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Admission Date: [2117-2-23] Discharge Date: [2117-4-2] Date of Birth: [2117-2-23] Sex: F Service: NB HISTORY: Baby girl 1 [Known lastname 71970] was born at 34-3/7 weeks to a 34-year-old G3 P2 mother with an [Name (NI) 37516] of [2117-4-4]. She is a spontaneous monochorionic diamniotic twin with a pregnancy remarkable for a growth discordance of twin B or twin 2 and then worsening growth restriction of this second twin. Mother was delivered for this worsening growth restriction on [2117-2-23] when the babies were at 34- 3/7 weeks. They were beta complete. Prenatal screen: A negative mother. Antibody negative. RPR nonreactive. Rubella immune. Hep B surface antigen negative. Unknown GBS. Baby admitted to the NICU for prematurity. Delivery unremarkable. Infant born with a large amount of oral secretions with some intermittent apnea which required few positive pressure breaths. However, the baby improved and was transported to the NICU on room air. Apgars of 7 at 1 minute and 7 at 5 minutes. PHYSICAL EXAMINATION: On admission, weight 2165 grams, head circumference 31.5 cm, length 45.25 cm. Infant with mild respiratory distress with intermittent grunting, mild retractions, palate intact. Nondysmorphic. Abdomen soft. normal female genitalia. Rash consistent with neonatal pustular melanosis. She was initially placed on room air and was started on ampicillin and gentamicin for 48 hour sepsis rule out. HOSPITAL COURSE: Respiratory: The baby has been on room air since she came into the NICU. Never on caffeine and has had no significant issues. Cardiovascular: She has been hemodynamically stable. She does, in fact, have a soft murmur at the left lower sternal border which has likely benign and secondary to flow dynamics. We recommend a pediatric cardiac evaluation if there is change in quality of the murmur or if any cardiorespiratory signs or symptoms. FENGI: The patient was on full feeds by day of life 5 and full p.o. feeds by day of life 35, [3-31]. She is currently on breast milk 25 kcals per ounce concentrated with Similac or breast feeding directly. She is also on a multivitamin 1 ml p.o. q.d. and iron supplements of 2 mg per kg per day. Infectious disease: Initial 48 hour rule out negative. Antibiotics discontinued at that time. No repeat antibiotic courses. Neurology: No head ultrasound secondary to late preterm infant at 34-3/7 weeks. Autology: Hearing screen was performed with automated auditory brain stem responses and was passed bilaterally. Ophthalmology: The patient not examined given advanced gestational age at delivery. The patient is stable at discharge. Discharge patient to home. Primary pediatrician: Dr. [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) 37303], [Hospital ] Pediatrics. Phone number [Telephone/Fax (1) 37304]. The FAX number is [0-0-]. CARE AND RECOMMENDATIONS: Feeds at discharge are to continue on fortified breast milk with Similac to 24 kcals per ounce or breast feeding directly. MEDICATIONS: 1. Continue ferrous sulfate 2 mg/kg/day. 2. Continue multivitamin 1 ml p.o. q.d. Car seat position screening passed. State newborn screening status. Screen sent on [2-25] and [3-9]. Immunizations received: hepatitis B vaccination on [3-15]. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria: Born at less than 32 weeks or born between 32 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 or 3: With chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and over the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home caregivers. Followup appointments: Primary pediatrician on [Last Name (LF) 766], [4-5] at 10 a.m. Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] Dictated By:[Last Name (NamePattern1) 71971] MEDQUIST36 D: [2117-4-1] 17:05:45 T: [2117-4-1] 18:01:31 Job#: [Job Number 71972]	[ "V290", "V053" ]
Admission Date: [2103-1-15] Discharge Date: [2103-2-2] Date of Birth: [2027-9-15] Sex: F Service: SURGERY Allergies: Procaine Attending:[First Name3 (LF) 1] Chief Complaint: Emergent small bowel obstruction Bilateral pneumonia Major Surgical or Invasive Procedure: [2103-1-17]: Exploratory laparotomy, extensive lysis of adhesions and repair of ventral hernia by component separation technique. [2103-1-30]: Flexible bronchoscopy with therapeutic aspiration and functional study. History of Present Illness: This patient was transferred from her rehabilitation facility to the [Hospital1 18] ED as an emergency with a bowel obstruction and bilateral pneumonia. She was a very heavy lady and had previously undergone at least 2 operations for bowel obstruction related to an incisional hernia. More than this we did not know owing to the emergent arrival of this patient at this hospital and her previous surgery had been performed elsewhere. Past Medical History: Type II DM obesity HTN GERD COPD Depression hx pna [1-22] anemia gout osteoarthritis hx renal stone s/p oophorectmy s/p trimalleolar fx right leg PPD neg [2101-2-23] Social History: NH resident at [Hospital 100] Rehab, son lives in [Name (NI) 1727], [First Name8 (NamePattern2) ] [Name (NI) 60308] phone # [Pager number ] (or [Telephone/Fax (1) 60309] distant hx smoking, pt reports <10 years of smoking < 1/2ppd -ETOH Family History: NC Pertinent Results: [1-15] Abd CT: 1. Bibasilar consolidation, which may represent aspiration pneumonia in the setting of small-bowel obstruction. 2. Right abdominal hernia containing loops of small bowel with evidence of small-bowel obstruction. No bowel wall thickening, significant stranding or pneumatosis to suggest bowel infarction. 3. Enhancing left renal mass and adjacent complex cyst concerning for renal cell carcinoma. 4. Sigmoid diverticulosis without evidence of diverticulitis. 5. Thickened right adrenal gland, which can be better assessed with CT with adrenal protocol once patient's acute issues resolve. [1-28] Chest CT: 1. Severe tracheomalacia. Bronchial tree is patent, but study is not designed for assessment of bronchomalacia. Nevertheless, both lower lobes and the posterior segment of the right upper lobe are collapsed. 2. Possible mitral valve dysfunction due to heavy annulus calcification. Left atrial enlargement. [1-30] Flexible bronchoscopy: Dynamic maneuvers revealed no significant loss of airway patency in the trachea and less than 50% reduction patency of both main-stem bronchi on forced expiration. The bronchoscope was passed into the right and left airways were a therapeutic aspiration was performed of mild to moderate secretions, left greater than right. The airways were patent to the level of the 4th order bronchi. [2103-1-15] 03:07AM BLOOD WBC-21.9* RBC-4.58 Hgb-12.1 Hct-39.6 MCV-86 MCH-26.4# MCHC-30.6 RDW-16.6* Plt Ct-328 [2103-1-28] 01:57AM BLOOD WBC-13.7* RBC-2.96* Hgb-8.1* Hct-24.8* MCV-84 MCH-27.4 MCHC-32.7 RDW-16.3* Plt Ct-358 [2103-1-29] 04:04AM BLOOD WBC-10.8 RBC-2.80* Hgb-7.8* Hct-23.3* MCV-83 MCH-27.8 MCHC-33.3 RDW-16.3* Plt Ct-360 [2103-2-2] 03:00AM BLOOD WBC-9.4 RBC-3.75* Hgb-10.2* Hct-30.8* MCV-82 MCH-27.2 MCHC-33.1 RDW-16.1* Plt Ct-447* [2103-1-15] 03:07AM BLOOD Glucose-233* UreaN-40* Creat-1.5* Na-139 K-4.4 Cl-93* HCO3-33* AnGap-17 [2103-1-17] 08:50PM BLOOD Glucose-78 UreaN-56* Creat-2.4* Na-132* K-4.0 Cl-99 HCO3-25 AnGap-12 [2103-1-18] 02:37AM BLOOD Glucose-83 UreaN-56* Creat-2.4* Na-135 K-4.0 Cl-101 HCO3-24 AnGap-14 [2103-1-19] 03:31AM BLOOD Glucose-128* UreaN-52* Creat-2.0* Na-136 K-4.0 Cl-101 HCO3-21* AnGap-18 [2103-2-2] 03:00AM BLOOD Glucose-102 UreaN-39* Creat-1.0 Na-142 K-4.4 Cl-102 HCO3-30 AnGap-14 [2103-1-15] 08:24AM BLOOD CK-MB-NotDone cTropnT-0.03* [2103-1-15] 09:16PM BLOOD CK-MB-4 cTropnT-0.06* [2103-1-16] 02:29AM BLOOD CK-MB-7 cTropnT-0.05* [2103-1-16] 04:44PM BLOOD CK-MB-12* MB Indx-2.9 cTropnT-0.06* [2103-1-17] 01:17AM BLOOD CK-MB-10 MB Indx-2.7 cTropnT-0.05* [2103-1-17] 09:03AM BLOOD CK-MB-7 cTropnT-0.05* [2103-1-16] 10:30AM BLOOD Cortsol-25.9* [2103-1-16] 02:30PM BLOOD Cortsol-39.0* [2103-1-16] 03:07PM BLOOD Cortsol-44.4* [2103-1-15] 07:18AM BLOOD Type-ART Rates-20/10 Tidal V-400 PEEP-12 FiO2-100 pO2-89 pCO2-70* pH-7.27* calTCO2-34* Base XS-2 AADO2-571 REQ O2-92 -ASSIST/CON Intubat-INTUBATED [2103-1-15] 12:52PM BLOOD Type-ART pO2-171* pCO2-52* pH-7.31* calTCO2-27 Base XS-0 Intubat-INTUBATED [2103-1-15] 01:46PM BLOOD Type-ART pO2-78* pCO2-56* pH-7.30* calTCO2-29 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2103-1-15] 02:52PM BLOOD Type-ART pO2-83* pCO2-68* pH-7.18* calTCO2-27 Base XS--4 [2103-1-16] 12:46AM BLOOD Type-ART pO2-83* pCO2-51* pH-7.35 calTCO2-29 Base XS-0 [2103-1-16] 02:38AM BLOOD Type-ART pO2-79* pCO2-53* pH-7.35 calTCO2-30 Base XS-1 [2103-1-30] 02:52AM BLOOD Type-ART pO2-91 pCO2-61* pH-7.43 calTCO2-42* Base XS-12 [2103-1-30] 11:58AM BLOOD Type-ART pO2-151* pCO2-54* pH-7.42 calTCO2-36* Base XS-9 [2103-1-30] 02:59PM BLOOD Type-ART pO2-95 pCO2-57* pH-7.42 calTCO2-38* Base XS-9 [2103-1-31] 03:19AM BLOOD Type-ART pO2-100 pCO2-56* pH-7.41 calTCO2-37* Base XS-8 [2103-1-31] 10:05AM BLOOD Type-ART pO2-102 pCO2-50* pH-7.41 calTCO2-33* Base XS-5 [2103-1-31] 01:19PM BLOOD Type-ART pO2-103 pCO2-53* pH-7.40 calTCO2-34* Base XS-5 [2103-2-1] 04:16AM BLOOD Type-ART pO2-107* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 [2103-2-1] 11:03PM BLOOD Type-ART pO2-82* pCO2-48* pH-7.44 calTCO2-34* Base XS-6 Comment-O2 DELIVER Brief Hospital Course: Brief summary: 75-year-old woman admitted [2103-1-15] following emergent exploratory laparotomy for small bowel obstruction. On admission patient was septic secondary to bilateral pneumonias. Her sepsis was successfully treated with 14-day course of IV antibiotics. She was endotracheally intubated for the majority of her stay as she repeatedly refused tracheostomy and was extubated on [2103-1-31]. She was discharged to rehab facility on [2103-2-2] in stable condition requiring O2. Neuro: Immediately post-op, patient was sedated and pain control was adequate. After sedation was discontinued, her pain was controlled with prn fentanyl. At discharge she had no pain medication requirements. After sedation was discontinued, patient was alert and interactive throughout her stay; no focal neurologic deficits were seen throughout her stay. CV: Troponins were elevated on admission but ECG did not demonstrate acute ischemic changes. [1-16] ECHO: Overall left ventricular systolic function is normal (LVEF>55%), tivial mitral regurgitation, mild pulmonary artery systolic hypertension. On [1-24] patient complained of bilateral calf pain; exam showed positive [Last Name (un) 5813] signs; BLE DVT scan was negative for DVT. During her stay she was transfused 2units of PRBCs on [1-18] and [1-31] for hematocrits of 22 and Hct rose appropriately. At discharge patient was CV stable. Pulm: Patient presented with bilateral pneumonias; this was confirmed on admission CXR. She was intubated and started on a 14 day course of IV Zosyn, Vancomycin, and Flagyl. She remained on endotracheal ventilation from admission on [1-15] until [2103-1-31]. Several discussions were held with the patient and her family regarding the therapeutic benefits of performing a tracheostomy; however, the patient firmly refused this procedure throughout her inpatient stay. Intubational sedation was stopped on [2103-1-17]. She was followed with serial CXR that showed gradual improvement in her pneumonia. On [2103-1-19] she developed increasing pressure requirement; CXR demonstrated a large right sided pneumothorax. A chest tube was placed with improved ventilation and follow-up CXR showed no pneumothorax. This chest tube was removed on [2103-1-25] and serial follow-up CXR demonstrated no reaccumulation of pneumothorax. The patient failed CPAP trials until [2103-1-23], following which her CPAP was gradually weaned on a daily basis. [1-28] chest CT showed resolution of her pneumonias but was somewhat concerning for bronchomalacia. Prior to extubation, patient was still requring CPAP. However, she indicated a firm desire for extubation. The interventional pulmonology service was consulted to optimize her pulmonary status prior to extubation and on [1-30] flexible bronchoscopy with therapeutic aspiration and functional study was performed; this showed no tracheomalacia and no mucous plugging of the bronchial tree. Following extubation on [2103-1-31] the patient required high oxygen supplementation with face mask of 60% but her serial ABGs were stable. She and her family confirmed her DNR/DNI status several times throughout her stay. GI: At admission she was made NPO and an NGT was placed. Intraoperative findings at time of emergent exploratory laparotomy included several feet of small bowel extruding through an internal hernia. Dobhoff tube was placed [2103-1-21]. Incision healed well, staples were removed. Renal: On admission, patient was dehydrated and volume depleted with a creatinine of 1.5. During her subsequent sepsis, her creatinine peaked on [1-18] at 2.4. It steadily declined to 1.0 at discharge. At time of discharge she had excellent urine output. UAs were negative for UTI throughout her stay. FEN: On [2103-1-18] low osmolality tube feeds were started. She was gradually advanced to her goal rate. Following extubation, a speech and swallow evaluation was performed that indicated patient could tolerate a soft, regular diet; on [2-2] she was started on and tolerated this diet with prethickened nectar liquids. ID: Sepsis and pneumonias resolved with a 14-day course of IV antibiotics. ICU surveillance cultures grew VRE but not MRSA. Sputum cultures early in her stay grew zosyn sensitive Klebsiella. Follow-up sputum cultures on [1-28] after clinical resolution of pneumonia had sparse growth of gram negative rods. At time of discharge she had been afebrile for more than 10 days and was being given any antibiotics. All blood cultures were negative. Medications on Admission: MVI celexa 10mg po daily [Doctor First Name 130] 60mg po daily lopressor XL 100mg po daily atrovent nebs albuterol nebs mylanta prn allopurinol 300 po daily protonix 40mg po daily asa325mg po daily metphormin 850am 500pm cozaar 25mg po daily serevent [Hospital1 ] spiriva qd amaryl 1mg' Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Injection TID (3 times a day). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold SBP <90, HR <60 . 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed. 4. Oxycodone 5 mg/5 mL Solution Sig: [11-21] solutions PO Q4-6H (every 4 to 6 hours) as needed for pain. 5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 8. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Per sliding scale Per sliding scale Subcutaneous four times a day. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation Q4-6H (every 4 to 6 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q4-6H (every 4 to 6 hours) as needed. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 12. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q4H:PRN breakthrough pain 15. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 16. Pantoprazole 40 mg IV Q24H Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: 1. Small bowel obstruction 2. Recurrent incarcerated ventral hernia 3. Sepsis secondary to pneumonia 4. COPD Discharge Condition: Stable Discharge Instructions: Patient is DNR/DNI. This has been confirmed with the family by both general surgery team and ICU teams. * Fever > 101.5 * Difficulty breathing, shortness of breath, significantly increased oxygen requirement * Worsening, intractable pain Followup Instructions: Please call Dr.[Name (NI) 10946] office for followup appointment. The number is ([Telephone/Fax (1) 9011]. Completed by:[2103-2-2]	[ "0389", "496", "99592", "25000", "4019", "53081" ]
Admission Date: [2185-1-7] Discharge Date: [2185-1-15] Date of Birth: [2106-8-5] Sex: F Service: MEDICINE Allergies: Coumadin / Penicillins / IV contrast / Sulfa (Sulfonamide Antibiotics) / Prednisone / Latex Attending:[First Name3 (LF) 2751] Chief Complaint: Hemoptysis/septic arthritis/ NSTEMI Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 78 yo female with h/o HTN, Type II DM, CAD s/p remote LAD stent, COPD, and recent right total knee replacement complicated by infected hardware s/p removal transferred from OSH for further management of hemoptysis and NSTEMI. Patient was admitted to [Hospital3 ] Hospital in late [Month (only) ] with right knee septic arthritis following a right total knee replacement, cultures grew Group B Strep. Hardware was removed at [Hospital 1562] hospital on [2184-12-17], replaced by antibiotic spacer. Per report, the patient had bilateral DVTs on [2184-12-15], noted again on LENIs from [2185-1-1]. At this time, it appears the patient was on prophylactic dose of enoxaparin. Patient was then discharged to rehab following hardware removal. Per report, she developed respiratory distress on [2185-1-1], with hypoxia and wheezing. No aspiration event was witnessed. There was a question of excess sedation. After being re-admitted to [Hospital 1562] hospital, she was initially treated with BiPAP and nebulizers, with good effect. IV fluids were given for hypotension and tachycardia. She had a second episode of respiratory distress, and was transferred to the ICU for further management. She then underwent diuresis, and was placed on BiPAP. She was intubated on [2185-1-3]. A Swan-Ganz catheter was placed on [2185-1-4] for hemodynamic monitoring in the setting of possible cardiogenic shock. She was then started on levofloxacin and clindamycin for aspiration pneumonia, and was transitioned to vancomycin, cefepime, and metronidazole. She also received pulse dose methylprednisolone for possible COPD exacerbation. Over past few days, vent wean has been complicated by low minute ventilation and airway secretions. Today, patient had episode of hemoptysis, with 50-100 cc of bright red blood suctioned through ET tube. Bronch showed lesions in left main stem bronch near second carina, one suspicious for an eroding broncholith. A bleeding lesion was injected with epinephrine and iced saline, with hemostasis. Patient was then transferred via [Location (un) 7622] directly to ICU for further management. Upon arrival to the ICU, patient was intubated, alert, on minimial sedation. She complained of pain in her right knee, and denied any other pain. Past Medical History: COPD ? OSA HTN CAD s/p stent to LAD in [2174] left subclavian occlusion critical left internal carotid stenosis s/p CEA Type II DM hypothyroidism GERD DVT in bilateral [Name Prefix (Prefixes) ] [Last Name (Prefixes) 88154] Social History: Lives in nursing home recently. no history of recent tobacco or alcohol use recently. Family History: non-contributory Physical Exam: VS: T 98 HR 70 BP 115/41 100% FiO2 30%, PEEP 5 GEN: elderly female, NAD, alert HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, JVD to angle of jaw, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout, although dimished in axillae CV: RR, S1 and S2 wnl, no r/g. II/VI systolic murmur at LUSB, with radiation to right carotid ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: fungal rash in inguinal folds NEURO: alert. 1+D TR's-patellar and biceps Pertinent Results: Admission labs: [2185-1-8] 12:29AM BLOOD WBC-7.3 RBC-3.44* Hgb-9.9* Hct-30.5* MCV-89 MCH-28.8 MCHC-32.4 RDW-16.1* Plt Ct-264 [2185-1-8] 12:29AM BLOOD PT-14.8* PTT-24.0 INR(PT)-1.3* [2185-1-8] 12:29AM BLOOD Glucose-120* UreaN-33* Creat-0.9 Na-141 K-4.0 Cl-97 HCO3-32 AnGap-16 [2185-1-8] 12:29AM BLOOD ALT-10 AST-27 CK(CPK)-66 AlkPhos-47 TotBili-0.5 [2185-1-8] 12:29AM BLOOD CK-MB-2 cTropnT-0.44* [2185-1-8] 12:29AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.8 [2185-1-8] 02:06AM BLOOD Type-ART Rates-/14 Tidal V-500 PEEP-5 FiO2-30 pO2-112* pCO2-37 pH-7.57* calTCO2-35* Base XS-11 -ASSIST/CON Intubat-INTUBATED [2185-1-8] 02:06AM BLOOD Lactate-1.0 Cardiac Enzymes CPK ISOENZYMES CK-MB cTropnT proBNP [2185-1-10] 04:33 2 0.381 Source: Line-Right CVL [2185-1-9] 00:31 3 0.511 Source: Line-CVL [2185-1-8] 13:33 3 0.551 Source: Line-picc [2185-1-8] 07:23 3 0.511 [Numeric Identifier 7260]2 Source: Line-central [2185-1-8] 00:29 2 0.443 Imaging: CXR [1-7]: FINDINGS: The tip of the endotracheal tube is 3.5 cm above the carina. There is a right IJ central venous catheter with distal lead tip in the proximal SVC. There is a nasogastric tube whose tip and side port are below the gastroesophageal junction. The cardiac silhouette is enlarged. There is a left IJ and subclavian central lumen catheters with the distal lead tip in the mid SVC. There is prominence of the pulmonary interstitial markings, compatible with fluid overload. There is left retrocardiac opacity and a small left-sided pleural effusion. TTE [1-10]: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.4 m/s Left Atrium - Peak Pulm Vein D: 0.2 m/s Right Atrium - Four Chamber Length: 5.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 30% >= 55% Left Ventricle - Stroke Volume: 50 ml/beat Left Ventricle - Cardiac Output: 3.42 L/min Left Ventricle - Cardiac Index: 1.65 >= 2.0 L/min/M2 Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aortic Valve - Peak Velocity: 2.1 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 19 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 8 mm Hg Aortic Valve - LVOT pk vel: 0.80 m/sec Aortic Valve - LVOT VTI: 16 Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: 1.2 cm2 >= 3.0 cm2 Aortic Valve - Pressure Half Time: 273 ms Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A ratio: 1.11 Mitral Valve - E Wave deceleration time: 192 ms 140-250 ms TR Gradient (+ RA = PASP): 32 to 34 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 1.0 m/sec <= 1.5 m/sec Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Moderately depressed LVEF. No LV mass/thrombus. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild AS (area 1.2-1.9cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. No MS. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: Trivial/physiologic pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately to severely depressed (LVEF= 25-30 %) with infeior, lateral, anterior and apical hypokinesis to akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets are mildly thickened (?#). There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Persantine Stress Test [2185-1-12] IMPRESSION: No anginal symptoms or additional ST segment changes from baseline. Nuclear report sent separately. Nuclear Imaging Status Post Persantine Stress Test [2185-1-12] The image quality is adequate but limited due to soft tissue, breast, and left arm attenuation. Left ventricular cavity size is increased. Rest and stress perfusion images reveal a predominantly fixed, moderate reduction in photon counts involving the entire inferior wall, and the mid and basal inferolateral walls. Gated images akinesis of the entire inferior wall and the mid and basal inferolateral walls. The calculated left ventricular ejection fraction is 29% with an EDV of 203 ml. IMPRESSION: 1. Predominantly fixed, large, moderate severity perfusion defect involving the PDA/LCx territory. 2. Increased left ventricular cavity size. Severe systolic dysfunction with akinesis of the entire inferior wall and the mid and basal inferolateral walls. Knee X-ray [1-10]: FINDINGS: Overlying knee brace obscures the bony detail of the knee. Multiple calcifications are seen in the soft tissues. Cement spacers are present at the distal femur and proximal tibia. No definite fractures. IMPRESSION: Right knee cement spacers. MICRO DATA: ([2185-1-8]) SPUTUM GRAM STAIN (Final [2185-1-8]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2185-1-10]): Commensal Respiratory Flora Absent. YEAST. RARE GROWTH. UCX- yeast BCX- negative x2 Brief Hospital Course: Mrs. [Known lastname 68990] is a 78 yo female with a PMH significant for CAD s/p PCI, HTN, HLD, COPD, recent right knee replacement complicated by septic joint, bilateral DVT s/p IVC filter transferred from OSH for management of hemoptysis and respiratory failure. # Hemoptysis- submassive: In the ICU, bronch showed two areas of ulceration of unclear etiology and a possible polypoid lesion. No diagnostic or therapeutic intervention performed by IP. No further hemoptysis. Upon transfer to the floor, discussion about repeat bronchoscopy to r/o any oozing lesions prior to starting anticoagulation (for DVT's per below). Went to IP procedure lab, but IP decided she was too high risk given recent cardiac pathology (see below). Given her stable HCT and no further hemoptysis since transfer from OSH, suggested starting systemic anticoagulation with a heparin gtt and following up with rigid bronchoscopy under general anesthesia if repeat bleeding were to occur. Started hepar gtt without issue, HCT was stable. No further interventions were needed. She will need a repeat bronchoscopy with biopsy in one month (when her cardiac issues have stabilized). Interventional pulmonology has the patient's information, and said they would contact the patient for arrangement of a follow up appointment. This was confimred with Dr. [Last Name (STitle) 88155] [Name (STitle) 13470]. THe patient was given contact information of the interventional pulmonology suite at ([Telephone/Fax (1) 17398] as well as [Hospital1 1388] main line at [Telephone/Fax (1) 250] with the IP fellows pager number at [Numeric Identifier 88156] in the event she has not been contact[Name (NI) ] within 3 weeks of discharge. The patient confirmed understanding of this issue prior to discharge. # Hypotension/Acute on chronic systolic heart failure: In the ICU her hypotension was thought to be secondary to acute systolic heart failure secondary to her NSTEMI and worsening systolic function. She had no evidence of distributive shock. Sedation also thought to be contributing. Dobutamine was weaned upon arrival without difficulty. TTE showed worsening systolic function with new EF of 25-30% (from baseline of 40%). Upon transfer to the floors, did not require further diuresis as physical exam was nt consistent with HF, no sob. Bilateral lower extremity was present throughout duration of stay thought to be due to bilateral DVT's. Given depressed EF, will need follow up evaluation by cardiology to assess the need for pacemaker placement once HF class can be determined with activity. Patient claims to have her own cardiologist, but also given the number of the [Hospital1 18] cardiology clinic if she would like to transition her care to the [Hospital1 18] system. # Respiratory failure: Likely a component of pulmonary edema from acute systolic heart failure given her improvement with diuresis. Low suspicion for PNA. PE was a possibility, although less likely given IVC filter. She was successfully extubated on [1-9]. She had no return of SOB while on the general medical floors. No further thoracic imaging was done to look for PE as patient was to receive systemic anticoagulation regardless for B/L DVT's. # NSTEMI: Patient was found to have elevated cardiac enzymes with TnTs peaking at 0.55. BNP 50k, MB flat. No EKG changes. Cardiology was consulted, but anticoagulation (plavix and heparin gtt) was held due to hemoptysis due to risk of bleeding. She was treated with ASA 325 mg daily and started on a statin and metoprolol. She had a TTE which showed an overall left ventricular systolic function which was moderately to severely depressed (LVEF= 25-30 %) with infeior, lateral, anterior and apical hypokinesis to akinesis (which is worse then her baseline EF of 40%). Upon transfer to the medical floor, troponin continued to downtrend. No ekg/telemetry changes were observed. Had pharmacologic stress test with persantine followed by MIBI. Stress was negative for EKG changes/anginal symptoms, and MIBI showed irreversible defect in the PAD/LCx distribution. Given irreversibility, cath not indiciated and Plavix not indciated given the duration post NSTEMI. Continued to medically manage NSTEMI with ASA, metoprolol, lisinopril, and high dose atorvastatin without issue. Placed back on home fenofibrate upon discharge (not given as non-formulary in house). # Bilateral DVT: Patient had an IVC filter placed at an OSH in mid-[Month (only) 1096] per her son. Systemic anti-coagulation was held as above in setting of hemoptysis, however she was given SC heparin as prophylaxis. After acute hemorrhaging was ruled out (per above) was started on heparin gtt. HCT stable on heparin gtt and tranisitioned to enoxaparin 90 mg [Hospital1 ] for at least 3 months of treatment (started anticoagulation [2185-1-11]) given provoked development of DVTs in the setting of orthopedic surgery and lack of mobility. Will need follow up in 3 months with f/u lower extremity ultrasounds to assess for dissolution of blood clots. Should be scheduled by her PCP. # Septic right knee s/p hardware removal: X-ray of knee showed hardware (cement spacers) in place. She was continued on ceftriaxone 2 grams IV daily, with day one of Abx treatment being [2185-1-4]. Will need at 28 days worth of antibiotics with ortho f/u for hardware replacement once infection has been deemed cleared. Discharged on pain control with 5 mg oxycodone q4 hours PRN and oxycontin 10 mg [Hospital1 ]. Patient's orthopedic surgeion Dr. [Last Name (STitle) 46850] was contact[Name (NI) ] regarding this issue and faxed a discharge summary. Patient also provided with Dr.[Name (NI) 88157] contact information. CHRONIC ISSUES # DM: continued SSI regimen w/o issue. . # GERD: disconitnued home PPI as past duration of therapy for GERD. Can restart if symptoms of GERD return. # COPD: Continued albuterol/ipratropium nebs prn without issue. . # Contact Precautions: has history of VRE per OSH records. will need to continue on contact precautions. Comm: patient, [Name (NI) ] [Name (NI) 68990], [Telephone/Fax (1) 88158], home [Telephone/Fax (1) 88159]. Code: full (discussed with son [Name (NI) ], HCP) PENDING LABS AT DISCHARGE: None TRANSITIONAL ISSUES: Will need f/u US for DVT reassessment in 3 months (To be completed by PCP). PCP should also affirm cardiovascular follow up, bronchoscopy follow up by 3/[2185]. Orthopedist aware of issues and has also been provided with copies of hospital course. PCP and orthopedist both faxed copies of DC summary on [2185-1-15] Medications on Admission: Medications at rehab: enoxaparin 30 mg Q12 gabapentin 300 mg TID metoprolol tartrate 12.5 PO BID fenofibrate 160 mg daily Zetia 10 mg daily Cefazolin 2 gram IV Q8 ASA 81 mg daily Prilosec 20 mg daily Vitamin B12 1000 mcg PO daily Vitamin D3 1000 units PO daily hydromorphone 2 mg PO Q4H PRN pain Meds on transfer: furosemide 40 mg IV Q12 enalapril 0.625 mg IV Q8H methylprednisilone 20 mg IV Q12 dobutamine gtt nitro paste 1 inch Q6H ceftriaxone 2 grams daily pantoprazole 40 mg IV daily ASA 81 mg daily fentanyl gtt midazolam gtt linezolid 600 mg x 1 (VRE in urine) TFs albuterol/ipratropium nebs Q6H PRN Discharge Medications: 1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed) as needed for rash. 2. insulin lispro 100 unit/mL Solution Sig: per SSI per SSI Subcutaneous ASDIR (AS DIRECTED). 3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation q6hr prn as needed for shortness of breath or wheezing. 5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation q6h prn. 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for for knee pain. 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain: Hold for sedation/ rR<10. Disp:qs for rehab Tablet(s)* Refills:0 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 16. polyethylene glycol 3350 17 gram/dose Powder Sig: [1-9] PO DAILY (Daily) as needed for constipation: Patient may refuse. At risk for constipation given need for opiods. Hold if having regular bowel movements. 17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 18. CeftriaXONE 2 gm IV Q24H Start: In am 19. 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. 20. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation: Hold if patient is having regular bowel movements. 21. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Hold if patient is having regular bowel movements. 22. Enema Enema Sig: One (1) Rectal [Hospital1 ] PRN: For constipation. Can use tap water enemas, soap [Last Name (un) ] enemas, and sodium phosphate enemas. 23. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day: hold for sedation/ RR<10. Disp:qs rehab Tablet Sustained Release 12 hr(s) Refills:0 24. zeita Sig: Ten (10) mg once a day. Discharge Disposition: Extended Care Facility: JML Center Discharge Diagnosis: Primary: Septic Arthritis Non-ST Elevation Myocardial Infarction Hemoptysis Bilateral Lower Extremity Deep Vein Thromboses Secondary: Chronic obstrucitve pulmonary disease Hypertension Coronary artery disease with stenting of left anterior descending artery in [2174] Internal carotid stenosis status post coronary artery dissection Type II Diabetes Mellitus Gastroesophageal Reflux Disease Osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 68990], It has been a pleasure taking care of you. You were originally transferred to [Hospital1 69] for management of multiple medical issues outlined below. At the previous hospital, you experience a heart attack known as a "Non-ST Elevation Myocardial Infarction" or "NSTEMI" for short. It is a heart attack which occurs without changes seen on an EKG, but is detected by blood tests which tell your medical team that your heart muscle has been affected. You were evaluated by cardiologists here that placed you on medication to optimize your cardiac function (outlined below). During your stay, you had a "Pharmacologic Stress Test" with a medication known as "Persantine" which mimics an exercise stress test. You also had a radionucleotide test to look at the tissue and function of your heart. The results of these two tests informed your physicains that having a repeat catherization of the vessels of your heart would NOT be beneficial at this time. Thus, you should continue to take your cardiac medication as prescribed to decrease the risk of having another cardiac event in the future. Additionally, you will need to follow up with a cardiologist. You can follow up with your own cardioloigst, or the number of the cardiology department at [Hospital1 18] has been provided for you to make a follow up appointment at your convenience. At the outside hospital, you had an episode of coughing up blood while you were intubated (this phenomenom is known as "hemoptysis"). Given this condition, the physicians at [Hospital1 ] reimaged your airway while you were in the ICU, and found an ulceration in one of the larger airways (Bronchus intermedius) with friable mucosa. This was most likely thought to be due to airway irritation from suctioning while you were intubated. You had Prior to coming to [Hospital1 18], you had "septic arthritis" after you right knee replacement. This is a complication that can occur in patients who experience a knee replacement, which you had. You had your knee replacement hardware removed, and cement "spacers" were placed between the bones of your leg for stability. You will need to continue antibiotic treatment for at least four weeks, with follow up with your orthopedic surgeon Dr. [First Name (STitle) ] to decide when would be the best time for you to have your knee replacement performed again. Additionally, you will need to conintue physical rehabilitation to keep the condition of your muscles up in order to optimize your recovery. . You have started many new medications, and some of your home medications have been changed. Please continue to take your medications as directed: Ipratropium Bromide MDI 2 PUFFs inhaled every 6 hours (for COPD) Albuterol Inhaler 2 PUFF inhaled every 6 hours as needed for shortness of breath Lisinopril 2.5 mg orally daily- new cardiac medication (controls blood pressure, helps heart muscle) Furosemide 20 mg orally daily (for fluid retention/heart failure) Metoprolol Tartrate 25 mg by mouth 2x a day- (cardiac medication: controls heart rate/blood pressure) Aspirin 325 mg DAILY Zetia 10 mg daily (for cholesterol) Atorvastatin 80 mg DAILY (cardiac medication- controls cholesterol and improves heart function/reduces risk of recurrent heart attack) CeftriaXONE 2 gm IV daily (IV antibiotic for septic arthritis)OxycoDONE (Immediate Release) 5 mg every 3 hours as needed for pain Oxycontin 10 mg 2x a day- long acting pain medication for basal pain control Enoxaparin Sodium 90 mg injections 2x a day (for blood clots in legs) Insulin Sliding Scale- for glucose control . We have discontinued your Prilosec 20 mg daily (Aka Omeprazole), a medication typically used for gastric reflux. The duration of being on this medication was longer than the usual therepeutic course. Please follow up with your primary care doctor if you have returning symptoms of reflux including heart burn/sour taste in the morning. . It has been a pleasure taking care of you [Known firstname ]!!! Followup Instructions: You will need to follow up with your primary care doctor. Your listed PCP is [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 70179]. Please schedule follow up within 1 week after your discharge form rehab. You will need to be seen by a cardiologist given your recent heart attack. You can follow up with your own cardiologist if you have one. If you would like to be seen by a [Hospital1 ] cardiologist, the number to our cardiology clinic is ([Telephone/Fax (1) 2037]. While in the hospital, you were seen by [Name6 (MD) ] [Name8 (MD) ], MD [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD. You may try to request follow up with them if you like. Given your episodes of hemoptysis (coughing up blood), you will need to follow up with interventional pulmonology for a repeat bronchoscopy to image your airway. Interventional pulmonology would like you to be seen for a repeat procedure within 30 days. They have your information, and will contact you for arrangement of follow up appointment. Dr. [Last Name (STitle) 88155] [Name (STitle) 13470], or one of her colleagues, will be in touch with you in the following weeks. If you do not hear from this team within the month, please call the interventional pulmonology suite at ([Telephone/Fax (1) 17398], or you can call [Telephone/Fax (1) 250] and have the number [Serial Number 88156] paged to speak with one of the interventional pulmonology fellows to rectify the issue. You will need to be followed up by your orthopedic surgeon Dr. [Last Name (STitle) 46850]. Please contact him at [Telephone/Fax (1) 88160] at your convenience regarding the status of your knee and when further interventions can be performed to replace your knee.	[ "41071", "51881", "496", "32723", "25000", "53081", "2449", "4019", "41401", "V4582", "4280" ]
Admission Date: [2117-11-30] Discharge Date: [2117-12-10] Date of Birth: [2054-3-12] Sex: F Service: MEDICINE Allergies: Inderal Attending:[First Name3 (LF) 7333] Chief Complaint: Dyspnea, chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization with bare matal stents to left circumflex artery and right coronary artery PICC line placement and removal History of Present Illness: SOURCE: Patient, interviewed with her adult son translating. ([Name2 (NI) ] cambodian interpreter available except via telephone). Son speaks excellent English and appears to speak fluently with his mother. . Ms [Known lastname ] is a 63 year old woman with a history of asthma, who was in her usual state of health, able to be up and about her house, rode here stationary bike etc on Sunday. Yesterday, she didn't feel as well, developed some dyspnea on awakening that persisted through the day. She had chest pain thru the day as well, though it waxed and waned, with her dyspnea worsening. She took her nebulizers and her other medications and this helped her shortness of breath and her chest pain. She has not had any fevers. Has a sore throat but she says she has had his for a long time. Says at least one month, where it is worse in the morning and improves with the albuterol nebs and resolves by midday. She presented to the ED where she was noted to be dyspneic and was treated for PNA +/- asthma flare with levofloxacin, nebulizers and steroids. She also received an aspirin. She is now admitted to the Medicine service for further evaluation and management. . ROS She later describes her pain as in her chest, extending across upper abdomen doesn't know how long she's really had this, seems to come and go, and patient is not really able to describe for how long she's had it. Says her medications make it better. No diarrhea, constipation. Decrease energy with acute illness. + dark stools x a long time (is on iron supplement). . All other ROS are otherwise negative Past Medical History: FROM OMR 1. Diabetes Mellitus, Type 2: She was diagnosed in [2104] and has been followed by Dr. [Last Name (STitle) 9006] since that time. She is controlled on insulin. Here most recent HbA1c was < 7%. 2. Chronic Hepatitis B. 3. Stage 2 - Chronic kidney disease (hyperparathyroidism [2-9] renal issues). 4. Nephrotic Syndrome. 5. Hypertension. 6. Asthma. 7. Hypertriglyceridemia. 8. CVA/TIA. 9. Raynaud's phenomena. 10. Generalized anxiety disorder. Social History: She lives with her daughter, son and husband. She has 9 children, 3 are deceased. Her occupation was as a housewife. She was born in [Country ] living in a rural area. She denies ever smoking cigarettes but does continue to chew betel. She denies alcohol abuse. She came to the United States in [2090]. Independent of ADLS. Has help with some IADLS. No recent falls. Son = [Name (NI) ] [Name (NI) 27411] [Telephone/Fax (1) 27413] (son). HCP = [Name (NI) 27414] [Name (NI) 27411] [Telephone/Fax (1) 27415] (daughter). . CODE STATUS CONFIRMED as FULL Family History: Per OMR: Daughter and son with asthma; no strokes or seizures in family per granddaughter. Physical Exam: 98.6 162/90 100 24-28 98% on 2L, FS 254 GEN: Obese woman, dyspneic, appears somewhat tired [Telephone/Fax (1) 4459]: Anicteric, MMM NECK: Unable to visualize JVP CV: Reg rate, tachycardic, distant LUNGS: Distant lung sounds, markedly diminished air entry, increased I:E ratio ABD: obese, some mild tenderness across upper abdomen, + distended, soft, otherwise no abnl, no HSM appreciated due to habitus EXT: warm, DPs palp NEURO: Alert, appropriate, follows commands, speech fluent . At discharge: same as above except: GEN: not dyspneic, comfortable, not tired-appearing LUNGS: CTAB Pertinent Results: [2117-11-30] 10:10AM GLUCOSE-245* UREA N-24* CREAT-1.3* SODIUM-141 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-17 [2117-11-30] 03:26PM LACTATE-3.4* [2117-11-30] 10:10AM cTropnT-0.03* [2117-11-30] 10:10AM WBC-8.2 RBC-3.73* HGB-11.5* HCT-36.0 MCV-96 MCH-30.8 MCHC-31.9 RDW-13.6 [2117-11-30] 10:10AM PLT COUNT-248 [2117-11-30] 10:10AM PT-12.4 PTT-26.4 INR(PT)-1.0 EKGs reviewed (as described below) TTE: from [3-16] The left atrium is mildly dilated. 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 aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [2113-7-14], the findings are similar. . Cardiac Catheterization [12-6]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate systemic hypertension. 3. Successful PCI of LCx with BMS 4. Successful PCI of RCA with BMS 5. Successful RRA TR band 6. [Hospital 27416] medical regimen. . Discharge Labs: [2117-12-10] 06:53AM BLOOD WBC-11.2* RBC-2.82* Hgb-8.9* Hct-26.3* MCV-94 MCH-31.5 MCHC-33.7 RDW-13.9 Plt Ct-198 [2117-12-10] 03:39PM BLOOD Hct-29.0* [2117-12-10] 06:53AM BLOOD Glucose-110* UreaN-32* Creat-1.3* Na-140 K-4.6 Cl-108 HCO3-27 AnGap-10 [2117-12-10] 06:53AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.5 [2117-12-2] 06:09AM BLOOD %HbA1c-7.9* eAG-180* Enzymes: [2117-11-30] 10:10AM BLOOD cTropnT-0.03* [2117-12-1] 02:30AM BLOOD CK-MB-18* MB Indx-6.9* cTropnT-0.11* proBNP-2431* [2117-12-1] 04:45AM BLOOD CK-MB-24* MB Indx-7.2* cTropnT-0.25* proBNP-2808* [2117-12-2] 06:09AM BLOOD CK-MB-33* MB Indx-5.7 cTropnT-2.87* [2117-12-3] 06:15AM BLOOD CK-MB-13* MB Indx-4.8 cTropnT-1.41* [2117-12-6] 10:18PM BLOOD CK-MB-5 [2117-12-7] 04:02AM BLOOD CK-MB-5 Brief Hospital Course: 63 yo F with DM II, HTN, DL and CKD who presents after multiple episodes of chest pain and SOB. Admitted initially for asthma exacerbation but later found to have an NSTEMI and found to have 3VD on cath [12-1]. . # CAD: S/P NSTEMI. Currently stable without CP. Received Cardiac Catheterization with bare matal stents to left circumflex artery and right coronary artery on [12-1]. She has done well post catheterization with a resolving small hematoma on the left radial site. She should have a full dose 325 mg aspirin and Plavix 75 mg every day for at least one month and possibly longer. she will also need to be on Atorvastatin 80 mg. Her Lisnopril was restarted on [12-8]. Her beta blocker was held and not restarted because of her severe asthma. She was rate controlled with increased dose of long acting Diltiazem. She has remained in a normal sinus rhythm. Her heart function is stable with a preserved EF at 60-65%, no significant valvular abnormality. She will see Dr. [Last Name (STitle) ] in cardiology here at [Hospital1 18] in 1 month. . # ASTHMA EXACERBATION: History of Asthma with exacerbations several times per year, but no history of intubations who presents with 2 day history of worsening shortness of breath, no URI symptoms, and intermittent chest pain. Started on standing nebs and prednisone pulse in the MICU, now on prednisone taper. Leukocytosis likely [2-9] prednisone. She has baseline DOE and tight breath sounds with no audible wheezes on exam. She also has a dry cough. Her Adviar dose was increased from home dose and she has no O2 requirement (also no home O2) . # Diabetes Mellitus: She is followed by Dr. [Last Name (STitle) 3617] at [Last Name (un) ] and has had high insulin requirements, started on u500 insulin as outpt. Her blood sugars have been labile and she will likely need more insulin given prednisone. She was transitioned to glargine with a humalog sliding scale. . # HTN: Currently well controlled on diltiazem and Lisinopril. . # Hyperlipidemia: restarted home simvastatin 40mg daily . # CKD: Patient with baseline 1.4-2.4. Cr rising slightly after contrast load with catheterization, should be monitored after discharge and avoid nephrotoxins. . # Chronic HBV infection with gastric varices. Viread was decreased to 300mg q 72 hours for renal function. Her MELD score is 12. Seen by hepatology during hospital stay and has an upoming outpt appt. . # Social: pt has a large family and her son is the HCP. She was previously living at home with her husband and son and was independent. She is deconditioned with some gait instability, should be on fall precautions until she is stonger. Medications on Admission: Viread 1 tab q72 hours albuterol mdi diltiazem 300 mg/d [Last Name (un) 12457] 1 tab po bid advair 100 mcg-50 mcg 1 inh [Hospital1 ] furosemide 80 mg po bid duoneb q4-6 hrs prn lisinopril 40 mg po bid metoprolol 25 mg po bid omeprazole 20 mg po daily simvastatin 40 mg po daily valsartan 320 mg po daily aspirin 81 mg po daily docusate 100 mg po bid iron 325 daily --> will hold given acute illness Vit D Omega 3 Fatty acids Humulin R as per Sliding Scale Discharge Medications: 1. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO Q72H (every 72 hours). 2. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO every other week. 3. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation Q4h () as needed for wheezing/SOB. 4. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation every six (6) hours. 5. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 9. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Hold SBP < 100. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. simethicone 80 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO QID (4 times a day) as needed for abdominal pain. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 17. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for coughing. 18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection twice a day. 19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritis. 20. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis. 21. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritis. 22. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous QPM. 23. insulin aspart 100 unit/mL Solution Sig: 2-14 units Subcutaneous four times a day. 24. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 25. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 26. prednisone 5 mg Tablet Sig: 0.5 to 2 Tablet PO once a day: TAPER: 10mg daily until [12-11], 5mg daily 12/5-7, 2.5mg daily [2117-12-15] then DC. . Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 3504] [Last Name (NamePattern1) ] Rehabilitation & Nursing Center - [Location (un) 538] Discharge Diagnosis: Non ST Elevation Myocardial Infarction Diabetes mellitus Asthma Exacerbation Hyperlipidemia 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 had chest pain and a heart attack. You had a cardiac catheterization and needed to bare metal stents to two of your heart arteries to open blockages. You were also treated for a severe asthma exacerbation with prednisone, nebulizer treatments and a long acting controller medicine called Advair. . We made the following changes in your medicines: 1. Stop taking Albuterol, [Location (un) ], Metoprolol and Valsartan 2. Increase aspirin to 325 mg daily 3. Increase Diltiazem long acting to 360 mg daily 4. Increase Advair to 250/50 mg twice daily 5. Start taking Plavix to keep the stent open. Do not stop taking Plavix for any reason or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) ] tells you to. 6. Start taking senna and Miralax to prevent constipation 7. Start taking Guaifenesin for your cough 8. Start taking Levalbuterol nebulizers as needed for your breathing 9. Start taking Benadryl as needed for your itching 10. Start using Sarna lotion and hydrocortisone cream as needed for your itching. Followup Instructions: Department: [Hospital3 249]: pls d/c if pt goes to ECF When: TUESDAY [2117-12-14] at 9:10 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: TUESDAY [2118-1-11] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: LIVER CENTER When: THURSDAY [2118-1-20] at 9:20 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "41071", "5849", "41401", "4280", "25000", "2724", "40390", "V5867", "2767" ]
Admission Date: [2102-10-19] Discharge Date: [2102-10-26] Date of Birth: [2033-2-12] Sex: F Service: SURGERY Allergies: tramadol Attending:[First Name3 (LF) 2777] Chief Complaint: 5.2cm descending thoracic aneurysm Major Surgical or Invasive Procedure: Thoracic endovascular aortic aneurysm repair with lumbar drain placement History of Present Illness: Ms. [Known lastname 82804] is a 69-year-old woman with hypertension and dyslipidemia referred by Dr. [First Name (STitle) ] [Name (STitle) 82805] for evaluation of a thoracic aortic aneurysm and has undergone serial CTs for surveillance the past two years. The aneurysm was found in [Month (only) 116] [2097] during workup for her long-standing chest pain/epigastric pain. She underwent evaluation at that time and was not felt to be appropriate for surgery due to small size of the aneurysm and she is not felt to be a candidate for endovascular repair. She since then had some growth but with persistent chest/epigastric pain, which tends to be brought on by exertion. She does not know of any family history of aneurysm and she has never smoked. Given the persistence of her epigastric discomfort, size of her thoracic aortic aneurysm measured at 5.2cm and her relatively increased risk given her smaller stature and her gender, it was decided to go forward with elective endovascular repair. Past Medical History: Hypertension Dyslipidemia Descending thoracic aortic aneurysm GERD Arthritis Pneumonia [2094] PSH: Hysterectomy, cataracts Social History: Denies tobacco/alcohol use or illicit drug use. Lives with son in [Name (NI) 3786],MA. Family History: No history of aneurysm or premature coronary artery disease Physical Exam: Upon discharge: Tmax 99.6, HR 76, BP 114/68, RR 20, O2 sat 95% RA General: Elderly appearing female lying in bed in NAD Neuro: A&Ox3, Haitian creole speaking Lungs: decreased breath sounds at bases Cardiac: RRR, no MRG appreciated Abd: soft, nondistended with normal bowel sounds, no rebound/guarding Groin puncture sites: CDI, no erythema Extremities: no CCE LLE: palp bilat DP/PT Pertinent Results: [2102-10-20]: CT Torso: 1. Status post thoracic EVAR with a partially visualized stent that appears appropriately positioned. Bibasilar atelectasis. No acute findings in the abdomen to explain the patient's symptoms. 2. Stable right renal cyst. 3. Probable slight narrowing at the celiac artery origin, which is due to atherosclerotic disease. [2102-10-24]: Bilateral LENIs: No right or left lower extremity deep venous thrombosis. [2102-10-21]: CXR Final Report STUDY: PA and lateral chest, [2102-10-21]. CLINICAL HISTORY: 69-year-old woman with fever. Evaluate for pneumonia. FINDINGS: Comparison is made to previous study performed four hours earlier. There is again seen consolidation at the lung bases concerning for aspiration or multifocal pneumonia. There are no signs for overt pulmonary edema. There is an aortic stent identified which is intact. There is also a right IJ line with distal tip in the mid SVC, unchanged. No pneumothoraces are present. [2102-10-25]: CXR Final Report CHEST RADIOGRAPH TECHNIQUE: PA and lateral radiographs of chest were reviewed in comparison to prior radiographs through [2102-10-13] to [2102-10-24]. FINDINGS: Right internal jugular line has been removed. Left descending aortic stent is seen in situ. Since [2102-10-24], the right lower lung opacity which was likely a combination of effusion and atelectasis has significantly resolved. Mild amount of pleural effusion, however, still persists. Right lower lung and middle lobe atelectasis is present. Increased retrocardiac density reflecting left lower lung atelectasis and mild-to-moderate left pleural effusion are similar in appearance. Cardiomediastinal silhouette is stable in appearance. IMPRESSION: Since [2102-10-24], right lower lung opacity which was likely a combination of atelectasis and moderate amount of effusion has significantly improved with mild residual fluid and minimal right basal and middle lobe atelectasis. Left lower lung atelectasis and mild-to-moderate pleural effusion is unchanged. [2102-10-25]: STUDY: Abdominal son[Name (NI) ]. INDICATION: 69-year-old female with abdominal pain. COMPARISON: None. Right upper quadrant son[Name (NI) 493] images demonstrate normal liver size and echotexture. No focal hepatic lesions are seen. There is no intra- or extra-hepatic biliary ductal dilatation. The gallbladder appears within normal limits. There is no splenomegaly. Limited images of the right kidney demonstrate three simple cysts within the right kidney, the largest of which is seen in the lower pole measuring 2.3 x 2.0 cm in size. There is a probable right renal parapelvic cyst. A small left pleural effusion is seen. The head and body of the pancreas appear within normal limits. The tail is obscured by overlying bowel gas. IMPRESSION: Simple renal cysts in the right kidney. Small left pleural effusion. [2102-10-19] 05:08PM BLOOD WBC-9.3 RBC-3.04* Hgb-9.5# Hct-28.8 MCV-95 MCH-31.2 MCHC-32.9 RDW-12.9 Plt Ct-248 [2102-10-20] 04:56AM BLOOD WBC-15.1# RBC-2.91 Hgb-9.1* Hct-27.4* MCV-94 MCH-31.2 MCHC-33.1 RDW-12.8 Plt Ct-199 [2102-10-21] 01:53AM BLOOD WBC-14.7* RBC-3.17* Hgb-9.9* Hct-29.4* MCV-93 MCH-31.2 MCHC-33.7 RDW-14.0 Plt Ct-182 [2102-10-22] 02:45AM BLOOD WBC-13.7* RBC-3.04* Hgb-9.3* Hct-28.3* MCV-93 MCH-30.6 MCHC-32.8 RDW-13.7 Plt Ct-170 [2102-10-23] 06:00AM BLOOD WBC-10.9 RBC-2.78* Hgb-8.8* Hct-26.2* MCV-94 MCH-31.7 MCHC-33.7 RDW-14.0 Plt Ct-183 [2102-10-24] 05:16AM BLOOD WBC-9.6 RBC-2.82* Hgb-8.7* Hct-26.4* MCV-93 MCH-30.7 MCHC-32.9 RDW-13.6 Plt Ct-270 [2102-10-25] 06:30AM BLOOD WBC-11.2* RBC-2.99* Hgb-9.3* Hct-28.0* MCV-94 MCH-31.1 MCHC-33.2 RDW-13.9 Plt Ct-303 [2102-10-26] 07:15AM BLOOD WBC-10.5 RBC-2.86* Hgb-8.8* Hct-26.7* MCV-93 MCH-30.9 MCHC-33.1 RDW-13.3 Plt Ct-420 [2102-10-26] 07:15AM BLOOD PT-14.9* PTT-30.5 INR(PT)-1.3* [2102-10-19] 05:08PM BLOOD Glucose-157* UreaN-13 Creat-0.9 Na-145 K-3.6 Cl-111* HCO3-23 AnGap-15 [2102-10-20] 12:23PM BLOOD Glucose-131* UreaN-10 Creat-0.7 Na-135 K-3.8 Cl-101 HCO3-27 AnGap-11 [2102-10-21] 01:53AM BLOOD Glucose-123* UreaN-9 Creat-0.8 Na-135 K-4.5 Cl-102 HCO3-23 AnGap-15 [2102-10-23] 06:00AM BLOOD UreaN-10 Creat-0.8 Na-135 K-3.6 Cl-99 [2102-10-24] 05:16AM BLOOD Glucose-101* UreaN-8 Creat-0.7 Na-136 K-3.6 Cl-100 HCO3-26 AnGap-14 [2102-10-25] 06:30AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-137 K-3.8 Cl-99 HCO3-28 AnGap-14 [2102-10-26] 07:15AM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-135 K-3.8 Cl-101 HCO3-27 AnGap-11 [2102-10-19] 05:08PM BLOOD CK(CPK)-64 [2102-10-20] 12:23PM BLOOD ALT-10 AST-21 AlkPhos-74 TotBili-1.0 [2102-10-23] 10:56AM BLOOD CK(CPK)-27* [2102-10-23] 06:14PM BLOOD CK(CPK)-22* [2102-10-24] 03:04AM BLOOD CK(CPK)-26* [2102-10-25] 08:06PM BLOOD ALT-13 AST-24 AlkPhos-102 Amylase-38 TotBili-0.4 [2102-10-25] 08:06PM BLOOD Lipase-24 [2102-10-20] 12:23PM BLOOD Lipase-11 [2102-10-19] 05:08PM BLOOD CK-MB-2 cTropnT-<0.01 [2102-10-20] 04:56AM BLOOD cTropnT-<0.01 [2102-10-20] 12:23PM BLOOD cTropnT-<0.01 [2102-10-23] 10:56AM BLOOD CK-MB-1 cTropnT-<0.01 [2102-10-23] 06:14PM BLOOD CK-MB-1 cTropnT-<0.01 [2102-10-24] 03:04AM BLOOD CK-MB-1 cTropnT-<0.01 [2102-10-26] 07:15AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.2 Brief Hospital Course: Mrs. [Known lastname 82804] was consented and underwent a thoracic endovascular aneurysm repair with lumbar drain placement on [2102-10-19]. She tolerated the procedure well and remained hemodynamically stable. She was extubated and transferred to the CVICU for close monitoring. She awoke neurologically intact without any deficits. The lumbar drain was removed later that day for bleeding around the drain. On POD 1, she complained of abdominal pain. CT showed a properly positioned thoracic aortic stent, and no acute abdominal findings to explain patient's symptoms. Her pain was controlled on dilauded. She was kept NPO. She was transfused 1unit PRBCs for postoperative anemia with hematocrit of 27. On POD 2, she was weaned off neosynephrine drip and was stable for transfer to the VICU for further recovery and close monitoring. She was febrile to 103.5. Sputum, blood and urine cultures, and chest xray were done. Chest Xray was concerning for a left lower lobe pneumonia. Sputum cultures grew out rare growth gram negative rods. She was started on Vancomycin, levofloxacin, and flagyl empirically. Her diet was advanced, which she tolerated well. On POD 3, Physical therapy was consulted for strength and mobility and continued to see her throughout her stay. On POD 4, She continued to complain of epigastric pain. ECG was unchanged and cardiac enzymes were negative times three. On POD 5, she was febrile to 101. Right IJ was removed and tip was sent for culture which was negative. Urine cultures were negative. CXR was repeated which showed large right lower lobe pleural effusion and unchanged pneumonia in left lower lobe. She was aggressively diuresed. Bilateral Lower extremity ultrasound was negative for DVT. On POD 6, chest xray showed improvement in right pleural effusion. She continued to complain of epigastric/abdominal pain, so abdominal ultrasound was peformed which showed a simple renal cyst. Physical therapy recommended rehab, however, patient did not have insurance benefits for rehab or [Last Name (LF) 269], [First Name3 (LF) ] she will be discharged to home with her son with a rolling walker. Throughout her admission, she continued to complain of epigastric pain, which was believed to be consistant with her chronic reflux after an extensive workup. She was switched to protonix 40mg po bid. She will follow up with her primary care physician next week and gastroenterologist to discuss her GERD symptoms. On the day of discharge, IV antibiotics were discontinued and she was started on a 5 day course of moxifloxacin for hospital acquired pneumonia. She was discharged to home on [2102-10-26]. She was afebrile with stable vital signs, tolerating small frequent meals, voiding adequate amounts, ambulating with a walker, with pain well controlled. Medications on Admission: omeprazole 20mg po daily hydrochlorothiazide 25mg po daily lisinopril 40mg po daily pravastatin 20mg po daily aspirin 81mg 2 tabs po daily cyanocobalamin 1000mcg po daily ?amlodipine 2.5mg po daily naproxen 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). 3. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 4. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: Start date=[2102-10-26]. Disp:5 Tablet(s) Refills:0 5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): See PCP for refills. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 7. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 8. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 7 days. Disp:20 Tablet(s) Refills:0 9. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever for 7 days. 10. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 5.2cm descending thoracic aneurysm 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: Please do not restart lisinopril and amlodipine until follow up with Dr. [Last Name (STitle) 3271]. Your blood pressure was too low here in the hospital to restart those. Please discuss restarting these medications with Dr. [Last Name (STitle) 3271] at your appointment next week. You should also discuss your reflux disease and re-connect with your gastroenterologist. Medications: ?????? Take Aspirin once daily per your home regimen ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? 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 [1-12] 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 [3-15] weeks for post procedure check and CTA Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2102-12-6] 10:45 [Hospital Unit Name 8591], [Location (un) 86], [Numeric Identifier 16457] Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3271], MD Phone: [Telephone/Fax (1) 59128] Date/Time: Tues [2102-10-31] 1:20am 300 [Location (un) ], [Hospital1 3494], [Numeric Identifier 82806] Completed by:[2102-10-26]	[ "4019", "2724", "53081" ]
Admission Date: [2173-8-25] Discharge Date: [2173-9-16] Date of Birth: [2101-1-26] Sex: F Service: CSU HI[Last Name (STitle) 2710]OF PRESENT ILLNESS: This 72-year-old white female had a chest x-ray in the middle of [6-/2173] for bronchitis with acute shortness of breath at her primary care physician's office. She is a long-time smoker. Chest x-ray showed an enlarged aorta, and she then had a chest CT which revealed a chronic thrombosed dissection in the level of the pulmonary veins to below the celiac access. The widest diameter in both lumens was 6.9 cm. The descending aorta above the dissection was 5.6 cm. There was no adenopathy or masses. It also showed gallstones and moderate bilateral adrenal enlargement. Dr. [Last Name (Prefixes) ] was then consulted. She then had an exacerbation of her chronic obstructive pulmonary disease and was admitted to [Hospital 5871] [Hospital ] Hospital for steroid therapy. She was admitted here for preop workup. An echo showed an ejection fraction of 55 percent with trace aortic insufficiency and trace mitral regurgitation and mild aortic sclerosis. She was admitted on [2173-8-25] for elective thoracic descending thoracoabdominal aneurysm repair. PAST MEDICAL HISTORY: History of gallstones, history of bronchitis and chronic obstructive pulmonary disease, and a history of osteoporosis. She is status post left ankle open reduction internal fixation with osteomyelitis and an artery transplant from the left thigh, status post lumbar discectomy, status post appendectomy, status post tonsillectomy. MEDICATIONS ON ADMISSION: 1. Albuterol inhaler 4 puffs q.i.d. 2. Combivent inhaler 4 puffs q.i.d. 3. She had been on a prednisone taper that has been discontinued. ALLERGIES: She has no known allergies. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: She lives alone. Has a 50-pack-year smoking history and is down to two cigarettes a day. She drinks one to two glasses of wine per day. REVIEW OF SYSTEMS: Review of systems is as above. PHYSICAL EXAMINATION: She is an elderly white female in no apparent distress. Vital signs stable, afebrile. HEENT exam: Normocephalic, atraumatic; extraocular movements intact; oropharynx is benign, edentulous. Neck is supple; full range of motion; no lymphadenopathy or thyromegaly; carotids 2 plus and equal bilaterally without bruits. Lung have bilateral expiratory wheezes. Cardiovascular exam: Regular rate and rhythm, normal S1, S2 with a faint I/VI systolic ejection murmur. Abdomen is soft, obese, nontender with no masses or hepatosplenomegaly; positive bowel sounds. Extremities are without clubbing, cyanosis, or edema. She has slight deformity and atrophy of the left ankle with a well healed surgical scar. Pulses were femoral 1 plus bilaterally, dorsalis pedis 2 plus on the right and nonpalpable on the left, PT is 1 plus on the right and nonpalpable on the left, radial is 1 plus bilaterally. Neuro exam is nonfocal. HO[Last Name (STitle) ] COURSE: She was admitted on [2173-8-25] and underwent repair of a thoracoabdominal aneurysm with a 26 mm gel weave graft by Dr. [Last Name (Prefixes) ] and Dr. [Last Name (STitle) ]. Cross clamp time was 36 minutes. She also had a CSF drain placed at that point. She tolerated this procedure well and was transferred to the CSRU in stable condition on propofol and nitro and insulin. On postop day 1 she was doing well. She woke up and moved everything. She was thought to not have a good pulse on the left femoral artery, but an ultrasound revealed good flow, no pseudoaneurysms and no hematoma. She also had some left lower lobe collapse on her x-ray and she was bronched on postop day 1 and had a lot of secretions. Her lung reexpanded well. We continued to try to wean her from the vent and give her aggressive respiratory therapy, and she also required a lot of aggressive diuresis, which she tolerated well. She continued to be attempted to be weaned and, on postop day number 5, her chest tubes were discontinued. On postop day 6 her intrathecal catheter was discontinued. She continued to be weaned. Also, her creatinine increased to 3.4 on postop day number 6, and she was followed by Renal. Renal ultrasound was normal and she had nonoliguric ATN, so she was just followed for that and continued to be diuresed. She was extubated on postop day 6. She required aggressive neb treatments and BI-PAP for the first day. On postop day 7 she also required intermittent BI-PAP but eventually improved and so required aggressive respiratory therapy. Remained in the unit for respiratory therapy and continued to slowly improve. She did also require steroids. Her extubation was followed by Interventional Pulmonology and she did have some exacerbations of her respiratory distress. She also went into atrial fibrillation several times, which she did not tolerate. This caused her to have respiratory distress. She was started on Amiodarone. She was followed by Electrophysiology for this. She also then had hoarseness and was seen by Speech and Swallow, who felt she could eat fine except she aspirated when she used a straw. Electrophysiology followed her and also added Diltiazem for her atrial fibrillation. She was seen by ENT. One cord is paralyzed. Her right vocal cord is sluggish and they said if she does not improve with her hoarseness, she could follow up with Dr. [Last Name (STitle) ] and he may inject her right vocal cord for medialization. She was transferred to the floor on postop day number 18. She continued to progress with aggressive respiratory treatment. She did have another bout of atrial fibrillation and converted on her own, but she does not tolerate it well, and she was discharged to Rehab on postop day number 22 in stable condition. DISCHARGE LABORATORY DATA: White count 11,600, hematocrit 27.2, platelets 247,000, sodium 140, potassium 3.8, chloride 102, CO2 30, BUN 26, creatinine 1.0, blood sugar 86, INR of 2.8. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Lasix 20 mg p.o. b.i.d. for 10 days 3. Zantac 150 mg p.o. b.i.d. while she is on steroids 4. Percocet 1 to 2 p.o. q.4 to 6h p.r.n. pain 5. Tylenol p.r.n. 6. Amiodarone 400 mg p.o. q. day for 7 days then decrease to 200 mg p.o. q. day for four weeks 7. Vitamin A 25,000 units p.o. q. day 8. Zinc sulfate 220 mg p.o. q. day 9. Albuterol nebs q.6h 10. Atrovent nebs q.6h 11. Aspirin 81 mg p.o. q. day 12. Diltiazem 240 mg p.o. q. day Sustained Release 13. Potassium 20 mEq p.o. q. day for 10 days 14. Advair Diskus 1 puff b.i.d. 15. Prednisone 20 mg p.o. q. day for 2 days and then decrease to 10 mg p.o. for 3 days and then discontinue 16. Coumadin 0.5 mg p.o. q. day once the INR is less than 2.5, titrate for an INR goal of 2 to 2.5 DISCHARGE DIAGNOSES: Thoracoabdominal descending aortic aneurysm and dissection Chronic obstructive pulmonary disease Atrial fibrillation Prolonged ventilation FO[Last Name (STitle) 996]P: She will follow up with Dr. ________ in 1 to 2 weeks, Dr. [Last Name (STitle) 55786] in 2 to 3 weeks, Dr. [Last Name (STitle) ] in 4 weeks, Dr. [Last Name (Prefixes) ] in four weeks, and Dr. [Last Name (STitle) ] of ENT in two weeks if hoarseness does not improve. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) 18588] MEDQUIST36 D: [2173-9-16] 10:49:53 T: [2173-9-16] 12:18:37 Job#: [Job Number 55787]	[ "5180", "5845", "42731", "2762", "51881" ]
