1 packs 2 TTF-1, cytokeratin 20 and P63 most compatible with a tumor of biliary pancreatic or upper gastrointestinal origin - [2167-1-5] - KUB partial small-bowel obstruction - [2167-1-9] - Gemzar/cisplatin started - [2167-1-20] - Presentation w abd pain and elevated bilirubin, ERCP w 12mm long segment of severe narrowing, sphincterotomy and placement of WallFlex TM biliary RX uncovered stent . PAST MEDICAL HISTORY - Metastatic gallbladder cancer - Recurrent bladder CA s/p primary resection ([2159]), penile/urethral metastatsis resection ([2165]) - HTN - HLD - LVH w mild LVOT obstruction and mildly dilated thoracic aorta - h/o cystectomy - h/o resection penile recurrence Social History: Lives with wife in [Name (NI) 86]. Emigrated from [Country 532] remotely. Retired engineer. Quit tobacco 20+ years ago, 36 pack years. Denies EtOH, denies illicits. Family History: Father with bladder cancer. Mother with either CVA or MI. Physical Exam: ADMISSION EXAM: . General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, LIJ in place Lungs: Coarse breath sounds bilaterally CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended, diffusely tender, especially in RUQ, very quiet bowel sounds, +guarding in RUQ, urinary ostomy bag in place with yellow urine. Ext: warm, well perfused, 2+ pulses, 3+ bilateral lower extremity edema Neuro: CN II-XII intact. Moving all extremities . DISCHARGE EXAM: . Pertinent Results: ADMISSION LABS: . [2167-1-24] 07:30AM BLOOD WBC-6.9# RBC-5.02 Hgb-11.3* Hct-34.4* MCV-69* MCH-22.5* MCHC-32.8 RDW-17.1* Plt Ct-1000# [2167-1-24] 07:30AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-2+ Acantho-2+ Ellipto-2+ [2167-1-24] 07:30AM BLOOD PT-15.2 PTT-28.1 INR(PT)-1.4* [2167-1-24] 07:30AM BLOOD Glucose-110* UreaN-23* Creat-1.4* Na-136 K-4.1 Cl-97 HCO3-23 AnGap-20 [2167-1-24] 07:30AM BLOOD ALT-16 AST-15 AlkPhos-675* TotBili-2.5* [2167-1-24] 07:30AM BLOOD proBNP-1532* [2167-1-24] 07:30AM BLOOD cTropnT-<0.01 [2167-1-24] 12:44PM BLOOD CK-MB-1 cTropnT-<0.01 [2167-1-24] 05:17PM BLOOD CK-MB-1 cTropnT-<0.01 [2167-1-24] 07:30AM BLOOD Albumin-2.6* [2167-1-24] 07:49AM BLOOD Lactate-5.1* [2167-1-24] 01:05PM BLOOD freeCa-1.03* . MICROBIOLOGY: . [2167-1-24] Urine culture - pending [2167-1-24] Blood culture (x 2) - pending [2167-1-24] MRSA screen - pending . IMAGING STUDIES: . [2167-1-24] CHEST (PORTABLE AP) - Slight prominence of the hila, could be due to vascular engorgement. Bibasilar opacities could represent atelectasis, aspiration, or infection in the appropriate clinical setting. . [2167-1-24] CT ABD & PELVIS W/O CON - Moderate-sized right and a small left pleural effusion, with bibasilar compressive atelectasis. Patchy opacities in the left lower lobe, concerning for acute infection/aspiration. known infiltrating gallbladder fossa mass, allowing for differences in Technique is similar to the prior study. Infiltration of the gastric antrum and ascending colon, with resultant gastric outlet obstruction. Moderate-to-large volume ascites, consistent with worsening omental metastatic disease, which is suboptimally assessed in this non-contrast study. Additional hypodense liver lesion, likely cysts. Lack of air within the biliary stent and left lobe of liver suggests stent occlusion. Interval improvement in the previously noted left hydroureteronephrosis in this patient status post urinary diversion and ileal conduit. . [2167-1-24] DUPLEX DOPP ABD/PEL POR AND LIVER OR GALLBLADDER US - Please note, patient had difficulty remaining in left lateral decubitus after obtaining only sagittal images, at which point the decision was made to transfer to the right lateral decubitus position. After obtaining left-sided images, patient was able to again return to left lateral decubitus position, at which point the right-sided transverse images were acquired. The right kidney measures 11.5 cm. The left kidney measures 10 cm. There is no evidence of hydronephrosis, stones, or masses. Patient is status post urinary diversion and ileal conduit. No bladder assessment performed. Significant ascites idenitifed throughout the abdomen. Brief Hospital Course: IMPRESSION: 75M with PMH significant for metastatic gallbladder carcinoma, bladder carcinoma (s/p primary resection with ileal conduit formation), hypertension and hyperlipidemia with recent hospitalization for ERCP in the setting of biliary stricture with metal stent deployment complicated by post-procedural pancreatitis and evidence of DVTs who now presents with nausea, emesis and hypotension concerning for septic shock requiring pressor support with evolving pneumonia, acute renal insufficiency and hyperbilirubinemia. Given worsening clinical status despite aggressive resuscitation and pressors, patient was transitioned to comfort measures only and expired on [2167-1-27]. . # ACUTE HYPOXIC RESPIRATORY FAILURE - Following volume resuscitation needs given his septic shock, the patient developed worsening respiratory concerns and hypoxia with an increased oxygen requirement. His CXR imaging demonstrated marked pleural effusions. After discussion with the family, it was clarified that he would not want to be intubated, thus he was made comfortable on supportive oxygen. . # SHOCK - Presented with hypotension and evidence of volume depletion with leukocytosis and bandemia in the setting of metastatic gallbladder carcinoma, with acute renal insufficiency and hyperbilirubinemia. Shock appears distributive or vasodilatory in the setting of sepsis. Possible sources of infection include: biliary obstruction or stent obstruction with gram negative or anaerobic enteric seeding vs. aspiration pneumonitis (CT imaging showed LLL opacification) or pneumonia vs. urinary tract infection. Patient was empirically antibiosed with Vancomycin, Levofloxacin and Zosyn. Lactate 5.1 on admission, trending downward with IV fluid resuscitation. Following aggressive volume resuscitation, his hypotension and tachycardia improved and his pressor support was weaned. His serial lactate and central venous oxygen saturations improved with broad spectrum antibiotics - Vancomycin, Levofloxacin and Zosyn (started [2167-1-24]). ACS surgery had been consulted given his evidence of delayed emptying and possible gastric obstruction with known biliary obstruction and felt no surgical intervention was feasible. They recommended palliation with possible duodental stent placement in discussion with the gastroenterology team based on his imaging findings. His imaging showed evidence of gastric antral obstruction. Given his overall poor prognosis, the family opted to enagage comfort measures only and a Dilaudid infusion was started. . # NAUSEA, EMESIS AND GASTRIC OUTLET OBSTRUCTION - CT imaging revealed tumor that extends to the gastric antrum and hepatic flexure with mildly distended stomach and some fluid in the lower esophagus; possibly related to partial gastric antral obstruction vs. delayed transit and slow emptying given his nausea and bilious emesis concerns. NGT remains in place. Evidence of tumor causing obstruction without definable surgical options - would likely require palliative stenting. ERCP 2-days prior allowed passage of endoscope to the level of the duodenum for biliary stenting, now with evidence of on-going obstruction. ACS surgery had been consulted given his evidence of delayed emptying and possible gastric obstruction with known biliary obstruction and felt no surgical intervention was feasible. ERCP team was also notified. Given his overall poor prognosis, the family opted to enagage comfort measures only and a Dilaudid infusion was started. . # ACUTE RENAL INSUFFICIENCY - Patient presents with baseline creatinine of 0.7-0.9 now with admission creatinine of 1.4 in the setting of septic shock, hypotension and low urine output. This likely represents poor forward flow and hypoperfusion with pre-renal azotemia in the setting of vasodilation and sepsis physiology generating hypotension. ATN certainly could have developed in the this time frame. Following fluid resuscitation, his creatinine continued to worsen. . # ASCITES - Likely malignant in the setting of know gallbladder carcinoma with metastatic involvement. Now with septic shock picture in the setting of multiple sources of infection. His RUQ ultrasound showed concern for no pneumobilia with possble obstruction at the level of his biliary stent. . # METASTATIC GALLBLADDER CARCINOMA, BLADDER CANCER - Metastatic gallbladder carcinoma currently receiving Gemzar/Cisplatinum. Bladder carcinoma treated with primary resection and cystectomy with ileal conduit. His outpatient Oncologist was notified of the admission and discussed with the family the overall very poor prognosis. Comfort measures were employed following that discussion. . # DEEP VENOUS THROMBOSES - DVT in both posterior tibial veins on the right and one posterior tibial vein on the left in 2/29. Heparin gtt started this admission (switched from Lovenox given renal dysfunction). He was maintained on a heparin gtt until comfort measures were established. . # HYPERTENSION - Hypotensive in the setting of sepsis, as noted above. Holding Metoprolol, Verapamil, Lisinopril. . Medications on Admission: Medications (per recent discharge summary) - enoxaparin 70mg q12hrs - metoprolol succinate 50mg daily - verapamil 120mg Extended Release daily - docusate sodium 100mg [Hospital1 ] - senna [Hospital1 ] - polyethylene glycol daily - oxycodone 5mg q6hrs prn - omeprazole 20mg daily - lisinopril 20mg daily - baclofen 10mg [Hospital1 ] prn hiccups Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: septic shock and metastatic gallbladder cancer Discharge Condition: expired Discharge Instructions: patient expired on [2167-1-27]. Followup Instructions: none	[ "0389", "486", "51881", "78552", "5845", "5119", "5990", "4019", "2724", "99592" ]
Admission Date: [2171-2-1] Discharge Date: [2171-3-18] Date of Birth: [2111-5-11] Sex: M Service: MEDICINE Allergies: vancomycin / daptomycin Attending:[First Name3 (LF) 3963] Chief Complaint: cough, dyspnea, O2 requirement, tranaminitis Major Surgical or Invasive Procedure: liver biopsy History of Present Illness: Mr. [Known firstname ] [Known lastname 4580] is a 59 year old male with monoclonal gammopathy, severe oral lichen planus, recent GIST tumor s/p surgical resection [2170-12-27], possible neuromuscular disorder who presents with cough and fever X 3 days. . His symptoms began three days ago beginning with one day of low grade fever to 100.4, cough, and fatigue. He was noted to have increased O2 requirement and transaminitis and was referred to the ED. Patient has had no abdominal or GI symptoms. . Of note patient has had a long and complicated medical history beginning in [2169-8-20] when he suddenly lost his sense of taste after treatement of social anxiety with proproanolol. It was the start of a progressive course of oral lichen planus. Due to loss of taste, he last 20 lbs. He developed respiratory problems including a number of sinus infections in the summer of [2170] requiring treatmetn with antibitotics. Workup by his PCP [Name Initial (PRE) 7837] "abnormal immunoglobulin levles, further evaluated with bone marrow biopsy revealing MGUS. He began to develop rashes, and worsening of his oral lichen planus with mouth, pain and thrush. He had biopsies of his tongue confirming diagnosis lichen planus. Biopsy of plaques on the dorum of his knuckles were suggestive of Gottren's papules, making diagnosis concerning for dermatomyositis. Given patient had not had weakness consistent with this, it was suggested that he had a diagnosis of sine dermatomyositis. Later with subsequent biopsy, this diagnosis was challenged with systemic lichen planus. Furthermore, as dermatomyositis was raised, patient underwent an exhausive workup for malignancy including colonsocopy and endoscopy. A gastric mass was discovered, found to be a benign GIST tumor. Throughout these hospitalization, patient became malnourished as workup for his symptoms continued. He developed several pneumonia . During his most recent hospitalization for low grade temperature, cough, and hypoxia, he was found to have a possible aspiration and/or bronchiectasis/bronchiolitis with resultant transpulmonary shunt. Sputum cultures grew MSSA and pan-sensitive Pseudomonas. He was treated with a 10day course of cipro and cefazolin. At time of discharge he was satting in the low 90s on room air with ambulatory sats in the mid-90s on room air. A cause of his weakness has not been discovered. Neurology has recommended a voltage gated calcium channel antibiody [Hospital1 ] nicotinic receptor binding antibody which must be ordered as outpatient. Weakness was also thought to be the cuase of his aspiration risk and NIF of -40. It was unclear whether this was a neuromuscular process or rheumatologic condition. Decision was made to initiate treatment with steroids. Patient's breathing improved (NIF improved to -80). He was discharged on a prolonged steroid course. . Of note, skin biopsy recently showed overlap between lichen planus and connective tissue disorder (lichen planus with immune deposition). Serologic tests include: negative [Doctor First Name ], ANCA, anti-synthetase antibodies and normal CK. Inflammatory markers were markedly elevated. Sine dermatomyositis was suggested, but seems less likely based on his clinical course. . In the ED, initial vital signs were 98.7 102 101/60 22. He triggered for hypoxia 84% on RA. CXR from earlier in the day was clear. He was not given antibiotics. He was admitted for management of hypoxia. He was given 1L NS. Vital sings on tranfer were: 112/75, 101, 90% 4L nc. . On the floor, patient has no new complaints. Looking forward to returning home. Past Medical History: Bronchiolitis, Bronchiectasis Monoclonal gammopathy with balanced 2;21 translocation and 10% plasma cells in [2170-4-20] Clinical judgement of "amyopathic dermatomyositis" 4.2 cm gastric stromal tumor s/p endo-lap resection [2170-12-27] Biopsy proven Lichen planus with oral and peripheral lesions Shingles 5 years ago s/p hernia repair at age 16 ?Autoimmune hepatitis ([1-/2171]) Social History: Is a self-employed TV engineering consultant who builds TV studios. Remote tobacco - quit [2144]. Rare alcohol (a few glasses of wine per week prior to getting sick, none with his altered taste sensation). No illicits. Married for 20+ years and lives with wife who travels around the world doing preformance art. No children. + cat (indoor only). No other pets. Summers at family home in [State 1727] on the ocean. No known exposures/bites including ticks. Family History: Mother died of MI in her 70s. Father had emphysema and angina and died at 78. Had one older brother who died of [Name (NI) 8751] in college. Physical Exam: On admission: Vitals: 95.9 98/64 97 20 90% on 3L General: Alert, oriented, emaciated gentleman appearing older than stated age, no acute distress HEENT: Sclera anicteric, MMM, oropharynx with healing mucosal ulcerations. Neck: supple, JVP not elevated, no LAD, muscle atrophy noted. Lungs: Fair airmovement, with audible expiratory wheezes, forced expiratory wheeze elicits cough. 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:CN2/12 intact. Strenth [4-25] throguhout, overall weak to my assessment, lower extremity worse than upper. Gait narrow and steady, mentally clear and responds to questions appropriately. On dishcarge: Patient expired. Temperature 96.2, no heart or breath sounds on ascultation. Pertinent Results: [2171-2-1] 10:45AM BLOOD WBC-3.4* RBC-4.27* Hgb-12.8* Hct-36.9* MCV-86 MCH-30.0 MCHC-34.8 RDW-16.2* Plt Ct-204 [2171-2-1] 10:45AM BLOOD Neuts-72.4* Lymphs-16.6* Monos-10.3 Eos-0.4 Baso-0.3 [2171-2-1] 04:10PM BLOOD PT-11.4 PTT-30.7 INR(PT)-1.1 [2171-2-1] 04:10PM BLOOD Glucose-136* UreaN-18 Creat-0.5 Na-132* K-3.6 Cl-97 HCO3-24 AnGap-15 [2171-2-1] 10:45AM BLOOD ALT-602* AST-259* AlkPhos-185* TotBili-0.6 [2171-2-1] 04:10PM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0 [2171-2-1] 10:45AM BLOOD calTIBC-216* VitB12-1676* Folate-15.7 Ferritn-2285* TRF-166* [2171-2-2] 06:45AM BLOOD TSH-2.0 [2171-2-2] 06:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2171-2-2] 11:26AM BLOOD AMA-NEGATIVE [2171-2-2] 06:45AM BLOOD Smooth-NEGATIVE [2171-2-2] 06:45AM BLOOD [Doctor First Name ]-NEGATIVE [2171-2-2] 06:45AM BLOOD IgG-971 IgM-18* [2171-2-2] 06:45AM BLOOD tTG-IgA-3 [2171-2-1] 04:37PM BLOOD Lactate-2.5* [2171-2-5] 03:29PM BLOOD CERULOPLASMIN- 34 [2171-2-5] 03:29PM BLOOD ALPHA-1-ANTITRYPSIN- 244 [2171-2-2] 06:45AM BLOOD VARICELLA ZOSTER ANTIBODY, IGM- neg [2171-2-2] 06:45AM BLOOD HERPES SIMPLEX (HSV) 2, IGG- neg [2171-2-2] 06:45AM BLOOD HERPES SIMPLEX (HSV) 1, IGG- neg [2171-2-2] 06:45AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM- neg CXR: PA and lateral chest compared to [1-10] through [1-16], extent of peribronchial thickening and impaction of extensive bibasilar bronchiectasis may have increased slightly since the most recent prior lateral chest radiograph, [1-10]. There is really no change in the appearance of the frontal views as recently as [1-16]. Generalized hyperinflation is due to emphysema. Heart size is normal. There is no pulmonary edema, consolidation. A tiny right pleural effusion may be new, but probably not clinically significant. Findings would therefore be attributed to decompensation of emphysema and bronchiectasis. RUQ U/S: 1. Normal hepatic Doppler examination. 2. Sludge and likely polyps within the gallbladder. No pericholecystic fluid or wall thickening. CT Abd: 1. Bibasilar bronchiectasis with mucoid plugging of several bronchi. 2. Normal morphologic-looking liver with a single hamartoma in segment III of the liver. 3. Bilateral renal cysts. 4. Replaced right hepatic artery arising from the superior mesenteric artery. Liver Bx: Liver, needle core biopsy: 1.Marked peri-centrivenular, mild portal and periportal inflammation consisting of lymphocytes, plasma cells, neutrophils and macrophages with apoptotic hepatocytes and peri-centrivenular hepatocyte drop out (confirmed by reticulin stain). 2.Associated foci of central endothelialitis with peri-centrivenular hemorrhagic necrosis identified. 3.No significant steatosis seen. 4.Trichrome stain highlights central vein damage; no definitive increase in fibrosis identified. 5.Iron stain shows mild iron within predominantly peri-centrivenular hepatocytes. 6.[Country 7018] red stains are negative for amyloid, with satisfactory control. Note: The features are those of a marked active hepatitis with a predominantly centrivenular pattern of injury. The differential includes an immune-mediated drug effect and autoimmune hepatitis; viral hepatitis is less likely. Further correlation with clinical and serologic findings is needed. Given the patient's history of monoclonal gammopathy and the presence of rare binucleate plasma cells, the case will be further reviewed by hematopathology and their findings issued separately in an addendum. . Video Swallow: Penetration, but no gross aspiration, with thin and nectar thick liquids, similar to prior study. . Thyroid US [2171-2-27]: 11 mm spongy nodule in the left thyroid without worrisome features. , EKG [2171-3-4]: Sinus tachycardia with increase in rate as compared with previoui tracing of [2171-2-23]. Variation in precordial lead placement. Except for rate, the tracing remains normal without diagnostic interim change. . CTA [2171-3-4]: 1. No evidence for PE. 2. Improved nodular opacities in the right lower lobe consistent with resolving infection. 3. Unchanged bronchiectasis with bronchial wall thickening and mucous plugging in the lower lobes. . CXR [2171-3-6]: Heart size and mediastinum are unremarkable. Right lower lobe and left lower lobe bronchiectasis with bronchial wall thickening and endobronchial impaction overall appear unchanged since the prior examination with no evidence of interval progression of the infectious process. Note is made that the left costophrenic angle was not included in the field of view. There is no appreciable pleural effusion or pneumothorax. The Dobbhoff tube tip is in the stomach. Substantial hyperinflation is redemonstrated. . CXR [2171-3-11]: IMPRESSION: 1. Dobbhoff feeding tube is seen coursing below the diaphragm with the tip not completely identified but positioned within the stomach proximally. It does not appear to be significantly changed. Bilateral lower lobe bronchiectasis is stable. No focal airspace consolidation is seen to suggest an acute pneumonia. No pleural effusions or pneumothoraces. Overall, cardiac and mediastinal contours are unchanged. Lungs remain hyperinflated. . CXR [2171-3-13]: Bronchial wall thickening or peribronchial infiltration in the lower lungs where most pronounced bronchiectasis is have worsened since [3-11] consistent either with a flare of bronchiectasis or development of peribronchial pneumonia. Heart size is normal. There is no pleural effusion, no pneumothorax. Feeding tube ends in the upper stomach. CXR [2171-3-14]: As compared to the previous radiograph, there is no relevant change. Moderate-to-severe overinflation with known areas of bronchiectasis and perifocal parenchymal opacities. The opacities are unchanged in distribution and severity. Normal size of the cardiac silhouette. Normal hilar and mediastinal structures. No newly appeared focal parenchymal changes. . CXR [2171-3-17]: 1) Small left effusion with underlying collapse and/or consolidation. In the appropriate clinical setting, the differential would include a pneumonic infiltrate. Findings discussed with the covering house officer on the afternoon of the exam. Brief Hospital Course: BRIEF HOSPITAL COURSE This is a 59 year old gentleman with systemic disease of unclear etiology now with fever, cough, hypoxia, and transaminitis who eventually decompensated on [2171-3-16] with respiratory failure (multifactorial, pls see below) and was made CMO on [2171-3-17] and passed away on [2171-3-18]. . . # Hypoxia: Likely [2-21] known bibasilar bronchiectasis, initially. Sputum with moderate pan-sensitive pseudomonas. Was treated with suppression ciprofloxacin, aggressive chest PT, mucolytics, nebulizers (many of which were refused). Transitioned from albuterol to xopenex nebs b/c the former left the patient feeling too "jittery". Remained stable on 2L O2 with O2 sat in low 90s. Had a desaturation episode on [2-22] in the setting of a prolonged attempt at dobhoff placement. Repeat CT at that time suggested no abscess but RLL nodular densities concerning for spread of infx (aspergillosis or fungal) vs inflammatory nodules. His respiratory status remained stable with a 2L O2 requirment. He was started on atovaquone for PCP [Name Initial (PRE) ] (bactrim held given possible contribution to LFT elevations and pt did not tolerate daptomycin --> episode of flushing, tachycardia). Pulmonary deferred on bronch vs VATS to bx the peripheral nodule given the patient's strong preference and his aspiration risk. Pulm also suggested an acapella flutter device, [Doctor First Name ] nebs 3x/wk (started [3-2]), and blood testing for CF. On the afternoon of [3-4] the patient had a desaturation episode in the setting of a fever to 102F. A CXR at that time demonstrated a new RLL PNA. His antibiotics were broadened and he stayed overnight in the MICU before returning to the floor. He improved gradually and his O2 requirement remained stable 2-3L. On [3-13] a CXR performed in the setting of persistent tachycardia demonstrated a flare of his bronchiectasis vs a peri-bronchial PNA. He was broadened to cefepime and the [Doctor First Name ] nebs were d/c'd. . By [2171-3-16], Patient was having trouble clearing secretions, with known pseduomonas colonization of his sputum. Patient was kept on cefepime, with daily aggressive chest PT and frequent reminders to take guaifenisen for mucolytic therapy, as he has significant difficulty clearing secretions. On [2171-3-17], respiratory status worsened with tachypnea, venous blood gas showed increased CO2. CXR showed LLL opacification/collapse. Case discussed with the pulmonary fellow and [Hospital Unit Name 153] team. The pulmonary fellow discussed with the patient and his wife the code status and recommended against CPAP/intubation as futile measures. The patient became DNR/DNI. A morphine drip to titrate to confort was started, as discussed and agreed by the patient, his wife, the pulmonary fellow, attending Dr [Last Name (STitle) ] and [Hospital Unit Name 153] resident. Patient's antibiotics and every other med including IVIG and CSA were continued. Despite increasing doses of morphine drip, patient continued to exhibit tachypnea and patient was made CMO that evening. Patient received morphine bolus doses on top of drip and all other medications were held. Patient passed away on [2171-3-18] at 4:05pm. . # Lichen planus: Worst in mouth but also has diffuse skin lesions. Appreciate dermatology c/s who discussed case w/ multiple colleagues and has been incredibly helpful throughout his course. His multiple skin biopsies are consistent with an exuberant lichen-planus like eruption, which for the moment we are categorizing as severe generalized lichen planus. Our work up for paraneoplastic syndrome, namely the LP varient of PAMS, has thus far been negative: no Dsg1 or Dsg3 antibodies, and indirect immunoflouresence has been negative (although immunoflouresence on rat bladder is still pending - will be run by [Hospital1 ]). Meanwhile, the search for an underlying cause (i.e. malignancy) has been unrevealing. Flow cytometry from [2-21]: no features of leukemia. BM bx suggested possible mastocytosis, but derm felt that skin biopsies were less consistent with this possibility, and a tryptase was negative. Paraneoplastic pemphigus send-out returned negative. Arsenic negative. Based on a discussion between heme/onc and derm, the pt underwent a 4-day course of IVIG 0.5 g/kg/day (25g/day) under the premise that though this is not a treatment for lichen planus per se it might target the underlying pathology. He was maintained on IV steroids briefly but then switched back to po prednisone and is currently on a long taper. After extensive discussion involving GI and heme/onc (appreciate derm's continued input), commenced cyclosporine 25 mg [Hospital1 ] on [3-7] and then increased to 50 [Hospital1 ] on [3-10] and 100 [Hospital1 ] on [3-14]. Has tolerated well so far. The rest of his skin regimen includes clobetasol + plastic wrapping, mupirocin for his lower face and neck, and topical tacrolimus (mixed 1:1 with vaseline) for around his eyes. . # Bacteremia: Grew out MSSA from blood cultures 2/03 in the setting of persistent fevers. Received linezolid [Date range (1) 19593] and also daptomycin but had a rxn during infusion. Started on cefepime (narrowed to nafcillin on [2-28]), and was afebrile until [3-4]. Blood cx grew GPC in clusters until [2-26] (last positive cx [2-25]). ID narrowed to nafcillin [2-28]. ID followed, but signed off [3-1] (note: pt should f/u with [Doctor Last Name 13895] of ID w/in 2 wks of d/c; need to fax labs qweek to ID dept). Pt had poor quality TTE that did not reveal vegetations but a TEE was deferred given aspiration risk and pt preference. Daily surveillence cultures were obtaiend [Date range (1) 19594]. Cultures remained negative and patient was afebrile. On [3-13] an infectious workup for tachycardia yielded blood cultures that grew MRSA, and on [3-14] he was broadened to cefepime/linezolid. . # Nutrition/deconditioning: Pt's weight down to ~115 from pre-illness weight 170. Poor PO intake [2-21] mouth pain a/w eating (due to oral lichen planus). An oral video swallow previously showed no change from prior. An EMG was normal. Pt is adamant in refusal of G-tube and TPN. Dobhoff placed [2-25] with help of surgery. TF to 90/hr x 12 hrs (9PM-9AM) on [2-27] (~1620 cals); pt tolerating well. Nutrition followed the patient while in house. He required dexamethasone and gelclair along with viscous lidocaine for oral care. He is unable to tolerate a variety of foods (dry, salty, spicy, tangy, etc.). His wife provides high-calorie milkshakes. TF were switched from cycled initially to continuous and then back to cycled (the last change to stimulate the patient's appetite). . # Transaminitis: Pt had mild transaminitis since [Month (only) ] of [2170]. From the 30s to 50s. This increased in [Month (only) 1096] to 100s range, thought to be secondary to antibiotic effect. At time of his most recent discharge he was set up to have LFTs followed up after discontinuation of antibiotics to ensure resolution of transaminitis. In follow up appointment he was noted to have LFTs with ALT 627, AST 276, Alk Phos 198, TBili 0.5. He was admitted to the hospital for workup. Hepatology was consulted. Vital hepatitidies, CMV, EBV, VZV, HSV with negative serologies and/or viral loads. RUQ ultrasound unremarkable, as was CT abdomen. He underwent liver biopsy which was suggestive of drug induced immune reaction vs autoimmune hepatitis. He was continued on high dose prednisone throughout. Despite this, during his hosptialization, his LFTs continued to rise peaking in 1400s. The hepatology team also recommended further workup with antiLKM ab, serum VEGF levels to r/o POEMS, which were all unrevealing. He was continued on prednisone (40-60 mg daily) and started on azathioprine with continued worsening of his transaminitis. Ultimately azathioprine was discontinued after 10 days ([Date range (1) ]). Bactrim was also held given its potential contribution. His LFTs started to improve without clear precipitant. Interestingly his synthetic function was intact throughout this period of liver injury. His LFTs continued to decline, and he was briefly transitioned to IV methylprednisolone before being switched back to prednisone. By the first week of [Month (only) 956] his LFTs had more or less stabilized at ALT 200s, AST ~100, AlkPhos ~200. LFTs were followed periodically after this and they continued to decline toward normal range. . # Hyponatremia - Na was persistently low despite IVF with NS, withholding free water from tube feeds, etc. Urine lytes [3-2] indicate SIADH (UOsm 799). However, pt was without symptoms per se and strongly preferred that his IVF be maintained (due to perceived dryness/cracking in mouth that prevents him from sleeping). Following a switch in the patient's continuous tube feeds (namely a different formula with a reduced free water content), the hyponatremia resolved. . # Thyroid nodule: 1.1 cm thyroid nodule discovered incidentally on chest CT on [2-22]. Given a potential connection between the patient's presumed autoimmune disorder and underlying malignancy, it was thought that this nodule merited further workup. T4 and TSH nl. Thyroid U/S performed [2-27]; nodule not concerning; defer further w/u for now. . # Leukopenia: Has been present since last admission. WBC declined < 3K but climbed after conclusion of IVIG tx 5-6K (~[2-23] - [2-26]). Has been declining since. . # PLASMA CELL DYSCRASIA/MGUS: Patient has 10% plasma cells, negative skeletal survey, normal calcium and no renal insufficiency. He refused BMBX on [1-15]. Given other hemotologic abnormalities repeat bone marrow biopsy may be indicated. . # Blepharitis/severe dry eyes: Pt c/o dry eyes; must use artificial tears to keep eyes open. Ophthalmology consulted re possible ocular involvement of lichen planus and additional options for eye care. They suggested gel vs frequent artificial tears. Felt that no ocular involvement per se. . # Anxiety: History of severe anxiety/panic attacks at his prior admission. Social work following ([First Name8 (NamePattern2) 636] [Last Name (NamePattern1) 12471]); has been a source of incredible support for pt and wife. On low-dose xanax for anxiety and clonazepam for sleep. Medications on Admission: 1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic TID (3 times a day). 2. dexamethasone 0.5 mg/5 mL Elixir Sig: Five (5) ML PO Q4H (every 4 hours). 3. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 4. Systane Balance 0.6 % Drops Sig: One (1) Ophthalmic prn () as needed. 7. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day, decreased to 30mg on Tuesday, [2171-1-29] 11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. lorazepam 0.5 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as needed for insomnia 16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day 17. GELCLAIR Gel in Packet Sig: 15ml Mucous membrane three times a day. 18. B Complex-Vitamin B12 Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: none. patient expired. Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired resp failure likely [2-21] bronchiectasis, mucous plugging, deconditioning, muscle weakness, and atelectasis. Discharge Instructions: patient expired Followup Instructions: patient expired	[ "51881", "5180", "V1582", "2859" ]
Admission Date: [2146-3-7] Discharge Date: [2146-3-13] Date of Birth: [2075-3-19] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1505] Chief Complaint: aortic stenosis Major Surgical or Invasive Procedure: aortic valve replacement (21mm St. [Male First Name (un) 923] tissue)with Talon plating [2146-3-7] History of Present Illness: This is a 70 year old female with hypertension,hyperlipidemia, and known aortic stenosis with complaints of progressive dyspnea, lightheadedness, and rare chest discomfort. She was seen in clinic in late [Month (only) 404] for evaluation for aortic valve replacement and possible coronary artery bypass. Past Medical History: Severe Aortic stenosis Hypertension Hyperlipidemia Atrial Fibrillation Hypothyroidism Asthma History of GI Bleed - [2145-7-14] Social History: Lives with: her husband ans her daughter. Primary caregiver to husband. [Name (NI) 6419] daughters will be staying with her during her recovery. Tobacco: Denies ETOH: Social Family History: No premature coronary disease Physical Exam: Admission: Pulse: 80 Resp: 20 O2 sat: 97% B/P Right: 146/65 Left: 140/62 Height: 5'5" Weight:224 lbs General: Elderly female in no acute distress Skin: Dry [x] intact [x] HEENT: NCAT, PERRLA, EOMI, Anicteric sclera, OP and teeth benign Neck: Supple [x] Full ROM [x] Chest: Clear to ausculatation Heart: RRR [x] Irregular [] Murmur 4/6 SEM radiating to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Obese Extremities: Warm [x], well-perfused [x] Edema - trace Varicosities: None [x] Slight superficial spider varicosities noted. 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 - transmitted murmurs noted Pertinent Results: Echo [2146-3-7] PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is [1-15]+ TR. POSTBYPASS Biventricular systolic function is preserved. There is a well seated, well functioning bioprosthesis in the aortic position. No AI is visualized. The remaining study is unchanged from prebypass. [2146-3-12] 04:52AM BLOOD WBC-7.8 RBC-3.42* Hgb-9.3* Hct-29.4* MCV-86 MCH-27.2 MCHC-31.7 RDW-14.6 Plt Ct-198 [2146-3-7] 10:35AM BLOOD WBC-12.0# RBC-2.88# Hgb-8.5# Hct-25.3# MCV-88 MCH-29.6 MCHC-33.8 RDW-13.7 Plt Ct-177 [2146-3-12] 04:52AM BLOOD PT-12.3 PTT-25.8 INR(PT)-1.0 [2146-3-7] 10:35AM BLOOD PT-12.9 PTT-33.0 INR(PT)-1.1 [2146-3-12] 04:52AM BLOOD Glucose-94 UreaN-32* Creat-0.8 Na-141 K-4.0 Cl-101 HCO3-33* AnGap-11 [2146-3-7] 12:12PM BLOOD UreaN-29* Creat-0.6 Cl-110* HCO3-25 [Known lastname 39369],[Known firstname ] [Medical Record Number 39370] F 70 [2075-3-19] Radiology Report CHEST (PA & LAT) Study Date of [2146-3-12] 9:42 AM [Last Name (LF) ],[First Name3 (LF) ] R. CSURG FA6A [2146-3-12] 9:42 AM CHEST (PA & LAT) Clip # [Clip Number (Radiology) 39371] Reason: eval for effusion [Hospital 93] MEDICAL CONDITION: 70 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for effusion Preliminary Report Preliminary reports are not available for viewing. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Imaging Lab [Known lastname 39369],[Known firstname ] [Medical Record Number 39370] F 70 [2075-3-19] Radiology Report CHEST (PA & LAT) Study Date of [2146-3-12] 9:42 AM [Last Name (LF) ],[First Name3 (LF) ] R. CSURG FA6A [2146-3-12] 9:42 AM CHEST (PA & LAT) Clip # [Clip Number (Radiology) 39371] Reason: eval for effusion [Hospital 93] MEDICAL CONDITION: 70 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for effusion Final Report PA AND LATERAL CHEST ON [3-12] HISTORY: Evaluate effusion after AVR. IMPRESSION: PA and lateral chest compared to [3-9]: Moderate right pleural effusion and right basilar atelectasis have increased. Left lower lobe is well aerated, small left pleural effusion may be present. Mild postoperative enlargement of the cardiomediastinal silhouette is stable. No pneumothorax. Right jugular line tip projects over the superior cavoatrial junction. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: SAT [2146-3-12] 10:05 PM Imaging Lab [2146-3-12] 04:52AM BLOOD WBC-7.8 RBC-3.42* Hgb-9.3* Hct-29.4* MCV-86 MCH-27.2 MCHC-31.7 RDW-14.6 Plt Ct-198 [2146-3-7] 10:35AM BLOOD WBC-12.0# RBC-2.88# Hgb-8.5# Hct-25.3# MCV-88 MCH-29.6 MCHC-33.8 RDW-13.7 Plt Ct-177 [2146-3-12] 04:52AM BLOOD PT-12.3 PTT-25.8 INR(PT)-1.0 [2146-3-7] 10:35AM BLOOD PT-12.9 PTT-33.0 INR(PT)-1.1 [2146-3-12] 04:52AM BLOOD Glucose-94 UreaN-32* Creat-0.8 Na-141 K-4.0 Cl-101 HCO3-33* AnGap-11 [2146-3-8] 03:31AM BLOOD Glucose-112* UreaN-27* Creat-0.8 Na-138 K-4.7 Cl-106 HCO3-26 AnGap-11 Brief Hospital Course: The patient was admitted to the hospital and brought to the Operating Room on [2146-3-7] where she underwent aortic valve replacement with a 21mm St. [Male First Name (un) 923] tissue valve, along with Talon plating for closure. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition, intubated, requiring pressors to optimize her cardiac function. POD#1 she awoke neurologically intact and was extubated without difficulty. Pressors were weaned off. Beta-Blocker/Statin/aspirin/diuretics were initiated. All lines and drains were discontinued in a timely fashion. Her creatinine rose to 1.5 (from her baseline of 0.8) on POD 2. Diuretic doses were decreased and her creatnine function improved to her baseline. Postoperatively she experienced paroxysmal atrial fibrillation. She was started on anticoagulation with Coumadin for her arrhythmia. POD#3 she was transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation of strength and mobility. She continued to progress and was cleared for discharge to home on POD#6. INR/Coumadin dosing to be foloowed by Dr.[Last Name (STitle) ]. All follow up appointments were advised. Medications on Admission: Advair 2 puffs IH daily Albuterol PRN ASA 81mg po daily Detrol 5mg po TID HCTZ 25mg po daily Prilosec 20mg po daily Synthroid 88mcg po daily Zestril 40mg po daily MVI qd Vitamin C Calcium Vitamin D2 Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 7. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation twice a day. Disp:60 Disk with Device(s) Refills:2 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:qs Refills:0 10. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Outpatient Lab Work Serial PT/INR dx: atrial fibrillation goal INR 2-2.5 Results to Dr. [Last Name (STitle) ] [Telephone/Fax (1) 8539] 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: vna carenetwork Discharge Diagnosis: Severe Aortic stenosis, s/p aortic valve replacement [2146-3-7] Hypertension Hyperlipidemia Atrial Fibrillation Hypothyroidism Asthma/?COPD History of GI Bleed - [2145-7-14] Severe Aortic stenosis s/p aortic valve replacement Hypertension Hyperlipidemia paroxysnmal Atrial Fibrillation Hypothyroidism Asthma History of GI Bleed - [2145-7-14] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with 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] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) ] [2146-4-14] @ 1pm ([Telephone/Fax (1) 170]) Primary Care Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 8539]) in [1-15] weeks Cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3497] ([Telephone/Fax (1) 37180]) in [1-15] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2146-3-13**]	[ "4241", "5849", "9971", "4019", "2724", "42731", "2449", "2859" ]
Admission Date: [2129-2-10] Discharge Date: [2129-3-1] Date of Birth: [2055-7-14] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: Bradycardia, increasing lower extremity swelling and pain Major Surgical or Invasive Procedure: DC cardioversion History of Present Illness: 73 yo f w/ h/o pulm embolism ([8-9]), presumed diastolic CHF (last echo normal), gout X 3 years, who presented to OSH on [2129-2-10] with gradual increasing lower extremity edema, bilateral foot pain, and increasing doses of colchicine at home. At OSH, she had decreased UOP and HR noted to be 30-40 w/ response w/ atropine 0.5mg to 70s (unclear if symptomatic). At that time, the pt also had Hct 24 with guiaic positive stool, transfused 1 unit PRBCs, 1 unit FFP, and noted to be in renal failure with BUN/Cr 134/6.1. At this point she was transferred to [Hospital1 18]. . Here, the pt was noted to be afebrile, with abd pain, and received IVF with bicarb, and underwent abd CT, showing an abdominal aortic aneurysm, and right kidney hyperdense lesion, small effusion and atelectasis. Also, she was given vanco, levo, and flagyl for presumed ?intraabd source in the ED. Cards was consulted and felt that patient likely had sick sinus syndrome given sinus brady w/ junctional escape rhythm on her EKG. She was admitted to the ICU. In ICU, remained bradycardic and asymptomatic, normotensive. On am [2-12], immediately tachycardic to 130s, with EKG showing an irregular tachycardia, afib? w/ ST depressions in lateral leads and in leads I and aVL. Renal was consulted as well regarding her ARF, thought [1-6] to a combination of increasing doses of colchicine and indocin in the setting of her increasing lower extremity pain/edema. She was dialyzed [2-11] and [2-12], started on phosphate binders, epo on [2-14], and on [2-15], renal felt that her renal HD catheter could be pulled (had to be off heparin gtt for this). On [2-16], renal felt HD no longer needed. Spoke w/ cards consult, originally felt that patient should not receive nodal [Doctor Last Name 360] for rate control but subsequently started PO Dilt 90mg QID. As of today (day of transfer, she is hemodynamically stable with an intact BP and so immediate plan will be to d/c her lopressor/norvasc and have atropine at bedside, keep [Hospital1 ] pads in place. She was evaluated by EP for possible pacer placement for tachy/brady syndrome, however, EP would like pt to undergo DC cardioversion tomorrow in holding area prior to pacer plans. Pt is to be continued on heparin gtt in anticipation of cardioversion. . The pt states she feels well. She c/o chronic bilateral lower extremity pain with swelling (several weeks). No CP/SOB/palpitations. No N/V. Tolerating po well. No abd pain. Urinating ok. Not able to walk [1-6] "pins and needles" sensation in lower extremities when bearing weight. She states the pain is at the bottoms of the feet bilaterally, like "knives." No other complaints. Past Medical History: 1. Gout: has had for past three years - mostly in left foot, recently in bilateral feet, knees. 2. CHF - first diagnosed fall [2127] - echos reportedly "normal" 3. PE - diagnosed [8-/2128] has been on coumadin since. 4. Left carotid endarterectomy in [2122]. 5. H/O rheumatic heart disease as a child. Social History: Lives in [Location ] with granddaughter, has five children. Spent [Month (only) 956] in [State 108]. 4ppd for 30 years, quit 20 years ago. No EtOH, no illicit drugs. Family History: Positive for strokes in mother, father, brother, CAD in brother, son, Physical Exam: T 97.5 P 40s SR BP 111/69 RR 16 O2 sat 96% RA Genl: Sitting up in bed, speaking comfortably, mild distress. HEENT: Anicteric, MMM, OP clear. Neck: Supple, elevated JVD, no appreciable carotid bruits. Heart: Bradycardic, 2/6 SEM at LUSB. Lungs: Slight bibasilar crackles. Abd: Soft, hypoactive bowel sounds, non-distended, non-tender. Guaic positive in ED. Ext: [12-6]+ B LE edema extending [2-5] of the way up shins. Tenderness to palpation diffusely on her bilateral feet. No erythema or warmth of her bilateral feet or knees. Neuro: A&O x 3, CN 2-12 grossly intact . Pertinent Results: Imaging: CXR [2129-2-10]: Mild Cardiomegaly. Bibasilar atelectasis. No chf. . [2129-2-11]: Abd CT: 1. Small right-sided pleural effusion and right lower lobe atelectasis. 2. Small ascites. 3. Nonspecific stranding in the anterior and posterior right pararenal spaces. Correlation with patient's amylase and lipase is recommended. 4. 3.2 cm Abdominal Aortic Aneurysm. Follow-up recommended. 5. Right kidney small hyperdense lesion. Evaluation with US recommended. . RENAL US [2129-2-11] RENAL ULTRASOUND: The right kidney measures 8.3 cm. The left kidney measures 8.4 cm. There is no evidence of hydronephrosis, nephrolithiasis, or renal masses. There is bilateral cortical thinning. The urinary bladder is not visualized and the patient has a Foley catheter in place. IMPRESSION: No evidence of hydronephrosis, nephrolithiasis, or renal mass. . TTE: [2129-2-11]: EF >55% 1. The left atrium is moderately dilated. The right 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%). 3. The right ventricular cavity is mildly dilated. 4. The aortic valve leaflets are mildly thickened. 5. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 6. There is mild pulmonary artery systolic hypertension. . ECG: [2-10] 51, sinus brady w/ junctional escape in the 40s. No ST-T wave changes. . [2-12] 136, nl axis, afib, std in V4-V6, I/L Brief Hospital Course: ASSESSMENT: 73 yo f w/ diastolic CHF, gout, PE p/w bradycardia thought to be due to sick sinus syndrome, acute renal failure, gout flare, GI bleed. . 1. CV: Pump: The patient has known diastolic dysfxn with last TTE on [2129-2-11] demonstrating EF>55%. Although there was no comment on E/A ratio, clinically this would indicate impaired relaxation as pt was clinically in flash pulmonary edema in the setting of hypertension. The clinical finding of flash pulmonary edema was confirmed with a CXR. The pt received one episode of HD to remove fluid but has since been able to diurese successfully. She was started on afterload reducing agents including hydralazine and nitrates. As her creatinine was elevated, she was not able to be started on ACEI or [Last Name (un) ] at the time of this admission. Her Hydralazine was increased to 75mg Q6hours, and isorsorbide dinitrate was increased to 60mg TID. These medications were chosen over her previous outpt regimen which consisted of amlodipine (as this can cause side effect of fluid retention and LE edema) and metoprolol (discontinued due to episodes of bradycardia and concern for sick sinus syndrome). She was aggressively diuresed on lasix 80mg IV BID and achieved neg 1L per day. She was subsequently converted to a PO regimen which included lasix 80mg in AM and lasix 40mg in PM. The pt was followed by the renal service for her renal failure and fluid overload who oversaw our management. At acute rehab, the pt should be continued on diuresis with PO regimens consisting of lasix 80mg PO QAM and 40mg PO QPM. She should have daily weights and ins and outs monitored to document appropriate diuresis (goal of neg 500cc/day). In addition, her renal function should be followed closely (electrolytes three times a week) to observe for worsening renal failure. She should follow up with the [Hospital 18] [Hospital 10701] clinic in one to two weeks time to assess her renal function. . Rhythm: The pt was initially admitted with bradycardia. This may have been secondary to a sick sinus syndrome vs. beta blocker overdose in setting of acute on chronic renal failure. The EP service was contact and believe the latter to be the case. Therefore no plans were made for PM placement. Since cessation of BB, the pt was without episodes of bradycardia and her metoprolol was discontinued all together. In addition to her bradycardia, the pt also had an episode of Afib with RVR. The pt had episode of HR in the 150s on [2-12] with isolated elevated BP (up to 180s systolic) and some ischemic changes on EKG, the etiology of which was unclear. [Name2 (NI) ] TSH was wnl. She was started on esmolol and dilt drip on [2-12] for sx control and was transitioned to dilt drip alone on [2-13]. She was subsequently transitioned to po dilt [2-16] 90 mg QID then lopressor 37.5mg po bid and HR has been stable. Pt was cardioverted on [2-18], which was initially successful in keeping pt in NSR. However, pt reverted to AFib with RVR on [2129-2-22]. Patient responded well to dilt 10mg IV x 1 then 60mg PO QID with excellent rate control. EP was notified, and per EP recs, patient also started on amiodarone 400mg QD. As on amiodarone, pt's metoprolol was d/c'ed and the diltiazem was titrated back to 30mg QID. At time of discharge, the pt was on amiodarone 400mg once daily which should be reduced to a maintenance dose of 200mg once daily upon evaluation by EP. She was also on diltiazem 150mg QID. In addition, the pt was anticoagulated with coumadin 5mg QHS with goal INR of [1-7]. She should have routine INR checked and dose of her coumadin should be adjusted as necessary. She should follow up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] of the [Hospital1 18] cardiology division for further management of her atrial fibrillation. . 3. Acute renal failure: The pt initially presented with ARF. This was thought to be secondary to NSAID overuse and hypovolemia/hypoperfusion. Cr peaked at 6.8 at [Hospital1 18], then decreased to 2.9. However this subsequently increased again to mid 4s. The secondary elevation in creatinine was thought to be due to poor forward flow in decompensated CHF. She was initially requiring HD on [4-17], but has been off since. She was diuresed as above with good success without significant change in her creatinine. She should received close monitoring of her electrolytes with three times a week chem7. She should follow up with the [Hospital 18] [Hospital 10701] clinic to assess for further progression of her renal disease and necessity for possible HD in the future. . 4. ID: Pt spiked fever to 100.9 on [2-21]. Cultures from [2-21] (earlier) grew GPC in pairs and clusters, however, pt did not appear bacteremic clinically. U/A from [2-21] was however positive for a UTI. Therefore the pt was started on levofloxacin for tx of UTI. The pt was continued on levoflox 250mg Q48hours due to renal function. She should receive her last dose of levoflox on [2129-3-2]. The pt was clinically stable throughout the admission from an infectious standpoint. . 5. GIB: The pt was noted at OSH to have a Hct of 24 with guiaic positive stool, and was also noted to have G+ stools on admission here. This was thought to be secondary to NSAID gastritis. She received 1 unit pRBC at OSH and 3 units pRBC here on [2129-2-12] and [2129-2-13]. Hct has been stable since that time. Pt also on epo for renal failure briefly and may require epo again at the discretion of the renal staff. We recommend further work up this as an outpatient. . 6. Hx of PE: The pt had a PE dx'd in fall, [2127]. She was anticoagulated as an outpt. LENI were neg, for DVT. The pt was started on anticoagulation with heparin followed by coumadin for afib as above which would also ppx again further DVT/PE events. . 7. Gout: Patient had been taking increasing doses of colchicine prior to initial presentation, this was thought likely to be the cause of her acute on chronic renal failure and her GIB. Therefore her colchicine and NSAIDS were stopped on admission to hospital. . 8. AAA: The pt was noted to have a 3.2cm AAA on CT abd during hospital course. She will follow up as an outpt to monitor development of the AAA. . 9. FEN: Cardiac low salt diet, moniter and replete lytes carefully PRN. . 10. Ppx: The pt was continued on DVT ppx during this admission with either heparin sub Q, hep gtt or coumadin. In addition, the pt was continued on GI ppx with PPI and a bowel regimen. . 11. Communication: with pt, family, PCP is [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 38329] [Last Name (NamePattern1) 65736] in [Location (un) ] [Telephone/Fax (1) 10070]. . 12. Code status: FULL CODE Medications on Admission: Meds - does not know her meds exactly: 1. Norvasc 10 mg qd. 2. Lopressor 100 [Hospital1 ]. 3. HCTZ 25 qd. 4. Coumadin 5 during week, 2.5 on weekend. 5. Zocor 80 qd. 6. Lopid 600 [Hospital1 ]. 7. Colchicine. 8. Vicodin. (Augmentin several weeks ago for "cold/pharyngitis"). Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Albuterol Sulfate 0.083 % Solution Sig: [12-6] Inhalation Q4H (every 4 hours) as needed. 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Isosorbide Dinitrate 20 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 12. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Diltiazem HCl 60 mg Tablet Sig: 2.5 Tablets PO QID (4 times a day). 15. Epoetin Alfa 10,000 unit/mL Solution Sig: as per renal. Injection ASDIR (AS DIRECTED). 16. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 days. 17. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4 hours) as needed. 18. Lasix 80 mg Tablet Sig: One (1) Tablet PO qam. 19. Lasix 40 mg Tablet Sig: One (1) Tablet PO qpm. 20. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: 1. CHF 2. Atrial fibrillation with rapid ventricular response 3. Flash pulmonary edema 4. Acute on chronic renal failure 5. UTI Discharge Condition: Good Discharge Instructions: Please take all of your medications as prescribed. Several changes have been made in your medication regimen. Please follow up with all of your doctors. Please weigh yourself daily. If your weight is increased by more than 3lbs, please call your PCP to have your Furosemide (lasix) dose increased. In addition, you should have your labs checked three times a week to evaluate your kidney function (chem7) and your coumadin dose (INR). If you experience any chest pain, palpitations, shortness of breath, dyspnea on exertion, worsening swelling in your legs, fevers, chills, abdominal pain, nausea, vomiting, diarrhea, please call your PCP or come directly to the ED. Followup Instructions: Please follow up with your PCP within two weeks of discharge. Please follow up with Dr. [Last Name (STitle) ] of the Cardiology department within one month of discharge. His office can be reached by calling [Telephone/Fax (1) 2934]. Please follow up with the nephrology clinic within one to two weeks of discharge. An appointment can be scheduled by calling [Telephone/Fax (1) 60]. [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910**]	[ "5849", "4280", "42731", "40391", "2762", "2767", "5990" ]
Admission Date: [2118-6-17] Discharge Date: [2118-7-20] Date of Birth: [2063-10-21] Sex: M Service: OMED Allergies: Gluten / Betalactams / Vancomycin Hcl Attending:[First Name3 (LF) 7591] Chief Complaint: 54 year-old male with an enteropathy associated T-cell lymphoma, status post hyper CVAD therapy and 5 cycles of CHOP, and recently ICE chemotherapy and collection, being admitted for auto-BMT. Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy ([2118-7-12]) History of Present Illness: 54 year-old male with an enteropathy associated T-cell lymphoma diagnosed in [2115], with known gastric and jejunal ulcers and history of small bowel resection for microperforation, admitted for auto-BMT on [2118-6-17]. He was previously treated with hyper-CVAD (did not tolerate) and 5 cycles of CHOP. His course was complicated by a bout of hepatitis in [2118-4-19] which was felt to be chemical in etiology and led to weight loss, sprue exacerbation and relapse. Following his bout of hepatitis, Mr. [Known lastname 45745] was started back on TPN and has been doing well on it. He was recently teated with a cycle of ICE chemotherapy and collected in preparation for auto-BMT. His bone marrow performed at the beginning of [Month (only) ] revealed some minimal involvement with his T-cell lymphoma. His liver biopsy performed on [2118-4-28] revealed numerous apoptotic hepatocytes, multiple small foci of sinusoidal mononuclear inflammation and enlarged Kupffer cells consistent with acute hepatitis. No neoplastic cells. Tissue EGD performed on [2118-5-12] showed some involvement by enteropathy associated T-cell lymphoma in one biopsy section. Past Medical History: 1. Sprue: Diagnosis [9-20], which was refractory to gluten-free diet at which point prednisone therapy was initiated. Further investigation led to biopsy of small bowel and the diagnosis of T cell lymphoma was made. 2. T cell Lymphoma: As per HPI. 3. Transaminitis: From [Date range (1) 45746] (peak AST 198, ALT 247, alk phos 1062, negative HAV, HBV, HCV, HIV, CMV, toxo, VZV, HSV1, HSV2). Thought to be secondary to chemo and/or TPN. Liver bx revealed non-specific inflammation consistent with acute hepatitis. Social History: Mr. [Known lastname 45745] lives with his wife, a nurse. [First Name (Titles) ] [Last Name (Titles) 42866] 1 pack of cigarettes per day, denies alcohol or illicit drug use. Family History: Mother with breast cancer. His father died of an unknown cardiac event at the age 34. Mother, sister and grandmother have diabetes mellitus. Physical Exam: On admission: Temperature 97.9, HR 80, RR 20, BP 86-98/50-64. General: Cachectic man in NAD. HEENT: PERRLA. Clear oropharynx. NECK: JVP not elevated. CVS: RRR. Normal S1, S2. No murmur, rub or gallop. RESP: CTA bilaterally. ABD: Soft and non-tender. No hepatosplenomegaly. EXT: No cyanosis, clubbing or edema. 1+ dorsalis pedis pulses bilaterally, 2+ peripheral pulses otherwise. Neuro: CN II-XII intact. Strenght [3-23]. Reflexes 2+ throughout. Sensation intact. Pertinent Results: Pertinent laboratory results on admssion include WBC-9.3 (differential NEUTS-87, BANDS-0, LYMPHS-6, MONOS-6, EOS-0, BASOS-0, ATYPS-0, METAS-0, MYELOS-1), HGB-11.1, HCT-33.7, PLT COUNT-521. Chemistry reveals GLUCOSE-104 UREA N-14 CREAT-0.4* SODIUM-140 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-23. Mildly elevated alkaline phosphatase on admission at 124, transaminases within normal limits (ALT-9, AST-15, TOT BILI-0.1). Normal coagulation profile. Urinalysis negative [2118-5-31] CMV IgG and IgM negative Brief Hospital Course: His hospital course will be reviewed by problems: 1) Enteropathy-associated T-cell lymphoma: He received Ara-C and Etoposide (day -6 to -3) and melphalan (day -2) as part of the BEAM protocol, followed by a rest day. Reinfusion was done on [2118-6-24], which was well tolerated. His period of neutropenia extended from [2118-6-27] to [2118-7-7], at which time his ANC was back up to 2230. He had evidence of only mild oropharyngeal mucositis which was treated with Peridex and Nystatin. On [2118-7-15], Mr. [Known lastname 45745] had an acute transfusion reaction to platelets, with hypotension, diffuse dermal edema and periorbital edema, currently under investigation. He received Solumedrol IV and Pepcid IV with symptomatic relief. Premedication changed to Hydrocortisone 100 mg IV, Benadryl 50 mg IV, Pecid 20 mg IV, Tylenol 500-650 mg PO. 2) ID: Mr [Known lastname 45745] had an isolated temperature spike on [2118-6-21] (day -3), at which time he was started on Vancomycin and Levoquin (latter to be started as part of the protocol on [2118-6-22]). He quickly defervesced, but developed a diffuse maculopapular rash on [2118-6-23], at which time Vanco was D/C'd as it was felt to be a possible culprit. Cultures from that time were negative. He became febrile again on [2118-6-30], at which time Vanco and Cefepime were started, and Levoquin was discontinued. He remained persistently febrile and an antifungal was added, along with Flagyl for a history of diarrhea (eventually C. difficile negative). His rash persisted, and decision was taken to D/C Cefepime (query contribution to persistent rash) and start Aztreonam. Given worsening of the rash with periorbital edema and query contribution to the fever, along with possibility of drug fever, all antibiotics were stopped on [2118-7-6] and he received 1 dose of Solumedrol. He defervesced for 24 hours, then his temperature rose again. He was restarted on Flagyl and Levo on [2118-7-9]. Ambisome was added on [7-10] secondary to a finding of pulmonary nodules on CT scan, however pulmonary did not feel these were significant, and ambisome was d/c'ed on [7-16] since the patient was not neutopenic. His temperature reached a peak to 104.6 on [2118-7-10]. CT chest on [2118-7-10] revealed multiple small non-specific nodules, felt by pulmonary to be non-significant. CT abdomen and pelvis negative on [2118-7-10]. Aztreonam was added to the regimen on [7-11]. ID was consulted, and antibiotics were changed to Meropenem and Flagyl, and continue Acyclovir. Daptomycin was added on [2118-7-12] given persistent fever and desire to broaden gram positive coverage (Vancomycin was felt to be a potential culprit in the rash). All cultures negative thus far except for a single bottle positive for Corynebacterium on [2118-6-30] felt to be a contaminant. An MRI of the liver done on [2118-7-13] was negative for hepatic candidiasis. Stool cultures were negative. Repeat CMV negative. He defervesced on the above regimen. His last temperature spike was on [7-13]. On [7-18] meropenem and flagyl were discontinued, with no further fever spikes. He will be discharged on acyclovir, and nystatin swish and swallow. 3) GI: On [2118-7-8], Mr. [Known lastname 45745] had a Hct drop from 27 to 21 with frankly guaiac positive stools. The source was felt most likely to be upper GI. He was seen by GI, who was reluctant to perform a scope given the patient's low platelets and leukopenia, although ANC > 500. Decision was taken to treat conservatively, with blood product support. On [2118-7-11], his Hct dropped again from 29 to 21.8 with persistent melanotic stools and he was transferred to the ICU. An EGD was performed on [2118-7-12], which revealed ulceration in D3 consistent with an area of ulcerative duodenitis without active bleeding. The EGD was otherwise normal to D2. Pill endoscopy was considered but cancelled given a prior history of small bowel stricture. The bleeding was also not significant enought for a tagged RBC scan. He received a total of 6 units PRBCs in the ICU, and 4 units of platelets. He was transferred back to the floor on [2118-7-14]. His Hct has remained stable since transfer, without further melena. Protonix IV changed to PO BID on [2118-7-16], which he will be discharged on. 4) Rash: History as above in ID section. He developed a diffuse maculopapular rash on [2118-6-23], which changed to a diffuse blanching erythematous rash on [2118-7-6] and persisted. He also developped some periorbital edema on [2118-7-6] and received a dose of Solumedrol. Dermatology was consulted, with an impression of erythroderma. Levoquin, Cefepime and Vancomycin considered potential culprits and to be avoided. He was treated symptomatically with Triamcinolone, and the rash resolved. 5) FEN: Mr. [Known lastname 45745] was given TPN while he was here, in addition to being encouraged to eat. He will go home with TPN cycled over 10 hours at night, and encouraged to eat a gluten free diet. Discharge Medications: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 2. Nystatin Mucous membrane 3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home With Service Facility: [Last Name (un) 6438] Discharge Diagnosis: MALT s/p auto-SCT [2118-6-24]. UGI bleed Discharge Condition: Good, stable. Discharge Instructions: Return to the hospital to have your blood drawn tomorrow. Take all meds as directed. Return if you experience any rectal bleeding or black stools, shortness of breath, chest pain. Take your temperature everyday and call Dr. [Last Name (STitle) 410] if it's greater than 100.4. Continue your TPN for 10 hours every night. Followup Instructions: Return to the unit tomorrow [7-21] for repeat blood work and to be seen by Dr. [Last Name (STitle) 410].	[ "2875", "2851" ]
Admission Date: [2172-3-17] Discharge Date: [2172-3-24] Date of Birth: Sex: F Service: CARDIOTHOR HISTORY OF THE PRESENT ILLNESS: The patient is an 86-year-old female who was recently in an outside hospital one month prior for transient ischemic attack. The patient presented again to the local emergency room with nonspecific mental status change and chest pain. The patient was worked up at the outside hospital on CT scan, which showed type A aortic dissection and a pericardial effusion. The patient was then transferred to [Hospital1 69] for further workup and definitive care. Pain had been of right shoulder pain and right upper chest pain. She noted shortness of breath. Previously, the patient had been seen at [Hospital ] Hospital on [2172-1-17] after paresthesia and weakness. At that time there were no focal abnormalities found on the examination or the head CT and the patient was discharged home. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Depression. 3. Hypertension. PAST SURGICAL HISTORY: History is significant for status post total abdominal hysterectomy and status post right hip repair. MEDICATIONS ON ADMISSION: 1. Levoxyl 125 mcg p.o.q.d. 2. Depakote 250 mg p.o.q.a.m. and 500 mg q.p.m. 3. Zyprexa 10 mg p.o.q.d. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives with daughters, does not use alcohol or tobacco. PHYSICAL EXAMINATION: Examination revealed the following: The patient was alert and oriented times two. HEENT: Within normal limits. LUNGS: Lungs were clear. HEART: Distant sounds, but regular rate and rhythm. ABDOMEN: Obese, soft, nontender. EXTREMITIES: Edematous, 1+ with palpable distal pulses. LABORATORY DATA: Laboratory studies revealed the following: White count 9.0; hematocrit 33.8; platelet count 95, PT 14, PTT 42.7, INR 1.4, 1.4, sodium 139, potassium 5.2, chloride 109, bicarbonate 22, glucose 119, CPK 71. EKG: EKG was significant for sinus bradycardia with left shift, no evidence of active ischemia, Q waves in V1 and widened QRS. CT scan was from an outside hospital, which was significant for a type A aortic dissection, pericardial effusion. HOSPITAL COURSE: The patient, on the day of admission, was taken to the operating room, where she underwent replacement of ascending aorta and re-suspension of aortic valve. She tolerated the procedure well. She was transferred to the PACU with nitroglycerin and propofol drip. Postoperatively, she was A paced. She was placed on nitroglycerin and Nipride drip to keep the systolic blood pressure 100 to 110. She was transfused one unit of packed red blood cells for the hematocrit of 26. Two units FFP were infused. In the unit, the patient was reversed, although she remained unresponsive. All sedation was withheld. She did have some reflexive motor function intact. She was not following any verbal commands and the family stated that the patient is hard of hearing. The patient remained hemodynamically stable on postoperative day #1. Neurologically, she continued to remain somnolent, withdrawing extremities to pain only. The patient's blood pressure did go above goal rate. She was started on Hydralazine p.r.n. for better rate and blood pressure control. On postoperative day #2, the patient developed rapid atrial fibrillation with episodes of hypotension. She was started on Neo-Synephrine to be continued to maintain blood pressure between 100 to 110 systolic. She was bolused with Amiodarone. She converted to normal sinus rhythm only to revert back to rapid atrial fibrillation that same day. She was continued on the Amiodarone. She maintained her blood pressure. She reconverted back to sinus and Amiodarone was continued. On postoperative day #3, the patient was much more awake, following commands. She was alert and oriented to person, but not place or time. She was able to stand, but was very weak and deconditioned. There was no evidence of any laterality regarding to weakness. On postoperative day #5, the patient continued to remain stable both neurologically and hemodynamically. She was transferred to the floor for the remain of her recovery. The patient remained awake, alert, and oriented. Occasionally, the patient had mild confusion. Blood pressure has been well controlled. On postoperative day #6, the patient did have an episode of atrial fibrillation. She was given 5 mg of Lopressor IV, which reconverted her to sinus rhythm. She remained afebrile and hemodynamically stable. On postoperative day #7, the wires were discontinued, catheter was discontinued. She was seen by the Department of Physical Therapy who agreed with rehabilitation for the patient. She remained stable and not ready for discharge. DISCHARGE DIAGNOSIS: 1. Ascending aorta dissection type A, status post aortic arch replacement and re-suspension of aortic valve. 2. Postoperative atrial fibrillation. 3. Hypothyroidism. 4. Depression. 5. Hypertension. MEDICATIONS ON DISCHARGE: 1. Lopressor 12.5 mg p.o.b.i.d. 2. Lasix 40 mg p.o.t.i.d. 3. Potassium chloride 20 mEq p.o.b.i.d. 4. Colace 100 mg p.o.b.i.d. 5. EC ASA 325 mg p.o.q.d. 6. Protonix 40 mg p.o.q.d. 7. Zyprexa 10 mg p.o.q.d. 8. Amiodarone 400 mg p.o.t.i.d. until [2172-3-26]; then Amiodarone 400 mg p.o.b.i.d. from [2172-3-27] to [2172-4-2]; then Amiodarone 400 mg p.o.q.d. from [2172-4-3] onward. 9. Captopril 6.25 mg p.o.q.8h. 10. Levoxyl 125 mcg p.o.q.d. 11. Depakote 250 mg p.o.q.a.m.; Depakote 500 p.o.q.p.m. 12. Miconazole powder applied p.r.n. 13. Heparin 5000 units p.o. subcutaneously b.i.d. 14. Tylenol 650 mg p.o.q.4h.p.r.n. 15. Advil 400 mg p.o.q.6h.p.r.n. CONDITION ON DISCHARGE: Stable. FOLLOW-UP CARE: The patient will followup with Dr. [Last Name (STitle) 70] in six weeks. The patient will followup with the primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 40439] in approximately two weeks. The patient's ready for rehabilitation at this time. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 40440] Dictated By: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. MEDQUIST36 D: [2172-3-24] 15:08 T: [2172-3-24] 15:32 JOB#: [Job Number 40441]	[ "9971", "42731", "2449", "4019", "311" ]
Admission Date: [2191-6-3] Discharge Date: [2191-6-7] Date of Birth: [2129-8-12] Sex: M Service: MEDICINE Allergies: Tegretol / Dilantin / Penicillins / Sulfonamides / Bactrim Attending:[Last Name (NamePattern1) 1171] Chief Complaint: Seizure, CP Major Surgical or Invasive Procedure: Catheterization CT scan of head History of Present Illness: Pt is a 61 y/o male with IDDM, s/p CABG a few months ago; sz d/o on lamictal presented to ED after tonic-clonic sz at home; per wife has h/o hypoglycemic sz that result in post-sz hyperglycemia (EMS FS was 320, pt seemed post-ictal). Pt did not have BM or urinate during seizure, and did not have a "feeling of this seizure" happening, no strange smells/color changes. Pt was afebrile, missed single dose of lamictal last night. He related no CP/SOB assoc with sz, but developed CP while in ED; initial ECG on arrival was like prior but repeat ECG with T changes in lateral, I, aVF (lead placement not changed), no ST elevations. Pt explains CP as a non-radiating right sub-sternal pain, [2-21], that felt like an ice-cube resting on his chest. He had no SOB/diaphoresis/dizziness but did remember nausea. Pt received SL nitro, lopressor, ASA which relieved his symptoms in the ED. Pt was started on Hep, bolused with 600mg Plavix and admitted to the [Hospital1 1516] service. Past Medical History: -DM-1: for 47 years. Retinopathy but no neuropathy, nephropathy -CAD: 4 stents [2180], RCA stent [11/2189], 3v-cabg [9-/2190] -Seizures: Pt states related to low blood sugar, none in years -HTN Social History: 2 cigars per week (equivalent to a 25 py hx) but has stopped within the past year. EtOH 1 drink with dinner. Retired H.S. English teacher. Lives with wife. [Name (NI) ] 6x/week-about half mile at a time. Family History: Father: MI @40 Sister: MI @50 Physical Exam: vitals: 96.9, 122/56, 64, 18, 98%RA Gen- NAD, alert/conversational HEENT- No LAD, MMM, EOMI, no JVD, thyromegaly Cv- RRR, s1s2, 2/6 systolic murmur (AS?), no r/g Pul- CTA b/l Abd- NT/ND, no bruits L extrm- no edema, palpable pedal pulses neuro- AAO x3, CN 2-12 intact groin site: stable, no hematoma, no ozzing, no bruits Pertinent Results: EKG: changes wit ST depression in anterior leads, T wave inversions in inferior leads, T wave flattenings . Significant labs Trop (most recent first): .32, .40, .44, .74, .55, .12 . CATH [6-6]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent OM and LIMA grafts. Occluded RCA graft. COMMENTS: 1. Selective coronary angiography revealed a right dominant system with LMCA that had 70% lesion distally. The LAD was occluded after a large D1. The D1 had patent stents. The distal LAD filled from the LIMA but was a small diffusely diseased vessel. LCX had an 80% lesion in the proxinal vessel and there was an occluded OM that was grafted. Native RCA had a 60% lesion distal to the patent stents. Graft angiography showed occluded SVG to RCA. SVG to OM was patent but had 40% lesions at the valves. LIMA to LAD was patent. 2. Left ventriculography was deferred. 3. Hemodynamic assessment showed normal systemic pressures. . EEG [6-4]: IMPRESSION: This is a normal study in the awake and drowsy states. Thepresence of beta activity can be seen with the intercurrent use of benzodiazepines or barbiturates. . CXR [6-3]: The patient is status post midline sternotomy and CABG. The heart size is difficult to assess on an AP radiograph. There is plate-like atelectasis at the lung bases. There are linear opacities in the left paramediastinal region which may represent atelectatic changes or scarring. The lungs appear otherwise clear. No pulmonary edema is seen. IMPRESSION: No evidence of pneumonia or CHF. Plate-like atelectasis at both lung bases. Brief Hospital Course: CC: CP, hypoglycemic seizure Pt is a 61 y/o male with IDDM, s/p CABG a few months ago; sz d/o on lamictal presented to ED after tonic-clonic sz at home; per wife has h/o hypoglycemic sz that result in post-sz hyperglycemia (EMS FS was 320, pt seemed post-ictal. Pt received SL nitro, lopressor, ASA which relieved his symptoms in the ED. Pt was started on Hep, bolused with 600mg Plavix and admitted to the [Hospital1 1516] service. . Pt had trigger event around noon on [6-3] for pt becoming altered and for high BG-396, pt received 8 units of humalog. Pt had no CP, no SOB. Pt appeared pale, confused, and responded slowly to verbal commands. His vitals signs remained stable, but his BP did briefly drop to 106/48 but HR(72) and O2 sat(100%2L) were stable. Following this episode the pt did vomit, non-bloody x1. Antiemitic was given and pt was sent for CT of head to r/o intracranial bleeding, wet read no bleed. . Had additional trigger event at 17:18 found to be unresponsive to sternal rub. Pt had noticable foaming from the mouth, without tonic-clonic movement, VSS were stable. BG was 234. Pt has not received lamictal today, problem getting to floor, received Ativan. No changes with EKG, no CP/SOB. Pt remained hemodynamically stable throughout the event. An ABG was drawn and sent to the lab. Pt placed on seizure precautions. . Due to the questionable seizure and ABG lactate of 7.8 (later that night was 1.0), he was moved to the CCU for closer evaluation. His temp spiked to around 102 and a LP was done. He was started on vanco and Meropenem. The meropenem was later stopped due to possibility for causing convulsions. Pt was loaded with phenobarbitol 10mg/kg and lamicatl. After a night stay in the unit, pt was back on floor and much more awake and responsive. AFter 72 hours of no growth on the CSF, the vancomyocin was stopped. Pt recieved his cath on [6-6], showed three vessel disease with patent OM and LIMA grafts. He does have an occluded RCA graft. No stents or angioplasty was done. The plan was to d/c the pt and have him get a stress test(possibly MIBI) in [12-18] weeks to determine if further intervention is needed. Pt never experienced another bout of CP since the presentation in the ED. The pt is to follow up with Dr. [Last Name (STitle) ] where I will ask him to draw the trough labs of lamictal and have them sent/faxed to Dr. [Last Name (STitle) 851] at [Telephone/Fax (1) 891] who will also contact Dr. [Last Name (STitle) ]. Emails of this summary will be sent to Drs. [First Name (STitle) ], [Name5 (PTitle) ], and [Doctor Last Name ]. . CAD: continue with ASA, plavix, statin, B-Blocker, ACE-i stress test(MIBI)in [12-18] weeks . Neuro: pt taking lamictal 150mg [Hospital1 ] and phenobarbital 60mg [Hospital1 ] pt will f/u as outpatient, get troughs of both meds, when Lamictal is at 8-10ug/ml, can stop phenobarbital. . DM: The patient's last Hgb A1C 7.6 on [2191-2-21]. He was continued on glargine with a humalog sliding scale per his home regimen. Recommend following up at [Last Name (un) ] within the next few months . HTN: well controlled as inpatient Medications on Admission: Lantus 27 units AM Humalog SS Atorvastatin 20 mg PO DAILY Lamotrigine 150 mg PO BID Moexipril HCl 7.5 mg PO BID Metoprolol 12.5 mg PO BID Aspirin 325 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 4. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:qs Capsule, Sust. Release 24HR(s) Refills:2 6. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 7. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 8. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: CAD, seizures, DM1, HTN Discharge Condition: Stable Po tolerant ambulating Discharge Instructions: Please take all your medications as directed. Please do not lift more than 10 lbs for at least one week, also do not participate in strenous activity for at least one week. Please call your primary care physician or return to the ER for: 1. shortness of breath 2. chest pain 3. fever to 101 4. palpatations 5. increased swelling in your feet 6. Bleeding or oozing from your groin site. Followup Instructions: Dr. [Last Name (STitle) ] on [2191-6-16] at 11:40 Dr.[Name (NI) 10444] office will be contacting you for an appt. Please call Dr. [First Name (STitle) ]([Telephone/Fax (1) 108285] to be seen in [12-18] weeks Please call and make an appt with Dr. [Last Name (STitle) 978] Completed by:[2191-6-9]	[ "41071", "5180", "41401", "V4582" ]
Admission Date: [2189-11-30] Discharge Date: [2189-12-13] Date of Birth: [2107-10-22] Sex: F Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2569] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: Cardiac Catheterization intravenous and intra-arterial TPA intubation and subsequent extubation transfusion of 9 units packed red blood cells and 2 units FFP History of Present Illness: 82 year-old female with h/o takosubo cardiomyopathy, s/p cath @ [Hospital1 2025] in [2188-8-7] which showed apical ballooning, hypertension, hypercholesterolemia, who presented to [Location (un) ] with chest pressure. Patient reports she was in her usual state of health until pain started evening of [11-29] at 10pm. The pain awoke her from sleep and she had a difficult time falling back asleep secondary to chest discomfort. She also felt nauseous throughout the evening. In the morning, she called her daughter and came into the [Name (NI) ]. Patient denies any recent illness or unusual stressful events. . At OSH, EKG reveals ST elevation in V3 - V6. Labs were significant for troponin I of 4.24 -> 8.17. She also complainted of epigastric pressure and had one episode of nausea and vomited bileous x1. Zofran given x1 with relief. Echo done today and reviewed by Dr [Last Name (STitle) 11493], but report is unavailable. Prior EF was 40%. Now "decreased." As OSH, patient given plavix 300, ASA 325, and started on heparin gtt. Patient was transferred to [Hospital1 18] for cardiac catheterization given concern for STEMI. . Vitals on transfer were 110/51 71 sr with PVCs resp18-20 sat 97-98% on 2L nc, 0/10. . Patient went for cardiac catheterization, which revealed normal LMCA, 30 - 40% stenosis in proximal and mid-LAD, 30% stenosis on Left Cx, and 30% mid-RCA stenosis. She had a left ventriculogram showing apical ballooning with non infarct zone hyperkinesis. . On the floor, patient reports chest pain is currently resolved. She denies nausea, vomiting, diaphoresis, dyspena, orthpnea. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: CMP with takosubo, cath @ [Hospital1 2025] 3. OTHER PAST MEDICAL HISTORY: Hyperlipidemia Hypertension Social History: -Tobacco history: Quit smoking 20 year ago (smoked for 20 years prior to quitting) -ETOH: None -Illicit drugs: None Patient live alone, her daughter lives one mile away. Family History: non-contributory. Physical Exam: On Admission: VS: T=98.9 BP= 104/82 HR= 60 RR= 17 O2 sat= 94% on 2L GENERAL: Elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple, JVP not elevated. CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. PMI located in 5th intercostal space, midclavicular line. LUNGS: CTAB, no crackles, wheezes or rhonchi. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: Trace edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Prior to discharge: Neuro: Awake and alert, follows some simple commands inconsistently; Says 'yes' and 'ok'. Dense right sided hemiplegia triple flexion in right leg to noxious. Moves left purposefully with good power and antigravity. Pertinent Results: [2189-11-30] 11:37PM BLOOD WBC-11.0 RBC-4.88 Hgb-13.6 Hct-39.9 MCV-82 MCH-27.9 MCHC-34.1 RDW-13.2 Plt Ct-229 [2189-12-1] 06:55AM BLOOD WBC-10.2 RBC-4.68 Hgb-13.0 Hct-39.4 MCV-84 MCH-27.8 MCHC-33.0 RDW-13.2 Plt Ct-245 [2189-11-30] 11:37PM BLOOD PT-13.6* PTT-115.1* INR(PT)-1.2* [2189-12-1] 06:55AM BLOOD PT-13.0 PTT-46.2* INR(PT)-1.1 [2189-11-30] 11:37PM BLOOD Glucose-134* UreaN-15 Creat-0.8 Na-141 K-4.0 Cl-106 HCO3-25 AnGap-14 [2189-12-1] 06:55AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-142 K-4.5 Cl-106 HCO3-27 AnGap-14 [2189-11-30] 11:37PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.8 [2189-12-1] 06:55AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.8 . TTE [2189-12-1]: The left atrium is mildly dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) secondary to extensive, severe, circumferential apical hypokinesis with focal apical dyskinesis. The basal segments are hyperdynamic but left ventricular outflow tract obstruction is not present. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. 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. Significant pulmonic regurgitation is seen. There is no pericardial effusion. . TTE [2189-12-9]: The left atrium is normal in size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the diatl anterior wall, septal walll, and apex. The remaining segments contract normally (LVEF = 45-50 %). A left ventricular mass/thrombus cannot be excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is a mild resting left ventricular outflow tract obstruction from focal basal hyperkinesis. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are mildly thickened (?#). There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild regional left ventricular systolic dysfunction. Mild left ventricular outflow tract gradient from basal left ventricular hyperkinesis. Borderline pulmonary hypertension. Compared with the prior study (images reviewed) of [2189-12-1], left ventricular systolic function has improved. . Cardiac Catheterization [2189-11-30]: 1. Selective coronary angiography of this right dominant system demonstrated no angiographically-apparent flow - limiting stenoses. The LMCA was patent. The LAD had a 30-40% proximal and mid stenosis. The LCX had an origin 30% stenosis. The RCA had a mid 30% stenosis. 2. Limited resting hemodynamics showed mildly elevated left sided pressures with LVEDP of 24 mmHg. There was no aortic valve gradient seen on careful pullback from left ventricle to aorta. 3. Left ventriculography revealed apical ballooning with non infarct zone hyperkinesis. FINAL DIAGNOSIS: 1. Coronary arteries had no angiographically- apparent flow-limiting disease. 2. Mildly elevated left ventricular filling pressures. 3. Marked apical balloning - during ventriculogram. . CTA - CTP Head and Neck: [2189-12-1] IMPRESSION: 1. Complete occlusion of the right M1 segement with no gross evidence of the [Doctor Last Name 352] white matter differentiation representing an acute infarct. 2. Perfusion images demontrate a matching decrease blood volume, blood flow and increased mean transit time involving the entire right MCA territory. . CT Head: [2189-12-1] IMPRESSION: Continued evolution of the large left MCA territorial infarction, similar in distribution to the blood volume map from the CT perfusion study of 8 hours earlier on [2189-12-1]. No evidence of intracranial hemorrhage (within the limitation of the recent IV contrast administration) . CT Chest, Abd and Pelvis with and without contrast: [2189-12-2] IMPRESSION: 1. Active extravasation or pseudoaneurysm in the right iliacus muscle with substantial right thigh subcutaneous hemorrhage and edema. 2. Right femoral venous catheter coursing through the right superficial femoral artery. . R Lower Ext Duplex: IMPRESSION: Unremarkable right groin with no pseudoaneurysm identified. . CT Head [2189-12-4]: IMPRESSION: Cpntinued evolution of left MCA territory infarct. Punctate areas of hyperdensity within suggest petechial hemorrhage. There is diffuse sulcal effacement involving the left hemisphere and mild effacement of the left lateral ventricle, but only minimal rightward midline shift and no evidence of central brain herniation. . CT Head Noncontrast: [2189-12-5] IMPRESSION: Large left MCA infarct with mild mass effect. Previously seen foci of hyperdensity are present, but less conspicuous compared to yesterday with a new focus of increased hyperdensity; these may represent petechial hemorrhages or cortical tissue, which appears relatively hyperdense adjacent to edematous hypodense tissue. . CT Head [2189-12-6]: IMPRESSION: 1. Continued evolution of the left MCA territory infarct with punctate areas of hyperdensity consistent with petechial hemorrhage. Additionally, a new gyriform hyperdensity consistent with hemorrhage is noted within the left cerebral hemisphere (3, 26). There is minimal rightward shift and effacement of the left ventricle which appears slightly more prominent on today's study compared to [2189-12-5]. . CT Head [2189-12-8] IMPRESSION: No significant change in large left MCA infarct with hemorrhagic transformation. Brief Hospital Course: Primary Reason for Hospitalization: Ms. [Known lastname 91601] is an 82 yo F with hx takosubo cmp diagnosed by cath @ [Hospital1 2025] in [2188], who was transferred from OSH with EKG revealed ST elevation in precordial leads with elevated troponins. . # Cardiomyopathy with Basal Sparing: Patient had catheterization showing apical ballooning but no major CAD. This appearance is typical of stress induced cardiomyopathy but there was no clear stressor. This is the patient's second such episode with the first being [2188-8-7]. Per report from the patient's cardiologist, Dr. [Last Name (STitle) 11493], she apparently had a full recovery after that episode and she had a normal ejection fraction as of 3 months ago. It is unclear what has precipitated these two events. The patient denies any significant social stressors and she did not have any features of generalized anxiety disorder or other specific phobias. Nevertheless she should avoid highly stressful situations in the future and her PCP should monitor her for signs of depression or anxiety. She was started on coumadin 5mg daily with lovenox bridge to prevent thromboembolism from ventricular hypokinesis. She will have INR drawn by VNA on thursday [2189-12-3] and faxed to PCP's coumadin clinic. [Hospital 197] clinic will contact her with dose changes and further INR testing recommendations. To aid in cardiac remodeling she was started on metoprolol succinate 50mg daily. She will also continue her quinapril. Amlodipine was stopped to avoid hypotension although it may be able to be resumed in the future if pressures tolerate in case there is a component of coronary vasospasm. Unfortunately the patient fell while in the bathroom on [12-1] and a code stroke was called. Neurology ICU course: 82-year-old right-handed woman, presented with acute onset right hemiplegia, left gaze deviation and mutism on [12-1] following a fall in the bathroom during NSTEMI admission where cath showed recurrent Takotsubo cardiomyopathy (EF 35%) with apical balooning. A code stroke was called and on examination, she had dense right hemiparesis and mutism. She was treated with tPA with little response and was intervenened by interventional neuroradiology and intubated, transferred to the ICU. In the early hours of [12-2] she became markedly hypotensive with SBP 40s and was found to have significant bleeding into the right thigh on CT. She had severe hypotension for at least 20 minutes and required pressor support and required 9 units RBCs and 2 units FFP. Her bleed was felt likely due to her fall at onset of stroke symptoms. CT-abdomen showed active bleeding in the lateral aspect of the right thigh with associated hematoma centered in the right thigh with additional active bleeding into the right iliacus with expansion of the muscle. She also had evidence of a right venous access catheter which had passed into femoral vein through SFA. She was weaned from pressor and remained hemodynamically stable with HCt dropping likely felt due to redistribution. Interventional neuroradiology removed right catheter [12-3]. She had a persistent dense weakness on the right but more awake [12-3]. CT on [12-4] showed large L MCA infarct with slight hemorrhagic conversion and some effacement of the left lateral ventricle. After family meeting [12-4], patient was made DNR/DNI and extubated [12-4] with result of family meeting to not re-intubate. S/C heparin was restarted on [12-4] and aspirin initially held due to hemorrhagic transformation. The patient remained stable and was transferred to the Stroke step-down unit on [2189-12-5]. Stroke Step-down/Floor Hospital Course: The patient's neurological status remained stable and her head CTs showed no further bleeding. Despite an increasing alertness level, the patient was unable to pass swallow examination and a NGT was placed after discussion with family. The patient's neurological exam in that she was alert, however she had no purposeful language and inconsistently followed a few simple commands. She remained hemiplegic on the right side. Her swallowing ability did not improve after more than 1 week of NGT tube feeds. The patient had composed a very explicit living will that she would not want artificial feeding or fluids, nor any surgeries if she were in a state where she could no longer feed herself. Palliative care was consulted and met with the family (son and daughter) on [2189-12-11]. Her family decided to honor her living will and had the NGT removed to make the patient comfort measures only per her wishes. Medications on Admission: Aspirin 81 mg daily Lipitor 10 mg daily Caltrate 1200 mg PO daily MVI Accupril 40 mg daily Amlodipine 2.5 mg daily Vitamin D [2178] units daily Discharge Medications: 1. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4H (every 4 hours) as needed for pain/fever. 2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Five (5) mg PO Q30MIN (Every 30 minutes as needed) as needed for respiratory distress. 3. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q4H (every 4 hours) as needed for agitation. 4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed for air hunger. Discharge Disposition: Extended Care Facility: [Location (un) ] Nursing & Rehabilitation Center - [Location (un) ] Discharge Diagnosis: - Cardiomyopathy with Basal Sparing - acute ischemic infarction with hemorrhagic conversion - anemia - right thigh hematoma Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro: Awake and alert, follows some simple commands inconsistently; Says 'yes' and 'ok'. Dense right sided hemiplegia triple flexion in right leg to noxious. Moves left purposefully with good power and antigravity. Discharge Instructions: Mrs. [Known lastname 91601], you went to the hospital because you had chest pain. At the other hospital you had an EKG and blood tests that suggested you might be having a heart attack. You were transferred to [Hospital1 18] for cardiac catheterization. The catheterization showed that you did NOT have a heart attack, however you did have what is called "apical ballooning". This means that part of your heart is not beating as well. Unfortunately during your stay you had a stroke on the left side of your brain. You received a medicine, TPA, to try to dissolve clot causing the stroke but unfortunately you were still left with severe disability from the stroke. Then there was bleeding into your right thigh and leg, likely related to your fall at the time of the stroke, that required transfusion of several units of packed red blood cells. Given your living will clearly stated your preferences, your family agrees with us honoring your wishes to now focus your care on comfort measures only. Followup Instructions: none [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575]	[ "2859", "4019", "2720" ]