Admission Date: [2169-1-19] Discharge Date: [2169-1-21] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: Severe mitral valve disease and CHF Major Surgical or Invasive Procedure: Cath with stent to left carotid. History of Present Illness: 82 yr old male w/severe mitral valve disease, CAD (cath on [2168-10-21] done d/t chf: 70% ramus, 40% d1, 80% CX, 80% RCA, EF=60%), HTN, dCHF, hyperchol, endocarditis x 2 complicated by stroke 2 yrs ago, bleeding duodenal ulcer/PUD. Pt had recent carotid ultrasound that showed significant left sided stenosis (report not available). Pt presents for a preop carotid angio and possible stenting for a cabg/mv repair scheduled for [2169-1-23]. Past Medical History: -MVR -CAD (cath on [2168-10-21] d/t chf: 70% ramus, 40% d1, 80% CX, 80% RCA) -HTN -HYPERCHOL -ENDOCARDITIS x 2 ([2164], [2166], second one complicated by stroke), both beta hemolytic streptococci, 500 mg twice daily since [2166], ampicillin prophylaxis for all dental work. -BLEEDING DUODENAL ULCER/PUD, helicobacter antibody positive -STROKE secondary to endocarditis [2166] -PROSTATE CA [2158] s/p surgery Social History: Married. lives with wife. Pt was a [Doctor Last Name 9808] operator. smoked [12-18] ppd 15-20 years, stopped when he was 40 y/o. drinks a glass of wine per wk to mo. no drugs. Family History: parents lived into 90s. brother still living. sister dies at age 80 of stroke. Physical Exam: VITALS: 98.6, 140/72, 72, 20 GEN: sitting at side of bed, talkative, nad HEENT: mmm, no lad, supple, no elevated JVP, no JVD, carotid bruit on right CV: rrr, nl s1/diminished s2, [2-19] holosystolic murmur best appreciated at apex, but radiating throughout precordium, no r/g PULMO: CTAB ABD: BS+, soft, NT, ND EXT: 1+ LE edema on right, 1+ DP/PT, warm Pertinent Results: MR [Name13 (STitle) 430]: There is an old infarct in the right cerebral hemisphere, posteriorly, mostly involving the inferior right parietal lobe, but also involving the contiguous posterolateral temporal lobe and far anterolateral occipital lobe, most likely within the right MCA territory. Microvascular changes in the cerebral white matter and old lacunes are also noted. MRA Head: There is no evidence of a significant stenosis. Carotid Cath: 1. Severe [Doctor First Name 3098] disease. 2. Moderate [Country ] disease. 3. Stenting of the [Doctor First Name 3098]. 4. Perclose of the groin. Brief Hospital Course: Mr. [Known lastname 3461] is an 82 y/o M w/ PMH of severe MR, CAD, endocarditis, CVA presenting for carotid angio/stenting prior to CABG/MV repair. CAROTID STENOSIS: Pt underwent cath and stenting of left carotid on [2169-1-20]. He was admitted to the CCU post-procedure, where he remained stable with a good blood pressure overnight. He was discharged home on Plavix and Aspirin. MR: Pt has severe by echo and exam. MR [Name13 (STitle) 60009] on Tuesday CHF: Pt euvolemic during admission on Furosemide 40 mg PO DAILY CAD: CABG on Tuesday with MR repair. Pt continued on outpt Lisinopril 5mg [Hospital1 ] and ASA 81mg qd. H/O BLEEDING DUODENAL ULCER/PUD: Pt started on Protonix. Consider breath test and treat appropriately for H. pylori if positive H/O ENDOCARDITIS: No active issues. Standing Penicillin was stopped per ID. Medications on Admission: Furosemide 40 mg PO DAILY Lisinopril 5 mg PO BID Aspirin 81 mg PO DAILY Penicillin 250 mg [Hospital1 ] KCl 10 mg QD Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:30 Tablet(s) Refills:2 4. 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 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Discharge Disposition: Home Discharge Diagnosis: Left Carotid Stenosis s/p Stent Placement Discharge Condition: Pt was in good condition with stable vital signs. Discharge Instructions: Please continue taking your medications as prescribed. Plavix was added to keep your stent open. Protonix was added for your ulcer. Call your doctor or return to the hospital if you experience bleeding, pain in your leg, chest pain, shortness of breath, visual changes, limb weakness, change in mental status. Followup Instructions: Return to the hospital on Tuesday for your heart surgery.	[ "4240", "4280", "41401" ]
Admission Date: [2153-12-6] Discharge Date: [2153-12-8] Service: [Hospital Unit Name 196] HISTORY OF THE PRESENT ILLNESS: Mrs. [Known lastname ] is an 84-year-old female with a past medical history significant for coronary artery disease, status post one vessel CABG in [2147], status post MI in [2149], status post aortic valve replacement, with atrial fibrillation, status post cardioversion times three, CHF with ejection fraction of 55%, who presented to the [Hospital6 1760] for elective cardioversion. The patient had a recent admission in [2153-10-8] for CHF and atrial fibrillation. At that time, she was started on anticoagulation with Coumadin and Amiodarone. The patient presented to [Hospital1 18] for admission in [2153-11-7] for left facial droop and slurred speech with evaluation significant for a negative head CT and carotid Dopplers. The patient was discharged to [Hospital3 ] and returns today for elective cardioversion. On arrival to the [Hospital6 256], she was noted to be hypotensive with systolic blood pressure in the 80s and a heart rate in the 70s, in atrial fibrillation. She was asymptomatic at the time. She received 150 cc of normal saline with an increase in her systolic blood pressure to the 90s. Oxygen saturation was 80% on room air and 100% on 2 liters nasal cannula. Her DC cardioversion was uneventful and she returned to sinus rhythm. Currently, the patient denied any lightheadedness, chest pain, shortness of breath, nausea, vomiting, palpitations, diaphoresis, or radiating pain. She has no recent fevers, chills, or night sweats. No abdominal pain, no cough. She does note pain at the site of her sternotomy which has been ongoing for three or more years. There is an erythematous area that she notes is improving in the last three to four months. CT Surgery evaluated the patient in the holding area of the Catheterization Laboratory and recommended sternal wire revision. The patient was admitted to the Cardiology Floor for monitoring due to her postprocedure hypotension and for heparinization while her INR came down so that she could have sternal wire revision procedure on Monday with a normal INR. PAST MEDICAL HISTORY: 1. Atrial fibrillation, status post cardioversion times three. 2. Coronary artery disease, status post MI, status post one vessel CABG in [2147]. 3. Status post aortic valve replacement. 4. Status post pacemaker in [2151-8-8]. 5. Status post bilateral breast cancer, status post right lumpectomy and XRT in [2139] and radical left mastectomy in [2146]. 6. Congestive heart failure with an ejection fraction of 55% on an echocardiogram in [2153-10-8]. 7. Hypertension. 8. TIA. 9. Status post TAH/BSO. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Coumadin 2.5 mg q.d. 2. Amiodarone 200 mg q.d. 3. Aspirin 325 mg q.d. 4. Lasix 60 mg q.d. 5. Atenolol 50 mg q.d. SOCIAL HISTORY: The patient is widowed and lives at the Alzheimer's Home. She denied any alcohol use and states that she quit smoking at the age of 50. FAMILY HISTORY: Positive for ovarian cancer. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile with a pulse of 68, blood pressure 96/40, respirations 18, oxygen saturation 100% on 2 liters. General: She was a frail-appearing female in no acute distress responding to all questions appropriately. The examination was significant for a dry oropharynx, JVP at 8-9 cm with prominent EJ pulsations, rales in the lungs present a third of the way up the left lung field posteriorly with decreased breath sounds in the right lung field a third of the way up posteriorly. No dullness to percussion. Moderate air movement. Heart: Regular with a I/VI systolic ejection murmur heard at the left upper sternal border. Abdomen: Benign. Extremities: Warm with 2+ pitting edema bilaterally from the feet to the knees. Skin: Notable for prominent sternotomy wires and an area of erythema and warmth over the third sternal wire and extreme tenderness to touch over all sternotomy wires. LABORATORY/RADIOLOGIC DATA: Significant for a hematocrit of 42, platelets 172,000 and an INR of 1.9. EKG showed atrial pacer spikes and a rate of 69 beats per minute with left bundle branch block. HOSPITAL COURSE: The patient was admitted to the Cardiology Service. 1. STERNOTOMY SITE INFLAMMATION: The CT Surgery Service was consulted and felt that the sternotomy site inflammation was not due to infection but was due to erosion of the skin over the wire. They were not able to see the patient on Monday and, therefore, suggested arranging an outpatient appointment for her at a further date. It was, therefore, decided that the patient would go home on her Coumadin and remain on Coumadin for three weeks in order to prevent increased stroke risk during the three weeks after cardioversion and will follow-up with CT Surgery for sternotomy wire revision at a later time once she is no longer in the window of increased stroke risk after cardioversion. The patient was, therefore, discontinued from her heparin and restarted on her Coumadin doses. 2. ATRIAL FIBRILLATION: The patient remained in sinus rhythm with rates between 68 and 100 beats per minute with no events other than one run of three minutes of ventricular tachycardia which was asymptomatic. Other than that, telemetry was uneventful. The patient was continued on her Coumadin with a goal INR of [3-11].5. 3. HYPOXIA: After diuresis with Lasix and Diuril, the patient's oxygen saturation improved. She was continued on diuresis. 4. CORONARY ARTERY DISEASE: The patient was continued on her aspirin, beta blocker, and statin. 5. BLOOD PRESSURE: The patient was hypotensive postprocedure with blood pressures as low as 70 systolic. She received 1 liter of fluids and still appeared dry with low blood pressures in the 80s to 90s systolic. She was, therefore, transfused with packed red blood cells in order to increase her intravascular volume and minimize the fluid to her periphery as it was deemed that she was intravascularly depleted but total volume overloaded. 6. LEFT LOWER EXTREMITY EDEMA: The patient was given pressure stockings which decreased the edema in her feet; however, there was still 2+ edema in her legs. She was continued on her Lasix and Zaroxolyn. 7. HEMATOLOGY: The patient's hematocrit decreased to 29 on the second day of admission. Therefore, she was transfused 2 units of packed red blood cells with Lasix in between. DISPOSITION: The patient was discharged to [Hospital3 1761] Center. She will return to see Dr. [Last Name (STitle) 952] as an outpatient in four weeks for sternal wire revision. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To [Hospital3 ] Center. DISCHARGE DIAGNOSIS: 1. Atrial fibrillation. 2. Hypotension. 3. Anemia. DISCHARGE MEDICATIONS: 1. Metoprolol 25 mg p.o. b.i.d. 2. Aspirin 325 mg p.o. q.d. 3. Colace 100 mg p.o. b.i.d. 4. Simvastatin 20 mg p.o. q.h.s. 5. Warfarin 2.5 mg p.o. q.h.s. 6. Metolazone 2.5 mg p.o. b.i.d. 7. Amiodarone 200 mg p.o. q.d. 8. Furosemide 40 mg p.o. b.i.d. FOLLOW-UP: The patient is to follow-up with Dr. [Last Name (STitle) 952] in four weeks for sternal wire revision. Call [Telephone/Fax (1) 170] for an appointment. The patient is to stop taking her Coumadin one week before her appointment for sternal wire revision. The patient is to have her INR checked daily and the results sent to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007]. The patient is to follow-up with Dr. [Last Name (STitle) 73] in one to two weeks. [Doctor First Name 900] [Name8 (MD) 901], M.D. [MD Number(1) 2144] Dictated By:[Last Name (NamePattern1) 5615] MEDQUIST36 D: [2153-12-7] 06:50 T: [2153-12-7] 19:21 JOB#: [Job Number 21017] cc:[Last Name (NamePattern4) 21018]	[ "42731", "4280", "5849", "412" ]
Admission Date: [2131-9-23] Discharge Date: [2131-9-25] Date of Birth: [2060-9-5] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 1115] Chief Complaint: Chief Complaint: "Droop" . Reason for MICU transfer: DKA Major Surgical or Invasive Procedure: None History of Present Illness: 71 year old female w/ diabetes, htn, on ASA/plavix p/w experssive aphasia x 2-3 days brought back by EMS after being signed out AMA earlier today. earlier today she had been evaluated for aphasia which neurology thought at that time not to be an acute neurological problem. However patient was found to be hyperglycemic to FSBG 440. She has had similar presentations in the past, seen by neuro and attributed to hyperglycemic episodes. Now, pt states her speech is more garbled than normal and her daughter also noticed the same over the telephone. Denies HA, cp/sob, numbness, weakness, tingling, gait problems or other symptoms. . In the ED, initial vitals were 99.4 108 124/46 22 99%. Physical exam showed no clear neuro deficits and patient had a fluctuating level of consciousness. Labs were significant for a glucose of 705 and 136/4.4/99/17/31/1.1 . Seen earlier today for expressive aphasia by neurology who felt unlikely to be stroke. Hyperglycemia with waxing/[Doctor Last Name 688] consciousness but she left AMA. Now BS 700's with AG. No insight into medical condition currently. 8 SC regular insulin and then on insulin drip. Clear CXR. No other symptoms. Given 2L IVF. Past Medical History: --HTN --hyperlipidemia --DM Type 1 ([First Name8 (NamePattern2) ] [Last Name (un) ] notes): has had problems with hypoglycemia unawareness, last HgbA1C 10.8 in [10-26], missed last [Last Name (un) ] appointment [2128-3-4] --CAD: [11-21] cath:LAD stent [2-22] cath: LAD stent with 95% instent restenosis, successful ptca [10-22]: cath LAD stent widely patent, 50% L cx lesion, RCA diffusely diseased to 60% Per Dr. [Last Name (STitle) ] [1-23] discussion - will need to stay on plavix indefinitely. [5-25] ETT MIBI: EKG changes and some throat tightness, mod inf wall ref defect. Per Dr. [Last Name (STitle) ], [First Name3 (LF) ] continue medical management of CAD. --?TIA: admitted for dysarthria in [2124], MRI/MRA brain normal, EEG w/ no epileptiform activity --glaucoma of right eye --prosthetic left eye Social History: Lives with her husband who she cares for. In the past (per OMR) she denies cigarette smoking and illicit drug use. She had drunk EtOH daily but had not for many years. She reportedly has lost significant weight [2-21] husband's illness Family History: Family history is negative for strokes, seizures, or peripheral nerve palsies. Diabetes is present in her sister and aunt. [Name (NI) ] sister also had stomach cancer. Physical Exam: Admission Physical Exam: Vitals: Tcurrent: 37.5 ??????C (99.5 ??????F), HR: 102, BP: 155/70(91) mmHg, RR: 22 insp/min, SpO2: 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, III/VI holosystolic murmur heard best LUSB, 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 . Exam on Discharge: VS: 97.7, 110/52, 62, 14, 100% RA General: AAOx3, in NAD HEENT: MMM, PEERLA Lungs: CTAB, no wheezes, rales or rhonchi Cardiac: RRR, 3/6 systolic mumur heard best at LUSB radiating to the carotids. NO rubs or gallops Abdomen: soft, nontender, nondistended Extremities: Warm, well perfused, 2+ DP pulses bilaterally, no edema. Neuro: CN II-XII intact, 5/5 strength in UE bilaterally and lower extremities bilaterally. Gait stable. Pertinent Results: Images: . [2131-9-23] CTA Head/neck: No hemorrhage large territorial infarct or acute process on non-contrast scan. Small vessel ischemic changes. CTA and perfusion imaging in progress. [2131-9-23] CT head w/o contrast: No acute intracranial process. [2131-9-23] CXR: Limited study with low lung volumes, but otherwise no acute pulmonary process noted. EKG: NSR, poor R wave progression TTE [2131-9-25] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. There is moderate (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. 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. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Labs on Admission: [2131-9-22] 05:15PM BLOOD WBC-10.7# RBC-4.49 Hgb-12.7 Hct-37.8 MCV-84 MCH-28.2 MCHC-33.5 RDW-13.0 Plt Ct-274 [2131-9-22] 05:15PM BLOOD Neuts-81.5* Lymphs-14.0* Monos-3.6 Eos-0.7 Baso-0.2 [2131-9-22] 05:15PM BLOOD UreaN-27* Creat-1.1 [2131-9-22] 05:19PM BLOOD Type-[Last Name (un) ] pH-7.41 Comment-GREEN-TOP [2131-9-22] 05:19PM BLOOD Glucose-460* Lactate-1.9 Na-142 K-4.8 Cl-99 calHCO3-27 [2131-9-22] 05:19PM BLOOD freeCa-1.20 Labs on Discharge: [2131-9-25] 06:30AM BLOOD WBC-6.4 RBC-3.94* Hgb-11.3* Hct-32.9* MCV-84 MCH-28.8 MCHC-34.5 RDW-12.7 Plt Ct-205 [2131-9-25] 06:30AM BLOOD Neuts-51.3 Lymphs-39.7 Monos-6.3 Eos-2.4 Baso-0.3 [2131-9-25] 06:30AM BLOOD Glucose-282* UreaN-13 Creat-0.6 Na-139 K-4.3 Cl-103 HCO3-29 AnGap-11 [2131-9-25] 06:30AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0 Pertinent labs: [2131-9-23] 05:50AM BLOOD ALT-22 AST-19 LD(LDH)-246 CK(CPK)-208* AlkPhos-140* TotBili-1.2 [2131-9-23] 01:50AM BLOOD cTropnT-<0.01 [2131-9-23] 05:50AM BLOOD CK-MB-4 cTropnT-<0.01 [2131-9-23] 08:27AM BLOOD VitB12-1060* [2131-9-23] 05:50AM BLOOD TSH-0.88 [2131-9-23] 08:27AM BLOOD Ethanol-NEG [2131-9-23] 05:50AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2131-9-23] 06:11AM BLOOD Type-ART Temp-37.3 Rates-/18 FiO2-20 pO2-84* pCO2-34* pH-7.44 calTCO2-24 Base XS-0 Intubat-NOT INTUBA [2131-9-23] 06:11AM BLOOD Glucose-311* Lactate-1.1 Na-146* K-3.9 Cl-109* Microbiology: [2131-9-22] URINE CULTURE (Final [2131-9-25]): GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. [2131-9-23] RAPID PLASMA REAGIN TEST (Final [2131-9-25]): NONREACTIVE. Reference Range: Non-Reactive. Brief Hospital Course: 71 y/o F w/ CAD, HTN, TIA, HLD presenting to ED w/ AMS and glucose of 704 and found to be in DKA. #DKA: On presentation to the ED, FSBG 705 with 40 ketones/1000 glucose in urine. She was admitted to the ICU where she was aggressively given IVF for hypovolemia, repleted with potassium, and contiued on insulin drip + dextrose until her anion gap was within normal limits at which time the patient was given her usual basal dose of 15U humalog and put onto lantus sliding scale. She was transferred to the floor where she seen by [Hospital1 ] physicians who helped in adjusting her sliding scale. After one day on the floor her BS were under better control. She no longer had a gap and was tolerating PO. It is unknown what the percipiting event for this patient's DKA was. CXR clear, WBC wnl, U/A clean. LFTs/trop/lipase unremarkable. Now with leukocytosis this AM and low grade fever, but still no clear source of infection. Patient endorses full compliance with home insulin regimen. After discharge, it was noted on her Microbiology results that she had 10,000 GPC in her urine culture. Her UA was negative for infection; suspect colonization or contamination. As she denied any dysuira or urinary symptoms and had a negative UA she was not treated inpatient for a UTI, and was afebrile throughout her stay. She will follow up with PCP [Last Name (NamePattern4) ] [2131-9-28]. #Neuro/Aphasia/Altered Mental Status: Upon presentation, the patient had an expressive aphasia in which she was unable able to follow commands but would answer questions inappropriately and with repetitive words and phrases. Altered mental status likely [2-21] to hyperglycemia as it has markedly improved now with decrease in glucose. NCHCT shows no acute infarct/hemorrhage. Her CTA was negative at the time of discharge. As her blood sugars were brought under control her speech improved. Neurology was consulted when she was in the emergency room and felt that this was most likely due to her hyperglycemia. #Leukocytosis: The patient did have a transient leukocytosis of 15.9 which resolved at time of admission which was thought to be a result of stress response. #Pulmonary HTN: A TTE was performed to evaluate finding concerning for pulmonary hypertension including loud [3-25] systolic murmur at LUSB, large R pulmonary artery on CXR, and poor R wave progression on EKG. The findings were consistent with previous TTE, and did not require any further interventions during this admission. #Chronic Issues: Patient was continued on home medications amlodipine 5 mg, isosorbide mononitrate 30 mg, lisinopril 40 mg, and metoprolol 25mg for hyptertension, atorvastatin 40 mg for hyperlididemia, aspirin 325 mg/clopidogrel 75 mg for vasculopathy. Transitional Issues: Patient has follow up with a certified diabetes educator at 2pm on [2131-9-27] at [Hospital1 ] Patient has follow-up with her PCP [Last Name (NamePattern4) ] [9-28] Pending tests- [2131-9-22]- Blood culture- PENDING -Sliding scale was changed, and she was increased to 16U Lantus qhs per [Hospital1 4087] -Patient was found to have positive urine culture after discharge. This will need to be addressed by her PCP [Last Name (NamePattern4) ] [9-28] whether or not she needs treatment as she is asymptomatic. Medications on Admission: Medications: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth daily CLOPIDOGREL [PLAVIX] - 75 mg Tablet - one Tablet(s) by mouth once a day no substitutions - No Substitution INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin Pen - 16 units at bedtime 3 month supply INSULIN LISPRO [HUMALOG KWIKPEN] - 100 unit/mL Insulin Pen - take per sliding scale qid up to 64 units per day ISOSORBIDE MONONITRATE [IMDUR] - 30 mg Tablet Extended Release 24 hr - one Tablet(s) by mouth daily LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day . Medications - OTC ASPIRIN - (OTC) - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - use as directed four times a day and as needed LANCETS,THIN - Misc - USE AS DIRECTED FOUR TIMES A DAY ONE TOUCH ULTRA SYSTEM - Kit - AS DIRECTED FOR TESTING BLOOD SUGAR Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Sixteen (16) Subcutaneous at bedtime. 9. insulin lispro 100 unit/mL Insulin Pen Sig: please take per sliding scale Subcutaneous four times a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: DKA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 102927], It was a pleasure taking care of you while you were admitted here at [Hospital1 18]. You were brought into the hospital for concern that your speech was not making sense and that you might be having a stroke. You were found to have an elevated blood sugar of 704. Neurology saw you and felt that these symptoms were from your elevated blood sugar and not from a stroke. As your blood sugar improved your speech improved to normal. You were admitted to the intensive care unit for diabetic ketoacidosis which can be a life threatening condition when your blood sugar gets too high. After your condition improved and was no longer critical you were transferred to the general medical floor and we continued to monitor your blood sugars and blood tests. You were tolerating eating and drinking well at the time of discharge and able to walk around well. We were unable to figure out why you had such high blood sugars (sometimes it can be caused by infections or not taking medications however you did not have anything on our workup to indicate you have an infection). Transitional issues: Your blood sugars have been high and need to be checked while you are at home. - Check your blood sugar 4 times per day, pre-breakfast, pre-lunch, pre-dinner, post-dinner. The following changes were made to your insulin treatment plan while you were here (per [Hospital1 ]). 1.We increased your nighttime lantus to 16U 2.Your sliding scale should be as follows (see attached sheet to use for your sliding scale) Comments: IF BLOOD GLUCOSE < 150 AT BEDTIME HAVE 4 PEANUT BUTTER CRACKER SNACKS. If skip meal but BG over 250 - take 1/2 dose Humalog -Please continue to take all of your other medications as directed. Appointments: It is very important that you make your follow-up appointment with your primary care doctor [First Name8 (NamePattern2) ] [9-28]. [2131] -We made an education appointment for you at [Hospital1 ] so that you can go over your new treatment plan after you have been discharged from the hospital- this is on Thursday [2131-9-27] -Pending tests- blood culture [2131-9-23]- still pending Followup Instructions: [Hospital6 30927] Appointment with Certified Diabetes Educator Thursday [9-27]. [2131] at 2pm At [Hospital6 30927] Department: [Hospital3 249] When: FRIDAY [2131-9-28] at 10:50 AM With: [First Name4 (NamePattern1) 1060] [Last Name (NamePattern1) 1520], MD. [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [Name10 (NameIs) 616*] this visit, you will see your regular primary care doctor in follow up.	[ "V5867", "4019", "2724", "41401", "V4582" ]
Admission Date: [2177-7-4] Discharge Date: [2177-7-10] Date of Birth: [2096-8-17] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 14802] Chief Complaint: Right SDH Major Surgical or Invasive Procedure: None History of Present Illness: 80M sent in for elevated INR. Patient is unsure why he takes coumadin, but has pig valve and pacer in place. INR at PCPs office was 6.5 today and was sent in for reversal given history of recent falls. INR 8.7 on arrival today. Patient denies any increased bleeding. No CP/SOB. No f/c. No abdominal pain. Patient is a relatively poor historian Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. Seizure disorder ([Doctor Last Name 11332] mal seizures have not occurred for many years; complex partial seizures with behavior patterns have not occurred for 1-2 years) 4. Sick sinus syndrome ([Company 1543] pacemaker placed on right side; interrogated [7-/2176]) 5. s/p mitral valve repair with MAZE procedure (atrial fibrillation) complicated by total occlusion of coronary artery - artery over-sewn during procedure and resulting CABG (RSVG from aorta to OM2) x 1-vessel and left femoral artery pseudoaneurysm (with thrombin injection). 6. Bilateral foot drop (resulting from coronary bypass surgery) 7. Left anterior wall acetabular fracture ([2175]) 8. Prostate adenocarcinoma 9. Colonic adenoma 10. Rheumatoid arthritis 11. Chronic anemia 12. Gout 13. Prior subdural hematoma (required Burr hole placement) 14. Lichen simplex chronicus Social History: Patient lives at home with his wife (has previously been at [Name (NI) 1188] [Last Name (NamePattern1) ]). Has one adult child. Retired mechanical engineer. Denies tobacco use or alcohol use; no recreational substance use. Family History: non-contributory. Physical Exam: On Admission: O: T: 98.8 BP: 119/68 HR: 80 R 18 O2Sats 97% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3->2 EOMs: intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-17] throughout except RUE 5-. Mild L pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: Normal bilaterally Toes downgoing bilaterally Handedness Right On discharge: Oriented to Person and place but not date. Motor exam intact. Pertinent Results: Head CT [7-4] New acute/subacute subdural hematoma overlying the right frontoparietal convexity. Previously seen small left frontal subdural hematoma is unchanged. New small subgaleal hematoma overlying the right vertex. No fractures seen. CT C/T spine [7-4] Nondisplaced acute compression fracture of T1. CT Head [7-5] Stable appearance of right frontoparietal and left frontal subdural hematomas with no new foci of hemorrhage. Stable subgaleal hematoma overlying the vertex. Brief Hospital Course: Pt was admitted to the neurosurgery service. Orthopedics was consulted for a T1 fracture and they felt it was not acute and needed no intervention. His coumadin was held and he was given FFP and vitamin K to reverse his INR and it normalized to 1.3 on [7-6]. He had a repeat CT head on [7-5] that showed no new hemorrhage and remained stable. He did become somewhat aggitated and required restraints on the evening of [7-5]. Social work was consulted per wife's request as she has been finding it difficult to care for him at home and to discuss her options of nursing facilities. On [7-7], patient remained stable. PT/OT was consulted and atrius was called to help move him forward to a nursing home facility. On [7-8], patient became slightly agitated and disoriented however this delerium began to clear the following day and he became more cooperative during the remainder of his hospital stay. At the time of discharge on [7-10] he was tolerating a diet, ambulating with a walker, afebrile with stable vital signs. Medications on Admission: amiodarone 200 mg Tab 2 Tablet(s) by mouth twice a day Please take 2 200mg tablets twice daily for 5 days. Then 1 200mg tablet twice daily for 7 days. Then 1 200mg tablet once daily until stopped by cardiologist. ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth DAILY (Daily) ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) calcium carbonate 500 mg calcium (1,250 mg) Chewable Tab 3 Tablet(s) by mouth twice a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) cholecalciferol (vitamin D3) 1,000 unit Tab 1 Tablet(s) by mouth DAILY (Daily) ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) digoxin 125 mcg Tab 1 Tablet(s) by mouth once a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) fluoxetine 10 mg Cap 1 Capsule(s) by mouth once a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) furosemide 20 mg Tab 1 Tablet(s) by mouth twice a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) glucosamine HCl 500 mg Tab 1 Tablet(s) by mouth once a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) levothyroxine 25 mcg Tab 1 Tablet(s) by mouth once a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) metoprolol tartrate 25 mg Tab 1 Tablet(s) by mouth twice a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) metronidazole 500 mg Tab 1 Tablet(s) by mouth three times a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) multivitamin Tab 1 Tablet(s) by mouth once a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) nystatin 100,000 unit/mL Oral Susp 5 ml by mouth four times a day swish and swallow ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) omeprazole 20 mg Cap, Delayed Release 1 Capsule(s) by mouth DAILY (Daily) ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) phenytoin sodium extended 100 mg Cap 1 Capsule(s) by mouth once a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) potassium chloride ER 20 mEq Tab, Particles/Crystals 1 Tablet(s) by mouth once a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) pravastatin 40 mg Tab 1 Tablet(s) by mouth once a day ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) tamsulosin ER 0.4 mg 24 hr Cap 1 Capsule(s) by mouth HS (at bedtime) ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) warfarin 1 mg Tab [1-13] Tablet(s) by mouth once a day Adjust for a goal INR of [2-13].5 for atrial fibrillation. Coumadin held [11-13] d/t INR of 2.9. ([First Name8 (NamePattern2) 5877] [Last Name (NamePattern1) ] [2177-7-4] 20:23) Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 1500 mg PO BID 4. Digoxin 0.125 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Fluoxetine 10 mg PO DAILY 7. Heparin 5000 UNIT SC TID 8. Levothyroxine Sodium 25 mcg PO DAILY 9. Metoprolol Tartrate 37.5 mg PO BID Please use IV meds if patient refused pills. Goal SBP<140 10. Phenytoin Sodium Extended 100 mg PO TID 11. Pravastatin 40 mg PO DAILY 12. Senna 1 TAB PO HS 13. Tamsulosin 0.4 mg PO HS 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1820] [Last Name (NamePattern1) ] Discharge Diagnosis: Subdural hematoma Confusion Agitation Chronic T1 compression fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen etc. ?????? Do not Resume Coumadin until follow up and discussion with your Neurosurgeon, Dr. [Last Name (STitle) ]. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ], to be seen in _4_weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [First Name (STitle) ] in the Traumatic Brain Injury (TBI) clinic the phone number is [Telephone/Fax (1) 6335]. If you have any problems booking this appointment please ask for [First Name8 (NamePattern2) 16367] [Last Name (NamePattern1) 16368]. Completed by:[2177-7-10]	[ "V5861", "4019", "2724", "2859" ]
Admission Date: [2199-7-24] Discharge Date: [2199-9-12] Date of Birth: [2139-6-17] Sex: M Service: NEUROSURGERY Allergies: Morphine Sulfate Attending:[First Name3 (LF) 78] Chief Complaint: IPH Major Surgical or Invasive Procedure: [2199-8-21]: PEG placement History of Present Illness: 60 yo old male with unknown history found in his car unresponsive. Was brought to OSH and was not following commands, aphasic, and hypertensive at 198/126. CT demonstrated IPH. Patient was given 20 mg of Labetalol and loaded with 1 gram of phosphenytoin and transfered to [Hospital1 ]. upon arrival here his BP was 160/90. He was given 4 mg of MS and went into bradycardia down to 43 and BP fell to 70/43. Patient was given 0.5 mg of atropine and pressures returned to 131/83. Patient remained saturating 95%. Past Medical History: gout, ETOH Social History: ETOH Family History: unknown Physical Exam: On Admission: O: T:98.2 BP: 160/90 HR:82 R18 O2Sats 95% Gen: comfortable, NAD. HEENT: Pupils: 4->3 BL Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, not following commands, Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 3 mm bilaterally. Visual fields are full to confrontation. No gross visual field cut III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: mile VIII: unable to assess IX,X, [Doctor First Name 81], XII:unable to asses. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-3] throughout. No pronator drift Sensation: withdraws all 4 extremities Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 crossed adduction toes upgoing on the right. Down on Left Coordination: unable to assess PHYSICAL EXAM UPON DISCHARGE: Alert, interactive, oriented to himself and place. [Last Name (LF) 2994], [First Name3 (LF) 2995]. Ambulating steadily. On discharge: Patient awake and alert, generally oriened to self and place, disoriented to time. Expressive aphasia, some receptive aphagia. Ambulates with good strength and balance with minimal assistance. Pertinent Results: CTA HEAD W&W/O C & RECONS [2199-7-24] 1. Intracranial hemorrhage in the left frontoparietal lobe having mass effect on the left lateral ventricle, change is difficult to ascertain between the prior study three hours ago due to differences in technique, but the hemorrhage may be slightly larger on this study. 2. Punctate area of high attenuation anterior to the primary hemorrhage, which may represent a secondary subarachnoid hemorrhage or a thrombosed vein. 3. No stenosis, occlusion or aneurysm seen on CT. Underlying mass lesion cannot be ruled out by this study. CT HEAD W/O CONTRAST [2199-7-26] 1. Unchanged appearance of intraparenchymal hemorrhage in the left frontoparietal lobe and mass effect on the left lateral ventricle. 2. Punctate area of high attenuation anterior to the primary hemorrhage which may represent secondary subarachnoid hemorrhage or thrombosed vein. 3. Non-contrast CT is unable to determine if there is an underlying mass lesion. CT Head [7-29]: IMPRESSION: Stable size and appearance of large left frontal intraparenchymal hemorrhage with surrounding edema. No new areas of intracranial hemorrhage or increased mass effect. MRI Head [7-29]: IMPRESSION: 1. Multiple chronic, superfically located cerebral microhemorrhages, which could be related to unusual early-onset amyloid angiopathy or multiple cavernomas. While it is unusual for numerous cavernomas to spare the deeper cerebral structures, the presence of two developmental venous anomalies favors the diagnosis of cavernomas. The left frontal cerebral hematoma is likely caused by the same process as these chronic microhemorrhages. 2. Linear rim of enhancement surrounding the left frontal hematoma is likely related to granulation tissue. Follow-up to resolution is recommended. 3. Edema or fluid adjacent to left atlanto-occipital joint may represent ligamentous injury. Recommend CT of the cervical spine to evaluate for a fracture. 4. No evidence of arteriovenous malformation or arterial aneurysm. [2199-7-31] Chest Xray: FINDINGS: As compared to the previous radiograph, the patient has received a Dobbhoff tube. The tube should be advanced by approximately 10 cm, the tip of the tube now projects over the gastroesophageal junction. [2199-8-2] Xray: IMPRESSION: Successful replacement of a Dobhoff tube with an 8-French [Location (un) 2174]-[Doctor First Name 1557] nasointestinal tube in the third part of the duodenum. [2199-8-3] Xray: Dobbhoff tube reaches the fourth portion of the duodenum but is coiled back and the tip is not clearly visualized. Recommended new film without respiratory motion for better evaluation of the tip of the Dobbhoff tube. [2199-8-4] Xray: FINDINGS: The feeding tube tip is at the fourth portion of the duodenum. [8-9] Cerebral Angiogram: IMPRESSION: [Known firstname ] [Known lastname ] underwent cerebral arteriography which failed to reveal any evidence of aneurysm, ateriovenous malformation or AV fistula. [8-15] EEG: IMPRESSION: This EEG monitoring showed a mildly slow background rhythm indicative of an encephalopathy. There were no areas of prominent focal slowing, but recording over the right hemisphere was markedly degraded after the first several hours. There were no epileptiform features or electrographic seizures. [8-19] LENIS: IMPRESSION: No evidence of acute deep venous thrombosis bilaterally. [8-19] Head CT: IMPRESSION: Continued evolution of left frontal intraparenchymal hemorrhage with associated significant vasogenic edema, greater in proportion than expected from the initial hematoma. Continued close surveillance is recommended. No new foci of hemorrhage. [8-20] Echo: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Doppler parameters are indeterminate for left ventricular diastolic function. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [8-23] Brain Scan: IMPRESSION: Small focal areas of increased perfusion immediately anterior and immediately posterior to the left frontal intraparenchymal hemorrhage and edema, which may serve as seizure foci. [2199-9-4] MRI/MRA Brain: IMPRESSION: 1. Interval decrease in size of the previously noted left frontal lobe intraparenchymal hemorrhage, continued followup is recommended until a complete resolution of the hematoma to rule out underlying pathology. 2. Multiple unchanged foci of magnetic susceptibility, suggesting amyloid deposits versus small cavernomas. No other new lesions are identified. After the administration of gadolinium contrast, no evidence of large vessels are demonstrated to suggest an arteriovenous vascular malformation. 3. Unchanged MRA of the head with no evidence of flow stenotic lesions or aneurysms, there is no evidence of enlarged vessels to suggest an arterial vascular malformation. [2199-9-10]: LENIS IMPRESSION: No evidence of deep vein thrombosis in either leg. Dilantin [2199-9-9]: 11.9 Brief Hospital Course: 60 y/o M with unknown past medical history was found unresponsive in car. He was taken to OSH aphasic, following no commands, and hypertensive. Head CT reveals a large L IPH. He was transferred to [Hospital1 18] for further neurosurgical care. He was admitted to the TSICU. Patient was agitated on exam and he was started on a CIWA scale. Repeat head CT was stable. On [7-27], patient's exam was EO to loud voice and spontaneous movement of all extremities, no commands. MRI was recommended to rule out underlying mass. [7-28]: Dilantin reloaded. [7-29]: Agitated overnight, leading to respiratory distress and hypoxia. Re-intubated at 0400hrs. A CT head was performed and stable. MRI brain was also performed which showed multiple lesions in the cerebellum likely small cavernoma's and indicating that larger left frontal lesion is also a Cavernoma. A follow up Angiogram has been scheduled for [2199-8-2]. [7-30]: patient was successfully extubated. A Doboff tube was placed for feeding. Patient will be evaluated by Speech Therapy to see if he can resume a P.O. diet. Transfer orders were written for patient to transfer out of the ICU to the Step down unit on [7-31]. [Date range (1) 30965] Pt seen by speech and swallow and initially failed for PO diet with plan to reevaluate on [8-2]. Pt seen on [8-2] and felt to be improving and DHT placed by IR. Tube feeds were started when post pyloric placement confirmed. Plan to re-evaluate on [8-5]. On [8-6] the patient was seen by speech and swallow and he was cleared for puree diet and nectar thick liquids. He would be re-evaluated later in the week. Nutrition recommended starting PPN and calorie counts while pt initiates PO diet. Angiogram scheduled and preop'ed for [8-7]. [8-7] Angio rescheduled for [8-9] due to scheduling conflict. Pt changed to TPN and diet restarted. His neurological exam is improving slightly with some verbalization therefore he was cleared for transfer to the floor. [8-8] pt was again seen by speech therapy and nutrition. His diet was advanced to thin liquids and soft solids with sips. [Date range (1) 78217] pt remained neurologically stable and was followed by nutrition. He continued to require TPN [1-1] poor po intake. [Date range (1) 87018] Pt remained on TPN for poor nutritional intake. His PO intake did increase over this time but still remained below his nutritional needs. Plan was to discuss PEG tube placement with his daughter and stop the TPN. Pt had a question of syncopal event vs seizure on [8-15]. He was found on the floor by nursing staff and was incontinent of his bowels. Upon exam he remained awake and alert, following simple commands and saying simple words. He had no extremity pain to movement or palpation and a CT head was obtained. CT head showed no change from his previous exams and EEG monitoring was ordered. EEG monitoring showed mildly slow waveforms but no epileptogenic activity. Syncope work up was initiated including an echo, cardiac enzymes, TSH & HgB A1c. On [8-18] the cardiac enzymes resulted negative times 3. Pt remained neurologically stable without other incident. On [8-19] the patient complained of bilateral lower extremity pain (pain with passive movement). Due to the difficulty examining the patient LENI's were ordered but found to be negative for DVT. In the afternoon the patient was ambulating with physical therapy and became unresponsive with dilated pupils and stiff flexion of upper extremities. Issues resolved within 2 minutes and the patient was neurologically back to his baseline. vitals remained stable. A head CT was obtained and revealed more resolution of the previous hemorrhage, otherwise stable. The event was a presumed seizure therefore the Keppra was increased and a Neurology consult was requested. On [8-20] a family meeting took place. The patient's elder daughter obtained guardianship in the AM from the court. The patient's nutrition status was discussed and it was decided to proceed with PEG placement. A consult with general surgery was then placed for the PEG. On [8-22]: This patient had PEG placed and was not able to be extubated following procedure. The PaO2 was 99 on FiO2 60 and PEEP of 10 with 1 hour of tachypnea to 30s. The cause of this was unknown. CXR showed pneumoperitoneum and small LLL pleural effusion. He required a dilantin load on [8-23]. On [8-26] he exhibited global aphasia and was given a Dilantin load of 500mg per neurology recomendations. On [8-27], he was reloaded with fosphenytoin and the corrected level was 13.6. On [8-29] his dilantin was corrected to 15.1. There was a family meeting and the son was obtaining conservaship. [Date range (1) 33651]: Patient remained stable. Awaiting Guardianship. [9-10]: LENIS were negative. on [9-12], the day of discharge, patient has returned to his hospital baseline. He is awake and alert on exam although generally confused. He ambulates in the halls with minimal assistance. He is taking a P.O. diet and his Peg is minimally used. As discussed with the daughter he will need to have the PEG in for 4 weeks before removal can be considered as discussed with General Surgery. Medications on Admission: None Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 4. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for discomfort. 7. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 11. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 12. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 14. HydrALAzine 10-20 mg IV Q6H:PRN HTN, SBP >160 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: [Location (un) 1459] Care and Rehabilitation Center Discharge Diagnosis: L IPH Protien/calorie malnutrition Right upper extremity hemiparesis Non verbal Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You have been prescribed Dilantin and Keppra for seizures. You must remain on this medication until your follow-up with Neurology. Please check a Dilantin level one week from discharge. Please call ([Telephone/Fax (1) 2528] with any questions regarding your seizure medication. ?????? You have a feeding tube and it may be removed after 8 weeks of insertion as it is no longer needed for nutrition. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 2102] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ?????? Please follow-up with Neurology - Dr. [First Name (STitle) ] regarding your seizures. Please call ([Telephone/Fax (1) 2528] to schedule this appointment. ?????? Please follow-up with General Surgery to discuss your PEG and removal 8 weeks after insertion ([2199-8-21]) ([Telephone/Fax (1) 14957] Completed by:[2199-9-12]	[ "5119" ]
Admission Date: [2102-4-12] Discharge Date: [2102-4-18] Date of Birth: [2044-9-13] Sex: M Service: MEDICINE Allergies: Demerol Attending:[First Name3 (LF) 943] Chief Complaint: GI bleeding Major Surgical or Invasive Procedure: IR embolization History of Present Illness: Mr. [Known lastname ] is a 57 year old male with past medical history of Crohn's Disease diagnosed 19 years ago, s/p colectomy with history of GI bleeding, hypertension and alcohol abuse who presented to [Hospital 1263] Hospital on [2102-4-9] with bleeding into his ileostomy bag, recently in ICU for stoma bleed, now being transferred for stomal re-bleed. Pt was in the MICU from [4-13] to [4-14] and transferred 1 unit PRBC's, and was hemodynamically stable and transferred to the floors on evening [4-14]. This afternoon pt had large rebleed from stomal site, BP's dropped to 70s systolic, pressure was placed, but required balloon tamponade. Pt was given 2 units PRBC's and transferred to unit. Pt is mentating well and otherwise feeling ok. Denies abdominal pain, nausea, vomiting, chest pain, SOB. He does have some lightheadedness. Pt initially GI bleeding Saturday [2102-4-1]. He describes this as painless ileostomy bleeding, requiring three bag changes and then he syncopized. He was admitted to [Hospital6 33] that evening and discharged Monday [4-3]. He re-presented to [Hospital 7912] Tuesday-Friday, [2014-4-3] for ongoing bleeding into his ileostomy bag. While at [Hospital3 ] he recieved a CTA, tagged red blood cell scan, video capsule study and endoscopy; all tests were negative for bleeding. He also had an ileoscopy as well which revealed a small ulceration but otherwise negative for signs of bleeding. The bleeding into his ileostomy bag occurs 3-4 times/week; it is intermittent, painless and stops on its own. He describes the blood as bright red mixed with dark green stool. Aside from the syncopal episode initially and intermittent fatigue, he has not had any other symptoms (chest pain, shortness of breath). He denies any recent trauma, nausea, vomiting, diarrhea, contipation. He has minimal left lower quadrant tenderness which is intermittent and unrelated to food intake. He denies any recent medication changes. On Sunday, [2102-4-9], the patient presented to [Hospital 1263] Hospital with persistent bleeding into his ileostomy. His vitals were normal but he was admitted to ICU for closer monitoring. His hematocrit remained stable around 32. In the ICU he did recieve 2 units of FFP, 4 units pRBC and 2 units of platelets. His bleeding resolved on its own. With concerns for Crohn's flare, he was placed on high dose pulse steroid therapy of hydrocortisone 100mg Q8H and continued on home Pentasa. CT enterography revealed cirrhosis with evidence of portal hypertension and venous collaterals. Ileoscopy revealed active stomal variceal bleed with limited other endoscopic findings. He was transferred for TIPS consideration after these findings. His hydrocortisone was discontinued. Ursodiol was held on transfer and atenolol was switched to nadolol 20mg daily with continuation of PPI prophylaxis. He had no bleeding observed during the hospital stay. Of note, the patient states his Crohn's Disease had been stable since colectomy without any need for other medications until [2101-9-12]. At that time, he developed GI bleeding that was more intermixed with stool and felt due to Crohn's Flare. He was treated with Pentasa with improvement in his symptoms. He was recently started on Prednisone 30mg on [Year (4 digits) 16337] [2102-4-7] upon discharge from [Hospital6 33]. The patient also has significant alcohol consumption history but denies hepatic encephalopathy, other GI bleeding (hematemesis), ascites. Also denies ever becoming jaundiced. He was admitted on [3-/2019] for consideration of TIPS. Abdominal ultrasound without remarkable findings and TTE (largely normal). Bled two large bloody movements, apparently achieved control with a foley in the ostomy. Ordered two units none given but did receive 1L NS. Urgent TIPS ordered. Upon going for TIPS, he was found to have a pressure gradient of 5, and was not considered a candidate for TIPS given that there was no significant benefit. Following this, he was transferred to [Doctor Last Name 3271]-[Doctor Last Name 679], where he was monitored for re-bleeding and maintained on nadalol, pantoprazole, and ctx. Past Medical History: Crohn's Disease - diagnosed 19 years ago, s/p colectomy ~15 years ago Hypertension Chronic lower back pain Alcohol abuse Social History: -Tatoos on bilateral arms 7-8 years ago -Tobacco history: None -ETOH: 3 drinks/day X years until 10-12 years ago; stopped secondary to feeling generally "lousy." The patient resumed alcohol consumption couple years ago, 2 drinks/day. Drink of choice: Vodka with coke (unclear how much vodka), quit three weeks ago with onset of GI bleeding -Illicit drugs: None, denies any history of intranasal cocaine, marijuana, IVDU * Also denies herbals, over the counters, anabolic steroids, excessive green tea -Home: Lives with wife, three children (aged 22, 23 and 3 years old) -Work: Bartender, does not find work to be stressful Family History: Father died of liver cancer at 71 years old, had MI when younger. Mother died of CVA, had diabetes s/p bilateral lower extremity amputations. Brother with mild diabetes mellitus. Children are alive and well. Physical Exam: Physical Exam on admission: GENERAL: Well appearing male who appears stated age. Comfortable, appropriate and in good humor HEENT: Sclera non-icteric. PERRL, EOMI, dry mucus membranes, normal oro/nasopharynx. NECK: Supple with normal JVP CARDIAC: RRR, normal S1/S2, no murmurs/gallops/rubs. No spider angiomas noted. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender to palpation. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness. Midline vertical subumbilical scar with ileostomy, balloon in place, no active bleeding EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. No cyanosis/ecchymosis/edema. Physical Exam on discharge: 99.5, 96-110/56-72, 69-86, 18, 98-99% RA GENERAL: Comfortable, appropriate and in no distress HEENT: Sclera non-icteric. PERRL, EOMI, dry mucus membranes, normal oro/nasopharynx. CARDIAC: RRR, normal S1/S2, no murmurs/gallops/rubs LUNGS: CTAB no w/r/ ABDOMEN: Soft, non-tender to palpation. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness. Midline vertical subumbilical scar with ileostomy bag in the right lower quadrant, with no blood in the ostomy; tan/green colored soft stool and pink mucosa. EXTREMITIES: wwp, 2+ distal pulses Pertinent Results: Labs on admission: [2102-4-12] 12:45PM BLOOD WBC-3.9* RBC-4.35* Hgb-12.5* Hct-37.4* MCV-86 MCH-28.6 MCHC-33.3 RDW-17.2* Plt Ct-68* [2102-4-12] 12:45PM BLOOD PT-13.8* PTT-27.8 INR(PT)-1.3* [2102-4-12] 12:45PM BLOOD Glucose-76 UreaN-13 Creat-0.9 Na-142 K-3.7 Cl-108 HCO3-27 AnGap-11 [2102-4-12] 12:45PM BLOOD ALT-242* AST-209* LD(LDH)-154 AlkPhos-79 TotBili-1.5 [2102-4-12] 12:45PM BLOOD Albumin-3.3* Calcium-8.7 Phos-4.1 Mg-1.9 [2102-4-13] 06:30AM BLOOD calTIBC-321 Ferritn-111 TRF-247 [2102-4-16] 01:01AM BLOOD Hapto-27* [2102-4-12] 12:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [2102-4-12] 12:45PM BLOOD Smooth-NEGATIVE [2102-4-13] 06:30AM BLOOD AFP-3.5 [2102-4-12] 12:45PM BLOOD [Doctor First Name ]-NEGATIVE [2102-4-12] 12:45PM BLOOD IgG-1215 IgA-235 [2102-4-12] 12:45PM BLOOD HCV Ab-NEGATIVE Microbiology: Urine cx [4-15]: No growth Blood cx [4-14] and [4-15] : NGTD Imaging: Echo [4-13]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal regional and global biventricular systolic function. Normal diastolic function. No pathologic valvular abnormalities. Mildly elevated pulmonary systolic pressure. RUQ US [3-/2019]: 1. Coarse liver echotexture and lobulated contour, suggestive of underlying cirrhosis. No focal hepatic lesion is identified. Hepatic vasculature is patent with hepatopetal flow. 2. Splenomegaly. 3. Small amount of ascites. 4. Cholelithiasis without evidence of acute cholecystitis. Labs on Discharge: [2102-4-18] 05:45AM BLOOD WBC-3.6* RBC-3.42* Hgb-10.1* Hct-28.6* MCV-84 MCH-29.7 MCHC-35.5* RDW-15.5 Plt Ct-36* [2102-4-18] 05:45AM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-138 K-3.7 Cl-105 HCO3-26 AnGap-11 [2102-4-18] 05:45AM BLOOD ALT-41* AST-45* LD(LDH)-162 AlkPhos-63 TotBili-0.9 [2102-4-18] 05:45AM BLOOD Albumin-2.8* Calcium-7.6* Phos-2.1* Mg-1.6 Brief Hospital Course: 57 year old male with past medical history of Crohn's Disease diagnosed 19 years ago, s/p colectomy with history of GI bleeding, hypertension and alcohol abuse who presented to [Hospital 1263] Hospital on [2102-4-9] with persistent bleeding into his ileostomy bag. # Gastrointestinal bleeding: Thought possibly due to stomal varices which were seen both on CT enteroscopy and ileoscopy. Of note, these were not frankly bleeding on ileoscopy. No evidence of gastric/esophageal bleeding given history and physical exam. Pt had radiographic cirrhosis and associated coagulopathy, thrombocytopenia, splenomegaly. The patient has not had complications, however, of encephlopathy or ascites. TIPS was attempted but his potosystemic gradient was only found to be 6 and therefore TIPS was not deemed to be an option to reduce the risk of bleeding from his stomal varices. Pt was then transferred to the ET service where he again had large stomal bleeding. He became hypotensive and was transferred back to the MICU. His blood pressure remained stable after 2 units of PRBC's and balloon tamponade of the stomal bleed. Pt was then taken to IR where two branches of the superior mesenteric vein were successfully thrombosed. Pt had no further bleeding after the procedure and serial Hct's remained stable. Pt was transferred back to the liver service on [4-16] and his hct remained stable and no further bleeding was experienced x 48 hours. Mr. [Known lastname ] was discharged with an increased dose of nadolol 40mg daily. . # Cirrhosis: Patient is a bartender with recent active drinking. Thus, cirrhosis most likely due to alcohol consumption although etiology not confirmed. Cirrhosis also not biopsy proven. He does not have classic 2:1 AST/ALT. Given history of auto-immune disease with Crohn's, auto-immune hepatitis is on the differential athough anti-smooth muscle antibody was negative. Imaging and laboratory evidence of portal hypertension, splenomegaly/ thrombocytopenia and impaired synthetic dysfunction. LFT's mildly increased with normal bilirubin. No signs of current decompensation including ascites, jaundice, encephalopathy. He does have possible varices with bleeding around ileal stoma. Normal AFP. . #Crohn's Disease: No current symptoms of clinical exacerbation aside from bloody stool. The bleeding into the ileostomy, however, is more brisk than what is usually seen with Crohn's. Patient did not improve this time with prednisone, and has no extra-intestinal manifestations (has never had fistulas, rashes, ulcers etc). Pentasa was continued. . # Alcohol abuse: Patient states he has been sober/abstinent for three weeks. Monitored for signs/symptoms of withdrawal and was placed on a DMV, thiamine nad folate. . # Hypertension: Stable, recent GI bleed, anti-hypertensives were held in the setting of stomal bleeding. Medications on Admission: Pentasa 1000mg QID Atenolol 50mg daily Ursodiol 300mg [Hospital1 ] Prednisone 30mg daily Calcium carbonate daily Fish oil daily Multivitamin daily Discharge Medications: 1. mesalamine 250 mg Capsule, Extended Release Sig: Four (4) Capsule, Extended Release PO QID (4 times a day). 2. calcium carbonate 400 mg (1,000 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 3. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 4. multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Stomal Varices Cirrhosis Crohn's disease Hypertension Chronic Low Back pain 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 at [Hospital1 18]. You were admitted with life threatening bleeding from your stoma site. We were able to control this bleeding with a non-invasive surgery known as embolization. We also increased some of your medications to help ensure that you do not bleed again. It is of paramount importance that you no longer drink! If you drink any more, it could kill you. The following medication changes were made: STOP Atenolol and ursodiol, these will be replaced by nadolol, nadolol will prevent bleeding STOP Prednisone START nadolol to prevent bleeding START thiamine and folic acid for nutrition START Cipro for 7 more days to prevent infection Followup Instructions: Please keep your regularly scheduled appointment with your primary care doctor [First Name (Titles) 2593] [Last Name (Titles) 16337]. Name: [Last Name (LF) ],[First Name3 (LF) ] Specialty: GASTROENTEROLOGY Location: [Hospital3 ] MEDICAL CENTER-[Location (un) ] Address: [State ], [Location (un) ],[Numeric Identifier 85712] Phone: [Telephone/Fax (1) 17663] We were unable to schedule an appointment with Dr [Last Name (STitle) 7493]. It is recommended you see the Dr [Last Name (STitle) 176] 1 week of your discharge. Please contact the office at the number above to schedule your appointment	[ "2851", "5180", "4019" ]
Admission Date: [2206-10-5] Discharge Date: [2206-10-11] Date of Birth: [2147-6-23] Sex: M Service: MEDICINE Allergies: Lovenox / Keflex Attending:[Last Name (un) 11974] Chief Complaint: VT storm Major Surgical or Invasive Procedure: Ventricular Tachycardia ablation History of Present Illness: 59yoM with nonischemic cardiomyopathy (EF 35% in [7-12]), s/p BiV/ICD device in [12/2199] with recent admission for firing in [7-12], chronic afib on dabigatran, HTN, pulm HTN, CKD who presents with increasing frequency of ICD firing, having gone off 9 times today, 14 times total in past 1.5 weeks. First episode of was about 1.5 weeks ago, was seen in clinic 6 days ago and things settled down by then. Yesterday was at bed bath and beyond when received first shock and has been going in and out of VT storm since. Pt denies any chest pain or shortness of breath, however right before he gets shocked he experiences feelins of heartburn, jaw pain, diaphosesis and palpitations. He does not have any sx of heart failure despite recent decrease in torsemide from 40->30 mg/daily and aldactone 25mg -->12.5 mg. Volume status is euvolemic currently. . He was recently admitted to the hospital in [2206-7-2] for an increasing frequency of symptomatic ventricular tachycardia noted on device interrogations. It was noted that he was on Amiodarone 200mg daily instead of 400mg daily when these episodes occurred. Cardiac catheterization (left sided) was done which showed no evidence of coronary artery disease. His amiodarone dose was increased to 600 mg daily with plan to decrease to 200mg twice daily after two weeks - which he is currently on. Prior to this admission, he reports that whenever he got defribrillated he would be out and did not feel anything. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . In the ER, initial VS: He received lidocaine bolus and was started on a gtt. On transfer from the ER, VS 98.6 po 92/67 70 15 96&2L Past Medical History: -Recent infected right leg hematoma ([Year (4 digits) 8974], completed Bactrim [2205-7-5]) -Nonischemic cardiomyopathy s/p BiV ICD implantation: EF 40%, ?viral -Hypertension -Systolic CHF: secondary to cardiomyopathy, EF 40% -Heart block: etiology unclear, R sided PPM placed then replaced with ICD (R)/BiV PPM (L) ([12/2199]) -Atrial fibrillation -Tracheobronchomalacia (recently diagnosed on CT chest [3-/2205]) -Sarcoidosis involving lungs, lymph nodes, ?heart -Pulmonary hypertension -Subglottic stenosis -Ventral hernia repair w/ prolonged respiratory failure, hospitalization -Obstructive sleep apnea (central and obstructive, untreated) -Obesity -Depression -Panic attacks -CKD, baseline Cr. ~1.5 -Neuropathy, following gastric stapling in [2192] - Left ankle reconstruction, bilateral knee surgeries Cardiac Risk Factors: -Diabetes, -Dyslipidemia, +Hypertension . Cardiac History: Biventricular Pacemaker/ICD, in [12/2199] Social History: Former consultant, married with two children but wife recently left him. Just went to daughter's college graduation. No current tobacco or alcohol use. Family History: Father had coronary artery disease and hypertension. Mother had hypertension, diabetes, ear tumor. Brother had renal cell carcinoma. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS:BP=96/62.HR=71 RR= 18.O2 sat= 99%RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP flat. CARDIAC: PMI located in 5th intercostal space. heart sounds were distant with no appreciable murmurs, RR, normal S1, S2. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ DISCHARGE EXAM: VS: BP 100s/ 60s HR 60s-70s RR: 14 96% RA Cardiac: rub heard best over precordium s/p ablation procedure Remainder of PE unchanged from admission Pertinent Results: Admission Labs: [2206-10-5] 03:05AM BLOOD WBC-7.1 RBC-4.62 Hgb-13.5* Hct-40.3 MCV-87 MCH-29.3 MCHC-33.6 RDW-15.4 Plt Ct-224# [2206-10-5] 03:05AM BLOOD Neuts-80.2* Lymphs-13.4* Monos-4.6 Eos-1.5 Baso-0.4 [2206-10-5] 03:05AM BLOOD Glucose-138* UreaN-45* Creat-2.1* Na-141 K-3.9 Cl-104 HCO3-24 AnGap-17 [2206-10-5] 03:05AM BLOOD CK(CPK)-82 [2206-10-5] 03:05AM BLOOD CK-MB-5 [2206-10-5] 03:05AM BLOOD cTropnT-0.04* [2206-10-5] 03:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4 [2206-10-5] 03:05AM BLOOD Digoxin-0.7* [2206-10-5] 01:39PM BLOOD Digoxin-0.6* Discharge Labs: [2206-10-11] 05:30AM BLOOD WBC-8.1 RBC-3.61* Hgb-10.8* Hct-31.8* MCV-88 MCH-30.0 MCHC-34.0 RDW-15.5 Plt Ct-183 [2206-10-11] 05:30AM BLOOD Glucose-100 UreaN-30* Creat-1.7* Na-143 K-3.8 Cl-110* HCO3-25 AnGap-12 [2206-10-11] 05:30AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.2 CHEST (PORTABLE AP) Study Date of [2206-10-5] Low lung volumes, no acute cardiopulmonary process Portable TTE (Focused views) Done [2206-10-7] LV systolic function appears depressed. with depressed free wall contractility. There is no pericardial effusion. Poor image quality Portable TTE (Focused views) Done [2206-10-10] The right ventricular cavity is dilated with depressed free wall contractility. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen Portable TTE (Focused views) Done [2206-10-11] LV systolic function appears depressed. RV free wall contractility is depressed. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Very small residual pericardial effusion Pathology Results SCAR TISSUE, NORM TISSUE (2 JARS) 1. Heart, "scar tissue," biopsy (A): Minute fragment of loose connective tissue with mild acute and chronic inflammation and macrophages; see note. 2. Heart, "normal tissue," biopsy (B): Fragment of myocardium with no diagnostic abnormalities recognized; see note. Note: Eight (8) levels examined on both samples. There is no evidence of inflammation, amyloid, iron deposition, or granulomas. No necrosis of myocytes or degeneration is noted. Case reviewed with Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 93333]. Brief Hospital Course: 59yoM with nonischemic cardiomyopathy (EF 35% in [7-12]), s/p BiV/ICD device in [12/2199] with recent admission for firing in [7-12], chronic afib on coumadin, HTN, pulm HTN, osa, CKD who presents with VT storm. # Ventricular Tachycardia: The pt was admitted to the CCU and started on a Lidocaine drip from rhythm control. He underwent a VT ablation procedure for prior multiple episodes of Vtach s/p ICD firings. He was found to have VT with multiple morphologies, epicardial in origin. The procedure was complicated by a RV puncture during difficult epicardial access resulting in a stable pericardial effusion without signs of tamponade physiology. Following the procedure the pt was restarted on Amiodarone and Mexilitene and sent back to CCU for observation. He was noted to have a new pericardial rub present on PE following procedure. This was felt to be due to pericardial inflammation as well as from the small effusion post procedure. He had one episode of asymptomatic hypotension following the ablation procedure with sbps in 70s that required dopamine administration but ultimately responded to fluid boluses. Dopamine was able to be weaned off. An echo obtained during the hypotensive episode showed pericardial constriction which was believed to be due to inflammation post procedure. The effusion size was noted to be trivial. Also repeat serial echos on succeeding days showed the pericardial effusion to be stable in size without evidence of tamponade. He was started on a 3 day course of steroids to help resolve the pericardial inflammation s/p ablation which he finished prior to discharge. No further episodes of Vtach were noted on tele after the ablation was performed. The pt also had no further episodes of hypotension either. His home Amiodarone dose was reduced to 200mg daily from [Hospital1 ] and Mexiletine 150mg TID was added to his home regimen for rhythm control. # CHF- Upon admission the pt appeared euvolemic. He developed bilateral crackles at the lung bases during this admission following fluid boluses due to an episode of hypotension. Diuresis was resumed with his home dose of torsemide and the pleural effusion improved. Prior to discharge the pt was restarted on Digoxin 125mcg daily, metoprolol tartrate was reduced to 12.5mg [Hospital1 ] from 50mg [Hospital1 ] in setting of baseline low sbps and HRs consistently in 60s post ablation. His torsemide dose was also reduced to 30mg QOD from daily. He was continued on aspirin, spironolactone and lisinopril at his home doses. #A.Fib- Initially his home dose of Pradaxa was held prior to VT ablation and then was resumed post procedure for anticoagulation. He remained rate controlled during this hospitalization. #Chronic Kidney Disease- His baseline Cr is approximately 1.9 per OMR records. On admission his Cr was 2.1 which was believed to be due to poor forward flow s/p his multiple episodes of Vtach prior to admission. We continued to trend renal function and prior to discharge his Cr trended down to 1.7. His Lisinopril was restarted prior to discharge. #[Name (NI) 12730] Pt slept with home BiPAP at 14-16/11 with 2L O2 his home settings. He slept well with the device on at night. #Transitional- He has follow up appointments with his PCP and cardiology following this admission. His blood pressures and volume status should be re-evaluated at these follow up visits considering we changed his home medication regimen during this admission. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler prn ALLOPURINOL - 150mg daily AMIODARONE - 200 mg [Hospital1 ] BUDESONIDE-FORMOTEROL [SYMBICORT] - 160 mcg-4.5 mcg/Actuation HFA Inhaler - 1 puff inh twice a day CLINDAMYCIN PHOSPHATE - 1 % Lotion - apply to bumps on chest twice daily as needed Qday as needed for PRN CLOBETASOL - 0.05 % Solution - at bedtime to the affected area DABIGATRAN ETEXILATE [PRADAXA] - 150 mg [Hospital1 ] DIGOXIN - 125 mcg daily FLUOCINOLONE [DERMA-SMOOTH/FS BODY OIL] - 0.01 % Oil - apply to areas of rash daily Qday as needed apply to damp skin as needed, avoid face KETOCONAZOLE - 2 % Shampoo - Apply as directed LISINOPRIL - 2.5 mg daily METOPROLOL SUCCINATE - 100 mg daily OMEPRAZOLE - 40 mg [Hospital1 ] SERTRALINE - 50 mg Qdaily SPIRONOLACTONE - 12.5 mg daily TORSEMIDE - 30 mg daily VARDENAFIL [LEVITRA] - 10 mg PRN ASPIRIN - (OTC) - 325 mg daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:90 Capsule(s) Refills:2 7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 9. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash on back. 11. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 13. torsemide 20 mg Tablet Sig: 1.5 Tablets PO QOD (). 14. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia Scarcoidosis Congestive Heart failure Chronic atrial fibrillation Hypertension Pulmonary hypertension Chronic kidney disease Gout Tracheobronchomalacia Subglottic stenosis -Ventral hernia repair -Obstructive sleep apnea - on CPAP -Obesity -Depression -Panic attacks Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 19940], You were admitted to the hospital after you had several firings of your ICD device. You underwent an ablation in the cath lab to help prevent future events. You also had low blood pressures post-procedure and required medications and fluids to increse your blood pressure. The doses of your heart medications were changed and you will need to follow up with your cardiologist in the next 5-7 days. Medication Changes: -amiodarone 200 mg daily (from twice daily) -digoxin 125 ugm daily (restart) -metoprolol tartrate 12.5 mg twice daily (dose reduced) -spirnolactone 12.5 mg daily (continue) -Torsimide 30 mg every other day (dose reduced) -Mexiletine 150 mg three times a day (new medication) -Asprin 325 mg daily (continue) -Lisinopril 2.5 mg daily (continue) -Pradaxa 150 mg daily (continue) Addtionally please weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: Cardiology -please schedule an appointment with Dr. [Last Name (STitle) 93334] for [Last Name (STitle) ] [2206-10-17] Department: CARDIAC SERVICES When: [Month/Day/Year ] [2206-10-17] at 2:30 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: THURSDAY [2206-10-16] at 11:30 AM With: DR [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]/[Company 191] POST [Hospital 894] CLINIC Phone: [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] South [Hospital ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [Name10 (NameIs) 616] this visit, you will see your regular primary care doctor in follow up [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 11975]	[ "42731", "5859", "53081", "32723", "V5861", "4168", "4280", "40390" ]