Admission Date: [2193-3-10] Discharge Date: [2193-3-28] Date of Birth: [2129-10-24] Sex: M Service: SURGERY Allergies: Levofloxacin Attending:[First Name3 (LF) 668] Chief Complaint: ?SBO Major Surgical or Invasive Procedure: [2193-3-11] exploratory laparotomy with total abdominal colectomy and end ileostomy [2193-3-14] percutaneous cholecystostomy tube placement History of Present Illness: 63M with h/o ESRD on PD, Diabetes, CAD s/p CABG, PVD s/p AKA presents with shortness of breath and hypotension to the Micu service [2193-3-10]. The history is ascertained through the patient's wife as patient is combative and uncooperative. Per the patient's wife he has not been feeling well x 1 week after URI. Poor appetite associated with hypoglycemia, fatigue and 1 episode of emesis Tues. +constipation requiring suppositories the past few days; last BM yesterday. Denies abdominal discomfort. He presented to the Ed today with chief complaint of SOB noted to be in respiratory distress .Heparinized in the ED for possible NSTEMI at the recs of cardiology. BP noted to drop from 90s to 70s. Upon arrival to Micu pt nauseous vomited x 1 bilious emesis. Unable to get CT Torso [3-5] pt refusal. Pt was given dose of azithro/zosyn and blood cultures drawn. Blood cultures and PD fluid sent for culture. PT was electively intubated during evaluation to facilitate CT scan. Pt received H1N1 vaccine. Past Medical History: 1. Type I DM-diagnosed at age 8, follwed by Dr. [Last Name (STitle) 10088] at [Last Name (un) ]; complicated by retinopathy, nephropathy, neuropathy 2. CAD s/p three vessel CABG in '[79], stent x2 to LMCA in 1/'[85], EF 45% ?MI- in [2184-7-2] 3. CRI/diabetic nephropathy-seen by Dr. [First Name (STitle) 805] (baseline Cr 6), now on PD (s/p catheter repositioning on [2192-4-30]) 4. PVD: s/p left AKA, right 4th toe amputated 5. s/p femoral-popliteal bypass in [2185] 6. Right eye vetreactomy after retinal hemorrhage 7. L eye laser surgery for retinopathy 8. Iron deficiency anemia 9. Urinary retetention Social History: Patient married with 2 kids. Ex-bartender, smoked between age [1-24] but quit since then smoked 2 ppd and quit 34 years ago, denies alochol or drugs. Family History: Father deceased in his 80's with CVA. Mother had HTN and valve replacement. [Name (NI) 1094] son with Type I DM. Physical Exam: On Admission: T:97.2 BP: 174/140 ( also drops to sbp 90s) HR: 134 RR: 25 O2 98% on CMV 100% 450 22 5 Gen: Pale appearing obese male agitated prior to intubation. HEENT:+ conjunctival pallor. No icterus. NECK: Supple, No LAD, No JVD. CV: RRR. nl S1, S2. No m/r/g LUNGS: Decreased BS throughout but clear, No W/R/C ABD: Distended tympanitic abdomen High pitched bowel sounds. No HSM No rebound or guarding EXT: s/p L AKA. right great toe with ulcer with surrounding erythema to DIP. No edema. SKIN: No rash NEURO: Agitated but answers some yes/no questions appropriately. CN 2-12 grossly intact. Pertinent Results: [2193-3-10] 05:15PM BLOOD WBC-13.9# RBC-3.32 Hgb-9.7* Hct-28.8* MCV-87 MCH-29.2 MCHC-33.6 RDW-16.7* Plt Ct-333 [2193-3-11] 08:03AM BLOOD WBC-23.6# RBC-3.23 Hgb-9.0* Hct-28.3* MCV-88 MCH-27.9 MCHC-31.8 RDW-16.3* Plt Ct-336 [2193-3-13] 02:38AM BLOOD WBC-19.1* RBC-3.05* Hgb-9.0* Hct-26.1* MCV-86 MCH-29.4 MCHC-34.3 RDW-16.3* Plt Ct-324 [2193-3-13] 03:43PM BLOOD WBC-18.8* RBC-3.21* Hgb-9.1* Hct-27.6* MCV-86 MCH-28.4 MCHC-33.0 RDW-16.4* Plt Ct-323 [2193-3-14] 02:52AM BLOOD WBC-23.2* RBC-3.26* Hgb-9.3* Hct-28.3* MCV-87 MCH-28.5 MCHC-32.8 RDW-16.6* Plt Ct-349 [2193-3-15] 04:03AM BLOOD WBC-26.6* RBC-3.19* Hgb-9.0* Hct-28.3* MCV-89 MCH-28.2 MCHC-31.8 RDW-16.6* Plt Ct-327 [2193-3-15] 08:39PM BLOOD WBC-33.5* RBC-3.13* Hgb-8.8* Hct-28.5* MCV-91 MCH-28.3 MCHC-31.1 RDW-16.8* Plt Ct-300 [2193-3-17] 03:59AM BLOOD WBC-28.8* RBC-2.89* Hgb-8.2* Hct-26.2* MCV-91 MCH-28.5 MCHC-31.3 RDW-17.8* Plt Ct-259 [2193-3-19] 05:03PM BLOOD WBC-24.1* RBC-2.83* Hgb-8.4* Hct-25.5* MCV-90 MCH-29.5 MCHC-32.8 RDW-18.3* Plt Ct-361 [2193-3-23] 02:01AM BLOOD WBC-15.3* RBC-3.18* Hgb-9.1* Hct-28.2* MCV-89 MCH-28.5 MCHC-32.2 RDW-18.1* Plt Ct-526* [2193-3-25] 07:40PM BLOOD WBC-12.9* RBC-2.84* Hgb-8.3* Hct-25.8* MCV-91 MCH-29.3 MCHC-32.3 RDW-17.7* Plt Ct-416 [2193-3-26] 04:53AM BLOOD WBC-12.3* RBC-2.83* Hgb-8.6* Hct-26.1* MCV-92 MCH-30.2 MCHC-32.8 RDW-17.6* Plt Ct-481* [2193-3-28] 09:37AM BLOOD WBC-17.3* RBC-2.78* Hgb-8.3* Hct-25.3* MCV-91 MCH-29.8 MCHC-32.7 RDW-17.4* Plt Ct-439 [2193-3-28] 05:00PM BLOOD WBC-18.4* RBC-2.79* Hgb-8.1* Hct-26.7* MCV-96 MCH-28.9 MCHC-30.2* RDW-17.1* [2193-3-10] 05:17PM BLOOD ALT-19 AST-57* LD(LDH)-523* CK(CPK)-294 AlkPhos-84 TotBili-0.2 [2193-3-13] 02:38AM BLOOD ALT-86* AST-256* CK(CPK)-4810* AlkPhos-152* TotBili-0.5 [2193-3-15] 04:03AM BLOOD ALT-90* AST-111* CK(CPK)-443* AlkPhos-258* TotBili-0.9 [2193-3-19] 03:31AM BLOOD ALT-43* AST-41* AlkPhos-235* TotBili-0.9 [2193-3-22] 04:00PM BLOOD ALT-38 AST-28 AlkPhos-231* TotBili-0.7 [2193-3-28] 05:00PM BLOOD ALT-22 AST-15 AlkPhos-160* TotBili-0.5 DirBili-0.3 IndBili-0.2 [2193-3-10] 05:17PM BLOOD CK-MB-22* MB Indx-7.5* cTropnT-1.57* proBNP-[Numeric Identifier 26403]* [2193-3-10] 11:46PM BLOOD CK-MB-24* MB Indx-9.5* cTropnT-1.54* [2193-3-11] 08:03AM BLOOD CK-MB-29* MB Indx-11.9* cTropnT-2.08* Brief Hospital Course: Mr. [Known lastname 26293] was admitted to the MICU service for a NSTEMI. A routine CT scan of his abdomen showed intra-abdominal free air but this was thought to be due to his recent PD catheter manipulation. Due to the unknown etiology of his condition it was decided to observe him over the next 1-2 hours. Two hours after his initial examination his pressor requirement increased. Due to the fact that we were not able to get an accurate abdominal examination, as he was intubated, we elected to take him to the operating room for an exploratory laparotomy. The rest of the hospital course will follow in the systems format. . Neurological: He remained sedated on the ventilator post-operatively. Once we were able to extubate he received prn doses of sedation as needed. He was confused initially post-extubation but this cleared as his condition improved. As he remained in the ICU for a number of days post-extubation he did develop multifactorial delerium. This was not believed to be due to infection as he was afebrile with a normal WBC count and negative culture data. All sedatives and narcotic pain medications were held. A head CT was obtained and this was normal. His room was changed to one that received sunshine and his delerium started to clear. . Cardiovascular: He was admitted with a diagnosis of NSTEMI. His cardiac enzymes were cycled and his CK-MB index peaked at 11.9%. Cardiology was consulted and they recommended continued medical management. His pressors were able to be weaned off. He did develop a-fib with rapid ventricular response requiring an amiodarone drip and digoxin. He was able to be transitioned to PO amiodarone with good rate control. He continued to have HR bursts up to 120-130 so lopressor was started with good effect. . Pulmonary: After extubation he continued to have volume overload due to IVF resuscitation. He did have small bilateral pleural effusions that improved with CVVH. The night before he expired he did develop tachypnea and increased oxygen requirement. A CXR obtained at that time showed pulmonary edema. CVVH was reinitiated and 1500cc removed with improvement in his respiratory status. The following morning he again became tachypneic with increased anxiety requiring reintubation. . Gastrointestinal: He underwent a total abdominal colectomy on [2193-3-11]. Final pathology was consistent with ischemia. Once he was stable hemodynamically and his ileostomy was functioning, tube feeds were started and advanced to goal. He passed a speech and swallow evaluation post-extubation and was started on a regular diet. His PO intake was no sufficient but he refused to have a feeding tube reinserted. Due persistent pressor requirements and a persistent leukocytosis he underwent a percutaneous cholecystostomy tube placement on [2193-3-14] due to concerns for cholecystitis. The percutaneous tube ultimately fell out on [2193-3-26]. His WBC did trend down but took a sharp upward trend and peaked at 36K. A CT scan of his abdomen showed no intra-abdominal pathology to explain the rise in WBC. He was started back on Flagyl for empiric C.diff treatment. . Genitourinary: A temporary HD catheter was placed in his right IJ. He underwent successful CVVH for a number of days. Once stable, he was started on HD and did not tolerate his first attempt. 900cc was removed and he became hypotensive requiring a small IVF bolus. A tunneled line placement was attempted by IR but the patient was too claustrophobic and uncooperative. When his pulmonary status worsened his line was replaced over a wire at the bedside in the ICU and CVVH reinitiated. The following day he was intubated and the line changed over a wire for a longer catheter. It was thought that he had line problems as they were too short and not reaching his right atrium. . FEN: He was started on TPN on POD3. Once he was stable hemodynamically with bowel function he was started on tube feeds. TPN continued once extubated as his PO intake was poor. . Hematological: He did received a total of 5units of RBC transfusions. His hematocrit remained stable at 26 and his last transfusion was on [2193-3-19]. . ID: He was initially placed on Vanc/Zosyn/Flagyl post-operatively. The Zosyn was changed to Meropenem. All blood, urine, C.diff, and sputum cultures remained negative on multiple occasions. He finished a 10 day course of empiric treatment. His WBC was initially 8 but then increased to a high of 23. It trended down to 18 but then took a sharp rise to 36. At this point a CT scan was obtained and it revealed no intra-abdominal pathology. The flagyl was discontinued but due to his elevated WBC it was resumed empirically. His WBC then trended down to 12. On POD3 he still had a pressor requirement and a leukocytosis so he receieved a percutaneous cholecystostomy tube. Bile cultured from this tube was negative for bacteria. . Endocrine: He is a diabetic and required an insulin drip due to hyperglycemia. This was able to be transitioned to sliding scale. . Skin: He developed a pressure ulcer on the posterior aspect of his neck from the device used to secure the ETT. Plastic surgery was consulted and they recommended enzymatic debridement. The ulcer was not infected. . Dispo: The patiented expired at 5:29pm on [2193-3-28] while in nuclear medicine receiving a HIDA scan. ACLS was initiated but unsuccessful. Medications on Admission: Nephrocaps 1 tablet daily Tessalon pearles TID prn Calcitriol - 0.5 mcg Capsule qd Plavix 75mg daily Guaifenasin w/codeine prn Epo 10,000U weekly Lasix 80mg [Hospital1 ] Neurontin 100mg TID Lisinoril 2.5mg 3x/week Toprol 150mg daily Nitro SL prn Sevelamer 800 mg Tablet - 3 Tablet w/ meals up to 10 a day. Simvastatin- 40 mg Tablet daily Flomax 0.4 mg daily Ascorbic acid 1,000 mg Tablet TIW Aspirin 81mg daily Colace 400mg qhs Ferrous Sulfate 325mg daily Regular insulin: 20 units three times a day adjust as needed blood sugar up to 6 times a day NPH Insulin-34U qam, 60-70Uqhs Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: NSTEMI Ischemic colitis End stage renal disease Cardiopulmonary Arrest Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A	[ "0389", "41071", "78552", "40391", "2762", "2761", "99592", "42731", "V4581", "V4582", "V5867" ]
Admission Date: [2162-9-30] Discharge Date: [2162-11-4] Date of Birth: [2162-9-30] Sex: M Service: Neonatology ADMISSION HISTORY: Baby boy [Known lastname ] is the 1795-gram product of 31 and [5-22]-week gestation (EDC [2162-11-27]) born to a 37-year-old G4/P1 to 2 mother with prenatal screens significant for blood type B positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative and GBS unknown. This pregnancy was complicated by previa which resolved. Mom was admitted approximately one week prior to delivery because of preterm labor. She was noted to have an abnormal fetal heart tracing at this time. Because of biophysical profile was [8-23] they decided to monitor until delivery. She was betamethasone complete during that admission. She was discharged home two days prior to delivery. She returned on the day of delivery for evaluation. She was again noted to have a biophysical profile of [8-23] but still with abnormal fetal heart tracing. The decision was made to deliver the infant. The infant was born by cesarean section. He was noted to have nuchal cord x 1. He had persistent cyanosis in the delivery room. His Apgar scores were 8 at one minute and 8 at five minutes. He was given blow-by O2 and taken to the NICU for further management. ADMISSION EXAM: IN GENERAL: This was an infant with respiratory distress. Weight of 1795 grams (which is the 75th percentile), length of 42.5 cm (which is the 75th percentile), head circumference of 28 cm (which is between the 25th and 50th percentile), temperature of 98.1, heart rate of 167, respiratory rate of 42 on CPAP, blood pressure of 64/37, with a mean of 47, room air saturation of 74%, oxygen saturation on CPAP of 96% HEENT: Normocephalic/atraumatic with an anterior fontanel that was open and flat. Red reflex was present bilaterally. Palate was intact, and neck was supple. LUNGS: Clear bilaterally with intercostal retractions and persistent grunting. CARDIOVASCULAR EXAM: Revealed a regular rate and rhythm no murmurs. Femoral pulses were 2+ bilaterally. Spine was midline with no sacral dimple. Anus was patent. Hips were stable. GENITOURINARY: Revealed normal premature male with testes undescended bilaterally. NEURO EXAM: Slightly decreased tone, but moved all extremities equally and normally. HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: Baby boy [Known lastname ] was intubated on the first day of life and received 1 dose of surfactant. He was then able to wean to CPAP and subsequently nasal cannula. He has been in room air since day of life #5 with no further respiratory distress. Baby boy [Known lastname ] had minimal issues with apnea of bradycardia of prematurity. He was never started on caffeine. He has remained without spells for greater than 1-week duration. 2. CARDIOVASCULAR: The patient was noted to have an intermittent murmur on day of life #3. The murmur was no longer heard by day of life #6. However, once again, he was noted to have a murmur more consistent by day of life #17. The patient had 4-extremity blood pressures which were normal. The patient also had a chest x-ray which was read as normal, and the patient had an EKG done which was preliminarily normal--to be reviewed by cardiologist (note: if there are any abnormalities, I will contact pediatrician directly with results). These were all done on day of life #34. 3. FEN: The patient initially was n.p.o. on IV fluids. On day of life #2 he was begun on feedings. These were slowly advanced over the course of the week. At the time of this dictation he was taking feeds ad lib on demand with a minimal of 120 cc/kg/day. He was taking these all by mouth. Feeds were of Enfamil 26. The patient's weight at the time of discharge was 2690g. A recent HC on [11-1] was 33 cm and L= 48cm. 4. GI: The patient was started on phototherapy on day of life #3 for hyperbilirubinemia. He remained on phototherapy until day of life #6 when it was discontinued. He has had no further issues with hyperbilirubinemia. 5. ID: The patient was started on ampicillin and gentamicin at time of delivery given preterm labor. A CBC was obtained which was benign. A blood culture was obtained which was no growth; and therefore antibiotics were discontinued after 48 hours. The patient has had no further infectious disease issues. 6. HEME: The patient did not require a blood transfusion during his course. He is on iron therapy. Most recent hematocrit was on day of life #24 which was 28.3 with a reticulocyte count of 2.7. 7. NEURO: The patient did have a head ultrasound on day of life #8 which was read as within normal limits. He had a repeat head ultrasound on day of life #34, at which time his corrected gestational age was 36 and 4/7 weeks. This head ultrasound was also read as normal. 8. SENSORY: Most recent eye exam was on [2162-10-16], which was day of life #16. At that time his eyes were read as immature zone 3 with a plan for follow-up in 3 weeks' time. 9. AUDIOLOGY: The patient passed the hearing screen. 10. Newborn state screening on [10-22] with in normal. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY CARE PEDIATRICIAN: Dr.[Last Name (STitle) 40505] at Pediatric Health Associates CARE RECOMMENDATIONS: 1. Feeds at discharge: Enfamil 26 calories per ounce made by 4 cal/oz of Enfamil and 2 cal/oz of corn oil. 2. Medications: Ferinsol: 0.25 cc po q day 3. Car seat positioning passed. 4. Monitor murmur--most probably peripheral pulmonic stenosis or due to anemia of prematurity. if change in quality or infant becomes symptomatic, would recommend cardiology consultation IMMUNIZATIONS RECEIVED: The patient did receive hepatitis B vaccine on [2162-11-2]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who are born at less than 32 weeks. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life) immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW-UP APPOINTMENTS RECOMMENDED: 1. Primary care pediatrician within the first 2 to 3 days after discharge. 2. Ophthalmology is recommended 1 week after discharge. 3. Early intervention referral was made. 4. VNA this week. DISCHARGE DIAGNOSES: 1. Prematurity at 31 and 5/7 weeks. 2. Rule out sepsis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 56662] Dictated By:[Last Name (NamePattern1) 58671] MEDQUIST36 D: [2162-11-3] 15:41:16 T: [2162-11-3] 16:55:14 Job#: [Job Number 62527]	[ "7742", "V053", "V290" ]
Admission Date: [2111-5-14] Discharge Date: [2111-5-28] Date of Birth: [2047-3-13] Sex: M Service: NEUROLOGY Allergies: Plavix / Dofetilide Attending:[First Name3 (LF) 21193] Chief Complaint: CC:[CC Contact Info 110287] Major Surgical or Invasive Procedure: none History of Present Illness: HPI:asked to eval this 64 year old white male with extensive PMH on coumadin for SDH. Pt states he hit his head on a low ceiling 2 days ago. Denies LOC at that time or since. Denies N/V, seizure, visula changes. Today he noted that his speech was slurred so he drove himself to his PCP's office. Was brought in by ambulance from PCP [Name Initial (PRE) 3726]. CT scan shows right sided SDH with interhemispheric component. Past Medical History: 1. CAD: s/p CABG in [2098] (LIMA to LAD, SVG to OM1, SVG to PDA) -[2109] echo: EF 20%, MR [First Name (Titles) ] [Last Name (Titles) ] -[12-11] stress: negative, though stopped [1-9] fatigue -[12/2102] cath: stenting of the proximal SVG-RCA lesion, angio-jet thrombectomy of the thrombotic occlusion SVG-OM graft, stenting of the mid-graft and ostial graft SVG-OM lesions -[10/2102] cath: done for recurrent angina showed severe native vessel disease, a patent LIMA with a 40% stenosis in the LAD distal to the touchdown, a proximal 50% stenosis in the SVG to RCA, and a mid 50% stenosis in the SVG to the OM branch. -[2098]: Coronary artery bypass graft x 3,including one arterial and two saphenous vein anastomoses, left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to first obtuse marginal, saphenous vein graft to posterior descending coronary artery. 2. type II diabetes mellitus. 3. Hypertension. 4. Hypercholesterolemia 5. CRI 6. BiV [Year (4 digits) 3941] placed in [12-11] for low EF, generator changed (DDD 45-120) on [2110-2-7] 7. Enterococcal bacteremia- admitted [4-12] 8. Afib- started on Coumadin [2-11]. Social History: Denies smoking and drinking. He works as a cab driver. Lives alone. There is no history of alcohol abuse. Family History: Father died at 59 years with diabetic complications. Mother died at 77 years. She had a coronary artery bypass graft in her mid 50s. Brother had a coronary artery bypass graft at the age of 53. Physical Exam: PHYSICAL EXAM: O: T:afebrile BP:116 / 68 HR: 74 R 18 O2Sats95% Gen: WD/WN, comfortable, NAD. HEENT: NCAT Pupils: ERRL EOMI Extrem: venous stasis changes to lower extremeties. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech slurred with good comprehension and repetition. Naming intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: right facial noted (slight), sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius difficult to assess/ (pt s/p sz at present and attempting to participate. XII: Tongue slight left deviation Motor: Normal bulk and tone bilaterally. Strength full power [3-12] throughout (?participartion). ? left pronator drift Toes downgoing bilaterally no clonus Pertinent Results: RADIOLOGY Final Report CT HEAD W/O CONTRAST [2111-5-14] 10:22 PM CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN Reason: S/P 2 SEIZURES, KNOWN SDH. ? EXPANSION. [Hospital 93] MEDICAL CONDITION: 64 year old man with SDH, now s/p 2 seizures REASON FOR THIS EXAMINATION: eval for expansion CONTRAINDICATIONS for IV CONTRAST: None. STUDY: CT head without contrast. INDICATION: 64-year-old male with subdural hematoma status post two seizures, evaluate for expansion. COMPARISON: [5-14], two hours prior. TECHNIQUE: CT head without IV contrast. FINDINGS: Again noted is a hyperattenuating collection along the right cerebral convexity and layering adjacent to the right side of the falx cerebri and tentorium cerebelli, consistent with an acute subdural hematoma. There has been no appreciable increase in mass effect from this collection. The major intracranial cisterns are preserved and there is no evidence of transtentorial or uncal herniation. There is no hydrocephalus or evidence of intraventricular extension of blood products. Again noted is opacification of the right maxillary sinus. There is some hyperdensity of the central components in this sinus- inspissated secretions or hemorrhage could both be considered. IMPRESSION: No significant increase in acute subdural hematoma or mass effect. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name 4391] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9987] Approved: FRI [2111-5-15] 9:26 AM RADIOLOGY Final Report CT HEAD W/O CONTRAST [2111-5-19] 10:14 AM CT HEAD W/O CONTRAST Reason: change in mental status, decreased L sided movement [Hospital 93] MEDICAL CONDITION: 64 year old man with REASON FOR THIS EXAMINATION: change in mental status, decreased L sided movement CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 64-year-old man with change in mental status and decreased left-sided movement. TECHNIQUE: Non-contrast head CT scan. COMPARISON STUDY: Numerous prior head CT scans, the last having been obtained on [5-17]. FINDINGS: There is continued demonstration of the longitudinally extensive acute subdural hemorrhage covering the right cerebral convexity surface, with a subtentorial component as well as a parafalcine component. Overall, there seems little progression in extent of the subdural hemorrhage. There is minor compression of the right lateral ventricular body, not overtly changed compared to the prior examination. There is no definite subfalcine or uncal herniation noted at this time. There is continued near complete opacification of the right maxillary sinus. No other new extracranial abnormality discerned. CONCLUSION: Stable but very extensive right cerebral hemispheric acute subdural hemorrhage as noted above. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9987] Approved: TUE [2111-5-19] 4:32 PM RADIOLOGY Final Report CHEST (PORTABLE AP) [2111-5-18] 12:52 PM CHEST (PORTABLE AP) Reason: s/p change of ETT. confirm placement [Hospital 93] MEDICAL CONDITION: 64 year old man with SDH, intubated for decreased mental status. NGT replaced REASON FOR THIS EXAMINATION: s/p change of ETT. confirm placement INDICATION: Endotracheal tube placement for decreased mental status. CHEST, ONE VIEW: Comparison with [2111-5-16], among multiple previous other studies. Endotracheal tube, nasogastric tube, triple-lead biventricular defibrillator, and nasogastric tube are unchanged in position. Heart shadow is enlarged but unchanged. Midline sternotomy wires, clips, and stent along the left heart border are unchanged. Bilateral perihilar fullness, bilateral small pleural effusions, and left lower lobe atelectasis are similar to the last examination. Osseous structures are also unchanged. IMPRESSION: Similar appearance of mild pulmonary edema, bilateral small pleural effusions, and left lower lobe atelectasis. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: TUE [2111-5-19] 6:43 AM RADIOLOGY Final Report UNILAT UP EXT VEINS US LEFT PORT [2111-5-17] 1:35 PM UNILAT UP EXT VEINS US LEFT PO Reason: SWELLING ASSESS FOR CLOT [Hospital 93] MEDICAL CONDITION: 64 year old man with subdural hematoma. left arm swelling REASON FOR THIS EXAMINATION: Assess for clot INDICATION: 64-year-old male with subdural hematoma and left arm swelling. Please assess for clot. FINDINGS: [Doctor Last Name ] scale, color and pulse wave Doppler son[Name (NI) 1417] were performed of the left internal jugular, subclavian, axillary, brachial, and basilic veins. Normal flow, compressibility, waveforms, and augmentation is demonstrated. No intraluminal thrombus is identified. IMPRESSION: No evidence of DVT in the left upper extremity. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5718] DR. [First Name (STitle) 3934] [Name (STitle) 3935] Approved: MON [2111-5-18] 10:50 AM Brief Hospital Course: Neurology: Patient was admitted to Neurosurgery service for acute SDH after presentation to PCP for slurred speech. His INR on admission was 3.9 with nml platelets. This was actively reversed with Profiline 9, Vit K and FFP. He was admitted to the ICU / neurosurgical service for observation. While in ED, the patient had 3 generalized tonic clonic seizures and patient was given a Dilantin load. He had one seizure after this with in the 24 hour period (no Dilantin post load level checked) and Keppra was started. The LP was neg for infection with CSF cx NGTD. Patient was noted to be very somulent and was intubated on HOD 2 for airway protection. He was noted to be more alert on the following days and EEG done on [2111-5-19] showed showed global encephalopathy without active or subclinical sz. Patient was monitored closely in Neuro ICU because of noted right cerebral edema though minimal midline shift noted. No neurosurgical intervention recommended. Neurology was consulted and recommended Glycerol and Mannitol which was started. The patient became slightly more alert in the ICU and was able to be extubated by HOD #7. He was then transferred to the Neurology Service Step down unit where he was noted to have a wax and [Doctor Last Name 688] alertness. His Mannitol was weaned off slowly. All sedating medications were discontinued and metabolic work-up revealed increased pulmonary edema. The patient's mental status gradually improved but follow-up head CT on [5-24] showed evidence of increased right cerebral edema with new 8 mm midline shift. Neurosurgery was notified and again no surgical intervention recommended. His neurological exam has been followed closely and it was felt patient was staying alert, awake, oriented, and interactive. No change in motor or sensory exam. He was seen with PT/OT which recommended acute rehab needs. He will also benefit from speech therapy as well. Patient had repeat EEG on [2111-5-28] which showed generalized slowing consistent with encephalopathy. The patient's Keppra was decreased to 1250 mg po BID and Dilantin should continue at 100 mg po tid CV: Patient has known EF 15-20% and biventricular [Date Range 3941] in place. Baseline SBP per PCP is [Name Initial (PRE) ] 80s to low 100s. He had some evidence of worsening pulmonary edema on CXRs and was treated with Lasix and Bumex standing medications. Last CXR was [2111-5-25] which showed increased pulmonary edema and Bumex was increased 2 mg po qday. On [2111-5-28], patient respiratory exam was stable and he was being titrated down for 35% face mask to room air. FEN/GI: Patient had multiple failed swallow studies for somulence. During this time patient was on NG tube feeds of Nutrin pulmonary at goal 60cc hour with free water flushes. On [2111-5-26], patient was finally alert enough to have a video swallow which revealed that though patient was impulsive, he could tolerate purees and thin liquids with crushed meds. One to one supervision with his diet is recommended. With encouragement, the patient is taking good oral intake. ID: Patient had UCX on [5-26]/o7 which grew coag negative staph. No treatment initiated. Endo: Patient was on NPH 10 units in the AM and 10 units qhs and insulin sliding scale. On [2111-5-28] early AM, he had one low fs of 50 and NPH dose was decreased by half. It may be prudent to decrease NPH dosing to half doses in rehab while patient working on oral feeds and following fingersticks closely. Social: Health Care proxy is daughter [Name (NI) ]. Medications on Admission: Medications prior to admission: coumadin 3mg / 3 tabs qd coreg 3.125 mg [Hospital1 ] lipitor 20 daily ASA 325 daily amioderone 200 qd bumex 2mg [Hospital1 ] ativan .5 qd-[Hospital1 ] prn lantus 22units at bedtime zantac 150 i tab daily humulin R [5-15] [Hospital1 ] Potassium Chloride 10 Meq, 3 tabs QD Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Acetaminophen 325 mg Tablet [Hospital1 ]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Miconazole Nitrate 2 % Powder [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 4. Amiodarone 200 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Carvedilol 3.125 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 6. Senna 8.6 mg Capsule [Hospital1 ]: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 7. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: [12-9] PO BID (2 times a day) as needed for constipation. 8. Phenytoin 100 mg/4 mL Suspension [Month/Day (2) ]: One (1) PO TID (3 times a day). 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Month/Day (2) ]: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed for wheezing. 10. Ipratropium Bromide 0.02 % Solution [Month/Day (2) ]: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) Injection TID (3 times a day). 13. Furosemide 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 14. Bumetanide 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 15. Levetiracetam 500 mg Tablet [Last Name (STitle) ]: 2.5 Tablets PO BID (2 times a day). 16. Insulin Regular Human 100 unit/mL Cartridge [Last Name (STitle) ]: sliding scale Injection qac and qhs: sliding scale per your institution. 17. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Cartridge [Last Name (STitle) ]: Ten (10) units Subcutaneous twice a day: Would use 1/2 dose if patient not taking good po or NPO. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: right subdural hematoma Discharge Condition: neurologically patient has left arm hemiparesis with proximal 0/5 delt, [1-12] triceps, [1-12] biceps, 0/5 WE, [1-12] WF and 5-/5 grip. He has [1-12] hip flexion and [1-12] quads, triple flexes with stim on left. Discharge Instructions: Weigh yourself every morning, call PMD if weight > 3 lbs. Adhere to 2 gm sodium diet. You have a seizure disorder after your brain injury. No bathing, swimming alone. Avoid heights. By Massachusettes Law, you cannot drive 6 months after last seizure activity. Followup Instructions: 1. call Dr. [Last Name (STitle) 548] for an appointment to be seen in 4 weeks with a CT scan of your brain. [Telephone/Fax (1) ] 2. Provider: [Name10 (NameIs) 1918] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 902] Date/Time:[2111-6-4] 2:40 Provider: [Name10 (NameIs) 3941] CALL TRANSMISSIONS Phone:[Telephone/Fax (1) 59] Date/Time:[2111-7-27] 11:30 3. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2111-9-28] 3:00 pm 4. [Hospital 878] Clinic Provider: [Name Initial (NameIs) 540]/[Doctor Last Name ] Phone:[Telephone/Fax (1) 44] Date/Time:[2111-7-8] 4:30 pm [Name6 (MD) 3523] [Name8 (MD) 3524] MD [MD Number(2) 21196]	[ "4280", "42731", "25000", "41401", "4019", "2724", "V4581" ]
Admission Date: [2130-12-4] Discharge Date: [2130-12-6] Date of Birth: [2098-3-16] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 32-year-old man with a history of fascioscapulohumeral muscular dystrophy with chronic respiratory failure on home bipap pressure support 18, PEEP 8 for the past 9 years (24 hours a day for the past 2 years), admitted on [2130-12-4] for an elective tracheostomy placement because of worsening nasal breakdown from the bipap nasal pillows. Plan was for him to eventually go home to be on mechanical ventilation. The patient is dependent for all his ADLs. REVIEW OF SYSTEMS: Positive only for a chronic cough for the last 12 months. He is followed by Dr. [First Name4 (NamePattern1) 622] [Last Name (NamePattern1) 36729] at the [Hospital3 1810]. Mr. [Known lastname ] [Last Name (Titles) 1834] a successful tracheostomy by Dr. [Last Name (STitle) ] on [2130-12-4] with no complications. He was initiated on SIMV plus pressure support and was given analgesics for mild tracheostomy site pain. He was transferred to the medical Intensive Care Unit teams care on [2130-12-5] for further ventilation. PAST MEDICAL HISTORY: Fascioscapulohumeral muscular dystrophy, G tube placement in [2121], bilateral congenital hearing loss, wears hearing aids both ears. No significant pneumonias or hospitalizations. Seasonal allergies. MEDICATIONS: Zoloft 50 mg PGT q day, Claritin 10 mg PGT q day, Ensure PGT, tube feeds PGT. ALLERGIES: Neoprene causes skin sensitivity. FAMILY HISTORY: No other family members with muscular dystrophy. Family history positive for cancer. SOCIAL HISTORY: Lives with his caring and devoted parents at home. Enjoys movies and computers. No history of alcohol, tobacco or drug use. PHYSICAL EXAMINATION: Vital signs, temperature 98.2, pulse 83, blood pressure 107/53, respiratory rate 13, O2 saturation 97% on FIO2 of 30%, ins and outs 1750 in and 800 out with a net positive 950, ventilator setting SIMV total volume 700 with an actual total volume 670, respiratory rate 8 with no spontaneous respirations, FIO2 30%, PEEP 5.3, PIP 24.8, compliance of 36. In general, no apparent distress, able to answer questions with head motions, mouthing and pointing to the letter board. HEENT: Trach site clear, dry and intact, no erythema, edema or drainage. Cardiovascular, regular rate and rhythm, 2/6 systolic murmur at left lower sternal border. Pulmonary, clear to auscultation bilaterally. Abdomen, PEG site clean, dry and intact, decreased bowel sounds, non distended, non tender. Extremities, no edema, hand contractures bilaterally. LABORATORY DATA: Patient refused blood draws during this hospitalizations. ABG on [12-4] 7.48/34/227 on FIO2 of 30%. Chest x-ray on [12-5], tracheostomy in adequate position, no pneumothorax, no infiltrate. HOSPITAL COURSE: 1. Pulmonary: On [2130-12-4] the patient was attempted on C-pap and pressure support vent setting, however, he experienced an episode of apnea and was switched back to the SIMV setting. His apnea was thought to be secondary to sedation from the pain medications he received. The goal currently is pressure support ventilation with no rate setting with an eventual goal setting of pressure support 10 through 15 and PEEP of 5. Given his apneic episodes, we would currently recommend IMV with respiratory rate of 10, total volume 600, pressure support of 15 for back-up, FIO2 30%. The patient is being discharged to [Hospital 3058] rehab so that he and his family can be taught tracheostomy care. He will also be evaluated for Passy-Muir valve once he is at least 48 hours passed surgery. He was also started on Prevacid 30 mg PGT q day for his chronic cough. 2. Nutrition: The patient was seen by the nutrition team who recommended tube feeds of ProMod with fiber at 120 cc per hour which is 1440 kilocalories, 90 gm protein, 1200 cc of water. He is also recommended free water boluses 250 cc via PEG tube qid. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: [Hospital 36730] [Hospital ] Rehabilitation Center. DISCHARGE DIAGNOSIS: 1. FSH. 2. Muscular Dystrophy with chronic respiratory failure, status post tracheostomy placement. 3. PEG tube in place. 3. Chronic cough most likely secondary to GERD. DISCHARGE MEDICATIONS: Zoloft 50 mg PGT q day, Claritin 10 mg PGT q day, Prevacid 30 mg PGT q day, tube feeds, ProMod with fiber at 150 cc per hour for 12 hours per day, free water boluses via PGT [Pager number ] cc qid, Bactroban ointment to bilateral nares [Hospital1 ], Roxicet 5-10 cc PGT q 4 hours prn. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Last Name (NamePattern1) 7069] MEDQUIST36 D: [2130-12-9] 05:03 T: [2130-12-10] 20:32 JOB#: [Job Number 36731] cc:[Hospital 36732]	[ "53081" ]
Admission Date: [2200-6-24] Discharge Date: [2200-7-22] Date of Birth: [2116-12-10] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: SBO with ischemic bowel Major Surgical or Invasive Procedure: [6-24]: Exploratory laparotomy with lysis of adhesions, resection of small bowel, and temporary closure of abdomen. [6-27]: Small-bowel resection with primary anastomosis and abdominal closure. History of Present Illness: 83M presented to his PCP's office on the morning of [6-24] complaining of one day of worsening abdominal pain and a firm abdomen. He was sent to the ED where he was noted to be of altered mental status (AAOx1), had a lactate of 8.3 and was increasingly tachypneic prompting intubation. At time of this exam, he is intubated, sedated and on norepinephrine to support his blood pressure. Per his wife, he was doing pretty well up until this morning except for mild complaints of abdominal pain the last day. No fevers or chills, nausea or vomiting at home. Past Medical History: PMH: GERD, HTN, HLD, rectal/colon ca s/p resection, mitral insufficiency, mild aortic stenosis, right inguinal hernia PSH: colonic resection (for colon/rectal CA) via lower midline laparotomy [2169], TURP [2191] Social History: Lives with wife (accompanying him today), 2 children (daughter lives locally, son in [Name (NI) ]) Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On Admission: Vitals: 103 88 90/73 20 100% 2LNC Gen: Intubated sedated, pupils 2mm->1mm Card: RRR Pulm: Vented respirations Abdomen: well-healed midline surgical scar, firm, distended nonincarcerated right inguinal hernia Ext: No edema On Discharge: Pertinent Results: Admission Labs: [2200-6-24] 10:30AM BLOOD WBC-13.1* RBC-5.08 Hgb-15.4 Hct-47.0 MCV-93 MCH-30.4 MCHC-32.8 RDW-14.0 Plt Ct-227 [2200-6-24] 10:30AM BLOOD Neuts-67 Bands-20* Lymphs-10* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [2200-6-24] 04:30PM BLOOD PT-17.6* PTT-34.6 INR(PT)-1.7* [2200-6-24] 10:30AM BLOOD Glucose-179* UreaN-34* Creat-1.5* Na-137 K-5.0 Cl-94* HCO3-19* AnGap-29* [2200-6-24] 10:30AM BLOOD ALT-15 AST-43* AlkPhos-78 TotBili-1.5 [2200-6-24] 10:30AM BLOOD cTropnT-<0.01 [2200-6-24] 10:30AM BLOOD Lipase-22 [2200-6-24] 04:30PM BLOOD Calcium-6.7* Phos-2.0* Mg-1.3* [2200-6-24] 10:44AM BLOOD Lactate-8.3* [2200-6-24] 11:30AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [2200-6-24] 11:30AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [2200-6-24] 11:30AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.025 [2200-7-9] 08:17PM URINE RBC-60* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 [2200-7-9] 08:17PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2200-7-9] 08:17PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.006 [2200-7-10] 07:20PM PLEURAL TotProt-1.0 Glucose-139 LD(LDH)-121 Cholest-8 [2200-7-10] 07:20PM PLEURAL WBC-41* RBC-14* Polys-5* Lymphs-54* Monos-0 Meso-4* Macro-33* Other-4* PERTINENT MICRO [2200-7-4] 4:45 pm BLOOD CULTURE Source: Line-cvl. FINAL REPORT [2200-7-7] Blood Culture, Routine (Final [2200-7-7]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. [2200-7-4] 6:57 pm STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2200-7-5] C. difficile DNA amplification assay (Final [2200-7-5]): Reported to and read back by DR [First Name8 (NamePattern2) 488] [Last Name (NamePattern1) ] [2200-7-5] AT 14:07. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). PERTINENT REPORTS: TTE [2200-6-24] The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size is normal. Tricuspid annular plane systolic excursion is depressed (12 mm) consistent with right ventricular systolic dysfunction. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate/severe posterior leaflet mitral valve prolapse. An eccentric, anteriorly-directed jet of Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricle. Moderate aortic stenosis with estimated valve area of 1.1 cm2. Depressed right ventricular systolic function. Prolapsed posterior mitral valve leaflet. CT Torso with Contrast [2200-6-24] Closed loop obstruction in the right lower quadrant with hypoenhancing loops of bowel and free fluid throughout the abdomen and pelvis, concerning for bowel ischemia. CT Head [2200-6-24] 1. No acute intracranial process. 2. Chronic left maxillary sinus mucosal disease. TEE [2200-6-25] There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The abdominal aorta is mildly dilated. There are complex (>4mm) atheroma in the abdominal aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate to severe (3+) aortic regurgitation is seen. There is severe posterior leaflet mitral valve prolapse. There is at least moderate and probably severe mitral regurgitation(3+ to 4+) . Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. CT Torso [2200-7-4] 1. No evidence of an anastomotic leak. 2. Thickening of the sigmoid colon and rectal wall suggestive for proctitis/colitis. 3. Large bilateral pleural effusions with associated atelectasis. 4. 2.5 x 1.9 cm hypodense hepatic lesion at the junction of segment II and [Doctor First Name 690] is incompletely characterized and requires an ultrasound or MRI for further characterization. TTE [2200-7-9] Focused, limited views due to the patient's inability to cooperate: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Aortic regurgitation is present, but cannot be quantified. The mitral valve leaflets are mildly thickened. There is moderate/severe posterior leaflet mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. Compared with the prior, complete study dated [2200-6-24] (images reviewed), based on transvalvular gradients and velocity only ([Location (un) 109] cannot be calculated currently as a parasternal long axis view is not available for reliable LVOT measurement), the degree of aortic stenosis is moderate and possibly underestimated given limited echocardiographic views. CT Torso [7-12] 1. Bilateral upper and middle lobe pulmonary opacities, compatible with infection. 2. Volume overload with pulmonary edema, pleural effusions, periportal edema, ascites, and anasarca. 3. Small left pneumothorax. 4. No evidence of bowel obstruction, abscess or fluid collection in abdomen or pelvis. CXR [7-17]: FINDINGS: In comparison with the study of [7-15], the endotracheal tube and nasogastric tubes have been removed. Right pleural catheter remains in place and there is no pneumothorax. Central catheters are in good position. Cardiac silhouette appears to be more prominent than on the previous study and there is further fullness of indistinct pulmonary vessels consistent with worsening pulmonary venous pressure. Brief Hospital Course: Mr. [Known lastname 7324] was brought to the ED by ambulance from his PCP's office where his abdominal pain was worsening and his mental status was noted to be of mild confusion. On arrival to the ED he was AAOx1 and tachypneic. He was intubated for airway protection. A CT scan was consistent with a closed loop bowel obstruction. He was noted to be hypotensive and placed on pressors. A central line was placed in the ED and he was rushed to the operating room for emergent abdominal exploration. In the OR, he was noted to have a sharply demarcated segment of ischemic small bowel due to compression from adhesions. This was resected. Prior to creating an anastamosis, however, his pressor requirement started to increase, to triple pressors (levo, neo and vaso). Due to this instability, the abdomen was packed and the procedure was aborted. He was volume resuscitated in the ICU post-operatively and placed on broad spectrum antibiotic (zosyn). He remained on triple pressors. An echocardiogram (TTE) revealed a 0.6mm2 aortic valve prompting a consult to cardiology for potential valvuloplasty. He was deemed not a candidate due to his concommitant aortic insufficiency. His pressors gradually weaned down to a single pressor, levophed, and he returned to the OR on [2200-6-27] for re-anastamosis and abdominal closure. Post operatively, his pressor was weaned further and he was started on a lasix drip to remove excess fluid (noted to be 20 liters positive, though this number is probably in excess as it does not account for insensible losses). He was extubated on [2200-6-29] only to be reintubated the same night for respiratory distress. His pressors were weaned off, he was further diuresed with a lasix drip and 25% albumin, and was successfully extubated on [2200-6-30]. The remainder of his hospital course by problem: Aortic stenosis and insufficiency: TEE showing a 0.6mm2 valve area but deemed insuitable for a valvuloplasty due to his aortic insufficiency. After his surgeries, he had been on the surgical floor, but had increasing respiratory distress due to volume overload. He was transferred to the medicine service, and for several days diuresis was attempted but was limited by SBP's in the 80-90's, so he was transferred to the CCU. He was on multiple pressors initially levo/neo/vaso which were weaned as tolerated. In total, he required pressors for about a week. His cardic output was calculated with a Swann-Ganz catheter and found to be high, even when he was hypotensive (CI >6). Thus, there was no concern that his AS was a cause of his hypotension and inability to maintain his pressures. His EF was greater than 55% and a TTE showed severe mitral regurgitation, but a valve area of 1.0-1.2 consistent with moderate aortic stenosis. Per cardiology, TTE more sensitive than TEE, and valvuloplasty not pursued as would not improve valvular surface area. . His lisinopril and metoprolol were held due to low blood pressures. LOS fluid balance at time of transfer was -8.7L. Recurrent Shock: Patient with multiple episodes of hypotension requiring pressor support with levophed. Unclear etiology of shock. Swan Ganz catheter placed on [2200-7-11]. PAP 64/24 and PAPm was 39. CO on Levophed was 6.8, and CI was 3.6 with SVR of 1381. Levophed was temporarily disocntinued and CO increased to 12.1 with CI of 6.4 and SVR of 444. Hemodynamics were suggestive of a non cardiac etiology of his shock, and concern for sepsis was rasied. An abdominal scan was pursued with contrast to look for occult abscess or infection, but was negative. Treated with meropenem empirically (after prior HCAP treatment with Cefepime/Vancomycin) for possible HCAP sepsis. The patient continued to have equivocal blood pressures for the next week, with PRN pressors including Levophed and Vasopressin. Meropenem course to be completed on [2200-7-21]. Recurrent respiratory failure: Intubated on arrival to ED, extubated post-op on [2200-6-29], reintubated 3 times during the hospital stay for respiratory distress. Eventually self-extubated and did well after gentle diuresis with lasix drip. He did have a CT chest which showed bilateral pleural effusions. He underwent a right thoracentesis with pigtail catheter placement to help his respiratory status since diuresis was limited by blood pressures. Ultimate etiology is unclear, but he did have a presumed HCAP and was treated with cefepime/vanc but continued to spike fevers until the abx were changed to meropenem. However, a bronchoscopy did not find any evidence of infection, only pulmonary edema so it is also possible that all his respiratory failure was volume related. Likely worse due to severe mitral regurgitation. On the evening of [7-20], patient's respiratory status acutely worsened after attempt at NGT was made. Became hypercarboic with rapid shallow breathing, requiring reintubation. Chest XRAY at that time showed worsening diffuse bilateral infiltrates concerning for flash pulmonary edema vs. ARDS vs aspiration pneumonitis. Pulmonary consult at that time placed for questionable superimposed ARDS on top of cardiogenic edema. Neuro: Initially sedated with fentanyl/versed while intubated. Even once extubated, he remained delirious, and required frequent re-orientation. While extubated, had episodes of recurrent delirium/waxing/[Doctor Last Name 688]. Small bowel obstruction with ischemic bowel: Taken to the OR on admission on [2200-6-24]. An ischemic portion of small bowel was resected and his abdomen was left open and bowel in discontinuity due to HD instability. He returned to the OR on [2200-6-27] for reanastamosis and abdominal closure. Tube feeds were started on [2200-7-1] when he was off pressors but the dobhoff was "self-dc'd" on [2200-7-1]. At this point he was assessed with a bedside swallow eval in which he did well. He was advanced to a regular diet. Surgery continued to follow, and per above for questionable sepsis requested a second CT torso to look for infectious etiology of his shock. CT torso was unrevealing for any infectious nidus... C. diff: He developed diarrhea post-op and C. diff PCR in stool was positive. He was treated with PO vancomycin 125 mg q6h, his course should continue for 14 days after finishing the meropenem for HCAP. Heme: He was initially placed on heparin SQ but his platelets (in the 200s on admission) dropped to <100 by HD [3-30]. Due to concern for HIT, this was dc'd and a HIT panel was negative for heparin-PF4 antibodies. His heparin SQ was restarted at this point but the next day his platelets dropped further to 60. The heparin SQ was dc'd again at this point and a serotonin release assay was sent, it was negative. SQH was restarted on [2200-7-2] and continued throughout the hospital stay. His platelets recovered to > 200s. It was thought that he was septic causing the thrombocytopenia. Metabolic Alkalosis: Duration of hospitalization had worsening alkalosis due to ongoing diuresis. Had correction with acetazolamide, potassium supplementation, vasopressin, and spironolactone. Hypernatremia: With increased diuresis became increasingly hypernatremic. Free water flushes instituted with Tube Feeds. Hyperlipidemia: Continued atorvastatin. On Hospital Day 28 through 29, multiple family meetings were held about the patient's goals of care. Ultimately, it was decided that his care should be focused on comfort instead of aggressive measures. His care was withdrawn on the evening of [7-22] and he shortly passed thereafter with his family at the bedside. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Admission Note. 1. Atorvastatin 80 mg PO DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. Aspirin 81 mg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Disposition: Expired Discharge Diagnosis: Heart Failure Cardiopulmonary arrest Cariogenic and septic shock Discharge Condition: Diseased Discharge Instructions: x Followup Instructions: x [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "0389", "51881", "2762", "78552", "5119", "4241", "4240", "4280", "2875", "2724", "4019", "42731", "25000", "99592" ]
Admission Date: [2141-4-12] Discharge Date: [2141-4-27] Date of Birth: [2057-2-13] Sex: M Service: NEUROLOGY Allergies: Penicillins / Novocain Attending:[Last Name (NamePattern1) 1838] Chief Complaint: confusion, disorientation Major Surgical or Invasive Procedure: none History of Present Illness: HPI: Mr. [Name14 (STitle) 78102] is an 84-year-old right-handed man with a history of HTN, DM, HLD and previous left MCA stroke who presents to the ED after changes in his mental status. Patient was found this morning wandering, confused and disoriented. Patient was leaning on walls. EMS was called and took him to [Hospital3 ], where a non-contrast head CT showed a new hypodensity in the right parietal lobe consistent with an acute infarct, along with changes suggestive of his old left MCA stroke. He was transported to [Hospital1 18] ED for further evaluation and management. I contact[Name (NI) ] Mrs [First Name8 (NamePattern2) 78103] [Name (NI) 27598], his sister-in-law, who saw him in the [Name (NI) ] around 12pm and she stated that he was confused and complaining of strong headache, no other details were given. ROS, Patient reports a mild bifrontal headache. No other inforamtion was available. Patient uses a cane at baseline. Past Medical History: Hypertension Hyperlipidemia Diabetes mellitus type 2 previous left MCA stroke Social History: Lives alone, his wife passed away 1 year-ago and she had dementia. Pateint does not have children. No siblings. The only family contact is Mrs [First Name8 (NamePattern2) 78103] [Name (NI) 27598] his wife's sister. [Name (NI) ] is his health care proxy. Remote smoking history. No alcohol. Family History: From previous notes: Father died at 52 and Mother died at 90, doesn't know the cause of either. Physical Exam: Physical Exam: Vitals: T: 98 P: 76 R: 16 BP: 147/72 SaO2: 99%RA General: Awake, non-cooperative. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: hyperemia in both legs. Neurologic: -Mental Status: Awake, disoriented, mildly agitated. Unable to relate history. Following very simple commands. Naming is quite poor. Signs of perseveration. Fluent speech. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 brisk. VF cut in right side not blinking to threat. . III, IV, VI: EOM gaze to the right side, impaired horizontal gaze. without nystagmus. V: Facial sensation intact to pinprick. VII: No Facial asymmetry. VIII: Hearing mildly impaired bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: moving all extremities antigravity. -Sensory: He responded to pinprick. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 1 0 R 2 2 2 1 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Mild low amplitude tremor was noted in the right hand. -Gait: Deferred. Pertinent Results: [2141-4-12] 06:15PM BLOOD WBC-8.5 RBC-4.44* Hgb-12.8* Hct-37.5* MCV-85 MCH-28.8 MCHC-34.1 RDW-14.0 Plt Ct-212 [2141-4-12] 06:15PM BLOOD Plt Ct-212 [2141-4-12] 06:15PM BLOOD PT-12.4 PTT-22.1 INR(PT)-1.0 [2141-4-12] 06:15PM BLOOD Glucose-117* UreaN-18 Creat-0.8 Na-142 K-4.5 Cl-105 HCO3-26 AnGap-16 [2141-4-13] 03:21AM BLOOD ALT-25 AST-34 LD(LDH)-229 CK(CPK)-453* AlkPhos-85 TotBili-0.7 [2141-4-13] 03:29PM BLOOD CK(CPK)-672* [2141-4-14] 01:45AM BLOOD CK(CPK)-632* [2141-4-13] 03:21AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9 Cholest-133 [2141-4-13] 03:21AM BLOOD %HbA1c-5.6 eAG-114 [2141-4-13] 03:21AM BLOOD Triglyc-97 HDL-40 CHOL/HD-3.3 LDLcalc-74 [2141-4-13] 03:21AM BLOOD TSH-0.93 [2141-4-12] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2141-4-14] 01:45AM BLOOD WBC-8.9 RBC-3.84* Hgb-11.1* Hct-33.1* MCV-86 MCH-28.9 MCHC-33.5 RDW-14.0 Plt Ct-185 [2141-4-15] 04:20AM BLOOD WBC-9.4 RBC-4.01* Hgb-11.3* Hct-33.1* MCV-83 MCH-28.2 MCHC-34.2 RDW-13.8 Plt Ct-195 [2141-4-16] 06:50AM BLOOD WBC-7.5 RBC-4.10* Hgb-11.9* Hct-35.1* MCV-86 MCH-29.2 MCHC-34.0 RDW-13.9 Plt Ct-211 [2141-4-18] 05:31AM BLOOD WBC-7.5 RBC-3.87* Hgb-11.2* Hct-33.0* MCV-85 MCH-29.0 MCHC-34.0 RDW-14.0 Plt Ct-267 [2141-4-16] 06:50AM BLOOD Neuts-69.7 Lymphs-16.4* Monos-9.3 Eos-3.3 Baso-1.3 [2141-4-17] 11:41AM BLOOD Neuts-64.2 Lymphs-19.9 Monos-9.4 Eos-5.7* Baso-0.8 [2141-4-18] 05:31AM BLOOD Neuts-62.7 Lymphs-23.1 Monos-9.5 Eos-4.2* Baso-0.4 [2141-4-14] 01:45AM BLOOD Plt Ct-185 [2141-4-15] 04:20AM BLOOD Plt Ct-195 [2141-4-17] 11:41AM BLOOD PT-11.8 PTT-22.8 INR(PT)-1.0 [2141-4-18] 05:31AM BLOOD PT-12.5 PTT-23.1 INR(PT)-1.1 [2141-4-18] 05:31AM BLOOD Plt Ct-267 [2141-4-14] 01:45AM BLOOD Glucose-108* UreaN-13 Creat-0.6 Na-141 K-3.7 Cl-106 HCO3-29 AnGap-10 [2141-4-15] 04:20AM BLOOD Glucose-132* UreaN-11 Creat-0.6 Na-141 K-3.6 Cl-103 HCO3-29 AnGap-13 [2141-4-16] 06:50AM BLOOD Glucose-144* UreaN-13 Creat-0.6 Na-139 K-3.7 Cl-104 HCO3-27 AnGap-12 [2141-4-17] 11:41AM BLOOD Glucose-146* UreaN-16 Creat-0.7 Na-141 K-3.6 Cl-103 HCO3-34* AnGap-8 [2141-4-18] 05:31AM BLOOD Glucose-127* UreaN-15 Creat-0.7 Na-143 K-3.5 Cl-104 HCO3-33* AnGap-10 [2141-4-14] 01:45AM BLOOD CK(CPK)-632* [2141-4-15] 04:20AM BLOOD CK(CPK)-329* [2141-4-17] 11:41AM BLOOD ALT-26 AST-28 AlkPhos-66 TotBili-0.4 [2141-4-13] 03:21AM BLOOD CK-MB-6 cTropnT-<0.01 [2141-4-14] 01:45AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.1 [2141-4-15] 04:20AM BLOOD Calcium-8.3* Phos-1.9* Mg-1.8 [2141-4-16] 06:50AM BLOOD Calcium-8.5 Phos-1.6* Mg-1.9 [2141-4-17] 11:41AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.1 [2141-4-18] 05:31AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0 [2141-4-13] 03:21AM BLOOD %HbA1c-5.6 eAG-114 [2141-4-13] 03:21AM BLOOD Triglyc-97 HDL-40 CHOL/HD-3.3 LDLcalc-74 [2141-4-13] 03:21AM BLOOD TSH-0.93 [2141-4-12] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2141-4-13] 03:21AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2141-4-17] 11:36AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 [2141-4-12] 07:20PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.010 [2141-4-12] 06:30PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 [2141-4-17] 11:36AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [2141-4-12] 07:20PM URINE Blood-TR Nitrite-POS Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2141-4-12] 06:30PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR [2141-4-17] 11:36AM URINE RBC-21-50* WBC-[7-13]* Bacteri-MOD Yeast-NONE Epi-0-2 RenalEp-<1 [2141-4-12] 07:20PM URINE RBC-0-2 WBC-[12-23]* Bacteri-FEW Yeast-NONE Epi-0-2 [2141-4-12] 06:30PM URINE RBC-0-2 WBC-21-50* Bacteri-OCC Yeast-NONE Epi-0-2 [2141-4-17] 11:36AM URINE AmorphX-FEW [2141-4-12] 06:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2141-4-27] 05:15AM 9.0 4.19* 12.0* 36.1* 86 28.8 33.4 14.5 411 [2141-4-26] 05:20AM 9.1 3.97* 10.9* 33.4* 84 27.4 32.6 14.3 368 [2141-4-24] 05:00PM 7.4 4.07* 11.5* 34.8* 86 28.3 33.1 14.4 406 [2141-4-22] 06:55AM 8.1 4.04* 11.5* 35.0* 87 28.4 32.8 14.5 336 [2141-4-20] 04:29AM 7.6 3.96* 11.4* 34.0* 86 28.9 33.7 14.5 297 [2141-4-19] 07:49AM 7.5 4.02* 11.1* 33.4* 83 27.7 33.3 14.1 264 Chemistry Glucose UreaN Creat Na K Cl HCO3 AnGap [2141-4-27] 05:15AM 1161 11 0.8 141 3.6 103 32 10 [2141-4-26] 05:20AM 1321 7 0.8 139 3.5 101 30 12 [2141-4-24] 05:00PM 1161 12 0.8 143 3.7 104 30 13 [2141-4-22] 06:55AM 991 19 0.8 142 3.6 104 29 13 [2141-4-19] 07:49AM 1551 13 0.6 142 3.2* 103 32 10 Microbiology [2141-4-12] 6:00 pm BLOOD CULTURE FINAL REPORT [2141-4-18] Blood Culture, Routine (Final [2141-4-18]): NO GROWTH. [2141-4-12] 6:15 pm BLOOD CULTURE FINAL REPORT [2141-4-18] Blood Culture, Routine (Final [2141-4-18]): NO GROWTH. [2141-4-12] 6:30 pm URINE FINAL REPORT [2141-4-14] URINE CULTURE (Final [2141-4-14]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION [2141-4-17] 4:39 pm URINE Source: Catheter. URINE CULTURE- no growth CT head [2141-4-12] Hypodensity in the right parietal lobe consistent with acute infarct. Left occipito-temporal lobe hypodensity c/w chronic infarct. TTE [2141-4-13] The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). 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 number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened (?#). No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No cardiac source of embolism seen. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Diastolic dysfunction. Moderate pulmonary artery systolic hypertension. MRI brain, MRA head/neck [2141-4-13] 1. Moderately-sized biparietal acute/subacute infarcts. 2. Laminar necrosis and post-ischemic encephalomalacia associated with the old left occipital infarct. 3. Mild intracranial atherosclerotic disease without high-grade stenosis or vascular malformation. 4. There appears to be moderate to high-grade narrowing at the origin of the right internal carotid artery, with further quantification limited on this examination. Correlation with son[Name (NI) 493] and/or CTA findings is suggested. CTA head/neck [4-14] IMPRESSION: 1. Bilateral cerebral infarcts in the parietotemporal region without acute hemorrhage. Unchanged appearance since the previous MRI. 2. 30-40% stenosis at the origin of right internal carotid artery. This stenosis is mild in nature. Otherwise patent arteries in the neck. Direct origin of the left vertebral artery from aorta a variation. 3. CT angiography of the head demonstrates diminished vascular structures in the infarcts. Otherwise tortuous arterial structures are seen without occlusion, stenosis, or an aneurysm greater than 3 mm. 4. Right parapharyngeal mass as seen on the previous studies. Chest X ray [4-17] IMPRESSION: AP chest compared to [4-12] through 12: The head and chin obscure much of the upper mid chest. Patient could not be positioned in any other fashion. Previous pulmonary edema has not recurred. Bibasilar atelectasis is relatively mild. Small bilateral pleural effusions are new or newly apparent. Heart size is top normal. Feeding tube has been removed. Right jugular line tip projects over the upper right atrium. Heart size top normal. A new left PIC line extends to the right of midline probably into the right subclavian vein. No pneumothorax is seen along the unencumbered pleural surfaces. CXR [4-20] FINDINGS: The course of the Dobbhoff catheter is unremarkable. The catheter is coiled in the proximal parts of the stomach. The tip projects over the proximal part of the stomach. On the displayed parts of the thorax there is no evidence of visible complications. CXR [4-23] FINDINGS: As compared to the previous radiograph, the Dobbhoff catheter has been replaced by a nasogastric tube. The tip of the tube appears to project over the distal parts of the stomach. However, the tube is coiled in the stomach. Normal course of the tube, no evidence of complications. Otherwise, the radiograph is unchanged. Brief Hospital Course: Mr. [Name14 (STitle) 78102] is an 84-year-old man with a history of hypertension, hyperlipidemia, DM and previous stroke who presents with changes in mental status and evidence of new stroke. Patient has new head CT with signs of acute RMCA stroke, now bilateral disease. In the initial evaluation, the patient was very confused and disoriented, and concerning for possible non-convulsive status epilepticus. He received Ativan 1 mg IV and had a further deterioration of his mental status. The patient was then intubated for airway protection and admitted to the neuro ICU. . Hospital course by problem; . Neuro; The patient was admitted to the neurological ICU after intubation in the Emergency Department. His home aspirin was discontinued and he was started on plavix. Given his disorientation and somnolence, he was initially started on keppra, however this was discontinued the following morning as his bilateral hemispheric disease from strokes were thought to account for his change in mental status. His blood pressure was allowed to autoregulate for the first 48 hours after the event. A transthoracic echocardiogram showed no cardiac source for his stroke. The patient's LDL was 74 and HbA1c was 5.6. He was continued on a statin and fingersticks were covered with regular insulin sliding scale. He underwent an MRI brain and MRA of his head and neck. The MRI brain confirmed the right parietal subacute infarct, however also appeared suspicious for possible acute infarct in the left parietal lobe in the region of his prior stroke in [2139], as this region was also bright on DWI and dark on ADC. This remains somewhat uncertain as the area of infarct appears unchanged when comparing to his imaging in [2139], although MRI sequences do reveal the concern for possible bilateral acute strokes. An MRA of the head and neck was notable for moderate to high-grade narrowing at the origin of the right ICA, although degree of stenosis was difficult to quantify. Therefore, the patient underwent CTA head and neck which showed 30-40% stenosis at the origin of right internal carotid artery, which was considered mild , and it did not show evidence of any other abnormality. A transesophageal echocardiogram was attempted which could not be completed owing to parapharyngeal mass. His examination is notable for inattention, fluent empty non meaningful speech, moving all extermities antigravity. . Respiratory; The patient was extubated on HD#2 after receiving his MRI/A. he was maintaining good saturation on oxygen mask after transfer from ICU to floor. . ID; The patient was found to have a urinary tract infection on [4-17] and was started on ciprofloxacin. A urine culture was sterile. He was given cipro for 7 days. . CV; The patient was continued on his beta blocker at 1/4 his home dose to allow for permissive hypertension in the acute setting of stroke and as he was bradycardic on telemetry with a heart rate in the 50s-60s. This can be titrated up to his home dose of atenolol 100 mg daily as tolerated. He was in atrial fibrillation, with controlled rate. Heparin or coumadin was not started immdiately because of concerns for hemorrhagic transformation. he was started on his home meds in stepwise fashion keeping a watch over his blood pressure. . GU; The patient had hematuria upon arrival to the ICU. This was thought to be secondary to traumatic foley placement. This responded to irrigation and his hematocrit remained relatively stable. . Endo; The patient was continued on his glipizide and fingersticks were treated with regular insulin sliding scale. ENT; patient was noted to have parapharyngeal mass for which ENT consult was sought. They felt that this does not require urgent work up and does not pose contraindication for anticoagulation, should felt necessary for other reasons. Nutrition He was evaluated by nutrition team. he was encouraged to increase PO intake and to undergo calorie count. It was felt that he would require PEG tube. He got PEG tube on [4-25], and feeds were started. . Goals of care; Unfortunately, the patient's wife passed away one year ago and he has no known family. His health care proxy is his sister-in-law, [Name (NI) 78103] [Name (NI) 27598]. She was frequently contact[Name (NI) ] and the goals of care were discussed on regular basis. It was decided to continue the care in extended care facility. Medications on Admission: Medications: Aspirin 325mg daily Simvastatin 20 mg po daily Lisinopril 40 mg po daily Furosemide 20 mg daily Atenolol 100 mg po daily Glipizide 5 mg po daily Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain\fever. 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day). 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain\fever. 9. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Dose needs to be monitered with INR goal of [3-8], and plavix needs to be stopped after INR is therapeutic. 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please stop after INR is therapeutic ([3-8]). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): For DVT prophylaxis,. Discharge Disposition: Extended Care Facility: [Hospital 169] Center - [Location (un) 3320] Discharge Diagnosis: Bilateral parietal lobe infarcts Discharge Condition: Mental Status: Confused - always Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted for evaluation of change in mental status. Initailly you were in the ICU and required mechanical ventilation for respiratory support. You had CT scan and MRI of brain which showed bilateral parietal strokes. You were evaluated by physical therapy, occupational thearpy and speech therapy who felt that.... Please take your medicines as advised. Please call 911 or your doctor if any concerns. Please follow with the appointments as scheduled. Followup Instructions: Provider: [Name10 (NameIs) 4267] [Last Name (NamePattern4) 4268], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 657] Date/Time:[2141-7-18] 1:00	[ "5990", "42731", "4168", "4019", "25000", "2724" ]
Admission Date: [2170-1-29] Discharge Date: [2170-2-2] Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: Trauma, s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 87 Italian-speaking F who had a witnessed fall at nursing home with apparent syncope with fall from standing, headstrike, and brief LOC. She was seen at [Hospital3 ] ED and complained of right-sided chest and abdominal pain. Head and spine CT showed no fractures or hemorrhage, and a CT of her chest showed right-sided rib fractures T3-8 with a small pneumothorax. She also complained of abdominal pain that was not present prior to her fall but was not imaged at OSH. Here, CT [Last Name (un) 103] showed no acute process Patient is satting 100% on 100%nrb and is being admitted to the TSICU for close monitoring given her age and the large number of rib fractures. Past Medical History: HTN, CRI, hyperK, HTN, afib, dementia with delerium and depression, anemia (Fe) Social History: NC Family History: NC Physical Exam: On discharge: T 98.2 HR 81 BP 132/66 RR 16 95%RA Gen: NAD, A/Ox3 Cardiac: RRR Lungs: CTA bilat, no resp distress Abd: soft, NT, ND Extrem: no edema Pertinent Results: [2170-1-29] 05:50PM BLOOD WBC-19.9* RBC-3.21* Hgb-9.8* Hct-30.0* MCV-94 MCH-30.6 MCHC-32.7 RDW-13.2 Plt Ct-394 [2170-1-29] 05:50PM BLOOD Glucose-134* UreaN-65* Creat-2.5* Na-147* K-4.5 Cl-110* HCO3-22 AnGap-20 CT head: Large right parietal subgaleal hematoma. No fracture and no acute intracranial process. CT Cspine: No fracture. Mild anterolisthesis of C7 on T1. Multilevel moderate degenerative changes. CT CAP: 1. Small right pneumothorax, right sixth through ninth rib fractures with worsening bilateral lung opacities, which may be due to contusions and/or aspiration, and small right pleural effusion. 2. No acute CT findings in the abdomen or pelvis. 3. Mild aneurysmal dilatation/ectasia of the distal abdominal aorta measuring up to 2.9 cm and moderate-to-severe atherosclerotic disease. 4. Moderate degenerative changes at the lower lumbar spine. ECHO: IMPRESSION: Biatrial enlargement. Normal left ventricular cavity size and wall thickness with low-normal global left ventricular systolic function. Mild aortic regurgitation. Mild to moderate mitral regurgitation. Mild to moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Carotid Ultrasound Impression: Right ICA <40% stenosis. Left ICA 40-59% stenosis. Brief Hospital Course: Ms. [Known lastname 91851] was admitted to the ICU for monitoring of her pneumothorax and support through her rib fractures. On HD1, an epidural was placed for pain control with good effect. Her home medications were started and she worked with physical therapy. Overnight, she was agitated and intermittently required haldol on the night of HD#2. She was transferred to the floor on HD#3. Her epidural was removed and she had good pain control with Tylenol and Ultram. She had carotid ultrasounds and an ECHO done for syncope workup, which were unrevealing. She continued to work with PT and was discharged back to her nursing home with physical therapy on HD 4. At time of discharge, her pain was well controlled, she was toelrating a regular diet, voiding without issues, and ambulating with assistance. She will follow up with her PCP. Medications on Admission: Depakote 250'' Trazadone 37.5' bed time Mucinex 600'' Bumetanide 0.25 ' Norvas 5' Hydrochlorotiazide 12.5' Vicodin prn FE 325' MVT Asa 81' Metoprolol 50' Tylenol prn 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. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. famotidine 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 6. trazodone 50 mg Tablet Sig: 0.75 Tablet PO HS (at bedtime). 7. bumetanide 0.5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. tramadol 50 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6 hours) as needed for Pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: Aberjona Nursing Center - [Hospital1 2436] Discharge Diagnosis: Multiple rib fractures Pneumothorax R parietal subgaleal 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: You were admitted to the trauma surgery service after a fall at your nursing home. Your imaging shows that you have some rib fractures. You had imaging done of your head and spine and there is no bleed in your brain. Other imaging of your chest, abdomen and pelvis were unrevealing. There is nothing to be done for your rib fractures. You will be sore for several weeks. You also had a workup done for a question of a syncopal episode. Your ECHO and carotid ultrasounds were unrevealing. But you should follow up with your PCP. Please use your incentive spirometer several times a day. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. You should follow up with your PCP in the next few weeks. Followup Instructions: Please follow up with your PCP in the next few weeks. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601]	[ "40390", "42731", "2767", "5859" ]
Admission Date: [2110-12-29] Discharge Date: [2111-1-2] Date of Birth: [2049-9-30] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: S/p MVC with splenic laceration grade III, dislocation of three frontal incisors, Left TMJ dislocation, facial/lip laceration Major Surgical or Invasive Procedure: Removal of teeth as per OMFS History of Present Illness: Pleasant 61 y.o. male involved in MVC where he was the driver of a car T-boned by a dump truck around 6:30 PM on [2110-12-29]. Taken to an OSH where initially stabilized then transferred to [Hospital1 18]. Trauma evaluation here revealed splenic laceration and B/L pulmonary contusions, patient also has a 6L oxygen requirement. Plastic surgery consulted for complex through & through lower lip laceration. Received tetanus at OSH and kefzol in the ER here. Currently patient immobilized on backboard and C-collar. AAOx3 and pleasant. No complaints of numbness over the chin in the area of the laceration. Past Medical History: HTN, Hypercholesterolemia Social History: Noncontributory Family History: Noncontributory Physical Exam: Vital signs stable, Afebrile. AAOx3, thick beard Scalp NCAT, Sclera clear, EOMI. No orbital stepoffs, no evidence of periorbital or post auricular ecchymosis. No malar or zygomatic tenderness. Nose midline and no stepoffs or blood around the nares. Complex 4 cm stellate laceration visible transversely over the mental crease. Mandible at base of entire length of this wound. On intraoral exam there is an impacted segmental fracture of the lower mandible alveolar ridge containing teeth #24-26 (lower centrals and right lateral incisor) with associated gingival laceration. There 4 cm laceration of the anterior gingivo-buccal sulcus along the mandible with shearing of the soft tissues off the mandible where they connect with the external 4 cm laceration. Mentalis muscle appears avulsed/lacerated B/L within this. Remarkably he does have normal sensation over the chin in the distribution of V3. Sutures in place. Abdomen slightly tender LUQ, otherwise unremarkable Rest of physical exam within normal limits. Pertinent Results: [2110-12-29] 09:59PM WBC-16.7* RBC-4.22* HGB-12.9* HCT-36.1* MCV-86 MCH-30.5 MCHC-35.6* RDW-13.2 [2110-12-29] 10:28PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2111-1-1] 05:20AM BLOOD WBC-6.5 RBC-3.36* Hgb-10.1* Hct-28.6* MCV-85 MCH-30.1 MCHC-35.3* RDW-13.2 Plt Ct-200 [2111-1-1] 05:20AM BLOOD Glucose-101 UreaN-12 Creat-0.8 Na-138 K-4.1 Cl-103 HCO3-31 AnGap-8 Brief Hospital Course: The patient was admitted to the trauma surgery service for evaluation and treatment after the events related in the HPI. His injuries were a splenic laceration grade III (hemodynamically stable, patient observed), three frontal incisors dislocated which was treated by a surgical procedure performed by OMFS, Left TMJ dislocation which was left untouched as per the opinion of OMFS, and a facial/lip laceration which was sutured by PRS. Systems-wise: Neuro: The patient received IV pain medications initially with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CT head was negative for hemorrhage. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout this hospitalization. GI/GU/FEN: The patient was made NPO with IVF initially. The patient's diet was advanced when appropriate, which was tolerated well. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization, and repleted when necessary. After oral and maxillofacial surgery was performed, the patient was discharged on a soft food/thin liquid diet after initially being started on a liquid diet. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required during this stay. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. Studies: [12-29] CT head: No hemorrhage [12-29] CT face: dislocation of lower three frontal incisors. [12-29] CT c spine: [Last Name (un) ] changes; Anterior dislocation of L mandib condyle. [12-29] CT torso: splenic lac grade III with free fluid in pelvis & around spleen. b/l atelectatsis [12-29] R shoulder XR: no fx, dislocation 2/2 L knee XR: small effusion, no fx, no dislocation At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a soft foods diet, ambulating, voiding without assistance, and pain was well controlled. Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 7 days. Disp:21 Capsule(s) Refills:0 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane QID (4 times a day). Disp:1800 ML(s) Refills:2 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:120 Tablet(s) Refills:1 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day): Apply to facial abrasions as directed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Medication Please continue taking all other medications as per your primary care provider. Discharge Disposition: Home Discharge Diagnosis: Splenic laceration grade III, dislocation of three frontal incisors, Left TMJ dislocation, facial/lip laceration Discharge Condition: Stable Discharge Instructions: Please wash your mouth with the Peridex that was prescribed for you as per Dr.[Name (NI) 80816] instructions, complete your course of antibiotics and stay on a soft foods diet until followup with Oral and Maxillofacial Surgery. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([9-10] lbs) until your follow up appointment. Followup Instructions: Please followup in [Hospital 3595] Clinic (call [Telephone/Fax (1) 11612] to schedule an appointment) on [1-6]/009 to remove the sutures on your face. Please followup in 1 week with Dr. [Last Name (STitle) 2866] in Oral and Maxillofacial Surgery Post trauma clinic. Completed by:[2111-1-2]	[ "5180", "4019", "2720" ]
Admission Date: [2200-9-29] Discharge Date: [2200-10-1] Date of Birth: [2133-7-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: HPI: Pt is a 67yo F w/ a PMH of CHF, HTN, CRI and COPD who was found at her [Hospital1 1501] to be acutely SOB this AM. On exam, she was found to be wheezing, her O2 sats were 66% and only improved to 72% on 3L. Rest of her VS were: temp of 96.3, BP was 200/80, HR 124, and RR 24. Pt states that she was trying to go to the bathroom when she became acutely SOB. Per documentation, she had had a large amount of loose stool at the time (she is incontinent of both stool and urine at baseline). Denies any CP, palp, dizziness, LH, arm or jaw pain, diaphoresis, nausea or vomiting. EMS was called and on arrival, applied a NRB with improvement in her sats to 99%. On arrival to the ER, her SBP was still elevated in the 210s and her HR was 110s. She was felt to have [1-14] word dyspnea. Labs and blood cx were sent. She was given nitropaste w/o effect. She was started on CPAP and was given IV lasix. Lactate returned at 4.9 and she was given CTX, azithromycin, and vancomycin. BNP returned at 31,089. CXR was c/w pulmonary edema. Her SBP remained in the 190s-200s, so a nitro gtt was started with improvement in her SBP to the 170s. After 2 hrs, CPAP was discontinued and the patient was able to maintain her O2 sats of 98-100% on 3L by nc. In total, she made 650cc of UOP. She was transferred to the ICU from the ED once her respiratory status was stable, as she was still on a nitroglycerin gtt. . ROS: denies fevers, chills, CP, palp, jaw or arm pain, dizziness, LH, n/v, + mild abd pain, ? diarrhea (pt denies, but likely per [Hospital1 1501] report); denies dysuria or hematuria but pt incontinent; denies URI sx; denies LE edema, orthopnea or PND; denies recent use of O2 Past Medical History: # CHF - EF 25-30% by ECHO in [7-19] # HTN # CVA x2-3 (per patient) - has residual R sided LE weakness # COPD # CRI - baseline Cr ~2.0 # DM # Depression # Hypercholesterolemia # GERD # Glaucoma # Legal blindness b/l (? post stroke) # s/p lithotripsy for kidney stone # s/p oophorectomy # s/p cholecystectomy Social History: 2 ETOH drinks daily, until CVA triggered nursing home residency. Pt denies tobacco use but records indicate smoking. Former bartender. Still married to husband [Name (NI) 449]. Family History: Father died at 66 y, DM. Mother died when pt was infant. No known diseases in siblings. Physical Exam: VS - 99.7, BP 170-177/76-82, HR 83-92, RR 17-22, O2 sats 96-97% on 3L nc nitro gtt: 5 mcg/kg/min Gen: WDWN older female in NAD. Lying in bed, cooperative, pleasant, answers questions appropriately. HEENT: Sclera anicteric. Pupils nonreactive to light bilaterally, opacified bilaterally. CV: RR, normal S1, S2. No m/r/g. Lungs: Crackles [1-14] way up bilaterally, with decreased BS at bases bilaterally. Abd: Soft, NTND. + BS. No masses, no HSM. Ext: No edema. 2+ DP pulses bilaterally. Neuro: Difficult to assess EOM due to blindness. Remaining cranial nerves (V-XII) appear intact. Strength is [4-17] in UE bilaterally, both distally and proximally. Strength on dorsiflexion and plantarflexion was [5-17] bilaterally. Could not assess patellar reflexes or ankle reflexes. No clonus. Toes equivocal bilaterally. Pertinent Results: Admission Laboratories: Hematology: CBC: WBC-10.1# RBC-3.80# HGB-11.4# HCT-35.0# MCV-92 MCH-30.1 MCHC-32.7 RDW-15.1 PLT COUNT-260 Differential: NEUTS-68.7 LYMPHS-26.6 MONOS-3.1 EOS-1.3 BASOS-0.3 PT-12.0 PTT-23.5 INR(PT)-1.0 . Chemistries: GLUCOSE-284 UREA N-38* CREAT-2.3* SODIUM-142 POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-19* ANION GAP-20 CALCIUM-8.6 PHOSPHATE-6.2# MAGNESIUM-2.3 . Other: [2200-9-29] 07:00AM CK-MB-3 proBNP-[Numeric Identifier 99043] [2200-9-29] 07:28AM LACTATE-4.9* [2200-9-29] 03:59PM LACTATE-1.7 . Cardiac Enzymes: [2200-9-30] 05:27AM BLOOD CK(CPK)-70 CK-MB-4 cTropnT-0.18* [2200-9-29] 11:13PM BLOOD CK(CPK)-83 CK-MB-5 cTropnT-0.22* [2200-9-29] 02:48PM BLOOD CK(CPK)-108 CK-MB-7 cTropnT-0.19* . MICRO: [2200-9-29] blood cultures - no growth as of [2200-10-1]. . IMAGING: EKG [2200-9-29]: rate of 112, LBBB, ? ST depressions in II, III, aVF (new from old), TWI in V5, V6 (old) . CXR [2200-9-29]: There is hazy bilateral patchy airspace process that likely represents pulmonary edema. There is a left pleural effusion. There is unchanged cardiomegaly. There is no pneumothorax. IMPRESSION: Findings consistent with fluid overload. Brief Hospital Course: A/P: 67yo F w/ a PMH of CHF, HTN, CRI and COPD who was found at her [Hospital1 1501] to be acutely SOB this AM, likely due to flash pulmonary edema. . # CHF: Patient was admitted with shortness of breath and pulmonary edema in the setting of hypertensive crisis. The etiology of her pulmonary edema was unclear but was felt to be secondary to her high blood pressure. She received lasix and BiPAP in the ER and was transferred to the MICU. Upon arrival to the MICU she was no longer significantly short of breath and was satting well on 3 L nasal cannula. She was placed on a nitroglycerine drip for immediate control of her blood pressure and was slowly started back on her home antihypertensive medications. She was noted to have a slightly elevated troponin which peaked at 0.22 but she did not complain of any chest pain and had no EKG changes. She was quickly weaned off of supplemental oxygen. Her chest xray on discharge showed interval improvement in her pulmonary edema. A number of changes were made to her medication regimen. Her hydralazine was switched from a TID dosing to a QID dosing. Her lisinopril was decreased from 10 mg TID to 10 mg [Hospital1 ]. Her lasix was increased to 40 mg PO daily from 40 mg PO every other day. She was tolerating this medication regimen well on discharge with blood pressures ranging from 130s to 140s systolic. . # Hypertensive Emergency: On admission the patient was noted to have a systolic blood pressure in the 200s with evidence of a mild troponin elevation and CHF consistent with hypertensive emergency. Her renal function was at her baseline and she had no evidence of encephalopathy. She was started on a nitroglycerine drip and her outpatient hypertensive regimen was altered as described above. Her blood pressure was stable on this regimen for the remainder of her hospital course. . # Elevated Lactate: On admission the patient was noted to have a lactate of 4.9 with evidence of an anion gap metabolic acidosis. It was thought that this was likely due to hypoperfusion in the setting of hypertensive crisis. Following intervention to decrease her blood pressure this decreased to 1.7. . # COPD: The patient has a history of COPD. On admission she had no evidence of COPD exacerbation. She was written for nebulizer treatments PRN but did not require these. . # Chronic Renal Insufficiency: The patient has a baseline creatinine of 2.3 which was her creatinine on presentation. Her medications were renally dosed for decreased GFR. . # Diabetes: The patient has a history of type II diabetes for which she takes oral hypoglycemics. During her MICU course she was maintained on an insulin sliding scale with good control of her blood sugars. She was discharged on her home diabetes regimen. . # Prophylaxis: She received subcutaneous heparin for DVT prophylaxis. Medications on Admission: glucerna shakes 1 can PO BID furosemide 40mg PO QOD isosorbide MN ER 60mg PO QD effexor XR 37.5mg PO QD lipitor 20mg PO QD aspirin 325mg PO QD senna 2 tabs PO QD ferrous sulfate 325mg PO BID lactulose 30mL PO BID coreg 12.5mg PO BID betoptic 0.25% O/S 1 drop in R eye [Hospital1 ] prilosec OTC 20mg PO QD hydralazine 25mg PO TID (hold for SBP <110) lisinopril 10mg PO TID (hold for SBP <110) ntg SL prn tylenol 650mg PO Q4 prn [Male First Name (un) ]-tussin SF 10mL PO Q4 prn cough [Name (NI) ] MOM 30mL PO QHS prn Fleet's enema 1 PR QD prn constipation O2 at 2l/min via NC prn Discharge Medications: 1. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed. 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day: Please hold for SBP < 110 or HR < 60. 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Ophthalmic [Hospital1 ] (2 times a day). 12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Please hold for SBP < 110 . 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Imdur 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Please hold for SBP < 110 . 15. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: Please follow insulin sliding scale. 17. Humalog Insulin Sliding Scale Insulin sliding scale for breakfast, lunch, dinner: < 60 - give [Location (un) 2452] juice and crackers 60-150 - give 0 units 151-200 - give 2 units 201-250 give 4 units 251-300 - give 6 units 301-350 - give 8 units 351-400 - give 10 units >400 - give 12 units and recheck within 1 hour . At Bedtime please give half of the dose for meal time sliding scale. 18. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual q5 minutes x 3 as needed for chest pain: Please take for chest pain. Can take up to three tablets total. Please call 911. . 19. Milk of Magnesia 7.75 % Suspension Sig: 30 mL PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare-[Location (un) 86] Discharge Diagnosis: Primary: Hypertensive Emergency Congestive Heart Failure . COPD Diabetes type II Hypercholesterolemia GERD Glaucoma Discharge Condition: Good Discharge Instructions: You were seen and evaluated for your shortness of breath. You were found to have an elevated blood pressure and evidence of fluid in your lungs. You were treated with medications for your blood pressure as well as for the fluid in your lungs. . Please take all your medications as prescribed. The following changes were made to your medication regimen. 1. Please take lasix 40 mg every day instead of every other day. 2. Please take hydralazine 25 mg every six hours instead of every 8 hours. 3. Please take lisinopril 10 mg two times a day instead of three times a day. . Please keep all your follow up appointments. You have an appointment scheduled with your cardiologist Dr. [Last Name (STitle) 2357] on [10-30]. You should also follow up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] within one week fo discharge. . Please seek immediate medical attention if you experience any chest pain, shortness of breath, fevers > 101.5 degrees, lightheadedness, diziness, numbness or tingling or any other concerning symptoms. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2200-10-31] 12:00 . Please follow up with your primary care physician [Last Name (NamePattern4) ]. [First Name (STitle) ] [Name (STitle) ] within one week of disharge. The office phone number is [Telephone/Fax (1) 6019].	[ "4280", "5859", "496", "53081", "25000", "2720" ]