Admission Date: [2122-9-17] Discharge Date: [2122-9-24] Date of Birth: [2051-9-18] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old male with a history of hypertension, ischemic cardiomyopathy, monoclonal gamma globulin of undetermined significance, and gout who presented to the Emergency Room on [9-17] with a complaint of several days of nausea, vomiting, shortness of breath, and cough. The patient was in his usual state of health until four days prior to admission when he developed nausea and vomiting and was unable to tolerate anything p.o. Apparently one day prior to admission the patient developed a nonproductive cough associated with shortness of breath. The patient felt progressively weak and presented to the Emergency Room. In the Emergency Department, the patient's temperature was a temperature to 101.7, blood pressure 99/60, heart rate 116, respiratory rate 34, oxygen saturation of 93% on room air and 97% on 2 liters. Chest x-ray showed left upper lobe pneumonia. Laboratories showed leukocytosis and a creatinine of 6.6. The patient's urine had muddy brown casts and epithelial cells. The patient was started on renally dosed Levaquin, given intravenous fluids, and transferred to the floor. On admission to the medical floor, the patient had a temperature of 102.1, blood pressure 112/60, and oxygen saturation of 89% on room air. Shortly thereafter, the patient's blood pressure dropped to 85/40. The patient was bolused 1 liter of normal saline with an increase in systolic blood pressure to the 90s. The patient was then transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Hypertension. 2. Ischemic cardiomyopathy. Transthoracic echocardiograms in [2116] showed enlarge left ventricle with global hypokinesis and an estimated ejection fraction of 20% to 25%. 3. Multiclonal gamma globulin of undetermined significance. 4. Gout. 5. History of pneumonia requiring intubation in [2115]. MEDICATIONS ON ADMISSION: 1. Zestril 40 mg p.o. q.d. 2. Lopressor 50 mg p.o. b.i.d. 3. Lasix 20 mg p.o. q.d. 4. Allopurinol. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married and lives at home with his wife. The patient has eight children. No tobacco or alcohol use. PHYSICAL EXAMINATION ON ADMISSION: On presentation to the Medical Intensive Care Unit temperature was 99.5, blood pressure 98/61, pulse 113, respiratory rate 24, oxygen saturation 92% on 4 liters. In general, the patient was alert, in no acute distress. HEENT revealed pupils were equal, round, and reactive to light. Extraocular muscles were intact. Scleral icterus. Oropharynx was clear. Neck was supple with no lymphadenopathy. Lungs revealed coarse dry scattered crackles bilaterally, left greater than right. Heart examination revealed the patient was tachycardic, regular rhythm. No murmurs appreciated. Abdomen was soft, nontender, and nondistended, with normal bowel sounds. Extremities had no edema. Neurologically, alert and oriented times three. He moved all four extremities. LABORATORY DATA ON ADMISSION: White blood cell count 11.5, hematocrit 30.9. Urinalysis revealed large blood, positive nitrites, greater than 30 protein, large bilirubin, moderate bacteria, muddy brown casts. Chloride 99, bicarbonate 15, BUN 81, creatinine 6.6. Creatine kinase #1 was 532 with a MB of 5. Creatine kinase #2 was 422 with a MB of 3. Liver function tests revealed ALT 41, AST 58, alkaline phosphatase 86, total bilirubin 8, albumin 2.2. RADIOLOGY/IMAGING: Electrocardiogram revealed sinus tachycardia [Company 109175] wave inversion in lead III, right bundle-branch block (new from [2118] electrocardiogram with exercised-induced on stress test in [2122-1-26]). Echocardiogram revealed an ejection fraction of 40% to 45%, left ventricular size was normal, moderate global left ventricular hypokinesis, mild 1+ mitral regurgitation, pulmonary artery systolic hypertension. HOSPITAL COURSE: 1. PULMONARY/INFECTIOUS DISEASE: The patient was admitted with multilobar pneumonia, community-acquired. Blood cultures showed no growth to date, and sputum culture had greater than 10 epithelial cells with contamination of oropharyngeal secretions. The patient was started on intravenous Levaquin, ceftriaxone, and vancomycin given previous history of pneumonia requiring intubation. The patient improved clinically, and on hospital day four was switched to p.o. Levaquin for a total of a 14-day course of antibiotics. 2. CARDIOVASCULAR: The patient became hypotensive, likely the result of significant hypovolemia from decreased p.o. intake. The patient responded to fluid boluses, but his mean arterial pressure was 65. Given the patient's acute renal failure the patient was started on Levophed in order to insure renal perfusion in the setting of acute renal failure. The patient was on Levophed for less than 24 hours. Given the patient's history of coronary artery disease, the patient was sent for an echocardiogram which showed an ejection fraction of 40% to 45%. Left ventricular cavity size was normal with moderate global left ventricular hypokinesis. There was mild mitral regurgitation. The patient did not show any signs of congestive heart failure during this admission. The patient was restarted on all of his cardiac medications at the time of discharge. 3. RENAL: The patient presented with acute renal failure with a creatinine of 6.6. Acute renal failure was likely a combination of prerenal azotemia and acute tubular necrosis. The patient's FENa on presentation was 0.3 with urinalysis showing muddy brown casts. The patient received intravenous fluids with a decrease in creatinine to 1.2 at the time of discharge. The patient also presented with metabolic acidosis with a bicarbonate of 15 on admission. Metabolic acidosis resolved with intravenous fluids with bicarbonate of 23 at the time of discharge. The patient went for abdominal ultrasound to evaluate elevated bilirubin. Abdominal ultrasound showed a mass in the kidney. The patient subsequently went for a CT scan of the abdomen which did not show any renal mass. 4. HEMATOLOGY: The patient presented with a hematocrit of 30.9 (baseline hematocrit of 33). With intravenous fluids the patient's hematocrit dropped to 26.6. Hemolysis and DIC panels were sent and were negative. The patient was transfused 2 units of packed red blood cells with a post transfusion hematocrit of 30.4. 5. GASTROINTESTINAL: The patient presented with a direct hyperbilirubinemia with a total bilirubin peaking at 10. In addition, the patient had a slight transaminitis with ALT peaking at 107 and AST at 177. Elevated liver function tests were likely the result of decreased perfusion to the liver at the time of presentation. The patient's liver function tests gradually improved during the admission with total bilirubin decreasing to 2.6 at the time of discharge. On admission, the patient's alkaline phosphatase remained elevated at 156. In reviewing the patient's records, the patient has had elevated alkaline phosphatase in the past. The patient underwent a CT scan of the abdomen which showed gallstones but no cholecystitis. CT was otherwise negative. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: The patient was discharged to home. MEDICATIONS ON ADMISSION: Levaquin 500 mg p.o. q.d. times seven days for a total of 14 days of antibiotics. DISCHARGE DIAGNOSES: 1. Multilobar pneumonia. 2. Acute renal failure. 3. Coronary artery disease. 4. Multiclonal gamma globulin of undetermined significance. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 29803] Dictated By:[Last Name (NamePattern1) 1297] MEDQUIST36 D: [2122-9-23] 17:31 T: [2122-9-27] 10:49 JOB#: [Job Number 109176]	[ "486", "5849", "0389", "4280", "41401", "4019" ]
Admission Date: [2108-8-9] Discharge Date: [2108-8-11] Date of Birth: [2052-9-7] Sex: M Service: NEUROSURGERY Allergies: Cephalosporins / Bactrim / Ceftazidime / Mold/Yeast/Dust / Sulfa (Sulfonamide Antibiotics) / Iodine / Hayfever / contrast dye Attending:[First Name3 (LF) 1835] Chief Complaint: L fronto-parietal lesion Major Surgical or Invasive Procedure: L craniotomy for resection of cystic mass History of Present Illness: Patient is an elective admit for resection of L cystic lesion Past Medical History: T11-T12 disc herniation, hypothyroid, arthritis Social History: tobacco free >12 months, prior heavy ETOH use Family History: NC Physical Exam: On Discharge: the patient's motor sensory exam was intact and we has amulating well Pertinent Results: [2108-8-9] CT Head FINDINGS: The patient is status post left parietal craniotomy with an expected small amount of subcutaneous gas seen adjacent to the craniotomy site as well as a small volume of pneumocephalus. The left cystic lesion has now been resected and note is made of edema within the resection bed in the left parietal and frontal lobes. There is no acute intracranial hemorrhage or vascular territorial infarction. Aside from the surgical bed, ventricles and sulci are normal in size and in configuration. [2108-8-10] MRI Brain with and without contrast IMPRESSION: Status post resection of left parietal mass. There is no definite residual nodular enhancement seen, but meningeal enhancement is identified in the region. Blood products and expected post-surgical changes are seen. Brief Hospital Course: 55 y/o M with L fronto-parietal cystic lesion presents electively for L craniotomy for resection of lesion. He was taken to the OR on [8-9]. OR course was uncomplicated and patient was transferred to the ICU for further monitoring. POstop CT head demonstrated moderate pneumocephalus and expected postop changes, no hemorrhage. POD1 [8-10] he underwent postop MRI that demonstrated and he was transferred to the regular floor. POD2 [8-11] he was ambulating well and was cleared to go home by physical therapy. Medications on Admission: ATENOLOL - 25 mg qday, ASTELIN 137 mcg Aerosol, Spray - 2 sprays each nostril 1 hour QHS, CELEBREX 200 mg [Hospital1 ], FEXOFENADINE 60 mg Tablet - 1 QHS FEXOFENADINE-PSEUDOEPHEDRINE - 60 mg-120 mg 1 qday,GABAPENTIN 300 mg [Hospital1 ], HCTZ - 25 mg ', LEVOTHYROXINE 175 mcg Tablet - 1 qday ,NASONEX 50 mcg Spray, Non-Aerosol - 2 sprays [Hospital1 ], SIMVASTATIN - 20 mg ' Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain . Disp:90 Tablet(s) Refills:0 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for constipation. Disp:90 Capsule(s) Refills:1 Discharge Disposition: Home Discharge Diagnosis: Cystic Mass at Left Fronto-Parietal Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you should stay off until follow up. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [7-15] days (from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [Hospital 341] Clinic in four weeks. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain with/ or without gadolinium contrast. If you are required to have a MRI, you may also require a blood test to measure your BUN and Cr within 30 days of your MRI. This can be measured by your PCP, [Name10 (NameIs) ] please make sure to have these results with you, when you come in for your appointment.	[ "2449", "4019", "2720" ]
Admission Date: [2194-4-2] Discharge Date: [2194-4-8] Service: MEDICINE Allergies: Penicillins / Quinidine Attending:[First Name3 (LF) 7333] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: DCCV History of Present Illness: 84 yo male with a history of biventricular heart failure, atrial fibrillation, ICD and CAD s/p CABG who was directly admitted to the CCU today from Dr.[Name (NI) 7914] clinic for medical treatment of volume overload. According to the patient's daughter, his primary complaint is fatigue. He feels "whole body" fatigue with minimal exertion. He was able to walk approximately 5 minutes without fatigue in the past, however recently has required resting for minimal movement including going from sitting to standing position. The patient reports improvement of BL LE edema, however increased amount of ascites. The daughter also reports decreased appetite. On review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, myalgias, joint pains, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: CARDIAC HISTORY: - MI X2 - CABG: 4 vessel [2165] - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: - Pacemaker placed [2183] for sick sinus syndrome - Upgrade to [Hospital1 ]-v ICD in [3-/2189] - Generator change [5-8], pocket revision [8-8] (lead protruding from skin) - s/p VT ablation - Atrial fibrillation - Systolic, diastolic CHF last EF: 50% with LV hypertrophy and severe global RV free wall hypokinesis and 4+ TR OTHER PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Prior TIA??????s with aphasia (none in the past 4 years) Orchiectomy due to a gunshot wound sustained in the service Central retinal vein occlusion CARDIAC RISK FACTORS: HTN, hyperlipidemia, former smoker Social History: -Tobacco history: Quit smoking approx 25 years ago, did have heavy pipe/cigar smoking for approx 8-10 years -ETOH: rare glass of wine -Illicit drugs: none Served in the Army Family History: No family history of early MI, otherwise non-contributory Physical Exam: VS: HR 77 BP 120/75 RR 15 O2 99% GENERAL: elderly man in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink. Hematoma on left anterior forehead with surrounding ecchymoses. NECK: Supple with JVP of anterior ear CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [2-7] holosystolic murmur at LLSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, ascites present, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ pitting edema to the thigh BL LE. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars. PULSES: Right: Carotid 2+ Femoral 2+ DP 1 PT 1 Left: Carotid 2+ Femoral 2+ DP 1 PT 1 Pertinent Results: ECG: V paced rhythm at 75, with possible atrial flutter at a rate of 150bpm. TELEMETRY: V paced rhythm at 75 bpm Admission Labs: [2194-4-2] 07:52PM GLUCOSE-113* UREA N-63* CREAT-2.0* SODIUM-137 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16 [2194-4-2] 07:52PM proBNP-6409* [2194-4-2] 07:52PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.0 [2194-4-2] 07:52PM TSH-7.2* [2194-4-2] 07:52PM DIGOXIN-0.4* [2194-4-2] 07:52PM WBC-4.5 RBC-3.17* HGB-10.0* HCT-29.4* MCV-93 MCH-31.4 MCHC-33.9 RDW-17.5* [2194-4-2] 07:52PM PLT COUNT-153 [2194-4-2] 07:52PM PT-36.6* PTT-38.9* INR(PT)-3.9* Brief Hospital Course: 1. CHF exacerbation: Biventricular failure secondary to ischemic cardiomyopathy, right sided failure secondary to left sided failure. The patient has severe tricuspid regurgitation, moderate mitral and aortic regurgitation on recent TTE. The patient does not have typical CHF symptoms considering his severe TR. His symptomatic equivalent is fatigue and whole body weakness. It seems that he has progressed over the past few months from Stage 3 NYHA classification to Stage 4, with symptoms with minimal exertion/rest. On admission, the patient was very volume overloaded. He was treated with IV lasix drip with good diuresis. Diuresis with lasix drip was initiated, with weaning and placement on torsemide 80mg PO daily he did not have adequate urine output and was thus placed back on the lasix gtt until discharge. As his BPs were low with the lasix gtt a PICC line was placed and dopamine was initiated to maintain adequate blood pressures while aggressive diuresis. He was continued on digoxin. Held carvedilol initially given attempt at diuresis and risk of hypotension, however then this medication were reinitiated to help control AF. Held midodrine and aminophylline given dopamine treatment and risk of tachyarrhytmias initially, then once weaned off dopamine, these medications were restarted. Aminophylline was increased to 100mg [Hospital1 ]. His torsemide was increased to 100mg [Hospital1 ] for discharge. He also was instructed to take metolazone daily prior to his AM dose of torsemide. Lasix drip was continued untill discharge when he was sent home on metolazone and torsemide. 2. Atrial Flutter: The patient has been in atrial fibrillation regardless of attempts at chemical cardioversion with amiodarone in the past. It appeared on 12 lead from admission that the patient is in atrial flutter at a rate of 150bpm. Continued amiodarone. Continued carvedilol. Continued coumadin, monitored INR daily. 3. CAD s/p CABG: Continued simvastatin, aggrenox. Coreg was held given hypotension initially and then re-started. 4. History of TIAs: Continued aggrenox. 5. BPH: Continued flomax, with holding parameters. 6. Cataracts: Continued opthalmic treatments including predfort, acular, zymar, and cosopt. 7. Gout: Continued colchicine 8. Hypothyroidism: The patient's daughter reports that they did not initiate levothyroxine therapy given unclear [Name2 (NI) ] results. TSH elevated but T4 and free T3 within normal limits. Did not make any changes to medications. 9. Long term goal: Palliative care was involved and discussion with patient and family took place re: long term goals of care. The decision to eventually go home with home care, and think about hospice care in the future. Medications on Admission: Midodrine 5mg 1 PO QAM, then 6 hours later Colchicine 0.6mg [Hospital1 ] Torsemide 50mg [Hospital1 ] Metolazone 5mg (1 or [1-3] tablet) prior to torsemide dosing Flomax 0.4mg QD Aminophylline 50mg QD KCL 10 mEq QD Amiodarone 100mg QD Carvedilol 3.125mg [Hospital1 ] Digoxin 125mcg [1-3] tab QD Aggrenox 1 cap QD Simvastatin 10mg QD Coumadin 5mg QD Predfort opthalmic Cosopt opthalmic Zymar opthalmic Acular opthalmic Discharge Medications: 1. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 8. Ketorolac Tromethamine 0.5 % Drops Sig: One (1) Ophthalmic QID (4 times a day). 9. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q6H (every 6 hours). 10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Aminophylline 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 12. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM. Disp:60 Tablet(s) Refills:2 13. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 14. Torsemide 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 15. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day: Please take 1 hour prior to torsemide dosing, if weight is increased by 2lbs. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnoses: Biventricular Congestive Heart failure Atrial Fibrillation/Atrial Flutter . Secondary Diagnoses: Hypertension Hyperlipidemia Prior TIA??????s with aphasia (none in the past 4 years) Orchiectomy due to a gunshot wound sustained in the service Central retinal vein occlusion Discharge Condition: The patient was hemodynamically stable at discharge. Discharge Instructions: You were admitted to [Hospital1 18] for evaluation and treatment of your heart failure. You were treated with IV medications to help remove excess fluid. You were changed back to most of your home medications prior to discharge, the changes are below. . These medications were changed: - Aminophylline increased to 100mg [Hospital1 ] - Torsemide increased to 100mg [Hospital1 ] - Metolazone to be taken one hour prior to dose of Torsemide in the event that your weight is 2lbs higher than the previous day - Coumadin decreased to 3mg QD, please check your INR in 2 days and adjust the coumadin dose accordingly . These medications were discontinued: - Midodrine . You should continue to weigh yourself every morning, [Name6 (MD) 138] your MD if your weight increases by 2 lbs. If your weight is elevated, please take 5mg of metolazone 1 hour prior to your torsemide dose. Please attempt to restrict your fluid intake to 1L per day. Please decrease the amount of salt intake to 2gm per day. . If you experience worsening fatigue, whole body weakness, shortness of breath, chest pain, fever, chills or any other worrisome symptoms please seek medical attention. Followup Instructions: Please follow up with your primary cardiologist, Dr. [Last Name (STitle) ], in 2 weeks regarding your treatment. . Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 7986], in [1-3] weeks. . Please have your labs drawn, specifically your INR in 2 days following discharge. Completed by:[2194-4-9]	[ "V4581", "4019", "2449", "2724", "4280", "42731" ]
Admission Date: [2187-7-7] Discharge Date: [2187-8-24] Date of Birth: [2123-1-22] Sex: M Service: SURGERY Allergies: Captopril Attending:[Known firstname 4748] Chief Complaint: right leg ischemia and infection Major Surgical or Invasive Procedure: [2187-7-10] R below-knee amputation and excision of infected [Month/Day/Year ] [2187-7-11] closure of R BKA site and groin incisions [2187-7-25] incision and drainage, right common femoral to above knee popliteal [Month/Day/Year ] removal [2187-7-27] Right groin washout, sartorius flap placement, VAC-placement [2187-8-8] Right IJ tunnel catheter History of Present Illness: 64M well known to the vascular service s/p recent discharge from our service on [2187-6-12] after PTA RCIA and stent RCIA, then a redo femoral to posterior tibial artery bypass with PTFE, who presented with leukocytosis to 26, nausea, emesis and ischemic right leg. Pt was seen by Dr. [Last Name (STitle) 1391] [2187-7-6] for discussion regarding failed bypass and need for amputation. He was sent home and felt well until this am when he was hypoglycemic to the 60s and nauseous. He vomited foodstuff x3 and called the ambulance. He was initially evaluated at [Hospital3 ], where he complained of mild abdominal pain. + BM this am, Nn diarrhea, no Abx use,+ fevers and chills x 24hrs. No sputum production, no dysuria, patient states he has been making the usual amount of urine. No pain over kidney [Hospital3 ] nor over vascular [Hospital3 ] site. Patient denies pain at RLE, but states that the mottling of RLE is worse. Sensation in RLE is intact and there is no weakness. He was also noted to have minimal drainage from the medial portion of his wound, stable for a few days, no foul smell. Temperature on arrival to OSH 102.6 HR 110 with Bp 150/ 58. He was found to have a leukocytosis to 26.7 w 13 bands at OSH. Vancomycin, Cipro and Flagyl given to patient prior to transfer. Past Medical History: hypertension, congestive heart failure (EF 25-30%) coronary artery disease, s/p MI , PVD, diabetes type 2, ESRD s/p renal transplant [10-14], history of MRSA bacteremia PAST SURGICAL HISTORY: [2176]: CABGx3 [2179-2-4]: Right common femoral artery to above knee popliteal with nonreverse greater saphenous vein [2180-6-20]: Left upper arm A-V fistula [2180-6-20]: Left femoral to above popliteal bypass [Month/Day/Year ] with PTFE [10-14]: renal transplant ([Hospital6 ]) [2181-2-15]: Left common femoral artery to below-knee popliteal artery bypass with polytetrafluorethylene(PTFE)[Month/Day/Year ]. [2181-8-16]: Re-do right femoral to below knee popliteal bypass with PTFE [2187-6-4]: Right lower extremity arteriogram with balloon angioplasty of right common iliac artery and stent placement at right common iliac artery [2187-6-7]: Redo femoral to posterior tibial artery bypass with PTFE Social History: married, lives in [Location ] with wife, quit smoking [2173], denies etoh/ilicit drugs Family History: DM2 - maternal & external, CAD - maternal (both deceased) Physical Exam: on admission: VS: 99.3 96 133/65 18 98% RA Gen: NAD, A&Ox3, Uncofortable c/o back pain, flushed, very warm to touch CVS: RRR Pulm: Clear anteriorly Abd: Soft, ND, mild tenderness in LLQ no Rebound, no guarding. No CVA tenderness. Ext: RLE with mottling and cyanosis foot, delayed cap refill. Motor intact, sensation intact bilaterally. Medial distal thigh with 0.3 cm opening with trace brown fluid, no fluctuance, no collections palpated no erythema of thigh. Trace calf erythema with blanching, no edema. Dry gangrene 1rst and 2nd digits. Pulses: Right and left femoral palp. Bilateral popliteal signals. No signals on the right Dp and pt, + signals Left dp and PT Pertinent Results: [2187-7-7] 06:35PM LACTATE-3.1* [2187-7-7] 07:00PM PT-29.4* PTT-31.2 INR(PT)-2.9* [2187-7-7] 07:00PM NEUTS-84* BANDS-13* LYMPHS-2* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2187-7-7] 07:00PM WBC-30.7# RBC-3.90 HGB-11.3* HCT-33.2* MCV-85 MCH-29.0 MCHC-34.1 RDW-14.9 [2187-7-7] 07:00PM CALCIUM-9.8 PHOSPHATE-2.6* MAGNESIUM-1.5* [2187-7-7] 07:00PM GLUCOSE-258* UREA N-49* CREAT-1.8* SODIUM-133 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-20* ANION GAP-21* [2187-7-7] 10:11PM LACTATE-3.4* [2187-7-8] 08:10AM BLOOD WBC-24.9* RBC-3.76* Hgb-11.0* Hct-32.9* MCV-88 MCH-29.3 MCHC-33.5 RDW-15.4 Plt Ct-192 [2187-7-9] 03:00AM BLOOD WBC-22.0* RBC-3.63* Hgb-10.4* Hct-31.2* MCV-86 MCH-28.6 MCHC-33.2 RDW-15.0 Plt Ct-168 [2187-7-9] 07:52PM BLOOD WBC-17.6* RBC-3.16* Hgb-9.0* Hct-26.6* MCV-84 MCH-28.4 MCHC-33.8 RDW-14.9 Plt Ct-166 [2187-7-10] 06:00AM BLOOD WBC-15.5* RBC-3.31* Hgb-9.4* Hct-28.0* MCV-85 MCH-28.5 MCHC-33.7 RDW-14.9 Plt Ct-159 [2187-7-11] 03:45AM BLOOD WBC-14.3* RBC-3.53* Hgb-10.1* Hct-29.4* MCV-83 MCH-28.5 MCHC-34.2 RDW-16.0* Plt Ct-179 [2187-7-11] 06:07PM BLOOD WBC-14.3* RBC-3.46* Hgb-9.9* Hct-29.1* MCV-84 MCH-28.7 MCHC-34.2 RDW-16.3* Plt Ct-198 [2187-7-12] 03:26AM BLOOD WBC-12.6* RBC-3.40* Hgb-9.2* Hct-28.6* MCV-84 MCH-27.1 MCHC-32.2 RDW-16.5* Plt Ct-201 [2187-7-13] 06:15AM BLOOD WBC-12.2* RBC-3.50* Hgb-9.8* Hct-29.8* MCV-85 MCH-27.8 MCHC-32.7 RDW-16.3* Plt Ct-222 [2187-7-14] 09:00AM BLOOD WBC-12.1* RBC-3.68* Hgb-10.0* Hct-31.0* MCV-84 MCH-27.1 MCHC-32.3 RDW-16.7* Plt Ct-282 [2187-7-15] 04:40AM BLOOD WBC-12.7* RBC-3.68* Hgb-10.2* Hct-30.6* MCV-83 MCH-27.8 MCHC-33.4 RDW-16.8* Plt Ct-286 [2187-7-16] 06:30AM BLOOD WBC-11.9* RBC-3.79* Hgb-10.5* Hct-32.4* MCV-86 MCH-27.6 MCHC-32.3 RDW-16.7* Plt Ct-337 [2187-7-8] 08:10AM BLOOD Glucose-162* UreaN-39* Creat-1.4* Na-136 K-4.4 Cl-101 HCO3-19* AnGap-20 [2187-7-16] 06:30AM BLOOD Glucose-200* UreaN-34* Creat-1.6* Na-129* K-4.8 Cl-95* HCO3-20* AnGap-19 [2187-7-8] 08:10AM BLOOD CK-MB-18* cTropnT-0.13* [2187-7-8] 07:30PM BLOOD CK-MB-17* MB Indx-2.9 cTropnT-0.28* [2187-7-9] 03:00AM BLOOD CK-MB-12* MB Indx-1.7 cTropnT-0.34* [2187-7-8] 08:10AM BLOOD tacroFK-4.1* [2187-7-16] 06:30AM BLOOD tacroFK-8.9 [2187-7-7] 6:10 pm BLOOD CULTURE Blood Culture, Routine (Final [2187-7-13]): STAPH AUREUS COAG +. [2187-7-8] 9:00 am BLOOD CULTURE SET 2. FINAL REPORT [2187-7-11] Blood Culture, Routine (Final [2187-7-11]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [Female First Name (un) 564] species. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [2187-7-9] 4:00 pm SWAB Site: GROIN RIGHT GROIN. GRAM STAIN (Final [2187-7-9]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2187-7-12]): STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final [2187-7-13]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [2187-7-9] 4:00 pm SWAB Site: LEG RIGHT THIGH [Month/Day/Year ]. GRAM STAIN (Final [2187-7-9]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. WOUND CULTURE (Final [2187-7-12]): STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S ANAEROBIC CULTURE (Final [2187-7-13]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [2187-7-10] 2:53 pm BLOOD CULTURE Source: Line-cvl. Blood Culture, Routine (Final [2187-7-16]): NO GROWTH. [2187-7-10] 5:45 pm BLOOD CULTURE Blood Culture, Routine (Final [2187-7-16]): NO GROWTH. CT abd/pelvis [2187-7-7]: 1. Post surgical change in the right groin subjacent to superior aspect of recently placed femoral to posterior tibial [Month/Day/Year ]. 2. Bilateral common femoral to popliteal grafts and right femoral to posterior tibial [Month/Day/Year ] are present, however, patency cannot be evaluated without contrast administration. 3. Moderate diffuse atherosclerotic disease. 4. 4.4 x 4.0 cm infrarenal aortic aneurysm. abdominal x-ray [2187-7-15]: No previous images. Bowel gas pattern is essentially within normal limits without evidence of obstruction or significant ileus. There are calcifications of the vas deferens bilaterally, suggesting the possibility of underlying diabetes. ECHO: Very poor image quality.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 probably moderately depressed (LVEF= 35 %) with global hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The ascending aorta is mildly dilated. The aortic valve is not well seen. No aortic regurgitation is seen. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Very poor image quality. Moderately depressed LVEF (35%). Compared to the prior report [2187-7-16] no definite change. US: IMPRESSION: 1. Minimally complex fluid in the left lower quadrant - consider CT if clinically warranted. 2. Small pleural effusion. 3. No hepatobiliary abnormality detected. CT SCAN [8-13]: IMPRESSION: 1. No left lower quadrant fluid collection is seen. Minimal free fluid in the abdomen without organized collection. 2. Small bilateral pleural effusions with associated compressive atelectasis. 3. Extensive atherosclerotic calcification of the aorta, coronary arteries, SMA, and renal arteries. There is a 4.3-cm saccular infrarenal abdominal aortic aneurysm, unchanged compared to prior. 4. Postoperative changes in the right groin. Brief Hospital Course: Patient was admitted to the vascular service and continued on vancomycin and Zosyn. Transplant nephrology was consulted for management of his immunosuppression and antihypertensives in the setting of sepsis. Patient's Coumadin was held and he was given vitamin K and started on a heparin drip. On [7-9], the decision was made the the patient's right leg was not salvageable due to critical ischemia, and he underwent a right below-knee amputation with excision of his prior [Month/Year (2) ]. Refer to Dr. [Name (NI) 47545] note for further details. The stump, thigh, and groin incisions were left open and packed, due to tissue and blood cultures positive for MRSA, and a JP drain was placed. Blood cultures obtain on [7-9] and since have been negative. Patient was transferred stable and extubated to the PACU and then to the VICU. Patient received 1 u pRBCs for an HCT of 26.6, with increase to 28.0. The heparin drip was discontinued. Due to patient's prior cardiac history, including a bypass and MI, serial troponins and EKGs (showing non-specific ST-T abnormalities) were obtained. Troponins range from 0.33 to 0.44. Patient was asymptomatic for chest pain and shortness of breath. On [7-10] home cellcept was restarted and antihypertensives were reintroduced. patient received 1 unit of pRBCs for an HCT of 25.9 with increase to 29.4. Cardiology was consulted and felt troponin elevation was due to demand ischemia. Home diltiazem was stopped and replaced with metoprolol. On [7-11] patient went to the OR for closure of his stump, thigh, and groin wounds after clearance from cardiology.Patient was diuresed for fluid overload (h/o CHF with EF 25-30%), with improvement in blood pressure. Patient's confusion, present since admission, had resolved. Since [7-14] sodium has ranged between 129 to 132, with institution of fluid restriction to 1 L and holding of home chlorthalidone. On [7-15] patient experienced nausea without vomiting. A cardiac workup and abdominal xray were negative. Patient had loose stools without abdominal pain, but c diff antigen was checked and was negative. Patient was evaluated by infectious disease for his bloodstream infection, with recommendations for 6 weeks of intravenous vancomycin. Patient worked with physical therapy since his amputation. From a surgical and infectious perspective patient was doing very well. His amputation site was healing well. The erythema had decreased. He had no fevers and his Wc and decreased to normal. However starting on [7-16] he began to have a rise in his creatinine. His ACE-I and lasix were stopped. Urine lytes looked c/w decreased pre-load but UA looked c/w ATN. Gentle IV fluids were re-instated. Tacrolimus level was elevated to 12 and with renal tx recommendations, dosing was decreased. On [7-22] the patient had flash pulmonary edema and was transferred to the ICU. He was stabilized on BIPAP. However, on [7-25] he acutely became hypotensive and developed severe R thigh pain. Zosyn was added empirically to his antibiotic regimen. A CT of the pelvis was done which revealed infection of his RLE bypass [Last Name (LF) ], [First Name3 (LF) ] he was taken to the operating room emergently and the [First Name3 (LF) ] was resected. Likely due to this second hypotensive insult, his transplant kidney stopped working. He was started on CVVHD and gradually transitioned to intermittent HD. His left upper extremity fistula was difficult to access because it was too deep, so a right IJ tunneled dialysis line was placed by IR. A VAC dressing was applied to his open thigh wound and eventually transitioned to wet to dry dressings. Gastroenterology was consulted after he had several episodes of guaiac positive stools Cdif was sent on multiple occasions but always returned negative. Eventually he was extubated successfully and transferred to the VICU. Psychiatry was consulted for his depressed affect and he was started on citalopram. Nutrition became an issue, as his appetite was decreased due to depression and he could not tolerate tube feeding via a dobhoff. He was started on Marinol and his PO intake improved. He worked with physical therapy and it was determined that he needed acute rehab. He also had an EGD on [8-20] that was grossly normal. By the time of discharge his oral intake was improved. He was still getting intermittent dialysis three times a week. His mood was somewhat improved. His vital signs were stable. To note recieved four weeks Zosyn, this was DC. He will remain on Vancomycin untill follow-up with ID. Medications on Admission: Humalog SS/Insulin detemir 30U AM, Coumadin 5mg (held) Prograf 0.5 mg qAM/ 0.5mg qPM, Diovan 80mg daily Diltiazem 30mg QID, Isosorbide mononitrate 30mg daily Lipitor 80mg daily, Metolazone 2.5mg qMon Lasix 80mg daily, Aspirin 325mg daily Cellcept 250mg [Hospital1 ], Chlorthalidone 50mg [Hospital1 ] Discharge Medications: 1. glucagon (human recombinant) 1 mg Recon Soln [Hospital1 ]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 3. nystatin 100,000 unit/g Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 4. camphor-menthol 0.5-0.5 % Lotion [Hospital1 ]: One (1) Appl Topical DAILY (Daily) as needed for itching. 5. levothyroxine 25 mcg Tablet [Hospital1 ]: 0.5 Tablet PO DAILY (Daily). 6. sodium chloride 0.65 % Aerosol, Spray [Hospital1 ]: [2-11] Sprays Nasal [Hospital1 ] (2 times a day) as needed for stuffy nose. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: Four (4) Inhalation Q4H (every 4 hours) as needed for wheezes. 8. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezes. 9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [Hospital1 ]: [2-11] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 10. citalopram 20 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 13. ipratropium bromide 0.02 % Solution [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 14. miconazole nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical TID (3 times a day) as needed for yeast. 15. acetaminophen 325 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 16. aspirin 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 17. atorvastatin 80 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 18. insulin regular human 100 unit/mL Solution [Last Name (STitle) ]: One (1) Injection ASDIR (AS DIRECTED). 19. dronabinol 2.5 mg Capsule [Last Name (STitle) ]: Two (2) Capsule PO BID (2 times a day). 20. nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO QID (4 times a day) as needed for thrush. 21. metoprolol tartrate 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO Q6H (every 6 hours). 22. midodrine 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 23. tacrolimus 0.5 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO Q12H (every 12 hours). 24. mirtazapine 15 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO QHS (once a day (at bedtime)) as needed for for sleep. 25. B complex-vitamin C-folic acid 1 mg Capsule [Last Name (STitle) ]: One (1) Cap PO DAILY (Daily). 26. mycophenolate mofetil 250 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO TID (3 times a day). 27. digoxin 125 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 28. loperamide 1 mg/5 mL Liquid [Last Name (STitle) ]: One (1) PO TID (3 times a day). 29. 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. 30. heparin (porcine) 1,000 unit/mL Solution [Last Name (STitle) ]: One (1) Injection PRN (as needed) as needed for line flush. 31. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 32. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 33. Calcium Gluconate 2 g IV PRN ICa<1.12 34. Vancomycin 500 mg IV HD PROTOCOL 35. Ondansetron 4 mg IV Q8H:PRN nausea 36. 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. 37. Coumadin 1 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day: MD will adjust to keep INR [3-15]. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: Infected occluded right femoral to posterior tibial artery bypass, s/p right BKA MRSA sepsis s/p kidney transplant ATN currently HD dependent hyponatremia cardiac demand ischemia atrial fibrillation, rate-controlled type 2 diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane) d/t R BKA Discharge Instructions: You underwent a right leg below-knee amputation and [Location (un) ] excision for infection and thrombosis. During your hospital course, you received hemodialysis to facilitate your kidneys post-operatively/ 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: . 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 Followup Instructions: Call Dr.[Name (NI) 1392] office at ([Telephone/Fax (1) 4852] to schedule an appointment to be seen in 2 weeks after discharge. [2187-9-4] 10:10a ID,[Location (un) ],[Location (un) ] LM [Hospital Unit Name ], BASEMENT ID WEST (SB) Call [Telephone/Fax (1) 673] to schedule an appointment with the transplant service (Dr. [Last Name (STitle) ]. You will need your your AV fistula superficialized once you are off antibiotics. You do not have aa cardiologist, you should make an appointment with a cardiogist regarding your new-onset atrial fibrillation. After rehab you should make an appointment with a psychiatrist in your area. You should follow up with nephrology at the [Hospital6 ] Completed by:[2187-8-24]	[ "5845", "99592", "2761", "2851", "2762", "4019", "42731", "4280", "2767", "4241", "V4581", "V1582", "V5861", "V5867" ]
Admission Date: [2122-12-10] Discharge Date: [2122-12-15] Date of Birth: [2066-8-6] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 165] Chief Complaint: throat pain Major Surgical or Invasive Procedure: [2122-12-10] Cardiac Catheterization [2122-12-11] Coronary Artery Bypass x3(Free LIMA/off SVG-LAD, SVG-PDA, SVG-OM) History of Present Illness: Ms. [Location (un) 91020] is a 56 year old woman without a prior CAD history who was admitted to [Hospital6 ] on [2122-9-3] with an acute MI. She had been at work and was experiencing lower back pain, a headache and throat discomfort. She did not have chest pain. Per report, at [Hospital1 112] she had anterior and inferior ST elevation, with some anterior R wave loss. . Cath at [Hospital1 112] revealed a small LM (smaller than the 6F guide). The LAD had a 99% stenosis in the mid vessel with TIMI 2 flow. The mid Cx had a 90% stenosis and the dominant RCA had a 90% stenosis. Surgery was consulted for potential CABG. Subsequent LV gram showed severe anterior wall hypokinesis. Based upon this and poor R wave progression on her EKG, she was turned down for CABG. The decision was made for PCI and the LAD was treated with DES. . In [2122-10-1] the patient underwent surveillance stress testing. Imaging revealed a moderate zone of ischemia involving the LV apex and anterior apical region. There was also a probable small anterior septal apical region that was fixed. LVEF was 62% with anterior hypokinesis, and apical dyskinesis/akinesis. As the patient was asymptomatic at the time, medical management was continued. . The patient had been in cardiac rehab since then. Last thursday while on the stationary bicycle she developed throat discomfort similar to what she experienced at the time of her MI. SL nitroglycerin relieved her pain. On [2122-12-8] the patient had similar discomfort while walking in her house, resolving with relaxation. She was therefore admitted for elective cardiac cath. Cath this morning revealed: LMCA: diffusely small with at least 70% at bifurcation LAD: mid stent widely patent LCX: sequential 80% proximal and mid lesions RCA: 60% mid; 80% lesion before bifurcation She is now being admitted for workup prior to CABG. . On arrival to the floor, patient denies any pain or SOB. . REVIEW OF SYSTEMS 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, or hemoptysis. 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, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Coronary Artery Disease, s/p CABG x 3 on [2122-12-11] PMH: Hyperlipidemia [2122-8-31]: Anterolateral MI, s/p LAD stenting (known 90% Cx and RCA disease untreated) Occasional rectal bleeding d/t hemorrhoids Psoriasis Past Surgical History: C-section x 2 Hernia repair Social History: - Tobacco: Patient smoked about 1 ppd x 17 years. Quit [Month (only) 216], [2122] - ETOH: None - Illicits: Denies - Patient is separated with two children, ages 19 and 17. She lives alone. - Works in an administrative position for Youth Services. Family History: Mother with CABG in her late 60's. Physical Exam: On Admission: VS: 96.9 125/41 56 16 100% on RA GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Plaques on extensor surfaces of elbows and knees consistent with psoriasis. Right femoral cath site clean with intact dressing. No tenderness, hematoma, or bruit. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs: [2122-12-10] 11:30AM BLOOD WBC-7.3 RBC-4.16* Hgb-12.1 Hct-36.1 MCV-87 MCH-29.2 MCHC-33.6 RDW-14.7 Plt Ct-284 [2122-12-10] 11:30AM BLOOD PT-12.8 PTT-32.0 INR(PT)-1.1 [2122-12-10] 11:30AM BLOOD Glucose-118* UreaN-15 Creat-0.9 Na-137 K-3.9 Cl-103 HCO3-24 AnGap-14 [2122-12-10] 11:30AM BLOOD ALT-17 AST-17 CK(CPK)-55 AlkPhos-71 Amylase-110* TotBili-0.1 [2122-12-11] 03:50AM BLOOD CK-MB-1 cTropnT-<0.01 [2122-12-10] 11:30AM BLOOD Albumin-4.1 [2122-12-10] 11:30AM BLOOD %HbA1c-5.8 eAG-120 . Discharge Labs: [2122-12-15] 05:45AM BLOOD WBC-10.1 RBC-3.14* Hgb-9.5* Hct-27.8* MCV-89 MCH-30.2 MCHC-34.1 RDW-14.2 Plt Ct-281 [2122-12-14] 05:02AM BLOOD WBC-12.5* RBC-3.06* Hgb-9.2* Hct-27.3* MCV-89 MCH-30.1 MCHC-33.7 RDW-14.3 Plt Ct-199 Intra-op TEE [2122-12-11] Conclusions PRE-CPB:1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. During a period of iscemia, with PA pressures of 75/45, the mitral regurgitation increased to 2+. After nitroglycerine therapy, the MR was trace. Dr. [Last Name (STitle) ] was notified in person of the results.] POST-CPB: On infusions of phenylephrine and nitroglycerine. A-pacing. Preserved systolic function from precpb. LVEF = 45%. Anteroseptal and anterior hypokinesis. MR, AI are 1 +. There was one episode of elevated PA pressures following a volume transfusion that resulted in transient 2+ MR, which responded to nitroglycerine. The aortic contour is normal post decannulation Brief Hospital Course: The patient was brought to the operating room on [12-11] where the patient underwent a [2122-12-11] CABG x3(Free LIMA/off SVG-LAD, SVG-PDA, SVG-OM). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. She developed nausea and was treated with Reglan and Zofran. There was no ileus on KUB. Narcotics were discontinued. Plavix was resumed for previous stents and poor targets. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. Medications on Admission: CAPTOPRIL 6.25 mg TID, CLOPIDOGREL 75 mg Daily, METOPROLOL SUCCINATE 50 mg Daily, NITROGLYCERIN 0.4 mg SL PRN, OMEPRAZOLE 20 mg Daily, ROSUVASTATIN 20 mg Daily, ASPIRIN 325 mg Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:40 Tablet(s) Refills:0 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 9. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 5 days. Disp:10 Tablet Extended Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA [Location (un) 5087] Discharge Diagnosis: Coronary Artery Disease, s/p CABG x 3 on [2122-12-11] PMH: Hyperlipidemia [2122-8-31]: Anterolateral MI, s/p LAD stenting (known 90% Cx and RCA disease untreated) Occasional rectal bleeding d/t hemorrhoids Psoriasis Past Surgical History: C-section x 2 Hernia repair Discharge Condition: DISCHARGE CONDITION: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace to 1+ 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 and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Dr.[Name (NI) 11272] office will call you with the following appointments: Wound Check: Surgeon: Dr. [Last Name (STitle) ],[First Name3 (LF) ] - [Telephone/Fax (1) 170] Cardiologist: Dr. [First Name (STitle) ] [First Name8 (NamePattern2) ] [Doctor Last Name ] Please call to schedule the following: Primary Care in [5-5] weeks. Name: [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Address: [Street Address(2) 4472],[Apartment Address(1) 24519], [Hospital1 ],[Numeric Identifier 9331] Phone: [Telephone/Fax (1) 18325] Fax: [Telephone/Fax (1) 18324] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2122-12-15]	[ "41401", "412", "2724", "V4582" ]
Admission Date: [2164-10-22] Discharge Date: [2164-10-31] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2777] Chief Complaint: Incidental asymptomatic left subclavian artery aneurysm Major Surgical or Invasive Procedure: [2164-10-22] - PROCEDURE: Right carotid to left carotid bypass with 6 mm PTFE, left carotid to left subclavian transposition [2164-10-23] - PROCEDURES: 1. Stent graft repair of aortic arch/left subclavian artery aneurysm with a [Doctor Last Name 4726] TAG endograft. The endograft data is the following: It is a [Doctor Last Name 4726] TAG graft, reference#[Serial Number 80235], lot #[Serial Number 80236]. 2. Thoracic aortography. 3. Placement of an aortic conduit for delivery of the stentgraft. [2164-10-23] - PROCEDURE: Thoracic aortic stent graft placement. History of Present Illness: Ms. [Known lastname ] is an 86-year-old woman referred by Dr. [Last Name (STitle) 29111] [Name (STitle) 11302] for evaluation of a newly detected asymptomatic left subclavian artery aneurysm. She had not been seen by doctor in many years, but was noticing difficulty with vision. She saw an ophthalmologist in preparation for cataract surgery. Her preoperative evaluation detected hypertension and significant hyperlipidemia. A chest x-ray, as part of the preoperative evaluation, noted a mass in the upper left chest prompting a CT scan, which demonstrates a 4-cm pseudoaneurysm originating at the inferior aspect of the origin left subclavian artery. She denies any history of major trauma, specifically she does not recall any motor vehicle accidents or major falls. She is a long-term smoker and ongoing smoker smoking three quarters of a pack per day. She does have newly diagnosed hypertension and hyperlipidemia. She does not have diabetes. She has no family history of aneurysms. She has not had any stroke or left arm ischemia or embolization and is not having any chest pain or arm swelling. Past Medical History: PMH: HTN, Chol PSH: neg Social History: She is a homemaker. She does not drink alcohol Family History: non-contrubutory. She has no family history of aneurysms Physical Exam: a/o x 3 supple farom neg lymphandopathy cta rrr pos bs surgical incision c/d/i Pulses: Fem DP PT [Name (NI) 1035] [Name (NI) ] Uln Rt 2+ D D 2+ 2+ mono Lt 2+ D D 2+ 2+ mono Pertinent Results: [2164-10-25] - [Hospital1 18] ECHOCARDIOGRAPHY REPORT - The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is asymmetric left ventricular hypertrophy in the basal septum. Mid to apical septum wall thickness appears to be normal. No mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The mitral valve leaflets are structurally normal. Moderate to severe eccentric jet (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension with estimated pulmonary [Last Name (un) ] systolic pressure around 40 mm Hg. There is no pericardial effusion. Radiology Report CTA NECK W&W/OC & RECONS Study Date of [2164-10-25] 5:39 AM The CT scan does not reveal a discrete area of change of density of the brain to suggest that there has been a new stroke. IMPRESSION: Extensive postoperative changes and other findings as noted above. Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [2164-10-25] 5:40 AM IMPRESSION: 1. No pulmonary embolism is noted. 2. Moderate bilateral pleural effusion and bibasilar atelectasis. 3. Status post stent grafting of aortic arch for exclusion of the pseudoaneurysm of aortic arch and status post tying off of the origin of the left common carotid artery. 4. Pathologically enlarged anterior precarinal node. Since this node was not as prominent on the prior study of [2164-10-9], an infectious etiology is suggested as a cause. 5. Small amount of high-density fluid in the abdomen. 6. possible splenic infarct. Radiology Report CHEST (PORTABLE AP) Study Date of [2164-10-25] 11:55 AM IMPRESSION: 1. ET tube in satisfactory position approximately 6.1 cm above carina. 2. Aortic stent with density related to known pseudoaneurysm stable compared with earlier the same day. 3. Small bilateral effusions. 4. Review of recent CT for correlation revealed a mass in right breast, possibly a seroma, dense cyst or dilated duct, but not fully characterized on this exam. A similar smaller left breast mass is also present. Clinical correlation and, if clinically indicated, further assessment with mammography or ultrasound should be considered, to conclusively exclude a neoplasm. [2164-10-30] 06:25AM BLOOD WBC-9.4 RBC-3.37* Hgb-10.1* Hct-30.9* MCV-92 MCH-30.0 MCHC-32.7 RDW-14.2 Plt Ct-313 [2164-10-29] 04:11AM BLOOD PT-11.9 PTT-24.7 INR(PT)-1.0 [2164-10-30] 06:25AM BLOOD Glucose-112* UreaN-17 Creat-0.6 Na-144 K-4.0 Cl-105 HCO3-30 AnGap-13 [2164-10-29] 04:11AM BLOOD Calcium-8.7 Mg-1.7 [2164-10-25] 06:31PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2164-10-30] 4:41 am STOOL CONSISTENCY: WATERY CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2164-10-30]): Feces negative for C.difficile toxin A & B by EIA. Brief Hospital Course: This is a 86F admitted for a Lt subclavian aneurysm She agreed to have an elective surgery. Pre-operatively, she was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. This was a staged procedure. [10-22] PROCEDURE: Right carotid to left carotid bypass with 6 mm PTFE, left carotid to left subclavian transposition She was prepped, and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She/ tolerated the procedure well without any difficulty or complication. Post-operatively, she was extubated and transferred to the CVICU for further stabilization and monitoring. She was kept NPO for the next part of her procedure. [10-23]: PROCEDURES: 1. Stent graft repair of aortic arch/left subclavian artery aneurysm with a [Doctor Last Name 4726] TAG endograft. The endograft data is the following: It is a [Doctor Last Name 4726] TAG graft, reference #[Serial Number 80235], lot #[Serial Number 80236]. 2. Thoracic aortography. 3. Placement of an aortic conduit for delivery of the stent graft which was performed Dr. [Last Name (STitle) ]. She was prepped, and brought down to the operating room for surgery. Intra-operatively, she was closely monitored and remained hemodynamically stable. She/ tolerated the procedure well without any difficulty or complication. Post-operatively, she transferred to the CVICU for further stabilization and monitoring. She was intubated. She had a epidural for pain control. Pain Service was following her. [10-24]: Nitro drip for pressure suport, pain control with Epidural, foley to gravity, intubated. [10-25]: Pressors remain, pain control with Epidural, foley, NGT and OGT for feeding, had increase in 02 requirements. CXR obtained. SQ hep, MPB's. Found to have pulmonary edema, Lasix drip to keep negative (cr stable) Pt experienced Right arm weakness, Neurology consult obtained. Epidural removed, Heparin IV started, Lasix drip for diuresis. CT scan negative. Resolution of arm weakness in the same day (thought to be peripheral not central). TPN for feeding. Remained intubated [10-26]: Pressors, heparin drip remained, foley gravity, lasix drip to keep negative (cr stable). TPN remained. Cardiolgy consulted for new MR found on echo intra - op. Recommended BB. Pt extubated without difficulty. [10-27]: Neurologically intact after extubation, remained on neo for pressure support, lasix DC'd, TF remained. diet advanced, heparin drip remained. foley to gravity. [10-28]: Changed to PO meds from IV, Heparin drip DC'd, OOB to chair, Neo weaned, foley to gravity. Pt much improved, OGT and NGT removed. [10-29] - [10-31] She was then transferred to the VICU for further recovery. While in the VICU she recieved monitered care. When stable she was delined. Her diet was advanced. A PT consult was obtained. When she was stabalized from the acute setting of post operative care, she was transfered to floor status. Tele DC'd. On the floor she remained hemodynamically stable with his pain controlled. She progressed with physical therapy to improve her strength and mobility. She continues to make steady progress without any incidents. Shewas discharged to a rehabilitation facility in stable condition. To note she did have an increase in her WBC. Also had looses stool. C-Diff negative. Stable for DC to rehab. creatinine at baseline. Medications on Admission: [Last Name (un) 1724]: Zocor 20' Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: Left Subclavian Artery Aneurysm Discharge Condition: Good Discharge Instructions: Post Surgery Wound Care Overview Your doctor has placed sutures (stitches) to keep the incision closed for proper wound healing. Sometimes, sutures need to be removed in a few weeks. Sometimes, the sutures are all under the skin and will eventual dissolve on their own and do not need to be removed. In either case, please follow these routine wound care instructions. Leave the original bandage that was applied at the time of your surgery in place for 48 hours. If the bandage should become loose, reinforce the dressing with surgical tape. After approximately 48 hours, you can gently remove the bandage. If you have steri-strips on your incision (little white paper tapes), keep them in place until they begin to fall off on their own. Do not pull the steri-strips off as this could put stress on the incision line. When the steri-strips start to peel off, they can be gently washed off. Please try to keep the incision line clean and dry. You can shower and gently wash the incision line with soap and water. Dry the incision area and keep the incision line open to air. It is not necessary to apply antibiotic ointment, alcohol, hydrogen peroxide, or a new bandage to the incision line. If your sutures get caught on your clothing or there is a small amount of drainage from the incision, you may want to cover it with small gauze for your own comfort. If so, please use as little tape as possible to hold the gauze in place as tape can irritate the skin. A small amount of drainage from the incision in the first few days after surgery is not unusual and it will probably resolve on its own. However, if you should notice bleeding from the surgical site, apply firm direct pressure for ten minutes. If the bleeding persists, reapply firm direct pressure for an additional ten minutes. If the bleeding does not stop after 20 minutes, call our contact phone numbers or go to the nearest emergency room for assistance. What to Avoid Please avoid the following: Do not submerge the incision line under water for a prolonged period of time with activities like taking a bath, swimming, or sitting in a hot tub. Do not participate in any vigorous activities or exercises that may put stress on the incision. Do not take aspirin, ibuprofen, or any other nonsteroidal anti-inflammatory medication that may cause problems with bleeding unless instructed by your doctor. Do not apply perfumes or scented lotions to the sutures as this may cause irritation. When to Call the Doctor Please contact us immediately if you develop: Fevers, chills, or night sweats Increasing redness, pain, or pus at the incision Bleeding that does not stop with firm pressure Followup Care If your sutures need to be removed, this is usually done [12-1] weeks after surgery. Even if your sutures will dissolve, the doctor usually likes to examine the incision while it is healing. Therefore, you should have been scheduled for a follow-up appointment in clinic at the time of your discharge from surgery. As this appointment is very important, please contact the clinic if you do not have one scheduled or you need to change the date and/or time. Followup Instructions: An breast cyst/mass was seen on your CT scan from [10-25] and on subsequent x-rays. You should schedule a mammography with your primary care physician to [Name9 (PRE) 702] on this breast mass. You should also schedule a follow-up appointment with your Dentist in reference to your tooth which was chipped during the process of intubation. Completed by:[2164-10-31]	[ "4019", "2720" ]
Admission Date: [2166-12-25] Discharge Date: [2167-1-17] Date of Birth: [2100-11-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 826] Chief Complaint: Infected right AV graft Major Surgical or Invasive Procedure: Excision of right arm AV graft Placement of right IJ permacath on [2166-12-28] Placement of a right groin temporary HD catheter Placement of a right tunneled HD line on [2167-1-9] History of Present Illness: 66 year-old male with multiple medical problems including CAD status post CABG, HTN, PAF not on anticoagulation [1-21] history of GI bleed, and ESRD on hemodialysis who has had multiple RUE AV access procedures. He was found to have an exposed RUE AV fistula/graft in clinic on [2166-12-25], and was sent to Pre-Op for a planned repair where he became febrile to 103.0, with chills. No headache, sore throat, cough, chest pain, shortness of breath, N/V, rash or abdominal pain. Mr. [Known lastname ] does not void. Past Medical History: 1. Coronary artery disease s/p MI in [12/2164], status post 2 stents to the LAD. Cath in [1-/2165] revealed re-stenosis of both stents. He is status post 3-vessel CABG on [2165-2-20] with LIMA to LAD, saphenous vein to RCA, saphenous vein to OM. 2. ESRD x 5 years on HD (MWF), felt secondary to HTN 3. Status post CVA in [2149] with residual left-sided hemiparesis 4. Hypertension 5. UGIB after cardiac cath on [12/2164] 6. Gout 7. Pancreatitis 8. Diverticulosis 9. History of multiple E coli bacteremias 10. Anemia of chronic disease 11. Hypercholesteremia 12. COPD 13. Afib/Aflutterm, not on anticoagulation secondary to history of GI bleed. Social History: The patient lives at home with his wife & daughter in a [Location (un) 6332] apartment with an elevator. No VNA care was necessary prior to admission, and the patient could attend to all of his own ADLs. Family History: Mother with hypertension No history of no strokes, seizures, or heart disease Physical Exam: Per transplant surgery admission note on [2166-12-25]: VITALS: T 193, HR 99, BP 130/59, RR 18 GEN: In NAD. Alert and oriented X 3. HEENT: No icterus. Clear OP. LN: No cervical or axillary LAD RESP: Chest CTA bilaterally. No wheezes. CVS: RRR. GI: BS normoactive. Abdomen soft and non-tender. No hernia. No mass. EXT: No pedal edema. Calves non-tender. INTEGUMENT: No rash. Pertinent Results: Admission labs [2166-12-25]: WBC-11.5# HGB-11.8 HCT-35.2* PLT COUNT-166 GLUCOSE-139* UREA N-56* CREAT-9.3# SODIUM-135 POTASSIUM-4.2 CHLORIDE-90 TOTAL CO2-31* ANION GAP-18 ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-145* TOT BILI-0.4 ALBUMIN-4.3 CALCIUM-11.2* PHOSPHATE-4.4 MAGNESIUM-1.9 PT-13.9* PTT-27.7 INR(PT)-1.2 [2166-12-25] EKG: Afib, rate 104. Lateral ST-T wave changes. [2166-12-25] CXR: No acute disease Relevant studies in hospital: [2166-12-30] CT HEAD: FINDINGS: There is an area of decreased attenuation involving the white and [Doctor Last Name 352] matter of the posterior left frontal lobe. This could be consistent with an evolving infarct. Diffuse areas of low attenuation in the periventricular white matter is consistent with chronic microvascular angiopathy. No intracranial mass lesion, hydrocephalus, or shift of normally midline structures is apparent. There is no evidence of intracranial hemmorage. Numerous calcifications are noted in the sulci, brain parenchyma and ventricles. Osseous and soft tissue structures are unremarkable. IMPRESSION: 1. Likely evolving infarct of the left posterior frontal lobe, which would be consistent with the patient's history of new expressive aphasia. 2. Numerous intracranial scattered calcifications, which could represent prior cystercercosis infection. Clinical correlation is recommended. 3. No evidence of intracranial hemorrhage. [2166-12-30] MRI HEAD: There is a wedge-shaped area of slow diffusion in the ventral portion of the left pons, consistent with an acute infarction. There is also slow diffusion involving the posterior aspect of the insular cortex, operculum, and anterior aspect of the left parietal lobe consistent with an acute infarction. There are multiple areas of increased T2 signal in the periventricular subcortical white matter consistent with chronic small vessel infarctions. There is also a region of magnetic susceptibility artifact in the posterior right thalamus, consistent with sequela from a prior intraparenchymal hemorrhage. There is associated Wallerian degeneration in the right cerebral peduncle. There are multiple areas of magnetic susceptiblity artifact throughout both cerebral hemispheres, which correspond to the multiple intraparenchymal calcifications, consisent with sequela from prior cystercercosis infection. On the postcontrast images, there is no abnormal enhancement in the brain parenchyma. In the MRA images, there is no evidence of a vascular occlusion, stenosis, or aneurysm involving the arteries in the circle of [Location (un) 431]. There is some motion artifact which limits the study. We do not have a good evaluation of the distal smaller branches of the intracerebral vasculature. The vertebral arteries, basilar arteries, intracranial internal carotid arteries, and the middle and anterior cerebral arteries are patent. There is a small T1- and T2-hyperintense mass in the soft tissues of the left frontal scalp. This may represent a small sebaceous or proteinaceous cyst. IMPRESSION: Acute infarctions involving the left ventral pons and the posterior left insular cortex, left temporal operculum, and left anterior parietal lobe. [2166-12-31] U/S carotids: Bilateral < 40% stenosis [2166-12-31] TTE: The left atrium is elongated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [2165-3-4], there is no significant change. [2167-1-6] TEE: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The interatrial septum is aneurysmal with a very small superior left-to-right shunt color Doppler at rest. 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. There are complex (>4mm non-mobile) atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened but severe aortic stenosis is not suggested and no discrete vegetations are seen. Mild to moderate ([12-21]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened but no discrete vegetations are seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: 66 year-old male with multiple medical problems including CAD s/p CABG, PAF on no anticoagulation [1-21] history of GU bleed, HTN, and ESRD on HD, admitted with an exposed and infected AV graft. His hospital course will be reviewed by problems. 1) Exposed/infected AV graft and MSSA bacteremia: Mr. [Known lastname ] was initially admitted to the transplant surgery service and taken to the OR on [2166-12-25] for the emergent removal of his exposed/infected RUE AV graft. The infected portions were removed. A temporary right groin HD catheter was placed. He was initially started on empiric Vancomycin, Levofloxacin and Flagyl. Blood cultures drawn on [2166-12-25] eventually all grew methicillin-sensitive Staph aureus, 6/6 bottles. Flagyl was D/C'd, and Vancomycin was eventually switched to Linezolid PO, which unfortunately was ordered but never approved. He received a short course of Oxacillin ([2166-12-30]), and ID was consulted on [2166-12-31], at which time antibiotics were switched to Cefazolin 2gm IV with hemodialysis ([2166-12-31]). Blood cultures from [12-26] grew MSSA 1/4 bottles. Surveillance blood cultures on [12-27] and [12-31] negative. Given his Staph aureus bacteremia, a TTE was performed on [2166-12-31] which was negative for vegetations. A TEE was subsequently performed on [2167-1-6], which was also negative for vegetations, although it revealed a small ASD. Nonetheless, per ID, given his high-grade staphylococcus aureus bacteremia on admission, removal of only the infected portions of the AV graft (? ends), negative TEE but possibly in the setting of having already thrown a vegetation, decision was taken to complete 6 weeks of antibiotherapy. Hence, plan is to continue Cefazolin 2 gm IV with hemodialysis, counting from [2166-12-27] (first negative blood cultures). Last dose on [2167-2-7]. 2) CVA: Mr. [Known lastname ] has a known history of PAF, and was not on anticoagulation on admission given a prior history of GI bleed. He also has a prior history of CVA, with residual left hemiparesis. On [2166-12-30], Mr. [Known lastname ] was noted to have new expressive aphasia, with a left sided mouth droop. CT head and MRI head were consistent with an acute infarct involving the left ventral pons and the posterior left insular cortex, left temporal operculum, and left anterior parietal lobe. Neurology was consulted, and Mr. [Known lastname ] was started on anticoagulation with Coumadin, as well as aspirin. Goal MAP>90. Of note, given his poor vascular access, Heparin could not be given. Lovenox was also not an option in the setting of his ESRD. Coumadin was temporarily held on [2167-1-9] for line placement. The etiology of his CVA was felt most likely cardioembolic in the setting of known PAF (in atrial fibrillation in hospital) and no anticoagulation. Septic embolus was also a concern given his MSSA bacteremia. Hence, he underwent a TTE on [2166-12-31], which was negative for vegetations. A carotid ultrasound revealed bilateral <40% stenosis of his carotids. A TEE was also performed on [2167-1-6], which was also negative for vegetations, although it revealed a small ASD. He is to remain on anticoagulation with goal INR [1-22], as well as ASA. He will need follow-up of his INR. INR 1.3 at discharge. Follow-up to be arranged with the [Hospital3 ]. 3) ESRD: Mr. [Known lastname ] was followed by the renal service throughout his stay. He was continued on hemodialysis 3 times per week. Meds were renally dosed. Of note, while in hospital, he was noted to have persistent hyperkalemia despite hemodialysis, which was felt secondary to dietary indiscretions and food brought by family. He was kept on a low potassium diet, with good results. He will need continued close monitoring of his electrolytes, especially phosphate with possible up titration of his meds. Of note, Mr. [Known lastname ] has extremely poor vascular access. Temporary lines were placed in his right groin and right IJ. A tunneled HD line was placed on [2167-1-9]. Permanent vascular access should be delayed until after completion of 6 weeks of IV antibiotics and documentation of sterile blood cultures 3 days after discontinuation of antibiotics. 4) CAD: Mr. [Known lastname ] has known CAD, and is status post CABG. No acute issues in hospital. He was continued on ASA, statin, ACE inhibitor. It is unclear why he is not on a beta-blocker as an out-patient. 5) Anemia: Mr. [Known lastname 32641] hematocrit was between 28-34 while in hospital. Iron studies on [2167-1-6] revealed Fe 43, TRF 148, Ferritin [2142], TIBC 192. He was transfused a single unit of PRBCs on [2166-12-29], and remained fairly stable afterwards. Hematocrit 28.8 at discharge. 6) FEN: Cardiac heart healthy ([2-20] gm Na)/ Renal diet. Ensure low potassium. Medications on Admission: Lipitor 10mg qd Nephrocaps 1 [Hospital1 ] Protonix 40mg qd Renagel 1200mg tid ASA 325mg qd Norvasc 5mg qd Clonidine 0.1mg [Hospital1 ] Enalapril 20mg qd Discharge Medications: 1. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Cefazolin Sodium 10 g Recon Soln Sig: Two (2) grams Injection Q HEMODIALYSIS (). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sevelamer HCl 400 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2 days: Please give Coumadin 5 mg PO QHS on [2167-1-10] and [2167-1-11] and check INR daily. Please adjust subsequent Coumadin dose for goal INR [1-22]. INR on [2167-1-10] 1.3. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Infected right arm AV graft Staphylococcus aureus bacteremia Atrial fibrillation Cerebrovascular accident End-stage renal disease Secondary diagnoses: Coronary artery disease Discharge Condition: Patient stable at discharge. Discharge Instructions: Please see below for recommended follow-up appointments. Please take all medications as prescribed. Please return to the ED if you develop recurrent temperature >101.5, weakness, slurred speach, confusion, chest pain, shortness of breath, redness or drainage from right groin catheter, increased redness or drainage from right arm, persistent pain, or any other worrisome symptoms. Followup Instructions: With Dr. [First Name (STitle) ] in one week. Please call for appt. [Telephone/Fax (1) 673] Please call your nephrologist and schedule an appointment to see him within 1 week of discharge. You will continue HD 3 times per week. Please call your PCP and schedule and appointment to see him/her withinh 2 weeks of discharge. We will call the neurology clinic at [Hospital1 18] and schedule an appointment. We will call you with the appointment date and time. You will need follow-up in the [Hospital3 ]. We will notify you with your appointment date and time. Completed by:[2167-1-10]	[ "496", "42731", "40391", "2767", "V4581", "2859" ]
Admission Date: [2175-12-11] Discharge Date: [2175-12-17] Date of Birth: [2175-12-11] Sex: F Service: NB HISTORY: Infant Girl [Known lastname ] III is a 34 [5-10] week triplet born to a 31 year old gravida I, para 0 mother with the following maternal laboratories: O positive, antibody negative, hepatitis B negative, RPR nonreactive, rubella immune, GBS unknown. Antepartum history was remarkable for in [Last Name (un) 5153] fertilization with resulting triplets. The mother had one prior admission at 29 weeks for preterm labor at which time she was treated with magnesium sulfate and betamethasone. On the day of delivery mom was found to be hypertensive at which time she was referred in for hospitalization for pregnancy-induced hypertension evaluation. Mother was found to be in preterm labor and she underwent a cesarean section under spinal anesthesia. Infant Girl [Known lastname ] III was born with spontaneous respirations and vigorous tone. Apgars were 8 and 9 at one and five minutes. The patient required no supplemental oxygen nor further resuscitative measures at birth. PHYSICAL EXAMINATION: On admission birth weight is 1870 grams, length 31.5 cm, head circumference 30.5 cm. Vital signs: Temperature 98, heart rate 188, respiratory rate 42, blood pressure 57/40. General: A preterm female on radiant warmer in no apparent distress. Head, eyes, ears, nose and throat: AFOF, oropharynx clear, palate intact. Neck supple, no crepitus. Respiratory: Clear to auscultation bilaterally, good air entry, no retractions noted. Cardiac: Regular rate and rhythm, S1, S2 normal, no murmur on examination. Abdomen: Soft, nondistended, normal active bowel sounds, no hepatosplenomegaly. Extremities: No cyanosis or edema, well perfused, femoral pulses 2 plus and brisk bilaterally. Spine intact, no dimpling, no Ortolani or Barlow's sign present. Neurologic: Appropriate tone on examination, spontaneous movement of all four extremities, suck, Moro, plantar and palmar grasp intact. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: This patient remained stable on room air at birth and remained on room air throughout her hospital course. She exhibited no signs of apnea of prematurity throughout her hospitalization. 2. CARDIOVASCULAR: This patient remained cardiovascularly stable throughout her hospital course. 3. FLUID, ELECTROLYTES AND NUTRITION: Patient was placed on D10W at 80 cc per kilo per day on day of life one. On day of life two patient was started on P.O. enteral feeds of Special Care 20 kilocalories per ounce or breast milk. On day of life three patient was on breast milk or Special Care 20 at 100 cc per kilo per day P.O./p. g. with no signs of intolerance. Discharge weight is 1735g. 4. GASTROINTESTINAL: The patient's bilirubin was 10.8 on the day of transfer; phototherapy was started. 5. INFECTIOUS DISEASE: No CBC or blood cultures were obtained from this patient secondary to the fact that there were no maternal risk factors for infection. 6. NEUROLOGY: Patient remained neurologically stable with a normal examination throughout her hospital course. 7. CARDIOLOGY: No hearing screening was performed prior to transfer on this patient. 8. OPHTHALMOLOGY: This patient did not quality for ophthalmologic prior to discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To [Hospital ] Hospital level two. Name of primary pediatrician is [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3321] ([Location (un) 4047]). CARE COMMENDATIONS: 1. Feeds at discharge: Breast milk or Special Care 20 kilocalories per ounce at 100 cc per kilo per day P.O./p. g. 2. Medications none. 3. Care seat position test not performed prior to transfer. 4. State Newborn Screen sent at 40 hours of life. 5. No immunizations administered during this hospitalization. DISCHARGE DIAGNOSES: 1. Prematurity at 34 4/7 weeks gestational age triplet. 2. Immature feeding. 3. Hyperbilirubinemia Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] Dictated By:[Last Name (NamePattern1) 56760] MEDQUIST36 D: [2175-12-15] 13:43:22 T: [2175-12-15] 14:47:47 Job#: [Job Number 60196]	[ "7742" ]
Admission Date: [2109-10-30] Discharge Date: [2109-11-1] Date of Birth: [2052-9-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 562] Chief Complaint: Alcohol Withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: This is a 57 year old man with PMH of depression and history of ETOH abuse who presented to the ED after a binge period of drinking 2-3 liters vodka for the last 3 days, with auditory/tactile halluncinations and tremulousness since he ran out of alcohol at 7am today. He denies any loss of consciousness or seizures. He also denies vomiting, though he was nauseous in the ED and received zofran with good effect. He denies visual hallucinations. He denies SI/HI. No fevers/chills. He denies history of seizures with withdrawal. No fall or loss of consciousness. . Of note, the patient has had multiple past admissions for alcohol withdrawal, the most recent ones [2109-10-1] and [2109-10-4]. She required 50mg valium on last admission and 130mg valium on the admission before that. He left AMA on both admissions. He has been evaluated by social work multiple times on previous admissions. He expresses interest in going to [Hospital1 1680] house for a detox program. He has been in programs at both [Hospital1 1680] and [Hospital1 ] previously. . Also, patient has been evaluated in the past for SVT by EP and placed on verapamil. However, on his last two admissions, he had not been on verapamil as an inpatient as he had never had the prescription filled in the outpatient setting. . In the ED, VS on presentation were 99.4 HR 111 BP 147/96 16 96% on RA. He was given 10mg IV Valium no effect, then another 10mg + 5mg w/ response in VS. Creatinine was 1.3 and serum alcohol 229. On transfer from ED, afebrile with HR 101 BP 130/90 RR 12 Sat 98% RA. Past Medical History: -Alcoholism (per past OMR notes, no history of complicated withdrawal, seizures, or DT's) -Depression -ADHD -History of melanoma excised from L back -DJD; reportedly recently told he may need a L hip replacement -Chronic Kidney Disease per chart; pt not aware of this, no renal f/u Social History: Per past OMR notes: He lives alone and has not worked for years secondary to depression and anxiety. Previously in "high-tech sales" selling "knowledge management" consulting software; lost his job when unit closed down and has not been able to work since then. Is receiving support from sister (pays his mortgage) and friends for food and financial support. Never smoked. Reports multiple recreational drugs including IVDU in the 60's but none since then. Past baseline of [2-8] pint per day of hard liquor, more recently 1 to 1.5 pints of vodka. Family History: Family history of alcoholism among males on both sides: maternal uncle and grandfather; as well as his father and brother. His mother died of CHF in her 80's. Father died of lung cancer and CHF. No family history of premature CAD or sudden cardiac death. No known family history of liver disease. Physical Exam: Vitals at time of exam: T=98.8, HR=96, BP=167/98, Sat=98% on RA GEN: NAD, tremulous, somewhat anxious. Otherwise friendly and interacts appropriately. HEENT: EOMI, MMM, no scleral icterus, no nystagmus CV: RRR, no m/r/g, nl S1/S2 PULM: CTAB ABD: Soft, ND, NT, no HSM appreciated. No angiomas, caput. EXT: No edema. WWP. NEURO: Finger-to-nose: continuing tremor but no distint intention tremor, and targetting remains intact. No asterixis distinct from ongoing medium-frequency symmetrical regular tremor. PSYCH: Engaged, full range of affect, worried, sad. Denies SI, HI. SKIN: Not jaundiced. No angiomas or caput. Well healed scar on Left upper back from previous melanoma removal. Pertinent Results: LABS ON ADMISSION: [2109-10-30] 01:55PM GLUCOSE-69* UREA N-20 CREAT-1.3* SODIUM-142 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-18* ANION GAP-28* [2109-10-30] 01:55PM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-1.5* [2109-10-30] 01:55PM ASA-NEG ETHANOL-229* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2109-10-30] 01:55PM WBC-5.1 RBC-4.28* HGB-13.7* HCT-41.9 MCV-98 MCH-32.0 MCHC-32.8 RDW-14.1 [2109-10-30] 01:55PM NEUTS-48.7* LYMPHS-38.5 MONOS-10.1 EOS-1.1 BASOS-1.6 [2109-10-30] 01:55PM PLT COUNT-281 LABS ON DISCHARGE: [11-1]: WBC-6.4 RBC-4.61 Hgb-14.7 Hct-44.9 MCV-97 MCH-31.9 MCHC-32.8 RDW-14.3 Plt Ct-243 [11-1]: Glucose-90 UreaN-18 Creat-1.2 Na-141 K-4.0 Cl-101 HCO3-26 AnGap-18 [11-1]: ALT-89* AST-103* Brief Hospital Course: This is a 57 year old man with a past history of alcohol abuse, who presents with ETOH level of 229 along with symptoms of withdrawal, with high requirements by CIWA scale for treatment. . ALCOHOL WITHDRAWAL High requirements in the ED. Continued CIWA scale in MICU Q1 hour with valium 10-20mg Q1 initially, now at Q2-4hours. Withdrawal symptoms are abating on transfer from MICU. Floor team was made aware that mental status changes may not be secondary to just ETOH withdrawal, but may also have componenet of benzo/ETOH intoxication considering the large amount of valium he had received in the MICU (>130mg). He was given zofran for nausea (amylase/lipase normal). Continued low-dose home amlodipine and atenolol, as well as PRN hydralazine for SBP>180's, while recognizing this could mask symptoms of withdrawal. Maintained on venlafaxine given interaction of EtOH w depression in this pt. Continued thiamine, folate, MVI. SW and addiction services were consulted. On the floor patient's benzo requirment decreased until benzos were no needed and pt requested to leave. Attending physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] felt it was safe for patient to leave. Pt. plans to enroll with [Hospital1 ] House on [Hospital1 766] . TRANSAMINITIS AST mildly higher than ALT. Consistent with prior labs. Alcoholic hepatitis likely although NASH, viral hepatitis given substance abuse history are also possible. Hepatitis serologies negative on [2109-10-3]. CT abdomen/pelvis [7-16] showed fatty liver, normal liver contour. Continued effexor at home dose given that he has been stable on this, may need dose reduction if liver impairment increases. . ACUTE RENAL FAILURE Creatinine elevated to 1.3 (baseline 1.1-1.2) on admission. Likely somewhat prerenal in the setting of recent binge. Creatinine trended down with hydration. . METABOLIC ACIDOSIS Likely due to starvation ketoacidosis, alcohol, ARF. Resolving upon transfer from MICU. . HYPERTENSION Patient hypertensive on admission, likely secondary to ETOH withdrawal. Also with baseline hypertension. Continued on home atenolol and amlodipine with PRN hydralazine as above. . DEPRESSION No current SI/HI. Continued on Effexor. . Medications on Admission: (based on OMR; patient does not know his other meds, just effexor and "BP meds") 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Venlafaxine 225 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 7. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Alcohol Withdrawal Discharge Condition: stable. afebrile. blood pressure controlled. normal heart rate. no tremor. Discharge Instructions: You were admitted to the hospital after an alcohol binge. On admission you had signs of withdrawal and were admitted to the intensive care unit because you required high doses of benzodiazepines (a medication which prevents alcohol withdrawal). Eventually you no longer needed these medication to prevent withdrawal symptoms and Dr. [Last Name (STitle) ] thought it was okay for you to leave given your great desire to do so. You will need to enter a rehabilitation program as discussed with our addictions social worker Ms. [Last Name (Titles) 2412]. No changes were made to your medications. . You should report to [Hospital1 ] House on [Hospital1 766] for Alcohol Abuse counseling and support groups. Your substance abuse counselor through the [Hospital 778] Clinic helped establish follow up with the [Hospital1 ] House. Return to the hospital if you develop hallucinations Followup Instructions: You should follow up with your primary care physician [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10564], [Telephone/Fax (1) 798], Wednesday, 12:40pm. Follow up with your Substance Abuse therapist at the [Hospital 778] clinic in the next week.	[ "5849", "2762", "4019" ]
Admission Date: [2137-6-20] Discharge Date: [2137-6-25] Date of Birth: [2087-2-13] Sex: F Service: MEDICINE Allergies: Aspirin / Ibuprofen Attending:[First Name3 (LF) 1055] Chief Complaint: Ethylene Glycol intoxication Major Surgical or Invasive Procedure: Right femoral hemodialysis catheter placement Hemodialysis History of Present Illness: 50F depression and suicidal ideation presents to OSH after family found her confused and "running around". Thought that she had overdosed on fioricet, trazodone, paxil, and brought her to ED for further eval. In ED @ OSH, noted to be confused, initial ABG 7.05/7/137/2 on RA, U/A notable for many RBCs, oxalate crystals, positive barbituates. In consultation with [Hospital1 18] tox, was thought to have ethylene glycol toxicity. Started on 150meq Bicarb, EtOH infusion, and transferred to [Hospital1 18] for further treatment. In [Hospital1 18] ED, given fomepizole 1g, noted to have "fluorescent" urine. Initial labs notable for HCO3 of 7. Seen by renal, and initiated on hemodialysis on arrival to MICU. After becoming aroused, pt remembers trying to "end it all" earlier in AM around 9-10AM, drinking about [1-7] cup antifreeze. Denies any other ingestions (she has run out of her medications). Otherwise, cannot remember any other events over the course of the day and first recollection was here at [Hospital1 18]. On ROS, has chronic subj fevers/chills, but denies weight loss, has chronic RLQ pain [2-7] abdominal adhesions, otherwise denies cough, chest pain, SOB, urinary symptoms, previous suicide attempt. Currently denies suicidal ideation. Denies melena or hematemesis. Of note, vomited fluorescent appearing vomitus during interview. Past Medical History: - Depression - Kidney stones - Cholecystectomy - Appendectomy - Diverticulitis - Gastric Ulcers - Kidney Stones - Partial Gastrectomy at 31 - SBO Social History: Lives with niece [Doctor First Name ], however wants daughter [Name (NI) ] who lives in [Name (NI) 531] to be HCP. [Name (NI) 1139]: 1PPD X 20 years Alcohol: Denies Denies drugs or IV drug use. Family History: NC Physical Exam: VS 106 96/56 16 99% 1L GENERAL: NAD, caucasian male appearing exhausted HEENT: anicteric, PERRL, [Last Name (LF) 3899], [First Name3 (LF) ] tacky. NECK: JVP flat, supple, no LAD, no bruits CARDIOVASCULAR: S1, S2, tachy, no MRG. LUNGS: diffuse soft rhonchi that clear with cough. ABDOMEN: large vertical scars in midline, soft, mildly tender in RLQ. EXTREMITIES: Warm, no CCE NEURO: SKIN: no rashes or petechiae Pertinent Results: [2137-6-20] 02:30AM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [2137-6-20] 02:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2137-6-20] 02:30AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.009 [2137-6-20] 02:30AM PT-10.8 INR(PT)-0.9 [2137-6-20] 02:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2137-6-20] 02:30AM ACETONE-NEG [2137-6-20] 02:30AM ALBUMIN-4.8 CALCIUM-9.9 PHOSPHATE-2.6* MAGNESIUM-2.7* [2137-6-20] 02:30AM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-125* AMYLASE-62 TOT BILI-0.3 [2137-6-20] 02:30AM GLUCOSE-131* UREA N-6 CREAT-0.8 SODIUM-147* POTASSIUM-5.1 CHLORIDE-118* TOTAL CO2-7* ANION GAP-27* [2137-6-20] 03:24AM PLT SMR-NORMAL PLT COUNT-231 [2137-6-20] 03:24AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [2137-6-20] 03:24AM NEUTS-90* BANDS-2 LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2137-6-20] 03:24AM WBC-26.8* RBC-4.71 HGB-15.9 HCT-49.3* MCV-105* MCH-33.7* MCHC-32.2 RDW-13.7 [2137-6-20] 05:36AM LACTATE-4.0* [2137-6-20] 06:47AM TYPE-ART PO2-78* PCO2-23* PH-7.49* TOTAL CO2-18* BASE XS--2 Brief Hospital Course: Imp: 50F here w/ suicide attempt by ethylene glycol ingestion. . Hospital Course: # Ethylene glycol toxicity: Initially the patient had severe metabolic acidosis. She received STAT hemodialysis treatment, was started on bicarb drip, and received fomepizole. Initial ethylene glycol level here was undetectable. Her anion gap closed, and her bicarb normalized. The renal team followed throughout this process With normalization of her gap, they felt there was no need for further need for bicarb or dialysis. . In the setting of an undetectable ethylene glycol level, it was felt that patient had likely metabolized all of the ethylene glycol and that fomepizole no longer played a role. The patient was observed in the MICU for renal function and acid base status for greater than 48 hours before being called-out to the floor. . # Anemia: The patient's course was complicated by oozing following removal of right groin dialysis catheter. Her hematocrit did fall by approximately 3 points, and the patient complained of chronic RLQ pain for which there was some concern of retroperitoneal bleed. However, her hematocrit stabilized and later CT abdomen demonstrated no evidence of hematoma. Her iron studies and folate level were unremarkable, though her B12 was borderline low. She is to be discharged on daily B12 supplementation. . # Suicide attempt: The patient was followed by psychiatry and was watched by a 1:1 sitter throughout the admission. She denied suicidal ideation or intent throughout the admission. She was restarted on her paroxetine and trazodone. She is to be discharged to an in-patient psychiatric facility. . # Abdominal pain: The patient's pain appears to be her chronic pain. This pain has been attributed to adhesions related to prior trauma and surgery. As above, a CT abdomen was negative for hematoma. She did have several kidney stones bilaterally, though none obstructing. There was a small hypodensity in her right kidney, which was read by the radiologist to represent either pyelonephritis or ethylene glycol-associated injury. The patient has been afebrile, has had multiple negative urinalyses since her initial U/A demonstrated large blood. The most likely diagnosis for the patient's pain remains her known adhesions, with some component of constipation likely contributing. The patient's pain was controlled with percocet as needed during the admission. She is to be discharged on her home vicodin. . # Elevated troponin: The patient had an elevated troponin for unclear reasons on admission. Two repeat levels demonstrated normalization. Serial EKGs had no concerning changes for myocardial ischemia or infarction. There is no further work-up indicated at this time. . # Nicotine addiction: The patient was continued on a nicotine patch daily. . # FEN: The patient was maintained on a regular diet. . # Prophylaxis: The patient was maintained on Sc heparin daily. . # Code status: full Dr. [Last Name (STitle) ] spoke to PCP and updated her. Medications on Admission: - Paxil - Prilosec - Vicodin - Trazodone - Excedrin PRN Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 69] - [Location (un) 86] Discharge Diagnosis: Ethylene glycol toxicity Acute renal failure Metabolic acidosis Suicide attempt Major depression Discharge Condition: Fair Discharge Instructions: You are being transferred to an in-patient psychiatric facility. Please follow up with your primary care physician as below following discharge from that facility. Please take all medications as precribed. Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], on discharge from your psychiatry care. The number to call for an appointment is [Telephone/Fax (1) 31592].	[ "2762", "5849", "3051" ]
Admission Date: [2146-8-26] Discharge Date: [2146-8-30] Service: NMED Allergies: Percocet Attending:[First Name3 (LF) 5868] Chief Complaint: Right hemiparesis, dysarthria Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 87 year old right-handed female with past medical history of hypertension who presented as a transfer to our hospital for right-sided weakness after left pontine stroke. Patient was in her usual state of health until Tuesday [2146-8-23]. She awoke that morning and found that her right side was weak when she was attempting to walk to the bathroom. She fell onto the bathroom floor and laid there for ~1 hour. No head injury or loss of consciousness status post fall. She made it back to her bed and went back to sleep. Later that morning, she called her daughter, who noted that her speech was slurred. At that point, she was taken to [Hospital3 ] in [Location (un) 2498]. While at [Hospital3 ], MRI reportedly showed a left pontine infarct and 2 small occipital lesions. She was started on Plavix. Carotid ultrasound showed no stenosis. Echocardiogram showed an ejection fraction of 55%, trace mitral regurgitation and trace pulmonic insufficiency. As MRA showed a tight mid-portion basilar stenosis, she was transferred to [Hospital1 18] on [2146-8-26] for further care. She denies recent fevers, chills, headaches, visual changes like blurry or double vision, chest pain, palpitations, shortness of breath, nausea, vomiting, urinary frequency or incontinence. She denies parasthesias, incoordination, dizziness or vertigo. Past Medical History: 1. Hypertension since [2114] 2. Left-sided hip surgery X 2 in [2079] and [2089] after fracture 3. Osteoarthritis 4. Status post cholecystectomy 5. Right cataract surgery Social History: Widowed. Has 11 children. Was a homemaker. Was living alone and independent in activities of daily living prior to this admission. Walks with a walker. Family History: Father and sister with strokes, at age 60s and 47 respectively. Oldest son died of MI at age 70. One son deceased from muscular dystrophy. Physical Exam: ON ADMISSION: Tc: 98.1 Tm: 100.1 BP: 160/76 HR: 70 (59-70) RR: 18 O2Sat.: 98%/2.5-3L FSBG: 95, 82 Gen: WD/WN, female, comfortable, pleasant, NAD. HEENT: NC/AT. Anicteric. MMM. Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No carotid bruits. Lungs: CTA bilaterally. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Able to recite [Doctor Last Name 1841] forwards and backwards. Registration intact. Recalled [2-2] objects at 5 minutes. Speech fluent with good comprehension and repetition. Naming intact. Moderate dysarthria. No paraphasic errors. No apraxia, no neglect. No right/left confusion. Cranial Nerves: I: Not tested II: Right pupil surgical Left pupils round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. Unable to assess optic disks. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Right facial droop. Left facial strength within normal limits. Facial sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk. Tone decreased right upper and lower extremities. No abnormal movements, tremors. +right drift. Strength: D T B WrF WrE FiF [Last Name (un) ] IO IP Q H TA Gas [Last Name (un) 938] R 3 4- 4- 4- 4- 3 1 1 3 5- 4 4+ 4+ 4+ L 5- 5- 5 5 5 5 5- 5- 5 5 5 5 5 5- Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 2 2 2 2 1 With upper extremity brisker than lower bilaterally. Grasp reflex absent. Toes upgoing bilaterally. Coordination: Normal on finger-nose-finger, rapid alternatingmovements on left. Right side limited by motor weakness. Gait: Did not assess. Pertinent Results: [2146-8-26] 06:05AM %HbA1c-6.1* [2146-8-26] 04:37AM GLUCOSE-137* UREA N-15 CREAT-0.7 SODIUM-143 POTASSIUM-3.1* CHLORIDE-108 TOTAL CO2-25 ANION GAP-13 [2146-8-26] 04:37AM ALT(SGPT)-18 AST(SGOT)-21 CK(CPK)-118 ALK PHOS-75 TOT BILI-0.7 [2146-8-26] 04:37AM CK-MB-4 cTropnT-<0.01 [2146-8-26] 04:37AM CALCIUM-8.5 PHOSPHATE-2.7 MAGNESIUM-1.9 CHOLEST-162 [2146-8-26] 04:37AM TRIGLYCER-125 HDL CHOL-39 CHOL/HDL-4.2 LDL(CALC)-98 [2146-8-26] 04:37AM WBC-11.5* RBC-3.67* HGB-12.2 HCT-34.1* MCV-93 MCH-33.2* MCHC-35.7* RDW-12.7 [2146-8-26] 04:37AM PLT COUNT-189 [2146-8-26] 04:37AM PT-13.3 PTT-25.4 INR(PT)-1.1 Brief Hospital Course: Ms. [Known lastname ] was admitted to the Neurology service with right hemiparesis and dysarthria. MRI/MRA revealed acute left pontine infarct, nonvisualization of right vertebral artery indicating occlusion, and high grade stenosis in the mid basilar artery. Echocardiogram provided no evidence for patent foramen ovale or a source of embolus. As her stroke was likely embolic in origin, she was started on coumadin and IV heparin. She continued to receive treatment for hypercholesterolemia. Her blood pressue during hospitalization was usually in the range of 140-160 systolic, 60-70 diastolic. Goal SBP as an putpatient was to be SBP: 120-130s, given her intracranial stenosis. She was seen by physical therapy, occupational therapy, and the speech consult services who all felt she would benefit from acute inpatient rehabilitation. Clinically, Ms. [Known lastname ] improved during hospitalization. She regained some strength in her right upper extremity and her speech improved. She was determined to to be at high risk for aspiration and was started on a soft solid diet with nectar thick liquids. In the future, stroke Neurology clearance will be necessary to optimize care, in the event that she ever needs to undergo surgery or stop anticoagulation. Medications on Admission: Home Medications Prior to Admission to [Hospital3 ]: 1. Prinvil 20 mg po qd 2. Atenolol 100 mg po qd 3. Norvasc 10 mg po qd Medications at [Hospital3 ] Prior to transfer to [Hospital1 18]: 1. Heparin SC 2. Plavix 75 mg po qd 3. Protonix 40 mg po qd Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 2. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 3. Insulin Regular Human 100 unit/mL Solution Sig: variable units Injection ASDIR (AS DIRECTED): Dispense qid per regular insulin sliding scale. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: 1. Stroke 2. Hypertension 3. Left sided hip surgery x 2 4. Osteoarthritis 5. Status post cholecystectomy 6. Right cataract surgery Discharge Condition: Fair; Residual dysarthira, right upper and lower extremity weakness. Discharge Instructions: Please seek medical attention if you experience weakness, numbness, difficulty speaking, chest pain or any other concerning symptoms. Followup Instructions: Follow up with Drs. [Last Name (STitle) 1693] and [Name5 (PTitle) ] in the [Hospital 4038] Clinic in 3 months. Please call [Telephone/Fax (1) 1844] for an appointment. Follow up with Dr. [Last Name (STitle) 39008] (PCP) in 2 weeks. Please call [Telephone/Fax (1) 57082] for appt. Dr. [Last Name (STitle) 39008] may want to restart therapy for hypertension. Additionally, Dr. [Last Name (STitle) 39008] will be responsible for following your Coumadin level via blood testing after your discharge from rehab. Goal INR is 2.0-3.0.	[ "4019", "2720" ]
Admission Date: [2181-1-27] Discharge Date: [2181-2-12] Date of Birth: [2127-4-8] Sex: M Service: MEDICINE Allergies: Cefepime Attending:[First Name3 (LF) 1936] Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: Pt's a 53-year-old male patient of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] is here for evaluation of fever. The patient states fever began two days ago along with a mild dry cough, fever was low-grade at that time. Day of admission, pt noticed to be 101.8 has some chills as well. No shortness of breath, no chest pain. Denies any headache, ear aches, and some scratchy throat. The patient denied any change in stools, ab pain, urinary sx, has some mild nausea on [1-27] but thought it more due to fever. No arthralgias or myalgias or rashes. The patient says cough is nonproductive. He did recently have URI symptoms beginning of the month which abated shortely . He then came on the 22nd for routine medical examination and was found to be in pretty good health and stated remains until these last two days. Of important note - pts kids had been sick earlier this week (both) - similiar sx - lasting just 3 days. Pt reports having the flu shot earlier this week. Noted poor po intake past few days. <br> Review of systems: <br> Constitutional: No weight loss/gain, fatigue, malaise, + fevers, +chills, NO rigors, night sweats, or anorexia. HEENT: No blurry vision, diplopia, loss of vision, photophobia. No dry motuh, oral ulcers, bleeding nose or [Male First Name (un) ], tinnitus, sinus pain. Cardiac: No chest pain, palpitations, LE edema, orthopnea, PND, DOE. Respiratory: No SOB, pleuritic pain, hemoptysis, does have mild DRY-cough as above. GI: + mild nausea but NO vomiting, abdominal pain, abdominal swelling, diarrhea, constiatpion, hematemesis, hematochezia, or melena. Heme: No bleeding, bruising. Lymph: No lymphadenopathy. GU: No incontinence, urinary retention, dysuria, hematuria. Skin: No rashes, pruritius. Endocrine: No change in skin or hair (has chronic hair loss), no heat or cold intolerance (noted thyroid meds recently adjusted). MS: No myalgias, arthralgias, or back or nec pain. Neuro: No numbness, weakness or parasthesias. No dizziness, lightheadedness, vertigo. No confusion or headache. Psychiatric: No depression, anxiety. Allergy: No seasonal or medication allergies. Past Medical History: -splenectomy -pericarditis -Hodgkin's disease, and bone marrow transplant in [2164], Hodgkin's treatment was in [2157] Social History: No tob, etoh, or drugs. Lives with wife and 2 kids, - employment - real estate developer. Family History: Mother with Breast CA/Uterine CA Physical Exam: Vitals: 99.5 138/80 95 18 96%RA Pain: denies Access: RUE PICC Gen: nad, thin man HEENT: anicteric, mmm CV: RRR, no m Resp: CTAB, improved L sided crackles, no wheezing Abd; soft, nontender, +BS Ext; no edema Neuro: A&OX3, grossly nonfocal Skin: no changes psych: appropriate Pertinent Results: WBC 20-->15.4-->12.4 (peak 26 [2-6]) Hgb [7-4]-->8.8 stable s/p 1U [2-9] plt 800s INR 1.3 retic 4.7 Chem panel unremarkable BUN 11/creat 0.9 LFTs normalized except alk phos 214, downtrending (peak 385 on [2-2], normal prior), albumin 2.8 . . Influenza swab +B Ag Sputum cx MSSA X2 Blood cx all NTD Urine Cx NTD Stool Cx NTD . . Imaging/results: CXR [2-8]: LUL consolidation, mod pulm edema, R PICC . . RUQ US [2-4]: 1. Unchanged appearance of mildly distended gallbladder containing layering sludge, without evidence of acute cholecystitis. 2. No focal liver lesions or biliary ductal dilatation. 3. Right pleural effusion. . [2-4] CT Chest: 1. Interval decrease in right-sided pleural effusion. Left- sided pleural effusion is unchanged. 2. Persistent multifocal pneumonia with interval worsening consolidation in the lingula and left upper lobe. 3. Nonspecific soft tissue stranding in the left upper quadrant, new from prior study but difficult to assess without oral contrast. Consider CT of the abdomen for more complete assessment, if warranted clinically. . . [2-2] Echo: EF 55%, mod pulm HTN. [1-28] CTA, no PE . . Brief Hospital Course: 53-year-old male patient with h/o of hodgkins lymphoma in BMT '[64], h/o splenectomy, h/o pericarditis, hypothyroidism was initially admitted for fever in setting +sick contacts. In ER, confirmed Influenza B + (Rx with Tamiflu X7days). Pt initially did well first night, but then had rapidly worsened hypoxia am of [2181-1-28] with CT chest showing new multilobar consolidations. Developed septic shock and ARDS, started broad Abx (vanc/cefepime/azithromycin), transfered to MICU, was intubated for hypoxemic resp failure [1-28]. Resp cultures grew MSSA and Abx changed to nafcillin to complete 3week course per ID (until [2-18] via R PICC). Was finally extubated [2-7] and transfered to Gen Med on [2-9]. On Gen Med, continued with rapid improvement, weaned off O2. There was some concern initially with persistant leukocytosis in 20s with fevers and imaging with pleural effusions that raised concern for parapneumonic efffuisons or empyema. However, WBC did start to trend down so [Female First Name (un) 576] was deferred. He will have ID f/u after Abx and needs repeat imaging. Still having low grade fevers and imaging with L>R infiltrates but clinically much better. Other infectious w/u negative. Of note, during hospitalization, pt had some LFT elevation with US/CT showing sludge but no evidence of cholecystitis and this was likely [1-29] acute illness and possible TPN which he recieved for few days (improving by time of discharge). Also developed Anemia 12-->8 w/o gross evidence of bleeding or hemolysis, s/p 1U prbc [2-9] with hgb stable 9s thereafter. this can be followed up as outpt. . . See progress note below for details according to each problem: 53 year-old male with a history of hodgkin's s/p BMT in 93, s/p splenectomy, h/o pericarditis, hypothyroidism, anemia, admitted [1-27] with influenza B (received antiviral treatment in ICU) complciated by severe MSSA bacterial superinfection-->ARDS/intubation, extubated [2-7], t/f to floor [2-9], doing very well, ambulating, tolerating PO, plan to d/c home today . . MSSA CAP, superinfection (Influenza B): ARDS, extubated [2-7]. Doing well, off oxygen. Some concern initially with persistant leukocytosis/fevers and CT with persistant L>>R pleural effusions concerning for parapneumonic effusions but white count finally down. Pt has been afebrile (low grade temps) - continue Nafcillin 2 gm IV q 4hr through [2-18] for total of 3 weeks per ID (confirmed plan) -since downtrending wbc, can hold off on [Female First Name (un) 576], but needs repeat imaging to ensure resolved effusions, f/u [Hospital ] clinic in [2181-3-6] - continue incentive spirometry - guiafenisin prn, duonebs -note, pt is post splenectomy, asked to confirm pneumovax and meningitis vaccine, but none here while PNA . . Leukocytosis: as above, 20s for several days, today down to 12, as above, concern for parapneumonic effusions but holding [Female First Name (un) 576] as above with repeat CXR in 1week. Currently with low grade temps, no fevers. As for other sources, LIJ tip not sent, PICC site looks good, no urinary complaints, no diarrhea. note, baseline elevated wbc partly due to post-splenectomy. . . Anemia and thrombocytosis: baseline hgb 12s, here 9-->7s s/p 1U prbc [2-9], now 9s. No obvious bleeding or hemolysis but was acutely ill. -Fe studies will be unreliable since got blood t/f, hold supp since Fe load with transfusion -will need to be followed as outpt -as for thrombocytosis, likely reactive (anemia, illness) and post-splenectomy . . Hodgkins disease s/p BMT'[64], no issues . . Hypothyroidism: cont levothyroxine 88mcg . . GERD: protonix 40-->prilosec at home . . Dyslipidemia; resume lipitor 10 . . Elevated Alk phos: RUQ [2-4] with sludge, no dilation, bili normal, no RUQ pain -slow trend down, monitor, follow as outpt . Medications on Admission: ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth once a day LEVOFLOXACIN [LEVAQUIN] - 500 mg Tablet - 1 Tablet(s) by mouth once a day LEVOTHYROXINE [SYNTHROID] - 88 mcg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE [PRILOSEC] - 10 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day Discharge Medications: 1. PICC care per protocol 2. Nafcillin 2 gram Piggyback Sig: Two (2) Intravenous every four (4) hours for 6 days: total 4g. continue until [2-18]. Disp:qs doses Refills:0 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [12-29] MLs PO Q6H (every 6 hours) as needed for cough. 5. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Influenza type B Severe MSSA multilobar pneumonia as superinfection causing ARDS Anemia s/p blood transfusion Discharge Condition: GOOD Discharge Instructions: You were admitted with influeza with superimposed severe bilateral pneumonia due to staph. YOu will need to complete IV antibiotics until [2-18]. If you have worsening of fevers/cough/shortness of breath, call your doctor or come to ER. Your PICC line will be removed after the antibiotics are complete. Please follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [3-6] as scheduled so that she can make sure you are stable, you will need repeat Chest xray as well. Confirm with your primary doctor that you are up to date with your vaccination since you have your spleen removed. Your medications are otherwise kept the same. You had anemia during this hospitalization likely from your severe illness, please follow this with your doctor to make sure this is getting better. You recieved 1 unit of blood for this. You can take daily Fe supplement to help with this. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13447], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2181-3-6] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8157], M.D. Phone:[Telephone/Fax (1) 1971] Date/Time:[2181-5-29] 10:45 Provider: [Name10 (NameIs) ] [Name8 (MD) 5647], M.D. Date/Time:[2182-1-24] 10:40	[ "0389", "51881", "78552", "99592", "2449", "2724", "2859", "53081" ]
Admission Date: [2187-7-17] Discharge Date: [2187-7-22] Date of Birth: [2131-7-17] Sex: M Service: CT SURGERY HISTORY OF PRESENT ILLNESS: This 56 year old male presents with positive enzymes consistent with myocardial infarction. The patient also complained of increasing chest pains over the last three to four weeks prior to his admission. The episodes occurred with increasing frequency and intensity. Initially the pain was only every few days lasting twenty to forty seconds. On [2187-7-13], the patient was started on Diltiazem after calling his cardiologist, but the pains continued to worsen. After calling the cardiologist the second time, the Diltiazem was stopped and the patient started taking sublingual Nitroglycerin. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Asthma. 3. Hernia repair on the left at age four. 4. Left orchiectomy at age 16. 5. Status post tonsillectomy and adenoidectomy. 6. Motor vehicle accident with pelvic fracture in [2170]. 7. Allergic rhinitis. 8. History of colonic polyps. MEDICATIONS ON ADMISSION: 1. Prilosec 20 mg one q.d. 2. Aspirin 81 mg once a day. 3. Singulair 10 mg. 4. Albuterol p.r.n. three to four times per month. 5. Vitamin E 400 once a day 6. Vitamin C 1000 once a day. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Temperature is 97.3, pulse 88, blood pressure 138/85, respiratory rate 13, oxygen saturation 95% on four liters. In general, the patient was pleasant in no acute distress. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. No lymphadenopathy. Neck - unable to assess jugular venous distention secondary to laying flat. Respiratory - clear anterior. Cardiovascular regular rate and rhythm, no murmurs appreciated. The abdomen was soft, nontender, nondistended, positive bowel sounds. Extremities negative, no edema. Neurologic - alert and oriented times three. LABORATORY DATA: White count 13.0, hematocrit 46.0, platelets 229,000. Sodium 141, potassium 3.8, chloride 104, CO2 23, blood urea nitrogen 14, creatinine 0.9, glucose 127. CK 9:00 a.m. was 106, troponin 0.2. At 4:00 a.m. there was a CK of 756 and MB of 68. Electrocardiogram at 7:30 on [2187-7-17], showed normal sinus rhythm at 87 beats per minute with ST elevations of 2.0 millimeters in V1 through V3, ST depressions in v1 through V6, I, II, III and aVF. Chest x-ray did not show any infiltrates. Cardiac catheterization showed 50% LMA, 80% OMI, 50% right coronary artery. HOSPITAL COURSE: The patient was admitted on [2187-7-17], and was started on Aspirin, Lopressor, intravenous Nitroglycerin, Heparin and Integrelin and the patient was prepped for surgery at that time. An intra-aortic balloon pump was started at that time. The patient also had serial CKs followed. On [2187-7-18], the patient was in the CCU on the same medications but off the Integrelin and was prepped for surgery. On the same day, the patient with the diagnosis of unstable angina and acute myocardial infarction and three vessel disease had a coronary artery bypass graft times four with left internal mammary artery to the left anterior descending and veins to OM1 and OM2 and veins to the right posterior descending artery. Indications for the surgery were unstable angina, three vessel disease with decreasing ejection fraction. The patient tolerated the procedure well and was admitted to the Cardiothoracic Intensive Care Unit. On postoperative day one, the patient was doing well and was transferred to the floor. The patient received one unit of packed red blood cells because of a hematocrit of 22.6 on postoperative day one. On postoperative day two, the patient was doing well and was tolerating physical therapy and regular diet. Also, his hematocrit was increased to 25.9. On postoperative day three, the patient was tolerating well. On postoperative day four, the patient was doing well with slight tachycardia. The Lopressor was up to 50 mg b.i.d. He had a physical therapy level of five and was tolerating stairs. After administration of 50 mg of Lopressor in the morning, his heart rate was in the mid 80s. On discharge physical examination, his temperature maximum was 99.3, heart rate was 112, blood pressure 112/72. Respiratory rate was 22, oxygen saturation 96% in room air. The patient's change in weight from preoperative was 2.5 kilograms. His input for 24 hours was 640 and his output was 1400. His incision was intact, clean and dry. His laboratories included a white count 6.6, hematocrit 25.9, platelets 129,000. Sodium 135, potassium 3.8, chloride 102, CO2 22, blood urea nitrogen 18, creatinine 0.8, glucose 119. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg p.o. b.i.d. 2. Lasix 20 mg p.o. b.i.d. 3. K-Dur 20 meq p.o. b.i.d. times seven days with Lasix. 4. Aspirin 81 mg p.o. q.d. 5. Percocet one to two tablets p.o. q4-6hours. 6. Singulair 10 mg. 7. Prilosec 20 mg q.d. 8. Albuterol p.r.n. 9. Vitamin E. 10. Vitamin C. DISCHARGE STATUS: The patient was to be discharged home in stable and good condition. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times four. 2. Gastroesophageal reflux disease. 3. Asthma. 4. Allergic rhinitis. DISCHARGE COMPLICATIONS: None. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern4) 959] MEDQUIST36 D: [2187-7-22] 11:44 T: [2187-7-22] 12:41 JOB#: [Job Number 31527]	[ "41401", "49390", "53081" ]
Admission Date: [2196-10-29] Discharge Date: [2196-11-2] Date of Birth: [2116-1-19] Sex: M Service: MEDICINE Allergies: Indocin / Lipitor Attending:[First Name3 (LF) 443] Chief Complaint: Chest Discomfort Major Surgical or Invasive Procedure: Permanent pacemaker placement History of Present Illness: 80 y/o male with CKD, HF with preserved EF (EF 55%, [2194-5-8]), AAA, and history of escape junctional bradycardia with retrograde P-waves that was attributed to excessive AV nodal blockade (Diltiazem) who presents with intermittent palpitations for approximately 4 days, each episode lasting approximately one minute in duration, which the patient describes as a funny feeling in his chest. He had an episode prior to arrival to the ED that had resolved prior to arrival. The patient's wife explicitly stated that he did not complain of chest pain but did have some back pain. The patient's family called EMS when he began expressing chest pain. Per EMS, he was bradycardic to the 30s for which he received Atropine once. He further received Aspirin 81 mg x 4. . Upon arrival to the ED, the patient stated that his chest pain had resolved as above but reported that he felt lightheaded and overall feeling unwell. His HR was noted to be in the 40s with SBPs in the 90s initially. No significant EKG findings other than bradycardia were reported. He was noted to have pulmonary crackles on exam but no other significant physical exam findings were reported. Labs were significant for a K of 5.7, BUN of 39, and serum creatinine 3.4 (up from a recent baseline of 2.0-2.4). He received Calcium gluconate, insulin and D50 for his hyperkalemia, which was later followed by an Albuterol nebs. He received several doses of Atropine (2) as well as Glucagon for reversal of any excess beta-blockade. His systolics were noted to be mostly in the 90s with one episode of hypotension to the high-70s, during which the patient was reportedly asymptomatic. He was subsequently started on Dopamine at 2.5 mg/min. Transfer vitals were HR 47, BP 103/60, RR 14, 93% on 2L. . Of note, his family noted a deterioration in his mental status following either administration of either Atropine or Glucagon. They further stated that he is typically a very organized and oriented individual though they did state that he has poor vision and decreased hearing. . Upoon arrival to the floor, the patient was noted to be delirius and unable to answer quetions. History was obtained via his family. The family believed that he may have been taking older or . Past Medical History: -distal abdominal aortic aneursym (3.5 cm [2196-10-7]) -Gastric ulcer treated with Protonix -Hyperlipidemia -Migraine headache -HTN -Gout -Prior Hepatitis B infection (surface Ag negative, surface and core Ab positive) -Chronic kidney disease secondary to FSGS -Hyperthyroidism -Lactose intolerance -diastolic CHF with preserved EF -stage II inflammation and stage II fibrosis of the liver Social History: Retired and lives in [Location 86] with family. Used chewing tobacco and smoked a pipe for 30-40yrs but quit 6yrs ago, ETOH: Quit 12 years ago, Illicit drugs: denies Family History: Negative for liver disease, cancer or metabolic syndrome Physical Exam: ADMISSION EXAM: VS: 97.6, 42, 123/57, 21, 98% on 6L GENERAL: NAD, AAOx1-2, [Hospital1 1516] pads in place HEENT: NCAT, unable to assess EOMI, MMM NECK: supple with inability to appreciate JVP while patient lying flat CARDIAC: bradycardic but regular, normal S1 and S2, no m/r/g LUNGS: unlabored respirations, lungs CTAB anteriorly with crackles at the bases bilaterally in the posterior lung fields ABDOMEN: S/NT/ND, BS+ EXTREMITIES: WWP, 2+ DP/PT pulses, zero to possibly trace edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas . DISCHARGE EXAM: Vitals - 98.1 155/90 81 18 94 on RA GENERAL: NAD NECK: supple with no JVD CARDIAC: normal S1 and S2, no m/r/g LUNGS: Crackles right base only, no wheezes. ABDOMEN: S/NT/ND, BS+ EXTREMITIES: WWP, 2+ DP/PT pulses, no edema SKIN: intact Pertinent Results: ADMISSION LABS: [2196-10-29] 06:45AM GLUCOSE-107* UREA N-41* CREAT-3.6* SODIUM-140 POTASSIUM-5.7* CHLORIDE-110* TOTAL CO2-22 ANION GAP-14 [2196-10-29] 12:45AM WBC-7.7 RBC-4.47* HGB-13.4* HCT-40.7 MCV-91 MCH-30.0 MCHC-32.9 RDW-13.5 [2196-10-29] 12:45AM NEUTS-60.1 LYMPHS-29.0 MONOS-5.2 EOS-5.0* BASOS-0.6 [2196-10-29] 12:45AM PLT COUNT-239 [2196-10-29] 12:45AM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-2.4 [2196-10-29] 12:45AM cTropnT-<0.01 [2196-10-29] 12:45AM CK-MB-1 [2196-10-29] 03:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-600 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG [2196-10-29] 07:03AM LACTATE-1.5 . DISCHARGE LABS: [2196-11-2] 06:40AM BLOOD WBC-7.7 RBC-4.79 Hgb-14.6 Hct-42.9 MCV-90 MCH-30.4 MCHC-34.0 RDW-13.3 Plt Ct-217 [2196-11-2] 06:40AM BLOOD Glucose-122* UreaN-54* Creat-3.4* Na-138 K-4.9 Cl-105 HCO3-24 AnGap-14 . EKG: [2196-9-28] Junctional rhythm with retrograde V-A conduction. Left ventricular hypertrophy. Prolonged Q-T interval. No major change compared to previous tracing. Intervals Axes Rate PR QRS QT/QTc P QRS T 39 0 122 518/481 0 -13 -3 [2196-11-2] Sinus rhythm. Ventricular ectopy. Left ventricular hypertrophy. Non-specific ST-T wave changes. Compared to the previous tracing of [2196-10-31] ventricular ectopy is new. Intervals Axes Rate PR QRS QT/QTc P QRS T 74 158 92 410/434 36 -29 24 . CXR [2196-11-2] FINDINGS: A dual-lead left pectoral pacemaker device has its leads terminating at expected locations in the right atrium and right ventricle. No pneumothorax. Bilateral pleural effusions and bibasal atelectases are mild. Bilateral lungs are remarkable for mild vascular and interstitial prominence, likely congestion. Normal heart size, mediastinal and hilar contours are unchanged in appearance since [2194-4-10]. Brief Hospital Course: 80 y/o male with CKD, dCHF, AAA, and h/o bradycardia who presents with symptomatic bradycardia with junctioanl escape rhythm. . ACTIVE ISSUES: # Bradycardia: Junctional escape rhythm with retrograde P waves likely related to initiation of metoprolol on previous admission. Metoprolol was held and isoproterenol was started. He returned to [Location 213] sinus rhythm shortly after admission. A permant pacemaker was succesfully placed. A EKG showed NSR above the set rate of pacemaker, CXR showed good placement of leads. He did have some episodes of tachycardia on telemetry. He may benefit from metoprolol to prevent tachycardia. . # Acute kidney injury on CKD: Serum creatinine elevated to 3.4, up from recent baseline of 2.0-2.4 believed to be from hypotension in the setting of bradycardia. His ACE and [Last Name (un) ] were held and his creatinine improved. He will have a follow up visit with his renal doctor [First Name (Titles) ] [Last Name (Titles) 3390] who will decide on restarting his ACE/[Last Name (un) ]. . # Acute on Chronic Diastolic Heart Failure: Had pulmonary edema on admission likely from bradycardia on baseline CHF also possible exacerbated by acute kidney injury. He was diuresed with IV lasix with resolution of euvolemia. . # Hypertension: Was hypotensive on admission but BP increased after he was in NSR. His BP meds were initially held. Amlodipine was restarted. ACE and [Last Name (un) ] were held in setting of [Last Name (un) ] but may possibly be restarted as directyed by outpatient [Last Name (un) 3390] and nephrology. Metoprolol was not restarted but may be beneficial to prevent tachycardia. TRANSITIONAL ISSUES: #Outpatient Renal follow-up #Creatinine check in 1 week Medications on Admission: - Gabapentin 300 mg PO TID - Aspirin 325 mg PO daily - Metoprolol tartrate 25 mg PO BID - Amlodipine 5mg PO daily - Lisinopril 40 mg PO daily - Losartan 50 mg PO daily - Febuxostat 40 mg PO daily - Vitamin D 1,000 unit PO daily Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four times a day for 2 days. Disp:8 Capsule(s) Refills:0 3. febuxostat 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO three times a day as needed for pain or fever for 4 days. 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain for 4 days. Disp:10 Tablet(s) Refills:0 8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. ketotifen fumarate 0.025 % Drops Sig: One (1) drop Ophthalmic twice a day. 11. Outpatient Lab Work Please check chem-7 and CBC on Friday [11-4] with results to [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7978], MD [Telephone/Fax (1) 7976] or fax [Telephone/Fax (1) 13238] Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Bradycardia s/p pacemaker placement Acute on Chronic diastolic congestive heart failure Acute Delerium Acute on Chronic Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a slow heart rate and needed a pacemaker. It is very important that you do not lift anything more than 5 pounds with your left arm or lift your left hand over your head for 6 weeks to let the pacer site heal and keep the pacer leads in the right place. We have stopped 2 of your blood pressure medicines because your kidney function is worse, another blood pressure medicine has been increased. You will need to get blood drawn on Friday to check your kidney function. Weigh yourself every morning, call Dr.[Name (NI) 3733] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. STOP taking lisinopril and losartan for now, Dr. [Last Name (STitle) ] may restart these again soon. 2. INCREASE the amlodipine to 10 mg daily 3. START taking clindamycin four times a day for 2 days to prevent an infection at the pacer site. 4. START tylenol 1000mg (2 extra strength) three times a day to treat the pain at the pacer site. You can also take one oxycodone every 6 hours if needed if the tylenol does not work for the pain. You should expect the pain to get better every day Followup Instructions: Department: WEST [Hospital 2002] CLINIC When: TUESDAY [2196-11-15] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2088], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: RADIOLOGY When: WEDNESDAY [2196-11-30] at 11:45 AM With: CAT SCAN [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: VASCULAR SURGERY When: WEDNESDAY [2196-11-30] at 11:45 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD [Telephone/Fax (1) 2625] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital1 7975] INTERNAL MEDICINE When: TUESDAY [2196-11-8] at 4:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7978], MD [Telephone/Fax (1) 7976] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: TUESDAY [2196-12-6] at 10:40 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4511], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2196-11-7] at 9:30 AM With: [First Name11 (Name Pattern1) 539] [Last Name (NamePattern4) 13861], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5849", "41401", "40390", "5859", "2724", "4280", "V1582", "2767" ]
Admission Date: [2196-10-4] Discharge Date: [2196-12-2] Date of Birth: [2137-9-14] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9223] Chief Complaint: 59 y/o with hmorrage in the occipital [Doctor Last Name 534] of the left lateral ventricle aassociated with focal edema and a sm3cm hematoma all amount of IPH in the adjacent left post pareital and occipital lobe. Associated obstructive hydrocephlus with dialtion of both the lateral and third ventricle. Major Surgical or Invasive Procedure: Ventriculostomy Drain Lumbar drain VP Shunt History of Present Illness: 59 y/o male with past medical history of CAD s/p CABG X4 in [2191], DM, HTN, hyperlipidemia was in usual state of health until [2196-10-1]. He went to [Hospital3 4107] compalining of bilateral leg pain and headache. Associated with one episode of emesis. He was diagnosed with UTI and admitted on [2196-10-1]. On [2196-10-2] he noted to have headache associated with vomitting. On [2196-10-4] he became comfused and agitated at CT scan at [Hospital1 2519] showed a 3cm edema and a small amount of IPH in the adjacent left post pareital and hematoma in occipital [Doctor Last Name 534] of the left lateral ventricle aassociated with focal occipital lobe. Associated obstructive hydrocephlus with dialtion of both the lateral and third ventricle. Past Medical History: CAD s/p CABG X4 in [2191], DM, HTN, hyperlipidemia, Peripheral vascular disease, osteoarthritis and Gout Social History: Originally from [Country 47535], visiting US by way of [Location (un) 14336]. Had been in Mass by way of [Location (un) 14336] for last week prior to admission. His wife is in [Country 47535]. Smoker quit in [2190] No alcohol or drug use Family History: Mother died of MI at age 61 Father alive age 84 Physical Exam: GEN: In no acute distress orientated X1 Chest: Clear bilaterally Cardiac: RRR S1/S2 ABD: Soft nontender Ext: No edema Neuro: Awake, alert, orientated X1, PERRLA-EOMI, no drift, cranial nerves [1-7] incact, strength 5/5 in out all muscle groups, reflexes 2+ throughout Sensation intact Pertinent Results: [2196-10-5] 12:37AM BLOOD Plt Ct-248 [2196-10-5] 01:35AM BLOOD PT-13.6 PTT-23.9 INR(PT)-1.2 [2196-10-5] 12:37AM BLOOD CK(CPK)-71 [2196-10-7] 02:40PM BLOOD ALT-11 AST-11 AlkPhos-69 Amylase-62 TotBili-0.4 [2196-10-5] 12:37AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.7 [2196-10-5] 12:37AM BLOOD Phenyto-10.0 [2196-10-5] 06:11AM BLOOD Type-ART Temp-37.6 pO2-96 pCO2-34* pH-7.49* calHCO3-27 Base XS-2 [2196-10-5] 06:11AM BLOOD freeCa-1.02* [2196-10-7] 02:29PM BLOOD HEPARIN DEPENDENT ANTIBODIES- Brief Hospital Course: Mr [Known lastname ] was admitted to the Neurosurgery Service, he had a ventriculostomy drain placed at [Hospital3 ]. He was admitted to the ICU for close neurologic and vital sign monitoring, his goal BP<140, He was ruled out for an MI. An MRI was obtainted to rule out a AVM, metatsis or anuerysm. He MRI work up was negative for all those possible diagnosis. On his first hospital day he was found to have increased solumlence, a GI consult was obtained for a upper GI bleed and low HCT who recommended conservative management of PPI and transfusion to follow up with endoscopy when discharged. A repeat head CT on [10-5] showed a stable clot. His second hospital Mr [Known lastname ] remained solumlent, a stroke neurology consult was obtainted to rule out stroke, they recommened a toxic metabolic workup and transfusion as his hct was again low to 24. Mr. [Known lastname ] [Last Name (Titles) ] also dropped to 58, his SQ Heparin held due to the possibility of HIT. A Hem Consult was also obtained. His ICP pressure remained in the 6-8 range. A dobhoff tube was placed for nutrition. On [2203-10-9] he became more wake alert and orientated X2 following commands. He also developed his first fever to 101.5. He was transferred to the Neurostep down unit on [10-9], tolerating soft foods. On [10-10] an ID consult was obtained due to fever work up showed [12-1] blood culutes was postive for GPC, he was started on 2 weeks of Vancomycin. He continued to have numerous cultures and X-Rays all were negative for a source of a fever. Mr [Known lastname ] was also on Dilantin and it was felt the fevers were related to Dilatin. A CBC showed increased esophinicils, even more suspicious for dilantin related to fever. His Dilantin was D/C'd on [10-25] and he had no further fevers Mr [Known lastname ] had his ventriculostomy drain discontinued on [10-13], on [10-14] a follow up LP was done which had a opening pressure of 26. He was followed serially with LPs on a daily basis which showed consistently high opening pressures and occasional improvement of mental status post LP. on [10-19] a Lumbar drain was placed without complications. If Mr [Name13 (STitle) 60241] had remained afebrile he would have had a VP shunt placed. However at the time his source of his fever was unknown his surgery was postponed until his ID issues were resolved. On [10-31] he was brought to the OR and had a VP shunt placed and his Lumbar drain was d/c'd. Postoperatively, he did well however a follow-up CT showed nonoptimal positioning of his VP shunt in the ventricle. He was brought back to the operating room and a new VP shunt placed without complications on [11-1]. Follow up CT showed good placement, neurologically he was awake, alert and orientated, walking without difficulty. He had a CSF culture from [11-2] positive for staph coag neg, felt to be a contaminent. He stayed on [11-3] to monitor his temperature and CBC. On [11-4] the patient complained of severe abdominal pain and a general surgery consult was obtained and the patient had a KUB which showed free air under the diaphragm. the patient had an ng tube placed. He was transfered to the ICU and intubated, Patient had an abd Ct which showed a high grade bowel obstruction. The patient was taken to the OR for exploratory lap. He had his abd left with temporary closure. He was monitored in the ICU and was taken back to the OR on [11-9] for closure of his abd. He then developed elevated amylase and lipase and was treated with bowel rest for pancreatitis. From the neurosurgical standpoint, he was getting serial LP's and eventually his opening pressures came back into the normal range he no longer required LP's. His condition improved he was extubated on [11-11]. patient continued to be followed by ID for CSF infection and a positive intra-operative swab which was positive for enterococcus. He was treated with two weeks of Linezolid. Patient had speech and swallow eval which he passed. His last LP was on [11-14] with an opening pressure of 14. The patient was transfered to the floor on [2196-11-16]. he remained neurologically stable with evaluation of his amylase and lipase daily. They contined to decrease and he was discharged in stable condition on [2196-12-2]. Discharge Disposition: Home Discharge Diagnosis: L Occipital Parietal IPH, CAD s/p CABG X4 in [2191], DM, HTN, hyperlipidemia, Peripheral vascular disease, osteoarthritis and Gout Discharge Condition: Neurologically stable Discharge Instructions: followup with neurosurgeon in [Country 6607] followup with PCP in [Name9 (PRE) 6607] Followup Instructions: see above [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 9225] Completed by:[2196-12-2]	[ "99592", "51881", "5849", "42731", "4019", "25000", "2724", "V4581" ]
Admission Date: [2135-7-19] Discharge Date: [2135-7-29] Date of Birth: [2072-11-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: Anemia, Gastrointestinal bleed Major Surgical or Invasive Procedure: EGD, colonoscopy History of Present Illness: 62 year-old male w/ HIV (last CD4 175), HTN, CAD s/p MI and 5 vessel CABG w/ MVR [2131], here presents with dizziness, black stools, and Hct 20. Pt reports intermittent black stools over the last month. He was in [Country 13622] Republic until [2135-7-16] and was hospitalized briefly there w/ these complaints. He was told his INR was high and he was given 3 units of PRBC's. He was not scoped and has never been scoped. He returned to the U.S. on [7-16] and received his lab results from the D.R. w/ hct 20 and INR 9.4. He went to see his PCP and was referred to ED from there. He has been off coumadin since [7-16] and noted black colored stool on his toilet paper but brown stool in toilet over last few days. He denies hematochezia, diarrhea, weight loss but does have mild SOB and dizziness. He takes NSAIDs regularly for aches/pains ([2-6] pills per day). In ED, VSS, Hct 19, INR 1.3. Given 2 units of blood (to HCT 23), 2 peripheral IV's, and NG lavage was immediately clear with no blood. He was guaiac positive. He was transferred to MICU because of complicated GIB and need for anticoagulation [3-9] mvr. Past Medical History: 1. HIV (VL 175 on [2135-6-21])- on HAART 2. HTN 3. CAD s/p MI x 2 and 5V CABG [2131] 4. MVR [2131] w/ cabg 5. left thoracotomy [8-6] for pleural effusion 6. cord compression/spinal stenosis w/ c4-c6 laminectomy and decompression [10-8] 7. H pylori positive [9-6] - unclear whether he got treated 8. EF 40% [2132] 9. anemia - fe deficiency (baseline hct 30), had been worked up for pancytopenia in the past and this was when his HIV dx was discovered. per pt, his only risk factor was transfusions during CABG. Family all aware. 10. Type II DM Social History: +smoker, 1pack/day for 42 years, occasional EtOH, lives in [Hospital1 1474] with wife and 2 sons. [Name (NI) ] used to work in business importing merchandise. Born in [Country 13622] Republic. Family History: Non-contributory Physical Exam: T 98.2 BP 171/ 78 (151-199/50-98) HR 75 RR 20-25 O2sat 99% RA I's/O's: 3900/1500 (24 HR). Total +5.6 L in the MICU Gen: NAD, pleasant, sitting up in chair HEENT: NC/AT, PERRL, anicteric sclera, MMM, no plaque or oral lesion CV: regular, mechanical S1, nl S2, II/VI holosystolic murmur at LLSB. Lungs: decreased BS at left base. Abd: soft, NTND, +BS Ext: no edema Neuro: AOx3, CN III-XII intact, moving all 4 extremities well. Brief Hospital Course: 1)GI bleed: Pt presented with Hct of 19 in a setting of supratherapeutic INR and weeks of melena. As his vital signs were stable, it was likely a slow bleed. He was initially in the MICU and received a total of 7 units of PRBC, and his Hct has been stable at 30 since. He underwent EGD and colonoscopy by GI which were essentially negative except fro grade I hemorroids. He also underwent small bowel follow through which was also negative. Plan is to do an outpatient capsule endoscopy since Hct stable. However since he does not have insurance, this procedure could not be done. He is in a process of applying for FreeCare. Once he is approved, he will need to have his PCP arrange for outpatient capsule study. He will be continued on Protonix [Hospital1 ]. Hct on discharge was 34.1. 2)MVR: In a setting of GI bleed, he was maintained on Heparin drip with low PTT goal (50-60). Once Hct was stable, he was restarted on coumadin with a goal INR of 2.5-3.5 for the mechanical valve. INR on discharge was 2.3, receiving coumadin 10mg po qd 3)HIV: He was started on Bactrim for prophylaxis (VL undetectable and CD4 175). He was continued on his HAART regimen. 4)HTN: His valsartan and metoprolol were titrated up till SBP<140. Currently, he is taking Valsartan Valsartan 320 mg qd and Metoprolol 37.5 mg [Hospital1 ]. Medications on Admission: robitussin stavudine 40 mg [Hospital1 ] valsartan 160 mg qd tenofovir 300 qd lamivudine 150 [Hospital1 ] coumadin 5 mg qd lasix 40 qd glucamide ?glyburide 5 mg qd atenolol 25 mg qd ?sulfametazone - unsure if he is taking this Discharge Medications: 1. Stavudine 40 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:30 Capsule(s) Refills:2 2. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday) as needed for PCP [Name Initial (PRE) 1102]. Disp:30 Tablet(s) Refills:2 5. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 7. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal Bleed Discharge Condition: excellent Discharge Instructions: Patient should follow up with PCP for coumadin level check on Tuesday next week. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 8499] on [2135-8-2] 10:30am [Hospital1 7975] INTERNAL MEDICINE Where: [Hospital1 7975] INTERNAL MEDICINE Phone:[Telephone/Fax (1) 7976] Date/Time:[2135-8-2] 10:30 Please follow up with Dr. [Last Name (STitle) 6173] in the [Hospital ] clinic on Tuesday [8-9], 11am. [Last Name (NamePattern1) ] in the basement suit GProvider: [Last Name (LF) ],[First Name3 (LF) ]	[ "2851", "4019", "V5861", "3051", "25000", "V4581" ]
Admission Date: [2110-6-3] Discharge Date: [2110-6-8] Date of Birth: [2047-4-24] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: Briefly, this is a 63 year old male with a history of alcoholism, insulin dependent diabetes mellitus, pancreatitis status post partial pancreatectomy who presented with abdominal pain, decreased p.o., vomiting, diaphoresis on [2110-6-4]. The patient was found to be in ketoacidosis with low bicarb. He was admitted to [Hospital Ward Name 517] and then transferred to medical ICU on the day of admission secondary to EKG changes and alcohol withdrawal symptoms. The patient subsequently ruled in for a small MI and was admitted to the medicine floor from the MICU on [2110-6-7]. PAST MEDICAL HISTORY: 1. Alcohol abuse. The patient reports drinking one pint per night with a history of morning tremors. 2. Hypertension. 3. History of pancreatitis status post partial pancreatectomy. 4. Gastritis. 5. Coronary artery disease with history of RCA occlusion, EF of 25% to 30%. The patient had cath in [2-20] which showed hypokinetic anterior basal, anterior lateral, inferior and posterior basal walls. MEDICATIONS ON ADMISSION: NPH 8 units in the a.m. and 6 units in the p.m., Prilosec 20 mg p.o. q.d., Captopril 50 mg p.o. t.i.d., folic acid 1 mg q.d., Wellbutrin SR 100 mg q.d., metoclopramide 10 mg q.i.d. ALLERGIES: Morphine and Motrin. SOCIAL HISTORY: The patient is married. Positive tobacco and alcohol history as previously mentioned. PHYSICAL EXAMINATION: On transfer to the floor from MICU the patient was a well appearing, black male in no apparent distress. Answered questions, but not very conversant. Appropriate. Cardiovascular exam revealed regular rate and rhythm, no murmurs, rubs or gallops. Respirations were clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended with positive bowel sounds and old scars. Extremities showed no clubbing, cyanosis or edema. LABORATORY DATA: On admission hematocrit was 40.4; by discharge it had dropped to 33.4. White blood cell remained stable throughout admission at 6. Platelet count went from 255 to 154. INR was normal on check at 1.1. Sodium on admission was 134 and went down to 127 on discharge. ALT and AST remained in the 20s. Amylase was initially 175 and went down to 50 prior to discharge. Lipase was 207 and went down to 18 by discharge. Troponin on [6-5] was elevated at 6.7 and subsequently dropped to 3.7. MB peak was 8. The patient did have large acetone on [6-3] was repeated and normal on [6-5]. Negative tox screen. Chest x-ray during admission showed COPD, left ventricular hypertrophy, but no CHF or pneumonia. HOSPITAL COURSE: 1. Gastrointestinal. The patient initially had pancreatitis which resolved by enzymes. He also had little p.o. intake on admission, but his diet was eventually advanced to full with minimal abdominal pain. The patient was maintained on Reglan and given Zantac during admission. He was kept on aspirin because of coronary artery disease, but ideally that would be discontinued. 2. Endocrinology. The patient was initially on an insulin drip which was able to be weaned and the patient was on his outpatient regimen of NPH with regular insulin sliding scale for coverage by discharge. The patient also had pretty good blood sugars prior to discharge. 3. Cardiovascular. The patient suffered a small myocardial infarction as seen by increase in MB as well as troponin. Cardiology followed the patient throughout his admission and recommended medical management only. The patient was maxed on Lopressor and ACE inhibitor. 4. Fluids, electrolytes and nutrition. The patient developed low sodium during his admission. This was felt secondary to low p.o. intake and the patient has been encouraged to free water restrict, but eat a regular diet and drink salty type fluids. The patient will need this checked as an outpatient. 5. Renal. The patient initially had respiratory alkalosis which resolved, followed by metabolic acidosis which also resolved. 6. Psych. The patient was initially on the CIWA scale with Ativan coverage, but little Ativan was needed and the patient was weaned off CIWA after several days. The patient did receive thiamine, folate, multivitamin for his history of alcoholism. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Alcohol withdrawal. 3. Pancreatitis. 4. Non-Q wave MI. DISCHARGE MEDICATIONS: 1. NPH 8 units in the morning, 6 units in the evening. 2. Thiamine 100 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Multivitamin p.o. q.d. 5. Folate 1 mg p.o. q.d. 6. Captopril 12.5 mg t.i.d. 7. Lopressor 75 mg p.o. t.i.d. 8. Prilosec 20 mg p.o. q.d. 9. Neutra-Phos one pack p.o. t.i.d. 10. Reglan 10 mg p.o. q.i.d. 11. Magnesium oxide 800 mg p.o. b.i.d. 12. Tylenol 650 mg p.o. q.four hours p.r.n. 13. Oxycodone 5 mg q.six p.r.n. FOLLOWUP: The patient should follow up with Dr. [Last Name (STitle) ], his primary care, within the week for repeat blood work. The patient needs chem-10 to make sure his cal, mag and phos are staying stable and that his sodium has also recovered. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[Name8 (MD) 6269] MEDQUIST36 D: [2110-6-8] 14:30 T: [2110-6-10] 16:25 JOB#: [Job Number 6270]	[ "41071", "41401", "496" ]