Admission Date: [2137-10-28] Discharge Date: [2137-11-2] Date of Birth: [2082-3-24] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1257] Chief Complaint: . GENERAL MEDICINE ADMISSION HISTORY AND PHYSICAL . . PCP: : [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1022] [Telephone/Fax (1) 250] Onc: Dr. [First Name (STitle) ] [Name (STitle) ] . . Chief complaint: jaundice, fatigue Major Surgical or Invasive Procedure: ERCP [10-29] with sludge removal with balloon History of Present Illness: 55 yo F with history of DM, recent diagnosis of hepatobiliary malignancy (?cholangiocarcinoma vs. HCC)s/p ERCP and metal stent placement ([8-30]) for obstructive jaundice admitted [2137-10-28] with one day of fatigue and jaundice. She was previously found to have a hilar mass with portal vein invasion which has yet to be biopsied for diagnosis. Had a metal stent placed [8-30] by Dr. [Last Name (STitle) ]. Was asymptomatic except for jaundic and fatigue. Plan was to admit for ERCP for possible stent obstruction. Past Medical History: hepatobiliary malignancy (?cholangioCa vs HCC) with portal vein invasion, s/p ERCP and metal stent placement by Dr. [Last Name (STitle) ] [8-30] Diabetes-diet controlled dyslipidemia H.pylori, recently diagnosed Social History: Lives with long time boyfriend. [Name (NI) ] h/o tobacco or etoh or illicits Family History: denies any significant family history of any illness/malignancies. Physical Exam: Physical Exam on admission Gen: pleasant, lying in bed, nad Eyes: scleral icterus, EOMI ENT: o/p clear, mm dry Neck: no jvd, no bruits CV: RRR, no m, nl S1, S2 Resp: CTAB, no crackles or wheezes Abd: soft, nontender, nondistended, +BS, no HSM appreciated Lymph: no cervical, axillary, inguinal LAD Ext: no edema, good peripheral pulses, no cyanosis Neuro: A&OX3, CNII-XII intact, strength equal b/l LE/UE, intact sensation Skin: warms, no rashes psych: appropriate . . On discharge Vitals: 98.5 120/74 58 18 99%RA Pain: 0/10 Access: PIV Gen: nad HEENT: mild scleral icterus, mmm CV: RRR, no m appreciated Resp: CTAB, no crackles or wheezing Abd; soft, nontender, +BS Ext; no edema Neuro: grossly nonfocal Skin: jaundiced psych: appropriate . . Pertinent Results: CTA [10-31]: IMPRESSION: 1. No pulmonary embolism to the subsegmental level. 2. Increased bilateral pleural effusion with septal thickening and scattered ground-glass, consistent with volume overload. 3. Right-sided aortic arch with mirror image type. Note that this pattern is strongly associated with congenital heart disease. 4. Mild cardiomegaly. 5. Borderline lymph nodes, could be related to congestive heart failure. . TTE [10-31]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is no pericardial effusion. . . ERCP REPORT [10-29]: A metal stent placed in the biliary duct was found in the major papilla. Evidence of a previous sphincterotomy was noted in the major papilla. There were multiple filling defects that appeared like sludge in the biliary tree within the wallstent. Sludge was extracted successfully using a 11.5 mm RX balloon. Subsequent occlusion cholangiogram demonstrated normal filling of the CBD and the right intrahepatics. . . CT Torso [10-30]: Infiltrating mass obliterating the fat at the hepatic hilum along the region of the left hepatic duct. This lesion encases the common and left hepatic artery and occludes the left portal vein, with narrowing of the main and right portal veins. Given these findings, most likely diagnostic consideration would be cholangiocarcinoma. 2. Small amount of perihepatic ascites. 3. Small bilateral pleural effusions, worse on the right than the left. 4. Right-sided aortic arch (mirror-image type). Note that this type of variant anatomy has high association with coexistant congenital heart disease. . [2137-10-28] RUQ ULTRASOUND: Minimal intrahepatic biliary ductal dilatation. Metallic stent identified in the common bile duct. . OSH hospital records: CT abd/pelvis with contrast [2137-9-18]: 2.5 x 3cm mass in porta hepatis which shows encasement of the portal vein. There is dilation of right intrahepatic ducts. the left portal vein is expanded and likely thrombosed there is direct extension of the mass into the left lobe of liver, measuring 2.5cm. There is no other intrahepatic mass seen. there is no evidence of pancreatic mass or pancreatic duct distention. Spleen is unremarkable. three is no evidence of renal mass or obstruction. There is no evidence of renal calcification or calculus. There is no evidence of pelvic mass or free fluid in the pelvis. . MRI Abdomen without and with contrast [2137-9-19]: There is a 3x3.5x2.5cm mass in the left lobe of liver, with contiguous exten into the porta hepatis. There is thrombosis of the left portal vein. There is encasement of the main portal vein. there is encasement and narrowing o the proximal common hepatic duct, with dilation of right intrahepatic ducts more than left intrahepatic ducts. The mass shows some enhancement after gadolinium. There are no other liver masses seen. The findings are consistent with cholangiocarcinoma. Metastatic disease cannot be completely excluded. The spleen and pancreas are unremarkable. There is no renal mass or obstruction. there is no retroperitoneal adenopathy identified. Conclusion: Most likely cholangio CA with contiguous extent to porta hepatis. Thrombosis of portal vein. Brief Hospital Course: 55year old vietnamese female with DM, recently diagnosed probably cholangiocarcinoma with portal vein invasion s/p palliative metal stent [8-30] admitted [10-28] with 1 day of lethargy and jaundice, found to have cholestatic elevation of LFTs. On first day of admission [10-29], she underwent ERCP for new jaundice with concern for stent obstruction. ERCP showed sludge s/p extraction with balloon wiht subsequent occlusion cholangiogram showing patent biliary tract. Following the procedure, the pt was hypotensive to 80/50, asymptomatic, and then spiked a temp to 102.6. Recieved total 2L IVF, not much improvement, thus transfered to ICU given concern for cholangitis vs. bleeding. She was started on Zosyn and vancomycin for possible sepsis, total 4L IVF, did better. CTA [10-31] showed no PE but some pulm congestoion/small effusions. TTE [10-31] showed normal EF with 2+ TR and borderline pulm HTN. LIkely was transient bacteremia (cx neg) from procedure as pt quickly recovered and did well. She was transitioned to levoflox on [11-2] (48hours neg cx) with plan to complete 7day course. Tranfsered to Gen Med [10-31] for further management [10-31]. As for diagnosing exactly what type of malignancy, she underwent EUS on [10-31] with attempt to biopsy mass, but the porta hepata mass was not identified. CT reconstruction showed mass in liver hilum, near porta hepatis, with occlusion of portal vein/encasement of hepatic artery. Plan was for CT guided biopsy but there was hesitance given high risk of bleeding given location. There was an attempt by radiology to get diagnostic paracenthesis [11-1] (CT showed ascites but done after large IVFs) but no fluid. Procedure scheduled for [11-5] as outpt. Dr [Last Name (STitle) ] notified of plan and pt has f/u with him on [11-6]. Niece: [Name (NI) 58533]: [Telephone/Fax (1) 79256] was updated with plan. she was transfused with I unit of RBC before discharge for Hgb of 7.3, although she was asymptomatic, for expected procedure. . . . . .. total discharge time 67 minutes. Medications on Admission: cholestyramine 4mg [Hospital1 ] simva 10mg qd docusate [Hospital1 ] PrevPac (lansoprazole/Amox/Clarithro) [Hospital1 ]. Discharge Medications: 1. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 2. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 7 days: finish on [11-11]. 3. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days: finish [11-11]. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Hepatobiliary malignancy,likely cholangiocarcinoma Obstructive jaundice s/p ERCP [10-29] and sludge removal, stent remaining in place Discharge Condition: Good Discharge Instructions: You were admitted with Jaundice and you underwent ERCP procedure to open up the stent that was blocked. after the procedure you developed fevers and low blood pressure and you were sent to ICU for a couple days for closer monitoring with IV antibiotics. You are now doing better and will go home to complete oral antibiotic course We are trying to get a biopsy of the mass near your liver but were not able to get this done while you were here. Given its location near the blood vessels, it is high risk, so we will try to do this under CT guidance on Tuesday [11-5] at 9am. Return if you have recurrent jaundice, fevers, pain. complete your levofloxacin, 4more days complete your H.Pylori treatment (prev-pac), should end near [11-11] do not restart your simvastatin Followup Instructions: Please come to [Hospital Ward Name 121] building, [Location (un) 453], 'DAY CARE' center at 9am on tuesday [11-5] for your procedure. Nothing to eat after midnight on [11-4] and do not take any aspirin products before procedure. Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2137-11-5] 10:30 Provider: [Name10 (NameIs) ] [Apartment Address(1) ] TEMP [Hospital Ward Name ] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2137-11-5] 10:30 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2137-11-6] 3:00	[ "5119", "99592", "78552", "25000", "2724" ]
Admission Date: [2136-6-12] Transfer Date: [2136-6-13] Date of Birth: [2136-6-12] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname 3321] was the 3.525 kg product of a 36 [4-21] week gestation born to a 38 year old gravida 2, para 1, now 2 Mom. Past obstetric history was notable for delivery in [2133] of a term female with antenatally diagnosed fetal pyloric stenosis, which required repair at six weeks of age. PAST MEDICAL HISTORY: Unremarkable with exception of psoriasis treated topically. Prenatal screens 0 positive, direct Coomb's negative, RPR nonreactive, Rubella immune, hepatitis surface antigen negative, Group B Streptotoccus unknown. ANTEPARTUM HISTORY: Expected date of delivery, [2136-7-2]. Pregnancy uncomplicated until ultrasound at 19 weeks showed bilateral hydronephrosis. This has been followed by daily ultrasounds with the most recent recorded on [2136-5-11], showing bilateral duplicated collecting systems with severe right-sided hydronephrosis and cortical thinning, ureterocele and left-sided mild hydronephrosis and caliectasis. Betamethasone course completed at 32 weeks. Because of evolving ultrasound findings labor was induced on the evening prior to delivery and progressed to spontaneous vaginal delivery under epidural anesthesia. Assisted rupture of membranes, three hours prior to delivery yielding clear amniotic fluid, intrapartum antibiotic therapy administered 4.5 hours prior to delivery. No maternal fever, fetal tachycardia or clinical chorioamnionitis. Infant delivered, vigorous upon delivery, orally and nasally bulb suctioned, dry free flow oxygen. Apgars were assigned at 8 and 9. PHYSICAL EXAMINATION: Physical examination on admission revealed birth weight 3.25 kg, anterior fontanelle soft and flat, nondysmorphic, palate intact. Neck and mouth normal. No nasal flaring. Mild intercostal retractions. Good breathsounds bilaterally, no crackles, well perfused. Regular rate and rhythm. Femoral pulses were normal S1 and S2, normal no murmur. Abdomen, soft, nondistended. Right kidney palpable. No palpable bladder. Liver, 2 cm below the right costal margin. Bowel sounds active, anus patent. Normal male genitalia. Testes descended bilaterally. Active, responsive to stimulation, crying vigorously but consoles appropriately. Tone normal and symmetric. HOSPITAL COURSE: (By systems) Respiratory - [Known lastname ] remained in room air throughout his hospital stay. Cardiovascular - No issues. Fluids - Initial birth weight was 3.525 kg and infant was on ad lib feedings. Did have episode of some spitting which resolved within the first 24 hours of age. The infant was passing meconium and voiding quantities sufficient. Genitourinary/gastrointestinal - Renal ultrasound performed on day of birth, confirmed prenatal findings including bilateral duplex collecting system, severe right hydronephrosis with caliectasis of lower pole leading to dilated ureter and upper pole eventually leading to the ureterocele. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 916] who is the surgeon at [Hospital6 2121] was contact[Name (NI) ] by Dr. [Last Name (STitle) ]. Dr.[Name (NI) 42552] recommendation, given low evidence of bladder outlet obstruction by normal urine output and normal stream, was to see the baby at one week of age. He would be willing to see the infant sooner if the mother desired. This information was conveyed to the mother, and a copy of the renal ultrasound was provided to the mother. Infectious disease - The infant was started on 20 mg/kg/day of Amoxicillin for prophylaxis. Sensory - Hearing screen has not yet been performed. CONDITION ON TRANSFER: Stable. DISCHARGE DISPOSITION: Newborn Nursery. PRIMARY CARE PEDIATRICIAN: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], phone [Telephone/Fax (1) 45538]. CARE RECOMMENDATIONS: 1. Feedings - Continue ad lib feedings. 2. Medications - Continue Amoxicillin 20 mg/kg/day 3. Screening - Carseat position preening, not applicable. State newborn screens have not yet been obtained. 4. Immunizations - The infant has not yet received immunizations. DISCHARGE DIAGNOSIS: 37 Week male, bilateral duplex collecting system with right ureterocoele and bilateral hydronephrosis (moderate to severe on right). [First Name11 (Name Pattern1) 37693] [Last Name (NamePattern4) 37927], M.D. [MD Number(1) 37928] Dictated By:[Last Name (NamePattern1) 38294] MEDQUIST36 D: [2136-6-13] 14:51 T: [2136-6-13] 16:04 JOB#: [Job Number 51209]	[ "V053" ]
Admission Date: [2135-5-4] Discharge Date: [2135-5-9] Date of Birth: [2051-2-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4071] Chief Complaint: weakness, A-fib with RVR Major Surgical or Invasive Procedure: None History of Present Illness: 84 yo M with a history of mitral valve regurgitation, [First Name3 (LF) 8813] stenosis (unknown valve diameter as no TTE info) who brought in by ambulance from PCPs office for tachycardia. Patient was recently admitted to [Hospital1 2025] from [4-28] to [5-1], for CHF exacerbation. He had a TTE and CXR done there, and was noted to have MR and AS. Apparently he was admitted with a shortness of breath, in the setting of congestive heart failure, after drinking lots of fluids after a gout attack. Awaiting OSH records. New atrial fibrillation diagnosed on that admit and patient started on metoprolol 50 mg [Hospital1 ], digoxin 0.125 every other day in addition to lisinopril continued at 2.5 mg and lasix initiated at 20 mg daily. Patient returned home but stated he felt fatigued and weak prior to discharge. Over two days increasing fatigue, large amounts of urination, with "bed wetting". No chest pain, sob, focal weakness or deficit, cough, orthopnea, PND, palpitations, lightheadedness. No fever, chills, N/V or diarrhea. As per patient he did not take his digoxin when he left the hospital as he was concerned about its indication. He also refused anticoagulation. . In the ED, initial vs were: T 98.4 P 140 BP 130/77 R 20 O2 sat 98% on 3L. Patient denied chest pain, shortness of breath, or lightheadedness. Patient was given 500cc NS, Dilatiazem 10mg IV x1, ASA 325mg po once, and Levofloxacin 500mg IV once. 500+ cc NS given. Foley placed with greater than 1 L removed. No acute change on EKG RBBB. Attempted dilt x2 with bp drop to 90. WBC 17.9, levo for presumptive pulmonary source. Cardiology was not consulted and patient admitted for A-fibb with RVR, HF, and leukocytosis. On transfer HR 130. BP systolic 100. -------------------- Addendum -[Hospital1 2025] records Presented to OSH [4-28] with SOB. 3 weeks prior had a gout flair. Treated with indomethacin. Drinking more fluids than usual. Over the following several weeks had difficulty sleeping because couldn't lie flat. SOB worsened to the point where he couldn't speak full sentences. -patient was ruled out for MI -diuresed -TTE: severe AS, moderate to severe MR [Name13 (STitle) 25215] consulted: suggested low dose BB, ACE-I, and d/c-ing diltiazem -patient declined valve repair -Afib: Dilt discontinued. Started on digoxin and metoprolol. Converted to NSR. Refused anticoagulation with coumadin. Discharged on ASA 325mg po daily. ECHO: EF 48%, RV hypokinetic. Moderate to severe MR. [First Name (Titles) ] [Last Name (Titles) 25216]e area of 0.8cm2. Peak trans AV gradient of 37mmHg. Mean trans AV gradient is 22mmHg. Past Medical History: 1. Congestive heart failure (I do not know his EF) 2. Atrial fibrillation- refused anticoagulation 3. [Last Name (Titles) ] stenosis- do not know valve diameter 4. Mitral regurgitation 5. Hypertension. 6. Significant anxiety. 7. Osteoarthritis. 8. Gout disorder. 9. BPH Social History: No tobacco, etoh, or drug use. Does not require oxygen at home. Family History: Non contributory. Physical Exam: Vitals: 98 106 113/58 18 97% +1600/-1900 General: Alert, oriented to self place time, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB. No wheezes CV: Irregularly irregular. Tachycardic. 4/6 SEM 2RIC no rad to cartids, depressed S2. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Large scab without warmth or erythema right abdomen. Non tender to palpation. Foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, trace edema Pertinent Results: Admission labs: [2135-5-4] 11:55AM BLOOD WBC-17.7# RBC-4.57 Hgb-13.3* Hct-39.0* MCV-85 MCH-29.0 MCHC-34.0 RDW-14.6 Plt Ct-255 [2135-5-4] 11:55AM BLOOD Neuts-81.0* Lymphs-12.5* Monos-5.9 Eos-0.4 Baso-0.2 [2135-5-4] 11:55AM BLOOD PT-14.4* PTT-26.3 INR(PT)-1.3* [2135-5-4] 11:55AM BLOOD Glucose-121* UreaN-40* Creat-2.1# Na-139 K-4.4 Cl-101 HCO3-26 AnGap-16 [2135-5-4] 11:55AM BLOOD ALT-26 AST-25 LD(LDH)-308 CK(CPK)-55 AlkPhos-81 TotBili-1.4 [2135-5-4] 11:55AM BLOOD CK-MB-NotDone proBNP-[Numeric Identifier 25217]* [2135-5-4] 08:23PM BLOOD CK(CPK)-38 [2135-5-5] 06:03AM BLOOD ALT-16 AST-16 LD(LDH)-204 CK(CPK)-40 AlkPhos-64 TotBili-0.9 [2135-5-4] 08:23PM BLOOD CK-MB-NotDone cTropnT-0.03* [2135-5-5] 06:03AM BLOOD CK-MB-NotDone cTropnT-0.03* [2135-5-4] 11:55AM BLOOD Calcium-9.9 Phos-4.6* Mg-2.9* [2135-5-4] 11:55AM BLOOD TSH-1.8 [2135-5-4] 11:55AM BLOOD Digoxin-1.0 . ECHO ([2135-5-5]): The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The [Month/Day/Year 8813] root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The [Month/Day/Year 8813] valve leaflets are severely thickened/deformed. There is severe [Month/Day/Year 8813] valve stenosis (valve area 0.8-1.0cm2). Trace [Month/Day/Year 8813] regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, splayed jet of moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Discharge labs: [2135-5-9] 12:45AM BLOOD WBC-9.9 RBC-4.13* Hgb-12.2* Hct-36.1* MCV-87 MCH-29.5 MCHC-33.8 RDW-14.6 Plt Ct-203 [2135-5-9] 12:45AM BLOOD Glucose-93 UreaN-16 Creat-1.0 Na-142 K-4.5 Cl-105 HCO3-26 AnGap-16 [2135-5-9] 12:45AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.2 Brief Hospital Course: 84 yo M with a history of CHF, Atrial fibrillation, moderate to severe AS, and MR, with recent admission at [Hospital1 2025] for CHF exacerbation and new onset atrial fibrillation, presented with weakness, afib with RVR. Initially admitted to MICU for atrial fibrillation with RVR with heart rate in 100-150s, and hypotensive. Likely hypotensive given tachycardia rate related. Given Digoxin, CE sent (at baseline and not trending upwards). Upon recs from cardiology, started on amiodarone gtt with initial loading dose. No anticoagulation due to patient refusal to take medication. Aspirin given, beta blocker started, and digoxin was discontinued. After being transferred to inpatient floor, patient was continued on amiodarone and converted to normal sinus rhythm. He was volume overloaded and diuresed to euvolemia. He was referred to cardiac surgery for consideration for [Hospital1 8813] stenosis surgical intervention which he will consider as an outpatient. He was also found to be in acute renal failure on admission likely post-renal given his acute on chronic urinary retention. He had a Foley placed with greater than 1L output but was asymptomatic with this. He described a history of chronic prostatic enlargement and overflow incontinence therefore this likely represents outflow obstruction from BPH. He failed a voiding trial and was discharged on finasteride with a Foley catheter and outpatient urology follow-up. Renal function had returned to baseline at time of discharge. Medications on Admission: ASA 325mg po daily Centrum silver once daily Digoxin 125mcg po daily Lasix 20mg po daily Indomethacin 25mg po tid PRN gout pain Lisinopril 2.5mg po daily Metoprolol 50mg po daily Simvastatin 40mg po daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): * 2 tabs twice daily for 7 days; * 2 tabs once daily for 7 days; * 1 tab daily thereafter. Disp:60 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Centrum Silver 500-250 mcg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). Disp:1 tube Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 4860] - [Location (un) 4310] Discharge Diagnosis: Atrial fibrillation [Location (un) ] stenosis Hypertension Urinary Rentention Acute diastolic heart failure Discharge Condition: Medically Stable for Discharge Discharge Instructions: You were admitted because you presented with fatigue and were found to have atrial fibrilation. We gave you amiodarone which converted you back to anormal heart rhythm. . You also have [Location (un) 8813] valve stenosis and we consulted cardiac surgery which recomended that you have this valve replaced. We understand your hesitation over this major surgery, but we do feel that it is the indicated treatment for your condition. . You also developed some difficulty urinating after a Foley catheter had been placed which has likely been happening for a long time. You were started a new medication and a Foley catheter was placed at discharge. You will need to follow up with a Urologist for further management. We made the following medication changes: 1. STOP digoxin 2. STOP indomethacin since you do not have active gout 3. START finasteride 5mg daily for your prostate 4. START amiodarone 400mg twice daily until [2135-5-10] then amiodarone 200mg twice daily until [2135-5-17] then 200mg daily 5. STOP lasix, if you feel short of breath, if you notice leg swelling, or if you gain more than 2 pound in weight, call your regular doctor and discuss starting low dose lasix (10 mg daily). 6. DECREASE simvastatin from 40mg to 20mg daily Please call your doctor or return to the ED if you have chest pain, shortness of breath, fatigue, palpitations, sweating, lightheadedness or swelling of your legs. Please weight yourself daily and report to your regular doctor if your weight changes by 2 pounds or more. Followup Instructions: Please follow up with Dr [First Name8 (NamePattern2) ] [Name (STitle) ], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2135-5-17] at 2:30pm An appointment was amde for you with a Urologist on [5-18] at 9:30am. The clinic is on the [Location (un) 470] of the [Hospital Ward Name 23] building. Please call ([Telephone/Fax (1) 772] with questions. Please ask to be refered to a cardiologist by your regular physician. [Name10 (NameIs) 17219] you may call [Telephone/Fax (1) 25218] to shedule an appointement with a cardiologist within the next 2 weeks. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4074] Completed by:[2135-5-10]	[ "5849", "4280", "42731", "4019" ]
Admission Date: [2177-2-12] Discharge Date: [2177-2-15] Date of Birth: [2119-7-28] Sex: M Service: MEDICINE HISTORY OF THE PRESENT ILLNESS: This patient is a 57-year-old man with a history of diverticulosis, esophagitis, GERD, who presented to [Hospital ] Hospital on [2177-2-8] with weakness and was found to have a hematocrit of 18.4 from a GI bleed. The patient said that he the patient had an extensive workup which included an EGD on [2177-2-8] which showed erosive gastritis with a question of slight blood but no active site of bleeding. There was also note of a nonobstructing thin Schatzki's ring. On [2177-2-9], the patient had a large amount of melena and the patient's hematocrit went from 18.4 to 25 after 5 performed which showed old blood in the fundus, approximately 175 cc. The patient then was taken to a tagged red blood cell scan which was positive for bleeding in the mid and left abdomen. On [2177-2-10], the patient was taken to Angiography which was a normal study and did not show any evidence of extravasation or site of bleeding. IgG for H. pylori was reportedly negative. The patient received a total of 13 units at the outside hospital of packed red blood cells as well as 2 units of FFP. On [2177-2-12], the patient's hematocrit dropped from 30 to 26.7 and the patient was transferred to the [Hospital6 1760] for further evaluation. PAST MEDICAL HISTORY: 1. Hypertension. 2. Esophagitis/GERD. 3. Hypercholesterolemia. 4. Diverticulitis. 5. History of GI bleeding. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Accupril. 2. Lipitor. 3. Norvasc. 4. Iron. 5. Pepcid. MEDICATIONS ON TRANSFER: 1. Protonix 40 mg IV q. 24 hours. 2. Tylenol. SOCIAL HISTORY: The patient is married with one 14-year-old son. [Name (NI) ] works as a trouble shooter for a high-tech equipment company. He drinks approximately one to two beers per week. He denied any tobacco or drug use. FAMILY HISTORY: The patient's father has coronary artery disease. PHYSICAL EXAMINATION ON ADMISSION: General: The patient is a middle-aged man in no acute distress. Vital signs: Temperature 98.6, heart rate 77, blood pressure 124/61, respiratory rate 13, oxygen saturation 100% on room air. HEENT: Pupils equal, round, and reactive to light, extraocular movements intact, oropharynx clear. Lungs: Clear to auscultation bilaterally. HEENT: Regular rate and rhythm. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: No clubbing, cyanosis or edema with 2+ peripheral pulses. LABORATORY DATA: White count 9.2 with a hematocrit of 24.4, platelets 235,000. Sodium 142, potassium 3.8, chloride 110, bicarbonate 26, BUN 32, creatinine 0.9, glucose 116, calcium 7.9, magnesium 1.8, phosphate 3.6, INR 1.2. Urinalysis: Negative. EKG: Normal sinus rhythm at a rate of 80 with normal axis, QTC at 449, no acute ST or T wave changes. HOSPITAL COURSE: 1. GASTROINTESTINAL: The patient was taken to Endoscopy on [2177-2-13] where they found gastritis, gastric arteriovenous malformations that were cauterized successfully and duodenitis. It was thought that the gastric AVMs were likely the cause of the patient's massive GI bleed. The patient was also started on Protonix 40 mg p.o. b.i.d. and the patient's diet was advanced slowly from a clear liquid diet to a full low-sodium diet. The patient did not have any further episodes of GI bleeding while in the hospital; however, he did require an additional 2 units of packed red blood cells to maintain his hematocrit above 26. The patient's hematocrit was stable after endoscopy and upon discharge his hematocrit was 28. The patient was tolerating a normal diet without any difficulty and was passing brown nonmelenic stools. The patient will need a repeat endoscopy for follow-up in three to four weeks with Dr. [Last Name (STitle) 1940]. 2. GENITOURINARY: The patient complained of difficulty emptying his bladder and increased urinary frequency on [2177-2-15] after his Foley catheter was discontinued on [2177-2-14]. The patient had a Foley catheter in place for approximately five to six days. The patient reports that prior to Foley catheterization he only had mild difficulty in initiating urination but did not have any problems emptying his bladder. A urinalysis was obtained on [2177-2-15] which was negative for any evidence of infection. A postvoid residual was checked and revealed 990 cc of urine in his bladder. It was thought that the patient may either have an obstructive lesion, however, the patient's prostate was normal on examination without tenderness. In addition, it is possible that the patient may have had a neurogenic bladder as a result of the Foley catheterization or that the Foley catheterization exacerbated the patient's prior mild case of urinary obstruction. The patient will be discharged home with a leg Foley bag and he will follow-up with his primary care physician in two days for removal of the catheter. He will also be started empirically on Levaquin 250 mg p.o. times five days for empiric treatment even though the patient's urinalysis was negative for infection. If the patient is not able to urinate upon removal of the Foley catheter then the patient will need urologic follow-up with possible urodynamic studies and cystoscopy. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSIS: 1. Gastrointestinal bleed secondary to gastric arteriovenous malformation. 2. Urinary retention with questionable obstruction. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. b.i.d. 2. Levaquin 250 mg p.o. q.d. times five days. 3. Atorvostatin 10 mg p.o. q.d. 4. Norvasc 5 mg p.o. q.d. 5. Accupril 10 mg p.o. q.d. FOLLOW-UP: The patient will follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1940] in approximately three to four weeks for repeat endoscopy. The patient will also follow-up with his primary care physician for his urinary obstruction/Foley catheter. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 13467] Dictated By:[Last Name (NamePattern1) 1336] MEDQUIST36 D: [2177-2-15] 12:10 T: [2177-2-16] 18:49 JOB#: [Job Number 48966]	[ "2720", "4019", "53081" ]
Admission Date: [2108-11-9] Discharge Date: [2108-11-19] Date of Birth: [2038-3-16] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 70 year old white female has a known history of coronary artery disease and is status post myocardial infarction in [2103], with multivessel disease by catheterization at that point, which was medically managed. She now presents with chest pain at rest for two days and borderline increased troponin with a non Q wave myocardial infarction. She is now admitted for cardiac catheterization. PAST MEDICAL HISTORY: Myocardial infarction in [2103]. History of noninsulin dependent diabetes mellitus. Hypertension. Hypercholesterolemia. Paroxysmal atrial fibrillation. Status post appendectomy. Status post hernia repair. Status post left knee surgery. Status post tonsillectomy. ALLERGIES: She has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Glucophage. 2. Diovan. 3. Zetia. 4. Lipitor. 5. Toprol. SOCIAL HISTORY: She lives alone, quit smoking fifteen years ago, has a twenty pack year history and does not drink alcohol. FAMILY HISTORY: Significant for coronary artery disease. REVIEW OF SYMPTOMS: Unremarkable. PHYSICAL EXAMINATION: On physical examination, she is an elderly white female in no apparent distress. Vital signs stable and afebrile. Head, eyes, ears, nose and throat examination is normocephalic and atraumatic. Extraocular movements are intact. The oropharynx is benign. The neck is supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids are two plus and equal bilaterally without bruits. Lungs are clear to auscultation and percussion. Cardiovascular examination reveals irregular rhythm, normal S1 and S2, with no murmurs, rubs or gallops. The abdomen is soft, obese, nontender, with positive bowel sounds, no masses or hepatosplenomegaly. Extremities were without cyanosis, clubbing or edema. Neurologic examination was nonfocal. HOSPITAL COURSE: She was admitted for cardiac catheterization, which revealed an 80 percent left anterior descending coronary artery stenosis, 90 percent left circumflex stenosis and an 80 percent right coronary artery stenosis with an ejection fraction of 62 percent. Dr. [Last Name (STitle) 70] was consulted. The patient had some angina while awaiting surgery and on [2108-11-12], she underwent a coronary artery bypass graft times four with left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to right coronary artery, obtuse marginal one and obtuse marginal two sequential. Cross clamp time was 52 minutes, total bypass time was 79 minutes. The patient was transferred to the CSRU on Neo-Synephrine and Propofol in stable condition. She was extubated on postoperative day number one. She had a short run of atrial fibrillation, which quickly resolved with Lopressor and one bolus of Amiodarone. She had her chest tubes out on postoperative day number two. She was transferred to the floor on postoperative day number three. She continued to require aggressive diuresis as she was quite fluid overloaded. She had her epicardial pacing wires discontinued on postoperative day number four. She continued to improve and was discharged to home on postoperative day number seven in stable condition. Her laboratories on discharge were hematocrit 32.6, white blood cell count 8.6, platelet count 394,000. Sodium 145, potassium 4.4, chloride 106, CO2 29, blood urea nitrogen 14, creatinine 0.8, blood sugar 128. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 mg p.o. daily. 2. Colace 100 mg p.o. twice a day. 3. Glyburide 2.5 mg p.o. daily. 4. Zetia 10 mg p.o. daily. 5. Amiodarone 400 mg p.o. twice a day for seven days, then 400 mg p.o. daily for seven days, then decrease to 200 mg p.o. daily. 6. Lipitor 80 mg p.o. daily. 7. Vicodin one to two p.o. q4-6hours p.r.n. pain. 8. Potassium 20 mEq p.o. twice a day for ten days. 9. Lopressor 50 mg p.o. twice a day. 10. Lasix 40 mg p.o. twice a day for ten days. 11. Iron 325 mg p.o. daily. 12. Vitamin C 500 mg p.o. twice a day. 13. Multivitamin one p.o. daily. FOLLOW UP: She will be followed up with Dr. [Last Name (STitle) 9955] in one to two weeks, Dr. [First Name (STitle) ] in two to three weeks and Dr. [Last Name (STitle) 70] in four weeks. DISCHARGE DIAGNOSES: Coronary artery disease. Noninsulin dependent diabetes mellitus. Hypertension. Hypercholesterolemia. Paroxysmal atrial fibrillation. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern1) 18588] MEDQUIST36 D: [2108-11-19] 18:08:22 T: [2108-11-19] 19:14:27 Job#: [Job Number 30154]	[ "41401", "42731", "25000", "4019", "2720" ]
Admission Date: [2162-10-14] Discharge Date: [2162-10-18] Date of Birth: Sex: Service: HISTORY OF PRESENT ILLNESS: This 30 year old, white female is status post cerebrovascular accident on [2162-9-7] and also had complaints of dyspnea on exertion. She had left arm weakness and presented to the Emergency Room. The symptoms had resolved by the time she was admitted and her work-up was essentially negative except for an echo which revealed a atrial septal defect. She was referred to Dr. [Last Name (STitle) 1537]. Her echo also revealed an ejection fraction of 55% with mitral valve prolapse and a right to left shunt. She is now admitted for repair of her atrial septal defect. PAST MEDICAL HISTORY: Significant for history of depression and history of carpal tunnel syndrome. She was on no medications. She is allergic to bees. She gets anaphylaxis. SOCIAL HISTORY: She works as a waitress. She quit smoking ten weeks ago. She drinks alcohol occasionally. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: She is a well developed, thin, white female in no apparent distress. Vital signs stable. Afebrile. HEAD, EYES, EARS, NOSE AND THROAT: Normal cephalic, atraumatic. Extraocular movements intact. Oropharynx benign. Neck was supple. Full range of motion. No lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally without bruits. Lungs were clear to auscultation and percussion. Cardiovascular examination: Regular rate and rhythm; normal S1 and S1; no murmurs, rubs or gallops. Abdomen soft, nontender, with positive bowel sounds, no masses or hepatosplenomegaly. Extremities were without cyanosis, clubbing or edema. Neurologic: Examination was nonfocal. She had 2+ pulses equally throughout and on [10-14], she underwent a minimally invasive atrial septal defect repair. The cross clamp time was 55 minutes. She was transferred to the CSRU on Propofol in stable condition. She was extubated. She was transiently on Neo on her postoperative night. Postoperative day number one, she did have some nausea but was otherwise stable. She was transferred to the floor on postoperative day number two. Her chest tube was discontinued. She continued to have a stable postoperative course but was a little slow to ambulate. On postoperative day number four, she was discharged to home in stable condition. LABORATORY DATA: Hematocrit of 28.5; white count 4,800; sodium of 137; potassium of 3.8; chloride of 104; C02 of 29; BUN 9; creatinine 0.4. Blood sugar 92. MEDICATIONS ON DISCHARGE: Percocet one to two p.o. every four to six hours prn for pain. Colace 100 mg p.o. twice a day. She will be followed by Dr. [Last Name (STitle) ] in one to two weeks and by Dr. [Last Name (STitle) 1537] in four weeks. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 34952] MEDQUIST36 D: [2162-10-18] 03:31 T: [2162-10-18] 18:05 JOB#: [Job Number 95970]	[ "4240" ]
Admission Date: [2168-11-16] Discharge Date: [2168-11-29] Date of Birth: [2101-2-2] Sex: F Service: NEUROLOGY Allergies: Tetracycline Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Seizure in the setting of intraparenchymal hemorrhage Major Surgical or Invasive Procedure: * Pt arrived intubated History of Present Illness: PER ADMITTING RESIDENT: The patient is a 67 year old woman with a history of AI s/p [Last Name (NamePattern1) 1291] on Coumadin, hypertension, and ESRD on HD qMWF who presents with left arm weakness since 9:30 am today ([First Name8 (NamePattern2) ] [Hospital 882] Hospital records) vs. intermittent episodes of rhythmic left arm twitching and preserved consciousness since 3:45 pm today (per her daughters) who was found to have a right posterior frontal parenchymal hemorrhage at the [Doctor Last Name 352]-white matter junction with subarachnoid spread in the setting of INR to 2.9. The patient is accompanied by her daughters [Name (NI) 12335] and [Name (NI) 1494]. Per the [Hospital 882] Hospital notes, the patient started having left arm weakness at 9:30 am today. However, per the patient's daughters, the patient had HD at 9:30 am today. She then called her daugther at 3:45 pm as she was having rhythmic twitching of her left arm. This would occur intermittently and last 5 minutes at a time. She had preserved consciousness during the episodes with no tongue biting or loss or bowel/bladder function. At that time she had no twitching in her left leg or her entire right side. She does not have a history of seizures. Her daughters did not notice any left sided weakness at 3:45 today. She has not had recent headache or head trauma, and has not had fevers/chills, coughs/colds, or diarrhea. Her daughters say she has not been feeling well for the past 2 weeks. She was initially taken to [Hospital 882] Hospital where vitals were afebrile, bp 161/83, HR 110, RR 16, SaO2 98% on RA. Exam showed alert and oriented x3, tachycardia, left arm flaccid with no reflexes noted, twitching in distal arm, lower extremities within normal limits. Labs showed INR 2.9, PTT 37.3, WBC 11.6 (90% neutrophils), Hct 32.8, plt 241, Na 143, K 4.2, Cl 97, CO2 33, BUN 32, Cr 8.1, glucose 103, Ca [69].1, AST 18, ALT 12, alk phos 144. Head CT showed a right frontal intraparenchymal hemorrhage with subarachnoid extension, and she was transferred to [Hospital1 18] for further evaluation. In the [Hospital1 18] ED, her INR was 3.1 on admission, and she was given Vitamin K 10 mg IV x1 and ordered for 2 U FFP. Per the ED attending she had a flaccid left arm on admission but was moving her left leg, coherent, speech clear, and no facial droop. While in the ED, she again had rhythmic twitching of her left hand AND foot, but was able to talk through it. This lasted for 5 minutes, and stopped after she received Ativan 2 mg IV x1. She was also given Labetalol 20 mg IV x1 for blood pressure. Repeat head CT showed stable exam with 2.4 x 2.5 cm right posterior frontal parenchymal hemorrhage at the [Doctor Last Name 352]-white matter junction with surrounding edema and extension of hemorrhage to the subarachnoid space with linear hyperdense blood within the right central sulcus. She was evaluated by Neurosurgery who did not think this was a surgical hemorrhage. Neurology was initially consulted for management of her seizure. Past Medical History: s/p St. [First Name5 (NamePattern1) 923] [Last Name (NamePattern1) 1291] reportedly for AI on Coumadin ESRD on HD qMWF Hypertension GERD C. diff colitis Asthma Migraines Staph epidermidis bacteremia . She has no history of hyperlipidemia or DM Social History: She lives with her daughter [Name (NI) 12335]. She is a retired lab assistant at the Red Cross. HABITS She quit smoking cigarettes >30 years ago, denies EtOH use. Her daughter tells me she smokes marijuana daily, but denies cocaine use. Family History: Her daughter has depression and her son has schizophrenia and is deaf. Physical Exam: ON ADMISSION: VS: temp 99.3, HR 100, RR 36, bp 150/64, SaO2 99% During the exam, her blood pressure drops to SBP 93 in the setting of receiving Dilantin, so she is layed flat in the bed and the Dilantin is slowed down. Genl: Awake, but very sleepy, yawning frequently during the exam HEENT: Sclerae anicteric, no conjunctival injection CV: Tachycardic, Nl S1, mechanical S2, II/VI systolic murmur best at LUSB, no rubs or gallops Chest: CTA bilaterally anteriorly, no wheezes, rhonchi, rales Neurologic examination: Mental status: Awake but sleepy, arouses to sternal rub and voice, uncooperative with exam. Prefers to keep her eyes closed. Oriented to person, but says place is [Hospital1 756] and date is [2168-4-6]. Speech is nonfluent, naming intact to glove and chair but does not name the other objects on the left side of the stroke scale card. Dysarthric. Probable left sided neglect. Cranial Nerves: Left pupil 5->3 mm, right pupil 3->2 mm. Does not comply with EOMI testing. Left UMN facial droop. Tongue midline. Motor/Sensation: Decreased tone in her left arm and leg. No observed myoclonus, asterixis, or tremor. Left arm flaccid and does not move it at all against gravity. She does not move her arm to noxious stimulus (nailbed pressure). She is able to keep her right arm against gravity and provides full 5 resistance at the right triceps but is not cooperative with the other muscle groups. She does not move her left leg against gravity, and triple flexes her left leg to noxious stimulus (nailbed pressure). She keeps her right leg against gravity, but does not cooperate with formal muscle strength testing. Reflexes: Trace left biceps, brachioradialis, and triceps reflexes, 1+ right biceps, brachioradialis, and triceps reflexes. Reflexes 0 and symmetric in knees and ankles. Toes upgoing bilaterally. Pertinent Results: Admission Labs: . GLUCOSE-147* UREA N-33* CREAT-8.3* SODIUM-139 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-27 ANION GAP-21* CALCIUM-9.7 PHOSPHATE-4.9* MAGNESIUM-1.7 PT-31.2* PTT-40.3* INR(PT)-3.1* CK-MB-NotDone cTropnT-0.52* . Dicharge Labs: TO BE FILLED IN . IMAGING: . CT Head without Contrast ([2168-11-16]): IMPRESSION: Stable exam with right posterior frontal lobe parenchymal hemorrhage with associated subarachnoid hemorhage. . CT Head without Contrast ([2168-11-16]): IMPRESSION: Interval enlargement of right frontal intracranial hemorrhage with subarachnoid extension with surroudning edema; likely ongoing hemorrhage. . CT Head without Contrast ([2168-11-17]): IMPRESSION: 4.5x4.7cm Right frontal lobe intraparenchymal hemorrhage with subarachnoid extension, slightly smaller in the AP dimension likely due to expected evolution; persistent surrounding edema unchanged. Underlying vascular or neoplastic causes cannot be exlcuded. Further evaluation after resolution of the hemorrhage is recommended to exclude the same. . Transthoracic Echocardiogram ([2168-11-17]): IMPRESSION: No valvular vegetations seen, although cannot be reliably excluded on the aortic prosthesis. Moderate to severe regional left ventricular systolic dysfunction (LVEF 30%), c/w extensive prior inferior myocardial infarction. At least mild mitral regurgitation. Moderate pulmonary hypertension. . Aortic Valve - Peak Velocity: 2.5 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 26 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 11 mm Hg . MRI/A/V of the head [11-25]: There is a large area of acute hemorrhage identified in the right parietal and posterior frontal region with surrounding edema and mass effect on the lateral ventricle. There is no midline shift seen. The area of hemorrhage measures approximately 6 x 5 cm. Additional small area of fluid-fluid level measuring approximately 2 cm is seen adjacent to the atrium of the right lateral ventricle. There is no additional surrounding area of restricted diffusion identified. A tiny area of high signal within the left posterior parietal convexity subcortical region on diffusion images appears to be secondary to T2 shine-through. There is increased signal seen within the right side of the pons and internal capsule extending to the medulla, indicative of acute wallerian degeneration. There are no other foci of chronic microhemorrhages identified. There is no hydrocephalus seen. IMPRESSION: Large area of hemorrhage is identified in the right parietal lobe with surrounding edema and mass effect on the right lateral ventricle. Acute wallerian degeneration is seen along the pyramidal tract from internal capsule to the brainstem region. Evaluation for underlying neoplasm is limited without contrast administration. If clinically indicated, gadolinium-enhanced study can be performed following obtaining a consent from the patient or family as clinically indicated. MRA OF THE HEAD: The head MRA does not include the area of hemorrhage. Around the circle of [Location (un) 431], there is no evidence of vascular occlusion or stenosis seen. Mild narrowing of the mid basilar artery may indicate mild changes of atherosclerotic disease. There is no aneurysm greater than 3 mm in size seen. IMPRESSION: No evidence of occlusion or high-grade stenosis in the arteries around the circle of [Location (un) 431]. MRV OF THE HEAD: Head MRV demonstrates normal flow in the superior sagittal and transverse sinuses. There is no evidence of venous sinus thrombosis seen. The deep venous system also appears patent. . Brief Hospital Course: Ms. [Known lastname 34108] is a 67 year old woman with a history including hypertension, AI s/p [Known lastname 1291] on Coumadin, and HD-dependent ESRD who initially presented to [Hospital 34109] Hospital with left upper extremity twitching and was found to have a left frontal intraparenchymal hemorrhage. Thereafter she was transferred to the [Hospital1 18] for further evaluation and care. She was admitted to the stroke service from [2168-11-16] to [2168-11-29], patient died on [2168-11-29]. . NEURO At the time of her arrival a repeat CT of the head demonstrated relative [Name (NI) 34110] of the left frontal hemorrhage. To reverse an INR of 3.1, the patient was given vitamin K, FFP, and ultimately profilne; subsequent INRs were measured at the target of less than 1.5. A head CT done in the context of a worsening exam later [2168-11-16] demonstrated interval progression of the hemorrhage. However, a CT done on [2168-11-17] revealed no further expansion of hemorrhage. A CT done [2168-11-18] showed stable hemorrhage. The etiology of the hemorrhage was unclear and the potential etiologies included a possible septic embolus from a perivavluvar abscess (see below), venous infarct or a malignancy. She underwent MRI/A/V on [11-25] of the brain that showed a stable hemorrhage, w/o evidence of a venous thrombus, no evidence of a vascular malformation. A mass could not be ruled out given inability to administer contrast in this patient with ESRD and HD. Given stability in the IPH, she was restarted on anticoagulation (heparin gtt) with a goal of 40-60 PTT to provide at least partial anticoagulation for her mechanical aortic replacement valve. . As she demonstrated ongoing evidence of left upper and lower extremity rhythmic movements, a dilantin load was administered, and a maintenance dose initiated to prevent further seizure activity, this was later changed to Keppra given suspected sedation and difficulty weaning from the vent. . To prevent increases in intracranial pressure, the head of the bed was maintained at >30 degrees. In addition, blood pressure was closely monitored with a goal systolic blood pressure under 160. The metoprolol was continued for cardioprotection. The outpatient lisinopril regimen was also continued. . Patient's mental status did not improve. She underwent LTM w/ EEG which did not show NCSE. It was felt that her condition was due to IPH, uremia and sepsis. . RESP Following her arrival at the [Hospital1 18], the patient's examination was observed to worsen acutely. She was intubated to protect her airway. The team was unable to wean her sedation as her MS never improved to permit non-invasive ventilation. There was no evidence of a PNA or volume overload. . CVS In the setting of an intraparenchymal hemorrhage, the coumadin was held. The risks and benefits of restarting anti-coagulation to protect her mechanical aortic replacement valve were discussed with family. Although restarting anti-coagulation with heparin gtt was considered risky given the subacute right frontal intra-parenchymal hemorrhage, it was considered even more high risk to hold anti-coagulation in light of her mechanical aortic valve. A heparin drip was started at four days following the onset of the right frontal IPH. The troponin was found to be elevated (and plateaued) at 0.52 and was felt to be due to ESRD and decreased clearance. She subsequently developed atrial fibrillation requiring initiation of amiodarone. Patient was also started on metoprolol to control her rate to goal of 70s. This was unsuccessful given prolonged infection/sepsis (see below). . RENAL Dialysis was continued according to Ms. [Known lastname 34111] outpatient monday, wednesday, friday schedule. There was no evidence of volume overload during her stay. . ID Patient was noted to have an episode of hypotension outside of her HD window. Given positive BCx at OSH for GPC, she was started on empiric coverage of Vancomycin and Gentamycin. Surveillance blood cultures were obtained which grew MSSA, consisted with reports from OSH where she also grew MSSA. She underwent an ECHOcardiogram wich showed a periaortic hypolucency suggestive of an abcess. Her coverage was narrowed to Nafcillin and Gentamycin once BCx returned as MSSA on [11-20]. Lines were resited. She remained tachycardic with elevated WBC in the 20K range. She was not deemed to be a surgical candidate by cardiothoracic team due to her many co-morbidities. She underwent a thorough investigation for source of the infection in addition to the perivalvular abcess, with only remaining studies to be performed inculding CT abdomen/pelvis w/ contrast (could not be performed due to lack of peripheral access) and MRI spine w/ contrast to assess for perispinal abcess and osteomyelitis (given ESRD). Since no alteration in management would occur as a result of these studies (patient not a surgical candidate and already on targeted ABx coverage) these were delayed to a point at which patient was more stable. Unfortunately, by [11-27] patient developed further fevers, her WBC rose to 40K. Coverage was broadened to Vancomycin/Meropenem for a possible aspriration PNA. . ABD/GI The patient was initially kept npo to prevent aspiration, she underwent NGT placement and was maintained on H2 blocker throughout her stay. . GOALS of CARE, CODE and Day of Death events. Code status was confirmed with family and was Full. Family was continuously updated re: patient status. Patient's poor prognosis given the combination of her comorbidities was explained at length on multiple occasions. In addition, it was discussed that curative surgery could not be performed. Per family wishes, patient was scheduled to undergo PEG and Tracheostomy placement. Unfortunately, prior to be able to proceede with these procedures, patient developed fevers, worsening WBC and hypotension. At 3:00 am patient had suddenly dropped her bp to 60 with HR down to the 50s. She was started on neosynephrine, bolused with 1 L IVF. Full code at this time was confirmed with the family. Venous lactate was 8.8, pH 7.29, CO2 13. Hct 26.CK 1485, Trop 2.25. A-line was placed, and her MAP was 20-30. She was maximized on 2 pressors. At this point, family elected to withdraw care. Patient died immediately after pressor suppor and ventilation were stopped. It was felt that she may have died due to cardiac failure in setting of high output state (sepsis) and rupture of the aortic root. Medications on Admission: PER PHARMACY ([2168]): neproxen 250 mg po daily prn pain calcium acetate 1334 mg po tid (with meals) metoprolol succinate 150 mg po bid nifedipine long acting 60 mg po daily calcium 1250 mg po daily renvela 800 mg po tid (with each meal) omeprazole 20 mg po daily sensipar 30 mg po daily lisinopril 40 mg po daily on non-HD days (T, TH, [Last Name (LF) ], [First Name3 (LF) ]) coumadin (per family): 4 mg po daily M, Sa, 3 mg po daily [Doctor First Name ], T, W, Th, F vicodin 5/500 mg po q8h prn pain epogen (per [Hospital 34112] Hospital) . Allergies: Tetracyclines Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: na Followup Instructions: na Completed by:[2168-11-29]	[ "5070", "40391", "42731", "49390", "53081", "2767", "V1582" ]
Admission Date: [2169-11-12] Discharge Date: [2169-11-18] Date of Birth: [2148-12-14] Sex: M Service: TRAUMA HISTORY OF PRESENT ILLNESS: This is a 20 year old male, status post stab wound to the neck the evening of admission. The patient was reported to be running for twenty minutes, status post injury before he was brought in by ambulance to [Hospital1 69] Emergency Department. The patient was combative on arrival and was therefore sedated, paralyzed and intubated. It was reported that a five inch kitchen knife was used as a weapon. The patient received two units of packed red blood cells in the Emergency Department and two liters of crystalloid. PAST MEDICAL HISTORY: Unknown. MEDICATIONS ON ADMISSION: Unknown. ALLERGIES: Unknown. PAST SURGICAL HISTORY: Unknown. PHYSICAL EXAMINATION: Vital signs revealed pulse 140, blood pressure 160/90. The patient was 100% and intubated. The patient was moving all extremities before intubation. The patient had equal pulses bilaterally. The patient had regular rate but tachycardic. The abdomen was soft, nondistended. Extremities were warm with palpable pulses distally. The lungs were clear and equal bilaterally. Neck examination revealed a stab wound to the left neck above the level of the sternal notch but below the cricoid. There was visible bleeding from the site and a visible palpable hematoma forming near the sternal notch. Carotids had 2+ pulses bilaterally with no bruits audible. LABORATORY DATA: On admission, white blood cell count was 8.6, hematocrit 40.0, platelet count 214,000. Alcohol level 204. Amylase was 106. Urinalysis was negative. Sodium 143, potassium 3.9, chloride 110, bicarbonate 20, blood urea nitrogen 10, creatinine 1.1, calcium 8.4, phosphorus 3.9. HOSPITAL COURSE: The patient was taken for a CT angiogram immediately due to the concern for arterial injury given the fact that this is a zone three neck injury. The patient's CTA showed no pericardial or pleural effusion, a small amount of air noted within the main pulmonary artery on the noncontrast images with a small curvilinear filling defect noted in the main pulmonary artery on the postcontrast images. There are also some air droplets noted within the mediastinum but no evidence of mediastinal hematoma and some patchy opacities at the lung bases which could represent either atelectasis or pulmonary contusions. This was concerning for significant vascular injury and the patient was taken to the operating room for a median sternotomy and exploration. The patient went to the operating room and it was found that there was a lacerated branch of an innominate vein as the source of bleeding. The patient had left mediastinal chest tubes placed and was admitted to the Surgical Intensive Care Unit. The patient did well postoperatively and was extubated on the evening of [2169-11-13], and was transferred to the floor. The patient had no postoperative complications, continued to drain small amounts through the chest tube. On [2169-11-15], the split tubes were separated into two chest tubes, each draining separately so that the drainage could be more adequately monitored. The patient had serial x-rays throughout showing no evidence of pneumothorax or fluid collection. On [2169-11-18], the patient had chest tubes removed, wounds looked uninfected and well healing. Follow-up chest x-ray showed no hemathorax or pneumothorax. The patient was discharged home in good condition. DISCHARGE DIAGNOSIS: Stab wound to the neck. RECOMMENDED FOLLOW-UP: Trauma Clinic on the following Tuesday for wound check and follow-up with cardiothoracic surgeon. MEDICATIONS ON DISCHARGE: 1. Percocet one to two tablets p.o. q4-6hours as needed. 2. Ibuprofen 800 mg one tablet p.o. three times a day. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Last Name (NamePattern1) 7586] MEDQUIST36 D: [2170-1-29] 18:17 T: [2170-1-29] 18:50 JOB#: [Job Number 53703]	[ "5180", "42731", "4019" ]
Admission Date: [2134-5-2] Discharge Date: [2134-5-8] Service: MEDICINE Allergies: Ciprofloxacin / Ambien Attending:[First Name3 (LF) 1711] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Left Subclavian line Left Arterial LIne History of Present Illness: 82 yr old female w/hx of gout, CAD s/p PCTA of in-stent restenosis of prox LAD lesion [2134-4-26], diastolic dyfunction, AF s/p successful DCCV [4-18] on amidoronone, who has been admitted twice last month for CHF exac. At [Hospital 100] rehab, pt was noted to be short of breath with increased orthopnea. Initial story was that pt was given fluid bolus as well as signficant amount of fluid via heparin bolus, as precipitant for heart failure. [Hospital 100] rehab physician denies this. Transferred to [Hospital1 18] for eval. Also, was being bridged on heparin and coumadin for recent AF. PTT >200 and INR >10 at [Hospital 100] Rehab, so she was given PO and IV vit K. In the ED, given 2mg IV morphine, lasix 80mg IV X 1, and ntg gtt started. Given her resp distress she was also started on BiPAP 10/10. Pt's BP dropped from SBP 180's to 80's. She remained assymptomatic during this episode. Febrile to 101 on admission. NTG stopped, and BiPAP stopped. She was taken to the CCU. Of note, she c/o abd pain that lasted ~30 minutes, relieved with defecation. No bloody diarrhea or persistent belly pain. Past Medical History: 1. Atrial fibrillation status post DCCV on [2133-3-18] and again on [2134-3-23] (still in AF) - chronically on coumadin. Successfully cardioverted [4-18]. Being bridged with hep and coumadin at [Hospital 100] Rehab. 2. Hypercholesterolemia/HTN 3. UTI: Klebsiella in past (pansensitive) 4. Diastolic congestive heart failure. Hemodynamic evaluation revealed moderately to severely elevated right-sided pressures (mean RA was 17 and RVEDP was 22 mmHg), severely elevated left-sided pressures (mean PCW was 29 and LVEDP was 31), and severely elevated pulmonary pressures (PA was 67/33 mmHg). There were prominent V waves on the PA tracing up to 50 mmHg, 2+MR. 5. CAD: s/p PCI of the proximal LAD on [2130-2-23], then had NSTEMI and in-stent restenosis treated with PTCA [2134-4-26] and PTCA of mid-LAD 70% lesion 6. Gout. 7. Obesity. 8. Obstructive sleep apnea on CPAP (setting of 12). 9. Status post cholecystectomy. 10. History of spinal stenosis Social History: Very functional, lives alone. She is able to shop, drive, all ADLS. She does not smoke or drink. Her daughter is her health care proxy. She has three children. Family History: n/c Physical Exam: Gen: NAD, obvious distress HEENT: MMM, no dentures, 11cm JVP CV: RRR, no m/r/g though distant HS Lungs: L>R crackles up 1/2 bilaterally Abd: + BS, soft, Nt, ND obese. No peritoneal signs. Skin shows mild breakdown and erythema. Ext: 1+ pedal edema to knees. Preserved peripheral pulses. Neuro: A&Ox3. non-focal Pertinent Results: Admission labs: [2134-5-4] 04:19AM BLOOD WBC-9.4 RBC-3.79* Hgb-10.5* Hct-31.3* MCV-83 MCH-27.8 MCHC-33.6 RDW-15.7* Plt Ct-279 [2134-5-4] 04:19AM BLOOD Neuts-63.9 Lymphs-27.7 Monos-4.2 Eos-3.2 Baso-1.0 [2134-5-4] 04:19AM BLOOD Hypochr-1+ Poiklo-1+ Microcy-1+ [2134-5-3] 04:31AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Stipple-OCCASIONAL [2134-5-4] 04:19AM BLOOD Plt Ct-279 [2134-5-4] 04:19AM BLOOD PT-14.6* PTT-99.2* INR(PT)-1.4 [2134-5-4] 04:19AM BLOOD Glucose-97 UreaN-45* Creat-1.4* Na-140 K-4.5 Cl-102 HCO3-28 AnGap-15 [2134-5-3] 04:31AM BLOOD CK(CPK)-28 [2134-5-2] 11:53PM BLOOD CK(CPK)-38 [2134-5-2] 01:30PM BLOOD CK(CPK)-40 [2134-5-2] 11:53PM BLOOD CK-MB-NotDone cTropnT-0.14* [2134-5-2] 01:30PM BLOOD CK-MB-NotDone cTropnT-0.19* [2134-5-4] 04:19AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.8* [2134-5-3] 04:31AM BLOOD Albumin-2.9* Calcium-7.6* Phos-3.6 Mg-1.7 [2134-5-2] 08:29PM BLOOD calTIBC-308 Ferritn-541* TRF-237 [2134-5-3] 08:16AM BLOOD Cortsol-60.6* [2134-5-3] 04:31AM BLOOD Cortsol-30.8* [2134-5-2] 02:52PM BLOOD Lactate-3.3* [2134-5-2] 06:49PM BLOOD Lactate-1.3 . EKG: Sinus rhythm [Month (only) 116] be Normal ECG but baseline artifact makes assessment difficult Since previous tracing of [2134-4-29], prolonged Q-Tc interval and T wave changes absent . ECHO ([5-3]): The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild to moderate aortic valve stenosis (area 1.1 and grad 24, mean) . Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . Brief Hospital Course: 82 y/o female with PMH CAD (s/p recent PCI), diastolic dysfunction, AS, AF (s/p cardioversion, on amiodarone) admit w/acute decompensated CHF. . 1. Hypotension/Hypertension: Developed hypotension the ED, requiring admission to CCU,likely secondary to overaggressive preload inhibition in setting of moderate AS and increased atenolol levels in setting of ARF. Pt required inotrop/pressor support for ~24 hours with dop gtt at 4-5. She was easily weaned off pressors. No evidence of CNS or cardiac ischemia. No evidence of distributive shock. Blood cultures neg. Does have UTI, but not uroseptic. Lactate improved from 3.3 to 1.3. Antihypertensives were held in the setting of hypotension; they were continued to be held on transfer to the floor. Within 24 hours of being on the floor, pt developed hypertension to 200s systolic, during which she developed flash pulmonary edema. See next issue for details. Pt was started on nitro drip and restarted on po lopressor w/ improved blood pressure. Hydralazine was subsequently added and nitro drip was titrated down. Pt was subsequently restarted on imdur and valsartan; nitro drip and hydralazine were discontinued. Pt's home antihypertensive regimen of lopressor, valsartan, and imdur were titrated for optimal bp control. . 2. Pump: 82 y/o female with PMH CAD (s/p recent PCI), diastolic dysfunction, AS, AF (s/p cardioversion, on amiodarone) admit w/acute decompensated CHF. Possible etiologies include high output failure in setting of UTI/fever, hypertension in setting of diastolic dysfunction. Pt was admitted cold and wet in class IV HF, secondary to recent fluid boluses in the form of heparin bolus and IVF bolus. She diuresed very well with IV lasix. She was transiently on dopamine drip in the CCU for blood pressure support, which helped with diuresis. Pt was hypoxic on admission and required positive pressure vent with BiPAP for ~24 hours. She was continued on CPAP at night. On floor day 1, pt developed flash pulmonary edema in the setting of severe hypertension off antihypertensives. She was noted to be hypoxic to 70s on 4L, with increase to mid 90s on 100% NRB. She was started on nitro gtt, lopressor, and hydralazine for BP control. CXR confirmed worsened pulmonary edema. She was given lasix for diuresis. After adequate diuresis and BP control, pt was able to be weaned down on her oxygen requirement. Pt was restarted on heart failure regimen of lopressor, valsartan, imdur; nitro gtt was weaned and hydralazine discontinued. Pt was diuresed with IV lasix daily for goal 1L daily, with signficant respiratory improvement. Pt should continue to be diuresed w/ IV lasix for 48 hours for goal negative 500cc daily prior to being switched to a po lasix regimen. . 3. CAD: Pt is s/p NTSEMI last month and is s/p PTCA to prox and mid LAD [4-26]. Pt was continued on asa, plavix, and statin. On admission was noted to have a slight troponin bump likely from demand ischemia and decompensated heart failue. She was restarted on bb, [Last Name (un) ], and imdur, which were titrated. . 4. Rhythm: S/P sucessful DCCV [4-18]. Pt remained in sinus. Dopamine drip did not cause reversion to AF. Amiodarone was held initially in the setting of bradycardia, but was restarted. She recieved oral and IV vit K at [Hospital 100] Rehab for INR of 10. Subsequently had suptherapeutic INR. She was restarted on heparin gtt and restarted coumadin 5mg daily for goal INR 2.0-3.0. Pt is being discharged on lovenox bridge . 5. Resp: Initially presented with large Aa gradient, attributed to pulmonary edema. She was hypoxic on admission, requiring BiPAP for ~24 hours. With diuresis, she had decreasing O2 requirements. Supplemental oxygen should continue to be weaned down, with further diuresis. . 6. ID: Pt was febrile to 101 in ED. Pt was noted to have UTI by UA. On day of last discharge she was noted to have >100,000 Staph aureus, which was attributed to contamination and not treated. Admission urine culture once again grew out >100,000 Staph aureus, found to be MRSA sensitive to vanco, gent, tetracyclin, and nitrofurantoin. Pt initially received emperic ceftriaxone and vancomycin. Ceftriaxone was subsequently discontinued. Pt was continued on vancomycin (renally dosed, q48h dosing) to complete a 10 day course. Vanco trough levels should be checked 30 minutes prior to 3rd dose of vanco. She should get a trough level on [5-7]. Pt's blood cultures remained negative. Repeat UA on the day before discharge is negative, with a urine culture that is negative to date. . 7. Renal: Pt has had ARF since [2134-4-27], secondary to contrast nephropathy vs. CHF (poor forward flow). Baseline is 1.0 to 1.3. She received 240mL contrast at time of cath. Creatinine improved with dopamine drip and treatment of heart failure. . 8. Anemia: She has a severe iron deficency anemia without evidence of acute bleed. Last C-scope 3-4 years ago, by report. Received 1U PRBC for goal hct >30. Hct remained stable. . 9. Gout: Stable. Continued on allopurinool . 10. OSA: CPAP at night at outpt settings. Pt was seen by pulmonary consult service who stated that pt has secondary pulmonary hypertension in the setting of left heart failure. Pt should follow up with Dr. [Last Name (STitle) ] for outpatient sleep study. . 11. Cerumen impaction: Pt was noted to have bilateral cerumen impaction preventing her from inserting her hearing aides. She was started on [Hospital1 ] hydrogen peroxide. Medications on Admission: Allopurinol 100mg qd amiodarone 200mg qd asa 325mg qd atenolol 50mg qd plavix 75mg qd simvastatin 80mg qd Valsartan 40mg qd Trazodone prn warfarin 5mg qhs lasix 40mg qd Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 3. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): until INR is 2. 7. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 5 days. 8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Lasix Please give Lasix 40mg IV qd x 3-4 days for diuresis of goal negative 500cc daily. Please restart appropriate po dosing of Lasix in a few days. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: Shock Decompensated CHF UTI Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L If you have these symptoms, call your doctor: - shortness of breath - cough - fevers - dizziness - chest pain - visual changes - palpitations Followup Instructions: Provider: [First Name11 (Name Pattern1) 5445] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5446], DPM Where: BA [Hospital Unit Name ] ([Hospital Ward Name ] COMPLEX) [Hospital Ward Name 1947] Phone:[Telephone/Fax (1) 543] Date/Time:[2134-5-19] 9:20 Provider: [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 3512] Date/Time:[2134-7-1] 9:30 Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2134-5-17] 10:30 Follow-up with Dr. [Last Name (STitle) ] on [6-10] at 4:15pm located on [Hospital Ward Name 23] floor 7.(call [Telephone/Fax (1) 612] to reschedule)	[ "5990", "42731", "5849", "V5861", "41401", "V4582", "2720", "4019" ]
Admission Date: [2137-2-7] Discharge Date: [2137-3-7] Date of Birth: [2090-1-30] Sex: M Service: MEDICINE Allergies: Fentanyl Citrate / Penicillins / Dilaudid / Morphine Attending:[First Name3 (LF) 1493] Chief Complaint: Reason for Transfer - UGIB; subspecialty care Major Surgical or Invasive Procedure: EGD on [2137-2-8]: Severe portal hypertensive gastropathy History of Present Illness: The patient is a 47 yo morbidly obese M with ETOH cirrhosis, portal hypertension, and GAVE who originally presented to the OSH on [2137-1-21] after being found unresponsive by his wife at home. Per OSH records, he was intially thought to have a brainstem stroke. CT Head was negative for overt stroke. At that time given his poor overall health the patient was made CMO. Remarkably, 3 days later, the patient became more responsive and was transferred to an acute rehab facility on [2137-1-30]. Code status at that time was changed to FULL. On [2138-2-3] (at rehab) the patient became increasingly somnolent and was started on ciprofloxacin for presumed UTI. Over the next 24 hours his somnolence increased and his hct was noted to have dropped from 32.7 --> 27.5. He began having melena and his hct continued to drop. He was then transferred to the OSH ICU. He was started on IV PPI and Octreotide and his hct stabilized at approximately Hct 25-26. An EGD was performed and showed severe portal gastropathy with active oozing. 24 hours later a repeat EGD showed improvement in the bleeding but continued severe portal hypertensive gastropathy. He was transfused 2 units of PRBC and 2 units of FFP while in the ICU. His encephalopathy improved with lactulose. Of note, urine cultures eventually returned negative and his antibiotics were stopped. The plan was to transfer to [Hospital1 18] for further management of his severe portal gastropathy and for further assessment. . Upon arrival here, the patient reports that he is feeling well. He denies any recent melena. Had brown stool today. Denies chest pain, shortness of breath, abdominal pain. + Chronic back pain. AAO x 3. Patient reports that since he was last seen at [Hospital1 18] 1.5 years ago, he has gone from 500lbs to 330lbs. Past Medical History: -- ESLD [2-16] presumed ETOH cirrhosis +/- NASH -- Chronic GI Bleeding [2-16] GAVE -- H/O GAVE; h/o argon plasma coagulation therapy in [2134] at [Hospital1 18] -- Anemia - [2-16] GAVE and chronic disease -- Morbid Obesity -- H/O MRSA; recurrent cellulitis of lower extremities -- GERD -- OSA -- Chronic Pain Syndrome -- Depression -- Mild asthma diagnosed in [2132] Social History: He is married for 16 years and has 3 children; they moved to [State 1727] this past year. He has not worked in the past 1.5 years [2-16] his poor health and obesity. Reports that he quit ETOH 1 year ago. Prior to that he drank "a lot". Denies smoking or drugs. Family History: Hereditary hemochromatosis in a cousin and brother. His father also has diabetes and ischemic heart disease status post myocardial infarction and CABG. Physical Exam: PHYSICAL EXAM: VS: 98.1 122/88 57 20 99%RA Gen: obese male, sitting at edge of bed, tearful at times discussing disease; able to state year, month, date, and place HEENT: pupils dilated, but reactive Neck: supple Lung: CTA B/L with good air movement Heart: RRR, II/VI SM at base Abd: obsese, non-tender, no flank dullness Ext: bilaterally erythematous; does not appear infected; necrotic ulcer on right heal; 2+ pulses bilaterally Neuro: CN II-XII intact, UE/LE strength is [5-20] and symmetric. AOx3, intact serial sevens, repetition. Pertinent Results: HEMATOLOGY [2137-2-8] 01:30AM BLOOD WBC-5.7 RBC-3.33* Hgb-10.0* Hct-29.8* MCV-90 MCH-30.1 MCHC-33.6 RDW-18.0* Plt Ct-168# [2137-2-8] 06:50PM BLOOD Hct-31.2* [2137-3-2] 06:20AM BLOOD WBC-2.1* RBC-2.43* Hgb-7.1* Hct-21.2* MCV-87 MCH-29.3 MCHC-33.5 RDW-17.8* Plt Ct-100* [2137-3-2] 06:05PM BLOOD Hct-25.8* [2137-3-3] 06:20AM BLOOD WBC-2.5* RBC-2.66* Hgb-7.6* Hct-23.7* MCV-89 MCH-28.7 MCHC-32.2 RDW-16.8* Plt Ct-111* [2137-3-5] 05:25AM BLOOD WBC-2.4* RBC-2.76* Hgb-7.9* Hct-24.9* MCV-90 MCH-28.7 MCHC-31.8 RDW-16.8* Plt Ct-116* [2137-3-7] 06:08AM BLOOD WBC-3.0* RBC-2.76* Hgb-7.9* Hct-24.2* MCV-88 MCH-28.7 MCHC-32.8 RDW-17.6* Plt Ct-152 COAGULATION [2137-2-8] 01:30AM BLOOD PT-17.5* PTT-32.9 INR(PT)-1.6* [2137-2-9] 06:05AM BLOOD PT-18.1* PTT-35.6* INR(PT)-1.7* [2137-2-10] 05:55AM BLOOD PT-18.3* PTT-34.4 INR(PT)-1.7* [2137-3-6] 05:15AM BLOOD PT-18.1* PTT-36.3* INR(PT)-1.7* [2137-3-7] 06:08AM BLOOD PT-18.4* PTT-36.5* INR(PT)-1.7* CHEMISTRY [2137-2-8] 01:30AM BLOOD Glucose-94 UreaN-4* Creat-0.8 Na-135 K-3.7 Cl-104 HCO3-25 AnGap-10 [2137-2-9] 06:05AM BLOOD Glucose-84 UreaN-3* Creat-0.7 Na-137 K-3.5 Cl-106 HCO3-25 AnGap-10 [2137-2-10] 05:55AM BLOOD Glucose-91 UreaN-3* Creat-0.8 Na-136 K-3.5 Cl-104 HCO3-26 AnGap-10 [2137-3-5] 05:25AM BLOOD Glucose-81 UreaN-6 Creat-0.7 Na-141 K-3.6 Cl-113* HCO3-23 AnGap-9 [2137-3-6] 05:15AM BLOOD Glucose-85 UreaN-6 Creat-0.7 Na-137 K-3.6 Cl-110* HCO3-22 AnGap-9 [2137-3-7] 06:08AM BLOOD Glucose-88 UreaN-6 Creat-0.7 Na-135 K-3.6 Cl-107 HCO3-24 AnGap-8 [2137-3-5] 05:25AM BLOOD Calcium-7.5* Phos-3.9 Mg-1.8 [2137-3-6] 05:15AM BLOOD Calcium-7.7* Phos-3.7 Mg-1.8 [2137-3-7] 06:08AM BLOOD Calcium-7.5* Phos-3.9 Mg-1.8 [2137-2-26] 06:20AM BLOOD Albumin-2.1* Calcium-7.5* Phos-3.7 Mg-1.8 Iron-18* LIVER [2137-2-8] 01:30AM BLOOD ALT-28 AST-69* LD(LDH)-295* AlkPhos-140* TotBili-2.6* [2137-2-12] 08:09PM BLOOD ALT-20 AST-37 CK(CPK)-35* AlkPhos-113 TotBili-1.8* [2137-3-6] 05:15AM BLOOD ALT-29 AST-56* LD(LDH)-198 AlkPhos-270* TotBili-1.2 [2137-3-7] 06:08AM BLOOD ALT-29 AST-53* LD(LDH)-213 AlkPhos-277* TotBili-1.4 [2137-2-8] 01:30AM BLOOD calTIBC-203* Ferritn-116 TRF-156* [2137-2-13] 08:40AM BLOOD VitB12-1295* IRON [2137-2-26] 06:20AM BLOOD calTIBC-176* Ferritn-35 TRF-135* AMMONIA [2137-2-12] 08:09PM BLOOD Ammonia-70* [2137-2-14] 03:23AM BLOOD Ammonia-96* [2137-2-22] 06:25AM BLOOD Ammonia-54* [2137-2-23] 09:29AM BLOOD Ammonia-65* PITUITARY [2137-2-12] 04:50AM BLOOD Prolact-18* [2137-2-13] 08:40AM BLOOD TSH-0.51 [2137-2-23] 09:29AM BLOOD Prolact-32* <-- following seizure HEPATITIS SEROLOGY [2137-2-25] 07:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE HCV NEGATIVE AFP SCREENING [2137-2-12] 04:50AM BLOOD AFP-1.1 URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [2137-2-20] NEG POS NEG NEG NEG NEG NEG 7.0 SM MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp [2137-2-20] 10:39PM 0-2 [3-20] MANY NONE 0 [2137-2-13] RPR NEGATIVE [Date range (1) 19593]/08 C DIFF NEGATIVE X2 URINE CULTURE (Final [2137-2-24]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML. OF THREE COLONIAL MORPHOLOGIES. ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S REPORTS AND STUDIES [2137-2-8] EGD Granularity, friability and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Otherwise normal EGD to third part of the duodenum [2137-2-8] US Sequelae of cirrhosis are evident with fatty infiltration of the liver, splenomegaly and small amount of ascites. No discrete focal lesions are seen; however, evaluation is markedly limited in the presence of fatty infiltration/coarsened echotexture. Gallbladder is free of stones and sludge. There is no intra- or extra-hepatic biliary dilatation seen. The main portal vein is patent and hepatopetal. Intrahepatic vessels are diminutive and not well seen. The left and middle hepatic veins are visualized with normal flow and phasicity. IMPRESSION: Patent main portal vein, with limited visualization of the intrahepatic vasculature. Sequela of cirrhosis as evidenced by splenomegaly and coarsened hepatic echotexture. [2137-2-13] HEAD CT This study is limited by motion artifact. There is no evidence of acute intracranial hemorrhage, shift of normally midline structures, mass effect, hydrocephalus or acute major vascular territorial infarction. There are post-surgical changes of the sinuses. Metallic surgical material is present along the posterior wall of the right maxillary sinus. Bilateral sinus surgeries are noted. There is moderate mucosal thickening of the maxillary and ethmoid sinuses. Frontal sinuses clear. Right sphenoid sinus air cells opacified. Mastoid air cells and middle ear cavities remain clear. IMPRESSION: No intracranial hemorrhage or mass effect. Post-surgical changes and mucosal thickening of the paranasal sinuses [2137-2-21] HEAD / NECK CTA The CT angiography of the head demonstrates bilateral normal flow within the arteries of anterior and posterior circulation. No vascular occlusion, stenosis, or an aneurysm greater than 3 mm in size is seen. Normal flow is identified in bilateral sylvian branches of the middle cerebral arteries. No abnormal vascular structures seen. Incidentally noted is a small infundibulum at the origin of left posterior communicating artery. IMPRESSION: 1. No acute abnormalities on head CT or change since the previous study. 2. No significant abnormalities on CTA of the head. No vascular occlusion or high-grade stenosis seen. Incidental small infundibulum at the origin of left posterior communicating artery. [2137-2-24] EEG This is an abnormal 24-hour video EEG telemetry in the waking and sleeping states due to the electrographic seizures noted with rhythmic [2-17] Hz blunted sharp and slow wave discharges seen particularly over the bilateral parasagittal regions with occasional extension into the left temporal lobe. There were also intermittent spike and slow wave discharges, particularly in the bilateral parasagittal regions. There was no clear electrographic correlate for these seizures. This recording, thus, demonstrates non-convulsive status epilepticus which is intermittent throughout the recording. The parasagittal and occasionally left temporal sharp discharges may suggest either a generalized abnormality or multiple potential foci of epileptogenesis. Brief Hospital Course: CIRRHOSIS & PORTAL HYPERTENSIVE GASTROPATHY The patient had a clinical diagnosis of cirrhosis, likely alcohol and non-alcohol induced steatosis, complicated by portal gastropathy with a history of transfusion support, no esophageal varices, no significant ascites, and no former diagnosis of encephalopathy. He had an upper endoscopy this admission which confirmed no esophageal varices, and noted portal hypertensive gastropathy but no GAVE. He continued on nadolol, and strong acid protection including PPI [Hospital1 ], H2 blocker, and sucralfate. The patient was on low dose lasix and aldactone that was continued. He had a neurologic event that was not fully characterized at an outside/referring hospital that considered to be a brainstem stroke, but when he recovered fully, this was thought to be related to hepatic encephalopathy. He was continued on rifaximin and lactulose while in our hospital. He clinically did not appear to be encephalopathic while in our hospital, never having the sign of asterixis. At times, he did appear to be speech arresting and having delayed responsivenes or inappropriate answers to questions, but it was never classic for hepatic encephalopathy as he would, in the course of the same visit/examination, be able to clearly answer orientation questions and perform adequately on mental status examination. On acceptance to our hospital, he was evaluated for insertion of a transjugular intrahepatic portosystemic shunt. However, he had a clinical seizure the day prior to scheduled TIPS, and the plan was aborted pending further characterization of his seizure disorder. At time of discharge, given concern that his seizure disorder could be an atypical manifestation of hepatic encephalopathy, TIPS was indefinitely postponed. However, it was felt that it could be entirely possible that they are completely unrelated as he had no other signs or symptoms of hepatic encephalopathy including asterixis or decreased orientation or confusion when he was not in a post-ictal state. He was counseled that he may require transfusions on an as needed basis, and was going to have follow-up care with his primary care provider in [Name9 (PRE) 1727]. He required only one transfusion of packed red cells (1 unit) this admission. He was started on iron supplementation 325mg PO TID after his iron studies showed that he was iron deficient. SEIZURE DISORDER / EPILEPSY The patient developed a new seizure disorder while in the hospital; further review of his history suggests that the patient's initial chief complaint in [Month (only) 404] prior to presenting to the hospital which ultimately referred him here was a seizure. The patient was witnessed to have two generalized tonic clonic seizures on the hospital floor, each self-limited lasting approximately one minute, with a [3-20] minute post-ictal period. He was loaded on keppra given his hepatic disease, and transferred to the intensive care unit for further EEG monitoring. This initial monitoring revealed no epileptiform activity, only nonspecific slowing. Head CT at this time was unrevealing for any mass lesions or old infarctions. MRI was deferred because the patient had clips that were not confirmed to be MRI compatable following sinus surgery. His weight/body habitus was borderline for scanner limits. One week later, the patient had several "spells" which he described as his vision "going blurry then black." The patient had no clear visual field deficit and visual acuity was grossly normal. Neurology saw the patient, and recommended a stat head CTA be performed to rule out vertebrobasilar insufficiency, which was normal. RPR was checked and was negative. One to two days later, he again developed generalized tonic-clonic seizure activity that was witnessed by the medical housestaff team and the neurology attending. The patient clinically had a left sided focus. EEG at this time did show epileptiform activity. He was loaded on dilantin and free dilantin levels were checked, aiming at the lowest dose that prevented seizures given possible hepatotoxity. Keppra was continued. He did not have further seizure activity. ANXIETY The patient had a history of OCD/generalized anxiety, and this was unfortunately severely exacerbated by the keppra. He had episodes of becoming very agitated, tearful, and feeling as if he were going to die. He described generalized pain. This abated somewhat with lowering his keppra dose from 2 gm [Hospital1 ] to 1.5gm [Hospital1 ]. He had several psychotropic home medications, but he was continued on only the active medication(Lexapro) at time of interhospital transfer. URINARY TRACT INFECTION/CYSTITIS The patient developed a UTI while foley catheter was in place. He grew E. coli and was treated with fluoroquinolone but switched to bactrim to complete his 7 day course given that fluoroquinolones can lower the seizure threshold. ASTHMA He was continued on PRN albuterol SLEEP APNEA The patient intermittently used CPAP. He did not have his home mask and felt uncomfortable, and unfortunately generally felt tired throughout the day. HEALTH CARE MAINTENANCE The patient should be immunized against Hepatitis B by his primary care provider. Medications on Admission: MEDICATIONS (at time of transfer): Benadryl PRN for itching Lexapro 20mg daily Nexium 40mg IV q12 Lactulose Miconazole powder Nadolol 20mg daily Spironolactone 50mg daily Ambien 5mg QHS:PRN Sucralfate 1g QID Iron 325mg daily MVI Octreotide drip (holding patients cymbalta, erythromycin, wellbutrin, lasix, and vicodin) . ALLERGIES: Penicillin Morphine/Percocet --> nausea. . Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 9. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abdominal discomfort or gas pain. 13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 16. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for 7 days. 18. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Disposition: Home With Service Facility: Androskoggin vna Discharge Diagnosis: PRIMARY: CIRRHOSIS - PORTAL HYPERTENSIVE GASTROPATHY SEIZURE DISORDER, GENERALIZED TONIC CLONIC SECONDARY: - Chronic Pain Syndrome - Anemia, secondary to past GAVE and portal hypertensive gastropathy - Depression, Obesessive Compulsive Disorder, Anxiety - Obstructive Sleep Apnea - h/o MRSA cellulitis, lower extremity - Gastroesophageal reflux disorder - Asthma, mild Discharge Condition: stable, ambulating with walker Discharge Instructions: You were transferred to [Hospital1 18] with advanced liver disease and concern for the liver being cause of altered concentration and mental status. You had clinical seizures while hospitalized and were started on an two anti-seizure drugs called Keppra and Dilantin while here. You had an upper endoscopy which showed a slow bleed from the high pressures in the veins around your stomach. Because of the seizure disorder, you did not have a TIPS procedure. You may periodically need blood transfusions. You should have your bloodwork reviewed closely by your primary care physician. MEDICATION CHANGES: You should continue the PANTROPRAZOLE(PROTONIX), SUCRALFATE(CARAFATE), and RANITIDINE(ZANTAC) for your stomach bleeding. For seizures, you should continue the PHENYTOIN(DILANTIN) and LEVETIRACETAM(KEPPRA). For Depression and anxiety, you are still on LEXAPRO, but the other medications were discontinued, including CYMBALTA and WELLBUTRIN. You can discuss with your outpatient treaters if these should be restarted. You should continue taking IRON three times daily for your anemia. RETURN to hospital if you develop any signs of altered mental status/confusion/encephalopathy, fever, chills, or other concerning symptoms. If you have a seizure lasting more than five minutes or that results in any injury, return to the hospital. For seizure lasting less than five minutes, please call your neurologist to discuss and be seen in clinic. Followup Instructions: Please follow-up with your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 2855] [Last Name (NamePattern1) 1968] in [State 1727] within the next 1-2 weeks. Please call to schedule a follow-up appointment with a gastroenterologist or hepatologist in [State 1727]. If you need a Hepatologist, you can schedule an appointment in the [Hospital1 18] liver center at [Telephone/Fax (1) 24157] Please schedule an appointment to be seen by a Neurologist or Epilepsy specialist. If you do not have a neurologist in [State 1727], you can be seen in the [Hospital 875] clinic at ([Telephone/Fax (1) 58666]	[ "2851", "5990", "49390", "32723" ]