Admission Date: [2178-6-25] Discharge Date: [2178-7-4] Date of Birth: [2109-4-25] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10593] Chief Complaint: Fever and cough Major Surgical or Invasive Procedure: Intubation Traumatic foley placement Urology foley placement with cystoscopy History of Present Illness: 69 yo male with history of metastatic prostate cancer to bone presented with fever and cough. He reports dry cough without dyspnea. The patient has been having 5 days of malaise, with fever as high as 104. He denies nausea and vomiting, but notes diarrhea since he finished his last course of radiation. He denies dysuria or abdominal pain. Of note, he finished a steroid taper on [6-18] for pain related to metastatic lesions. In the ED, initial vs were: 98.8 113 119/67 24 90% on RA. Patient was given IVF, combivent nebs, and levaquin with plans to admit to OMED until desatturated to 85% on RA with RR 20-30. He was put on a 100% NRB with improvement in his sats to 100%. RR improved to 18. CXR with RML PNA. Rectal exam did not reveal a tender or boggy prostate. Urinalysis was sent. Access: 18G V/s prior to transfer: 99 86 122/72 20 99% on 100% NRB. On the floor, he is transiently tachypneic but appears comfortable. He is coughing with sputum production. He notes that his prior rib pain is well controlled. Past Medical History: Prostate Cancer -- Diagnosed in [2162], involving right lobe with [Doctor Last Name ] score of 3+4, who was treated with brachytherapy and has been followed up periodically. -- Lupron, Metformin Trial: [2178-3-24] . Other Past Medical History: Hemorrhoids. Obesity. History of bladder stones Social History: Originally from [Country 2559]. Lives in [Location 1468] with wife, has several young grandchildren. Retired mechanic. - Tobacco: denies - etOH: denies - Illicits: denies Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: 102.9 105 161/77 14 97% on 100% NRB General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMdry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles at right base to mid lobe CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, soft, non-tender, non-distended, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Physical Exam: 35.9 ??????C, HR 69, BP 118/68, RR 10, SpO2: 96% on 5L NC General: Awake, alert, NAD HEENT: MMM Neck: no JVD, no cervical LAD Lungs: bibasilar rales, 1/3way up lung fields, slightly decreased breath sounds on right Heart: nl S1/S2, I/VI SEM at RUSB Abd: soft, nd/nt, +hypoactive BS Extr: no peripheral edema, 2+ peripheral pulses Pertinent Results: Admission Labs: [2178-6-25] 10:50PM ABG PO2-72* PCO2-32* PH-7.51* TOTAL CO2-26 BASE XS-2 [2178-6-25] 04:35PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.002 [2178-6-25] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2178-6-25] 12:21PM LACTATE-2.1* [2178-6-25] 12:17PM UREA N-15 CREAT-0.8 SODIUM-136 POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-26 ANION GAP-16 [2178-6-25] 12:17PM estGFR-Using this [2178-6-25] 12:17PM ALT(SGPT)-28 AST(SGOT)-21 LD(LDH)-351* ALK PHOS-114 TOT BILI-1.4 [2178-6-25] 12:17PM WBC-9.9 RBC-3.59* HGB-11.4* HCT-31.1* MCV-87 MCH-31.7 MCHC-36.6* RDW-16.5* [2178-6-25] 12:17PM NEUTS-77* BANDS-1 LYMPHS-16* MONOS-4 EOS-0 BASOS-1 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-1* [2178-6-25] 12:17PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ [2178-6-25] 12:17PM PLT SMR-NORMAL PLT COUNT-247# Relevant labs: [2178-6-26] Beta glucan>500 Microbiology: [2178-6-25] 7:43 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2178-6-28] MRSA SCREEN (Final [2178-6-28]): No MRSA isolated. [2178-6-25] 4:35 pm URINE Site: CLEAN CATCH FINAL REPORT [2178-6-26] URINE CULTURE (Final [2178-6-26]): NO GROWTH. [2178-6-25] 12:17 pm BLOOD CULTURE #1. FINAL REPORT [2178-7-1] Blood Culture, Routine (Final [2178-7-1]): NO GROWTH. [2178-6-25] 1:15 pm BLOOD CULTURE #2. FINAL REPORT [2178-7-1] Blood Culture, Routine (Final [2178-7-1]): NO GROWTH. [2178-6-25] 11:50 pm URINE Source: CVS. FINAL REPORT [2178-6-26] Legionella Urinary Antigen (Final [2178-6-26]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [2178-6-28] 8:23 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT [2178-6-30] GRAM STAIN (Final [2178-6-28]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2178-6-30]): NO GROWTH. [2178-6-29] 2:58 pm Mini-BAL GRAM STAIN (Final [2178-6-29]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2178-7-1]): NO GROWTH, <1000 CFU/ml. POTASSIUM HYDROXIDE PREPARATION (Final [2178-6-29]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2178-6-30]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Imaging: CXR on admission [6-25]: FINDINGS: Lung volumes are decreased since the prior exam. A hazy opacity projects over the right lung base on PA projection without a clear correlate on lateral image. Cardiomegaly is unchanged. No effusion or pneumothorax is present. Several expansile blastic metastases are again seen, most notably in the anterior left sixth rib. Healed fractures of the lateral aspects of several right middle ribs with associated pleural thickening is unchanged. Calcifications of the thoracic aorta are stable. IMPRESSION: Right lung base opacity/consolidation raising concern for pneumonia in the appropriate clinical context. CXR prior to intubation [6-26]: Comparison film [6-25]. There is increasing opacification in both the right and left lungs and I suspect that most of this is due to failure rather than a diffuse spread of pneumonia. IMPRESSION: Cardiac failure. CXR [6-28]: HISTORY: ARDS versus severe pneumonia. FINDINGS: In comparison with the study of [6-27], there has been a dramatic decrease in bilateral pulmonary opacifications. Rapid clearing suggests a flash pulmonary edema in a patient with some enlargement of the cardiac silhouette. No evidence of acute focal pneumonia at this time. The endotracheal tube and nasogastric tube remain in place. Evidence of previous right rib fractures with expansion of what appears to be the seventh or eighth ribs on the left, apparently consistent with the patient's known metastatic disease. CXR [6-29]: The lungs are low in volume and show bilateral multifocal airspace opacities. The cardiac silhouette is enlarged. The mediastinal silhouette is widened but unchanged. The hilar contours are normal. There is a confluent left lower lobe opacity. No definite pleural effusions or pneumothorax is present. An NG tube appears out of view below the diaphragm. An ET tube terminates 5 cm above the carina appropriately. IMPRESSION: Mild pulmonary edema. Left lower lobe opacity could represent atelectasis or pneumonia. CXR [6-30]: FINDINGS: The endotracheal tube is in satisfactory position. The tip of the orogastric tube is beyond the view of radiograph. Bilateral lung volumes are low. There is a mild vascular congestion with stable confluent left lower lobe opacity. There is minimal increase in left retrocardiac opacity which could be due to an atelectasis or pneumonic consolidation. Pleural effusions if any are mild bilaterally. The cardiac silhouette is enlarged and stable. Transthoracic Echocardiogram [6-30]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Discharge: [2178-7-2] 07:00AM BLOOD WBC-8.9 RBC-3.40* Hgb-10.7* Hct-29.5* MCV-87 MCH-31.3 MCHC-36.1* RDW-16.6* Plt Ct-298 [2178-7-2] 07:00AM BLOOD Glucose-104* UreaN-20 Creat-0.9 Na-136 K-4.5 Cl-99 HCO3-28 AnGap-14 [2178-7-2] 07:00AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.3 Iron-49 [2178-7-2] 07:00AM BLOOD calTIBC-239* VitB12-958* Folate-15.0 Ferritn-927* TRF-184* Brief Hospital Course: 69 yo male with history of metastatic prostate cancer presented with fever, cough, and diarrhea was found to have sepsis secondary to pneumonia complicated by hypoxemic respiratory failure. # Sepsis: The patient presented with fever, tachycardia, differential with left shift, and evidence of RML infiltrate, indicating SIRS with source of infection. The most likely source of infection was pneumonia, given CXR on admission and his physical exam, but other causes including bacteremia and UTI were investigated. Differential diagnosis for his pneumonia included bacterial pneumonia, PCP pneumonia and fungal pneumonia, which were investigated on a mini-BAL that did not identify a pathogen. Of note, the patient's beta glucan level was > 500, suggesting PCP or fungus. He received IVF boluses, to maintained MAP > 70, and UOP>0.5 cc/kg/hr. Additionally, broad spectrum anitbiotics (cefepime, vancomycin and levofloxacin) were administered for 8 days to cover for HCAP, as he had been recently hospitalized on [2178-5-15]. He was not hypotensive during this admission. He remained febrile for four days, but this resolved. Additionally, his WBC differential with left shift resolved. # Hypoxemic respiratory failure # Bacterial pneumonia # Sepsis Most likely initial cause was pneumonia; however, differential diagnosis included PCP, [Name10 (NameIs) ] given history of malignancy, and pleural effusion. The patient was empirically treated with broad spectrum antibiotics. Due to increasing hypoxemia, the patient was intubated on [6-26]. He initially improved on mechanical ventilation, but developed worsening hypoxemia on [6-27], with a chest x-ray that was concerning for ARDS vs. diffuse alveolar hemorrhage vs. flash pulmonary edema. A chest x-ray the following day showed very significant improvement of the lung process, which made ARDS less likely. He improved on CPAP/PSV, then self-extubated on [6-30]. Following extubation, he continued to have good oxygen saturation on supplemental oxygen by nasal cannula. His respiratory function continued to improve on the medical floor, with completion of 8 days of broad spectrum antibiotics (Vanc, levofloxacin, Cefepime) and successful weaning off of oxygen. # Anemia: From an admission Hct of 31, the patient's Hct dropped slowly. He had a normocytic anemia from his pre-hospitalization baseline of 35.6. Differential diagnosis of his anemia included diffuse alveolar hemorrhage, which had been suggested on CXR, vs. dilution although not all cell lines were affected vs. GI bleed though the patient was Guaiac negative. Hemolysis labs were unremarkable. His anemia is suspected due to his period of critical illness, and possible splenic sequestration. # Prostate cancer: Patient received Lupron (given every 3 months) prior to admission. He has significant pain secondary to bony metastases, and pain was controlled during this admission. No further management was done on this issue. # Prostatic urethral tear: During the admission, pt had a traumatic foley placement for which Urology was consulted. Cystoscopy was performed with finding prostatic urethral tear and a bladder neck contracture. A foley was placed by urology with visualization. His foley remained in place until [7-3], when it was discontinued at the direction of Urology. His post-void residuals were followed to ensure he did not develop obstruction; his post-void residuals were zero. Follow up with Urology may be considered after discharge. Medications on Admission: Fluticasone 50 mcg intranasal spray, 1 spray twice daily Lactulose 10 g/15 mL solution, 1 tablespoon PO 2-3 times per day PRN constipation Leuprolide (3 month) 22.5 mg syringe kit every 3 months Pantoprazole 40 mg tablet, delayed release, 1 tablet PO once per day Acetominophen 500 mg, 2 tablets PO every 6 hourse PRN pain Docusate sodium 100 mg, 1 capsule PO twice daily Sennoside Discharge Medications: 1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). 2. lactulose 10 gram/15 mL Solution Sig: One (1) tablespoon PO three times a day as needed for constipation. 3. Leuprolide (3 month) 22.5 mg syringe kit every 3 months 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain . 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: # Sepsis # hypoxic respiratory failure # bacterial pneumonia # Metastatic prostate cancer # Urethral bleeding from traumatic foley Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with severe breathing problems and were found to be very sick with pneumonia. You were treated with antibiotics and you improved. You have completed your course of antibiotics. Followup Instructions: Please consider referral to Urology after discharge for follow up of his urethral bleeding. Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2178-7-7] at 10:30 AM With: [First Name11 (Name Pattern1) 2946] [Last Name (NamePattern4) 3217], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2178-7-14] at 8:30 AM With: [First Name11 (Name Pattern1) 2946] [Last Name (NamePattern4) 3217], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: TUESDAY [2178-7-21] at 3:10 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "0389", "51881", "5849", "2859" ]
Admission Date: [2173-2-5] Discharge Date: [2173-2-12] Date of Birth: [2173-2-5] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: [Known lastname ] [Known lastname ], [First Name3 (LF) ]. is the former 3.475-kilogram product of a 37-1/7-week gestation pregnancy born to a 25-year-old G2, P2 living 1 woman. OBSTETRICAL HISTORY: Is notable for an intrauterine fetal death at 36 weeks. PRENATAL SCREENS: Blood type O-positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group B Strep status unknown. This pregnancy was complicated by insulin dependent gestational diabetes and elevated blood pressure. The mother was taken to repeat cesarean section due to the history of fetal demise and decreased fetal heart rate with this infant. Apgars were 8 at 1 minute and 9 at 5 minutes. The infant was evaluated in the delivery room for respiratory distress and admitted to the neonatal intensive care unit for further observation and treatment. PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 3.475 kilograms, length 48 cm, head circumference 34.5 cm, all appropriate for gestational age. General: Normocephalic, nondysmorphic infant with retractions and grunting. Skin: Mongolian spot on buttocks. Head, eyes, ears, nose, and throat: Fontanel open and flat. Palate intact. Red reflex: Present bilaterally. Neck: Supple. Chest: Lungs clear with mild intercostal retractions, intermittent grunting, no flaring. Cardiovascular: Regular rate and rhythm, no murmur. Femoral pulses: 2+ bilaterally. Abdomen: Soft with active bowel sounds, no masses or distention. Extremities: Warm, well perfused, brisk capillary refill. Anus: Patent. GU: Normal male. Testes: Palpable bilaterally. Spine: Midline, no sacral dimple. Hips: Stable. Neuro: Good tone. Normal suck, gag, and Moro. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: [Known lastname ] had oxygen saturations less than 90% in room air. Was started on nasal congestion O2. His maximum oxygen requirement was 1.5 liter per minute. He remained in oxygen through day of life #4. Chest x-ray initially was suggestive of transient tachypnea of the newborn with fluid in the fissure, normal lung volumes. Due to the progression of his clinical course, a repeat chest x-ray was done that was more consistent with aspiration or pneumonia, and [Known lastname ] was treated with a week of antibiotic therapy. At the time of his discharge, he is breathing comfortably in room air with a respiratory rate of 30-60 breaths per minute with oxygen saturations 96-99% in room air. 2. Cardiovascular: [Known lastname ] has remained normotensive with normal heart rates. No murmurs have been noted. Baseline heart rate is 140-160 beats per minute. 3. Fluid, electrolytes, and nutrition: [Known lastname ] was initially NPO and maintained on intravenous fluids. Enteral feeds were started on day of life #2 and gradually advanced. At the time of discharge, he was breast feeding or taking Enfamil 20. Weight on the day of discharge is 3.335 kilograms with a corresponding head circumference of 34 cm and a length of 48 cm. Serum electrolytes were checked on day of life #1 and 2 and were within normal limits (Na 143 K 4.8 Cl104 CO2 21). 4. Infectious disease: Due to the unknown etiology of the respiratory distress, [Known lastname ] was evaluated for sepsis. A complete blood count was within normal limits (wbc 19.7 79 Poly 1Band 12 Lymph. A blood culture was obtained prior to initiating ampicillin and gentamicin therapy. Blood culture was no growth at 48 hours. [Known lastname ] completed a 7-day course of antibiotics because of pneumonia. Gentamicin levels were within normal limits (peak 8.4 trough 0.7). 5. Gastrointestinal: Peak serum bilirubin occurred on day of life 4, total of 11.5 mg per deciliter/0.3 mg per deciliter direct. Repeat on day of life #5 had a total of 11.3 with the same direct value. No treatment was necessary. 6. Neurological: [Known lastname ] has maintained a normal neurological exam during admission. There are no concerns at the time of discharge. 7. Hematology: Hematocrit at birth was 50%. [Known lastname ] did not receive any transfusions of blood products. Plt count 267. 8. Sensory: Audiology: Hearing screening was performed with automated auditory brainstem responses. [Known lastname ] passed in both ears. 9. Circumcision: The evening prior to discharge [Known lastname ] had his circumcision performed. He was noted to have some prolonged bleeding. The obstetrician who performed the procedure placed surgiseal on the wound. Just prior to discharge it began to bleed again. The covering obstetrician cauterized the site with resolution of the bleeding. He was observed in the NICU approximate 1.5 hours after the cauterization without any further bleeding noted. CONDITION AT DISCHARGE: good. DISCHARGE DISPOSITION: Home with the parents. The primary pediatrician is Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 65472], [Hospital 7658] Pediatrics, [Location (un) 65473], [Location (un) 7658], [Numeric Identifier 65474]; phone #[Telephone/Fax (1) 43197]; fax #[Telephone/Fax (1) 65475]. Appointment set for [2173-2-15] 11:00 am. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Ad-lib breast feeding or supplemental Enfamil 20. 2. Medications: Tri-Vi-[Male First Name (un) ] 1 mL p.o. once daily. 3. Car seat position screening was performed due to the presentation with respiratory distress. [Known lastname ] was observed in his car seat for 90 minutes without any episodes of bradycardia or oxygen desaturation. 4. State newborn screen was sent on [2173-2-8] with no notification of abnormal results to date. 5. Hepatitis B vaccine was administered on [2173-2-10]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1. Born at less than 32 weeks; 2. Born between 32 and 35 weeks with 2 of the following: Daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or 3. With chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. 7. Follow-up appointments: Appointment with Dr. [Last Name (STitle) 65472] on [Last Name (LF) 766], [2173-2-15] at 11 a.m. DISCHARGE DIAGNOSES: 1. Respiratory distress secondary to presumed pneumonia. 2. Suspicion for sepsis. 3. Infant of an insulin-dependent diabetic mother. 4. Status post circumcision. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2173-2-12] 01:19:52 T: [2173-2-12] 04:27:52 Job#: [Job Number 65476]	[ "486", "V290", "V053" ]
Admission Date: [2114-5-14] Discharge Date: [2114-5-24] Date of Birth: [2039-9-13] Sex: F Service: MEDICINE Allergies: Latex / Codeine Attending:[First Name3 (LF) 12131] Chief Complaint: Weakness and lethargy, hyponatremia Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 74F with metastatic melanoma s/p CyberKinfe and WBI to brain mets, currently on vemurafenib, HTN and anxiety who presented to the ED with 1 week of weakness. She states that since she started radiation treatments, which she estimates as approximately 1 month ago. She describes the weakness as generalized and feeling like she has low energy. She has severe weakness of her right hand for many months which is unchanged. She also endorsed weakness of the legs bilaterally. She is still able to walk but states that she started using a walker recently and has trouble standing up from a chair. She also states that for the past week she has felt increasingly nauseous with dry heaves. During this time, she has had poor PO intake. She endorses cough productive of clear sputum for the past [3-4] weeks. She states that she went to a walk in clinic last week because she thought she was getting a pneumonia and was diagnosed with "upper respiratory tract infection" for which she was given "erythromycin" (?azithromycin). She has no sick contacts and denies fever or chills at home. She was diagnosed with melanoma in [2104] and was found to have brain metastases in [2113]. She was recently started on Zelboraf in [3-/2114] for her metastatic melanoma. She had previously been enrolled in clinical trials before she was started on this new medication, but was not improving. In [2113], she was noted to have brain metastases which was assoicated with right hand weakness. This was managed with whole brain radiation, CyberKnife and dexamethasone for the edema which she is still being tapered off of. Her MRI on [2114-5-7] showed numerous bilateral metastases in the brain with interval improvement after the above treatment. In the ED, initial VS were: 98.4 73 150/60 20 100%. Sodium was noted to be 117. She had a CXR with concern for RLL infiltrate and she was started on Levofloxacin. On arrival to the MICU, the patient was feeling tired and weak, but was unchanged from the past day or two. She denied any pain and complained of only mild nausea. Past Medical History: -Malignant melanoma s/p Cyberkinfe and WBI -hypertension -anxiety -sciatica -mitral valve prolapse -hiatal hernia -peripheral neuropathy ONCOLOGIC HISTORY: [2104], wide local excision of melanoma on the right thigh with lymph examination [5-/2111], recurrent nodule at previous site. [2112-4-5], new lesion melanoma positive, status post wide local excision, sentinel lymph node biopsy with Dr. [Last Name (STitle) 519] negative. [2112-7-19], status post external beam radiation to right thigh. [2112-11-9], excision of lesion on right arm and new lesion on right thigh. [2113-3-27], cycle 1, day 1 of protocol 10-056 part C monotherapy on GSK. [2113-11-6], nodule adjacent to the spleen consistent with metastasis. By protocol, patients on monotherapy are able to cross over to receive both GSK [Telephone/Fax (1) 85556] and GSK [Telephone/Fax (1) 85557] at the first sign of progressive disease. [2113-12-27], CT scan significant interval increase in the left upper quadrant soft tissue nodule, highly suggestive of metastatic focus interval stability of previously described nodules in the left breast and right proximal thigh interval increase in hypervascular nodule in the inferior aspect of the right breast. Interval decrease in the size of the left anterior superior chest wall nodule, right axillary nodule, right lower lobe pulmonary nodule. [2114-1-2], discontinued protocol 10-056 for progression. [2114-2-6], brain MRI. New multiple nodular enhancing lesions distributed in both cerebellar hemispheres and right cerebellum, the largest a left parietal lesion 3 x 2.2 cm associated with the vasogenic edema, but no evidence of midline shift. [2114-2-7], CT torso metastatic melanoma unchanged within the left breast and anterior spleen increasing nodules within the right breast and lateral right shoulder. Social History: Married and lives at home with her husband. She is a retired secretary. EtOH - denies Smoking - denies Drugs - denies She did secretarial work for many years. She lives with her husband and has been married to him for 50 years. She denies any tobacco or alcohol use. She has two children, both sons, age 40 and 46. Family History: -Mother - MI in 70s -Father - MI in 70s -Brother - prostate CA Her parents died in their 70s from cardiac disease. She has two brothers, age 64 and 71. Her eldest brother has some cardiac history and prostate cancer. Her sons are well. No family history of melanoma. Physical Exam: Admission exam: Vitals: T 97.9 HR 76 BP 154/60 General: Awake but appears tired HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP flat, no LAD CV: Irregular rhythm, 2/6 systolic murmur at the LUSB Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, 3+ edema of the LEs to the knee bilaterally. Neuro: A&Ox3. CNII-XII intact. Strength: [4-5] in proximal UEs bilat. [2-4] right hand grip, [4-5] left hand grip. 3/5 strength in proximal LE hip flexors bilaterally. 4/5 strength in dorsiflexion/plantarflexion bilaterally. Sensation grossly intact bilaterally. Discharge exam: Vitals: 98.2, 134/48, 83, 20 General: Awake but appears tired HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP flat, no LAD CV: Irregular rhythm, 2/6 systolic murmur at the LUSB Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, 3+ edema of the LEs to the knee bilaterally. Neuro: A&Ox3. CNII-XII intact. Strength: [4-5] in proximal UEs bilat. [2-4] right hand grip, [4-5] left hand grip. 3/5 strength in proximal LE hip flexors bilaterally. 4/5 strength in dorsiflexion/plantarflexion bilaterally. Sensation grossly intact bilaterally. Pertinent Results: Admission labs: [2114-5-14] 12:45PM BLOOD WBC-6.5 RBC-3.59* Hgb-11.4* Hct-31.8* MCV-89 MCH-31.7 MCHC-35.8# RDW-17.7 Plt Ct-234 [2114-5-14] 12:45PM BLOOD Neuts-73.3* Lymphs-11.0* Monos-10.6 Eos-4.2* Baso-0.8 [2114-5-14] 09:09PM BLOOD PT-10.5 PTT-26.9 INR(PT)-1.0 [2114-5-14] 12:45PM BLOOD Glucose-120* UreaN-15 Creat-0.7 Na-117* K-3.2* Cl-81* HCO3-25 AnGap-14 [2114-5-14] 09:09PM BLOOD Calcium-8.4 Phos-2.0# Mg-1.8 [2114-5-14] 09:09PM BLOOD Osmolal-241 [2114-5-14] 09:09PM BLOOD TSH-2.3 [2114-5-15] 05:02AM BLOOD Cortsol-7.5 [2114-5-16] 07:44AM BLOOD Cortsol-16.3 [2114-5-14] 09:09PM URINE Hours-RANDOM UreaN-636 Creat-89 Na-86 K-67 Cl-72 [2114-5-14] 09:09PM URINE Osmolal-587 Discharge labs: [2114-5-24] 05:25AM BLOOD WBC-11.2* RBC-3.16* Hgb-10.0* Hct-28.5* MCV-90 MCH-31.6 MCHC-35.1* RDW-17.2* Plt Ct-296 [2114-5-23] 06:00AM BLOOD WBC-8.2 RBC-3.30* Hgb-10.5* Hct-30.0* MCV-91 MCH-31.9 MCHC-35.1* RDW-17.3* Plt Ct-246 [2114-5-22] 05:30AM BLOOD Neuts-89* Bands-0 Lymphs-6* Monos-3 Eos-0 Baso-2 Atyps-0 Metas-0 Myelos-0 [2114-5-22] 05:30AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Acantho-1+ [2114-5-24] 05:25AM BLOOD Plt Ct-296 [2114-5-24] 05:25AM BLOOD PT-10.6 PTT-31.7 INR(PT)-1.0 [2114-5-24] 05:25AM BLOOD [2114-5-24] 05:25AM BLOOD Glucose-110* UreaN-15 Creat-0.8 Na-132* K-3.3 Cl-93* HCO3-27 AnGap-15 [2114-5-24] 05:25AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.3 [2114-5-24] 05:25AM BLOOD ALT-54* AST-37 LD(LDH)-210 AlkPhos-93 TotBili-0.7 Micro: -BCx - no growth -Urine legionella - negative Imaging: -CXR ([2114-5-14]): Probable bibasilar atelectasis though in the appropriate clinical setting a developing pneumonia cannot be excluded. -CXR ([2114-5-15]): PICC line in the mid SVC. Bibasilar atelectasis. -LENI ([2114-5-19]): IMPRESSION: No DVT in right lower extremity. -Bilateral hip Xrays ([2114-5-21]): 1. No definite osseous lesions. If there is high continued clinical concern, recommend MRI. 2. Right gluteus calcific tendinopathy. 3. Mild degenerative changes in both hips. -CT chest/abdomen/pelvis ([2114-5-22]) 1. New asymmetry of the right obturator muscle, which may represent metastatic involvement of the muscle or adjacent lymphadenopathy. 2. Nodules adjacent to the spleen, one of which is stable in size and one of which is new since the prior study. 3. Right and left breast nodules smaller in size. 4. Stable hepatic and renal cysts. -CXR ([2114-5-23]) No acute cardiopulmonary process. Improved pulmonary aeration. Brief Hospital Course: 74F with metastatic melanoma s/p Cyberknife and WBI as well as treatment with vemurafenib, HTN and anxiety who presents with hyponatremia and weakness. # Hyponatremia: Na was 116 at admission and reached nadir of 114. Baseline Na appears to be in the 140s as recently as 2/[2113]. Initially, etiology was thought to be hypovoluemic hyponatremia given her poor PO intake prior to admission, flat neck veins, and poor skin turgor. She was given 1L NS on the night of admission and her Na trended down from 116->114. Urine lytes then showed a patter consistent with SIADH. Uosm was in the 500-600s at admission, UNa was 89. She was then fluid restricted and placed on salt tabs PO. Her Na slowly improved with these conservative interventions, although she was mentating normally during her entire admission. Renal was consulted and she was started on 3%NS at a rate of 20cc/hr given her failure to significantly improve with conservative measures. She continued on this for approximately 12 hours and her Na improved appropriately from 122->128 during this time. She was then placed back on a fluid restriction, salt tabs and started on Lasix 20mg PO daily to reduce her medullary concentration gradient and her Na remained in the high 120s to low 130s. The etiology of her SIADH is likely multifactorial and related to her brain metastases, pneumonia as well as her pain and nausea. Her fluoxetine was stopped at admission as SSRIs can cause or contribute to hyponatremia. TSH was normal and AM cortisol was not low. Her sodium level improved considerably, and we were able to stop lasix at the time of discharge. She will continue to require salt tablets, will require ongoing monitoring of her sodium level following discharge. We were able to liberalise her fluid restrictin to 1200ml daily. # Afib: She reportedly has a h/o "irregular heart beat" and had a few episodes of atrial fibrllation with RVR in the [Hospital Unit Name 153] abnd on the floor. These improved with IV metoprolol, although on one occasion she dropped her blood pressure to 80s/50s. Her atenolol was chanegd to metoprolol 12.5mg PO, eventually uptitrated to TID. She was not anticoagulated for her PAF given her brain mets. # Community acquired pneumonia: LLL infiltrate seen on CXR at admission, better appreciated on lateral view, although unclear whether this is atelectasis or infection. She endorses productive cough for the past 3-4 weeks, was recently treated with antibiotics prior to admission. She is somewhat immunosuppressed from her recent chemo as well as the dexamethasone. Notably, she was not on PCP prophylaxis at admission despite receiving dexamethasone for her brain mets. She received a 5 day course of levofloxacin this admission. Following this, she continued to have some itnermittent cough with yellowish sputum. Repeat chest X-rays showed no pneumonia. We started her on azithromycin at the time of discharge, and she will complete this course of antibiotic for empiric treatmetn of possible bronchitis as an outpatient. # Lower back and groin pain: The pain is similar to what she experiences at home, partially related to the prior surgery she had on her hip for melanoma. Pain was improved with PO morphine and Lidoderm patches. Zelboraf can also cause muscoloskeletal pain, and following discussion with her oncologist Dr. [Last Name (STitle) ], we decided to hold the medication for one week starting [2114-5-23]. Please contact Dr. [Last Name (STitle) ] on [2114-5-30] to discuss restarting this medication. Xrays of her hip did not show any bony changed. CT of the hip did show some soft-tissue changes around the right obturator muscle that might be contributing to her symptoms. # Weakness: Most likely cause for her generalized weakness over the week prior to admission is her hyponatremia and poor PO intake, as described above. Aside from her ongoing right hand weakness, there was no other focality to her weakness. Low concern for cord compression or spinal lesions given her neuro exam findings. Her chemotherapy drug, Zelboraf is also known to cause generalized weakness: we decided to trial holding this medication for one week starting [2114-5-23] to see if her symptoms improve off the medication. #Anemia: Baseline Hct in our records is very variable, she was 32 at admission down from 40 on last check in 3/[2113]. This may be explaining some of her weakness and fatigue. There is no obvious evidence of bleeding from history or exam. # Metastatic melanoma: She has recently received WBI and Cyberknife therapy for her brain mets and was currently on Zelboraf after being enrolled in clinical trials with no improvement in her disease. She is being tapered off dexamethasone which she was started to help reduce cerebral edema during her rad/onc treatments. We stopped dexamethasone on [2114-5-23], and she will need to followup with neuro-oncology for further management of her brain metastases. She was continued on Zelboraf for most of this admission, but it was held temporarily for one week starting [2114-5-23] to assess whether the drug might be contributing to her pain. CT chest/abdomen/pelvis on [2114-5-22] showed some improvement in disease burden, sugegsting that zelboraf is still eficacious in this patient. Please call Dr.[Name (NI) 28511] office on [2114-5-30] to discuss restarting this medication. # Hypertension: BP well controlled this admission. As above, atenolol was changed to metoprolol. # Anxiety: Continued on home clonazepam # Code status this admission: FULL # Transitional issues: 1. Hyponatremia: At the time of discharge Sodium level was 132. He sodium has been stable above 130 for several days and we discontinued lasix on [2114-5-23]. Please check Chem7 with a sodium level on Saturday, [2114-5-26]. If sodium level is above 132, please continue current medication regimen and check chem7 every 7 days to monitor her hyponatremia. If sodium level is below 132, please consider restarting lasix and 20mg PO daily, then recheck sodium on [2114-5-26], then every 3 days until stable, and then every 1 week. 2. Metastatic melanoma: We stopped dexamethasone on [7-23]. Due to concern that zelboraf might be contributing to this patient's hip pain, we are holding zelboraf from [2114-5-23] to [2114-5-30]. Please have the patient call her oncologist Dr. [Last Name (STitle) ], on [2114-5-30] to discuss whetehr or not to restart Zelboraf. She will also need ongoing outpatient followup with Drs. [Last Name (STitle) ] and [Name5 (PTitle) 724]. 3. Bronchitis: We started azithromycin to treat possible bronchitis on [2114-5-24]. Please complete the course of this medication. 4. Ms. [Known lastname 85558] WBC count was elevated to 11.2 on [2114-5-24]. CXR and UA were normal and we started treatment for a possible bronchitis. Please repeat CBC on [2114-5-25], Friday, to check that WBC coount is not trending up. 4. Afib with RVR: Ms. [Known lastname 85558] heart rate is controlled with metorpolol. Please continue this medication. Medications on Admission: -atenolol 25mg daily -clonazepam 0.5mg [Hospital1 ] -dexamethasone 1mg qOD -fluconazole 200mg daily -fluoxetine 20mg daily -vemurafenib 960mg [Hospital1 ] -calcium/VitD 500mg/200 units daily -Multivitamin 1 tab PO daily -ranitidine 150mg [Hospital1 ] Discharge Medications: 1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): please do not take if drowsy or driving. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. morphine 15 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain: please do not take if drowsy or driving. 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) patches Topical DAILY (Daily): Please apply 1 patch to each hip. 12 hours on during the night, then 12 hours off. 9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: do not take if drowsy or driving. 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for Constipation. 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for abdominal discomfort. 15. sodium chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 18. multivitamin Capsule Sig: One (1) Capsule PO once a day. 19. azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: give on [4-21]. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Primary: Hyponatremia, syndrome of inappropriate anti-diuretic hormone secretion Secondary: Metastatic melanoma, hip pain 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: Ms [Known lastname ], It was a pleasure taking care of you at the [Hospital1 771]. You were admitted with weakness, and were found to have low sodium. We also found that you had pneumonia. We treated your pneumonia, and changed any medications that might have been contributing to your low sodium. We also treated you intially with intravenous concentrated saline, and eventually with salt tablets. Please continue to restrict your water intake to 1200ml daily. You also had pain in your back, hips and legs. We performed a CT scan of your torso and X-rays of your hips, which did not show any lesions in your bones or joints. Following discussion with Dr. [Last Name (STitle) ], we think that your pain is a combination of your sciatica and a side-effect of your vemurafenib. The CT also showed that the melanoma is still responding to the vemurafenib. As discussed with Dr. [Last Name (STitle) ], please stop taking the vemurafenib for one week to help evaluate whether this drug is contributing to your pain. Please call Dr.[Name (NI) 28511] office in one week's time to discuss whether you should restart vemurafenib. It is also very important that your followup in Dr.[Name (NI) 28511] office in [7-10] days. While you were in the hospital, you sometims developed a fast heart rhythm (atrial fibrillation). We started you on a medication(metoprolol) to help prevent your heart from going into this rhythm. We made the following changes to your medications: STOPPED: -atenolol -dexamethasone -vemurafenib (for one week. Please call Dr.[Name (NI) 28511] office in one week to discuss restarting this medication. -fluoxetine -fluconazole STARTED -senna, colace and bisacodyl to help you move your bowels -maalox for gas -metoprolol to help control your heart rate -tylenol, tramadol, morphine and lidocaine patch for pain -prochlorperazine for nausea INCREASED clonazepam to three times daily Please continue taking your other medications as usual. Please followup with your doctors, see below. Followup Instructions: Department: NEUROLOGY When: MONDAY [2114-6-25] at 1 PM With: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD [Telephone/Fax (1) 1844] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST [Hospital 2002] CLINIC When: MONDAY [2114-7-2] at 1:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage We are working on a follow up appointment with Dr. [Last Name (STitle) ] in the next 1-2 weeks. You will be called at rehab with the appointment. If you have not heard within 2 business days or have questions, please call [Telephone/Fax (1) 13016]. Completed by:[2114-5-25]	[ "486", "42731", "2859", "4019", "4240" ]
Admission Date: [2198-11-11] Discharge Date: [2198-11-11] Service: PURP [Doctor First Name 147] NOTE: The patient was admitted to the Purple Surgery Service on [2198-11-11], and transferred to the Cardiology Service on [2198-11-16]. HISTORY OF PRESENT ILLNESS: The patient is an 81 year old male with a history of abdominal pain times three days and a left inguinal hernia. The patient's family reports that the hernia has increased in size in the last three weeks. There has been no nausea or vomiting. The patient did have flatus on the day of admission, but decreased bowel movements in the past week. The hernia was reported to the primary care physician. [Name10 (NameIs) ] patient has no history of incarceration, and no fever or chills. The patient has been tolerating an oral diet. The patient is deaf and mute and illiterate; however, the patient does understand sign language. PAST MEDICAL HISTORY: 1. Hypertension. 2. Large B-cell lymphoma, status post CHOP. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Lopressor 50 mg twice a day. 2. Nifedipine XL 60 mg q. day. 3. Accupril 20 mg twice a day. 4. Hydrochlorothiazide 20 mg three times a day. LABORATORY: White blood cell count 13.5, hematocrit 38.5, platelets 118, 70% neutrophils, 22% lymphocytes. Sodium 125, potassium 3.2, chloride 90, HCO3 22, BUN 36, creatinine 1.6, glucose 113. KUB: Dilated loops of bowel with air fluid levels. EKG with left bundle branch block. PHYSICAL EXAMINATION: Vital signs with temperature at 95.9 F.; 66; 100/47; 10; 100% on two liters. Respiratory: Rales left lung base. Cardiovascular: Regular rate and rhythm. Abdomen soft, nontender, slightly distended. Rectal with no masses, heme negative. Groin: Large left inguinal hernia, nonreducible; no skin changes. Extremities warm. HOSPITAL COURSE: On [2198-11-11], the patient was taken to the Operating Room for repair of an incarcerated left inguinal hernia. As part of the procedure the patient underwent an ileocecectomy and a left [Doctor Last Name 11455] hernia repair. Intraoperatively, the inguinal hernia was found to be strangulated. Please see dictated Operative Note for further details. The patient came from the Operating Room with [Initials (NamePattern4) ] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drain routed to the left scrotum and a second [Location (un) 1661]-[Location (un) 1662] drain to the right pelvis. The [Location (un) 1661]-[Location (un) 1662] drain that went to the right pelvis was removed on postoperative day four. Postoperatively, the patient was found to be in atrial fibrillation and an EKG showed T waves in V2 and V3, lead III and lead AVF. Because of this and the patient's electrolyte abnormalities, the patient was sent to the Unit for a day. The patient was placed on Cefazolin and Flagyl, both of which were continued throughout the patient's stay on the Purple Surgery Service. Postoperatively, the patient had three sets of cardiac enzymes and ruled out for a myocardial infarction; however, the patient continued in ventricular fibrillation. He was placed on Metoprolol and the dose was gradually increased for rate control. At the end of postoperative day one, the patient was transferred to the floor. The following day, the patient appeared to be in moderate distress; he had end expiratory wheezes and a tender abdomen with voluntary guarding. The [Location (un) 1661]-[Location (un) 1662] in his scrotum put on two ml and the [Location (un) 1661]-[Location (un) 1662] in his abdomen put out 30 ml. Because of the patient's pain, the patient was changed to an intravenous PCA machine. By postoperative day two, the patient's sodium had risen to 132 with an ongoing infusion of normal saline. His potassium continued to drop periodically, being 3.4 on postoperative day two, for which he was repleted. His BUN was 25 and his creatinine was 1.1. A Cardiology consultation was obtained and they found that the atrial fibrillation and left bundle branch block were new on this admission. They recommended oral anti-coagulation when consistent with surgery and rate control. Cardioversion was anticipated when the patient had a therapeutic INR. They suggested an increase in beta blockers and a TSH level and Coumadin with a goal INR of 2.0 to 3.0 when safe. The patient's TSH came back at 6.1 and the patient was therefore started on oral Levothyroxine. An echocardiogram was also obtained which showed an left ventricular ejection fraction of 25 to 30% with hypo and akinesis of several walls, suggestive of coronary artery disease. The patient also had a three plus mitral regurgitation, a four plus tricuspid regurgitation and probably mild aortic stenosis. They felt that this represented a case of ischemic cardiomyopathy with severe systolic heart failure and severe valvular disease added to the atrial fibrillation. They suggested that the Metoprolol be increased, that an ACE inhibitor be started, and that digoxin be added to the patient's regimen. All of these were done. On postoperative day three, the patient continued to have voluntary guarding of his abdomen but his pain appeared to be brief. Later on postoperative day three, the patient reported a large amount of flatus and was therefore begun on a clear diet. His intravenous was Hep-locked and he continued to require repletion for low potassium. On postoperative day five the patient had a benign abdominal examination and reported flatus. He tolerated his liquid diet the previous day very well and therefore he was advanced to a full diet which he again tolerated well. On postoperative day five, the patient was transferred to the Cardiac Service for further work-up of his ischemic cardiomyopathy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 304], M.D. [MD Number(1) 23652] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2198-11-18] 10:54 T: [2198-11-18] 19:49 JOB#: [Job Number 23653]	[ "51881", "5070", "4280", "42731", "5849" ]
Admission Date: [2109-1-27] Discharge Date: [2109-2-4] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 3290] Chief Complaint: shortness of breath, hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname ] is an 87y/o Cantonese-speaking lady with history of CHF (last EF 50-55%), aspiration pneumonia, hypertension, and CVA who was brought to the ED due to hypoxia. She lives in a nursing facility, and per her daughter she has been feeling weak for a few days. She has been requiring more help to ambulate with her walker. Yesterday ([1-26]), she was noted to have O2 sat in the 70's, so she was placed on supplemental O2. By the evening, her extremities were blue and EMS was called. Was placed on 100% NRB with improvement in color and O2 sat up to the 90's. . In the [Hospital1 18] ED, initial VS were: VS were T 102.8, HR 83, BP 102/46, RR 27, POx 99%NRB. She had JVD. Labs notable for WBC 29.3, Hct below baseline at 24.1, Cr 3.5 (baseline 2 one year ago). ABG was 7.36/121/22 on 100%NRB. Given her history of CHF (admitted last year to the CCU) she was given Lasix 40mg IV and was placed on NIPPV. CXR revealed likely RML PNA so she received Tylenol and was started on Vancomycin/Levaquin, as well as maintenance IVF. . On arrival to the MICU, she is smiling and interactive, but has noticeably labored breathing. She feels tired and chilly, and asks for more blankets. . Review of systems: Unable to assess as patient is on NIPPV. . On arrival to the floor, the patient is dyspnic with movement. She is slightly tachypnic. She has diffuse crackles. Past Medical History: Congestive heart failure (LVEF 50-55% in [3-/2108]) Hyperlipidemia Hypertension CVA (? left-sided weakness) Chronic kidney disease (Cr was 2 in [1-/2108]) Anemia from GI blood loss Gout Food/vomitus pneumonitis Failure to thrive History of fall History of UTI Social History: -Tobacco history: none -ETOH: none -Illicit drugs: none -Home: She lives in a nursing home currently in [Location (un) ]. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM; Vitals: T: 100.2 axillary, BP: 106/52, P: 81, R: 25, O2: 96% on PEEP 10, pressure support 8 General: frail-appearing elderly lady breathing fast and using accessory muscles of respiration HEENT: Sclera anicteric, dry MM Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: thin, warm, 2+ DP and PT pulses, no clubbing, cyanosis or edema Neuro: oriented to self, hospital (not hospital name), bilateral foot drop, left-sided leg and arm weakness, sensation to light touch grossly intact bilaterally DISCHARGE EXAM - expired Pertinent Results: ADMISSION LABS: [2109-1-27] 01:58AM BLOOD WBC-29.3# RBC-2.16 Hgb-7.9* Hct-24.1* MCV-112# MCH-36.5 MCHC-32.7 RDW-14.2 Plt Ct-176 [2109-1-27] 01:58AM BLOOD Neuts-79* Bands-12* Lymphs-4* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2109-1-27] 01:58AM BLOOD PT-11.6 PTT-25.3 INR(PT)-1.1 [2109-1-27] 01:58AM BLOOD Glucose-121* UreaN-101* Creat-3.5# Na-131 K-5.6* Cl-97 HCO3-21* AnGap-19 [2109-1-27] 01:58AM BLOOD proBNP-[Numeric Identifier ]* [2109-1-27] 01:58AM BLOOD cTropnT-0.06* CXR [2109-1-27]: IMPRESSION: Findings consistent with pneumonia. Followup to resolution recommended to exclude underlying lesion. Mild pulmonary edema. CXR [2-3]: There is gradual progression of widespread consolidation, now involving entire lungs, but with no substantial change as compared to the recent radiograph from [2109-1-31]. There is most likely present small amount of pleural effusion. No pneumothorax is seen. Findings might be consistent with infectious multifocal process or ARDS. Cardiomegaly is moderate, unchanged. Brief Hospital Course: Ms. [Name13 (STitle) ] is an 87y/o lady with CHF and h/o aspiration PNA who presents with hypoxemic respiratory failure in the setting of fever, leukocytosis, and CXR suggesting pneumonia. The patient subsequently developed ARDS and was made CMO. She expired on [2109-2-4]. . # Multifocal Pneumonia c/b ARDS: The patient presented with cough, SOB, leukocytosis, and fever consistent with pneumonia. She had multifocal consolidations and she was treated with Vancomycin, Cefepime, and Ciprofloxacin. The patient refused invasive measures including BiPap. She was made CMO and transfered out to the floor. She developed ARDS and passed away on HD#9. Medications on Admission: Captopril 100 mg TID Carvedilol 6.25 mg [Hospital1 ] Nifedipine ER 60 mg daily Lasix 40 mg daily Potassium chloride ER 10 mEq daily Allopurinol 300 mg daily Protonix 40 mg EC daily Vitamin D 50,000IU weekly Folic acid 1 mg daily Vitamin B-12 1,000 mcg daily Colace 200 mg [Hospital1 ] Senna 8.6 mg QHS Bisac-Evac 10 mg Rectal Suppository PRN Tylenol 325-650 mg Q4-6H PRN Guaifenesin 100 mg/5 mL: 10mL Q4-6H PRN Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "486", "51881", "5849", "5990", "2760", "4280", "40390", "5859", "2724" ]
Admission Date: [2161-2-6] Discharge Date: [2161-2-12] Date of Birth: Sex: M Service: This discharge summary dictates the [Hospital 228] hospital cousre from the [4-6] to the [4-12] at approximately 10:00 a.m. HISTORY OF PRESENT ILLNESS: The patient is a 80 year-old male who is brought to [Hospital6 3105] by EMS after a neighbor had not seen the patient for two to three weeks. EMS found the patient slumped over the radiator unresponsive with a faint tachycardic pulse. He was intubated and supported on IMV. At the time his vital signs were reportedly temperature 93.3, heart rate 148, blood pressure 124/86, respiratory rate 16. The Emergency Room nurse [First Name (Titles) ] [Hospital6 3105] noted a blood pressure of 50/palp and a respiratory rate 20. CT scan at the time was negative for intracranial hemorrhage. Fluid boluses were negative with amps of sodium bicarb. No arterial blood gases was performed prior to this treatment. The patient was started on broad spectrum antibiotics at [Hospital3 ] for presumed aspiration pneumonia. The patient's skin was noted to be necrotic in different areas including his toes, feet, fingers and the tip of his penis. In addition the patient had an eschar over the sacrum reportedly over the skin that was intact with the radiator and an abrasion over the left scapular. These areas were treated with silver sulfadiazine DuoDerm dressings. He was transferred here for further treatment of his ischemic extremities and management of his ventilatory status. PAST MEDICAL HISTORY: None known. He has reportedly not seen a doctor in more then 20 years. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: Digoxin .125 mg intravenous q.d., Ceftriaxone 1 gram intravenous q.d., Ciprofloxacin 400 mg intravenous q.d., Metronidazole 250 mg intravenous q 6 hours, ________________ 20 mg intravenous b.i.d., morphine sulfate 1 to 10 mg intravenous q one hour prn. The patient received two doses on the [4-6]. SOCIAL HISTORY: Unable to obtain. The patient lives alone. FAMILY HISTORY: Not obtainable. PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature 96.8. Heart rate 65 and regular. Blood pressure 140/45. Vent settings SIMV 700 by 8, pressure support 10, PEEP of 5, FIO2 .5, getting an O2 sat of 100%. He has a right subclavian and right art line in place. In general he is intubated and noted sedative drip is hanging. HEENT pupils are pin point bilaterally, mildly reactive, positive corneal reflex. Sclera are anicteric. Lungs decreased breath sounds at bases bilaterally. No wheezes, rhonchi or crackles. Heart regular rate and rhythm with S1 and S2. No S3 or S4. Abdomen positive abdominal bruit in abdomen, pulsatile aorta. Skin over the left scapula, there is an excoriation measuring 17 by 7 cm with black eschar covered with DuoDerm. On the coccyx there is a stripped sheet eschar 15 by 7 cm with surrounding skin breakdown. Toes and fingers are cold and cyanotic. There are open superficial sores on the tibia bilaterally. There is warm erythema proximal to the areas of necrosis. Ankles have blisters bilaterally. Neurologically, there is no response to sternal rub. He has positive corneal reflex. No gag. Toes are equivocal. Vascular, femoral pulses are palpable 2+ bilaterally. Popliteal pulses dopplerable bilaterally. Biphasic dorsalis pedis pulse and posterior tibial pulse are not dopplerable or palpable. Radials are 2+ bilaterally. LABORATORIES FROM [Hospital3 ] [2-5]: White blood cell count 12.5, hematocrit 37, platelets 88. Differential is 56 neutrophils, 36 bands, 1 lymph. Electrolytes are 145, potassium 4.8, chloride 104, bicarb 30, BUN 188, creatinine 5.4, glucose 249, CK 6040, calcium 7.5. On the [4-6] his laboratories at [Hospital3 ] white count 13.2, hematocrit 34, platelets 74. Differential 84 neutrophils, 13 bands, 1 lymphocytes, sodium 144, potassium 3.9, chloride 100, bicarb 35, BUN 140, creatinine 3.9, troponin is .37 and CK is 6767. On admission to [Hospital3 ] white count 14.8, hematocrit 33.8, platelets 95, INR 1.5, PTT 26.5, sodium 148, potassium 3.9, chloride 105, bicarb 36, creatinine 3, glucose 103, calcium 8.1, magnesium 2.3, phosphate 4.9, albumin 1.8. CK 6322. Arterial blood gas is 7.50, 41 and 142. Microdata, sputum from [2-4] 4+ staph aureus. Chest x-ray here showed an ETT/OGT in place, subclavian on the right was advanced into the right atrium. This was subsequently pulled back. Right lower lobe infiltrate without effusions. No cephalization. No pneumothorax. Electrocardiogram from the 20th, atrial fibrillation with ventricular rate of 132, QRS duration of 149, QTC 536, left bundle branch block. On admission he was in sinus at 64, PR 162, QRS 120, QTC 473, normal axis, left bundle branch morphology, poor R wave progression, T wave inversions inferiorly. No prior comparison is made with an electrocardiogram before the [4-4]. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. 1. Ventilatory management: The patient was continued on SIMV for the first several days of his hospital admission. On the [4-10] he had an arterial blood gas of 7.49, 42 and 146. On the 27th it was 7.45, 41 and 162. He had a good rapid shallow breathing index of 35. His compliance was 60. The decision was made to extubate the patient on the [4-11]. He was extubated successfully and placed on 4 liters nasal canula and has been maintaining good oxygen saturation. He has not required reintubation. 2. Rhabdomyolysis: The patient's CKs were noted to be elevated greater then 6000 on admission. These trended down, but are not normal as of this dictation. The patient's renal failure was suspected to be secondary to this rhabdomyolysis. Urine sediment was examined on the night of admission and demonstrated muddy brown cast. The patient was hydrated first with normal saline and then with half normal saline and D5W. The patient's creatinine fell and at the time of this dictation it was .8. His BUN is 27. 3. Ischemic extremities: A vascular surgery consult was requested on the second hospital day. They did not see a need for acute intervention and felt that the ischemic areas would become gangrenous. Possibly requiring amputation. After consultation with the family amputation was determined to be inconsistent with the patient's premorbid wishes and the Vascular Surgery Service signed off. 4. Disseminated intravascular coagulopathy: The patient's platelets rose gradually reaching a level above 150 by hospital day five. His INR and PTT were also normal. DIC is not an active issue at present. 5. Infectious disease: The patient was initially started on Vancomycin and Ceftriaxone for coverage of sputum with staph aureus. Upon speciation of his sputum it was determined that it was sensitive to Oxacillin. He was changed to Oxacillin on hospital day number three and this was subsequently discontinued when the patient was made comfort measures only. The patient's family saw him on the [4-9] and were concerned about his prognosis. As the patient's mental status did not seem appropriate an electroencephalogram was ordered and this demonstrated encephalopathic changes. The patient's family made the decision to withdraw care and make the patient comfort measures only on [2-11]. His medications were changed at that time to a Fentanyl drip and an Ativan drip both titrated for his comfort and intravenous fluids to keep his vein open and prn Tylenol. The patient is currently comfort measures only. DISPOSITION: To be determined. [Name6 (MD) 2467] [Last Name (NamePattern4) 10404], M.D. Dictated By:[Last Name (NamePattern1) 5476] MEDQUIST36 D: [2161-2-12] 10:18 T: [2161-2-12] 10:36 JOB#: [Job Number ]	[ "5849", "5070" ]
Admission Date: [2139-12-1] Discharge Date: [2139-12-4] Date of Birth: [2083-6-22] Sex: M Service: MICU HISTORY OF THE PRESENT ILLNESS: The patient is a 56-year-old man with brittle diabetes, end-stage renal disease of transplanted kidney, long medical history, who presents from an outside hospital with DKA. Most of the history was obtained by the patient's wife by phone as the patient was very confused upon arrival. She reports an acute disorientation on the morning of admission with a glucose [Location (un) 1131] of "unreadable" on the machine. Neither she nor the patient have a clear idea about the precipitant of the hyperglycemia. The wife reports increased lethargy, increased sleep, and decreased p.o. intake over the last one to two days. She said "he didn't feel well", but could not pinpoint any specifics. The patient denied nausea, vomiting, fevers, chills, shortness of breath, chest pain, pain, diarrhea, or dysuria. The patient does make urine, approximately four bathroom trips per day with a decent amount of output. His last hemodialysis was on [2139-11-29] per the patient. He reports being compliant with his insulin and Accu-Cheks. When the patient arrived at [Hospital 487] Hospital, his glucose [Location (un) 1131] was 868 with an anion gap of 15. His initial arterial blood gas was 7.22/55.9/145 on 2 liters nasal cannula. Upon arrival to the [Hospital1 18] the patient was confused but was able to answer most questions. PAST MEDICAL HISTORY: PCP is [First Name4 (NamePattern1) 1356] [Last Name (NamePattern1) ]. 1. Insulin-dependent diabetes times 28 years secondary to alcohol-induced pancreatitis. 2. Severe peripheral vascular disease with toe amputations. 3. End-stage renal disease of transplanted kidney. 4. Transplant of kidney in [2133]. 5. Right tibia-fibula fracture, status post ORIF complicated by wound infection, osteomyelitis in [2139-8-24]. 6. Per notes, renal failure is secondary to pyelonephritis in [2137]. 7. Neuropathy. 8. Back pain. 9. Anemia. 10. DVT of right upper extremity. 11. History of MRSA in [2136-9-23]. 12. GERD. 13. Depression. 14. Penile prosthesis. 15. Malabsorption. 16. Vocal cord polyps. 17. Questionable seizures with hypoglycemia. ADMISSION MEDICATIONS: 1. Folate and multiple vitamin. 2. Wellbutrin 100 t.i.d. 3. Protonix 40 q.d. 4. Neurontin 300 q.d. 5. Clorhexadine 50 t.i.d. 6. Aspirin 81 q.d. 7. Pancreatic enzymes. 8. Calcium carbonate 500 t.i.d. 9. Amlodipine 5 mg b.i.d. 10. Insulin regimen 22 units of NPH in the a.m., 8 units q.h.s. with Humalog sliding scale throughout the day. 11. Colace 100 mg b.i.d. 12. Clonidine 0.3 b.i.d. 13. Hydralazine 75 q.i.d. 14. Lovenox 40 q.d. 15. Prednisone 5 mg q.d. 16. Celexa 20 mg q.d. 17. Metoprolol 100 mg b.i.d. 18. Oxycontin 40 mg b.i.d. 19. Atorvostatin 10 mg q.d. 20. Calcitriol 0.5 mg q.d. ALLERGIES: Codeine, Prograf, Phenergan, Haldol. SOCIAL HISTORY: The patient lives with wife, remote alcohol, and tobacco history. No IV drug use. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.7, blood pressure 160/91, pulse 69, respirations 12, oxygen saturation 100% on 2 liters. Glucose 150. I&O 250 out at the outside hospital. No urine output here. General: The patient was a lethargic man looking older than age. HEENT: Dysconjugate gaze, mucous membranes dry. The oropharynx was clear. Neck: There were distended neck veins, supple. Cardiovascular: Regular rate and rhythm, distant heart sounds, no murmurs, rubs, or gallops. Pulmonary: Bilaterally clear to auscultation. Abdomen: Two well-healed scars, normoactive bowel sounds. No hepatosplenomegaly. Transplanted kidney in the left lower quadrant. Extremities: Amputated toes on left foot, scaly dry skin. The patient has a fixator on his right leg. Neurologic: Alert and oriented times two, lethargic but cooperative. LABORATORY/RADIOLOGIC DATA: Upon admission, the white blood cell count was 9.8, hematocrit 36.9, platelets 220,000. Coagulation studies were normal. Chemistries: Sodium 144, potassium 4.2, chloride 111, bicarbonate 22, BUN 41, creatinine 6.2, glucose 81 with an anion gap of 11. The liver function tests were normal. Calcium 7.1, magnesium 1.9, phosphorus 5.9. Blood cultures were pending. Chest x-ray was clear. Blood gas was 7.32/36/140 on 2 liters nasal cannula. EKG showed normal sinus rate of 64, old T wave inversions in V1 through V3, no ST changes, biphasic Ts. HOSPITAL COURSE: 1. DIABETIC KETOACIDOSIS: The patient's sugars were well controlled by the time he arrived at the [Hospital1 18]. His anion gap had closed. The patient's insulin drip was discontinued soon after arrival and he was covered with NPH as well as a Humalog sliding scale during admission. The [Last Name (un) ] Consult Service followed the patient and adjusted his Humalog sliding scale. The patient's precipitant of his DKA is unclear but is thought to be likely noncompliance with insulin regimen. Blood cultures and urine cultures were obtained and were negative at the time of this discharge summary. The patient was also ruled out for a myocardial infarction. Other likely precipitants could have been a viral syndrome since the patient had been fatigued with decreased p.o. intake on days before admission. A hemoglobin A1C level was checked and is pending at the time of this discharge. 2. END-STAGE RENAL DISEASE: The patient was initiated on hemodialysis to continue his three day a week dialysis regimen. The Renal Service followed the patient and he had dialysis on [2139-12-3] without incident. The patient's Calcitriol was continued along with his calcium carbonate and prednisone for his transplanted kidney. 3. CORONARY ARTERY DISEASE: The patient was continued on his aspirin, metoprolol, and Atorvostatin. The patient ruled out for a myocardial infarction by enzymes and EKG. 4. HYPERTENSION: The patient has resistant hypertension and was admitted on a four drug regimen. The patient was restarted on his metoprolol, hydralazine, clonidine, and amlodipine during admission. Dose adjustments were made upon discharge as the patient's blood pressure did lower with dialysis. 5. NUTRITION: The patient was maintained on a diabetic diet and was continued on his folate and multivitamin. Pancrease and Viokase were continued for his pancreatic insufficiency. 6. DEPRESSION: The patient was continued on his Citalopram and Bupropion. The patient is a full code and was evaluated by physical therapy. Physical therapy evaluation is pending at the time of this dictation. The patient is expected to be discharged to home with VNA along with nursing at hemodialysis. DISCHARGE DIAGNOSIS: 1. DKA. 2. Insulin-dependent diabetes mellitus. 3. Severe peripheral vascular disease with toe amputations. 4. End-stage renal disease of transplanted kidney. 5. Status post transplant of kidney in [2133]. 6. Right tibia-fibula fracture. 7. Neuropathy. 8. Chronic back pain. 9. Anemia. 10. Gastroesophageal reflux disease. 11. Depression. DISCHARGE MEDICATIONS: 1. The same as the medications upon admission with the exception of Clonidine 0.3 mg b.i.d. 2. Amlodipine 5 mg q.d. 3. Calcium carbonate 1,000 mg t.i.d. 4. Insulin regimen recommended upon discharge is a standing dose of Glargine 12 units q.h.s. and Humalog coverage at meals as determined by [Last Name (un) ]. The patient's sliding scale of Humalog should be glucose 0-50, Humalog dose 0; glucose 51-100, receive 2 units of Humalog at breakfast, lunch, and dinner, and 0 at bedtime; glucose 101-150, receive 4 units of Humalog at breakfast, lunch, and dinner with 0 units at bedtime; glucose 151-200, the patient should receive 6 units of Humalog at breakfast, lunch, and dinner, and 0 units at bedtime; glucose 201-250, the patient should receive 7 units at breakfast, lunch, and dinner, and 2 units at bedtime; glucose 251-300, the patient should receive 8 units of Humalog at breakfast, lunch, and dinner, and 3 units at bedtime; glucose 301-350, the patient should receive 10 units of Humalog at breakfast, lunch, and dinner, and 4 units at bedtime. Glucose readings 351-400, the patient should receive 12 units of Humalog at breakfast, lunch, and dinner, and 6 units at bedtime; glucose greater than 400, the patient should receive 1,400 units of Humalog at breakfast, lunch, and dinner, and 8 units at bedtime. The patient should take juice or Dextrose if his glucose is less than 60. OUTPATIENT FOLLOW-UP: 1. The patient will follow-up at [Last Name (un) ] with Dr. [First Name (STitle) 3636] on [2139-12-15] at 2:30 p.m., phone number [Telephone/Fax (1) 2384]. 2. The patient will also be seen at the [Hospital 191] clinic with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], Nurse Practitioner, on [2139-12-9] at 11:20. DISCHARGE STATUS: Stable. DISCHARGE CONDITION: To home with VNA. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 5587] Dictated By:[Last Name (NamePattern1) 9244] MEDQUIST36 D: [2139-12-3] 03:03 T: [2139-12-6] 09:03 JOB#: [Job Number 106444]	[ "40391", "2859", "311", "53081" ]
Admission Date: [2188-4-14] Discharge Date: [2188-4-21] Date of Birth: [2136-11-10] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [4-14] MVR (33mm St. [Male First Name (un) 923] Mechanical Valve), ASD closure History of Present Illness: 51 y/o gentleman who had a heart murmur detected on a routine physical exam in [2182]. Mitral valve prolapse was found and he was watched by serial echocardiogram. More recently, Mr. [Known lastname 32239] developed bradycardia of 26 and sought attention from his PCP. [Name Initial (NameIs) ] pacemaker was placed. His most recent echocardigram revealed severe mitral valve regurgitation and he now presents for surgical management. Past Medical History: MVP/MR s/p #33 [First Name8 (NamePattern2) ] [Male First Name (un) 923] mechanical/ASD closure [2188-4-14] Sinus bradycardia s/p PM [2183] VEA (PVCs, bigeminy) Broken collar bone as teenager Social History: Was working as a correction officer. He is single and lives with his mother. [Name (NI) ] has never smoked or used alcohol Family History: Maternal GM with colon CA. No CAD / sudden death Physical Exam: Pulse 60 BP 140/90 74" 240lbs GEN: WDWN in NAD HEART: RRR, III/VI SEM LUNGS: Clear ABD: BEnign NEURO: Nonfocal Pertinent Results: [2188-4-21] 07:10AM BLOOD Hct-28.0* [2188-4-21] 07:10AM BLOOD PT-29.7* INR(PT)-3.1* [2188-4-21] 07:10AM BLOOD UreaN-14 Creat-0.9 K-4.6 [2188-4-19] CXR Persistent tiny left pneumothorax. [Last Name (NamePattern4) 4125]ospital Course: Mr. [Known lastname 32239] was admitted to the [Hospital1 18] on [2188-4-14] for elective surgical management of his mitral valve disease. He was taken to the operating room where he underwent a mitral valve replacement with a 32mm St. [Male First Name (un) 923] mechanical valve and an atrial septal defect closure. Postoperatively, his pacemaker was interrogated and reprogrammed by the electrophysiology service. He was then taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [Known lastname 32239] [Last Name (Titles) 5058] neurologically intact and was extubated. Beta blockade and aspirin were resumed. A chest tube was placed for drainage of a left pleural effusion. Coumadin was started for anticoagulation for his mechanical valve. The physical therapy service was consulted for assistance with his postoperative strength and mobility. On postoperative day three, he was transferred to the cardiac surgical nursing floor for further recovery. Mr. [Known lastname 32239] was gently diuresed toward his preoperative weight. Amiodarone was started for atrial tachycardia which was likely atrial fibrillation. As his INR was slow to reach a therapeutic range, heparin was started as a bridge. Mr. [Known lastname 32239] continued to make steady progress and was discharged home on postoperative day seven. On discharge, his INR was 3.1, his wounds were clean and dry and his hemodynamics were stable. Mr. [Known lastname 32239] will follow-up with Dr. [Last Name (Prefixes) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Atenolol Cozaar Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. 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 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 2 weeks. Disp:28 Tablet Sustained Release(s) Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 9. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg [Hospital1 ] x1 wk then 400mg QD x1 wk then 200mg QD . Disp:60 Tablet(s) Refills:2 10. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day: 4 mg [4-21] and [4-22] thenas directed by Dr[Name (NI) 32240] office. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: NashobaVNA Discharge Diagnosis: s/p MVR(#33 [First Name8 (NamePattern2) ] [Male First Name (un) 923] mechanical)/ASD closure PMH:MR,ASD,PPM for bradycardia,vertigo,VEA, collarbone fracture Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No heavy lifting or driving. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (STitle) ] 2 weeks and for coumadin dosing. [Hospital 409] clinic in 2 weeks Dr. [Last Name (Prefixes) ] 4 weeks Completed by:[2188-6-3]	[ "4240", "42789" ]
Admission Date: [2141-10-4] Discharge Date: Date of Birth: [2079-5-27] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This patient is a 62-year-old male who is status post MI in [2126] with PTCA in [2124], admitted [2141-10-3] with substernal chest pain with a positive stress test. Cath showed a left main 70% occluded LAD, minor disease, left circumflex 80% occluded, RCA 80% occluded. PAST MEDICAL HISTORY: Significant for coronary artery disease, MI in [2126], hypercholesterolemia, history of tobacco use. MEDICATIONS: At home, Aspirin 81 mg po q d. HOSPITAL COURSE: The patient was taken by Dr. [Last Name (STitle) 70] to the operating room on [2141-10-6] for CABG times three, LIMA to LAD, SVG to RPDA and OM1. Postoperatively the patient did well. Hospital course was uneventful. On postoperative day #2 the patient had chest tube and drips weaned off without any problem. On postoperative day #2 the patient had a low hematocrit and was transfused one unit of blood. After transfusion the patient's hematocrit was 25.6. The patient showed no further signs or symptoms. Prior to discharge the patient's condition was stable, heart rate was sinus. The patient was able to achieve a level 5 on physical therapy and patient showed the ability to climb stairs and walk greater than 300 feet. Upon discharge the patient's condition was stable. Chest was clear to auscultation bilaterally. Heart, regular rate and rhythm, normal sinus. Incision was clean, dry, intact, no drainage, no pus, sternum was stable. DISCHARGE MEDICATIONS: Lopressor 25 mg po bid, Lasix 20 mg po bid times five days, KCL 20 mEq po bid times five days, Aspirin 81 mg po q d, Percocet 1-2 tablets po q 4-6 hours prn. The patient was arranged to have a VNA for wound check and vital sign monitoring and patient was told to follow with Dr. [Last Name (STitle) 70] in [3-5] weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Name8 (MD) 186] MEDQUIST36 D: [2141-10-12] 13:06 T: [2141-10-12] 13:16 JOB#: [Job Number 26435]	[ "41401", "4019", "2859", "2720", "V1582" ]
Admission Date: [2146-3-2] Discharge Date: [2146-3-18] Date of Birth: [2100-8-2] Sex: M Service: CHIEF COMPLAINT: Gangrene, left fourth toe. HISTORY OF PRESENT ILLNESS: The patient is a 45 year old male with a past medical history of insulin dependent diabetes mellitus, now presenting with gangrene of left fourth toe which started in mid-[Month (only) 1096]. He was admitted to [Location 39045], [Hospital ] hospital (home town), and started on intravenous antibiotics. Amputation was recommended after an angiogram and MRA were performed. He is now here for a second opinion. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus since [2105] with triopathy. 2. Legally blind. 3. Hypertension. 4. Coronary artery disease status post silent myocardial infarction times two. 5. Status post kidney transplant in [2126]. 6. Peripheral vascular disease status post right below the knee amputation. 7. Hyperlipidemia. 8. Anemia. PAST SURGICAL HISTORY: 1. Living related kidney transplant in [2126]. 2. Open cholecystectomy in [2138]. 3. Right below the knee amputation. 4. Left total knee replacement. MEDICATIONS ON ADMISSION: 1. Imuran 125 mg q. day. 2. Lopid 600 mg twice a day. 3. ASA, 325 mg q. day. 4. Axid 150 mg twice a day. 5. Medrol 10 mg q. day. 6. Valium 5 mg twice a day. 7. Duricef 500 mg twice a day. 8. Toprol XL 25 mg q. day. 9. Demerol 25 mg q. day p.r.n. 10. Humulin N 30 units q. a.m. 11. Regular insulin sliding scale. 12. Epogen 8000 units subcutaneously on Monday, Wednesday and Friday. 13. Nitroglycerin spray p.r.n. 14. Lasix 20 mg p.r.n. 15. Captopril 25 mg three times a day. 16. Phenergan p.r.n. 17. Iron sulfate 325 mg three times a day. 18. Colace 100 mg twice a day. 19. Neurontin 300 mg p.o. q. h.s. ALLERGIES: Shrimp and iodine. HOSPITAL COURSE: Mr. [Name14 (STitle) 39046] was admitted under the Vascular Surgery Service. He was started on antibiotics. An angiogram was performed which revealed high-grade stenosis of the tibial peroneal trunk with two-vessel anterior tibial and posterior tibial runoff below that includes feeding into posterior tibial and dorsalis pedis artery. [Last Name (un) ] consult was obtained to optimize diabetic management. Renal, Podiatry and Cardiology consults were also obtained. He underwent a cardiac catheterization on [3-7], per Cardiology recommendation which revealed three-vessel disease. Coronary artery bypass surgery was recommended prior to the Vascular Surgery. He underwent coronary artery bypass graft times two (saphenous vein graft to left anterior descending, saphenous vein graft to distal right coronary artery), on [3-8]. His postoperative course was routine. He then underwent a left below the knee amputation on [2146-3-14]. He tolerated the procedure well. His postoperative course was again routine. He was transiently hypotensive on postoperative day two, although he was asymptomatic. He responded to a fluid bolus. He normally runs with systolic blood pressure of around 85 to 95 mm of Mercury. He is now ready to go to rehabilitation. MEDICATIONS ON DISCHARGE: 1. Insulin 22 units subcutaneously a.m. and 6 units subcutaneously p.m. 2. Regular insulin sliding scale. 3. Levaquin 500 mg p.o. q. day. 4. Lopid 600 mg p.o. twice a day. 5. Medrol 10 mg p.o. q. day. 6. Imuran 125 mg p.o. q. day. 7. ASA 325 mg p.o. q. day. 8. Lopressor 15 mg p.o. twice a day. 9. Colace 100 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient may not weight bear on upper extremities for up to five weeks due to recent coronary artery bypass graft. 2. He may be fitted for prosthesis to the right stump. 3. He may get out of bed with maximum assistance. 4. Follow-up with Dr. [Last Name (STitle) 1391] in two weeks. DISCHARGE DIAGNOSES: 1. Non-healing ulcer, left foot, status post left below the knee amputation. 2. Coronary artery disease, status post coronary artery bypass graft. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4417] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2146-3-18] 10:51 T: [2146-3-18] 11:02 JOB#: [Job Number 39047]	[ "41401", "2851", "4019", "412" ]
Admission Date: [2188-10-29] Discharge Date: [2188-11-3] Date of Birth: [2128-7-16] Sex: M Service: MED Allergies: Penicillins Attending:[First Name3 (LF) 613] Chief Complaint: "Black stools" Major Surgical or Invasive Procedure: Blood transfusion History of Present Illness: 59yo M with ESRD on HD, CAD s/p CABG s/p stenting to LMCA in [6-26], presented to the [Hospital1 18] on [2188-10-29] with dizziness with black stool. . Pt was in his USOH until [2188-10-29] when he returned from HD to home at 6pm. Experienced nausea, ate "spicy schezuan" meal, then had abd upset and passed brown/black stools. Went to bed and at MN awoke and passed black diarrhea. Felt dizzy and felt that BS might be low; on way to fridge, collapsed with LOC, with sudden feeling of dizziness and weakness. Denies CP, palps, SOB. Regained conciousness and called EMS. This was pt's first episode of melana. Denies GERD. . Pt takes aspirin and plavix. Sigmoidoscopy 2mo ago was unremarkable. . While in [Name (NI) ], pt rec'd R femoral line, a-line, and 2 U pRBC's. Had episodal emesis trace. Vitals on presentation to ER: 98.4 91 104/91 10 100%FM Pt noted to have ST depressions on presentation. Past Medical History: 1. Cardiac - CAD s/p CABG [2171] (LIMA --> LAD, SVG --> OM). - NSTEMI in [6-26] s/p left main stent, PTCA x 2. - Nuclear stress test in [4-27] with reversible defects in the LAD and PDA territories. 2. CHF - H/o systolic and diastolic HR. Echo [2-27] showed EF 30%. 3. PVD s/p R TMA. 4. DM. 5. HTN. 6. Hypercho. 7. ESRD on HD since [2188], [2-25] to DM2. S/p insertion of RIJ permacath and [2-27] placement of L brachiocephalic fistula. 8. H/[Initials (NamePattern4) ] [Last Name (NamePattern4) 10834] 4 melanoma, s/p right shoulder ressection in [Month (only) ] [2188], no reccurence. Social History: Lives with mother in [Name (NI) 4628]. 20 py smoking history but quit in [2187]. No EtOH. No IVDU. Family History: Mother - recent stroke. Physical Exam: Morbidly obese, well-appearing, NAD, talkative, A+Ox3 MMM, o/p clear EOMI, PERRL RRR, 2/6 SEM loudest at LUSB Lungs CTA bilaterally Abd Soft, distended, obese, +BS Extr 2+ pitting edema bilaterally Pertinent Results: [2188-10-29] 10:45AM WBC-16.5# RBC-3.29 HGB-10.6# HCT-31.8 MCV-97 MCH-32.3* MCHC-33.4 RDW-15.3 [2188-10-29] 10:45AM PLT COUNT-259 [2188-10-29] 10:45AM NEUTS-80.1* LYMPHS-14.3* MONOS-4.5 EOS-0.5 BASOS-0.6 [2188-10-29] 01:23PM LACTATE-2.9* . [2188-10-29] 10:45AM GLUCOSE-377* UREA N-100* CREAT-8.7# SODIUM-140 POTASSIUM-5.2 CHLORIDE-93* TOTAL CO2-25 ANION GAP-27* [2188-10-29] 10:45AM ALBUMIN-3.9 CALCIUM-10.7* PHOSPHATE-3.3# MAGNESIUM-1.8 [2188-10-29] 10:45AM ALT(SGPT)-38 AST(SGOT)-26 LD(LDH)-226 CK(CPK)-57 ALK PHOS-131* AMYLASE-57 TOT BILI-0.3 . CK 57 --> --> 209 --> --> 57 CKMB 15 --> --> 5 cTnT .16 --> --> 1.14 Brief Hospital Course: 1. GIB: Pt seen by GI who did not want to emergently scope pt since he was having an NSTEMI. He recieved 1 unit PRBCS in the ED and another 2 overnight within 12 hrs of his arrival to the unit. His vitals signs remained stable and Hct bumped appropriately to the mid 30's after the two units (29.8 --> 34.5). He arrived with a femoral cordis, which later was displaced, so two periperhal IVs were started. Protonix IV. Q6h hcts were done, and then decreased to q8 and then q12. He was called out on the morning of his first hopsital day since he was stable and was transferred to the [Hospital Ward Name ] on HD #2. The pt had no further episodes of melena in the hospital and was entirely asymptomatic. Diet was adv as tolerated, and plan was for outpt EGD and colonoscopy in 2-3wks. Plavix and beta-blocker were held in hospital. Transfusion goal was hct>30; pt did not require further transfusion. After discussion with GI, pt was discharged on aspirin and on a [Hospital1 ] PPI (new) prior to the procedure. Pt was instructed to hold plavix at home until the colonoscopy. . 2. NSTEMI: In the [Last Name (LF) ], [First Name3 (LF) ] EKG showed ST segment depressions and TWI in the lateral leads which were different from prior EKG. His troponin was 0.16 in the ED but increased 8 hours later, along with a rise in his CK and MB. These continued to climb over the next 24 hours, but plateued by the second hospital day. Serial EKG's were checked which showed no new change. Cardiology consult obtained in the ED; decision was to defer intervention as this was likely demand ischemia, hold plavix since he had been 1 yr out form his stnet placement. Pt placed on tele with no events and he never had chest pain or other anginal symptoms. On the floor, pt had several brief episodes of asymptomatic bradycardia to 30's with increased ectopy. An EKG showed no changes. Echo showed: EF > 60%. No AS, no AR. Mild PA HTN. Suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. . 3. ESRD: Renal consult obtained in ED did not find a need for emergent HD. Pt had HD on ICU day 1. Pt's home HD is Tu/Th/Sat. . 4. DM: On home regimen with good control. . 5. Hyperchol. Increased lipitor to 40qd. . 6. Proph: PPI, OOB . 7. Pt discharged to home with very close follow-up: PCP, [Name10 (NameIs) 2085], GI Medications on Admission: Insulin 70/30, 30qAM 30qPM Aspirin 325 Nephrocaps Lisinopril 10 Lipitor 10 Plavix 75 Tums Lopressor 5 [Hospital1 ] Discharge Medications: 1. Pantoprazole Sodium 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 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:60 Tablet(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:0 Refills:0 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO QD (once a day). 8. Insulin 70/30 70-30 unit/mL Suspension Sig: as directed units Subcutaneous twice a day: Take 20 units in am and 20 units in pm. Discharge Disposition: Home Discharge Diagnosis: 1. GI bleed 2. Diabetes mellitus 3. Hypertension 4. Elevated cholesterol 5. Coronary artery disease 6. History of myocardial infarction 7. End stage renal disease on hemodialysis Discharge Condition: Good Discharge Instructions: Call or return if you develop chest pain, shortness of breath, lightheadedness, or dizziness. Call or return if you develop nausea, vomiting, abdominal pain, black stools or bloody stool. * Please DO NOT take your plavix until you have either spoken with Dr. [Last Name (STitle) 911] or had your colonoscopy and spoken with the gastroenterologist. * You will receive receive a prescription for protonix, which is important after your GI bleed. Followup Instructions: 1. Follow-up with your primary care physician [Last Name (NamePattern4) ] 1 week. 2. Follow up with your cardiologist Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911]. Please call [Telephone/Fax (1) 62] for an appointment. 3. Follow-up with a gastroenterologist for an outpatient colonoscopy in two weeks. Call [Telephone/Fax (1) ]. 4.Provider: [First Name11 (Name Pattern1) 354] [Last Name (NamePattern4) 3013], M.D. Where: [Hospital6 29] [Hospital3 1935] CENTER Phone:[Telephone/Fax (1) 253] Date/Time:[2189-1-7] 10:00. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "41071", "4280", "40391", "2851", "25000", "V4581", "412", "2720" ]
Admission Date: [2181-4-7] Discharge Date: [2181-4-11] Date of Birth: [2135-11-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1377] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: none History of Present Illness: 45 y/o male with PMHx of HIV, HepB, HepC who initially presented to OSH on [4-5] with complaints of lower extremity pain, back pain and subjective fevers. Decribed the lower extremity pain as cramping in nature. He was seen at [Location (un) 7188] ED prior to his admission there with leg pain and fevers and was sent home with tylenol and vicodin, at that time it was noted that his ALT/AST were in the 500-700 range. He then returned a few days later when the LE pain progressed and he continued to have fevers. Patient states that he ate some bad seafood that caused him to have fevers, nausea and have diarrhea. When he presented the second time to [First Name5 (NamePattern1) 745] [Last Name (NamePattern1) 30746] his LFTs were noted to be 3000-4000 range with Tbili upto 6. He was noted at that time to have a temp of 102. An acetominophen level was checked which was undetectable, however patient put on mucomyst protocol and he was sent to their ICU for concern of fulminent liver failure. The patient was never encephalapathic. He had an abdominal U/S that showed GB thickening and pericholecystic fluid but no CBD and no significant abdominal ascites. His AST on admission was 4108 and increased to 4606; his ALT on admission was 2968 and increased to 3333, his Alk phos remained at 160 and Tbil ranged from 6.3-6.9 with GGT of 125. A monospot was sent which was negative. He was transferred to [Hospital1 18] for further workup of his liver failure. On arrival to [Hospital1 18] patient complaining of RUQ pain which he states has been present since his admission to OSH. He denies any SOB, CP, n/v. Denies any dysuria. He states that his diarrhea has improved. States leg pain has improved. Denies eating any unuasal herbs, mushrooms. However he does did eat old minced clams that were out-of-date and tasted "funny" prior to his hospitalization ROS: Recent 30-40 lbs weight loss in the last 3 months. Past Medical History: HIV diagnosed [2164]; Last CD4 187 and HIV VL 6000- he was to start HARRT therapy outpatient but had recent episode of illness. He was told to start Bactrim but could not afford to fill Rx HepB HepC [Last Name (un) ] Social History: Married, former truck driver currently unemployed, noted for heavy etoh use: 1pint whisky and 12 pack beer daily, stopped on [4-3]. He also has history of [11-21] ppd tobacco use x 5years. Used IVDU (heroin/cocaine) but quit in [2169] Family History: Sister and brother with HepC Physical Exam: T 97.0 HR 59 BP 106/68 RR 18 O2Sat 98% RA Gen: NAD Heent: PERRL, EOMI, sclera icteric, OP clear, no thrush, MM dry Neck: supple, no LAD Lungs: CTA B/L Cardiac: RRR S1/S2 no murmurs Abdomen: soft, + tenderness at RUQ; + hepatomegaly; no splenomegaly appreciated; no shifting dullness or fluid wave Ext: no edema; no asterixis Neuro: AAOx3 MS [3-24] UE/LE, sensory grossly intact Skin: + jaundice Pertinent Results: Liver U/S: FINDINGS: Liver appearance is unchanged from previous day's exam, with no focal or echotextural abnormality. Gallbladder is contracted, but wall edema is unchanged. There is a small round echogenic focus within the fundus of the gallbladder, which may represent a nonmobile stone or a small polyp. There is no intra- or extra-hepatic biliary ductal dilatation. The common duct measures 3 mm. Color Doppler examination of the main portal vein, right portal vein and branches, and left portal vein demonstrate normal color flow and waveforms. The hepatic veins are widely patent. IMPRESSION: 1. No significant change since prior exam. Patent portal and hepatic veins. No evidence of Budd-Chiari syndrome. 2. Unchanged gallbladder wall edema, without gallbladder distention to suggest cholecystitis. CXR: FINDINGS: There is subsegmental atelectasis in the left lung base. No consolidation or superimposed edema is noted. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No pleural effusion or pneumothorax is evident. The visualized osseous structures are unremarkable. IMPRESSION: Left basilar subsegmental atelectasis with no consolidation or edema. PERTINENT RESULTS: LFTs: [2181-4-7] 08:44PM BLOOD ALT-2648* AST-1684* LD(LDH)-332* AlkPhos-148* TotBili-10.4* [2181-4-8] 06:08AM BLOOD ALT-2392* AST-1289* AlkPhos-149* TotBili-11.0* [2181-4-9] 04:45AM BLOOD ALT-1857* AST-617* AlkPhos-141* TotBili-10.8* [2181-4-10] 04:50AM BLOOD ALT-1248* AST-277* LD(LDH)-187 AlkPhos-132* Amylase-33 TotBili-8.6* [2181-4-11] 04:57AM BLOOD ALT-966* AST-161* AlkPhos-133* TotBili-7.6* [2181-4-7] 08:44PM BLOOD PT-17.3* PTT-33.4 INR(PT)-1.6* [2181-4-8] 06:08AM BLOOD PT-16.1* PTT-33.0 INR(PT)-1.5* [2181-4-9] 04:45AM BLOOD PT-16.4* PTT-29.9 INR(PT)-1.5* [2181-4-10] 04:50AM BLOOD PT-15.9* PTT-30.1 INR(PT)-1.4* [2181-4-11] 04:57AM BLOOD PT-14.0* PTT-28.9 INR(PT)-1.2* SEROLOGIES: [2181-4-8] 06:08AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HBc-NEGATIVE [2181-4-8] 06:08AM BLOOD Smooth-POSITIVE (1:20 titer) [2181-4-8] 06:08AM BLOOD AFP-2.8 [2181-4-8] 06:08AM BLOOD HCV Ab-POSITIVE [2181-4-8] 02:41PM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Neg [2181-4-8] 02:41PM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test Neg CMV Viral Load-PENDING HIV-1 Viral Load/Ultrasensitive-PENDING CBC on discharge: [2181-4-11] 04:57AM BLOOD WBC-2.7* RBC-4.44* Hgb-14.6 Hct-42.0 MCV-95 MCH-33.0* MCHC-34.8 RDW-14.4 Plt Ct-99* [2181-4-9] 04:45AM BLOOD Neuts-55.6 Lymphs-35.3 Monos-5.8 Eos-3.0 Baso-0.2 Brief Hospital Course: 45 y/o male with HIV, HepB, HepC who presents to OSH initially with abdominal pain, fever, and leg cramps who was found to have worsening liver failure. His active hospital issues included: . ## Elevated Transaminases: Patient presented with very high levels of AST and ALT suggestive of hepatitis causes such as HepD infection. EtOH and tylenol/vicodin use was also considered a possible etiology. Autoimmune hepatitis was ruled out ([Doctor First Name ] 1:20). No report from U/S of clot in hepatic or portal vasculature. Repeat Abdominal U/S with doppler revealed patent hepatic arteries. Pain was well controlled with PO dilaudid. By discharge, his LFT's had continued to improve, and Patient will follow-up with Dr. [Last Name (STitle) 497] at liver clinic in one week. Other diagnostic tests included: - Hep D pending at discharge - CMV VL pending at discharge; CMV IgG pos and IgM equivocal - EBV positive for past infection, no acute infection - Iron studies normal - Patient had [Last Name (un) ] in the past and Hep A IgM nonreactive on [2181-3-6]. - Repeat Hep A IgM pending at discharge - Hep C VL: pending at discharge ## Thrombocytopenia/Leuckopenia - This was most likely related to HIV as patient reports long standing history of low platelets. No evidence of TTP-HUS. ## HIV - Patient with CD4 187, VL 6000 two weeks ago. ID was consulted to help determine how patient will be managed as an outpatient. Patient will follow-up with Dr. [First Name (STitle) ] as an outpatient. He was started bactrim for PCP [Name Initial (PRE) ]. ## FEN: regular diet well tolerated, IVF as needed ## PPx: held heparin given thrombocytopenia, pneumoboots, bowel regimin ## Comm: [Name (NI) ] [Name (NI) 72629] [Telephone/Fax (1) 72630] Medications on Admission: Dilaudid and vicodin Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for 1 weeks. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: hepatitis C Hepatitis B HIV acute liver failure Discharge Condition: stable, pain improved Discharge Instructions: You had hepatitis resulting in liver dysfunction. We are not sure what the cause was. Please follow-up with Dr. [Last Name (STitle) 497] next week to discuss treatment for your liver disease. Please call your doctor if you have any worsening abdominal pain, yellowish skin tone, itchiness, fever, chills, nausea, vomiting, or any other concerning symptoms. Please take all medications as prescribed. Please attend all follow-up appointments. Followup Instructions: Liver: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2181-4-13] 8:20 Please call to make an appointment to follow-up with Dr. [First Name (STitle) ] when you return home. You should see Dr. [First Name (STitle) ] within the next 2 weeks. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379]	[ "2875" ]
Admission Date: [2179-5-7] Discharge Date: [2179-5-9] Date of Birth: [2115-5-27] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7744] Chief Complaint: UGIB Major Surgical or Invasive Procedure: [2179-5-8] esophago-gastro-duodenoscopy (EGD) History of Present Illness: 63 yo M physician with history of hypothyroidism, GERD, colonic adenoma and arthritis presenting about 7-10 days of melena, generalized weakness, and presyncope. Patient reports taking 445 mg Aleve [Hospital1 ] daily for the last [2-5] months for his tendonitis as well as ASA 81 mg daily for prophylaxis. He stopped his omeprazole about 9 months ago after his GERD symptoms resolved. Patient noticed about melena with stomach "queasiness" for about 7-10 days. He also has increased weakness and fatigue. He attribute these symptoms to a viral illness. He denies chest pain, shortness of breath. He denies BRBPR. Today, he went to see his PCP and was found to have guiaic postive melenic stool with Hct down to 27 from previous of 42.8 in 9/[2178]. He was referred to the ED for further evaluation. In the ED, initial VS were: T 98.2, HR 67, BP 127/84, RR 18, O2Sat 100%. Repeat HCT was stable at 27.7. Patient was started on a protonix infusion at 8mg/hr. GI was consulted and recommended admission to MICU for possible EGD today. He did not receive blood products. He has 2 peripheral IV 18 Gs. VS upon transfer: 97.1, 67, 130/82, 16, 100% RA On arrival to the MICU, patient reports feeling okay. Past Medical History: - ankle sprian - esophageal reflux - hypothyroidism - colonic adenoma - h/o hematuria - basal cell carcinoma '[65], Left malar - HTN - HDL Social History: Patient is an OB/GYN M.D Never smoked, does not drink. Drinks about [2-5] cups of coffee daily Married. Family History: Father with HTN Mother with glaucoma Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.2, 73, 123/74, RR 16, 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 and S2, occasional S3, no m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Rectal: dark guaiac + stool Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, gait deferred. . DICHARGE PHYSICAL EXAM: afebrile, BP 110-120s/60-70s, HR 60s-70s, saturations >98% RA exam unchanged Pertinent Results: ADMISSION LABS: [2179-5-7] 03:51PM BLOOD WBC-6.4 RBC-2.84* Hgb-9.0* Hct-27.8* MCV-98 MCH-31.5 MCHC-32.2 RDW-14.2 Plt Ct-210 [2179-5-7] 03:51PM BLOOD Neuts-60.8 Lymphs-29.6 Monos-5.4 Eos-3.6 Baso-0.6 [2179-5-7] 03:51PM BLOOD PT-10.8 PTT-29.4 INR(PT)-1.0 [2179-5-7] 03:51PM BLOOD Glucose-76 UreaN-23* Creat-1.4* Na-137 K-4.5 Cl-105 HCO3-24 AnGap-13 [2179-5-8] 03:07AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0 . DISCHARGE LABS: [2179-5-8] 08:50PM BLOOD Hct-27.2* [2179-5-9] 07:08AM BLOOD Hct-26.3* [2179-5-9] 07:08AM BLOOD Glucose-97 UreaN-18 Creat-1.5* Na-137 K-3.8 Cl-103 HCO3-25 AnGap-13 [2179-5-9] 07:08AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.3 . [2179-5-8] EGD: Esophagus: Mucosa: Localized erythema of the mucosa with no bleeding was noted in the gastroesophageal junction. These findings are compatible with Mild esophagitis. . Stomach:Mucosa: Localized erythema and erosion of the mucosa with no bleeding were noted in the antrum. These findings are compatible with Moderate gastritis. . Duodenum: Mucosa: Diffuse erythema, congestion and friability of the mucosa with no bleeding were noted in the duodenal bulb compatible with Severe duodenitis. Excavated Lesions A single non-bleeding 1.5 cm ulcer with clean base was found in the duodenal bulb. There were no stigmata of recent bleed. . Impression: Erythema in the gastroesophageal junction compatible with Mild esophagitis Erythema and erosion in the antrum compatible with Moderate gastritis Erythema, congestion and friability in the duodenal bulb compatible with Severe duodenitis Ulcer in the duodenal bulb Otherwise normal EGD to third part of the duodenum . Recommendations: The findings account for the symptoms Antireflux regimen: Avoid chocolate, peppermint, alcohol, caffeine, onions, aspirin. Elevate the head of the bed 3 inches. Go to bed with an empty stomach. Continue Protonix drip. Serial Hct. Avoid NSAIDs. Check H.Pylori Ab in serum and treat if positive. Clear liquids today.Advance diet today/tomorrow if no further bleeding. If stable, patient can be transferred to floor today/tomorrow. Discharge on [Hospital1 ] PPI high dose. Brief Hospital Course: Dr. [Known lastname 9192] is a 63 year old male with hypothyroidism and left ankle sprain who presented with 7-10 days of melanotic stool and hematocrit drop in the setting of NSAID use x 2-3 months for the ankle sprain. Found to have gastritis/duodenitis with duodenal ulcer on EGD. . # Upper gastrointestinal bleed: Because of melena and the hematocrit drop of 14 points (from baseline [2178]), he underwent an EGD which showed large 1.5 cm duodenal ulcer with duodenitis, gastritis, esophagitis consistent with NSAID injury. The GI team felt this definitely explained his symptoms and was most likely from chronic NSAID use for left ankle pain (thought to be a acute on chronic sprain in [1-/2179]) and aspirin use. H. pylori IGG negative from the clinic, biopsy results pending. Patient was started on pantoprazole bolus with drip. Serial hematocrit remained stable and did not have further melena during admission. He did not require blood transfusion. He was transitioned from IV pantoprazole to PO BID and should continue [Hospital1 ] for 2 weeks then daily until follow-up with GI. . # Left ankle sprain: NSAIDs were stopped due to bleeding above. He will use tylenol for joint pains and this ankle sprain. . # Hypothyroidism: He was continued on home levothyroxine 100 mcg daily # Hypertension: Diet controlled. # Hyperlipidemia: Diet controlled. . TRANSITIONAL ISSUES: - Please follow-up final biopsy results from duodenal ulcer - Please encourage adherence to recommended diet Medications on Admission: - Aleve 445 mg [Hospital1 ] - ASA 81 mg - levothyroxine 100 mcg daily - MVI daily - Fish Oil daily Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 2 weeks. Disp:28 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS duodenal ulcer due to NSAID use anemia of acute blood loss Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Dr. [Known lastname 9192], You were admitted to the hospital because you had melena and a hematocrit drop. You underwent an EGD which showed a duodenal ulcer and gastritis/duodenitis. We think that this is due to excessive NSAID intake. You should avoid NSAIDs completely for at least a month and then only take them sparingly with food. Try to use acetaminophen instead for pain but also do not exceed 4 grams per day. Also, there are some diet modifications for your ulcer: Antireflux regimen: Avoid chocolate, peppermint, alcohol, caffeine, onions, aspirin, tomatoe-based foods. Elevate the head of the bed 3 inches. Go to bed with an empty stomach. The following changes were made to your medications: - INCREASE pantoprazole to 40 mg twice daily for 2 weeks. After this, you can decrease to once daily again - STOP taking NSAIDS, use acetaminophen for pain instead. Do not exceed 4 grams of acetaminophen per 24 hours - STOP aspirin 81 mg daily until you have completed the 14 days of pantoprazole. If you motice melena again, then you should stop the aspirin and see your PCP or GI doctor. It is very important that you make follow-up appointments with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] specialists. It was a pleasure taking care of you in the hospital! Followup Instructions: Please call to make an appointment with your primary care doctor, Dr. [Last Name (STitle) ] within 2 weeks. The information is Name: [Last Name (LF) 17528],[First Name3 (LF) 17529] Location: [Location (un) 2274]-[University/College ] Address: [Hospital1 3470], [University/College ],[Numeric Identifier 23943] Phone: [Telephone/Fax (1) 17530] Fax: [Telephone/Fax (1) 6808] Also, please call to make an appointment with the GI team. You can pick who would like to start seeing as an outpatient. The attending physician on your EGD here was Dr. [First Name8 (NamePattern2) 1586] [Name (STitle) 2161]. The phone number for [Hospital1 18] GI is: ([Telephone/Fax (1) 2233].	[ "2851", "25000", "4019", "2720", "53081", "2449" ]
Admission Date: [2133-10-25] Discharge Date: [2133-10-27] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5893] Chief Complaint: Rigors Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 3827] is an 84 year old gentleman with history of CAD s/p CABG ('[20]), CHF with biventricular systolic dysfunction (EF 35%), atrial fibrillation on coumadin, BPH s/p TURP, Parkinson's disease, and recurrent UTIs due to intermittent catheterizations who presents from home with 1 day of rigors and cough. He had been in his usual state of health until two days prior to admission he noted a sore throat and fatigue, but no associated shortness of breath. On the day of admission his voice was hoarse and he had a cough productive of yellow sputum. He has a 24/7 nursing assistant who lives in his home and was monitoring q2H temperatures which had been normal until 8PM this evening when she got a temp of 99 (high for him) and noted that his whole body was shaking. He was brought to [Hospital1 18] by EMS. Reportedly no recent nausea, vomiting, diarrhea or urinary symptoms. Of note the patient reports frequent episodes of food going "down the wrong tube" and resultant coughing fits. He has been on a dysphagia and nectar thickened diet during past admissions to [Hospital1 18]. . In the ED, VS were T 105 (rectal), BP 108/76, HR 80, RR 22, O2sat 94% on RA, 97% on 3L NC. With 1g PR tylenol temperature improved to 103.6. Systolic BP remained stable in high 90s to low 100s. Labs notable for elevated white count with bandemia. Lactate 2.0. Blood and urine cultures sent. Chest xray was consistent with a new multifocal pneumonia (LUL). Head CT negative for bleed. He was given 1700cc NS boluses, one dose of ceftazidime 2gm x1 and vancomycin 1gm x1 while in the ED. Per ED discussion with daughter, DNR but intubation ok. . On arrival to the floor, he denies any shortness of breath, chest pain, lightheadedness, dizziness. Denies any dysuria, urinary frequency. No sick contacts. . At baseline, Mr [Known lastname 3827] is able to feed himself, and go on short walks around his block - can walk 1 mile w/o shortness of breath, oriented x 3. He and his wife have 24-7 nursing assistance at their home in [Location (un) 4628] and have multiple family members who live near by. Past Medical History: 1. Coronary artery disease status post CABG in [2120], no cath since then. 2. Atrial fibrillation on coumadin. 3. Biventricular heart failure with an EF of 35%. 4. Mild AS, MR [First Name (Titles) ] [Last Name (Titles) ] 5. Benign Prostatic hypertrophy status post TURP x 2, now 3x daily catheterizations and keflex chronic suppression. 6. Anemia for which he receives darbepoetin every 2 weeks. 7. Macular degeneration in left eye. 8. Multiple UTIs last culture [2132-6-26] showed E.coli and corynebacterium (diphtheroid) resistant to cipro/levo/bactrim/amp, but sensitive to ceftriaxone; UTI in [2130] grew bactrim, ticarcillin and fq resistant bacteria; UTI in [2129] grew pan sensitive enterobacter cloacae 9. Parkinson's disease Social History: Former smoker - quit 50 years ago. He drank EtOH regularly until 25 years ago, and now only drinks rarely. Lives at home with wife. Wife with dementia-has 24 hour caretaker. Active, walks independently and independent of ADLs plays golf. Family very involved with his care. HCP = [Name (NI) ] [Name (NI) 1182] cell [Telephone/Fax (1) 97770], and daughter [Name (NI) ] [Telephone/Fax (1) 97771] is second HCP. [Name (NI) ] used to be in the navy, then worked in a creamery, and then owned two restaurants and was in catering before he retired. Family History: Non-contributory Physical Exam: VS T100.6, BP 120/97, HR 90, RR 22, O2sat 97% on humidified O2 Gen: Thin, elderly appearing male in NAD HEENT: dry MM, EOMI, PERRL Neck: no LAD, no thyromegaly, no carotid bruits Pulm: scattered rhonchi, , no wheezes or rhonchi Cor: s1, irregularly, irregular, 2/6 systolic murmur at apex radiating to axilla Abdomen: scaphoid, nontender, nondistended, no organomegaly Extremities: no cyanosis or edema. LE cool to touch. Neuro: AOx2 (year [2134]). Resting tremor, bradykineasia. CN II-XII intact. Pertinent Results: [2133-10-24] 09:15PM BLOOD WBC-12.3# RBC-2.91 Hgb-10.4* Hct-30.9# MCV-106 MCH-35.8* MCHC-33.7 RDW-23.3* Plt Ct-181 [2133-10-25] 03:10AM BLOOD WBC-17.4* RBC-2.58* Hgb-9.3* Hct-27.4* MCV-107* MCH-36.1* MCHC-33.9 RDW-23.1* Plt Ct-146* [2133-10-26] 12:37PM BLOOD WBC-15.0* RBC-2.46* Hgb-9.0* Hct-26.4* MCV-107* MCH-36.5* MCHC-34.1 RDW-22.9* Plt Ct-135* [2133-10-27] 03:27AM BLOOD WBC-37.6# RBC-3.09# Hgb-11.1* Hct-32.7* MCV-106* MCH-35.8* MCHC-33.8 RDW-23.5* Plt Ct-241# [2133-10-24] 09:15PM BLOOD Neuts-80* Bands-12* Lymphs-6* Monos-1* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* [2133-10-24] 09:15PM BLOOD PT-36.5* PTT-41.0* INR(PT)-4.0* [2133-10-26] 12:37PM BLOOD PT-21.3* PTT-46.9* INR(PT)-2.1* [2133-10-27] 03:27AM BLOOD PT-18.0* PTT-51.8* INR(PT)-1.7* [2133-10-24] 09:15PM BLOOD Glucose-159* UreaN-27* Creat-1.0 Na-139 K-4.3 Cl-104 HCO3-25 AnGap-14 [2133-10-26] 03:51AM BLOOD Glucose-114* UreaN-34* Creat-1.1 Na-138 K-4.6 Cl-107 HCO3-20* AnGap-16 [2133-10-27] 03:27AM BLOOD Glucose-113* UreaN-51* Creat-2.1* Na-140 K-4.7 Cl-108 HCO3-20* AnGap-17 [2133-10-26] 03:51AM BLOOD ALT-72* AST-91* LD(LDH)-371* AlkPhos-76 Amylase-31 TotBili-2.1* [2133-10-26] 12:37PM BLOOD ALT-26 AST-76* LD(LDH)-342* AlkPhos-69 Amylase-34 TotBili-2.7* [2133-10-27] 10:33AM BLOOD CK-MB-12* MB Indx-2.0 cTropnT-1.83* [2133-10-24] 09:15PM BLOOD Calcium-8.4 Phos-3.0 Mg-2.2 [2133-10-26] 03:51AM BLOOD calTIBC-126* VitB12-1497* Folate-12.1 Ferritn-1161* TRF-97* [2133-10-27] 10:33AM BLOOD Cortsol-37.0* [2133-10-27] 01:26PM BLOOD Cortsol-49.1* [2133-10-25] 03:10AM BLOOD Digoxin-0.7* [2133-10-26] 09:49AM BLOOD Type-ART FiO2-70 pO2-66* pCO2-42 pH-7.33* calTCO2-23 Base XS--3 [2133-10-26] 02:02PM BLOOD Type-ART pO2-205* pCO2-42 pH-7.38 calTCO2-26 Base XS-0 Intubat-INTUBATED [2133-10-26] 06:19PM BLOOD Type-ART Rates-14/ PEEP-5 FiO2-60 pO2-60* pCO2-39 pH-7.39 calTCO2-24 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2133-10-26] 10:48PM BLOOD Type-ART Temp-38.3 Rates-18/ Tidal V-500 FiO2-70 pO2-105 pCO2-58* pH-7.21* calTCO2-24 Base XS--5 -ASSIST/CON Intubat-INTUBATED [2133-10-27] 12:18AM BLOOD Type-ART Temp-37.2 Rates-/16 Tidal V-600 FiO2-70 pO2-147* pCO2-48* pH-7.26* calTCO2-23 Base XS--5 -ASSIST/CON Intubat-INTUBATED [2133-10-27] 10:43AM BLOOD Type-ART pO2-132* pCO2-45 pH-7.24* calTCO2-20* Base XS--7 [2133-10-24] 09:27PM BLOOD Lactate-2.0 [2133-10-27] 10:49AM BLOOD Lactate-1.7 . STUDIES: [10-24] CXR: FRONTAL CHEST RADIOGRAPH: New multifocal, patchy bilateral airspace opacities are seen, left greater than right. Cardiac and mediastinal contours appear stable. Again seen is evidence of prior CABG. Pulmonary vascularity remains within normal limits. No definite pleural effusions identified. IMPRESSION: Findings consistent with multifocal pneumonia. . [10-24] CT Head: FINDINGS: There is no evidence of acute intracranial hemorrhage, shift of normally midline structures or hydrocephalus. Again seen are focal lacunes involving the right caudate head and bilateral cerebral hemispheres. These do not appear significantly changed compared to prior study. [Doctor Last Name ]-white matter differentiation appears grossly preserved. Again noted is a hypoplastic right maxillary sinus. No mucosal thickening is seen in the visualized paranasal sinuses. IMPRESSION: No evidence of acute intracranial hemorrhage. Old lacunes in the right caudate head and bilateral cerebellar hemispheres again seen, unchanged from prior. . [10-26] TTE: No obvious vegetations seen on mitral, aortic, or tricuspid valves although due to valvular thickening, the sensitivity of TTE to detect endocarditis is decreased. Severe left ventricular systolic dysfunction. Mild right ventricular systolic dysfunction. Mild to moderate aortic stenosis. Moderate pulmonary hypertension. Moderate mitral regurgitation. Biatrial enlargement. . Compared with the prior study (images reviewed) of [2133-7-1], left ventricular systolic function has declined. Estimated pulmonary artery pressures are higher. Right ventricular dysfunction is now present. The heart rate is markedly faster. The severity of mitral regurgitation has increased. Brief Hospital Course: Assessment and Plan: 84 y/o M with history of CAD s/p CABG, CHF (EF35%), AF on coumadin who presents to the ED with 1 day of rigors, found to have new multifocal pneumonia, with progressively worsening respiratory status, ultimately intubated, however continued to do poorly, and decision made to change goals of care to comfort measures only. pt expired [2133-10-27]. . . # respiratory distress - pt with gradually worsening respiratory status, specifically increased RR, worsening ronchi on exam, and CXR with worsening bilateral infiltrates, concerning for ARDS. decision made to proceed with intubation on [10-26] [3-13] elevated RR, hypoxia, however agreed to 7d trial, as pt would not want tracheostomy per family. he was continued on abx empirically for now awaiting sputum cx. respiratory status continued to worsen despite intubation with rising pressures, and poor oxygenation. decision made to change goals of care to comfort measures only and pt expired on [10-27]. . . # Sepsis: Presented with rigors and cough, temperature to 105, bandemia (12%), and tachycardia (HR 120s in ED) with evidence of multifocal PNA on CXR. Also some confusion upon arrival to ED. pt treated with broad spectrum antibiotics for empiric coverage. blood and urine cultures sent in ED. attempted to get sputum culture pt given aggressive fluid resuscitation to maintain MAP >65. Received 1700cc in ED with minimal UOP and continued to receive IVF in MICU, however ultimately started levophed, and then added neo given episodes of tachycardia. culture data remained unremakrable throughout hospital course (some yeast in sputum sample), however pt treatd wtih ceftaz/vanco and flagyl empirically. SBPs remained stable after fluid resuscitation, and pt did tolerate gentle diuresis given pulmonary edema contributing to hypoxia, however required pressors as above. ultimately, given hypotension and worsening respiratory status, decision made to change goals of care to comfort measures only on [10-27] and pt expired that day. . # Cardiac ## Ischemia: +h/o CAD s/p CABG, no chest pain currently. pt continued outpatient regimen of aspirin. digoxin initially held amiodarone started. dig level not toxic. CE unremarkable. - Check dig level with AM labs . ## Rhythm: pt with Atrial fibrillation. INR supratherapeutic, thus held warfarin for supratherapeutic INR. Not on beta [Last Name (LF) 7005], [First Name3 (LF) ] OMR due to severe bradycardia. on [10-26] ?wide complex tachycardia, given amio 150mg iv load and amiodarone gtt for ?SVT with aberrancy vs VT, with some improvement in rate. Given likely is abberancy, d/c'd amdio in favor of diltiazem 10mg iv bolus then dilt gtt for afib. also restarted dig as above. . ## Pump: Last echo done [6-/2133] which showed EF 35-40% with mild AS, mild MR. [First Name (Titles) ] [Last Name (Titles) 21177] and lasix for now given borderline BPs. . # BPH: Requires TID catheterizations and prophylaxis, pt continued on home regimen of daily keflex and foley placed. . # Anemia: Baseline of 28. On admission hematocrit 30.9, likely hemoconcentrated from depleted intravascular volume, however remained stable throughout admission. . # [Name (NI) 5895] Disease - pt continued on carbidopa-levodopa as per home regimen . # FEN: NPO as diet given tenuous respiratory status. . # PPx: supratherapeutic coumadin, PPI, bowel regimen . # Code: initially DNR only per family and patient, ok to intubate, discussed with daughter [Doctor First Name ] and son [Name (NI) ] again [10-26]. plan will be for 7d trial of intubation, with plan to reassess goals of care at that time (specifically re trach). however pt continued to do poorly with difficult to maintain oxygenation on [10-27] and blood pressure (on neo and levo), and decision made to change goals of care to comfort measures only. pt expired [10-27]. Medications on Admission: Medications: (from last d/c summary) Carbidopa-Levodopa 25-100 mg PO TID Digoxin 125 mcg Tablet daily Aspirin 81 mg Tablet daily Cephalexin 500 mg Capsule Q24H [Month/Year (2) ] 5 mg Tablet daily Docusate Sodium 100 mg daily Lasix 20 mg Tablet Every monday, thursday, saturday. Coumadin 10 mg Tablet daily, on Monday takes 12.5mg Omeprazole 20 mg Capsule daily Discharge Medications: pt expired. Discharge Disposition: Expired Discharge Diagnosis: pt expired Discharge Condition: pt expired Discharge Instructions: pt expired Followup Instructions: pt expired	[ "486", "4280", "51881", "2851", "42731", "V4581" ]
Admission Date: [2153-10-3] Discharge Date: [2153-10-8] Date of Birth: [2095-9-17] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4358] Chief Complaint: diabetic ketoacidosis Major Surgical or Invasive Procedure: None History of Present Illness: Mr [Known lastname 6818] is a pleasant 58M with diabetes x 30yrs, CAD sp MI and stents x2, who was brought to the ED today by his wife for poor po intake x weeks, dizziness and weakness for 4 days. The patient is unable to recount much of the history but states that he was fed up with his medications and and thought they were too expensive so stopped taking all of them several months ago. Denies fevers, cp, sob, abdom pain, N/V, dysuria, endorses polyuria and polyphasia. Per his wife, he has had intermittent abd pain, and decreased appetite, did not go to work on tuesday because of fatigue. She also states that he had two falls recently but does not know if he hit his head. In the ED, inital vitals were 96.1 111 93/60 16 100%. Labs were notable for a bicarb of 5, lactate of 7.1, gap of 42. Lipase was elevated at 210. Gas showed pH of 6.97 12 151. Trops were negative, WBC elevated to 11.2. He was given 4 L IVF, 7 units insulin, and started on 7 u/hr drip, given 40 kcl. Lactate improved to 5.0 with fluids. CXR was unremarkable. EKG was performed and showed sinus tach, TWI and ST depressions inferolaterally. Head CT was performed for unclear reasons, likely AMS. . On the floor, pt states he is thirsty, but otherwise denies symptomatology. Specifically no abd pain, CP, SOB. . Review of sytems: (+) Per HPI, polyuria, polydipsia, constipation. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea or abdominal pain. No recent change in bowel habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: DM, diagnosed in [2119] CAD s/p MI with multiple stents placed 10 yrs ago Depression Social History: Lives with wife. [Name (NI) ] 2 grown children, ages 24 and 28. Works as a custodian at a school. No tob, etoh, illicits. Family History: mother with diabetes. Denies any family hx of malignancy, heart disease. Physical Exam: Vitals: T:97.6 BP:166/77 P:101 R:20 O2:100% RA General: aao x 3 but somnolent, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly intact in all extremities Pertinent Results: Admission labs: [2153-10-3] 09:30PM WBC-11.2# RBC-6.07 HGB-17.4 HCT-53.2 MCV-88# MCH-28.7 MCHC-32.8 RDW-12.8 [2153-10-3] 09:30PM NEUTS-90.1* LYMPHS-5.9* MONOS-3.7 EOS-0.1 BASOS-0.1 [2153-10-3] 09:30PM PLT COUNT-331 [2153-10-3] 09:30PM PT-11.9 PTT-21.2* INR(PT)-1.0 [2153-10-3] 09:30PM GLUCOSE-714* UREA N-52* CREAT-3.2# SODIUM-132 POTASSIUM-5.1 CHLORIDE-85* TOTAL CO2-5* ANION GAP-47* [2153-10-3] 09:30PM ALT(SGPT)-27 AST(SGOT)-25 LD(LDH)-205 ALK PHOS-110 TOT BILI-0.4 [2153-10-3] 09:30PM LIPASE-210* [2153-10-3] 09:30PM cTropnT-<0.01 [2153-10-3] 09:38PM GLUCOSE-GREATER TH LACTATE-7.1* K+-5.1 [2153-10-3] 10:19PM PO2-151* PCO2-12* PH-6.97* TOTAL CO2-3* BASE XS--28 [2153-10-3] 11:15PM GLUCOSE-484* UREA N-46* CREAT-2.4* SODIUM-137 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-6* ANION GAP-37* Chemistry trend: [2153-10-3] 09:30PM BLOOD Glucose-714* UreaN-52* Creat-3.2# Na-132 K-5.1 Cl-85* HCO3-5* AnGap-47* [2153-10-3] 11:15PM BLOOD Glucose-484* UreaN-46* Creat-2.4* Na-137 K-4.4 Cl-98 HCO3-6* AnGap-37* [2153-10-4] 03:01AM BLOOD Glucose-268* UreaN-42* Creat-2.1* Na-133 K-4.4 Cl-101 HCO3-9* AnGap-27* [2153-10-4] 10:59AM BLOOD Glucose-137* UreaN-30* Creat-1.7* Na-136 K-3.6 Cl-106 HCO3-18* AnGap-16 [2153-10-4] 03:20PM BLOOD Glucose-210* UreaN-26* Creat-1.5* Na-136 K-4.0 Cl-105 HCO3-15* AnGap-20 [2153-10-4] 01:30PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-300 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG Discharge labs: [2153-10-8] 05:55AM BLOOD WBC-4.7 RBC-4.37* Hgb-12.8* Hct-35.2* MCV-81* MCH-29.3 MCHC-36.4* RDW-12.5 Plt Ct-195 [2153-10-8] 05:55AM BLOOD Glucose-69* UreaN-16 Creat-1.0 Na-141 K-4.1 Cl-103 HCO3-31 AnGap-11 Micro: [10-4] Urine culture negative [10-3] Blood cultures pending (negative at time of d/c) Imaging: [10-3] EKG: Sinus tachycardia. Diffuse T wave inversions in the inferior and anterolateral leads. There is a suggestion of left ventricular hypertrophy, although the voltage criteria are not met. Abnormal tracing. Compared to the previous tracing sinus tachycardia is new and the T wave and ST segment abnormalities are new. The prior tracing was recorded on [2140-4-23]. [10-3] CXR: IMPRESSION: No acute cardiac or pulmonary process. [10-3] CT Head: IMPRESSION: Carotid arterial atherosclerotic calcifications. Otherwise normal study. [10-4] EKG: Normal sinus rhythm. Diffuse non-specific ST segment abnormalities. Abnormal tracing. Compared to the previous tracing sinus tachycardia is no longer present and the T wave inversions are much less marked. Brief Hospital Course: Pleasant 58 yo gentleman admitted for DKA in the setting of medication non-compliance and found to have major depression requiring inpatient psychiatric stay. # Diabetic ketoacidosis: Patient arrived with large gap in the ED. He had a severe metabolic acidosis with arterial pH 6.97, bicarb 5, from both ketoacidosis and lactic acidosis. He was started on fluids and insulin drip in ED. No infectious source was found, but patient had been off of all of his medications. Lactate improved rapidly with rehydration. He had aggressive K+ and fluid repletion with Q4hr labs and venous pH monitoring. When his anion gap improved, he was taken off of the regular insuling drip and transitioned to 27 units of lantus with a humalog sliding scale. He was discharged back on his home lantus regimen of 54 units with reduced sliding scale given his poor appetite and low PO intake. # ST depressions: While tachycardic, no symptoms of ACS, two sets of troponins were negative. Likely due to fixed defect in setting of tachycardia. He may benefit from an exercise stress test as an outpatient. # Acute renal failure: Creatinine up to 3.2 from baseline 1.1 to 1.2. Likely pre-renal in the setting of severe dehydration from DKA, as his creatinine improved quickly with rehydration. # Depression: Likely contributing to med non-complicance. Pt denies depression currently but wife states he has been acting depressed at home. Found to be severely depressed by our social worker and then sectioned by psychiatry to require inpatient treatment. Medications on Admission: Pt has not been taking any meds x 2 months. - [Company 4916] [Hospital1 ], MA med list: #. Lantus 54units SC qhs (last [7-5]) #. Novolog - 20units @ breakfast, 18units @ lunch/snack, 36units @ dinner (last [7-5]) #. Isosorbide mononitrate 60mg PO daily (last [3-5]) #. Amlodipine 10mg PO daily (last [3-5]) #. Clonidine 0.1mg PO BID (last [3-5]) #. Simvastatin 80mg PO daily (last [11-3]) --- additional meds on Atrius records: #. Lisinopril 20mg PO daily #. Atenolol 100mg PO Daily #. Mirtazapine 15mg PO qhs #. MVI 1tab PO daily Discharge Medications: 1. insulin glargine 100 unit/mL Solution Sig: Fifty Four (54) units Subcutaneous at bedtime. 2. Humalog sliding scale Please continue the attached Humalog insulin sliding scale. 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 9. Cepacol Sore Throat 15-3.6 mg Lozenge Sig: One (1) lozenge Mucous membrane twice a day as needed for sore throat. Discharge Disposition: Extended Care Facility: [Hospital ] hospital Discharge Diagnosis: Diabetic ketoacidosis Major depressive disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with very high blood sugars after stopping all of your medications including your insulin. You had a condition called diabetic ketoacidosis which improved with fluids and insulin treatment. We restarted your other home medications as well. We felt you were depressed and you will be transferred to a facility to help focus on your mood. The following changes were made to your medications: 1. Adjusted your sliding scale as attached as you are not eating much food right now. Please discuss adjusting this scale with your doctors once [Name5 (PTitle) ] get out of the hospital and your appetite improves. 2. Reduced your simvastatin dose to 20mg daily as it can intereact with your blood pressure medication amlodipine. 3. Stopped your mirtazapine while psychiatry is figuring out a different medication regimen for you. 4. Stopped your clonidine as your blood pressure was controlled without it. Followup Instructions: Please follow-up with your PCP after discharge from your psychiatric facility.	[ "5849", "412", "41401", "4019", "V4582", "V1582", "V5867" ]
Admission Date: [2183-9-3] Discharge Date: [2183-9-8] Service: SURGERY Allergies: Percocet / Sulfa (Sulfonamide Antibiotics) Attending:[Doctor First Name 5188] Chief Complaint: gallstone pancreatitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: 89 y/o F with PMHx of Afib and HTN who presented with severe epigastric pain, nausea & vomiting to [Hospital 1562] Hospital on the evening of [9-2]. She was found to have a WBC of 21, Amylase 4590, lipase 3000, Tbili 1.3 and RUQ ultrasound revealing small gallstones and peripancreatic fluid. Per report, she was also found to have a UTI. She was given Zosyn, morphine and zofran prior to transfer to [Hospital1 18] ED for further management. . In the ED, initial vs were: T 97.4 P 94 BP 120/64 R 14 O2 sat 97% on 2L NC. Pt underwent RUQ which showed signs of early cholecystitis and mild intrahepatic biliary duct dilation. Both surgery and ERCP were consulted, she was given Zosyn, Morphine, Potassium and NS IVF prior to transfer east. . On arrival to the ICU, pt was sleepy and mildly uncomfortable, c/o generalized abd pain. She denied any current CP, SOB, nausea, fevers or chills. She did report decreased po intake and vomiting for 2 days. Past Medical History: Chronic Atrial Fibrillation Hypertension Osteoarthritis h/o SBO s/p LOA Social History: Social History: Pt lives at [Location 83418] [Hospital3 400], her son lives nearby and assists with some activities of daily living. Family History: N/c Physical Exam: Vitals: T: 97.6 BP: 135/56 P: 76 R: 18 Sats O2: 100% General: Alert, mildly disoriented HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: RRR, normal s1/s2, soft gr II/VI SEM over LUSB Abdomen: soft, mild diffuse tenderness to palpation, bowel sounds present, no guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: [2183-9-3] 02:20AM BLOOD WBC-21.6* RBC-3.58* Hgb-11.8* Hct-33.9* MCV-95 MCH-33.0* MCHC-34.9 RDW-12.6 Plt Ct-179 [2183-9-6] 09:10AM BLOOD WBC-11.7* RBC-3.53* Hgb-11.2* Hct-33.4* MCV-95 MCH-31.8 MCHC-33.6 RDW-12.8 Plt Ct-183 [2183-9-3] 02:20AM BLOOD Neuts-84* Bands-6* Lymphs-7* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2183-9-5] 04:38AM BLOOD Neuts-88.5* Lymphs-6.9* Monos-4.0 Eos-0.5 Baso-0.2 [2183-9-6] 09:10AM BLOOD Plt Ct-183 [2183-9-5] 04:38AM BLOOD PT-13.2 PTT-28.3 INR(PT)-1.1 [2183-9-3] 02:20AM BLOOD PT-14.4* PTT-25.5 INR(PT)-1.3* [2183-9-7] 06:13AM BLOOD Glucose-101 UreaN-19 Creat-0.7 Na-143 K-3.3 Cl-107 HCO3-26 AnGap-13 [2183-9-3] 02:20AM BLOOD Glucose-162* UreaN-25* Creat-1.0 Na-145 K-3.2* Cl-106 HCO3-26 AnGap-16 [2183-9-3] 02:20AM BLOOD ALT-103* AST-178* LD(LDH)-306* AlkPhos-87 TotBili-3.2* DirBili-2.7* IndBili-0.5 [2183-9-3] 11:34AM BLOOD ALT-92* AST-104* LD(LDH)-248 AlkPhos-76 Amylase-1437* TotBili-1.5 [2183-9-5] 04:38AM BLOOD Lipase-177* [2183-9-3] 02:20AM BLOOD Lipase-6375* [2183-9-4] 07:58PM BLOOD CK-MB-4 cTropnT-<0.01 [2183-9-5] 04:38AM BLOOD CK-MB-4 cTropnT-<0.01 [2183-9-7] 06:13AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7 [2183-9-3] 02:20AM BLOOD Albumin-3.9 Calcium-9.1 Phos-2.6* Mg-1.5* [2183-9-7] 10:38AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.013 [2183-9-7] 10:38AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-TR [2183-9-7] 10:38AM URINE RBC-2 WBC-6* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 . URINE CULTURE (Final [2183-9-4]): NO GROWTH . MRSA SCREEN (Final [2183-9-4]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. IMAGING: ERCP [9-3]: Biliary dilation w/ CBD measuring 8mm; No definite stone seen, though the portion of the CBD posterior to the cystic duct was not well seen; d/t concern of cholangitis and current medical condition, sphincterotomy and duct sweep were not performed; a 10F 9cm Cotton [Doctor Last Name ] biliary stent was placed with excellent drainage post placement . ECHO [9-3]: mild symmetric LVH; overall LV systolic fxn is mildly depressed (LVEF= 40-50 %) secondary to hypokinesis of the inferior and posterior walls. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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. . CONSULTS: [9-6] [Female First Name (un) 1634]: Patient with Confusion and Agitation: Recommendation to d/c Albuterol, Ipratropium, Quetiapine, to change famotidine for protronix and call again if needed [Pager number 83419] . [9-7] PT: anticipate pt will need rehab on d/c to maximize function; pt would benefit from OT at rehab to assess question of cognitive/safety deficits Brief Hospital Course: 89 y/o F with PMHx of Afib, HTN who presents with gallstone pancreatitis and early cholecystitis. . # Gallstone Pancreatitis: Admitted with lipase 6000s, WBC >20,000 with bandemia and lactate of 2.6 and RUQ US with evidence of early cholecystitis. Initially given aggressive IVF hydration and started on unasyn 3 gm Q6H. She was taken to ERCP where she was noted to have biliary dilitation with CBD measuring 8 mm without definitive stones. Due to concerns for cholangitis, sphincterotomy and duct sweep deferred. Biliary stent placed with good drainage. WBC trended down to 16,000 with improvement in pancreatic enzymes to lipase 177 and normalized LFTs at time of transfer. All cultures negative at time of transfer. . # Atrial fibrillation: With known history of atrial fibrillation. BB held in acute setting and reintroduced with improving LFTs, WBC. Transitioned from atenolol as outpatient to metoprolol 25 TID in house. Also continued on home digoxin. . # LBBB: Chest pain free. Prior ECG obtained and showed old LBBB. Pt did have an episode of transient chest pain on hospital day #2 that self-resolved. ECG without acute changes and cardic biomarkers negative. ECHO with mildly depressed LVEF at 40-50% with HK of inferior and posterior wall defects. . # Delirium: With waxing and [Doctor Last Name 688] mental status, with sun-downing. Felt that this is related to toxic metabolic encephalopathy/delirium in setting of of gallstone pancreatitis and cholecystitis. Given haldol prn with good effect. At time of transfer, written for QHS zyprexa and zyprexa as needed. . Medications on Admission: Digoxin 125 mcg daily Atenolol 25mg daily Isosorbide Mononitrate SR 60mg daily Lipitor 10mg daily Vasotec 5mg daily Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Male First Name (un) 4542] Nursing Center - [Hospital1 1562] Discharge Diagnosis: Primary Pancreatitis Cholecystitis Secondary Chronic Atrial Fibrillation Hypertension Osteoarthritis Discharge Condition: Stable Discharge Instructions: You were admitted with inflammation of your pancreas and infection of your gallbladder. You were treated with antibiotics and had an ERCP to have a stent placed. Your pain improved and your lab tests indicating infection and inflammation also improved. The following medication changes were made during your hospital stay: 1. You are being given cipro/flagyl for your gallbladder infection 2. Your atenolol was switched to metoprolol for better control of your atrial fibrillation 3. Your lipitor was held in the acute setting 4. You are being started on zyprexa for your confusion Followup Instructions: Please follow up with your doctors as recommended by [Hospital 1562] hospital. [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190] Completed by:[2183-9-8]	[ "5990", "42731", "4019" ]
Admission Date: [2172-9-27] Discharge Date: [2172-10-2] Service: NEUROMEDICINE HISTORY OF THE PRESENT ILLNESS: [Known firstname ] [Known lastname 43541] is a 79-year-old right-handed man with a past medical history of left temporal hemorrhage in [2169], felt to be due to amyloid angiopathy. He was in his usual state of health until about 6 PM today, when he went to sleep in his reclining chair. He sleep and she states that he was somewhat confused at that time. He told her it was raining outside, but that was not the case. His wife woke him at 7 PM to tell him that the baseball game was on TV and the patient work for several seconds, shook his head at his wife, and then fell back to sleep. His daughter returned at about 7:45 PM and stated that he was confused and still had difficulty waking up. to speak and that he could not get up out of his chair. At 8 PM she also realized that he had evidence of right arm and leg weakness. At about 8:20 the family called an ambulance. En route to the hospital, trouble speaking was getting worse and he was noted to have complete right-side weakness per EMS. There were no other symptoms noted. The family was not aware of any arm of leg shaking. PAST MEDICAL HISTORY: 1. Left temporal hemorrhage in [2169] with a residual expressive aphasia and seizure disorder. 2. Chronic obstructive pulmonary disease. 3. Hypertension. 4. History of noncompliance with medications. PAST SURGICAL HISTORY: History is significant for laminectomy several years ago and gastrectomy. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Atenolol 50 mg PO q.d. 2. The patient had, in the past, been on phenobarbitol 90 mg PO q.d., however, that was stopped about a year ago. 3. He was on Wellbutrin, which was stopped about three weeks ago. 4. He also has a history of being on Cogentin, but he also self discontinued prior to admission. SOCIAL HISTORY: The patient lives with his wife. His son works in information services. He also has a daughter. History of heavy tobacco and alcohol use for over 50 years. FAMILY HISTORY: History is significant for diabetes mellitus in his mother and lung cancer in his father. PHYSICAL EXAMINATION: Examination at the time admission revealed that he was afebrile. Blood pressure was 164/52, pulse 76, respirations 16, and he was saturating well on room air. GENERAL: The patient was an elderly man, confused. Neck was supple with no evidence of carotid bruits. Lungs were clear to auscultation. Heart was regular rate and rhythm. Abdomen: Benign. Extremities: No evidence of edema. Neurological: Mental status examination revealed that the patient was awake and alert, but not cooperative with the examination. He makes eye contact, however, he was not able to follow any commands. He was now oriented to person, place, month, day or year. The only thing he could say was "no." Attention: He could not say the months of the year forward or backward. Language: He had sparse speech with minimal word output. He was able to say "no and pen." But, he was unable to name any other items. He was unable to repeat. Fund of knowledge was difficult to assess. Registration: He could not repeat or recall any items. Cranial nerve examination: It was noted that his eyes were both deviated to the right. He also had evidence of decreased blink to threat on the right. He would not cooperate with extraocular movements. Pupils equal, round, and reactive to light bilaterally. Facial sensation could not be assessed. He had evidence of a right facial droop. Hearing seemed to be intact. The patient would not cooperate with palpate or tongue movements. On motor examination, he had intermittent twitching of the right eye and right pectoralis major muscle. Otherwise, he had evidence of normal bulk and tone and no evidence of any other adventitious movements. Strength: 0 out 5 on the right. He would not move arm or leg. He would not cooperate with the examination on the left, however, the strength on the left appeared to be intact at the time of admission. Sensation: Sensation was unable to be assessed. Reflexes were 2+ and symmetrical throughout. Toes were upgoing bilaterally. Coordination and gait could also not be assessed due to poor patient cooperation. LABORATORY DATA: Laboratory data on admission revealed the following: White count of 10.6, hematocrit 44.6, platelet count 234,000, sodium 142, potassium 3.6, BUN 14, creatinine 0.8, glucose 94, calcium, magnesium, and phosphorus were all within normal limits. INR was 1.3. He had a head CT, which showed no evidence of new hemorrhage or new strokes. HOSPITAL COURSE: The patient is a 79-year-old man with a past history of left temporal hemorrhage and a question of associated seizure disorder, who presents with the sudden onset of right face, arm, and leg weakness, aphasia, and a right gaze, as well as focal muscle twitching on the right side. In the emergency department he was given 2 mg Ativan, which improved the strength in his right arm and leg. He was now able to move them against gravity and against mild resistance. He had a MRI scan because he was still very confused and aphasic, but he was unable to sit still for the examination. He was admitted initially to the Neurointensive Care Unit just for close observation. At that time it was felt that the most likely etiology for his resolving hemiparesis, as well the right gaze deviation in the setting of a right paresis with seizure activity, especially if he has a history of a prior seizure disorder associated with his left temporal hemorrhage and he has not been taking any antiepileptic medications recently. He had no evidence of acute stroke on head CT. EEG was ordered, which was not performed for several days and by the time the EEG was performed, there were no abnormalities. However, prior EEGs in [2169-2-27] revealed the following: Evidence of left temporal slowing, especially in the left temporal region on EEG and on another EEG in [2171-10-28]. He also had a slightly abnormal EEG due to some focal slowing. In the ICU, he was loaded with Dilantin and maintain on this. However, later in the hospital course he was transferred to the floor and his wife said that he did not tolerate Dilantin in the past very well because of excessive drowsiness. So, he was loaded with phenobarbital and planned to transition him off the Dilantin in order to increase medical compliance. Throughout the remainder of the hospital stay he continued to improve on a day-by-day basis. The strength in the right side greatly improved. The Department of Physical Therapy evaluated the patient. They thought that he had some unsteady ambulation, but, otherwise, he was doing fairly well. The aphasia was the slowest to resolve. However, that also continued to improve throughout the hospital stay. He was started on Zyprexa, as well as Trazodone to help him sleep at night. He did eventually receive a MRI of the head, which showed no new evidence of any acute process. At the IV site on the right upper quadrant, he had some evidence of cellulitis and he was begun on Ampicillin. The patient is to be discharged to rehabilitation today. DISCHARGE DIAGNOSES: 1. History of left temporal hemorrhage. 2. History of seizure disorder. 3. History of hypertension. 4. Chronic obstructive pulmonary disease. 5. History of medication noncompliance. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: The patient is discharged to rehabilitation. DISCHARGE MEDICATIONS: 1. Phenobarbitol 30 mg PO t.i.d. 2. Trazodone 25 mg PO q.8 PM. 3. Olanzapine 2.5 mg PO q.h.s. 4. Aspirin 325 mg PO q.d. The patient is also going to be tapered off Dilantin over the next week. He can received 100 mg PO twice a day for three days and then 100 mg PO once a day for three days and then the Dilantin can be discontinued. Also, he can be sent out on Amoxicillin 500 mg PO q.8h. times five more days and then discontinue. [Known firstname ],[Doctor Last Name ] R. M.D. [MD Number(1) 17304] Dictated By:[Last Name (NamePattern1) 1203] MEDQUIST36 D: [2172-10-2] 11:55 T: [2172-10-2] 12:00 JOB#: [Job Number 9017]	[ "496", "4019" ]
Admission Date: [2122-6-10] Discharge Date: [2122-6-24] Date of Birth: [2122-6-10] Sex: M HISTORY: 33 [2-22] week infant born to a 29-year-old gravida 3, para 2 mother. Prenatal [Name2 (NI) ], A+, antibody negative, hepatitis B negative, RPR non reactive, GBS unknown. in triplet pregnancy. Triplets are di-di and mono-di with triplets 2 and 3 being identical twins. Mother was followed closely by high risk OB for triplets and short cervix. Admitted at 27 weeks for preterm labor and cervical shortening and subsequent inpatient treatment with Magnesium Sulfate. Decision to deliver was based on maternal discomfort. percentile), length 45.5 cm (60-75th percentile), head circumference 32.5 cm (75-90th percentile). Physical exam revealed a pink and well appearing preterm infant in no distress, with stable vital signs, no abnormalities. HOSPITAL COURSE ASSESSMENT: Respiratory: Patient has been on room air since birth. The patient has had apnea of prematurity with no episodes during the 5 days before discharge. Cardiovascular: The patient is cardiovascularly stable. Fluids, Electrolytes & Nutrition: The patient was initially started on IV fluids and then quickly transitioned to full feeds. He is currently ad lib feeding, Enfamil 24 calories/oz. Discharge weight is 2295 g, head circumference 32.5 cm, length 46 cm. GI: Patient developed mild hyperbilirubinemia but did not require phototherapy. Heme: Initial hematocrit was 40. Normal WBC differential and platelets. ID: Blood cultures were negative in 48 hours, no antibiotics were given. Received empiric ilotycin ointment for persistent eye drainage. Health Maintenance: Newborn screen sent. Passed car seat test. Passed hearing screen. Hepatitis B vaccine given [2122-6-23]. Pediatrician: DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 43918] - [Location (un) ]. Appointment made for Friday [2122-6-26] at 3pm. DISCHARGE DIAGNOSIS: 1. Prematurity, 33+ weeks. 2. Triplet #2. 3. Apnea of prematurity, resolved. 4. Hyperbilirubinemia, resolved. 5. Status post circumcision. 6. Conjunctivitis versus dacryostenosis. DR [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 50.563 Dictated By:[Last Name (STitle) 43919] MEDQUIST36 D: [2122-6-16] 16:15 T: [2122-6-16] 17:36 JOB#: [Job Number 43920]	[ "7742", "V290", "V053" ]