Admission Date: [2175-6-14] Discharge Date: [2175-6-18] Date of Birth: [2111-3-23] Sex: F Service: MEDICINE Allergies: Ampicillin Attending:[First Name3 (LF) 7475] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 64F w/PMHx significant for DM, COPD, HTN, who after having an outpt stress echo had increasing SOB during the evaluation, feeling tight in the lungs. The stress echo was normal, no ekg changes and, although low exercise capacity due to dyspnea, had normal BP and HR response w/out any ischemic changes. Cards fellow thought pt had wheezing and sent pt to ED for further evaluation. . In the ED, initial vs were: 98.8, 92, 112/65, 20, 96/4L. Patient was given azithro, CTX and levo. Pt received Albuterol and Ipratropium nebs during which had sats of ?80%/3L at some point during treatment. Methylprednisolon 125mg was also administerd. Pt endorsed cough and subjective fever over the last day or so. Of note, has peak flow 150, decreased air movement but no focal crackles. CXR was obatianed which showed ?multifocal pna but final read is pending; no focal consolidation but diffusely patchy on R side suggestive of PNA. Cardiac enzymes added on and pending at time of transfer. ED deferred ABG to ICU setting. On transfer access: 22G, satting low 90s 4-5L on NC. Tachypneic 30-35. Retracting some. 115/70 106, 32 97% on nebs. . On the floor, pt breathing ok on 4-5L. Pt reported having several days of worsening productive cough and fever with sore throat. Pt noted getting a cold roughly a week ago; granddaughter was [Name2 (NI) ] but symptoms significantly worsened over the last day. In generally, pt has noted increased fatigued for the last month leading up to this, having low energy which prompted cessation of smoking. Of note, pt did report smoking up until a few weeks ago. Per note on [2175-2-14] pt received flu shot and the pneumovax. . Review of sytems: (+) Per HPI; pt reported fever and cough over last few days. Had sore throat, nasal congestion and headache. Fatigue over the last month or so. Noted decreased urine outpt in association w/decreased PO intake (-) Denied chest pain or pressure, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. Hypercholesterolemia 2. Type 2 Diabetes Mellitus 3. Hypertension 4. h/o Diverticulitis requiring colon resection 5. Emphysema 6. Pulmonary Nodule Social History: Home: lives in [Location 686] with her daughter Occupation: retired secretary with the Department of Defense EtOH: Social Drugs: Denies Tobacco: 1 PPD x 20 years Family History: Mother - heart disease and died of a stroke Father - prostate cancer. Physical Exam: Admission: Vitals: T:97.7 BP:98/59- 113/65 P:91 R: 24 O2: 91% 4L NC General: Alert, oriented, tired but no acute distress, appears to be breathing more comfortably than what was reported in ED HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: fine wheezes no rhonchi but had decreased air movement on exam; no cough on exam but reported cough; sounded hoarse and congested CV: mild tachycardia, RR, 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 Neuro: alert oriendted, able to releate hx, CNII-XII grossly intact, did not assess gate, sensation intact. . Discharge Physical exam Physical Exam: Vitals: T: 96, BP: 124/76, P: 77, RR: 20, O2sat: 97% RA. General: Alert, oriented, NAD. HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: improved air movement with no expiratory wheezes. No rales or rhonki. CV: RRR, 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 Neuro: alert oriendted, able to releate hx, CNII-XII grossly intact, did not assess gate, sensation intact. Pertinent Results: [2175-6-14] 09:00PM TYPE-ART TEMP-36.5 O2 FLOW-5 PO2-77* PCO2-29* PH-7.46* TOTAL CO2-21 BASE XS--1 INTUBATED-NOT INTUBA [2175-6-14] 06:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2175-6-14] 06:50PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-<1 [2175-6-14] 03:55PM GLUCOSE-130* UREA N-14 CREAT-0.9 SODIUM-136 POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16 [2175-6-14] 03:55PM cTropnT-<0.01 [2175-6-14] 03:55PM CALCIUM-9.7 PHOSPHATE-2.7 MAGNESIUM-1.5* [2175-6-14] 03:55PM WBC-6.6 RBC-4.07* HGB-12.6 HCT-36.2 MCV-89 MCH-31.0 MCHC-34.8 RDW-13.7 [2175-6-14] 03:55PM NEUTS-71.7* LYMPHS-21.6 MONOS-4.0 EOS-1.7 BASOS-1.0 CXR [2175-6-14]: Emphysema with subtle ground-glass opacity occupying both lungs which may represent atypical pneumonia, and close followup is advised . Discharge Labs [2175-6-18] 07:05AM BLOOD WBC-9.4 RBC-3.87* Hgb-12.0 Hct-34.2* MCV-88 MCH-31.1 MCHC-35.2* RDW-13.8 Plt Ct-223 [2175-6-16] 06:50AM BLOOD Neuts-82.0* Lymphs-14.3* Monos-3.3 Eos-0.1 Baso-0.3 [2175-6-14] 03:55PM BLOOD Neuts-71.7* Lymphs-21.6 Monos-4.0 Eos-1.7 Baso-1.0 [2175-6-17] 06:35AM BLOOD Plt Ct-218 [2175-6-18] 07:05AM BLOOD Glucose-123* UreaN-19 Creat-0.8 Na-138 K-3.6 Cl-101 HCO3-27 AnGap-14 [2175-6-17] 06:35AM BLOOD Glucose-125* UreaN-12 Creat-0.7 Na-140 K-3.6 Cl-103 HCO3-27 AnGap-14 [2175-6-16] 06:50AM BLOOD Glucose-147* UreaN-13 Creat-0.7 Na-140 K-4.2 Cl-104 HCO3-26 AnGap-14 [2175-6-15] 04:51AM BLOOD CK(CPK)-89 [2175-6-14] 03:55PM BLOOD cTropnT-<0.01 [2175-6-18] 07:05AM BLOOD Calcium-10.1 Phos-3.2 Mg-1.9 [2175-6-17] 06:35AM BLOOD Calcium-9.9 Phos-2.7 Mg-2.0 [2175-6-16] 06:50AM BLOOD Calcium-9.3 Phos-2.5* Mg-2.1 [2175-6-14] 06:46PM BLOOD Lactate-1.1 [2175-6-14] 09:00PM BLOOD Type-ART Temp-36.5 O2 Flow-5 pO2-77* pCO2-29* pH-7.46* calTCO2-21 Base XS--1 Intubat-NOT INTUBA . Micro: blood cx. pending at the time of discharge, urine cx negative and legionella urine antigen negative Brief Hospital Course: [Hospital Ward Name 121] 2 general [Hospital1 ] course This is a 64 year old female with PMH significant for DM, COPD, HTN, who developed acute dyspnea following an outpatient stress echo in the setting of worsening productive cough and subjective fevers and admitted to the ICU for management of community acquired atypical PNA and COPD exacerbation.Was transferred to the floor and was able to ambulate with improved oxygen saturations and air movement. . # Respiratory distress: In the setting of week long duration of fevers, productive cough, poor involvement and chest radiograph findings, clinical picture most likely consistent with atypical pneumonia and COPD exacerbation. Has improved with PO antibiotics and standard medical management of COPD exacerbation with albuterol and ipratropium nebulizers. Was on prednisone from the day of admission and will continue 20 mg daily today for 2 more days on discharge .Converted standing nebs to standing Advair and Tiotropium with PRN albuterol inhalers. Continue levofloxacin; day 1 is [2175-6-14] to day 7 [2175-6-20]. Culture data was negative to date.Urine legionella was negative. . # Hypertension: Has history of uncontrolled HTN despite reported adherence to BP meds w/ systolics in the 170-180s. BPs well controlled in ICU. Re-initiation of home antihypertensive medications including home metoprolol,home HCTZ and ramipril. . #Depression: -Patient restarted on Paroxetine 10 mg PO/NG DAILY . # Hypercholesterolemia: Stable. Continued home statin. . # Type 2 Diabetes Mellitus: on metformin at home. Was controlled on insulin sliding scale as inpatient and discharged on home metformin . . # Hx of arthritis: on tramadol , and was not active as inpatient. [Hospital Unit Name 153] course: Presented with dyspnea and wheezing during stress test that showed no ischemic changes on EKG. At home, she had subjective fever and cough, CXR with evidence of atypical PNA. She had increased O2 requirement and received standing albuterol and ipratroprium nebs, as well as IV methylprednisolone. Peak flow initially 150 mL. She was ruled out for MI, steroids were switched to prednisone 60 mg daily x 5 day course, and levofloxacin was started for community acquired PNA. Home medications initially were held for hypertension as she was noted to have SBP 98-113 in ICU, restarted home metoprolol prior to transfer to floor. Metformin from home was held, and pt was started on ISS. Fingersticks noted to be in 300s-400s after initiation of steroids, so lantus started for basal coverage while on steroids and not on home metformin. On transfer out of the [Hospital Unit Name 153], peak flows improved to 200s, oxygen sats were 95% on 3L NC. ------------------- Outpatient follow up in lieu of TWI in lateral precordial leads, would consider outpatient stress when respiratory stress is stabilized Medications on Admission: Mirtazapine 15mg QHS Albuterol sulfate 90 mcg HFA Aerosol Inhaler - 1-2 puffs inh q4-6 hours as needed for wheeze, shortness of breath atorvastatin 20 mg Tablet - 1 (One) Tablet(s) by mouth daily fluticasone-salmeterol (advair) 230 mcg-21 mcg/Actuation Aerosol - 1 puff(s) inhaled twice a day hydrochlorothiazide 25 mg daily IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA Aerosol Inhaler - 3-4 puffs inhaled four times a day as needed for shortness of breath, cough metformin 1000mg [Hospital1 ] metoprolol tartrate 50mg [Hospital1 ] ramipril 10mg daily aspirin 81 my daily ibuprofen 800mg Q6H prn Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times 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). Disp:1 Cap(s) Refills:2 7. ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing . 11. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 12. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. Disp:2 Tablet(s) Refills:0 14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:2 Tablet(s) Refills:0 15. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Atypical Pneumonia COPD Exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to care for you as your doctor. . You were brought to the hospital because of a respiratory infection which caused a exacerbated of your chronic disease COPD. Your cough improved with antibiotics and breathing treatments. . We made the following changes to your home medication list: STOP Ipratropium, and START Tiotropium daily as prescribed which is a long acting medication. CONTINUE ADVAIR and take daily as prescribed. CONTINUE Albuterol , but only as needed for shortness of breath. START Fluticasone nasal spray for your stuffy nose We made no other changes to your home medication list. Please continue to take the rest of your medications as you were before coming to the hospital. START Prednisone 20mg daily for 2 days. This is a medication for your COPD Please take Tums for the next couple of days to protect your stomach from the effects of prednisone . Please follow up with the outpatient appointments below Followup Instructions: If you would like to schedule an appointment here at [Hospital1 18] closer to your home, the number to call is [Telephone/Fax (1) 250]. Department: [Hospital1 ] When: FRIDAY [2175-6-23] at 8:15 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7476], MD [Telephone/Fax (1) 7477] Building: [State 7478] ([Location (un) 86], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: None Department: [Hospital1 ] When: MONDAY [2175-7-24] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7479], MD [Telephone/Fax (1) 7477] Building: [State 7478] ([Location (un) 86], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: None Department: PULMONARY FUNCTION LAB When: WEDNESDAY [2175-8-16] at 1:10 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) ] [Last Name (NamePattern4) 7480] MD, [MD Number(3) 7481]	[ "486", "25000", "4019", "2720", "2859", "311" ]
Admission Date: [2112-3-22] Discharge Date: [2112-4-2] Date of Birth: [2032-2-27] Sex: F Service: MEDICINE Allergies: Aspirin / Cefazolin / Flushield Attending:[First Name3 (LF) 1850] Chief Complaint: epistaxis Major Surgical or Invasive Procedure: 1. Parathyroid resection. 2. IVC filter History of Present Illness: 80 y/o female admitted with epistaxis and supratherapeutic INR s/p recent admit for FTT/dehydration/ARF discharged on levoquin for UTI (now completed course), who p/w coughing up clots of blood and epistaxis x 3 days. Also found to have worsening renal insufficiency with creatinine of 2.3. Past Medical History: 1.)HTN 2.)Rheumatoid arthritis 3.)Primary hyperparathyroidism 4.)Breast CA (early [2086]'s) s/p mastectomy (no post-op chemo/xrt) 5.)CTA that showed RUL segmental PE. A follow-up Doppler study demonstrated a left popliteal DVT 6.)primary hyperparathyroidism: awaiting endocrine evaluation 7.) Glaucoma 8.) Anemia of chronic disease Social History: She is a widow for 19 years and lives alone in a senior building. She has 11 children, ages 42 to 60. Two of her children have died, a daughter from AIDS and a son who was killed in a shooting accident. Her children are very involved in her care. She does not drink any alcohol and does not smoke any tobacco. She used to smoke a few cigarettes/day but quit over 20 years ago. Prior to the onset of sx, she would frequently walk one block to the nearby library. Family History: Pt has h/o DM in family and daughter with breast CA. Significant for a niece with rheumatoid arthritis and a sister with diabetes. She has no family history of hypertension or hypercholesterolemia, CAD, [Last Name (LF) 499], [First Name3 (LF) 691] neurological or psychiatric illnesses. Physical Exam: T 98, HR 106, BP 128/69, 96% O2 on RA gen- elderly, frail female in NAD heent- no active bleeding; dried blood crusting in nares b/l neck- supple. jvp flat pulm- clear to auscultation b/l CV- RRR. no m/r/g ABD- soft, NT/ND. NABS EXT- ulnar deviation of hands, severe RA changes; Rectal- guaiac negative Pertinent Results: Admission Labs: * CBC: WBC-17.4* RBC-3.25* HGB-9.6* HCT-29.2* MCV-90 PLT 249 DIFF: NEUTS-86.2* BANDS-0 LYMPHS-12.4* MONOS-0.9* EOS-0.3 BASOS-0.2 * Coags: PT-25.9* PTT-48.6* INR(PT)-4.2 * CHEM: ALBUMIN-2.9* CALCIUM-9.9 PHOSPHATE-2.4* MAGNESIUM-2.0 GLUCOSE-76 UREA N-54* CREAT-2.3* SODIUM-140 POTASSIUM-5.0 CHLORIDE-112* TOTAL CO2-20 * LFT's: ALT(SGPT)-21 AST(SGOT)-26 LD(LDH)-239 ALK PHOS-149 AMYLASE-70 TOT BILI-1.5 LIPASE 24 * U/A: RBC->50 WBC-[6-10]* BACTERIA-OCC YEAST-NONE EPI-0-2 TRANS EPI-0-2 [2112-3-22] 08:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM * Radiologic Studies- [3-22] CXR PA/LAT: no definite effusions or consolidations [3-25] CXR PA/LAT: * [3-23] CT A/P non-contrast: A 4 mm renal stone is noted in the midpole of the left kidney, nonobstructing. There is no renal hydronephrosis. The spleen, pancreas, stomach, and bowel loops are normal. No masses are seen. Brief Hospital Course: She was admitted to the medicine service with a supratheraopeutic INR in setting of levaquin and ARF. She underwent parathyroidectomy on [2112-3-28] that was complicated by hypoxia and was transferred to the [Hospital Unit Name 153]. Hypoxia: She was started on BIPAP and given a nitro gtt on the night of admission to the [Hospital Unit Name 153] to reduce preload. She was diuresed with lasix. Her CXR continued to worsen. There was concern for DAH v. post negative pressure pulmonmary edema v. diastolic CHF v. TRALI. She was given solumedrol in case this was DAH. She was given morphine for pulmonary venous dilation. IVC filter was placed given her history of PE. HEME:- Initially admitted with supratherapeutic INR. THis fell after holding coumadin. Her hct was falling and she was guiaic positive. GI was consulted but her hct stabilized after transusions and they did not want to scope her in setting of repsiratory distress. Primary hyperparathyroidism- Patient had recently diagnosed primary hyperparathyroidism by labs and confirmed with imaging U/S and parathyroid nuclear scan. Underwent surgery on [3-29] with Dr. [Last Name (STitle) 5182]. We continued on Vitamin D supplementation. Post op course complicated by hypoxia. Renal insufficiency- She presented with acute on chronic renal insufficiency. This was felt likely pre-renal based on her clinical hypovolemia. However, initial Fena was 2% (on last admission was also >2%). Her high FeNa was felt secondary to hypercalcemic state. She was hydrated with stabilization of her renal insufficiency. CT stone protocol was repeated to r/o obstructing stone. This showed a 4mm stone- still non-obstructing with no associated hydronephrosis. Urology service was also formally consulted to evaluate potential treatment of stone. However, it was felt that treatment was not indicated at this time given her supratherapeutic INR and urinary infection. Renal was consulted and attributed her renal failure to hyperparathyroidism but the acuity was not consistent with this. Hemodialysis was considered but the family and pt refused. Cardiac: Echo showed EF of 20-25% on [2112-3-31]. This was felt to be secondary to an MI in the midst of the ICU stay. She was started on dobutamine for inotropic support. Goals of care: Given the pt's poor prognosis and multiple organ failure: renal, cardiac, respiratory a family meeting was held and it was decided to make the patient CMO on [2112-4-1] and passed away peacefully with family at her side on [2112-4-2]. 5. anorexia- This is a chronic issue for the patient and may be related to her underlying hypercalcemia. She was encouraged to [Last Name (un) ] in PO's and supplements with meals. However she continued to have poor intake. She was hydrated gently with standing IVFs. 6. UTI- started on Bactrim for 14 d course (given recurrent proteus UTI). follow INR closely on abx. 7. leukocytosis- unclear [Name2 (NI) ]. f/u urine cx final data, CXR, blood cultures. 8. Anemia- AOCD (likely from RA). Increase aranesp to 30 mcg q week SC. Rec'd 2 U PRBC's on [2112-3-23] Medications on Admission: lipitor 40mg daily latanoprost prednisone 2mg daily verapami 180mg daily megestrol 40mg daily coumadin 2mg per day aranesp 23mcg weekly vitamin D levaquin 250mg daily (completed one week course 1 day PTA) Discharge Medications: N/a Discharge Disposition: Extended Care Discharge Diagnosis: 1. Epistaxis 2. Supratherapeutic INR 3. Urinary Tract Infection 4. Non-obstructing renal stone 5. Acute on chronic renal insufficiency 6. Primary hyperparathyroidism 7. Anorexia Discharge Condition: Expired Discharge Instructions: N/a Followup Instructions: N/A [First Name8 (NamePattern2) 1176] [Name8 (MD) 1177] MD [MD Number(2) 1851]	[ "51881", "5845", "40391", "41071", "5990" ]
Admission Date: [2121-7-15] Discharge Date: [2121-7-21] Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: Mr. [Known firstname ] [Known lastname 46373] is an 84- year-old male who presented to this institution for elective surgical treatment of bleeding 8-mm and 2.5-cm cecal polyps. The patient was recently hospitalized at this institution following a fall. At that time, he was noted to have guaiac- positive stool. The patient was on aspirin for chronic atrial fibrillation and spent a short course at rehabilitation before eventually being discharge to home. The patient is doing well at this time and denies blood in his stools. He has noted no change in his bowel pattern. He appetite has been good, and he has had no weight loss. PAST MEDICAL HISTORY: Coronary artery disease. Congestive heart failure (with an ejection fraction of 35 percent). Atrial fibrillation. Prostate cancer. Hypercholesterolemia. Hypothyroidism. Aortic stenosis. Hypertension. Gastritis. History of upper gastrointestinal bleed. Status post cerebrovascular accident. Diverticulosis. PAST SURGICAL HISTORY: Coronary artery bypass grafting. Cholecystectomy. Left knee surgery. Bilateral carotid endarterectomy. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg by mouth once per day. 2. Lasix 40 mg by mouth once per day. 3. Toprol-XL 25 mg by mouth once per day. 4. Lipitor 10 mg by mouth once per day. 5. Doxazosin 4 mg by mouth once per day. 6. Levoxyl 125 mcg by mouth every day. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs revealed his temperature was 98.5, his pulse was 83, his blood pressure was 113/57, his respiratory rate was 10, and his oxygen saturation was 96 percent on room air. In general, the patient is an elderly male who appeared his stated age. He was in no distress and was sitting comfortably in a stretcher. The oropharynx was clear. The mucous membranes were moist. The neck was supple without lymphadenopathy. The heart was regular in rate and rhythm. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended with one paramedian well-healed surgical scar. The extremities were warm with 2 plus distal pulses and no edema. SUMMARY OF HOSPITAL COURSE: On the day of admission, the patient was taken to the operating room where an elective laparoscopic-assisted right colectomy was performed. The patient tolerated this procedure well with an estimated blood loss of 100 cc. The patient did receive 2 unit of packed red blood cells intraoperatively. Approximately 4 liters of clear ascites were drained at the time of surgery from the abdomen. The patient remained intubated and was transferred to the Intensive Care Unit postoperatively for close monitoring. The patient was extubated postoperatively. He was treated with albumin intravenously for two days to elevate his oncotic pressure. The postoperative hematocrit was 35.6 percent. His INR was elevated at 2.1 despite the absence of Coumadin. The patient was treated with morphine as needed postoperatively for pain. He was given Levophed for approximately two days to maintain his systolic blood pressure at greater than 100. Cardiac enzymes were sent on postoperative day one as the patient was persistently tachycardic. The electrocardiogram revealed a right bundle branch block, but the enzymes were negative for ischemia or infarction. The patient was given Lasix 40 mg intravenously twice per day to alleviate his abdominal ascites. He was given perioperative doses of Kefzol and Flagyl. On postoperative day three, the patient was converted to his home medications. At this time, the patient had passed flatus and had a formed bowel movement, and he was started on clear liquid diet. Around this time, the patient self- removed his Foley catheter. It was not replaced as he was able to void independently. At this time, the patient was transferred to the regular hospital floor. He was on a regular diet with supplemental Boost shakes three times per day. He was given Haldol intermittently to prevent him from climbing out of bed as he was deemed unsafe and at risk for falls. On postoperative day six, after the patient had been tolerating a regular diet and was hemodynamically stable, he was discharged to a skilled nursing facility in good condition. His wound did not have any evidence of erythema or discharge. His staples are to be removed in approximately one week. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: The patient was discharged to a skilled nursing facility. DISCHARGE DIAGNOSES: Cecal adenoma times two. Status post laparoscopic-assisted right colectomy. Coronary artery disease. Congestive heart failure (with an ejection fraction of 35 percent). Atrial fibrillation. Prostate cancer. Hypercholesterolemia. Hypothyroidism. Aortic stenosis. Hypertension. Gastritis. History of an upper gastrointestinal bleed. Status post cerebrovascular accident. Status post coronary artery bypass grafting. Status post cholecystectomy. Status post left total knee arthroplasty. Status post bilateral carotid endarterectomy. Ascites. Diverticulosis. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 mg by mouth once per day. 2. Lasix 40 mg by mouth once per day. 3. Toprol-XL 25 mg by mouth once per day. 4. Lipitor 10 mg by mouth once per day. 5. Doxazosin 4 mg by mouth once per day. 6. Levoxyl 125 mcg by mouth every day. 7. Tylenol No. 3 as needed for pain. 8. Colace 100 mg by mouth twice per day. DISCHARGE FOLLOW-UP PLANS: The patient was discharged on a regular diet with supplemental Boost shakes three times per day. He was instructed to follow up with Dr. [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ] in approximately two weeks. His staples should be removed from his abdominal wound in approximately one week. The patient was instructed to follow up sooner if he developed fevers greater than 101.5 degrees Fahrenheit, severe abdominal pain, vomiting, drainage from the abdominal wound, or if he had any other questions or concerns. [First Name11 (Name Pattern1) 333] [Last Name (NamePattern4) 366], [MD Number(1) 367] Dictated By:[Last Name (NamePattern1) 22791] MEDQUIST36 D: [2121-7-21] 09:58:12 T: [2121-7-21] 10:31:17 Job#: [Job Number 46374]	[ "9971", "42731", "2449", "2720", "V4581" ]
Admission Date: [2147-4-26] Discharge Date: [2147-5-25] Date of Birth: [2076-6-19] Sex: M Service: MEDICINE Allergies: Aleve Attending:[First Name3 (LF) 4219] Chief Complaint: hip fracture Major Surgical or Invasive Procedure: R hip ORIF [2147-4-27] Cental line (R IJ, R subclavian dialyisis line) R PICC line placed [2147-5-12] History of Present Illness: 70yo man with ESRD not yet on HD, DM, PVD who initially presented s/p fall while getting out of bed in setting of hypoglycemia and poor appetite. He landed on his R hip and sustained a displaced femoral neck fracture. He was found by his son on the floor next to his bed, who called EMS. On arrival to an OSH he was found to have FS 36 and the above fracture and he was sent to [Hospital1 18] for further management. He was recently treated at an outside hospital from [Date range (1) 61322] for a R great toe cellulitis and was discharged to home on IV antibiotics (imipenem and zyvox). He was found to have a necrotic R great toe on arrival. He was medically cleared for the OR and had a hemiarthroplasty of the R hip, immediate post op period was complicated by DKA and the patient was sent to the micu, where he was kept on an insulin drip for one day. Since then he has had very volatile FS, running between very elevated and quite low. [Last Name (un) ] has been following and with their recs the pt's FS have been stable off D5 for the last 24 hours. . [Hospital 1094] hospital course has also been complicated by hospital acquired LLL pneumonia for which he is being treated with vanco/zosyn, MS changes believed to be due to narcotics/psychotropic meds, development of a coccygeal decubitus pressure ulcer, and elevated INR in setting of coumadin use s/p femoral fracture (avoiding lovenox given CRI). He has been followed by renal, ID, [Last Name (un) ], [Last Name (un) 1106] surgery and orthopedic surgery throughout his stay. . ROS: pt reports mild pain in his r hip and r toe. no cp, no sob, no other complaints. eating well. Past Medical History: CRI DM PVD with R great toe cellulitis/necrosis HTN Social History: lives with son and daughter-in-law, usually I in ADLs; 100+ py tobacco hx, quit [2129] ([4-12] ppd x 40y); no etoh or other drugs Family History: NC Physical Exam: 99.1, 155/52, 63, 13, 98% RA, FS 74-123 Gen: confused man, NAD, oriented x 3 with much effort, answers questions but very circuitously HEENT: PERRL, OP not injected, MMM, CM II-XII intact Neck: no JVD, no LAD Pulm: decreased BS and inspiratory rhonchi at bilateral bases anteriorly Cor: rrr, s1s2, no r/g/m Abd: soft, NT, ND, +bs, no hsm Ext: R great toe black and necrotic, R hip wound c/d/i, staples in place, nontender, nonerythematous, trace edema bilaterally, small 2x2cm coccygeal decub stage II, bilateral PT and DP not palpable GU: yellow urine in foley, scrotum erythematous with fungal skin infection around scrotal skin and inguinal folds Pertinent Results: Labs: 141 110 56 83 AGap=13 4.6 18 4.7 . Ca: 7.4 Mg: 2.1 P: 4.8 Other Blood Chemistry: Vanco: 21.2 (last dose on [5-3]) . ....7.6 87 15.3>---<191 ...23.5 . PT: 26.6 PTT: 112.3 INR: 2.7 . ColorYellow AppearClear SpecGr1.012 pH 5.0 UrobilNeg BiliNeg LeukNeg BldLg NitrNeg Prot100 Glu100 KetNeg . Mg: 2.1 Acetone:Negative Comments: Detects Acetone + Acetoacetate Not Beta-Hydroxy Butyrate _ _ _ _ _ _ _ _ _ ________________________________________________________________ FEMUR (AP & LAT) RIGHT [2147-4-26] 1:17 AM PELVIS (AP ONLY); HIP UNILAT MIN 2 VIEWS RIGHT AP PELVIS AND AP AND LATERAL VIEWS OF THE RIGHT FEMUR. There is a right subcapital/transcervical femoral fracture with superior displacement of the distal fracture with limb shortening. There is varus angulation of the fragments. The femoral head articulates with the acetabulum appropriately. The left femoral neck appears intact. No fractures are detected involving the right femur or knee. The soft tissues are unremarkable. IMPRESSION: 1. Right femoral subcapital/transcervical fracture with impaction and varus angulation of the distal fragment. 2. Extensive [Month/Day/Year 1106] calcifications. _ _ _ _ _ _ _ _ _ ________________________________________________________________ CHEST (PRE-OP AP ONLY) [2147-4-26] 1:23 AM IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Lungs clear. Heart size top normal, exaggerated by low lung volumes and supine positioning. No pleural effusion or evidence of central adenopathy. No pneumothorax. Tip of a right-sided central venous catheter projects over the junction of the brachiocephalic veins. _ _ _ _ _ _ _ _ _ ________________________________________________________________ CT HEAD W/O CONTRAST [2147-4-30] 11:35 AM NON-CONTRAST HEAD CT: No priors for comparison. No hydrocephalus, shift of normally midline structures, hemorrhage, or infarct is identified. Calcified internal carotid arteries are noted. No fracture. Retention cyst vs polyp in left maxillary sinus; other imaged sinuses are clear. There is cavernous carotid artery calcification. _ _ _ _ _ _ _ _ ________________________________________________________________ CHEST (PA & LAT) AP AND LATERAL CHEST RADIOGRAPHS: Dating back to [2147-4-26], there has been interval development of left lower lobe consolidation obscuring the left hemidiaphragm consistent with pneumonia. Cardiac, mediastinal, and hilar contours are stable. Right internal jugular catheter tip is seen within the mid SVC. No evidence of pneumothorax or pleural effusions. Osseous and soft tissue structures are unremarkable. _ _ _ _ _ _ _ _ _ ________________________________________________________________ RADIOLOGY Final Report AORTA AND BRANCHES AORTA AND BRANCHES U/S [2147-5-8] 1:15 PM The abdominal aorta is normal in caliber measuring 2.3 cm in maximal diameter and showing no focal aneurysmal dilatation. There is some elevated atherosclerotic plaque in the distal abdominal aorta and at the iliac bifurcation. These plaques do not compromise flow, however. The possibility of the plaques being a source for peripheral emboli cannot be assessed by this technique. Iliac arteries are normal in caliber bilaterally. _ _ _ _ _ _ _ _ _ ________________________________________________________________ Cardiology Report ECHO Study Date of [2147-5-10] MEASUREMENTS: Left Ventricle - Ejection Fraction: 60% (nl >=55%) INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV systolic function. AORTA: No atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or vegetations on aortic valve. No AR. MITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral valve. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on tricuspid valve. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No vegetation/mass on pulmonic valve. Conclusions: 1. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 2.Overall left ventricular systolic function is probably normal (LVEF>55%), however, the probe was not passed beyond the GE junction and transgastric views were not obtained. 3.Right ventricular systolic function is normal. 4.There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. 6.The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Physiologic mitral regurgitation is seen (within normal limits). 7. No vegetation/mass is seen on the pulmonic valve. _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ VIDEO OROPHARYNGEAL SWALLOW [2147-5-16] 2:49 PM OROPHARYNGEAL VIDEO FLUOROSCOPIC STUDY: Oropharyngeal video fluoroscopic swallowing evaluation was performed with speech and swallow therapist, and demonstrates mild oral and pharyngeal dysphasia, mild swallowing delay. Mild silent aspiration was noted. No significant improvement in mild aspiration. For further details please refer to speech and swallow report. _ _ _ _ _ _ _ _ _ ________________________________________________________________ FOOT AP,LAT & OBL BILAT [2147-5-17] 3:26 PM BILATERAL FEET, SIX VIEWS: No cortical destruction or irregularity is identified to indicate osteomyelitis. The mineralization is normal. There are diffuse [Year/Month/Day 1106] calcifications. The joint spaces are preserved. There is a posterior and plantar calcaneal spur on the left. IMPRESSION: No radiographic evidence of osteomyelitis. Brief Hospital Course: # R great toe and left [2-10] toe necrosis: Likely embolic. TEE, aorta MRA and lower extremity angiogram did not show any source of emboli. Pt was on anticoagulation for right hip orif..completed several weeks of heparin gtt..and currently on aspirin for prophylaxis. Also started on statin for possiblity of cholesterol emboli. Xray do not show sign of osteomylelitis. No signs of active infection. Followed by vasuclar surgery while in house who plan for amputation after discharge at outpt follow up. . # R femoral neck fracture s/p hemiarthroplasty- Repaired on [4-27] - Pt to f/u with Dr. [Last Name (STitle) 1005] in ortho clinic 1-2w after discharge [Telephone/Fax (1) 1228]. - WBAT for pt. - staples removed [2147-5-11] . # DM/DKA: Initially developed DKA in setting of orthopedic surgery around [2147-4-27]. Treated with insulin drip in the ICU. Sent to floor with closed gap. Developed DKA again on [2147-5-1] in setting of fever and hospital aquired PNA/ Again treated in teh ICU with insulin drip. Transferred back to floor on [5-7]. GLucose has been stable and lantus dose titrated up as diet increased. Has been difficult to follow GAP with renal acidosis. Have been following urine ketones which are negative at the time of discharge. . # CRI: pt with ESRD but not yet on HD. renal following during hospitalization and pt requiring frequent adjustments to phosphate binders, lytes, etc. Never required HD despite dye load from angiogram. Renal care will needs to be continued, unclear when pt will need hemodialysis. . # LLL pneumonia: likely hospital acquired, Treated with 14d course of zosyn and vanco for broad coverage. afebrile. cultures negative. . # MS change: Confused in the settin gof high INR (up to 13). Head ct negative. Likely delerium secondray to illness and medication (narcotics and benzodiazepines). Mental status is now back to baseline. . #Hypotension/Hypoxia/Bradycardia - On[2147-5-11], pt was found unresponsive at 9am. The previous night he had been getting hydration for renal ppx prior to dye load. Initial assement - RR 5, BP 50/pal, sinus brady at 34. Given 200 mg IV lasix push, 1 amp atropine, and narcan. Pt responed with increased HR and RR. CT scan done showed no bleed. Likely volume overload, leading to hypoxia and and bradycardia. Resolved quickly and never recurred. # HTN: fairly well controlled at present. continue BB, norvasc, hydralazine. titrate as tolerated. . # diarrhea; c diff negative x 3. continue to follow for frequency. . # coccygeal decubitus ulcer and penile ulcer- continue wound care as previously. turn q2 hours as tolerated. coccygeal swab + for pseudomonas which was more likely a colonization rather than infection. coccygeal ulcer had an overlying fungal infection that improved with local care. . # penile necrosis - secondary to foley trauma from pt pulling on it in setting of altered mental status. Seen by urology who recommend leaving foley in place, securing it tightly to leg, and local wound care with bacitracin and silvadeine. # access: PICC placed [2147-5-12]. . #Aspiration risk - pt failed speech and swallow eval. recommend thin liquids and observation. Medications on Admission: ASA lantus 35, HISS Iron sulfate qday mag oxide 400mg po qday sodium bicarb 650po [Hospital1 ] norvasc 10 qday toprol 25 po qday allopurinol 100 po qday was on 6wk course of imipenem 250mg [Hospital1 ], zyvox 600mg [Hospital1 ] Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day): apply to penis. 4. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical QID (4 times a day): apply to penis. 10. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ml Injection QMOWEFR (Monday -Wednesday-Friday). 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 15. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 18. Insulin Glargine 100 unit/mL Cartridge Sig: Seven (7) units Subcutaneous once a day. 19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 21. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 24. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 25. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) ] Nursing & Rehabilitation Center - [Location (un) ] Discharge Diagnosis: hip fracture renal failure peripheral [Location (un) 1106] disease diabetic ketoacidosis pneumonia Discharge Condition: Stable Discharge Instructions: Please follow up as directed. Followup Instructions: Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2147-6-13] 11:15 . Please see the Urology department at the first available appointment on [2147-6-7] 3pm with Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 10426] . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2147-6-6] 3:00 . Provider: [Name10 (NameIs) 5865] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2147-6-6] 2:40 . Please make a follow up appointment with your renal (kidney) doctor. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4231] Completed by:[2147-5-25]	[ "5849", "486", "40391", "2875", "V5867" ]
Admission Date: [2103-3-31] Discharge Date: [2103-4-2] Date of Birth: [2050-4-12] Sex: M Service: [Company 191] MEDICINE HISTORY OF PRESENT ILLNESS (PER ADMITTING [Male First Name (un) ] INTENSIVE CARE UNIT RESIDENT): Mr. [Known lastname 41243] is a 52 year-old Spanish speaking patient transferred to [Hospital1 188] from [Hospital3 ]. The patient's recent past medical history is remarkable for an initial admission at [Hospital3 ] on [3-12] with hematemesis. The patient's hematocrit at that time was reportedly 33%, and an esophagogastroduodenoscopy was reportedly negative (although there was some question of some [Doctor First Name ]-[Doctor Last Name ] tears that had healed). The patient was treated and released from [Hospital3 ] and was subsequently readmitted there on [2103-3-15] with some similar complaints. His hematocrit on this readmission was 15.6. An esophagogastroduodenoscopy on the second admission to [Hospital1 3494] revealed fundal ulcer in the stomach with a visible vessel. This ulcer and vessel were reportedly sclerosed and the patient was given a total of 8 units of packed red blood cells in the hospital over a fourteen day period. Repeat esophagogastroduodenoscopy on [2103-3-22] reportedly revealed an ulcer base that had shrunk, but had remained present and with a visible vessel. Biopsy was reportedly negative for cancer or H-pylori, however, subsequent serology revealed that the patient was positive for H-pylori exposure and the patient was started on Amoxicillin, Clarithromycin, and Protonix. A chest, abdominal and pelvic CT had reportedly revealed a possible malignant ulcer in the upper gastric fundus. The patient was subsequently discharged from [Hospital3 ], however, he represented one day after admission to [Hospital1 3494] Emergency Department with a hematocrit of 22. The patient was thus transferred to [Hospital1 69] for consideration of embolization of the ulcers artery. PAST MEDICAL HISTORY: Alcohol abuse. The patient denies history of cardiac, renal and liver disease. He denies history of diabetes. OUTPATIENT MEDICATIONS (PRIOR TO ADMISSION TO [Hospital3 ]): None. MEDICATIONS ON TRANSFER FROM [Hospital3 ] TO [Hospital1 ]: Protonix 40 mg q.d., Amoxicillin 1 gram b.i.d., Clarithromycin 500 mg b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is from El [Country 19118]. He has eleven children. One of the patient's sons lives in the [Name (NI) 86] area, although the patient does not see him often. The patient is reportedly homeless. The patient denies current tobacco or other drug abuse. The patient admits to drinking. He sometimes consumes up to thirty beers per day. At the time of his transfer to [Hospital1 188], the patient had not had any thing to drink since the beginning of [2103-3-9] reportedly. LABORATORY DATA ON PRESENTATION: CBC revealed a white blood cell count of 10.4, hematocrit of 22.2, platelets 237. MCV 91. Coag studies revealed an INR of 1.3, PT 13.6, PTT of 26.9. Chem 7 revealed sodium 141, potassium 4.0, chloride 110, bicarb 24, BUN 22, creatinine 0.7, glucose 104. Liver function tests revealed ALT of 10, AST 19, alkaline phosphatase 70, amylase 96, total bilirubin of 0.2, lipase of 44. The patient's albumin was 2.9, calcium 6.0, phosphorus 5.5, and magnesium 1.3. HOSPITAL COURSE: The patient was transferred from [Hospital3 16786] to the [Hospital Ward Name 332] Intensive Care Unit on [2103-3-31]. During the patient's stay in the Intensive Care Unit he was transfused with 4 units of packed red blood cells, after which his hematocrit rose appropriately. On [2103-3-31] the patient underwent esophagogastroduodenoscopy that revealed a single, acute, 18 mm ulcer at the proximal stomach body near the cardia. A visible vessel suggested recent bleeding. The area was injected with epinephrine times three and electrocautery was employed for successful hemostasis. The patient's brief Intensive Care Unit course was barely stable. He did have some mild hypotension (systolic blood pressure to the 80s and 90s, asymptomatic), which responded to intravenous fluid boluses. The patients hematocrit remained fairly stable and he was transferred to the [Company 191] Service on the Medicine Floor on [2103-4-1]. The patient was maintained on his H-pylori treatment and his hematocrit was monitored while on the medicine floor. Additionally, the patient's diet was advanced, first to clears and then to full regular diet. The patient tolerated this well without nausea, vomiting, diarrhea or any further gastrointestinal bleeding. The patient's blood pressure on the medicine floor was noted to be mildly and transiently depressed. The patient reported occasional dizziness, although this eventually resolved with advancement of his diet. The patient was ambulating well and did not feel or exhibit any signs or symptoms of imbalance. CONDITION AT DISCHARGE: Vital signs stable. Afebrile. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed, gastric ulcer, status post epinephrine injection and sclerotherapy on esophagogastroduodenoscopy. 2. History of alcohol abuse. DISCHARGE MEDICATIONS: The patient was discharged with prescriptions for Amoxicillin, Biaxin and Protonix as well as a multi vitamin. The patient has six more days of his H-pylori treatment to complete. FOLLOW UP: The patient is to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557] in the [Hospital 191] Clinic on [2103-5-11] at 2:00 p.m. (this is the earliest date at which a Spanish interpreter would be available). Additionally, the patient is to follow up with the [Hospital ] Clinic in approximately eight weeks for a repeat esophagogastroduodenoscopy. The patient was given references for outpatient alcohol rehab/detox programs, but is not currently interested in pursuing these options. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Last Name (NamePattern1) 1550] MEDQUIST36 D: [2103-4-2] 15:08 T: [2103-4-3] 12:45 JOB#: [Job Number 23205]	[ "2851" ]