Admission Date: [2163-6-14] Discharge Date: [2163-6-17] Date of Birth: [2087-5-3] Sex: F Service: MEDICINE Allergies: Codeine / Penicillins Attending:[First Name3 (LF) 1436] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Heart catheterization History of Present Illness: 76 yo WF with PMH of CAD s/p MI, ?CVA, HTN, tobacco abuse and CRI, who presents with chest pain. The pt reports onset of chest pain on Monday night while watching TV. She initially attributed this to her first prednisone which had been started that day for a gout flare. The patient reported chest pain as sharp, [9-27] with radiation to both arms. The chest pain was associated with bilious emesis x [4-23] at 9p.m as well as diaphoresis and SOB. She was BIBA to [Location (un) ] ED at 12MN. At the time, EMT believed her to be in SVT/RAF and gave adenosine 6mg x3 and diltiazem 18mg IV. Her initial ECG was concerning for anterior lateral ischemia. Her CE were significant for CK/MB which trended as follows: 70/na - 389/53 - 487/80 and Trop: 0.12 - 3.14 - 8.93. In addition, her creatinine was 2.4 and blood sugar was 700. She was given ASA 325mg x1, Plavix 300mg x1, morphine 2mg x1, Lopressor 5mg x1, and started on heparin gtt and nitro gtt with resolution of ECG changes. In addition, she was started on insulin gtt at 6 units/hour for a FSBG of >500. She has been pain free since 8AM today. She was transferred to [Hospital1 18] for cardiac catheterization. The pt underwent a cardiac catheterization which revealed no significant CAD in LAD, LCx but chronically occluded appearing RCA. An attempt was made to cross the RCA lesion with a guide wire, however she developed bradycardia with transient heart block. She was given Atropine which resulted in tachycardia with possible Afib. LVEDP was 20 at the beginning of cath but during this episode, PCWP was 30 and PaSaO2 was 44%. An IABP was placed during the cardiac catheterization and PaSaO2 inc. to 64%. She was never hypotensive during this episodes. She was given protamine to reverse the hep gtt thinking this episode of hypotension may have been due to tamponade. However the stat TTE did not demonstrate any tamponade physiology. Past Medical History: PAST MEDICAL HISTORY: 1. CAD s/p MI with neg stress test in '[60]. 2. CHF 20% in '[60] with global hypokinesis. No cath in past. Repeat TTE in '[61] with EF of 50%. 2. ?TIA/CVA in '[60] without residual defects 3. DM diagnosed today! 4. HTN 5. Hypercholesterolemia 6. Gout of left knee Social History: SOCIAL HISTORY: The patientt lives by herself in [Location (un) 1439], with ADL and IADL in tact. Tob: former smoker, 80-120 pack year - 1.5ppd x 60 years but quit after first MI in '[60]. EtOH: social drinking every friday. Family History: Mother: HTN and MI at age 74. Two sons and daughter are healthy. Physical Exam: VS: HR: 90, BP: 112/50, RR: 12, SaO2: 100% on NC at 2L GEN: obese elderly female in NAD but alternating between lethargic and interacting. HEENT: PERRL, EOMI, op clear, dry mm NECK: supple, no JVP CV: RRR, distant S1, S2, systolic crescendo-decrescendo murmur with "whistle" quality at apex. Difficult to appreciate due to balloon pump. CHEST: CTA bilaterally ABD: firm, no rebound, guardin', BS + bilaterally, no HSM EXT: wwp, 2+ LE biltarel, + tenderness over Left knee which is also warm GROIN: right groin oozing with sheath in place. No hematoma, no bruits. VASC: bounding radial pulses and 1+ DP Pertinent Results: [2163-6-15] 01:30PM BLOOD calTIBC-233* Ferritn-249* TRF-179* . [2163-6-15] 05:15AM BLOOD Triglyc-312* HDL-40 CHOL/HD-5.1 LDLcalc-103 . [2163-6-14] 09:28PM BLOOD %HbA1c-7.6* . [2163-6-14] CARDIAC CATHETERIZATION: 1. Coronary angiography revealed a right dominant system. The LMCA showed no angiographically apparent stenoses. The LAD showed a 40% midsegment stenosis and appeared tortuous. The LCx was a small vessel without significant stenoses. The RCA showed a proximal 100% stenosis with considerable left to right collaterals to the distal segment and RPDA from the LAD. 2. Resting hemodynamics after onset of atrial fibrillation with rapid ventriular response demonstrated severely elevated filling pressures including mean right atrial pressure of 27 mmHg and mean pulmonary capillary wedge pressure of 32 mmHg. Cardiac output was moderately depressed with cardiac index of 2.1 L/min/m2. After restoration of sinus rhythm and balloon pump insertion, hemodynamics markedly improved with mean right atrial pressure of 7 mmHg, PCWP mean of 10 mmHg, and cardiac index of 3.2 L/min/m2. 3. Attempt to angioplasty proximally occluded RCA were complicated by bradycardia with heart block followed by atrial fibrillation with rapid ventricular response, with the hemodynamic changes described above. 4. Unsuccessful attempt to recanalize the totally occluded RCA. 5. Successful insertion of a 7 French IABP. . [2163-6-15] TTE: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Cannot exclude basal inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-20]+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2163-6-14], left ventricular systolic function now appears much improved although prior study was technically suboptimal. Of note, patient on IABP during today's study. Brief Hospital Course: ASSESSMENT: Ms. [Known lastname ] is a 76yo F with CAD s/p MI, CVA, DM, HTN, hypercholesterolemia, and long h/o tobacco abuse who presented with acute onset chest pain. . 1. CV: A. Coronary Artery Disease: The pt has known CAD which was confirmed with the finding of an RCA lesion on catheterization. However it is unlikely that her episode of chest pain was an acute plaque rupture. Given the appearance of the lesion, the complication which resulted from the attempt, and presence of collaterals, this is most likely a chronic occlusion. Given the episode of decompensation in the cath lab and the chronic nature of her occlusion, it was decided that no further attempts at catheterization would be attempted, and the patient was medically optimized on ASA, Lisinopril, and Lipitor. Plavix was not considered to be necessary in the absence of stenting. . B. Pump: The pt has a history of CHF with previously low EF of 20% in '[58] with documentation of improvement to 50% in '[61]. A stat TTE performed in the cath lab during her episode of decompensation revealed a severely depressed LV function with an EF of [10-7]%, and an intra-aortic balloon pump was placed emergently. Repeat TTE on the following day revealed an EF of 50%. In the presence of high MAP's in the 24 hours s/p catheterization, the IABP was discontinued without complications. Given the documented acute change in her hemodynamics, this may suggest the presence of a stiff ventricle, possibly myocardial stunning from NSTEMI. Her outpatient regimen of Digoxin was discontinued in the absence of heart failure at time of discharge. Through her hospital course, she was up titrated on her beta-blocker and AceI as tolerated by her BP, with goals to maintain SBP <130 and HR <70. . C. Rhythm: The pt had an episode of bradycardia followed by tachycardia/afib which may be the result of vagal stimulation from attempts to intervene on RCA. She remained in NSR for the remaining duration of the hospitalization. . D. Valve: Some evidence of mitral valve leaflet thickening on TTE. . 2. DM: The pt has admission glucose of 700 (gap of 11) but reported no known diagnosis of diabetes. She was eventually transitioned from an insulin gtt to SSI coverage and finally to oral hypoglycemic [Doctor Last Name 360] with good control. Her HgA1C of 7.6 confirmed a new diagnosis of Type II D.M. In the setting of CAD, she was started on an oral TZD [Doctor Last Name 360] and instructed to follow-up with her PCP for further management. She received diabetic nutritional counseling prior to discharge. . 3. ARF: On admission to the CCU, Ms. [Known lastname ] creatinine level was elevated to 1.8, likely secondary to the dye load received by the patient in the cath lab. With post-cath hydration of bicarb in D5W, her renal failure resolved and creatinine treanded towards her baseline. In the setting of improved renal function, her AceI and diuretic medications were up titrated. . 4. Gout: The pt reported an acute flare of gout prior to this hospitalization and continued to have residual evidence of acute flare, particularly with tenderness and decreased mobility in her left knee. Although she was recently started on prednisone for her gout we will avoid this medication given the NSTEMI and potential for "thinning" the LV resulting in free wall perforation. Instead a regimen of allopurinol and colchicine were dosed renally; other alternatives such as NSAIDS or prednisone were considered to be less desirable. . 6. Anemia: Ms. [Known lastname ] hematocrit remained stable, hovering around 25, both pre and post cath. No evidence of post-cath hematoma. Although her hematocrit has been stable, in the setting of anemia and heart failure, she was electively transfused with one unit PRBC's. . 8. FEN: Patient was started on a cardiac, diabetic, diet with careful repletion of electrolytes to keep k>4 and Mg>2. . . 7. Dispo: Patient was discharged to home at functional baseline per PT evaluation. She was discharged with home VNA services for monitoring of vital signs, assistance with her new medication regimen, and diabetic teaching. . 10. Code status: DNR/DNI. Discussed with patient. ICU consent signed and placed in chart. Medications on Admission: MEDICATIONS ON TRANSFER: 1. Nitro gtt 2. Heparin gtt 3. Insulin gtt with q one hour FS 4. ASA 325mg once daily 5. Plavix 75mg once daily 6. Mucomyst 600mg [Hospital1 ] 7. Lopressor 5mg IV Q6hours 8. Morphine 2mg IV q 1 hours 9. Protonix 40mg PO once daily 10. Digoxin 0.125mcg once daily . MEDICATIONS AT HOME: Confirmed by [Doctor First Name ] Pharmacy in [Location (un) 2624] ([Telephone/Fax (1) 68043]). 1. ASA 81mg once daily 2. Lopressor 50mg [Hospital1 ] 3. Lisinopril 40mg once daily 4. Lipitor 40mg once daily 5. Lasix 40mg TID 6. Digoxin 0.125mcg once daily 7. Allopurinol 200mg once daily 8. Colchicine 0.6mg [Hospital1 ] PRN 9. Prednisone 30mg once daily started on Monday for a taper. 10. Protonix 40mg once daily 11. Oxazepam PRN 12. Oxycodone 5mg once daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:30 Tablet(s) Refills:2 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:20 Tablet(s) Refills:0 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: 1) NSTEMI 2) Type 2 DM 3) Acute renal Failure 4) Gout Discharge Condition: Good. Discharge Instructions: 1) You have suffered a heart attack, leading to this hospitalization. You have known coronary artery disease, in multiple vessels. You should call 911 or go to the emergency room if you experience shortness of breath, chest pain, or heart palpitations. . 2) You have a new diagnosis of diabetes and have been started on a once daily oral [Doctor Last Name 360] called pioglitazone to help control your blood glucose levels. Your target range for your blood glucose is 80-120. A visiting nursing aide will be coming to your home to help you learn more about how to check your blood glucose levels yourslf and about how to manage this condition. You should also be sure to keep your appointment with Dr. [Last Name (STitle) ] on [6-22] to discuss your diagnosis further. Be aware that on this new medication, you may experience hypoglycemia (blood sugars that are too low). You should not skip meals while taking this medication. If you feel lightheaded or dizzy you should have a sip of [Location (un) 2452] juice. . 3) You do not have any evidence of heart failure. It is safe to discontinue or reduce your dose of Lasix. You are being diagnosed with a prescription of 40 mg daily (less that you were taking previously). You may decide with Dr. [Last Name (STitle) ] that you can discontinue this medication altogether. You can also discontinue taking Digoxin in the absence of heart failure. . 4) You have received a prescription for Ativan. This is a medication to help with your anxiety. You should only take it when you are feeling anxious, and you should not operate a vehicle while under its influence. . 5) The dosage of your medications for gout have been changed to every other day. This is to protect your kidneys. . 6) Continue to take your daily Asprin and Lipitor to protect yourself against progression of heart disease. . 7) Your diet should be a low-salt, cardiac, diabetic diet. Do not skip meals as you are at risk for becoming hypoglycemic. Followup Instructions: Keep your previously scheduled appointment with Dr. [Last Name (STitle) ] on [6-22] to discuss further management of your newly diagnosed diabetes. . Follow-up with Dr. [Last Name (STitle) 5293], your cardiologist, in [1-21] weeks. . Both Dr. [Last Name (STitle) 5293] and Dr. [Last Name (STitle) ] will receive a copy of your discharge paperwork.	[ "41071", "42731", "4280", "4240", "5849", "496", "4019", "3051", "25000", "2859", "41401" ]
Admission Date: [2135-12-21] Discharge Date: [2135-12-28] Date of Birth: [2077-4-30] Sex: M Service: Cardiothoracic HISTORY OF PRESENT ILLNESS: Patient had a history of a myocardial infarction in [2129], catheterized and stented at that time, also diagnosed with cerebrovascular accident at the same time with no residual deficits, recently has been experiencing increasing shortness of breath and dyspnea on exertion. Had a positive exercise tolerance test, and an echocardiogram which showed an ejection fraction of 55%, aortic root dilatation. Patient was catheterized here at [Hospital1 69] which showed an ostial left anterior descending artery with a 90% occlusions, left circumflex with mild disease and an OM-1 with 90% occlusion. The right coronary artery is proximally occluded. Please see the catheterization report for full details. PAST MEDICAL HISTORY: 1. Insulin dependent-diabetes mellitus. 2. Hypertension. 3. Hypercholesterolemia. 4. Cerebrovascular accident. 5. Coronary artery disease status post myocardial infarction, status post stenting and rotablading. 6. Penile implant. 7. Glaucoma. ALLERGIES: The patient has no known allergies. MEDICATIONS PRIOR TO ADMISSION: 1. Aspirin 325 q day. 2. Lopressor 100 mg [Hospital1 ]. 3. Lipitor 80 mg q day. 4. Univasc 15 mg q day. 5. Desipramine 50 mg q day. 6. Niaspan 500 mg q day. 7. Alphagan one drop OS tid. 8. Lumigan one drop OS q hs. 9. Insulin 16 units of Humalog and 40 units of NPH at breakfast, 10 units of Humalog at lunch, 12 units of Humalog, and 10 units of NPH at dinnertime and 18-14 units of NPH at bedtime. PHYSICAL EXAMINATION: General: In no acute distress. HEENT within normal limits. No jugular venous distention, no bruits. Chest was clear to auscultation. Cardiovascular: regular, rate, and rhythm, no murmurs. Abdomen is soft, nontender with positive bowel sounds, [1-17] lower extremity pulses bilaterally. No clubbing, cyanosis, or edema and no varicosities. Neurologic is alert and oriented times three. Cranial nerves II through XII are grossly intact. On [12-21], the patient was brought to the operating room at which time, he underwent coronary artery bypass grafting x4. Please see operative report for full details. In summary, the patient had a CABG x4 with a LIMA to the left anterior descending artery, left radial to the PDA, saphenous vein graft to the ramus and to the PL sequentially. He tolerated the operation well and was transferred from the operating room to the Intensive Care Unit. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from sedation, weaned from the ventilator, and successfully extubated. The following morning he was weaned off all cardioactive IV medications, however, he had elevated serum glucose levels requiring continuation of his insulin drip, therefore necessitating his stay in the Intensive Care Unit. Over the next two days, the patient underwent several attempts at weaning his insulin drip each effort being unsuccessful, and on postoperative day four, [Hospital ] Clinic was consulted to assist in glycemic control for this patient. During that time, the patient remained hemodynamically stable. On postoperative day five, the patient was successfully weaned from his insulin drip and on postoperative day six, he was transferred from the Intensive Care Unit to Far 2 for continuing postoperative care and cardiac rehabilitation. Over the next two days with the assistance of the nursing staff and physical therapy, the patient's activity level was increased and on postoperative day seven, it was decided that he was stable and ready to be discharged to home. At the time of discharge, the patient's physical exam was as follows: Vital signs: Temperature 96.7, heart rate 84, sinus rhythm, blood pressure 128/70, respiratory rate 20, and O2 sat is 96% on room air. Weight preoperatively was 108.1 kg, at discharge it was 109.4 kg. LABORATORY DATA: White blood cell count 11.5, hematocrit 31.2, platelets 421, sodium 135, potassium 4.2, chloride 101, CO2 25, BUN 14, creatinine 0.7, glucose 78. PHYSICAL EXAMINATION: Alert and oriented times three, moves all extremities, follows commands. Breath sounds are clear to auscultation bilaterally. Cardiovascular examination regular, rate, and rhythm, S1, S2 with no murmur. Sternum is stable. Incision with Steri-Strips, opened to air, clean, and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused, no clubbing, cyanosis, or edema. Left radial incision with Steri-Strips open to air clean and dry. Right knee incision open to air clean and dry. Small ecchymotic area of the right thigh. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting x4 with a LIMA to the left anterior descending artery, left radial to the PDA, saphenous vein graft to the ramus, and the PL sequentially. 2. Insulin dependent-diabetes mellitus. 3. Hypertension. 4. Hypercholesterolemia. 5. Status post cerebrovascular accident. 6. Status post penile implant. 7. Glaucoma. DISCHARGE MEDICATIONS: 1. Colace 100 mg [Hospital1 ]. 2. Potassium chloride 20 mEq [Hospital1 ] x10 days. 3. Lasix 40 mg [Hospital1 ] x10 days. 4. Imdur 60 mg q day x3 months. 5. Ferrous sulfate 325 mg q day. 6. Vitamin C 500 mg [Hospital1 ]. 7. Norvasc 15 mg q day. 8. Atorvastatin 80 mg q day. 9. Desipramine 50 mg q day. 10. Metoprolol 75 mg tid. 11. Lumigan one drop OS q hs. 12. .................... one drop OS tid. 13. Alphagan 1 drop OS tid. 14. Insulin NPH 60 units q am, 30 units q pm. 15. Regular insulin-sliding scale. 16. Percocet 5/325 1-2 tablets q4h prn. CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: He is to be discharged to home. He is to have followup in the [Hospital 409] Clinic in two weeks. Follow up with Dr. [Last Name (STitle) 1537] in [2-14] weeks and follow up with his primary care provider in four weeks. He is also to have followup in the [Hospital ] Clinic in one month. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2135-12-28] 11:18 T: [2135-12-28] 11:29 JOB#: [Job Number 40828]	[ "41401", "4019", "412" ]
Admission Date: [2130-6-12] Discharge Date: [2130-6-19] Date of Birth: [2058-12-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5893] Chief Complaint: Primary ONC: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] . CC: fever Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname ] is a 71 yo M with hodgkins and non hodgkins lymphoma s/p chemoradiation, paroxysmal Afib with RVR who was admitted [2130-6-12] with fevers of unknown etiology, transferred to the ICU for Afib with RVR. On the day of transfer he converted from sinus to Afib with RVR with rate in 150's, blood pressure 100-110 systolic, asymptomatic other than palpitations. He was given diltiazem 20mg IV and shortly after converted to normal sinus rhythm with rate in 80's. Blood pressure remained stable in the low 100's systolic. Of note he had low oxygen saturation in the 90's on admission which is lower than his baseline, unknown etiology, he denies any dyspnea. He was also noted to have elevated LDH and lactate as well as swelling of his left leg greater than right for which he had CTA chest prior to transfer. . Of note, he was recently admitted from [6-2] -[2130-6-9] for his first cycle of ICE. His hospital course during that admission was complicated by volume overload and Afib with RVR for which he was admitted to the ICU twice. He was diuresed with lasix gtt and temporarily treated with IV diltiazem. His RVR at that time was felt to be triggered by acute volume overload. Following diuresis he was continued on his home dose of diltiazem ER. He was discharged on [6-9] and received a neulasta shot on [2130-6-10]. That evening he had a temperature to 100.2 for which he was advised to come to the ED for further evaluation. He is without localizing symptoms other than nasal congestion. He has been afebrile since admission, with unremarkable chest xray. He has been treated with cefepime and levofloxacin to cover for bacterial cause for fever in the setting of recent chemotherapy. . On arrival to the ICU he is resting comfortably, HR in normal sinus rhythm in the 80's. Past Medical History: PAST MEDICAL HISTORY: 1. Hodgkin's Lymphoma (diagnosed [2121], relapsed [2126] treated with AVBD c/b Afib w/RVR, bleomycin lung toxicity, PCP [Name Initial (PRE) 1064]) and Non-Hodgkin's lymphoma (diagnosed [2127], treated w/rituxan in [2128]). 2. Bleomycin toxicity 3. h/o PCP [Name Initial (PRE) 1064] 4. Paroxysmal A-Fib: Noted in clinic on day of his first dose of neupogen, [2127-3-11], has been recurrant in setting of pulmonary edema, chemotherapy, fever. 5. Hypertension 6. Hypercholesterolemia 7. Nephrolithiasis 8. Retinal detachment [6-/2129] 9. Peripheral neuropathy Social History: Mr. and Mrs. [Known lastname ] remain in a temporary apartment as their house is being repaired due to flooding. They have 2 children and several grandchildren. He is a retired telecommunications engineer. He denies tobacco or alcohol use. Family History: Non-contributory Physical Exam: per ICU admit: VITAL SIGNS: T99.1 BP 134/63 HR 88 RR 22 94% on NC GEN: A&O x3, resting comfortably in NAD HEENT: NC AT, PERRL. Oropharynx is moist without erythema, lesions or thrush. NECK: Supple LUNGS: basilar crackles bilaterally, no wheezing HEART: RRR, 2/6 systolic murmur audible throughout the precordium ABDOMEN: Soft, nontender, and nondistended, normal bowel sounds and without hepatosplenomegaly or other masses appreciated. EXTREMITIES: With trace ankle edema. Pertinent Results: Labs on Transfer to ICU: [6-15] ABG: 7.45/36/52/26 lactate 3.2 Na 146 Creat 1.2 LDH 717 WBC 23.1 8%bands, HCT 23 PLT 79 INR 1.4 [2130-6-12] Blood Cultures: NGTD . Imaging: [2130-6-14] CTA Chest - preliminary read - No PE . [2130-6-13] CXR - Borderline interstitial edema which cleared from [6-4] to [6-12] has recurred. Mild azygous distention suggests volume overload. There are no lung findings to suggest pneumonia. Heart size is normal and there is no pleural effusion. Streaky opacities at the left base are probably atelectasis. . [2130-5-24] ECHO: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Micro: [2130-6-12] Blood - pending Brief Hospital Course: Mr. [Known lastname ] is a 68 year old gentleman with relapsed Hodgkin's disease admitted with fever, transferred to the ICU for Afib with RVR. ICU course by problem: . #Afib with RVR - Asymptomatic with HR in 150's. Converted back to sinus with rate in the 80's prior to transfer to the ICU after getting 20mg IV diltiazem on the floor. No hypotension in response to IV dilt. He has been prone to paroxysms of atrial fibrillation in the setting of chemotherapy, volume overload in the past. BMT team concerned for possible pulmonary process such as PE as cause for acute afib given elevated lactate, LDH and hypoxia, however prelim report of CTA negative. We spoke with Dr. [Last Name (STitle) 73] to help with rate control. He recommended we increase dilt to 180 ER daily. He also recommended that we diurese and improve his hematocrit. We did both. We made these intervention and he remained HD stable. Had very short runs of AFib to the low 110s but this was not hemodynamically significant. Dr. [Last Name (STitle) 73] recommends an outpatient pulm appointment to discuss whether BB would be harmful to lungs. If not, this may be recommended. . #Hypoxia - new asymptomatic hypoxia of unclear etiology with [Name (NI) 85993] of 52 on ABG on ICU admit in the setting of Afib with RVR. BMT team concerned for pulmonary embolism given elevated lactate, new hypoxia and concern for L > R le swelling. Preliminary report of CTA negative for PE. He was diuresed in the ICU and his sx improved. . # Fever - patient is s/p ICE on [2130-6-2], last granulocyte count on [6-9] was 30, has been given neulasta in the meantime with WBC count up to 23. No localizing symptoms or signs to indicate pneumonia or UTI. CXR and CTA unremarkable. Has been treated with cefepime for febrile neutropenia by the BMT service. Further abx therapy per BMT . #Anemia - possibly due to recent chemotherapy with HCT down to 23 from 26 on admission. No evidence of blood loss at this time however will monitor closely. We gave 2u in ICU per d/w Dr. [Last Name (STitle) 73]. Medications on Admission: Medications on Discharge [2130-6-9]: 1. Allopurinol 100 mg PO DAILY 2. Cyanocobalamin 50 mcg PO DAILY 3. Omeprazole 20 mg DAILY 4. Bactrim DS 160-800 mg one po 3X Week MWF. 5. Glucosamine 1500 Complex 500-400 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Levofloxacin 750 mg Tablet PO Q24H 7. Diltiazem 120 mg Sustained Release DAILY 8. Albuterol 90 mcg/Actuation Aerosol Q6 prn 9. Multivitamin PO DAILY 10. Lovastatin 20 mg PO once a day 11. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection once a day: to be given in outpatient clinic. . Medications on Transfer: Diltiazem Extended-Release 120 mg PO DAILY 150 mEq Sodium Bicarbonate/ 1000 mL D5W Continuous at 75 ml/hr for 300 ml Levofloxacin 750 mg PO Q24H Acetylcysteine 20% 600 mg PO BID x 4 doses Lovastatin 20 mg Oral daily Allopurinol 100 mg PO DAILY Pantoprazole 40 mg PO Q24H Albuterol MDI 2 PUFF IH Q4H:PRN CefePIME 2 g IV Q12H Clotrimazole 1 TROC PO QID Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR) Cyanocobalamin 100 mcg PO DAILY . ALLERGIES: No known drug allergies. History of bleomycin toxicity. Discharge Disposition: Home Discharge Diagnosis: Paroxysmal Atrial fibrillation with rapid ventricular response Neutropenic fever Hypoxia secondary to volume overload Discharge Condition: Stable Followup Instructions: Pt is to follow up with oncology services and primary care physician within two weeks of discharge. . Pt instructed to notify physician or return to hospital if experiencing fever, shortness of breath, chest pain, loss of consciousness, or heart palpations.	[ "42731", "4019", "2720" ]
Admission Date: [2160-8-13] Discharge Date: [2160-10-10] Date of Birth: [2097-8-19] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old woman with a history of hypertension and chronic obstructive pulmonary disease who was transferred from [Hospital 28978] Medical Center with a large right intraparenchymal hemorrhage and bilateral subarachnoid blood throughout the sulci, Hunt and [Doctor Last Name 9381] Grade V. The patient was sitting alone at a restaurant this evening when she became unresponsive. She was intubated at the scene and was brought to an outside hospital. PAST MEDICAL HISTORY: 1. Hypertension. 2. Arthritis. 3. Question of chronic obstructive pulmonary disease. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On examination she was intubated, sedated and paralyzed. Her blood pressure was 135/53, heart rate 49, respiratory rate 23, saturating 100%. The right pupil was 5 and nonreactive; left was 3?????? and slightly reactive. Lungs had equal breath sounds but with some rhonchi. Respiratory rate was stable. Cardiac was regular rate and rhythm, no murmurs, gallops, or rubs. Abdomen was nontender, positive bowel sounds, nondistended. Extremities had no edema, bilateral pulses. She was intubated and sedated. She withdrew her left leg and left arm and right foot to painful stimuli. HOSPITAL COURSE: She was admitted to the intensive care unit for close neurologic observation after transfer from an outside hospital. She had a left ventricular drain placed on admission. On [2160-8-23] the patient remained intubated and sedated. Pupils were 3 down to 2 mm bilaterally. She had coiling done for a ruptured middle cerebral and anterio communicating artery aneurysms on [2160-8-23], and then was taken to the operating room for craniectomy. Her postoperative course was complicated by pulmonary edema and adult respiratory distress syndrome, as well as the need for ventricular drain placement. The patient grew out gram-negative rods in her blood and was on Cipro and ceftazidime for treating blood sepsis. She also had Klebsiella in her sputum and an episode of elevated liver function tests. She had a right upper quadrant ultrasound. The patient was on Levophed and Neo-Synephrine to keep her blood pressure up. She had episodes of pulmonary edema requiring Lasix. She had a Swan placed on [2160-8-15]. On [2160-8-16] she had bursts of atrial fibrillation and flutter with narrow-complex tachycardia. She was started on Lopressor. She was less arousable on [2160-8-17] and had a head CT that showed increased swelling. Her ICPs were 15-24 at that time and her drain was at 0. She had a CT on [2160-8-19] that showed worsening bleeding and also again on [2160-8-20]. She was sedated and paralyzed. She continued to have problems with atrial fibrillation and flutter and was on Lopressor. On the 17th she had [Initials (NamePattern4) ] [Last Name (NamePattern4) ] bolt placed. Her ICP was 17-20. Her CT was unchanged. On [2160-8-22] she had an angiogram that showed no spasm and her CT was unchanged. On [2160-8-23] her saturations dropped along with her oxygenation and her pressor requirements were increasing. On [2160-8-26] she was off sedation. Her CT was unchanged. She had the vent drain placed on [2160-8-28] for hydrocephalus. Neurologically her craniotomy site was pulsatile. Her pupils were 4 down to 2 mm and symmetric. There was no movement in the extremities. She had positive corneal reflexes bilaterally. On [2160-8-28] her pupils were equal and reactive to light. She did not withdraw to pain in her upper extremities. She did not grimace to pain. She did not withdraw her lower extremities. She did have positive corneals. The vent drain was placed on [2160-8-28]. On [2160-8-29] the patient's neurological status was unchanged. She was unresponsive except for left foot withdrawal to pain. Pupils were 3 mm and were briskly reactive. She had a weak gag and weak cough reflex. Her [Last Name (un) ] bolt ICP levels were [5-14]. Ventricular drain noted to be [9-14]. Her sites were clean, dry and intact. She continued on Levophed and Neo-Synephrine drips to titrate to keep her pressure 150-180. On [2160-8-31] neurologically she had slight withdrawal to deep nail bed pressure on the left lower extremity, otherwise did not respond to withdrawal, pain, or sternal rub. She did open her eyes at times but did not track. She had positive corneals. Pupils were 4-5 mm and brisk. Vent drain remained in place and the [Last Name (un) ] bolt, and were both intact with ICPs [5-15]. Dr. [Last Name (STitle) 1132] met with the family on [2160-9-1] and the plan was to continue current treatment. On [2160-9-1] the amlodipine was discontinued and the patient's triple H therapy was weaned off. The family wished to continue with the current care. On [2160-9-2] her brain flap was soft. Her eyes were open spontaneously, her pupils were equal, round and reactive to light. She had no movement to painful stimulation and no spontaneous movement. On [2160-9-4] the patient had PEG and tracheostomy placement without intraoperative complications. Neurologically she opened her eyes, looked around the room, did not follow commands, grimaced to painful stimulation in the upper and lower extremities with small movement of the left lower extremity. On [2160-8-23] she had Klebsiella in her blood and was continued on vancomycin for IV antibiotics. On [2160-9-7] the patient had swelling in the left upper extremity. Vascular surgery was consulted. An ultrasound revealed a thrombus in the left subclavian and axillary veins with flow in the cephalic vein, no flow in the brachial. The patient therefore had a superior vena cava filter placed on [2160-9-7]. Bone flap surgery actually was postponed due to positive blood cultures. The patient had gram-negative rods growing in her blood. Infectious disease was consulted. The patient was on Flagyl for anaerobes and being covered with vancomycin, levofloxacin, and Flagyl for antibiotic coverage. She had gram-positive cocci in her blood, thought to be a contaminant and gram-negative rods in her blood also, but that was not considered to be a contaminant. Diagnosis was VRE from a femoral stick on the 15th. She was continued on levofloxacin and Flagyl. Vancomycin was changed to linezolid 600 mg p.o. b.i.d. On [2160-9-19] the patient opened her eyes spontaneously and to stimuli, roving eye movements, but following staff, not following commands, no seizure activity, ventricular drain was in place. She had bone flap replaced on [2160-9-24] without intraoperative complications. Post procedure the patient was awake and attentive, tracking movements with her eyes, not following commands but moving her extremities to painful stimulation x 4. Her drain was raised to 15 cm above the tragus. Her drain continued to be raised and was finally discontinued on [2160-9-30], and the patient had a lumbar puncture the following day with an ICP of 20. She was transferred to the regular floor on [2160-10-1]. She was awake, attentive, smiled appropriately, was following commands centrally. Pupils were equal, round, and reactive to light. She moved the right side spontaneously, more so than the left side but both sides were moving. She was afebrile and her vital signs were stable. On [2160-10-8] she went to the operating room for ventriculoperitoneal shunt placement. There were no intraoperative complications. Postoperatively she is awake, alert, attentive, following midline commands, moving the right side more spontaneously than the left side. DISCHARGE MEDICATIONS: 1. Dilantin 200 mg nasogastric q. 12 hours. Her Dilantin level was high and her Dilantin was held for three days. Her last level on [2160-10-9] was 15 and her dose was decreased to 200 nasogastric q. 12 hours. 2. Cefazolin 1 gram IV for 48 hours to be discontinued on [2160-10-10]. 3. Insulin sliding scale and fixed dose. 4. Lasix 20 mg p.o. q. day. 5. Epoetin 10,000 units subcutaneous three times a week, Monday, Wednesday, and Friday. 6. Metoprolol 25 down her tube t.i.d. 7. Loperamide 2 mg p.o. q.i.d. p.r.n. 8. Miconazole powder topically q.i.d. p.r.n. 9. Levofloxacin 500 mg IV q. 24 hours for a total of three weeks. 10. Nystatin swish and swallow 5 cc p.o. q.i.d. 11. Fluticasone propionate 110 mcg, two puffs inhaled b.i.d. 12. Lansoprazole oral solution 30 mg nasogastric q. day. 13. Artificial Tears. 14. Tylenol 650 p.o. q. 4 hours p.r.n. for pain. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient will be discharged to rehabilitation with staples to be removed on postoperative day number 10 and follow up with Dr. [Last Name (STitle) 1132] in two weeks with repeat head CT. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2160-10-9] 10:24 T: [2160-10-9] 10:48 JOB#: [Job Number 51046]	[ "496", "51881", "0389", "4280", "42731" ]
Admission Date: [2161-11-13] Discharge Date: [2161-11-20] Date of Birth: [2086-1-10] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 710] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: Ir-Guided embolization and stenting of right vertebral branch of aorta History of Present Illness: This is a 75F aith newly diagnosed atrial fibrillation s/p cardioversion and coumadin initiation with lovenox bridge discharged from [Hospital1 ] on [11-9] who returned to the ED this morning with spontaneous RP bleed. Pt had been discharged on [11-9] to a nursing home following her admission with the goal of trying to improve her strength and conditioning. She developed right-sided low back pain yesterday. The morning she was noted to be pale and unresponsive and was transferred back to [Hospital1 ]. . In the ED, intitial vitals 99.4 130/50 62 20 99%RA. Hematocrit was 24.4 down from 29 on [11-9]. CT scan showed large retorperitoneal bleed. Head CT negative for acute intracranial process. Cardiac enzymes negative x1. EKG unchanged from baseline. Pt was guaiac negative. Pt was given 10mg Vitamin K IV, 1L NS amd transfused 2 units FFP. She was transferred to IR for embolization. There she developed hives consistent with a transfusion reaction to the FFP. The FFP was stopped and the patient was given 25mg benadryl IV with resolution of her symptoms. Aortogram showed active bleed from right L4 lumbar branch bleed, embolized 2 branches with gel foam and 2 coils each. . On arrival to the ICU, vitals 100.1 80 115/62 18 97% 2L. Pt's primary complaints are of thirst and discomfort from having to be on her back. She denies current abdominal or back pain, chest pain, nausea, diarrhea, or shortness of breath. Past Medical History: 1. Orthostatic hypotension 2. Memory loss without hallucinations. 3. Tremors. 4. Depression. 5. Anxiety. 6. Leg weakness. 7. History of TIA x2. 8. Question Parkinson's disease 9. Atrial fibrillation s/p cardioversion [2161-11-6] Social History: Pt is elderly with baseline dementia and extreme anxiety, lives with her husband, previously smoked cigarretes 20 years ago 1 pack per week for > 10 years.She denies alcohol and use of illicit drugs. Family History: Mother with diabetes and hypertension Father died of MI at age 62 Physical Exam: Admission: Physical Exam: VS: 99.6 156/78 94 26 96/3L Gen: Uncomfortable, lying in bed, mildly tachypneic, baseline tremor, CV: Irregularly irregular Resp: Clear, with transmitted upper respiratory sounds. Abd: NT, ND, BS+ Ext: No edema, pulses 2+ b/l Neuro: EOMI, moves all extremities, no facial droop, + tremor, tangential speech. Discharge: Physical Exam: VS: 97.7 62 62-82 152/66 (80/52-172/80) 22 94/RA Gen: Comfortable, sitting up in bed, baseline tremor, CV: Regulkar, no m/r/g Resp: Clear, mild crackles R base Abd: NT, ND, BS+ Ext: No edema, pulses 2+ b/l Neuro: EOMI, moves all extremities, no facial droop, + tremor, speech fluent Pertinent Results: [2161-11-13] 11:00AM BLOOD WBC-10.6# RBC-3.15* Hgb-7.8* Hct-24.4* MCV-78* MCH-24.9* MCHC-32.1 RDW-17.5* Plt Ct-279 [2161-11-20] 05:33AM BLOOD WBC-6.6 RBC-3.48* Hgb-9.3* Hct-28.5* MCV-82 MCH-26.7* MCHC-32.6 RDW-18.1* Plt Ct-359 [2161-11-13] 11:00AM BLOOD PT-22.5* PTT-40.8* INR(PT)-2.1* [2161-11-17] 06:30AM BLOOD PT-12.6 PTT-27.6 INR(PT)-1.1 [2161-11-13] 11:00AM BLOOD Glucose-105 UreaN-15 Creat-1.0 Na-134 K-3.7 Cl-99 HCO3-27 AnGap-12 [2161-11-20] 05:33AM BLOOD Glucose-94 UreaN-15 Creat-0.7 Na-140 K-3.4 Cl-104 HCO3-27 AnGap-12 [2161-11-14] 05:23AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.1 [2161-11-20] 05:33AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1 CT Head: IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. 2. Stable age-related atrophic changes. CXR admission [2161-11-13]: Bilateral pleural effusions with lower lobe compressive atelectasis. CXR [2161-11-15]: Moderate to large right pleural effusion has increased in amount. Small left pleural effusion also has increased. Bibasilar opacities right greater than left consistent with atelectasis have increased. Mild interstitial edema is new. There is no pneumothorax. Cardiac size cannot be evaluated. CXR [2161-11-18]: comparison with the study of [11-15], there is continued evidence of _____ pleural effusions, more prominent on the right. However, the degree of adjacent atelectasis has decreased and the pulmonary vascularity is now essentially within normal limits. Chemoembolization: [2161-11-13] 1. Aortogram demonstrated active extravasation of contrast from branches of the right fourth lumbar artery. 2. Selective catheterization of right fourth lumbar artery with successful embolization using Gelfoam slurry and microcoils. CT Abd/Pelvis: 1. Large right retroperitoneal hematoma likely secondary to right psoas hematoma with rupture. Areas of active bleeding noted in the right retroperitoneal space, for which catheter embolization is suggested. 2. Left retroperitoneal hematoma may be secondary to bleeding from the left psoas muscle which is also heterogeneously enlarged. 3. Left rectus sheath hematoma. 4. Cholelithiasis. 5. Renal and liver hypodensities, incompletely characterized, though may represent cysts. 6. Diverticulosis without evidence of diverticulitis. 7. Right adnexal cyst, for which pelvic ultrasound is recommended to further assess on a non-emergent basis. 8. Bilateral moderate-sized simple-appearing pleural effusions with associated lower lobe compressive atelectasis. Brief Hospital Course: RP Bleed - Spontaneous retroperitoneal bleed in the setting of new coumadin/lovenox therapy following cardioversion for atrial fibrillation. Initial INR 2.1, got 2 units FFP and 10mg IV Vitamin K. Underwent IR-guided embolization of right fourth lumbar artery on [11-13]. Hct 19% on arrival to ICU, improved to 26% after 2U PRBC. Coumadin, lovenox, aspirin held. Hematocrit remained stable at 28% through the remainder of her stay. . Hypoxia. - On arrival to the floor, patient was tachypneic with a respiratory rate of 28, and had an oxygen saturation of 86% of 3L. A chest x-ray demonstrated worsening pleural effusions. She was given IV lasix and returned to the MICU. With diuresis her breathing and oxygen saturation improved. She was discharged on her home dose of lasix. . Orthostatic Hypotension. Patient's blood pressure was volatile during this admission, with SBP varying from 80-200, depending on position and time of day. She had one hypotensive episode of 80/50. She was laid supine and her pressure came up to 110/60. She was given 250cc NS bolus, and her lasix was reduced to her home dose of 20mg PO daily. The timing of her lisinopril administraton was changed to qhs. Her blood pressure remained stable after these medication changes. . Atrial Fibrillation - Discharged from [Hospital1 ] on [11-9] following cardioversion. Put on coumadin with lovenox bridge (both held on admission, as above). Continued amiodarone 400mg daily. Her dose of metoprolol was decreased to 25mg PO bid. On telemetry, she was in normal sinus rhythm with a rate of 70-90. She did have several episodes of atrial fibrillation with a rate in the 70s-80s, during which she was asymptommatic. . Diarrhea - Pt had 2 episodes of loose stools upon arriving to the hospital and Clostridium difficile was ruled out. . Depression - Her dose of sertraline was increased to 25mg. . Anxiety disorder- Her ativan was continued at her home dosing. . Parkinsonism/dementia - Continued sinemet. . FEN - She was evaluated by speech/swallow, who recommended a ground dysphagia diet and nectar thickened liquids. A video swallow study showed no abnormalities and she was advanced to soft solids/thin liquids. Medications on Admission: Tylenol 650mg q4h prn fever Carbidopa-Levodopa 25mg-100mg one tab po bid Ferrous Sulfate 325mg po daily Oscal 500mg + 200IU [Hospital1 ] Ativan .25mg po q6am, 12pm, 6pm Ativan .5mg qhs Ativan .25mg po prn anxiety Ativan .5mg qhs prn insomnia Sertraline 12.5mg qhs(to be increased to 25mg on [11-15]) Lovenox 80mg q12h Coumadin 7.5mg daily Aspirin 81mg daily Furosemide 20mg po daily Lisinopril 20mg po daily Metoprolol Succinate 100mg SR daily Amiodarone 400mg po tid ([Date range (1) 65374]) Amiodarone 400mg po daily ([Date range (1) 65375] then decrease to 200mg daily) Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Daily weights Please perform daily weights. If weight increases 3 lbs, please give an extra dose of lasix 20mg PO x 1. Discharge Disposition: Extended Care Facility: [Doctor Last Name ] Nursing Rehab Discharge Diagnosis: Retroperitoneal Hematoma Atrial Fibrillation Dementia Orthostatic Hypotension Discharge Condition: Stable. Alert, oriented to person place and time. Ambulates to chair with assistance. Discharge Instructions: You were admitted for mental status changes and back pain. A CAT scan revealed a retroperitoneal hematoma, bleeding into your back. Your anticoagulation for atrial fibrillation was reversed. A procedure was performed to stop the bleeding. The following changes were made to your medications: Please STOP taking metoprolol succinate (XL) Please START taking metoprolol tartrate 25mg tablet, take one tablet twice daily Please CHANGE your dose of sertraline from 12.5mg to 25mg, by mouth daily. Please change the time that you take lisinopril. Please take 20mg every evening. Please review all changes in your medications with your outpatient physicians. Please adhere to your follow-up appointments. They are important for managing your long-term health. . Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please follow up with the following appointments: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2161-11-30] 2:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2847], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2161-12-24] 2:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8708], M.D. Phone:[Telephone/Fax (1) 719] Date/Time:[2161-12-24] 3:00	[ "5119", "42731", "V5861", "V1582" ]
Admission Date: [2128-8-14] Discharge Date: [2128-8-20] Date of Birth: [2059-12-4] Sex: M Service: CHIEF COMPLAINT/IDENTIFICATION: The patient is a 68 year old man with a history of atrial fibrillation, myocardial infarction times four, and coronary artery bypass grafting times three in [2113], who presents from an outside hospital with persistent chest pain following an episode of rapid ventricular response with his atrial fibrillation. PAST MEDICAL HISTORY: 1. Coronary artery disease, coronary artery bypass grafting times three in [2113] with left internal mammary artery to left anterior descending artery, saphenous vein [Year (4 digits) ] to ramus intermedius and saphenous vein [Year (4 digits) ] to right posterolateral. 2. Diabetes mellitus type 2, diagnosed two years ago, on oral hypoglycemic agents. 3. History of pacemaker placement for "three seconds of asystole" in [2120], pacer taken out for repeated Staphylococcus aureus infections. MEDICATIONS ON ADMISSION: Enteric coated aspirin 325 mg p.o.q.d., metoprolol 12.5 mg p.o.q.d., Lipitor 10 mg p.o.q.d., Zestril 5 mg p.o.q.d., Flovent 220 mcg two puffs b.i.d., Coumadin 7.5 mg p.o.q.d. except for 10 mg p.o.q. Friday, Glucotrol, and Lasix. ALLERGIES: Isuprel inhaler. HISTORY OF PRESENT ILLNESS: The patient was in his usual state of health and developed retrosternal chest pain with shortness of breath and diaphoresis at rest. The patient took three sublingual nitroglycerin without resolution of his ten out of ten chest pain. The patient presented to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital in [Location (un) 5028] and was noted to be in atrial fibrillation with a ventricular rate in the 160s. His systolic blood pressure was approximately 120. His ventricular rate was controlled with intravenous diltiazem. He also received heparin, Integrilin and intravenous nitroglycerin. The patient also received a dose of morphine and, despite the therapies, continued to have chest pain. He was transferred by [Location (un) 7622] to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] and received 200 mcg of fentanyl during the flight. Upon arrival, the patient was chest pain free. The patient claims that he has had increasing dyspnea on exertion over the past few weeks with climbing a flight of stairs. During that period of time, he also had some occasional retrosternal chest pain, which had been relieved with nitroglycerin. SOCIAL HISTORY: The patient has a remote history of smoking and quit in [2112]. He drinks alcohol occasionally and lives at home with his wife. [Name (NI) ] is currently retired, and previously worked as a longshoreman. He has three children. FAMILY HISTORY: The patient's father died of prostate cancer and his mother died after three strokes. PHYSICAL EXAMINATION: On physical examination on arrival, the patient had a temperature of 96.1, heart rate 80, irregularly irregular, blood pressure 107/52, respiratory rate 20 and oxygen saturation 99% on two liters nasal cannula, with a weight of 90 kilograms General: Well appearing man in no acute distress. Head, eyes, ears, nose and throat: Oropharynx moist, no lymphadenopathy, anicteric sclerae. Cardiovascular: No jugular venous distention, normal S1 and S2, no S3 or S4, no murmurs or peripheral edema, palpable pulses in extremities. Respiratory: Unremarkable apart from scattered crackles and wheezes. Neurologic examination: Alert and oriented times three, no focal deficits. LABORATORY DATA: Platelet count was 247,000, hematocrit 37.6, and white blood cell count 15.7 with 92 neutrophils, 6 lymphocytes and no bands. Partial thromboplastin time 85.3 on heparin, and INR was elevated at 3.2 with Coumadin. Chem-7 was unremarkable apart from a potassium of 5.9 due to a hemolyzed sample and a BUN of 25 and creatinine 1.2. Cardiac enzymes showed a CK of 122, MB fraction 10 and troponin 2.2. Calcium was 9.4 and magnesium 1.9. Electrocardiograms at the outside hospital demonstrated the patient to be in atrial fibrillation with a rate of 150 and a left bundle branch block with ST depressions in leads V2 to V6; the ST depressions subsequently improved once the patient's rate was brought down to a rate of 100. Electrocardiogram on arrival at [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] showed the patient to be in atrial fibrillation at a rate of 90 with a left bundle branch block and no ischemic changes. Chest x-ray was normal, without any evidence of congestive heart failure or pneumonia. HOSPITAL COURSE: The patient was not catheterized immediately due to his elevated INR. He was continued on the heparin and nitroglycerin and Integrilin until his INR decreased. The patient was taken to the cardiac catheterization laboratory on [2128-8-16]. On catheterization, the patient was found to have a patent left internal mammary artery to left anterior descending artery [Last Name (LF) ], [First Name3 (LF) ] occluded saphenous vein [First Name3 (LF) ] to the ramus intermedius and a patent saphenous vein [First Name3 (LF) ] to the right posterolateral. The patient was noted to have a normal circumflex artery and a 30% left main lesion. At the time of cardiac catheterization, the patient was felt to be of higher risk for percutaneous coronary intervention, thus he did not receive any intervention. The patient continued on his heparin and his Integrilin and nitroglycerin were weaned off. The patient remained without chest pain during his entire hospital stay. It was noted on the night of admission that the patient had a 15 beat run of nonsustained ventricular tachycardia. The patient was generally asymptomatic after that episode, apart from some mild palpitations and slight lightheadedness. Because of this event, the electrophysiology department was consulted. Upon discussion with the patient, the patient declined an AICD. It was also felt, due to the patient's refusal to have a pacemaker because of his previous bad experience with pacemakers, that the patient should not be started on amiodarone because of the potential to require a pacemaker afterwards. The patient had his metoprolol and lisinopril titrated upwards during his hospital stay. On [2128-8-19], the patient underwent a stress Cestimibi study, which demonstrated an area of mild reversibility in his lateral wall. He also had a fixed defect inferiorly. His left ventricular ejection fraction was noted to be at 44%. During the three minutes that he was able to tolerate the modified [Doctor First Name ] protocol, the patient experienced some lightheadedness and a drop in his blood pressure from 130 systolic to 100 systolic. Following the stress Cestimibi study, the patient's options were discussed and the patient elected to proceed with medical management at this time. The patient was discharged to home on [2128-8-20] in stable condition. FOLLOW-UP: The patient was instructed to follow up with his primary care physician on [2128-8-23] for his INR check. He is to be on Lovenox 60 mg subcutaneously twice a day while warfarin was being loaded and until further notified by his primary care physician. DISCHARGE MEDICATIONS: Enteric coated aspirin 325 mg p.o.q.d. Metoprolol 75 mg p.o.b.i.d. Lisinopril 10 mg p.o.q.d. Lipitor 10 mg p.o.q.d. Zestril 5 mg p.o.q.d. Flovent 220 mcg two puffs b.i.d. Albuterol p.r.n. Lovenox 60 mg s.c.b.i.d. until notified by primary care physician to stop. Lasix 20 mg p.o.q.h.s. Glucotrol as directed. [Name6 (MD) 9272] [Name8 (MD) 9273], M.D. [MD Number(1) 9274] Dictated By:[Name8 (MD) 26201] MEDQUIST36 D: [2128-8-20] 14:01 T: [2128-8-24] 17:56 JOB#: [Job Number 36262]	[ "41401", "42731", "25000", "2720" ]
Admission Date: [2109-8-4] Discharge Date: [2109-8-9] Date of Birth: [2038-9-24] Sex: F Service: MED-[Hospital1 ] HISTORY OF PRESENT ILLNESS: This is a 70 -year-old woman with a history of morbid obesity, obstructive sleep apnea, status post tracheostomy in [2089], who presented with increasing somnolence and respiratory distress. The patient was in her usual state of health until one week prior to admission when she began to suffer from abdominal pain when eating, leading to diminished po intake. She also had suffered from right upper quadrant and right shoulder pain not related to eating and not relieved by acetaminophen. Additionally, she had been experiencing mild cough and increasing shortness of breath. The patient's mobility over this time has been further limited by the elevated ambient temperatures because she only has air conditioning in her bedroom. Furthermore, the patient had not used the aerosolizer with her supplemental oxygen over this time period secondary to power concerns. In this situation, the patient's condition has slowly, but progressively worsened over the week prior to admission until the day of admission when the patient's sister noted that she was falling asleep while talking to her on the phone in the middle of the day. The sister came to visit the patient and noted her to be having difficulty breathing and increased airway sounds around her tracheostomy. For these reasons the patient was presented to the [Hospital3 ] - [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] Emergency Department. In the Emergency Department, the patient was found to have concretions in her tracheostomy and this tracheostomy was changed. The patient was also begun on mechanical ventilation for her initial arterial blood gas of 7.20 / 100 / 63. Her initial ventilator settings of AC tidal volume 600, rate of 12, FiO2 of 60% and PEEP of 5.0, were decreased over the course of the next two days to AC tidal volume of 500, rate of 8.0, FiO2 of 50% and PEEP of 5.0. Throughout this time, her initial suction requirements decreased and the secretions were of thinner quality. Furthermore, the patient had been treated empirically with levofloxacin for a concern of pneumonia, given the increased secretions, the respiratory distress, and possible left lower lobe consolidation on chest x-ray. By [2109-8-6], which was her third day in the Medical Intensive Care Unit, the patient was tolerating a tracheostomy mask trial and has been off mechanical ventilation since that time. Her last arterial blood gas on tracheostomy mask with an FiO2 of 50% was 7.35 / 62 / 62. This is thought to be at or near the patient's baseline. With regard to the other systems, she presented with a history of chronic renal insufficiency and a creatinine of 1.8, but following moderate hydration has had a better than normal value of 0.8. She presented with decreased mental status complicated by episodes of hypoglycemia, but she was ruled out for intracranial process by head CT scan, found to have normal electrolytes, and had her hypoglycemia corrected. Her mental status subsequently quickly improved. The complaints of abdominal pain prior to admission resolved during the first few days of her stay in the hospital. Work up was negative. This patient also presented with a history of atrial fibrillation / atrial flutter and a supratherapeutic INR. This was corrected during her stay and she was continued on low dose Coumadin. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Obstructive sleep apnea, status post tracheostomy in [2089], on supplemental oxygen of six liters at home. 3. Polycythemia. 4. Status post stroke in [2089] with residual right sided deficits. 5. Diabetes mellitus. 6. Pulmonary hypertension. 7. Cor pulmonale. 8. Atrial fibrillation / atrial flutter, status post ablation in [2102]. 9. Arthritis. ADMITTING MEDICATIONS: Potassium chloride, Lasix 80 mg po bid, theophylline 300 mg po bid, Diltiazem CD 180 mg po q day, Coumadin 2.0 mg to 5.0 mg po q day, Glucotrol 2.5 mg po q day, and metaxalone 2.5 mg po twice per week. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives with a companion / caretaker and has a distant tobacco history, no alcohol or IV drug use. PHYSICAL EXAMINATION: On admission, the patient was afebrile at 98.6 F, pulse of 68, blood pressure 106/57, respiratory rate of 12, and she had an oxygen saturation of 95% on an unknown oxygen level. In general, she was awake and responsive in bed, mechanically ventilated, and in no acute distress. Chest showed diffuse upper airway sounds, diminished breath sounds, no wheezes, no crackles. Cardiovascular examination was a regular rate and rhythm, a II/VI systolic murmurs and distant heart sounds. Abdominal examination was soft, mild right upper quadrant and epigastric tenderness, obese, no rebound tenderness, and normal bowel sounds. Extremities: minimal bilateral lower extremity edema, 1+ dorsalis pedis pulses and 2+ radial pulses bilaterally. Neurologic examination: she was alert and oriented times three, pupils were equal, round, and reactive to light, and she had 2+ patellar and biceps deep tendon reflexes bilaterally. LABORATORY DATA: Included a white count of 7.3, with a differential of 72 neutrophils, 10 lymphs, 10 monos, 8 atypical cells, and 7 nucleated red cells, a hematocrit of 53.4, and platelets of 243,000. Her PT was 44.6, PTT of 49.2, INR of 13.5. Chem 7 was sodium 142, potassium 6.6 which was hemolyzed, chloride 100, bicarbonate 28, BUN 48, creatinine 1.8, and glucose 116. Calcium of 8.9, phosphorus 3.5, magnesium of 2.2, ionized calcium of 0.94, albumin of 3.8. CKs were 118, 148, 53 with negative MB indexes and one troponin level of less than 0.3. Theophylline level was 3.0. Chest x-ray showed enlarged heart, symmetric increased opacification of lung fields, possibly due to congestive heart failure, tracheostomy in good position, and bilateral effusions. Head CT scan was negative for an acute intracranial process. Electrocardiogram showed normal sinus rhythm at 69 and no ST-T-wave changes from previous electrocardiogram. HOSPITAL COURSE: Since being transferred to the floor on [2109-8-7], the patient has continued to have stable respiratory status on approximately 50% FiO2 by tracheostomy mask, which appears to be at or near her baseline levels. She continues to be treated with Levaquin for this possible pneumonia, although she has remained afebrile throughout her course. DISPOSITION: She was evaluated by Physical Therapy and it was determined that this patient would benefit from short term rehabilitation prior to returning home. Therefore, this patient is being discharged today to short term rehabilitation. DISCHARGE DIAGNOSES: 1. Hypercapnic respiratory failure. 2. Possible pneumonia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5447], M.D. [MD Number(1) ] Dictated By:[Last Name (NamePattern1) 15470] MEDQUIST36 D: [2109-8-9] 09:15 T: [2109-8-9] 10:36 JOB#: [Job Number 102062]	[ "51881", "486", "42731", "25000" ]
Admission Date: [2145-6-7] Discharge Date: [2145-6-8] Date of Birth: [2067-9-12] Sex: M Service: MEDICINE Allergies: Coreg Attending:[First Name3 (LF) 2880] Chief Complaint: Recurrent Ventricular tachycardia and syncope Major Surgical or Invasive Procedure: central line placement intubation ABG History of Present Illness: HPI: This 77 year old male patient with non ischemic cardiomyopathy with an EF of 20%, a fib (on warfarin at home), DM, HL, prior CVA, s/p BiV ICD re-placement for VT 6 weeks prior, who originally presented to [Hospital3 417] Hospital for ICD firing. Was transferred to [Hospital1 18] for further management. . Per OSH, family reports that after starting metolazone and lasix (once 6 weeks ago and once last week),he developed several shocks from AICD which he has never had before. With firings, has brief loss of consciousness lasting less than one minute. He was noted to fall in the bathroom with injury to his right knee and shoudler. Was brought to [Hospital3 417] ([6-6]), where he had several episodes of VT on presentation where his device fired several times converting him to AV paced rhythm. Blood pressures were reportedly stable. However he did have 1 episode on that admission where he became [Doctor Last Name ] [Doctor Last Name 352] and had diffuculty repiratory effort and was slow to recover.Pacer interrogation demonstrated eight shocks delivered since [2145-6-5] due to VT with rates from 180-250, fourteen VT since since [2145-5-16] treated with ATP. 2 AT/AF episodes noted. Lidocaine bolus at 80mg IV followed by gtt, Given IV lopressor and 1L fluid bolus, and 2 g magnesium sulfate. Continues on PO amiodarone from recent admission to hospital. Per OSH records, echo with EF <20% and global hypokinesis, mod MR/TR, mild pulm HTN. Cardiac enzymes negative times three. . Given diuretics and fluid alternating for few rounds with diuretics finally held because of creatinine 2.1 and SBP in the 90s. . On review of systems, 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. Denies claudication, orthopnea, PND, lightheadedness Pitting edema to ankles, (+) CVA [2130] . 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: Paroxysmal atrial fibrillation Pacemaker [2140-6-14] CHF CVA in [2130] no residual [12-30]+ mitral regurgitation and tricuspid regurgitation moderate pulmonary hypertension Diabetes Hypertension Sciatica Cardiac catheterization at [2144]??????s Renal stent Cancer melanoma chest and basal on forehead Hyperlipidemia GERD Hyperthyroidism Hyperlipidemia Social History: (-) CIGS quit 12 years ago smoked 1 PPD Residing at [Hospital ] Nursing Home since AICD insertion Worked in garment factory retired in [2129] ETOH: family denies. . Family History: Mother MI and died at 80. 1 brother and 1 sister with heart disease Physical Exam: VS: T=99.6 BP=100/80 HR=85 RR=15 O2 sat= 94% NC 2L GENERAL: Patient cyanotic lips and cheeks. Oriented x1. Confused and talking nonsense. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Systolic murmer heard in left 4th intercostal space ([1-30]), radiating to the left axilla. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, crackles at lung bases bilaterally on expiration and inspiration, no wheezes or rhonchi. ABDOMEN: Soft, NTND. Hepatomegaly which crosses midline and down to 11th rib, non tender to palpation. Abd aorta not enlarged by palpation. No abdominial bruits.Abdomen is distended, BS +,Neg fluid wave. EXTREMITIES: Bilateral pedal edema 2+. No femoral bruits. SKIN: stasis sacral dermatitis, no ulcers, scars, or xanthomas. Neuro: Flapping tremor with general body tremors. No focal neuro signs. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: Admission Labs [2145-6-7] 11:23PM PT-29.6* PTT-42.3* INR(PT)-2.9* [2145-6-7] 11:23PM PLT COUNT-335 [2145-6-7] 11:23PM WBC-7.2 RBC-3.49# HGB-9.6# HCT-29.7# MCV-85 MCH-27.6 MCHC-32.5 RDW-14.8 [2145-6-7] 11:23PM CALCIUM-8.7 PHOSPHATE-4.9 MAGNESIUM-2.6 [2145-6-7] 11:23PM CK-MB-2 [2145-6-7] 11:23PM CK(CPK)-63 [2145-6-7] 11:23PM estGFR-Using this [2145-6-7] 11:23PM GLUCOSE-109* UREA N-67* CREAT-2.4# SODIUM-134 POTASSIUM-6.1 CHLORIDE-90* TOTAL CO2-32 ANION GAP-18 . Labs on floor [2145-6-8] 10:54AM BLOOD WBC-10.4 RBC-3.01* Hgb-8.2* Hct-26.3* MCV-87 MCH-27.3 MCHC-31.2 RDW-15.3 Plt Ct-277 [2145-6-8] 03:12AM BLOOD WBC-8.6 RBC-3.69* Hgb-10.2* Hct-32.0* MCV-87 MCH-27.6 MCHC-31.9 RDW-14.8 Plt Ct-342 [2145-6-8] 10:54AM BLOOD Plt Ct-277 [2145-6-8] 03:12AM BLOOD Plt Ct-342 [2145-6-8] 03:12AM BLOOD PT-35.1* PTT-44.8* INR(PT)-3.6* [2145-6-8] 10:54AM BLOOD Glucose-60* UreaN-56* Creat-2.1* Na-GREATER TH K-3.4 Cl-109* HCO3-GREATER TH [2145-6-8] 03:12AM BLOOD Glucose-117* UreaN-68* Creat-2.7* Na-134 K-4.9 Cl-88* HCO3-31 AnGap-20 [2145-6-7] 11:23PM BLOOD Glucose-109* UreaN-67* Creat-2.4# Na-134 K-6.1 Cl-90* HCO3-32 AnGap-18 [2145-6-8] 10:54AM BLOOD CK(CPK)-38* [2145-6-8] 03:12AM BLOOD ALT-25 AST-30 LD(LDH)-279* AlkPhos-158* TotBili-2.4* [2145-6-8] 10:54AM BLOOD CK-MB-2 [2145-6-7] 11:23PM BLOOD CK-MB-2 [2145-6-8] 10:54AM BLOOD Calcium-5.7* Phos-4.9* Mg-1.9 [2145-6-8] 03:12AM BLOOD Albumin-3.5 Calcium-8.9 Phos-5.3* Mg-2.6 [2145-6-7] 11:23PM BLOOD Calcium-8.7 Phos-4.9* Mg-2.6 [2145-6-8] 03:12AM BLOOD Ammonia-6* [2145-6-8] 03:12AM BLOOD Digoxin-2.3* [2145-6-8] 12:53PM BLOOD Type-ART Temp-37.0 pO2-93 pCO2-78* pH-7.04* calTCO2-23 Base XS--11 Intubat-INTUBATED [2145-6-8] 11:25AM BLOOD Type-ART pO2-57* pCO2-78* pH-7.06* calTCO2-24 Base XS--10 [2145-6-8] 10:57AM BLOOD Type-ART pO2-VERIFIED,Q pCO2-74* pH-7.08* calTCO2-23 Base XS--11 Intubat-INTUBATED Vent-CONTROLLED [2145-6-8] 12:53PM BLOOD K-4.8 [2145-6-8] 11:25AM BLOOD Glucose-58* Lactate-11.5* K-4.5 [2145-6-8] 10:57AM BLOOD Lactate-9.6* [2145-6-8] 12:53PM BLOOD O2 Sat-90 [2145-6-8] 11:25AM BLOOD freeCa-1.17 [2145-6-8] 10:57AM BLOOD freeCa-0.96* . Reports . CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 83830] Reason: please evaluate for aspiration, PNA [Hospital 93] MEDICAL CONDITION: 77 year old man with BiV pacer/ICD in place admitted for multiple episodes V Tach with ICD firing, altered mental status and recent asystole requiring CPR. REASON FOR THIS EXAMINATION: please evaluate for aspiration, PNA Final Report INDICATION: Insertion of biventricular pacemaker, decline in cognitive function, cardiac arrest with subsequent intubation and frank hemoptysis. Supratherapeutic INR. FINDINGS: Comparison made with a radiograph dated [2145-6-8] at 01.47 hours (pre-cardiac arrest). There is new asymmetric opacity in the right lung and new bilateral alveolar and interstitial opacities in both lungs on a background of moderate cardiomegaly. No rib fractures or pneumothorax. An endotracheal tube and nasogastric tube have been inserted since the previous radiograph and are in satisfactory positions. The positions of the right atrial, right ventricular and epicardial pacing wire are satisfactory and unchanged. Moderately severe bilateral glenohumeral subluxation is incidentally noted. IMPRESSION: Alveolar and interstitial pulmonary edema, worse on the right. The diffuse ground-glass opacity in the right lung may be attributable in part to pulmonary hemorrhage, which would fit with the given clinical history. The study and the report were reviewed by the staff radiologist. . CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 83831] Reason: Any acute lung process? [Hospital 93] MEDICAL CONDITION: 77 year old man with with non ischemic cardiomyopathy with an EF of 20%, CVA, DM, A fib (on warfarin at home), 6 weeks ago had BiV ICD re-placement s/p VT, who was transferred from [Hospital3 ] hospital after ICD interrogation demonstrated 86 episodes of VT with intermittent firing REASON FOR THIS EXAMINATION: Any acute lung process? Final Report HISTORY: Ischemic cardiomyopathy. FINDINGS: No previous images. There is enlargement of the cardiac silhouette with pulmonary vascular congestion and a dual-channel pacemaker device in place. Epicardial lead is also seen. Mild retrocardiac opacification consistent with atelectasis. No definite pleural effusion. DR. [First Name11 (Name Pattern1) 1569] [Initial (NamePattern1) ] [Last Name (NamePattern4) 11006] Approved: TUE [2145-6-8] 9:56 AM . Overall left ventricular systolic function is severely depressed (LVEF= 20%). The right ventricular cavity is markedly dilated with depressed free wall contractility. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. Ech [6-8]: IMPRESSION: Severe left ventricular systolic dysfunction. Dilated right ventricle with systolic dysfuction. No pericardial effusion. Ascites. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171], MD, Interpreting physician [Last Name (NamePattern4) ] [2145-6-8] 12:04 . [6-7] EKG: A-V paced rhythm. Baseline artifact. No previous tracing available for comparison. Clinical correlation is suggested. Brief Hospital Course: ASSESSMENT/PLAN: This 77 year old male patient with non ischemic cardiomyopathy with an EF of 20%, CVA, DM, A fib (on warfarin at home), 6 weeks ago had BiV ICD re-placement s/p VT, who was transferred from [Hospital3 ] hospital after ICD interrogation demonstrated 86 episodes of VT with intermittent firing. . #Nonsustained Ventricular Tachycardia- No V tach tracing was available from outside hospital. Patient presented with persisitent episdoes of ventricular tachycardia while on Sotalol and Biv ICD. Most likely caused by arrythmic substrate from past myocardial infarctions. There is a question if zaroxolyn is related.We continued Lidocaine gtt and continued Amiodarone 400mg [Hospital1 ] p.o. We Hemodynamically monitored the patient with frequent vital signs check and kept him NPO in anticipation of a possible EP study in the AM.We also continued metoprolol tartrate 25mg [Hospital1 ] p.o . #Atrial Fibrilliation- He was being A-V paced on presentation. Patient took Warfarin at home. -INR was 2.9 and we held his coumadin with continued rate control with metoprolol. . # Acute on chronic systolic CHF- appeared to be volume overloaded on exam. Noted to have [12-30]+ MR/TR on last echo.He could have been volume overloaded however intravascular depleted because of his high creatinine. We Continued Digoxin as well as ordered a chest radiograph. We Followed I's and O's and considered a echo in the AM. We waited to recheck lytes and make sure his potassium level was normal which it was prior to giving lasix 80mg IV . #Acute on Chronic Renal Failure: recent baseline 2-2.2. Ordered Urine lytes, serum lytes , and UA, and held diruetics. . #Altered Mental Status- Patient had experienced delirium for the past 6 weeks which was acute in onset. His first altered mental status coincided with his first hospital admission for V tach. 6 weeks ago. -Frequent reorientation. Held sedating medications. Measured ammonia levels for suspicion of hepatic encephalopathy, the ammonia levels were normal. . #DM Held oral diabetic medications (glyburide).Started insulin sliding scale. . #HTN- -Continued Metoprolol, however held hydralazine and isosorbide given SBP in 90's. . #Hyperlipidemia -Continued Simvastatin . #History of CVA: Without any persistent neurologic sequelae on presentation. . #Musculoskeletal pain: Secondary to trauma. -Considered imaging and X ray of right shoulder, ordered pain control with tylenol . #Sciatica -Held Lyrica for potential sedating effects. . #Melanoma . #GERD: Continued Famotidine . FEN: NPO . ACCESS: PIV's . PROPHYLAXIS: -DVT ppx with pneumoboots -Pain management with tylenol -Bowel regimen with Senna and Colace . CODE: Presumed full . Cardiac arrest call at 10:37 after found unresponsive, CPR was commenced and found to be in PEA. Pt was intubated and central/arterial line access was established. 1x shock when rhythm returned to VT. Pulse came and went and required 3 vials of epinephrine, 2 vials of atropine and 2 vials of bicarbonate with good CPR. Bloody ++ secretions on suction via ETT. ROSC 10:57 with blood pressure on A-line A dopamine infusion was commenced at 11:08. 2nd cardiac arrest call at 12:30 in PEA requiring 2 amps epinephrine,1 amp bicarb 1 amp atropine and dopamine titrated to maximum. Despite maximum pressors unable to sustain adequate blood pressure. Following this a family meeting was held and decision to make the patient comfort measures only was made. Time of death and confirmation: Time of death 13:50 with no pulse trace on A-line with no recordable although still ventilated at the request of family. Daughters and next of [Doctor First Name ] present at time of death. Confirmation of death at 14:47 when ventilator was switched off. Relatives and next-of-[Doctor First Name ] were offered and declined an autopsy at 14:50. Full external examination and vital signs at 14:47: No A-line trace. No BP. O2 sats 0. No respiratory effort, no breath sounds on auscultation for 1 minute. No carotid pulse palpable for 1 minute and no heart sounds on auscultation for 1 minute. Pupils bilaterally fixed and dilated Death certificate documentation completed by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]: Chief cause of death: end-stage congestive heart failure Immediate cause of death: Electro-mechanical dissociation Other antecedent causes: Acute aspiration I, Dr [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] hereby confirm the death of Mr [Known firstname 3613] [Known lastname ] ([2067-9-12]) at 14:47 on [2145-6-8], an in-patient on the CCU of the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] Total time spent: 15 minutes Dr [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MB ChB MRCP Intern in medicine Pager [Numeric Identifier 38143] License No [Numeric Identifier 83832] Medications on Admission: (at the time of transfer) - amiodarone 400mg PO BID - famotidine 20mg PO daily - lidocaine gtt at 2 mg/min - isosorbide dinitrate 10mg PO TID - pregabalin 50mg PO daily - coumadin - hydralazine 10mg PO TID - simvastatin 20mg PO daily - digoxin 0.125mg PO daily - metoprolol 25mg PO BID - plavix 75mg PO daily . HOME MEDS: - glyburide 5mg PO daily - amiodarone 400mg PO BID - lidoderm patch to lower back - lasix 120 PO BID - hydralazine 10mg PO TID - zocor 20mg PO daily - digoxin 0.125mg PO daily - coumadin 2mg PO daily - plavix 75mg PO daily - folic acid 1mg Po daily - lyrica 50mg PO daily - colace 100mg PO BID - metoprolol 25mgPO [Hospital1 ] - isosorbide dinitrate 10mg PO TID Discharge Medications: patient has expired Discharge Disposition: Expired Discharge Diagnosis: patient has expired Discharge Condition: patient has expired Discharge Instructions: patient has expired Followup Instructions: patient has expired [First Name11 (Name Pattern1) 900] [Last Name (NamePattern1) 2882] MD, [MD Number(3) 2883]	[ "5849", "4280", "2724", "25000", "42731", "4168", "40390", "5859" ]