Admission Date: [2191-9-2] Discharge Date: [2191-9-9] Date of Birth: [2110-8-25] Sex: F Service: MEDICINE Allergies: Levofloxacin Attending:[First Name3 (LF) 2181] Chief Complaint: diarrhea Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [Name13 (STitle) 22950] is an 81yo female with PMH significant for prior c. diff infection. She presents with 1 month history of diarrhea, approximately [4-7] loose stools each day. Over the past week, she has felt more tired and was noted to have a fever at the rehab facility. She was started on Flagyl 500mg PO TID 5d ago but no report of c. diff cultures in records. She denies N/V, chest pain, SOB, dizziness, or dysuria. She associates the diarrhea with crampy abdominal pain. She states that her symptoms are very similar to what she experiencd 1 year ago with her prior c.diff infection. No recent travel. She was found to be hypotensive at the rehab facility today with BPs in low 80's. She was transferred to [Hospital1 18] for further work-up. Of note, she was recently admitted to [Hospital1 18] for spinal stenosis and pain control. . In the ED initial vitals were T 100.6 Tmax 103.6 BP 137/42 AR 95 RR 22 O2 sat 92% RA. She received Vancomycin 1gm IV, Ceftriaxone 1gm IV, and Flagyl 500mg IV. . Past Medical History: * HTN * COPD (no PFTs on file) * subclavian vein thrombosis, s/p subclavian bypass in [2184], on chronic warfarin * s/p hysterectomy * s/p appendectomy * admitted [Date range (1) 22949] to plastic surgery service for repair of right hand contractures secondary to past surgeries for distal radial fracture which was complicated by median nerve compression requiring open palmar surgeries, most recent [5-9] * LVH, anterolateral TWI * Infrarenal AAA 4.4cm [5-8] * Peripheral vascular disease (b/l tibial disease) * h/o vocal cord paralysis s/p Silastic stent * h/o C.diff in [2189] Social History: Patient currently staying at [Hospital 100] Rehab after recent hospitalization. Usually lives with her sister at home in [Name (NI) ]. No current tobacco or IVDA. Drinks 1 wine/day. . Family History: Mother died of cancer (unknown) at 87 years of age. Her father had a history of diabetes and died of a blood clot secondary to prostate surgery at 63. She has a brother with diabetes, hypertension, and CAD. She has a sister with hypertension and CAD, and another sister with no health problems. [Name (NI) ] other pertinent histories. Physical Exam: Physical Exam on admission: VS: T 100.3 BP 91/48 AR 95 RR 13 O2 sat 96% on 4L NC Gen: Patient lying in bed, NAD HEENT: Dry MM Heart: irreg irreg., No m,r,g Lungs: CTAB Abdomen: soft, diffusely tender, +RUQ tenderness, +BS Extremities: No edema, 2+ DP/PT pulses bilaterally . Physical Exam on Discharge: Extremities: L > R UE edema, especially of the forearm and bicept area; minimal erythema and warmth of the same areas, improved from earlier in the week but persistent. Abdomen: + BS, soft, minimally TTT in the right quadrants, but no rebound or guarding, minimally distended. Systolic BP's: 110 - 120's . Pertinent Results: ADMISSION LABS: [2191-9-1] 10:22PM BLOOD WBC-18.0# RBC-4.10 Hgb-12.2 Hct-37.6 MCV-92 MCH-29.7 MCHC-32.3 RDW-16.1* Plt Ct-259 [2191-9-1] 10:22PM BLOOD Neuts-85* Bands-6* Lymphs-8* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2191-9-1] 10:22PM BLOOD PT-24.1* PTT-35.9* INR(PT)-2.4* [2191-9-1] 10:22PM BLOOD Glucose-125* UreaN-17 Creat-1.0 Na-138 K-4.5 Cl-106 HCO3-20* AnGap-17 [2191-9-1] 10:22PM BLOOD CK(CPK)-22* [2191-9-2] 02:27AM BLOOD ALT-6 AST-12 LD(LDH)-314* AlkPhos-48 Amylase-20 TotBili-0.5 [2191-9-2] 02:27AM BLOOD Albumin-2.9* Calcium-8.3* Phos-3.4 Mg-1.9 [2191-9-1] 10:34PM BLOOD Lactate-1.5 [2191-9-3] 02:20AM BLOOD PT-46.4* PTT-43.8* INR(PT)-5.4* DISCHARGE LABS: [2191-9-9] 05:40AM BLOOD WBC-12.0* RBC-3.01* Hgb-8.9* Hct-27.9* MCV-93 MCH-29.6 MCHC-31.9 RDW-17.1* Plt Ct-334 [2191-9-8] 08:00PM BLOOD Neuts-77.1* Lymphs-17.8* Monos-2.0 Eos-2.8 Baso-0.3 [2191-9-9] 05:40AM BLOOD Plt Ct-334 [2191-9-8] 08:00PM BLOOD PT-21.5* PTT-37.6* INR(PT)-2.1* [2191-9-9] 05:40AM BLOOD Glucose-77 UreaN-10 Creat-0.6 Na-145 K-3.9 Cl-115* HCO3-22 AnGap-12 [2191-9-7] 07:15AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.9 Relevant Imaging: 1)Cxray ([9-2]): Small left pleural effusion and left basilar opacity which could be atelectasis but pneumonia not excluded. . 2)CT abdomen/pelvis ([9-2]): 1. No significant change in infrarenal abdominal aortic aneurysm compared to [2191-8-3]. 2. Small left pleural effusion and opacity at the left lung base more likely atelectasis. . 3)CTA ([9-2]):1.Abdominal aortic aneurysm with atheroma/thrombosus within it. Atherosclerosis and occlusion of the vessels below the trifurcation in both lower extremities as described above. 3. Extensive atherosclerosis is present in the vasculature including but not limited to the aorta and its branches as well as the coronary arteries. . 4)[9-5] Left upper extremity ultrasound: Partially occlusive thrombus within the left cephalic vein with minimal compressibility surrounding the PICC line. Dampened waveforms within the left subclavian vein with normal waveforms in the right subclavian vein. These findings support the venogram performed from prior PICC line consistent with occlusions of the left subclavian vein. . 5) [9-7] ABDOMEN, SUPINE AND ERECT: No dilated loops of bowel or free intraperitoneal air. As noted on prior reports, calcification to the left of the lumbar vertebrae may represent calcification of the aorta. IMPRESSION: No evidence of obstruction or free air. . Brief Hospital Course: 81 yo f with HTN, COPD, p/w fever and hypotension at rehab (SBP 80's), diarrhea (has h/o Cdif). Received Abx for PNA at rehab 1 wk ago, here with WBC count 45. C.diff positive here, on vancomycin 250 mg PO Q6 hours (started on [2191-9-2]; planned for a two week course). Pt. was initially kept in the MICU due to concenr for sepsis and hypotension; she required no pressors and was stabilized with IVF and by holding HTN meds. . She was transferred to the floor on [2191-9-3] in a stable condition. THe number of her bowel movements decreased and they becamed more formed-- she is currently having [2-5] bowel movements per day. . Her WBC count continued to rise and she was complaining of continued abd pain and cramping, although she remained afebrile and had no rebound or guarding on abdominal exam. She admitted to feeling less abdominal pain, so it was felt she was having gas pains. Nonetheless, KUB and lactate were ordered to rule out toxic megacolon and ischemic bowel on [9-7]; they were both normal. She was put on simethicone and feels significantly improved now. . On [9-5], she was also found to have a new clot in the left cephalic vein after it was noted that she had asymetric upper extremity swelling with erythema and warmth of the skin. The clot was around a PICC line, which was subsequently pulled. There was no intervention done at the time as she was already on Coumadin for prior thromboses (was actually supratherapeutic at the time). Although there is still some swelling in the left arm, it is significantly improved from earlier this week. . A hypercoagulable workup was not performed here and was deferred to her primary care doctor, as that doctor is in a different hospital system and several of the neccessary studies cannot be done in an acute setting. Of note, Ms. [Known lastname 22951] has had a personal hx of multiple upper extremity venous clots as well as a family history of clots (her father and sister). She might benefit from testing for Factor V Leiden, Protein C/S deficiency, etc. . On [9-8], she was complaining of dysuria and increased urinary frequency (patient in incontinent). Urine analysis was + LE, + nitrites, 6 - 10 WBC's; UCx form [9-8] are NGTD. She was placed on empiric Bactrim DS [Hospital1 ] (for a three day course finishing [2191-9-10]), and it is likley that her UTI is complication of the C. diff diarrhea. . Also of note, she was found to have LLL opacities on portable and PA/lateral chest Xrays, which was interpreted as resolving consolidation from a prior PNA (she was recently treated for LLL PNA). Although the patient was originally febrile and had a leukocytosis on admission, these were considered to be [2-4] C. diff colitis and resolved when the C. diff was treated. Furthermore, she did not have an respiratory symptoms. . Medications on Admission: Oxycodone 2.5mg PO Q8 hours PRN Albuterol MDI 1-2 Puffs every [4-8] PRN Aspirin 81mg PO daily Cholestyramine 4gm PO BID Tiotropium Bromide Citalopram 20mg PO daily Famotidine 20mg PO daily Acetaminophen 650mg PO Q6H Senna 8.6mg PO BID PRN Polyvinyl Alcohol 1.4 % 1-2 Drops Ophthalmic PRN Warfarin 2mg PO daily Aspirin 81mg PO daily Furosemide 10mg PO 3x/week Metoprolol 25mg PO BID Gabapentin 100mg PO BID Dulcolax PRN Discharge Medications: PLEASE NOTE THE FOLLOWING CHANGES TO MEDICATIONS: (1) Hypertension meds were held for hypotension in the setting of dehydration from diarrhea. These will likely need to be restarted soon according to her pressures. (2) Her INR levels were supratherapeutic in the setting of diarrhea. INR was 2.1 on day of discharge with a Coumadin dose of 1.5 mg PO. COumadin may need to be redosed according to INR. (3) Vancomycin 250 mg PO every six hours-- taken for C. diff colitis; two week course ends on [2191-9-16]. (4) Bactrim DS [Hospital1 ] for UTI-- last dose to be taken on [2191-9-10] for three day course. 1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed. 5. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Please take until [2191-9-16] (this will complete a two week course that was started when you were in the hospital). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for for pain: Please take for your neck pain. 7. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)): Dosage was decreased from out-pt dosage b/c INR was found to be supratherapeutic on admission in the setting of the diarrhea. Levels will need to be adjusted in the next week as the diarrhea resolves. 8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for UTI: Take through [2191-9-10]. Patient put on a three day course for a UTI on [2191-9-8]. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: (1) C. diff infection of your colon causing diarrhea. (2) New blood clot of the left cephalic vein in your arm. Discharge Condition: Stable-- still c/o minimal abdominal pain, but no point tenderness and the pain is much improved when she passes gas. Able to ambulate with some assistance. Talking and mentating as normal. Discharge Instructions: Please return to the emergency department if your develop sevre abdominal pain that is not rleieved by passing gas. If you develop fevers or worsening diarrhea, please call your doctor or return to an emergency department. You have a urinary tract infection. Please continue taking the Bactrim through [2191-9-10]. Your medicine (vancomycin by mouth) for your C. diff diarrhea infection should be continued when you go to rehab-- your last dose will be on [2191-9-16] (will be a full two week course of antibiotics). Please note: your Coumadin dose was decreased from 2 mg each night ot 1 mg each night because your blood levels were too high when you came into the hospital. Having diarrhea can make this happen. In the next week or so as your diarrhea goes away, you should have your coumadin levels checked ot make sure that you are getting enough of the medicine. Please return to the emergency department if your develop sevre abdominal pain that is not rleieved by passing gas. If you develop fevers or worsening diarrhea, please call your doctor or return to an emergency department. You have a urinary tract infection. Please continue taking the Bactrim through [2191-9-10]. Your medicine (vancomycin by mouth) for your C. diff diarrhea infection should be continued when you go to rehab-- your last dose will be on [2191-9-16] (will be a full two week course of antibiotics). Please note: your Coumadin dose was decreased from 2 mg each night ot 1 mg each night because your blood levels were too high when you came into the hospital. Having diarrhea can make this happen. In the next week or so as your diarrhea goes away, you should have your coumadin levels checked ot make sure that you are getting enough of the medicine. Followup Instructions: (1) Please keep the follow-up appointment with your primary care doctor at the end of [Month (only) ] that you told us about. (2) You should consider going to a gastroenterologist (belly doctor) if your diarrhea symptoms continue much more than another week or after you stop taking the antibioitcs. It is possible that you may need ot be on prophylactic antibiotics for recurrent C. diff infection. PENDING ISSUES: (1) Please follow blood pressure as hypertension meds were held for relatively low pressures in the hospital. (2) Please check INR and adjust coumadin dose to keep levels between 2 - 3. (3) Please monitor number of bowel movements patient is having. Currently having 2 - 3 loose stools per day. If having more diarrhea, please call the primary doctor.	[ "5990", "4019" ]
Admission Date: [2200-2-4] Discharge Date: [2200-2-7] Date of Birth: [2141-3-5] Sex: M Service: CCU ADMISSION DIAGNOSIS: Acute myocardial infarction. HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old gentleman who was transferred from [Hospital3 3583] with an acute anterior ST-elevation myocardial infarction. The patient initially presented to the outside hospital two days prior to admission with chest pain that occurred at rest. This pain was not relieved by nitroglycerin. The patient was subsequently discharged the day after presentation, as he had opted for medical management only. On the day of admission, the patient had recurrence of his chest pain which increased after taking sublingual nitroglycerin. The patient also reported nausea and diaphoresis at this time. The pain increased with inspiration. The patient denied shortness of breath, palpitations, and lightheadedness. He had no history of syncope. The patient has no history of orthopnea or paroxysmal nocturnal dyspnea. He has had nocturnal angina over the past few weeks. One month prior to admission, the patient had exertional pain in his chest with lifting. He has no symptoms of intermittent claudication. He has no amaurosis fugax. He denies weakness or dysarthria. He has had no fevers or chills. The patient had an upper respiratory tract infection one week prior to admission. He denies melena or bright red blood per rectum. He denies hematuria. The patient was transferred to the [Hospital1 190] and went to the catheterization laboratory where he was felt to have a right-dominant coronary system. The left main was normal. The left anterior descending artery had diffuse irregularities. There was a 30% ostial stenosis. A total midline occlusion with in-stent restenosis which was opened with a cutting balloon. The left circumflex had a 50% lesion at the first obtuse marginal. The right coronary artery had diffuse proximal and medial irregularities with 60% stenosis. The patient was transferred to the Coronary Care Unit after his procedure. At this time, he was on an Aggrastat drip. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post percutaneous transluminal coronary angioplasty in [2185] of his right coronary artery. A second percutaneous transluminal coronary angioplasty in [2191] showed an ejection fraction of 60% with anterolateral hypokinesis. There was a normal left main. There was an 80% right coronary artery stenosis which received percutaneous transluminal coronary angioplasty. 2. Gastroesophageal reflux disease. 3. Blind in right eye; status post vitrectomy since [2176] from toxoplasmosis. 4. Type 2 diabetes for greater than five years. 5. History of L4-L5 discectomy in [2178]. MEDICATIONS ON ADMISSION: The patient unsure of doses, but home medications included Lopressor, metformin, Diovan, Lipitor, Nexium, and Isordil. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient quit smoking in [2181]. He drinks approximately four to five beers per month. He is a small business owner. FAMILY HISTORY: His father died at the age of 58; he had coronary artery disease and diabetes. His mother is alive and well at the age of 92. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 95.8, blood pressure was 144/74, heart rate was 72 and regular, respiratory rate was 10, and oxygen saturation was 99% on 2 liters. The patient weighed 102 kilograms. The patient was in no apparent distress and was breathing comfortably. Head, eyes, ears, nose, and throat examination revealed extraocular movements were intact. The oropharynx was normal. Neck revealed there was no jugular venous distention. There was a bruit in the left carotid. Chest was clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. There was no third heart sound or fourth heart sound murmurs. The abdomen revealed bowel sounds were present. The abdomen was soft and nontender. There were no pulsatile masses. His right groin had venous and arterial sheaths in place without hematoma. Extremity examination revealed there was no clubbing, cyanosis, or edema. Dorsalis pedis pulses were 1+ on the and 2+ on the left. Neurologic examination revealed the patient did not have a facial droop. The tongue was midline. His strength was [4-14] bilaterally. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a sinus rhythm at 57 beats per minute. The axis was normal. There were normal intervals. There was ST segment upsloping in leads V2 to V4. Post catheterization electrocardiogram revealed a sinus rhythm at 70 beats per minute. There were normal intervals. There were ST segment elevations in leads V2 through V4 with Q waves. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Coronary Care Unit. His hospital course will be discussed by systems. 1. CORONARY ARTERY DISEASE: The patient remained on an Aggrastat drip for 18 hours. He was maintained on aspirin, Plavix, and a statin. His beta blocker was reintroduced after his catheterization. The patient was also started no an ACE inhibitor while in the hospital. The patient underwent an echocardiogram while in the hospital which showed an ejection fraction of 30% to 40%. There was mild symmetric left ventricular hypertrophy. The echocardiogram could not rule out an left ventricular thrombus. The patient had 1+ mitral regurgitation and trivial tricuspid regurgitation. There was severe hypokinesis of the mid ventricular and apical segments of the anterior septum and anterior free wall. There was dyskinesis of the apex. In light of this, the patient was started on Lovenox and Coumadin. He was to continue on the Lovenox until his INR is therapeutic. The patient also underwent a signal-averaged electrocardiogram while in the hospital. This was negative. The patient was asked to return to the hospital on [2-27] at 1:15 for a T-wave alternans stress test. On that day, he will also pick up a full-term monitor to be worn for 24 hours. The patient had no issues with his rhythm while in the hospital. 2. TYPE 2 DIABETES ISSUES: The patient was initially maintained on an insulin drip. His oral hypoglycemics were held. He was then transitioned to a regular insulin sliding-scale. The patient was discharged home on his home dose of oral hypoglycemics. 3. GASTROESOPHAGEAL REFLUX DISEASE ISSUES: The patient was maintained on Protonix while in house. DISCHARGE DIAGNOSES: 1. Acute anterior myocardial infarction secondary to in-stent restenosis. 2. History of coronary artery disease (please see Past Medical History). 3. Type 2 diabetes. 4. Gastroesophageal reflux disease. 5. Blind in the right eye. 6. History of L4-L5 discectomy. MEDICATIONS ON DISCHARGE: 1. Lovenox 100 mg subcutaneously b.i.d. (until INR therapeutic). 2. Aspirin 325 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. (for nine months). 4. Lopressor 25 mg p.o. b.i.d. 5. Atorvastatin 20 mg p.o. q.d. 6. Coumadin 5 mg p.o. q.d. (until instructed to change dose by primary care physician). 7. Metformin 500 mg p.o. b.i.d. 8. Nitroglycerin 0.3 mg sublingually every 5 minutes as needed. 9. Nexium 20 mg p.o. q.d. 10. Lisinopril 5 mg p.o. q.d. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to see his primary care physician (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]) in [Location (un) 3320] on [2-10] to have his INR checked. 2. The patient was also to return to the [Hospital1 346] on [2-27] for a T-wave alternans stress test as well as to pick up a Holter monitor. CONDITION AT DISCHARGE: Condition on discharge was good. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 222] MEDQUIST36 D: [2200-2-7] 11:43 T: [2200-2-8] 03:57 JOB#: [Job Number 40751]	[ "41401", "53081", "25000" ]
Admission Date: [2116-2-2] Discharge Date: [2116-2-28] Date of Birth: [2043-7-9] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: mitral valve repair via right thoracotomy [2-20] cardiac cath colonoscopy upper endoscopy dental extraction History of Present Illness: 72M h/o sCHF (EF 35%); CAD s/p CABG x2; LCx stent [2110]; 4+MR; s/p BiV ICD; recurrent pAF w/ RVR s/p AV node ablation; DM2, presented to the ED with SOBx 2 days, as well as with one recorded temperature at home to T 100. Of note, pt had been discharged on [2116-1-11] after undergoing AV node ablation, and had denied respiratory distress during [1-23] EP outpatient follow-up; at that time, ICD had been interrogated and found to be WNL. (On this presentation, however, pt stated that he had been SOB since his latest discharge.) . Pt also reported that he had been coughing x3 days, producing white phelgm, and had been in contact with a granddaughter recently [Name2 (NI) ] with influenza. . ROS: Positive for SOB, increased peripheral edema x1day, decreased ability to sleep given SOB, and decreased exercise tolerance. Negative for chest pain, abd pain, N/V, changes in urinary/bowel habits, myalgias/arthralgias. . ED course: # Vitals: O2sat 91 on RA, mid 80s on RA with conversation, 96 on 2L # Meds: Furosemide 40mg IV (excreted 400cc urine), levofloxacin Past Medical History: # CAD s/p inferior MI, CABG x2 ([2080], [2100]: SVG to OM, SVG to LAD, patent in [2110]), LCx stent [2110] # Systolic CHF [12-28] ischemic CM (EF 35%) s/p BiV ICD [2110], replaced [2114] # HTN # 4+ MR # h/o paroxysmal atrial fibrillation s/p cardioversion [2114], s/p AV node ablation [2115] # COPD: No home O2 # DM2 # Hypercholesterolemia # Chronic renal insufficiency # GERD Social History: # Personal: Lives with wife, has 2 sons. [Name (NI) 24075]-speaking only. # Professional: Retired construction worker. # Tobacco: Smoked maximum 4ppd # Alcohol: Social # Recreational drugs: None Family History: Noncontributory Physical Exam: VITALS: T 96.8, BP 100/50, HR 70, RR 20, O2sat 95 on 2L, FS 245 HEENT: NCAT, OP clear, MMM, no LAD NECK: JVP elevated to ear. No carotid bruits. CHEST: Bilateral rales 3/4 up. Apices clear. No rhonchi, wheezes. CARDIAC: RRR, S1S2, 2/6 SEM @ apex. ABDOMEN: Soft, NT/ND, BS+, no HSM EXT: BLE to ankles, 1+ B DP. NEURO: A&Ox3 Pertinent Results: Studies/imaging: # EKG: V-paced at rate 69 # CXR: Mild cardiogenic pulmonary edema although no definite focal infection is visualized. Repeat radiography after appropriate diuresis is helpful to assess for underlying infection. . ECHO [2116-2-4]: Conclusions The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the inferior, inferolateral and inferoseptal walls, and hypokinesis of the apex, c/w multivessel CAD. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. A very eccentric, posteriorly directed jet of [Location (un) ] (4+) mitral regurgitation is seen, likely on the basis of the posteromedial papillary muscle dysfunction. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Dilated left ventricle with moderate regional systolic dysfunction, c/w multivessel CAD. Severe secondary mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [2115-12-25], mitral and tricuspid regurgitation are more severe and pulmonary pressures are higher. The other findings are similar. Findings disscussed with Dr. [Last Name (STitle) 24076] at 1140 hours on the day of the study. . C.CATH Study Date of [2116-2-11] COMMENTS: 1. Coronary angiography of this right dominant system revealed three vessel coronary disease. The LMCA had mild disease. The LAD was totally occluded proximally with the distal vessel filling via a patent SVG. The LCX had a widely patent stent supplying OM2 which filled by a patent SVG. The RCA was known to be totally occluded and therefore was not selectively engaged. 2. Venous conduit arteriography revealed widely patent SVG-LAD and SVG-OM1. 3. Resting hemodynamics revealed an RASP of 11 mm Hg, RVEDP of 18 mm Hg, PASP of 43 mm Hg, and PCWP of 21 mm Hg. The cardiac output was 4.0 and the index 2.3. 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. [Hospital1 ]-ventricular diastolic dysfunction. 3. Patent SVG-LAD, SVG-OM1. . CHEST (PRE-OP PA & LAT) [2116-2-12] 3:14 PM FINDINGS: In comparison with study of [2-2], there is again enlargement of the cardiac silhouette in this patient who has undergone a previous CABG procedure with intact sternal sutures. Defibrillator device remains in place. Prominence ill-defined interstitial markings is consistent with the clinical diagnosis of vascular congestion. . [2116-2-2] 12:05PM BLOOD WBC-8.3 RBC-3.61* Hgb-8.5* Hct-29.2* MCV-81* MCH-23.5* MCHC-29.1* RDW-19.4* Plt Ct-232 [2116-2-9] 05:00AM BLOOD WBC-6.3 RBC-3.65* Hgb-9.2* Hct-29.8* MCV-82 MCH-25.3* MCHC-30.9* RDW-20.0* Plt Ct-143* [2116-2-17] 06:43AM BLOOD WBC-6.2 RBC-3.68* Hgb-9.2* Hct-30.3* MCV-83 MCH-25.0* MCHC-30.3* RDW-19.4* Plt Ct-153 [2116-2-28] 05:20AM BLOOD WBC-6.6 RBC-3.30* Hgb-8.8* Hct-28.2* MCV-85 MCH-26.7* MCHC-31.3 RDW-18.7* Plt Ct-162 [2116-2-2] 01:05PM BLOOD PT-36.2* PTT-32.7 INR(PT)-3.9* [2116-2-9] 05:00AM BLOOD PT-14.4* PTT-26.5 INR(PT)-1.3* [2116-2-17] 06:43AM BLOOD PT-14.1* PTT-59.0* INR(PT)-1.2* [2116-2-28] 05:20AM BLOOD PT-30.1* PTT-33.9 INR(PT)-3.1* [2116-2-2] 12:05PM BLOOD Glucose-193* UreaN-53* Creat-1.8* Na-134 K-5.5* Cl-97 HCO3-23 AnGap-20 [2116-2-9] 05:00AM BLOOD Glucose-151* UreaN-23* Creat-1.4* Na-141 K-3.7 Cl-103 HCO3-30 AnGap-12 [2116-2-18] 09:30AM BLOOD Glucose-263* UreaN-19 Creat-1.5* Na-135 K-4.1 Cl-102 HCO3-25 AnGap-12 [2116-2-28] 05:20AM BLOOD Glucose-145* UreaN-27* Creat-1.5* Na-138 K-5.6* Cl-102 HCO3-27 AnGap-15 [2116-2-25] 02:51AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.2 Brief Hospital Course: He was taken to cardiac cath and found to have three vessel disease. He was Iron deficient by labs and given the concern for GI bleed, though stool guaiac was documented as negative, he was taken to colonoscopy and EGD, which showed no source of bleed. His Plavix was held upon admission in anticipation for cardiothoracic surgery. His Coumadin was discontinued and he was maintained on heparin drip once GI bleed was ruled out until surgery. On [2-17] he had three teeth extracted. He was then taken to the operating room on [2-20] where he underwent a mitral valve repair via right thoracotomy. Please see operative report for surgical details Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He was given 48 hours of vancomycin as he was in the hospital preoperatively. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. He was restarted on Coumadin for his atrial fibrillation. Also started on beta blockers and diuretics and gently diuresed towards his pre-op weight. He remained in the ICU for pulmonary toilet. Chest tubes and epicardial pacing wires were removed per protocol. On [2-24], post-op day four, he underwent right thoracentesis for 250 cc. He was transferred to the floor on post-op day five. He worked with physical therapy for strength and mobility. He continued to slowly recover and was discharged to home with vna services and the appropriate medications and follow-up appointments. Dr. [Last Name (STitle) 1911] will follow his INR and adjust Coumadin accordingly. Medications on Admission: Atorvastatin (Lipitor) 20 mg daily Furosemide 60 mg [Hospital1 ] Glyburide 5 mg [Hospital1 ] Ranitidine (Zantac) 150 mg [Hospital1 ] Warfarin 2 mg daily ASA 81mg daily Clopidogrel 75 mg daily Toprol XL 150 mg daily Imdur 30 mg daily Spironolactone 25 mg daily Discharge Medications: 1. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:1 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. 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. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:1 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:1 Refills:2 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 Refills:2 11. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 weeks. Disp:65 Tablet(s) Refills:0 12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 1 doses: Titrate dose as directed by the office of Dr. [Last Name (STitle) 1911]. Disp:40 Tablet(s) Refills:1 13. Outpatient Lab Work INR to be drawn Saturday with results faxed to [First Name4 (NamePattern1) 2808] [Location (un) 24077], RN in the office of Dr. [Last Name (STitle) 1911] [Telephone/Fax (1) 14926]. 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary: severe mitral regurgitaion now s/p Mitral Valve Repair coronary artery disease chronic systolic heart failure anemia . Secondary: # h/o paroxysmal atrial fibrillation - s/p cardioversion [3-2] - s/p AVJ ablation [2116-1-10] # COPD # amio lung toxicity # HTN # Diabetes type 2 # Hypercholesterolemia # Chronic renal insufficiency # GERD Discharge Condition: Stable Discharge Instructions: 1)Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. 2)Please shower daily. No baths. Pat dry incisions, do not rub. 3)Avoid creams and lotions to surgical incisions. 4)Call cardiac surgeon if there is concern for wound infection. 5)No driving for at least one month. Followup Instructions: Dr. [First Name (STitle) 679] 2 weeks Dr. [Last Name (STitle) 1911] 2 weeks Dr. [First Name (STitle) ] 4 weeks Please fax INR results to [First Name4 (NamePattern1) 2808] [Location (un) 24077], RN at the office of Dr. [Last Name (STitle) 1911] [Telephone/Fax (1) 14926]. Confirmation e-mailed from [Doctor Last Name 2808] on [2116-2-27] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2116-2-28]	[ "4240", "41401", "496", "4019", "25000", "2720", "40390", "5859", "42731", "4168", "V4581", "4280" ]
Admission Date: [2129-7-20] Discharge Date: [2129-7-28] Date of Birth: [2060-2-27] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2129-7-22] Coronary Artery Bypass Graft x 3 (Left Internal Mamary Artery to Left Anterior Descending artery, Saphenous Vein Graft to RAMUS, Saphenous Vein Graft to Obtuse Marginal) [7-20] Cardiac Cath History of Present Illness: 69 yo M with PMH significant for hypertension, hyperlipidemia, IDDM, and family history of CAD who presented to [Hospital3 ] with chest pain. The patient states that he has been experiencing substernal chest pressure with exertion, such as walking up stairs, for 2 months. EKG showed T-wave inversions, but enzymes were negative. He was transferred to [Hospital1 18] for cardiac cath which showed LM and 2VD. Past Medical History: Hypertension Hyperlipidemia Insulin Dependent Diabetes Mellitus (?non-adherence to medical regime per chart) Retinopathy Erectile Dysfunction Low back pain s/p epidural steroid injections L4-L5 (last inj. [2127]) Vitamin D Deficiency Torn Right rotator cuff-unrepaired Torn posterior medial meniscus Left Knee-unrepaired Chronic insomnia ?Obstructive Sleep Apnea Social History: Race:African American Last Dental Exam:many years ago, full denture on top, bottom teeth are his own Lives with:wife Occupation:Recently retired from the court system Tobacco:+Cigars, chews on them only ETOH:Denies Rec drugs: Denies Family History: Father died age 53 CAD Physical Exam: Pulse:61 Resp:21 O2 sat: 99%RA B/P Right:161/79 Left:154/80 Height:5'7" Weight:210 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +1 PT [Name (NI) 167]: +1 Left: +1 Radial Right: Cath site Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [2129-7-20] Cath: 1. Selective coronary angiography in this left-dominant system demonstrated left main and 2-vessel disease. The LMCA had 60-70% distal stenosis. The LAD had 90% stenosis at the origin. The IM had 70% stenosis at the origin. The distal LCx had 30% stenosis. The RCA was non-dominant. 2. Resting hemodynamics reveals moderate to severe systemic arterial systolic hypertension with an SBP of 177 mmHg. 3. Left ventriculography revealed an estimated EF of 55% with no apparent mitral regurgitation. [7-22] Echo: PREBYPASS: The left atrium is normal in size. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular free wall contractility is normal. The ascending aorta is borderline mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.6cm2) with peak/mean gradients of [11-9] mmHg. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POSTBYPASS: The patient is in sinus rhythm and is not on any infusions. Left ventricular function continues to be normal (LVEF>55%). Trace mitral regurgitation, trace aortic regurgitation, and mild tricuspid regurgitation persist. Normal thoracic aorta. Pre operative [2129-7-20] 02:13PM PT-13.9* PTT-99.7* INR(PT)-1.2* [2129-7-20] 02:13PM PLT COUNT-202 [2129-7-20] 02:13PM WBC-5.6 RBC-4.01* HGB-11.6* HCT-33.9* MCV-85 MCH-28.9 MCHC-34.2 RDW-13.7 [2129-7-20] 02:13PM TRIGLYCER-99 HDL CHOL-48 CHOL/HDL-4.6 LDL(CALC)-151* [2129-7-20] 02:13PM %HbA1c-10.9* eAG-266* [2129-7-20] 02:13PM ALBUMIN-1.9* CHOLEST-219* [2129-7-20] 02:13PM ALT(SGPT)-4 AST(SGOT)-8 CK(CPK)-56 ALK PHOS-74 AMYLASE-7 TOT BILI-0.4 [2129-7-20] 02:13PM GLUCOSE-191* UREA N-7 CREAT-0.3* SODIUM-127* POTASSIUM-3.3 CHLORIDE-97 TOTAL CO2-22 ANION GAP-11 [2129-7-20] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG Discharge [2129-7-27] 05:50AM BLOOD WBC-10.2 RBC-3.42* Hgb-9.9* Hct-29.8* MCV-87 MCH-29.0 MCHC-33.4 RDW-13.9 Plt Ct-264# [2129-7-27] 05:50AM BLOOD Plt Ct-264# [2129-7-22] 12:44PM BLOOD PT-14.3* PTT-27.5 INR(PT)-1.2* [2129-7-28] 05:20AM BLOOD Glucose-87 UreaN-16 Creat-0.9 Na-138 K-3.7 Cl-101 HCO3-27 AnGap-14 [2129-7-25] 04:17AM BLOOD ALT-34 AST-49* AlkPhos-96 Amylase-32 TotBili-0.9 Radiology Report CHEST (PA & LAT) Study Date of [2129-7-27] 10:07 AM [Hospital 93] MEDICAL CONDITION: 69 year old man with s/p cabg Final Report PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Status post CABG evaluate for pleural effusion. Moderate cardiomegaly is stable. Small bilateral effusion left greater than right are associated with minimal adjacent atelectasis. There is no pneumothorax. Sternal wires are aligned. Moderate degenerative changes in the thoracic spine. DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] [Known lastname 18169],[Known firstname ] L [Medical Record Number 99936] M 69 [2060-2-27] Radiology Report ABDOMEN U.S. Study Date of [2129-7-25] [Hospital 93] MEDICAL CONDITION: 69 year old man with Rt upper and lower quadrant tenderness after cabg REASON FOR THIS EXAMINATION: assess for cholecystitis Final Report FINDINGS: The liver is mildly echogenic consistent with mild fatty infiltration. No focal liver lesion is identified. No biliary dilatation is seen and the common duct measures 0.5 cm. The gallbladder is normal. The pancreas and midline structures are obscured from view by overlying bowel. The spleen is unremarkable and measures 10.3 cm. No hydronephrosis is seen. The right kidney measures 11.3 cm and the left kidney measures 10.8 cm. A left pleural effusion is seen. IMPRESSION: 1. Normal gallbladder. 2. Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 3. Left pleural effusion. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 20982], RDMS DR. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 569] [Last Name (NamePattern1) 7832] Radiology Report CT HEAD W/O CONTRAST Study Date of [2129-7-24] 1:02 PM [Hospital 93] MEDICAL CONDITION: 69 year old man s/p CABG X3,CHANGE IN MS Final Report HISTORY: 69-year-old man, status post CABG x 3. Now with acute change of mental status. Assess for acute ischemic events. FINDINGS/IMPRESSION: 1. No acute intracranial process. If clinical concern for acute ischemic event persists, MRI is more sensitive. 2. Small air-fluid level in the right sphenoid sinus. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]/DR. [First Name (STitle) ] [Name (STitle) 12563] Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname ] was transferred from an outside hospital to [Hospital1 18] for cardiac cath. Cath revealed left main and two vessel coronary artery disease. He was appropriately worked-up for bypass surgery and received medical care until surgery. On [7-22] he was brought to the operating room where he underwent a coronary artery bypass grafting. Please see operative report for surgical details. In summary he had: Coronary artery bypass grafting x3 with left internal mammary to left anterior descending coronary; reverse saphenous vein single graft from aorta to ramus intermedius coronary artery; reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery. Endoscopic left greater saphenous vein harvesting. Epiaortic duplex scanning. His CARDIOPULMONARY BYPASS TIME was 71 minutes, with a CROSSCLAMP TIME of 56 minutes. He tolerated the operation well and was transferred from the operating room to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one beta-blockers and diuretics were started and he was diuresed towards his pre-op weight. Chest tubes and epicardial pacing wires were removed per protocol. Had brief mental status change with gaze preference to right. Head CT was negative. Narcotics were stopped and this continued to slowly improve. He complained of right upper quadrant abdominal pain, liver function tests were in normal ranges and an abdominal US showed normal gallbladder without cholestasis. On post-op day 4 he was transferred to the telemetry floor for further recovery from surgery. He progressed slowly and on POD #6 was discharged to rehabilitation at [Location (un) 5481] in [Location (un) 2624]. Pt is to follow up as per discharge instructions. Medications on Admission: Medications at home: ASA 81mg po daily Lantus Vitamin D 1000units daily Benicar 40/12.5mg po daily Meds on transfer: Lipitor 80mg po daily Plavix 75mg po daily Lantus 20 units q HS Metoprolol 25mg po daily ASA 325mg po daily NPH 40 units po qAM Plavix - last dose: 75 mg [7-20], 300mg [7-19] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily): stop when Lasix d/c'd. 8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day: until at preop weight (210 lbs). 9. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Eight (28) units Subcutaneous Q AM. 10. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) Subcutaneous ACHS: per SS. Discharge Disposition: Extended Care Facility: Commons Residence At Orchard - [Location (un) 2624] (a.k.a. [Location (un) 5481]) Discharge Diagnosis: Coronary Artery Disease s/p Coronary artery bypass graft x 3 Past medical history: Hypertension Hyperlipidemia Insulin Dependent Diabetes Mellitus (?non-adherence to medical regime per chart) Retinopathy Erectile Dysfunction Low back pain s/p epidural steroid injections L4-L5 (last inj. [2127]) Vitamin D Deficiency Torn Right rotator cuff-unrepaired Torn posterior medial meniscus Left Knee-unrepaired Chronic insomnia ?Obstructive Sleep Apnea Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg- Left - healing well, no erythema or drainage. Edema-none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [Last Name (STitle) 914] on Tuesday [8-16] @ 2:15 pm [Hospital Ward Name ] 2A Cardiologist Dr. [Last Name (STitle) 10543] [Name (STitle) 766] [8-29]@ 1:45 pm Please call to schedule appointments with your: Primary Care Dr. [Last Name (STitle) ] [Name (STitle) 17369] in [3-7] weeks [Telephone/Fax (1) 17368] 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:[2129-7-28]	[ "41401", "2851", "2761", "2724", "4019", "V5867" ]
Admission Date: [2155-10-13] Discharge Date: [2155-10-18] Date of Birth: [2102-5-20] Sex: M Service: SURGERY Allergies: Bactrim Attending:[First Name3 (LF) 4691] Chief Complaint: s/p 6 ft Fall Major Surgical or Invasive Procedure: [10-17] Operative repair left wrist History of Present Illness: 53 yo male physician who fell off of his porch while doing some work on his house. Fell ~[5-30] ft, landed on neck, back. +LOC. He was transported to [Hospital1 18] for further management. Past Medical History: Atrial fibrillation s/p C6-C7 fusion Social History: Employed as an internist Family History: Noncontributory Physical Exam: Upon admision to ED: T: 97.7 BP: 139/71 P:60 RR: 15 97% on RA Gen: WD/WN, comfortable, NAD. HEENT: L parieto-occipital scalp laceration. PERRL [1-23] bilaterally, EOMI. Neck: Supple. Lungs: CTA bilaterally. Tenderness to palpation over L-sided ribs, no deformity or ecchymoses. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Rectum: NL tone Extrem: Warm and well-perfused. Spine: Lumbar midline tenderness over spinous processes. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [Last Name (un) 938] G R 5 5 5 5 5 5 5 5 5 5 L 5 5 5 0 0 5 5 5 5 5 (unable to assess L hand due to pain from displaced wrist fracture) Sensation: Intact to light touch, propioception bilaterally except L hand- palmar aspect of 1st-3rd digits have decreased sensation to LT. Propioception intact Pertinent Results: [2155-10-13] 06:13PM GLUCOSE-102 LACTATE-2.6* NA+-143 K+-3.7 CL--104 TCO2-25 [2155-10-13] 06:00PM UREA N-15 CREAT-1.3* [2155-10-13] 06:00PM AMYLASE-134* [2155-10-13] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-18.7 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2155-10-13] 06:00PM WBC-10.1 RBC-5.11 HGB-15.9 HCT-44.9 MCV-88 MCH-31.1 MCHC-35.3* RDW-13.1 [2155-10-13] 06:00PM PT-11.3 PTT-21.7* INR(PT)-1.0 [2155-10-13] 06:00PM PLT COUNT-295 MR L SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Reason: 53 Y/O MAN WITH TRAUMA POST FALL,BURST FRACTURE [Hospital 93] MEDICAL CONDITION: 53 year old man with lumbar burst fx from fall. REASON FOR THIS EXAMINATION: assess for spinal cord compromise CONTRAINDICATIONS for IV CONTRAST: None. ROUTINE MRI OF THORACIC & LUMBAR SPINE WITHOUT GADOLINIUM. HISTORY: Known burst fracture. Comparison is made with CT from the same date. There is a compression fracture of the L3 vertebral body and left aspect of L2 vertebral body as well as the left transverse process of L2. The fracture also extends into bilateral, right greater than left pars interarticularis and the right L2 transverse process. There is an epidural hematoma posterior to L3 and to a lesser extent posterior to L4 vertebral body, without significant mass effect on the thecal sac. This is somewhat asymmetric to the left of midline. There is evidence for ligamentous injury of the posterior interspinous ligament from L2 through L4. Multilevel spondylotic changes are identified. There is a large right renal cyst which is incompletely evaluated. No large disc protrusion is seen. Evaluation of the thoracic spine demonstrates no fracture, compression deformity or canal compromise. There is no epidural hematoma or cord contusion. There are small central disc protrusions in the mid thoracic spine abutting the anterior aspect of the thecal sac. IMPRESSION: Fracture at L3 and L2 with small anterior epidural hematomas, not causing significant compromise on the thecal sac. Ligamentous injury of the posterior interspinous ligaments at the fracture level. CT C-SPINE W/O CONTRAST Reason: ?trauma Field of view: 25 [Hospital 93] MEDICAL CONDITION: 53 year old man with fall onto head, 6feet, obvious head lac, numbness in L arm REASON FOR THIS EXAMINATION: ?trauma CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 53-year-old gentleman with fall off a porch on to head with numbness in left arm. Evaluate for cervical spine injury. COMPARISON: Head CT [2155-10-13]. TECHNIQUE: Multidetector helical scanning of the cervical spine was performed in soft tissue and bone algorithm. Coronal and sagittal reformats were displayed. CT OF THE CERVICAL SPINE: There is no evidence of fracture or malalignment of the cervical spine. Anterior fusion of C6-7 with an anterior plate and interosseous screws appears intact. The lateral masses of C1 are well seated about the dens and with those of C2. There is no prevertebral soft tissue swelling. The trachea is patent. Again noted are bilateral maxillary mucous retention cysts and mild rightward deviation of the nasal septum. The visualized lung apices are unremarkable. IMPRESSION: No evidence of fracture or malalignment involving the cervical spine. C6-7 fusion is intact. CT HEAD W/O CONTRAST Reason: ?trauma Field of view: 25 [Hospital 93] MEDICAL CONDITION: 53 year old man with fall onto head, 6feet, obvious head lac REASON FOR THIS EXAMINATION: ?trauma CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 53-year-old gentleman with fall off a porch onto head, with obvious laceration. Please evaluate for bleed. No prior examinations. TECHNIQUE: Non-contrast head CT. FINDINGS: There is no acute intracranial hemorrhage, shift of normally midline structures, or major vascular territorial infarct. [Doctor Last Name ]-white matter differentiation is preserved. The ventricles are normal in size and configuration. The visualized paranasal sinuses and mastoid air cells are clear. The external auditory canal and middle ear cavities appear normal. There is no calvarial fracture. Moderate-sized soft tissue laceration and subcutaneous edema is seen in the left parietal scalp. Bilateral maxillary sinus retention cysts and mild rightward nasal septum deviation are noted. IMPRESSION: Left scalp laceration, with no evidence of skull fracture or intracranial hemorrhage. WRIST(3 + VIEWS) LEFT Reason: s/p closed recution L distal radius fracture, assess positio [Hospital 93] MEDICAL CONDITION: 53 year old man with fall onto head, L arm pain, numbness in median nerve distribution REASON FOR THIS EXAMINATION: s/p closed recution L distal radius fracture, assess position HISTORY: Status post closed reduction of left distal radius fracture. Comparison is made to prior radiograph obtained on same date. THREE VIEWS OF THE RIGHT WRIST. FINDINGS: There has been marked improvement and reduction of comminuted intraarticular distal radial fracture and distal radioulnar articulation. Slight dorsal (perhaps 20 degree) angulation of the distal radial articular surface persists. Soft tissue swelling persists and osseous detail is obscured by new overlying cast material. IMPRESSION: Reduction of distal radius intraarticular fracture and distal radioulnar joint subluxation. Brief Hospital Course: He was admitted to the Trauma Service. Neurosurgery/Spine was consulted to evaluate his lumbar spine injuries further. These were deemed nonoperative. He was measured and fitted for a lumbar brace which is to be worn at all times when out of bed. He will require follow up with Dr. [Last Name (STitle) 548] in 3 months time. Orthopedics was also consulted for his left wrist injury; throughout his stay his symptoms of numbness in the median nerve distribution were self-reported to be worsening. On [10-17] therefore he went to the OR with Dr. [Last Name (STitle) ] for ORIF L distal radius, carpal tunnel release. He tolerated it well. On his CT abdomen it was noted: Incidentally noted 1 cm cystic lesion within the body of the pancreas - likely either a residual pseudocyst or incidental intraductal papillary mucinous neoplasm (IPMN). Recommend further evaluation with MRI on a non- emergent basis. Follow up with Dr. [Last Name (STitle) ] has been arranged to assess this lesion. He was reluctant to take narcotics for pain control; only choosing to take Tylenol prn. The narcotics remained on his medication list in the event that he chose to take them. A bowel regimen was also initiated. He was evaluated by Physical therapy who have recommended that he go home without Services. He was discharged on [10-18] with follow up made. The patient was in good condition. Medications on Admission: aspirin 81 qd Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6hours as needed. Disp:60 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Trauma Left distal radius fracture L2-L3 spinal fractures L3 anterior aspect of supior endplate fx Discharge Condition: Good Discharge Instructions: Continue to wear your brace when out of bed at all times. Please resume your regular diet. You may resume your regular medications. Take all new medications as directed. Please do not drive while taking narcotic pain medications. Continue to wear you TLSO back brace as directed. Wear the left wrist splint until follow up with Dr. [Last Name (STitle) ]. Please call or return if you have: - Increased pain - Fever (> 101 F) - New weakness or numbness - Other concerning symptoms Followup Instructions: Follow up with Dr. [Last Name (STitle) 548] in [10-3] weeks, call [Telephone/Fax (1) 1669] for an appointment. Follow up with Dr. [Last Name (STitle) ] in 2 weeks, call [Telephone/Fax (1) 1228] for an appointment. Follow up with Dr. [Last Name (STitle) ] next week for removal of your head staples; call [Telephone/Fax (1) 6429] for an appointment. Follow up with your primary care doctor in the next 2-3 weeks; you will need to call to arrange for an appointment.	[ "42731" ]

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