Admission Date: [2198-5-16] Discharge Date: [2198-6-2] Date of Birth: [2148-6-17] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 922] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [2198-5-17] 1. Mitral valve repair with a [Company 1543] Profile 3-D annuloplasty ring cyst, model #680R, serial #[Serial Number 52467]. 2. Tricuspid valvuloplasty with an [Doctor Last Name ] MC3 annuloplasty system, model #4900, size is 30 mm, serial #[Serial Number 52468]. The size of the [Company 1543] Profile 3-D was 32 mm. 3. Full left and right-sided Maze procedure with a combination of the [Company 1543] Irrigated BP-2 bipolar RF system as well as the CryoCath. [2198-5-16] Cardiac Cath History of Present Illness: 49 year old gentleman who has been followed for mitral regurgitation since [2191-3-6]. He has severe hypertension that resulted in left ventricular dilatation and mitral regurgitation. Over the course of six years, the mitral regurgitation has worsened (left ventricular ejection fraction has not changed from 30%) despite attempts to gain control over his systemic blood pressure. Follow up echocardiograms revealed severe mitral regurgitation with similiar left ventricular function and a severely dilated left ventricle. He continues to be relatively asymptomatic of his mitral disease. He has seen Dr [Last Name (STitle) 914] for an operation and is here today for a catheterization before proceeding. Past Medical History: Mitral Regurgitation Tricuspid Regurgitation Hypertension Atrial fibrillation (since [2191]) Social History: Lives with: He is initially from [Country 3594]. He lives with his girlfriend. Occupation: [Name2 (NI) ] previously worked on a cruise ship, and did carpentry. Currently unemployed Tobacco: Denies ETOH: Rare use Family History: Father who died of a stroke at the age of 48. Mother died at 56yo, possibly of MI Physical Exam: Pulse: 62 Resp: 18 O2 sat: 100% B/P Right: 151/114 Left: 165/107 Height: 5'7" Weight: 178lb General: NAD, WGWN, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur -no murmur appreciated Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] no Edema; On the right medial side of the calf has large area of varicous veins, which are soft and non painful. Right leg is w/o any varicosities. Neuro: Grossly intact X Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [2198-5-16] Cath: 1. Selective coronary angiography of this right dominant system demonstrated angiographically apparent flow-limiting coronary artery. The LMCA, LAD, LCx, and RCA had no angiographically significant disease. 2. Resting hemodynamics revealed mildly elevated left- and right-sided filling pressures with a mean PCWP of 16 mmHg and an RVEDP of 14 mmHg. Pulmonary arterial pressures were mildly elevated at 35/27 mmHg. Cardiac output was significantly decreased at 2.4 L/min with an index of 1.3 L/min/m2. [2198-5-17] TEE: PRE-CPB:1. The left atrium is markedly dilated. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 30 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 4. The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with normal free wall contractility. 5. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. No mass or vegetation is seen on the mitral valve. There is bilateral leaflet restriction. Moderate to severe (3+) mitral regurgitation is seen. There is dilatation of the annulus, which measures 5.1 cm 8. The tricuspid valve leaflets fail to fully coapt. The tricuspid annulus is enlarged and measures 4.2 cm. Dr. [Last Name (STitle) 914] was notified in person of the results. POST-CPB: On infusions of milrinone, norepinephrine, amiodarone. AV pacing ,then apacing for slow JR. [Name (NI) ]-seated annuloplasty rings in the mitral and tricuspid positions. Trivial MR [First Name (Titles) ] [Last Name (Titles) ]. No gradient across mitral or tricuspid valves with CO= 7 L/min. LVEF is now 35% on inotropic support. Normal RV systolic function on inotropic support. AI remains trace. Aortic contour is normal post decannulation. Brief Hospital Course: The patient was brought to the operating room on [2198-5-17] where the patient underwent Mitral Valve Repair, Tricuspid Valve annuloplasty and full Maze procedure. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. He was found to be in junctional escape rhythm and EP was consulted. Beta blocker was held initially and the patient was gently diuresed toward the preoperative weight. He was started on IV Nitro for hypertension and oral agents were titrated. Anti-coagulation was resumed with Coumadin for atrial fibrillation. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was planned for discharge on post-op day nine but spiked a temperature. Incision was clean without erythema or drainage. Blood cultures and U/A were negative. In addition he developed abdominal discomfort with elevated LFT's. Transplant Surgery was consulted and the underwent multiple imaging studies which were all negative. LFTs were normalizing by the time of discharge. He did develop some runs of ventricular tachycardia. He remained hemodynamically stable. EP evaluated the patient and recommendations were made. Ultrasound was performed on the RLE for tenderness and swelling that would return negative for DVT. By the time of discharge the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. [Company 191] anti-coagulation to continue managing Coumadin/INR. Medications on Admission: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily CARVEDILOL [COREG] - 25 mg Tablet - 1 Tablet(s) by mouth twice daily FUROSEMIDE - 80 mg Tablet - one Tablet(s) by mouth every other day (prn) LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily WARFARIN - 5 mg Tablet - 1 Tablet by mouth daily five days per week; one & one-half tablets twice per week; or as directed by [Hospital 263] clinic Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR Coumadin for A-fib Goal INR 2-2.5 First draw [2198-6-3] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [Hospital 191] [Hospital ] clinic Results to phone [Telephone/Fax (1) 2173] 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 6. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Dose may change for goal INR 2-2.5, managed by [Hospital 191] [Hospital ] clinic. Disp:60 Tablet(s) Refills:0 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 13. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for lower extremities . Disp:qs Refills:0 14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Mitral Regurgitation s/p MV repair Tricuspid Regurgitation s/p TV repair Atrial fibrillation s/p MAZE procedure and LAA ligation Post operative junctional rhythm Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Dilaudid Sternal Incision - healing well, no erythema or drainage Edema: trace, R>L 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 and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: The following appointments are already scheduled for you Surgeon: Dr. [Last Name (STitle) 914] [Telephone/Fax (1) 170] on [6-19] at 1:15pm Cardiology/heart failure [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP [Telephone/Fax (1) 62] [7-3] 2:30 Please call to schedule the following: Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] T. [Telephone/Fax (1) 52469] in [5-8] weeks Labs: PT/INR Coumadin for A-fib Goal INR 2-2.5 First draw [2198-6-4] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [Hospital 191] [Hospital ] clinic Results to phone [Telephone/Fax (1) 2173] Completed by:[2198-6-6]	[ "4240", "4280", "4019", "42731", "V5861" ]
Admission Date: [2157-1-1] Discharge Date: [2157-1-10] Date of Birth: [2094-3-28] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Exploratory laparotomy, drainage intra-abdominal abscess, resection necrotic distal common bile duct and hepaticocholedochojejunostomy. History of Present Illness: 62 yo M s/p Liver transplant [2156-12-8], s/p C. Cath [12-27], prox LAD calcification, occlusion D2 & mid RCA, dissection D2 during cath w/guidewire, presents with 8/10 chest pain that began day of admission. The pain was [8-27] started in the center of the chest and radiated to both shoulders. The pain was associated with dyspnea and felt like pressure. He took 1 sl NTG that brought the pain from an 8 to [4-27]. The pain persisted during the day but lessened. His wife found that his heart rate was 120s and called the cardiologist (Dr. [Last Name (STitle) ] who recommended evaluation at [Hospital3 ]. There he was found to be in atrial fibrillation and was treated with lopressor x 3 and dig x1. His heart rate was difficult to control and had decreased BP that limited further beta blocker administration. He was given sl NTG. Found to have elevated trop at 0.39. At [Hospital1 18] ED initial vitals were 98.6, 120 93/55 96% RA. He was given metoprolol 25 mg once and oxycodone 5 mg. . Patient reports that he has been essentially pain free since leaving [Hospital3 ] at rest. However, when he moves or gets up he again has chest pain. Patient reports that the pain is similar in severity and quality to the pain he had during the cardiac catherization this week. . Of note, pt feels like he hasn't felt great since leaving [Hospital1 18] last week. He has been anxious about the chest pain and feels nervous that no intervention was done. Past Medical History: 1. Alcohol-related cirrhosis status post TIPS placement [2154-10-8] requiring dilatation [2154-10-15] now s/p orthotopic liver transplant [2156-12-8] 2. Upper GI bleeding in [2152]. Patient was treated at an outside hospital and it is unclear whether his upper GI bleed was secondary to esophageal varices or peptic ulcer disease. 3. Coronary artery disease status post angioplasty in the [2129]. 4. Diabetes mellitus type 2 diagnosed in [2152]. Hemoglobin A1c [2154-10-4] was 6.3 5. Umbilical hernia status post repair [2154-11-3] 6. Right knee surgery 7. Depression 8. HCC, growth [Last Name (un) 64259] 2.5x2.5cm confirmed on [2156-9-8] at the dome of the liver 9. Recurrent recent paracentesis due to refractory ascites Social History: Married with two adult sons. Formerly worked as a vice president of a trucking company. Drank from the age of 20 until [2154-9-19]. He never smoked. Denies IV drug use. Family History: Father and brother died of MI at the age of 52. His mother and sister have diabetes. Physical Exam: T 99.1 BP 130/59 HR 67 RR 18 O2 sat 99%RA Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of approx 8-10 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, diffusely tender, but mildly so. Large scar that is mildly erythematous with bandages but no drainage or sigificant tenderness. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Multiple ecchymoses on arms Guaiac negative Pertinent Results: [2157-1-1] 07:45PM BLOOD WBC-6.9 RBC-3.26* Hgb-10.1* Hct-29.0* MCV-89 MCH-30.8 MCHC-34.6 RDW-17.0* Plt Ct-185 [2157-1-10] 05:40AM BLOOD WBC-6.8 RBC-3.16* Hgb-10.0* Hct-28.1* MCV-89 MCH-31.7 MCHC-35.6* RDW-16.0* Plt Ct-164 [2157-1-1] 07:45PM BLOOD Neuts-93.8* Lymphs-4.5* Monos-1.2* Eos-0.6 Baso-0 [2157-1-2] 01:43AM BLOOD PT-15.6* PTT-31.1 INR(PT)-1.4* [2157-1-10] 05:40AM BLOOD PT-21.1* PTT-76.2* INR(PT)-2.0* [2157-1-3] 11:49AM BLOOD Fibrino-654# [2157-1-3] 12:53AM BLOOD Gran Ct-1040 [2157-1-1] 07:45PM BLOOD Glucose-148* UreaN-27* Creat-1.7* Na-136 K-4.7 Cl-105 HCO3-21* AnGap-15 [2157-1-10] 05:40AM BLOOD Glucose-128* UreaN-34* Creat-2.1* Na-135 K-3.9 Cl-105 HCO3-21* AnGap-13 [2157-1-10] 05:40AM BLOOD ALT-21 AST-19 AlkPhos-260* TotBili-0.9 [2157-1-9] 05:50AM BLOOD ALT-20 AST-18 LD(LDH)-193 AlkPhos-245* Amylase-59 TotBili-1.1 [2157-1-8] 06:40AM BLOOD ALT-13 AST-16 AlkPhos-184* TotBili-1.3 [2157-1-7] 05:10AM BLOOD ALT-10 AST-13 CK(CPK)-12* AlkPhos-115 Amylase-34 TotBili-2.3* DirBili-1.6* IndBili-0.7 [2157-1-6] 07:19AM BLOOD ALT-12 AST-13 CK(CPK)-23* AlkPhos-91 Amylase-17 TotBili-3.9* [2157-1-6] 02:22AM BLOOD ALT-9 AST-12 AlkPhos-87 Amylase-16 TotBili-3.6* [2157-1-5] 08:20PM BLOOD CK(CPK)-33* [2157-1-5] 02:19PM BLOOD ALT-12 AST-12 CK(CPK)-25* AlkPhos-82 Amylase-11 TotBili-3.3* [2157-1-4] 10:20PM BLOOD CK(CPK)-50 [2157-1-4] 05:40AM BLOOD CK(CPK)-38 [2157-1-4] 03:00AM BLOOD ALT-13 AST-12 LD(LDH)-156 AlkPhos-78 Amylase-6 TotBili-3.7* [2157-1-3] 10:34PM BLOOD CK(CPK)-28* [2157-1-3] 03:19PM BLOOD CK(CPK)-27* [2157-1-3] 12:53AM BLOOD ALT-14 AST-10 LD(LDH)-150 AlkPhos-141* Amylase-19 TotBili-1.3 [2157-1-2] 06:00AM BLOOD ALT-15 AST-12 CK(CPK)-20* AlkPhos-165* TotBili-1.0 [2157-1-2] 01:42AM BLOOD CK(CPK)-25* [2157-1-1] 07:45PM BLOOD ALT-18 AST-15 LD(LDH)-174 CK(CPK)-21* AlkPhos-186* TotBili-0.8 [2157-1-9] 05:50AM BLOOD Lipase-57 [2157-1-3] 12:53AM BLOOD Lipase-16 [2157-1-7] 05:10AM BLOOD CK-MB-NotDone cTropnT-0.04* [2157-1-6] 07:19AM BLOOD CK-MB-NotDone cTropnT-0.06* [2157-1-5] 08:20PM BLOOD CK-MB-NotDone cTropnT-0.06* [2157-1-5] 02:19PM BLOOD CK-MB-NotDone cTropnT-0.08* [2157-1-4] 10:20PM BLOOD cTropnT-0.10* [2157-1-4] 05:40AM BLOOD CK-MB-NotDone cTropnT-0.11* [2157-1-3] 10:34PM BLOOD CK-MB-NotDone cTropnT-0.10* [2157-1-3] 03:19PM BLOOD CK-MB-NotDone cTropnT-0.09* [2157-1-2] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.17* [2157-1-1] 07:45PM BLOOD cTropnT-0.15* [2157-1-1] 07:45PM BLOOD Albumin-2.8* Calcium-7.7* Phos-3.3 Mg-1.3* [2157-1-10] 05:40AM BLOOD Albumin-2.3* Calcium-7.5* Phos-3.0 Mg-1.6 [2157-1-2] 06:00AM BLOOD FK506-6.9 [2157-1-3] 06:25AM BLOOD FK506-6.1 [2157-1-4] 05:40AM BLOOD FK506-11.7 [2157-1-5] 05:35AM BLOOD FK506-25.4* [2157-1-7] 05:10AM BLOOD FK506-21.2* [2157-1-8] 06:40AM BLOOD FK506-11.4 [2157-1-9] 05:50AM BLOOD FK506-12.1 [2157-1-4] 10:55AM BLOOD Lactate-1.3 [2157-1-3] 11:49AM BLOOD Glucose-135* Lactate-1.6 Na-130* K-4.3 Cl-105 liver biopsy [1-3]: Features consistent with resolving zone 3 preservation/reperfusion injury; no active necrosis is identified, minimal portal and scant lobular mononuclear cell inflammation, likely non-specific, no features of acute cellular rejection are seen, rare cholestasis and focal, minimal bile duct proliferation seen; no significant bile duct damage or associated neutrophilic inflammation identified, no steatosis or intracellular hyalin present, trichrome stain shows mild portal and pericentrivenular fibrosis; a rare focus of sinusoidal fibrosis is seen, iron stain shows rare, minimal iron deposition in Kupffer cells. echo [1-3]: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. There are complex (mobile) atheroma in the descending aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. [1-7] biliary cath check: Gravity cholangiogram through a previously placed biliary catheter demonstrates mild stenosis at the hepaticojejunostomy anastamosis with mild left greater than right intrahepatic biliary ductal dilatation and mild delay of contrast passage into jejunal loops. This is likely secondary to postoperative edema at the anastamosis. No evidence of biliary leak. Brief Hospital Course: Mr. [Known lastname 64260] was admitted to the cardiology service for management of unstable angina along with his new onset atrial fibrillation and rapid ventricular response. He was seen by cardiac surgery who agreed with medical management at that point. He was started on a heparin drip and continued on his PO metoprolol/Imdur and aspirin. However, on [2157-1-3] he developed sharp pain in his epigastric region. A CT scan revealed new intraperitoneal free air in the setting of recent liver transplant and bile leak with increasing gas and fluid collection with the appearance of a developing abscess in the retrohepatic space. Because of this he was started on IV vancomycin and zosyn and was taken the operating room for exploratory laparotomy, drainage of the intra-abdominal abscess, resection of the necrotic distal common bile duct and hepaticocholedochojejunostomy. He was transfered to the ICU following the procedure. Initially he was difficult to extubate and went into rapid atrial fibrillation on [2157-1-4]. He was placed on a diltiazem drip and converted to sinus rhythm on [2157-1-5]. After this point, he did well and was transferred to the floor. On [2157-1-7] he underwent a cholangiogram which demonstrated mild stenosis at the hepaticojejunostomy anastamosis with mild left greater than right intrahepatic biliary ductal dilatation and mild delay of contrast passage into jejunal loops with no evidence of biliary leak. The vancomycin and zosyn were discontinued and his diet was advanced without difficulty. On [2157-1-8] he was started on coumadin for anticoagulation for his atrial fibrillation. His JP drain was discontinued on [2157-1-9] and he was tolerating a regular diet. He was discharged in good/stable condition. Medications on Admission: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 2 doses. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Tablet(s) 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 17. Lantus 18 U SC qhs Discharge Medications: 1. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 9. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 10. Insulin Lispro 100 unit/mL Solution Sig: Zero (0) units (sliding scale as below) Subcutaneous three times a day: Glargine 12 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL 1 amp D50 1 amp D50 1 amp D50 1 amp D50 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 3 Units 3 Units 3 Units 3 Units 201-250 mg/dL 6 Units 6 Units 6 Units 6 Units 251-300 mg/dL 9 Units 9 Units 9 Units 9 Units 301-350 mg/dL 12 Units 12 Units 12 Units 12 Units 351-400 mg/dL 15 Units 15 Units 15 Units 15 Units . 11. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 14. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Tacrolimus 1 mg Capsule Sig: One Capsule PO Q12H (every 12 hours). 16. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day: Please get labs on Thursday and adjust your dosing as instructed at that time (start by taking 3 mg of coumadin daily). Disp:40 Tablet(s) Refills:2 17. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:21 Tablet(s) Refills:0 18. Outpatient Lab Work Please check CBC, chem 10, AST, ALT, amylase, lipase, tbili, alk phos, albumin, PT, PTT, INR, and FK level on Thursday [2157-1-13]. Please fax these results to [Telephone/Fax (1) 697]. Discharge Disposition: Home With Service Facility: [Location (un) 6138] VNA Discharge Diagnosis: CAD, biliary leak Discharge Condition: improved/good/stable Discharge Instructions: You were admitted to the hospital with chest pain. You have known coronary artery disease. Please continue on all of your cardiac medications. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Please schedule a follow-up appointment with your PCP if you have continued symptoms. * Continue to amubulate several times per day. * Please return to have your labs checked on Wednesday Followup Instructions: Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2157-1-13] 8:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2157-1-19] 2:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2157-1-26] 1:40 Completed by:[2157-1-10]	[ "2762", "41401", "42731", "25000", "V5867", "V5861" ]
Admission Date: [2126-7-8] Discharge Date: [2126-7-17] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1167] Chief Complaint: dyspnea and peripheral edema Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 66000] is an 84 year old male with PMH of CAD and biventricular congestive heart failure who presented to his PCP with [Name Initial (PRE) ] chief complaint of increasing edema and fatigue. The patient was admitted to [Location (un) ] and found to have a HR up to 120; he received IV lopressor with a drop in his blood pressure. Echocardiogram demonstrated EF 10% (down from prior 20-25%) as well as a thickened septum thought to be consistent with amyloid. He was placed on renally-dosed dopamine and BP meds were held. Dr. [Last Name (STitle) 1911] evaluated the patient on [7-7] and on interrogation of his AICD found him to be in atrial tachycardia at a rate 130. He was placed on IV heparin for atrial fibrillation. Dopamine was continued but as his blood pressures improved, he was started back on a beta blocker and aldactone. The decision was made for transfer to [Hospital1 18] for further treatment. At the time of transfer, the patient was still on dopamine at a rate of 7.5. He stated that his breathing is "not too good," but only woke up briefly to relate this. He denied chest pain. ROS: Endorses urinary frequency. Not able to obtain other ROS due to mental status. EKG demonstrated an atrial rate of ~ 100, ventricular rate 70. At times appeared V paced but not consistently. No ST/T wave changes. Past Medical History: PMHx: Biventricular heart failure:CHF: Dilated biventricular cardiomyopathy EF 20-25%. Mild MR, Pulm HTN Atrial tachycardia/atrial fibrillation (at OSH); prior history of atrial fibrillation but taken off of amiodarone, Pacemaker/ICD [2125-3-7] 2V CAD Hypertension DM type 2, insulin dependent CRI (baseline creatinine 2.6) Dementia Arthritis History of hernia repair GI bleed Cardiac studies: Cardiac cath [3-/2125]: Right dominant system. Two vessel CAD - 60% lesion in distal portion of the RPDA. LCx 90% distal stenosis. Elevated right and left pressures (RVEDP = 24 mm Hg; PCWP mean = 32 mm Hg). Severe pulmonary HTN. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Severe systolic ventricular dysfunction. 3. Severe pulmonary hypertension. . Echo: EF 25-30%. The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal with severe global hypokinesis and inferior wall akinesis. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic root is moderately dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Prominent symmetric left ventricular hypertrophy with global and regional systolic dysfunction c/w multivessel CAD or other diffuse process. Right ventricular free wall hypokinesis. Dilated aortic root. Social History: The patient lives in [Hospital3 ] with his daughter and son-in-law who are essentially his 24 hour/day caregivers. Retired. [Name2 (NI) ] previously smoked but quit several years ago. He does not drink alcohol. Family History: Not obtainable from patient. Physical Exam: PHYSICAL EXAMINATION: VS: T 96.1 BP 96/66 HR 72 RR 14 O2 97% on 4 L NC Wt 100 kg Gen: Obese male in mild distress. Oriented to self. Using accessory muscles to breath. Drowsy but arousable. HEENT: Conjunctiva injected bilaterally. PERRL, EOMI. No pallor or cyanosis of the oral mucosa. Wearing glasses. Neck: JVP at angle of the mandible. CV: RR and rhythm. normal S1, S2. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were slightly labored with use of accessory muscle use. Crackles with rhonchi bilaterally throughout lung fields. Abd: Obese but nontender. Normoactive bowel sounds. No HSM or tenderness. Abd aorta not palpated. No abdominial bruits. Ext: total body anasarca. R UE swelling more pronounced than L UE swelling. Skin: Scattered ecchymoses. Pulses: Right: Carotid 1+ DP 1+ PT 1+ Left: Carotid 1+ DP 1+ PT 1+ Pertinent Results: LABORATORY DATA (from OSH): potassium 5.6, BUN 61, creatinine 2.8 WBC 6.6, Hct 47, plt 133 BNP 866 (normal 0-100) CK 111 --> 107 Troponin 0.22 --> 0.24 --> 0.22 LAB RESULTS (at [Hospital1 18]): [2126-7-8] WBC-5.6 RBC-4.20* Hgb-14.4 Hct-44.1 MCV-105* MCH-34.2* MCHC-32.5 RDW-15.3 Plt Ct-118* [2126-7-13] WBC-5.8 RBC-3.44* Hgb-12.3* Hct-34.5* MCV-100* MCH-35.7* MCHC-35.7* RDW-16.0* Plt Ct-178 [2126-7-8] Glucose-60* UreaN-54* Creat-2.2* Na-131* K-4.5 Cl-95* HCO3-29 [2126-7-12] Glucose-175* UreaN-51* Creat-2.2* Na-129* K-4.1 [2126-7-13] Calcium-9.4 Phos-2.7 Mg-2.3 [2126-7-8] ALT-21 AST-26 LD(LDH)-293* AlkPhos-175* TotBili-2.2* [2126-7-8] Albumin-3.4 Calcium-8.8 Phos-3.1 Mg-2.8* EKG from [2126-7-8] demonstrated v-paced (inconsistent) with atrial rate ~ 100. No ST/T wave changes IMAGING: 2D-ECHOCARDIOGRAM performed on [7-7] at [Location (un) ] demonstrated (by report): LV not dilated; moderate biatrial enlargement. Marked septal thickening (2.2). LV walls considerably more thickened compared to [2125-3-7]. Elevated CVP 20 mmHg. Elevated PA systolic pressure (50 mmHg). EF ~ 10%. RV is dilated. Septal flattening consistent with volume overload. No significant valvular disease. Does have restrictive mitral inflow pattern. TTE performed on [7-8]: The left atrium is markedly dilated. The right atrium is markedly dilated. The estimated right atrial pressure is >20 mmHg. There is severe symmetric left ventricular hypertrophy. Overall left ventricular systolic function is severely depressed (ejection fraction 20 percent) secondary to akinesis of the inferior and posterior walls and severe hypokinesis of the inferior septum and lateral wall. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is dilated. There is severe global right ventricular free wall hypokinesis. The aortic root is moderately 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. The mitral inflow is consistent with a restrictive filling pattern, a marker of severe diastolic and/or systolic dysfunction. Compared with the findings of the prior study (images reviewed) of [2125-3-26], the left ventricular ejection fraction is further depressed; right ventricular contractile function is now severely depressed. R upper extremity ultrasound performed on [7-7] at [Location (un) ] was negative for DVT R upper extremity ultrasound on [7-11] demonstrated: No evidence of DVT in the right upper extremity. KUB on [7-7] at [Location (un) ]: large amount of stool, mildly dilated small bowel loops which are nonspecific and probably due to ileus CXR (from [Location (un) ], [7-7]): limited study with possible tiny pleural effusions or pleural thickening CXR [7-8] demonstrated: The heart is enlarged. Considerable tortuosity of the aorta is present. The position of the multiple pacemaker leads is unchanged since the prior chest x-ray of [3-12]. No significant failure is present. Costophrenic angles appear clear. IMPRESSION: Cardiomegaly, no gross failure. CXR [7-12]: There is prominence of the indistinctness of pulmonary vessels with fullness of the hila, to a greater extent than before. There are no pleural effusions or pneumothorax.IMPRESSION: New mild congestive heart failure. Brief Hospital Course: Pt is an 84 year old male with history of nonischemic cardiomyopathy, biventricular dysfunction, CAD, atrial fibrillation with pacemaker, DM2 and HTN admitted for decompensated heart failure. . CAD. Patient had catheterization in [3-12] which demonstrated 2 vessel coronary disease (90% distal LCx stenosis, 60% distal RPDA stenosis). No intervention was performed at that time. His current presentation did not appear consistent with ischemia. He had elevated cardiac enzymes that peaked, but were likely not significant given his renal insufficiency. . Atrial fibrillation. Patient has a history of afib and was thought to have an underlying atrial rhythm, so EP was consulted and his AICD/pacer was interrogated which showed Atach/Afib with multiple mode switches. Patient was continued on a heparin drip. Given patient's restrictive left ventricular dysfunction it was felt that rhythm control would not provide much benefit as the atrial kick would not contribute significantly to filling. Rate control was targeted with IV lopressor which was titrated up as his blood pressure tolerated, to achieve a HR 70-90bpm, and he was eventually switched to po metoprolol 25mg po TID. He was weaned off the dobutamine drip. Metoprolol was switched to Toprol XL prior to discharge. Patient was sent home on Coumadin 2.5 mg po qday and the heparin drip was discontinued. INR to be monitored every week by hospice services and faxed to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 12982] at [Telephone/Fax (1) 15181]. INR goal is 2.0. Pacemaker ICD function was turned off prior to discharge. . Pump. The patient had an EF of 10% at OSH and 20% on echo done here, and was grossly volume overloaded with total body anasarca. Patient was determined to be in decompensated heart failure and was maintained on a milrinone drip, which was titrated up to 0.5 mcg/kg/hr and a lasix drip which was titrated up to 15mg/hr. 250mg IV Diuril was added daily to assist in diuresis, with good effect. We slowly attempted to change him to po meds, starting first by taking him off the lasix drip and giving bolus doses of IV lasix after po metolazone (thiazide diuretic). Patient remained hemodynamically stable and improved clinically with slowly decreasing edema and decreasing JVP. Eventually milrinone was d/c'd and Lasix was switched to po dosing with stable hemodynamics. Patient was sent home on Lasix 100 mg PO BID and metolazone 5 mg PO BID, 30 minutes prior to lasix. If patient becomes more symptomatic with increased shortness of breath, please titrate home oxygen therapy to comfort and administer roxanol prn. . R upper extremity edema. Though patient was grossly edematous, patient had persistent R>L upper extremity edema, which was concerning for DVT. A repeat doppler of the RUE on [7-11] was negative for DVT (as above). Care was made to avoid placement of BP cuff and RUE and the edema appeared to decrease with overall diuresis. . Hyperlipidemia. Not on treatment with statin. . DM: On lantus with sliding scale insulin with fingersticks QID. Oral diabetic meds were held while in the hospital. Patient to continue on sliding scale with Lantus 20 units QHS. . Depression. On celexa. . Anemia: Patient on home iron. His HCT was 47 at the OSH but dropped gradually to 34.5 during admission. HCT was monitored daily. . CRI: Patient's BL Cr is 2.6. During the course of the hospitalization the Cr remained stable at 2.1-2.5, in spite of aggressive diuresis. . FEN: Cardiac, diabetic diet. After heavy diuresis the patient became slightly hyponatremic. Electrolytes were monitored regularly and repleted as necessary. . Dispo. Patient returned to [Hospital3 ] with hospice. . Code. DNI/DNR per HCP (daughter) [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 66001]. Palliative care was consulted to discuss long-term goals of care with family. A meeting was held with Dr. [First Name (STitle) 437] in which the family expressed a desire for no escalation in care, with continuing to manage medically to d/c to [Hospital3 ] with hospice care. If he deteriorates clinically while at home(i.e. worsening renal status, hyponatremia, worsening heart failure) he will be made CMO and there will be no further escalation of care. Medications on Admission: MEDICATIONS (on transfer): heparin gtt (not on upon arrival) glucotrol XL 15 mg daily humalog sliding scale celexa 20 mg daily namenda 10 mg [Hospital1 ] iron 325 daily centrum daily glucosamine/chondroitin 500/400 1 tab QAM, 2 tabs QHS toprol XL 25 mg daily lasix 40 mg IV aldactone 25 mg QAM prilosec 20 mg daily lantus 25 U QHS midodrine 10 mg TID dopamine drip (at 7.5) MEDS at home: glucotrol 5 mg, lasix 80QAM 40Qnoon and 40 QPM, aldactone 25 mg daily, prilosec 20 mg daily, celexa 20 mg daily, iron, aspirin 325 mg daily, namenda 10 mg [Hospital1 ] Discharge Medications: 1. Roxanol Concentrate 20 mg/mL Solution Sig: One (1) 5-20 mg PO q1hour as needed for pain. Disp:60 mg Refills:0 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for consipation. 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-8] Drops Ophthalmic PRN (as needed). 7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 10. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Congestive heart failure Discharge Condition: Patient is saturating well on room air, with minimal extremity edema. Discharge Instructions: You have been treated for your end-stage congestive heart failure with intravenous diuretics. It is recommended that you adhere to 2 gm sodium diet. . You will be continued on your coumadin. Please have your INR checked every week. This will be performed by your visiting hospice nurses. Dr. [Last Name (STitle) 12982] will be monitoring this level and adjusting your coumadin dosage as needed. Please fax INR level to Dr. [Last Name (STitle) 12982] at [Telephone/Fax (1) 15181] . If you experience any shortness of breath please use home oxygen and take Roxanol as needed to relieve your shortness of breath. Followup Instructions: Please call Dr.[Name (NI) 66002] office at [Telephone/Fax (1) 62842] to schedule a follow-up appointment in [4-12] weeks.	[ "42731", "5859", "4280", "41401", "25000", "V5867", "40390", "V1582", "2724", "311", "2859" ]
Admission Date: [2193-8-21] Discharge Date: [2193-8-29] Date of Birth: [2124-12-20] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: Fever, mental status change Major Surgical or Invasive Procedure: Permacath placement History of Present Illness: The patient is a 68yo F admitted to the [Hospital1 ] MICU on [2193-8-21] with fever, chills, delirium, and hypertension during hemodialysis (SBP to 240). In the ER, a head CT and LP were negative. On exam she was found to have bright red blood oozing from her rectum and was given 3 U of fresh frozen plasma and SQ vitamin K. Past Medical History: 1. Cerebrovascular accident times two, most recent with hemorrhage [7-/2192] with residual speech impairment. 2. Seizure disorder since [2189] after a stroke. 3. End-stage renal disease on hemodialysis since [95]/[2189]. 4. Type 2 diabetes, insulin dependent. 5. Hypertension. 6. Hypercholesterolemia. 7. History of Staphylococcus line infection. 8. History of pelvic fracture. 9. Peripheral [Year (4 digits) 1106] disease, severe. 10. Left arteriovenous fistula in [2189]. 11. Amputation of right first toe in [2192]. 12. Right lower extremity bypass surgery in [2192]. 13. History of osteomyelitis in 09/[2192]. Social History: Nursing home resident Physical Exam: Tmax 103 Tcurrent 101.1 93 140/50 95%2L AAx2 in NAD, cooperative Moderate sized lump on forehead MM dry, o/p clear, no LAD, no nuchal rigidity RRR s1s2 2/6 SEM CTAB, R SCL HAD cateheter clean, dry, no erythema No lower extremity edema RLE with multiple clean based ulcers, healing patent graft LLE dry ulcers Bilateral chronic ischemic skin changes Neuro: Strength 4/5 UE bilaterally, pateint uncopoperative with LE exam, neuro exam grossly nonfocal Pertinent Results: [2193-8-21] 07:53PM CEREBROSPINAL FLUID (CSF) PROTEIN-30 GLUCOSE-84 [2193-8-21] 07:53PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-0 LYMPHS-60 MONOS-40 [2193-8-21] 05:37PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.010 [2193-8-21] 05:37PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.010 [2193-8-21] 05:37PM URINE RBC-0-2 WBC-[12-28]* BACTERIA-MANY YEAST-NONE EPI-0 [2193-8-21] 03:40PM GLUCOSE-170* UREA N-13 CREAT-3.7# SODIUM-140 POTASSIUM-3.3 CHLORIDE-94 TOTAL CO2-32* ANION GAP-17 [2193-8-21] 03:40PM PHENYTOIN-7.6* [2193-8-21] 03:40PM WBC-15.2# RBC-4.26# HGB-14.1# HCT-43.8# MCV-103 MCH-33.1* MCHC-32.1 RDW-17.0* [2193-8-21] 03:40PM NEUTS-91.0* LYMPHS-6.3* MONOS-1.2* EOS-1.1 BASOS-0.3 [2193-8-21] 03:40PM PLT COUNT-303 [2193-8-21] 03:40PM PT-20.6* PTT-150* INR(PT)-2.8 [2193-8-21] 03:39PM LACTATE-1.9 Brief Hospital Course: Hospital course by problem: 1. MSSA bacteremia. On [2193-8-22], blood cultures were found to be GPC positive, and after a T to 101, her hemodialysis line as well as her femoral line was d/c'ed. The patient remained afebrile after the lines were pulled for the remainder of her hospital course. Vancomycin was begun in the ER and was continued until the organism type was known. On [2193-8-24], the organism was shown to be MSSA, and the patient was taken off Vancomycin and begun on oxacillin. However, in anticipation of discharge, and given her MRSA+ foot wound culture, she was switched back to Vancomycin, to be given at dialysis to complete a 2-week course. 2. Mental status change. The patient's mental status improved over the course of her hospitalization. By discharge, she was awake, alert, talkative, and A+Ox3. Her mental status change was attributed to bacteremia. 3. ESRD, on HD. Hemodialysis was continued while the patient was in the hospital. On [2193-8-23] a Quenton was placed in order to continue HD after the catheter had been removed. On [2193-8-27], a Permacath was placed by interventional radiology. 4. GI bleed. The patient's hct was stable throughout her hospitalization and after reversal in the ER she was guaiac negative. GI was consulted and recommended outpatient colonoscopy. 5. Hypertension. The patient continued to be hypertensive despite her admission regimen of metoprolol 100 [Hospital1 ], lisinopril 40 qd, nifedipine 90 qd, and doxazosin 4 qhs. In the hospital nifedipine was increased to nifedipine CR 120 qd, and then hydralazine 25mg po q6 was added as well. With the addition of the hydralazine, the patient achieved slightly better control, with SBP's in the 170's rather than low 200's. 6. DM. The patient was maintained on an insulin sliding scale with tight glucose control. Although not requiring insulin in the nursing home, she will require insulin sliding scale for monitoring, at least initially. 7. PVD. A right heel wound culture was positive for MRSA, representing colonization, and was not treated. The [Hospital1 1106] service followed the patient and a right lower extremity graft surveillance was done on [2193-8-27]. The patient was scheduled for follow up with Dr. [Last Name (STitle) 94164] approximately 1 month after discharge. The patient was also noted to have marked asymmetry between her right and left calves, R>L, no erythema or tenderness to palpation. Although this was felt to be most likely due to [Last Name (STitle) 1106] drainage as a result of her LE bypass surgery, she was evaluated for deep venous thrombosis with LENI's, which were found to be negative. 8. Anemia of chronic disease. The patient was given Epogen during HD. 9. Hypophosphatemia, likely due to malnutrion. Monitored and repleted. Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 6. Doxazosin Mesylate 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Naphazoline HCl 0.1 % Drops Sig: 1-2 Drops Ophthalmic Q8H (every 8 hours). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). 11. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QD (once a day). 12. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 13. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [Hospital3 8221] - [Location (un) 583] Discharge Diagnosis: Methicillin-sensitive Staph aureus bacteremia LGI bleed Discharge Condition: Good Discharge Instructions: Please return to the ER if you have any fevers or chills, any chest pain, or difficulty breathing. Also return if you have bleeding at your catheterization site. Changes to medications: Will continue on vancomycin at hemodialysis for her MSSA bacteremia. Last dose will be [9-6] at hemodialysis (2 week total). Needed insulin for glucose control, and may need monitoring and treatment with sliding scale at the nursing home. Nifedipine increased to CR 120 XR qd and hydralazine 25mg q6 was added. Patient will need colonoscopy as an outpatient. Followup Instructions: Provider: [Name10 (NameIs) ],MONDAY ORTHOPEDICS-SCC2 Where: [Hospital6 29] ORTHOPEDICS UNIT Phone:[Telephone/Fax (1) 5499] Date/Time:[2193-9-9] 8:20 Provider: [Name10 (NameIs) ],MONDAY ORTHOPEDICS-SCC2 Where: [Hospital6 29] ORTHOPEDICS UNIT Phone:[Telephone/Fax (1) 5499] Date/Time:[2193-9-16] 9:40 Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY Where: [Last Name (NamePattern4) ] SURGERY Date/Time:[2193-9-17] 12:00 Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ]. GASTROINTESTINAL, [2200-9-9] am. [Location (un) ] [Hospital Ward Name 23] Center. Please call [Telephone/Fax (1) 1954] before appointment with insurance information. NEEDS PRIMARY CARE APPOINTMENT.* [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "40391" ]
Admission Date: [2103-3-13] Discharge Date: [2103-3-18] Date of Birth: [2103-3-13] Sex: F Service: NEONATOLOGY HISTORY OF THE PRESENT ILLNESS: [First Name8 (NamePattern2) 36972] [Known lastname 49531] is the former 2.25 kilogram product of a 34 week gestation twin pregnancy born to a 37-year-old gravida I, para 0 woman. Prenatal screens: Blood type O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, group beta Streptococcus status unknown. The mother's medical history was notable for depression, treated with Zoloft, and gastroesophageal reflux disease, managed with Zantac. This pregnancy was notable for intrauterine insemination, achieved twins who were dichorionic/diamniotic. There was normal fetal survey. On [2103-3-11], the mother presented to the [Hospital6 1760] with premature rupture of membranes. She was placed on bed rest, treated with ampicillin and betamethasone. On the day of delivery, she was electively delivered by cesarean section. There was no fever. The only sepsis risk factor was prolonged rupture of membranes. This infant emerged with good tone and spontaneous cry. She was bulb suctioned, stimulated, received blow-by oxygen. The Apgar scores were seven at one minute, eight at five minutes. The infant was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAMINATION ON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 2.25 kilograms, length 45 cm, head circumference 31 cm, all 50th percentile for 34 weeks. General: Pink, alert, nondysmorphic preterm female. The head, eyes, ears, nose and throat: Anterior fontanelle soft and flat. No molding. Ears normally set. Neck supple without anomalies. Palate intact. Red reflexes bilaterally. Chest: Lungs with fair to good aeration, coarse with crackles. No significant grunting, flaring, or retracting. Cardiovascular: Regular rate and rhythm, no murmur, 2+ femoral pulses. Abdomen: Soft, positive bowel sounds, no hepatosplenomegaly, three vessel cord. GU: Normal preterm female, patent anus. Spine: No sacral anomalies. Hips stable. Extremities: Pink and well perfuse. Neurologic: Symmetric Moro, normal tone and strength. HOSPITAL COURSE: 1. RESPIRATORY: [Doctor First Name 36972] required treatment for transitional respiratory distress with nasopharyngeal CPAP. She was able to be weaned to room air by the next day of life. She remained in room air throughout the rest of her Neonatal Intensive Care Unit admission. She has not had any episodes of spontaneous apnea. 2. CARDIOVASCULAR: [Doctor First Name 36972] has maintained normal heart rates and blood pressures. No murmurs have been noted. 3. FLUIDS, ELECTROLYTES, AND NUTRITION: [Doctor First Name 36972] was initially n.p.o. and treated with intravenous fluids. Enteral feeds were started on day of life number one and gradually advanced. At the time of discharge, she is on 140 cc per kilogram per day of Preemie Enfamil 20 calories per ounce or breast milk. Most of her intake is by gavage. She had electrolytes drawn on day of life number one that were within normal limits. Weight at the time of discharge is 2.03 kilograms which reflects her low weight since birth. 4. INFECTIOUS DISEASE: Due to the prolonged rupture of membranes and her prematurity, [Doctor First Name 36972] was evaluated for sepsis. A white blood cell count was 14,400 with differential 53% polys, 0% bands. A blood culture was obtained prior to starting intravenous antibiotics. The blood culture was no growth at 48 hours and the antibiotics were discontinued. 5. HEMATOLOGIC: Hematocrit at birth was 51.7%. [Doctor First Name 36972] has not received any transfusions of blood products. 6. GASTROINTESTINAL: Serial serum bilirubins have been obtained. Peak serum bilirubin occurred on day of life number four with a total of 10.1/0.2 direct mg per deciliter. A repeat on [2103-3-18] was a total of 9.1 total, 0.2 direct, 8.9 indirect mg per deciliter. She has not been treated with phototherapy. 7. NEUROLOGY: [Doctor First Name 36972] has maintained a normal neurological examination during admission and there are no concerns at the time of discharge. 8. AUDIOLOGY: Hearing screening was performed with automated auditory brain stem responses. [Doctor First Name 36972] passed in both ears. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to [Hospital3 ] for continuing level II care. The primary pediatrician is Dr. [Last Name (STitle) 19419] of [Hospital 246] Pediatrics, [Location (un) 246], [State 350]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding: Breast milk or Premature Enfamil 20 calorie per ounce formula, 140 cc per kilogram per day. 2. No medications. 3. Card seat position screening not as yet performed. 4. State newborn screen was sent on [2103-3-16] with no notification of abnormal results to date. 5. No immunizations administered thus far. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria. First, born at less than 32 weeks. Second, born between 32 and 35 weeks with plans for DayCare during RSV season, with a smoker in the household, or with preschool siblings or thirdly, with chronic lung disease. 2. 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. DISCHARGE DIAGNOSIS: 1. Prematurity at 34 weeks gestation. 2. Twin number two of twin gestation. 3. Suspicion for sepsis, ruled out. [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (Titles) 37548] MEDQUIST36 D: [2103-3-18] 07:17 T: [2103-3-18] 08:46 JOB#: [Job Number 49533]	[ "V290" ]
Admission Date: [2113-3-18] Discharge Date: [2113-3-19] Date of Birth: [2034-2-16] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Morphine Attending:[First Name3 (LF) 5438] Chief Complaint: Chest pain Reason for transfer to MICU: ?sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 79 yo woman w/ h/o known CAD s/p RCA stent [2103] and [2105], severe MR, A fib, tachy/brady s/p PM, h/o GIB, and chronic urinary retention s/p recent cystectomy with ileal loop who presents as transfer from OSH ED after being evaluated there for c/o CP. While at rehab following recent surgery, patient has had constant pain in abdomen since her surgery, as well as nausea over the last several days. She then noted onset of intermittent SSCP yesterday, ~[5-21]. This continued most of the day, but improved w/ percocet administered by her rehab. Patient then reports waking up this AM with 10/10 chest pain. CP described as "heaviness," similar to prior MI. This was associated with radiation of pain to her stomach, and legs. Also associated with nausea, but denies associated SOB. CP continued, so she was taken to the OSH ED. . On arrival to OSH ED, BP 120/51, HR 125. EKG revealed sinus tach with lateral ST depressions. Given Zofran 4mg x1, ASA 162mg x1, and Morphine 4mg IV x1 initially. Started on heparin gtt. CP not controlled, so patient given Nitro drip, then Lopressor 5mg IV x1. Per ED records, she is also noted to have a WBC count of 22.1 w/ 9% bands. Afebrile per records at OSH ED w/ temp 96.8. +UA per ED records, however, patient has urostomy bag. Given ceftriaxone 1mg IV x1 at OSH. Given concern for ACS, patient transferred to [Hospital1 18] cardiology service for further management. On transfer, ED records indicate "disposition vital signs" with a blood pressure of 87/42. . On arrival to [Hospital Ward Name 121] 6, patient normotensive w/ BP 104/54, HR 96. Patient denies chest pain, but c/o [4-20] abdominal pain. Of note, she reports having abdominal pain every day since her surgery on [2113-2-16]. Reports subjective fevers, and nausea x several days. Denies dysuria or diarrhea, stating "I have a bag." Unsure if increased output from ostomy bags." . While on [Hospital Ward Name 121] 6 her blood pressure dropped into the 80's. Given the overall picture of hypothermia, elevated white count, low BP, and tachycardia, MICU was called to assess the patient. . On interview patient says she has not felt truly well since having her surgery on [2-16]. She says she's had unremitting abdominal since that time, which has gotten acutely worse over the past 2-3 days. The worsening pain has been accompanied by nausea and a desire to vomit but says she hasn't been able to bring anything up. She says she's lost about 30 pounds in teh past 2-3 years. Past Medical History: - CAD s/p IMI - s/p RCA stenting in [2103] and [2106-5-13] - Chronic atrial fibrillation - Diabetes - Severe MR - Cardiomyopathy w/ evere systolic and diastolic ventricular dysfunction on last cath (no EF on file here) - Hx of chronic urinary retention, w/ indwelling foley catheter many years with recurrent UTI's; s/p recent cystectomy with ileal loop at [Hospital3 ] Hosp by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 29848] - Carotid artery disease, s/p right CEA - [2-13] permanent pacemaker implantation due to tachy-brady syndrome - Hx of recurrent GIB's, most recently in [8-17], s/p cauterization of bleeding ulcer [5-17] - s/p ileocolectomy for a cecal polyp - Pancreatic cyst - s/p cholecystectomy - s/p appy - TAH (patient believes that she might have had some form of cancer) - Bladder suspension - Prior MVA (hit by a car) Social History: Patient is widowed and lives alone in [Hospital3 4634]. She has four children. One son, [Name (NI) ] lives in the area and is her HCPShe is followed by VNA in the [Name (NI) ] area. +h/o tobacco use (~60 years), quit 2 months ago. Denies EtOH. Family History: "whole family" has heart disease Physical Exam: VS: 81/22 88 24 98% Gen: elderly female, laying in bed, sleeping, NAD. HEENT: NCAT. Sclera anicteric. EOMI. very dry MM, OP clear Neck: Supple with flat JVP. CV: RR, normal S1, S2. +2/6 systolic murmur at apex. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: +urostomy bag RLQ, +colostomy bag LLQ - under appliance no visuble ostomy; NABS, Soft, diffusely tender to palpation, no HSM, no guarding. neg [Doctor Last Name ] sign. Ext: No c/c/e. +1 DP pulses Neuro: alert, oriented Pertinent Results: [2113-3-18] 11:34PM TYPE-ART PO2-92 PCO2-39 PH-7.38 TOTAL CO2-24 BASE XS--1 [2113-3-18] 11:34PM K+-4.7 [2113-3-18] 06:53PM GLUCOSE-294* UREA N-65* CREAT-3.2# SODIUM-128 POTASSIUM-GREATER TH CHLORIDE-88* TOTAL CO2-23 [2113-3-18] 06:53PM estGFR-Using this [2113-3-18] 06:53PM ALT(SGPT)-49* AST(SGOT)-177* CK(CPK)-164* ALK PHOS-227* AMYLASE-200* TOT BILI-1.1 [2113-3-18] 06:53PM CK-MB-3 cTropnT-0.20* [2113-3-18] 06:53PM CK-MB-3 cTropnT-0.20* [2113-3-18] 06:53PM CALCIUM-9.0 PHOSPHATE-9.3# MAGNESIUM-4.3 [2113-3-18] 06:53PM DIGOXIN-1.8 [2113-3-18] 06:53PM WBC-22.2* RBC-3.59* HGB-11.4* HCT-35.8* MCV-100# MCH-31.8# MCHC-31.9 RDW-17.8 [2113-3-18] 06:53PM NEUTS-89* BANDS-5 LYMPHS-0 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [2113-3-18] 06:53PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SPHEROCYT-1+ BITE-OCCASIONAL [2113-3-18] 06:53PM PLT COUNT-653# [2113-3-18] 06:53PM PT-14.5 PTT-48.0* INR(PT)-1.3* Brief Hospital Course: Patient arrived in the MICU. She was mentating beautifully despite BP in the 80-90's, with two peripheral IV's, 1 of which was running the heparin gtt for her ACS and the other running the remaining IVF which had been ordered for her on the floor. Initially she seemed to be responding to the IVF, with her pressures up into the high 80's-90's. While getting the ICU consent, she refused several things on the consent form including A-lines, LP, etc. There was a fairly involved discussion about central lines because there was a high liklihood that she might need one, and she did agree to one if necessary. Her pressures/MAPS did not improve and the RN's couldn't get any further PIV's. Her mentation remained excellent but there was some concern as her BP wasn't stabilizing, and we also needed more access for IV antibiotics. The RN's also discovered that her ostomy appeared very strange when they removed her ostomy appliance - it didn't look like a normal round, ostomy - it appeared sunken, more like a natural fistula than a surgically created ostomy. Her abdominal exam was somewhat tender to palpation but no rebound or guarding. The MICU attending was called and there were multiple failed attempts at placing a central line. The patient's BP dwindled after the fluid was completed and did not respond to another bolus, staying in the low eighties and then dropping further to the seventies. Patient was started on periheral dopamine to support her blood pressure. Her mental status began to deteriorate and We (Attending, primary RN, other RNs, and resident) stopped and discussed the overall situation. We had failed to get any central access and the patient was requiring a supratherapeutic dose of peripheral dopamine to maintain any kind of BP/MAP. Her stat labs had come back and were overall worse with notable ARF. We discussed whether there was any utility in calling a surgery consult. During the initial interview, the patient had made it clear that she did not want any aggressive interventions and was very specific about not wanting any further surgeries. Given her HD instability, active ACS, her ARF, and previously stated wishes, the attending spoke to the patient, who was sleepy but mentating to some degree, explaining that she was extremely ill, and that we were going to stop all invasive aggressive procedures and try to treat her with IV antibiotics. The patient agreed. Her son was [Name (NI) 653] and it was explained that his mother had multiple system failure and that all interventions except medications had been stopped. IV antibiotics were started. Her BP remained low but stable on peripheral dopa. She remained rousable for a while, but eventually become somnolent. She went into V tach, then V fib, and became asystolic. She was pronounced dead at 2:17 AM. The family declined an autopsy. Medications on Admission: Prilosec 20mg daily Sandostatin 100mcg SC TID Mag Oxide 500mg PO BID Digoxin 0.125mg PO daily Captopril 6.25mg PO TID Lasix 20mg PO daily Nystatin S&S Toprol XL 100mg PO daily Maalox prn Tylenol prn Percocet prn Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "0389", "5849", "42731", "4240", "4280", "2767", "99592", "41401", "V4582", "25000", "4019" ]
Admission Date: [2199-1-15] Discharge Date: [2199-1-25] Date of Birth: [2131-6-2] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: chest pain Major Surgical or Invasive Procedure: coronary artery bypass graft x3 (LIMA-LAD, SVG to OM, [First Name3 (LF) ]) History of Present Illness: 67M with history of CAD (non-Q wave MI [11-27]) s/p LCX stent, hypertension presents with history of chest pain. He has done well since [2192] but recently during a business trip to [State 8449] developed chest pressure described as substernal burning/pressure during hiking that relieved with rest and decreased altitude. He returned to [Location 86] and had similar symptoms while walking that were relieved with rest and SLNG. Noticed reduced exercise tolerance when working out. He presented to PCP and sestamibi stress test was performed. He developed symptoms and said that he almost past out, there were 1-[Street Address(2) 1766] depressions in the inferior and lateral leads, with nuclear images revealed anteroapical ischemia. He underwent outpatient cardiac cath on [2199-1-15] which revealed >95% proximal LAD lesion with "non critical" diseases in the left main. Of note, given plavix prior to transfer. He was transferred to [Hospital1 18] for further management, possible CABG vs. PCI. Past Medical History: 1. CARDIAC RISK FACTORS:: - Hypertension 2. CARDIAC HISTORY: -CABG: none -PCI: [11-27] LCX stent ([Hospital3 2005]) -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - cervical radiculopathy - BPH - carpal tunnel syndrome Social History: Married, lives with wife -Retired, president of technology company -Tobacco history: None -ETOH: [3-28] drinks wine daily, no withdraw -Illicit drugs: None Family History: Mother - 81 Pneumonia Father - 47 lung cancer Physical Exam: VS: 96.4 117/58 78 95%RA GEN: awake, alert caucasian male in NAD HEENT: oropharynx clear, anicteric NECK: JVP at clavicle, supple CV: S1, S2 regular rhythm, I/VI early systolic murmur LUNG: unlabored resp, CTA bilaterally, no wheezes ABD: soft, ntnd, no gaurding EXT: warm, distal pulses intact, left groin no hematoma, no bruit NEURO: oriented x3, CNII-XII intact, MAE antigravity Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 5259], [Known firstname ] [Hospital1 18] [Numeric Identifier 84281] (Complete) Done [2199-1-21] at 9:16:12 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] [Street Address(2) 15115] [Location (un) 15116], [Numeric Identifier 15117] Status: Inpatient DOB: [2131-6-2] Age (years): 67 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: CABG ICD-9 Codes: 786.05, 786.51, 424.1 Test Information Date/Time: [2199-1-21] at 09:16 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3318], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: aw1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mild (1+) AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: No PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is mildly depressed (LVEF= 40 - 45 %), with global distal and apical HK. Mild RV hypokinesis. There are simple atheroma in the descending thoracic aorta. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post-CPB: Patient is AV-Paced, on low dose phenylephrine. Preserved biventricular systolic fxn. 1+ AI, no MR, trace TR. Aorta intact. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD, Interpreting physician [Last Name (NamePattern4) ] [2199-1-21] 10:44 [2199-1-23] 05:47AM BLOOD WBC-8.9 RBC-3.01* Hgb-9.8* Hct-28.8* MCV-96 MCH-32.6* MCHC-34.0 RDW-13.8 Plt Ct-171 [2199-1-21] 11:26AM BLOOD PT-13.3 PTT-31.3 INR(PT)-1.1 [2199-1-23] 05:47AM BLOOD Glucose-132* UreaN-12 Creat-0.8 Na-135 K-4.3 Cl-100 HCO3-28 AnGap-11 Brief Hospital Course: 67 yo male with history of hypertension and CAD s/p Left circumflex stent in [2192] with exertional chest burning/pain. He had a positive stress test and was sent to [Hospital3 ] for cardiac catheterization, which revealed complex Left main and 99% Left anterior descending. Underwent surgical revascularization. He was taken to the operating room on [2199-1-21] and underwent coronary artery bypass graft x2 (LIMA-LAD, SVG to [Last Name (LF) ], [First Name3 (LF) ]). See operative note for details. Post operatively he was admitted to the ICU intubated and sedated. He awoke neurologically intact, weaned and extubated without difficulty. He was started and betablockers, diuretics and statin therapy. His chest tubes and temporary pacing wires were removed per protocol. He was evaluated and treated by physical therapy for strength and conditioning and cleared for discharge to home. He was discharged to home on post-operative day four. Medications on Admission: -aspirin 81mg daily -atorvastatin 10mg daily -metoprolol 50mg [Hospital1 ] -SLNG PRN -Naprosyn 500mg [Hospital1 ] . Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever. 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 Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:2 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:2 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Hypertension,CAD s/p Non-Q Wave Myocardial infarction s/p Left circumflex stent [11-27] ,BPH,Carpal tunnel syndrome Coronary artery bypass graft x3 Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your 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] Followup Instructions: Recommended Follow-up:Please call to schedule appointments Surgeon Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Primary Care Dr. [Last Name (STitle) ] [Name (STitle) 76850] in [1-26] weeks Cardiologist Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [1-26] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2199-1-25]	[ "41401", "V4582", "4019", "412" ]
Admission Date: [2187-3-19] Discharge Date: [2187-3-31] Date of Birth: [2117-6-1] Sex: M Service: ORTHOPAEDICS Allergies: Dilantin Kapseal Attending:[First Name3 (LF) 11415] Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: ORIF Right Anterior Column Fracture History of Present Illness: 69yom w/ETOH, chronic SDH and mult falls transferred from OSH after admission 4d prior for unwitnessed fall, sent to MICU for profound hypokalemia and ETOH withdrawal. c/o hip pain, found to have mult pelvic fx's. Transferred for ortho trauma higher level of care. Past Medical History: Medical Hx: EtOH Abuse c/b withdrawal seizures, Thrombocytopenia, Acne rosacea, Adenomatous polyps Surgical Hx: L hip replacement; Right inguinal hernia repair ([10-27], [Doctor Last Name 519]); appendectomy; Exploratory laparotomy, Lysis of adhesions, Small bowel resection; R cataract extraction ([4-2], Turon); Polypectomy Social History: Social Hx: has a girlfriend, has been at rehab facility after leg surgery. Patient has a daughter and sister who are involved with his care. History of ETOH abuse. Family History: NC Physical Exam: Admission Examination: PE: VSS, NAD, AOx3 BUE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Arms and forearms are soft No pain with passive motion R M U [Month/Year (2) 2189] EPL FPL EIP EDC FDP FDI fire 2+ radial pulses BLE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis + pain with lateral compression of pelvis Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN [First Name9 (NamePattern2) 2189] [Last Name (un) 938] FHL GS TA PP Fire 1+ PT and DP pulses Contralateral extremity examined with good range of motion, SILT, motors intact and no pain or edema Pertinent Results: [2187-3-19] 09:45PM GLUCOSE-96 UREA N-16 CREAT-0.8 SODIUM-136 POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-32 ANION GAP-11 [2187-3-19] 09:45PM estGFR-Using this [2187-3-19] 09:45PM CALCIUM-8.4 PHOSPHATE-3.2 MAGNESIUM-2.2 [2187-3-19] 09:45PM WBC-3.2* RBC-3.12* HGB-10.0* HCT-32.3* MCV-104# MCH-32.2 MCHC-31.1# RDW-14.8 [2187-3-19] 09:45PM PLT COUNT-84* [2187-3-19] 09:45PM PT-12.2 PTT-22.6* INR(PT)-1.1 Brief Hospital Course: The patient was admitted to the Orthopaedic Trauma Service for repair of his right pelvic fracture. The patient was taken to the OR and underwent a complicated open reduction and internal fixation. Patient had extensive blood loss requiring 2 units of PRBCs during the surgery, in addition to FFP. The patient, however, tolerated the procedure without complications and was transferred to the PACU in stable condition, still intubated. He was extubated later on post-operative day zero without difficulty. Please see operative report for details. Post operatively pain was controlled with a PCA with a transition to PO pain meds once tolerating POs. On Post-operative day 1, patient's mental status deteriorated and patient became increasingly hypotensive despite 2 more units of PRBCs and fluid boluses. Patient underwent a head CT which showed a stable chronic subdural hematoma. His neurological exam improved, but later on POD1, he again became hypotensive. Repeat Hct showed decline and an abdominal CTA showed patient's pelvic hematoma increased in size with arterial bleeding. Patient was transferred to the surgical ICU and sent to Interventional Radiology for embolization of his right iliac vessels. Patient tolerated this procedure well and was transferred back to the SICU. Patient was weaned off of his sedation and extubated. Repeat hematocrit showed patient to have stabilized. Patient was transferred out of the SICU on Post-operative day 5 with stable hematocrit. He continued to require oxygen thought to be secondary to all of the blood products he recieved. He continued on his home lasix dose and was slowly diuresed. The patient had trouble swallowing with concern for aspiration. He was evaluated by the speech and swallow service who thought that patient was unsafe to take nutrition by mouth at this time. An NGT was inserted and patient began receiving tube feeding while in the ICU. On POD6, patient was re-evaluated by speech and swallow, and again was determined to be of great aspiration risk. He underwent a video assisted swallow study on POD7, at which point it was determined that he was not safe to take anything by mouth. Please see speech and swallow evaluation for further information. A Dobhoff NGT was placed on POD7 that patient tolerated well. A chest x-ray was done that showed that tube needed advancement. Tube was advanced an additional 5 cm to be in correct position. He will continue to get tube feeding per nutrition recommendations until he can be reassessed. Patient made steady progress with PT. Weight bearing status: touch-down weight bearing right lower extremity. The patient received peri-operative antibiotics as well as Lovenox for DVT prophylaxis. The incision was clean, dry, and intact without evidence of erythema or drainage; and the extremity was NVI distally throughout. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. The patient will be continued on chemical DVT prophylaxis for 4 weeks post-operatively. All questions were answered prior to discharge and the patient expressed readiness for discharge. Medications on Admission: Keppra, Folic Acid, MVI, Thiamine, Metolazone, Lasix, Albuterol IH Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 3. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe Subcutaneous QPM (once a day (in the evening)). 9. ipratropium bromide 0.02 % Solution Sig: One (1) Nebulizer Inhalation Q6H (every 6 hours). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Nebulizer Inhalation Q6H (every 6 hours) as needed for wheezing. 11. oxycodone 5 mg Tablet Sig: [12-25] to 2 Tablet PO Q3H (every 3 hours) as needed for pain. Disp:80 Tablet(s) Refills:0 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Right anterior column fracture 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: ****SIGNS OF INFECTION****** should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers >101.5, chills, redness or drainage at the incision site; chest pain, shortness of breath or any other concerns. -Wound Care: You can get the wound wet/take a shower starting from 3 days post-op. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. No dressing is needed if wound continued to be non-draining. **WEIGHT-BEARING*** **MEDICATIONS******* - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink 8-8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. -Medication refills cannot be written after 12 noon on Fridays. *ANTICOAGULATION** - Take Lovenox for DVT prophylaxis for 4 weeks post-operatively Followup Instructions: Please have your staples removed at your rehabilitation facility at post-operative day 14. Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 2 weeks for evaluation. Call [Telephone/Fax (1) 1228] to schedule appointment upon discharge. Please follow up with your PCP regarding this admission and any new medications/refills. You will need a repeat speech and swallow video swallow study performed in approximately one week to reassess your ability to swallow. At that time the determination will need to be made whether or not you will be able to have your diet advanced. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417**]	[ "2851", "5990", "2760", "2875" ]
Admission Date: [2101-1-19] Discharge Date: [2101-1-26] Date of Birth: [2046-5-21] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Progressive Dypnea on Exertion Major Surgical or Invasive Procedure: AVR(23mm St. [Male First Name (un) 923]) [2101-1-20] Cardiac Catheterization [2101-1-19] History of Present Illness: Ms. [Known lastname ] is a splendid 54 year old female with known aortic stenosis. She reports that over the past few weeks, she has experienced progressive, worsening dyspnea on exertion. She has also noticed some dizziness related to positional changes. An echocardiogram on [9-23] showed worsening aortic stenosis with an aortic valve area of 0.7cm2, a bicuspid aortic valve, a peak gradient of 91mmHg, a mean gradiant of 60mmHg and an ejection fraction of 55%. Due to the progression of her disease she was referred to Dr. [Last Name (STitle) ] for surgical management. She underwent a cardiac catheterization today in preparation of her aortic valve surgery which showed normal coronary arteries and severe aortic stenosis. Past Medical History: Bicuspid aortic valve Venous stasis changes of lower legs Systemic tremor Social History: Married and lives in [State 2748]. Works full-time. Never smoked and drinks alcohol rarely. Family History: Father with CABG at age 56 Physical Exam: Ht: 5'9" Wt: 200 VS: 65 SR 113/71 97% RA GEN: Laying flat in bed in no acute distress LUNGS: CLear CARDIAC: Regular rate and rhythm, IV/VI systolic murmur. GI: Soft, nontender, nondistended. NEURO: Alert. No focal deficits EXT: Warm, well perfused. Bilateral varicosities. PULSES: 2+ of upper and lower extremities bilaterally Pertinent Results: [2101-1-19] 10:16AM HGB-12.8 calcHCT-38 O2 SAT-96 [2101-1-19] 02:58PM URINE RBC-0-2 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 [2101-1-19] 02:58PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2101-1-19] 05:11PM ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-229 ALK PHOS-51 AMYLASE-62 TOT BILI-0.5 [2101-1-24] 06:40AM BLOOD WBC-6.4 RBC-2.66* Hgb-8.1* Hct-24.2* MCV-91 MCH-30.6 MCHC-33.7 RDW-13.9 Plt Ct-165# [2101-1-26] 06:50AM BLOOD PT-16.9* PTT-37.8* INR(PT)-1.8 [2101-1-24] 06:40AM BLOOD Glucose-110* UreaN-18 Creat-0.7 Na-137 K-4.5 Cl-100 HCO3-30* AnGap-12 [2101-1-19] CXR Tiny left pleural effusion. No congestive heart failure or pneumonia. [2101-1-24] CXR No change in the mediastinal contour or appearance of the sternotomy wires to suggest a mediastinal infectious process, but CT would be more sensitive. Persistent moderate sized right and small sized left pleural effusions. [2101-1-19] Cardiac Catheterization 1. Coronary arteries are normal. 2. Normal ventricular function [2101-1-19] EKG Sinus rhythm, rate 66. Borderline left atrial abnormality. Othewrise, normal tracing. No previous tracing available for comparison Brief Hospital Course: Mrs. [Known lastname ] was admitted to the [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1675] [Last Name (NamePattern1) ] Medical Center on [2101-1-19] for further management of her aortic stenosis. She underwent a cardiac catheterization which was significant for severe aortic stenosis, a dilated aortic root, normal coronary arteries and a normal left ventricular function. She was worked-up by the cardiac surgical service in the usual preoperative manner. On [2101-1-20], Mrs. [Known lastname ] was taken to the operating room where she underwent an aortic valve replacement utilizing a 23 mm St. Jude valve and an ascending aorta replacement utilizing a 26 mm gelweave graft. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. She was coagulopathic postoperatively requiring blood products. Her drain output slowly tapered off without further intervention. On postoperative day one, Mrs. [Known lastname ] awoke neurologically intact and was extubated. Coumadin was started for anticoagulation. She was then transferred to the cardiac surgical step down unit for further recovery. She was gently diuresed towards her preoperative weight. She was transfused with packed red blood cells for postoperative anemia. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Her drains and pacing wires were removed per protocol. Mrs. [Known lastname ] continued to make steady progress and was discharged home on postoperative day six. She will follow-up with Dr. [Last Name (STitle) ], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Fosamax 35mg weekly Aspirin 81mg daily Multivitamin Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 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:2 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 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:2 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day: Take as directed by Dr. [Last Name (STitle) 33667] for INR goal of 2.5-3. Disp:90 Tablet(s) Refills:2 10. FOSAMAX 35 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Home With Service Facility: VNA of Eastern [State 2748] Discharge Diagnosis: Aortic stenosis. Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 33668] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) 33667] for 2-3 weeks. Make an appointment with Dr. [Last Name (STitle) ] and Dr. [First Name (STitle) 2031] for 4 weeks. Completed by:[2101-1-26]	[ "42731" ]
Admission Date: [2195-9-8] Discharge Date: [2195-9-9] Service: Medical Intensive Care Unit CHIEF COMPLAINT: Hypertension HISTORY OF PRESENT ILLNESS: An 88-year-old white male with history of congestive heart failure, multiple sclerosis and neurogenic bladder with an indwelling Foley catheter transferred to the Medical Intensive Care Unit with fever and hypertension. The patient was initially transferred from the nursing home to the [Hospital1 ] Emergency Department because the patient's chronic indwelling Foley catheter had come out. After unsuccessful attempts to replace the Foley by the Emergency Department staff, as well as the urology service. A cystoscopy was performed by urology. This revealed multiple urethral strictures. Following this, a suprapubic tube was placed by urology. The patient was initially planned to go back to the nursing home, but then decompensated spiking a fever to 101.8?????? with a heart rate of 110 along with a blood pressure of 70/palpation. The patient was initially given intravenous fluid boluses and then begun on a dopamine drip. He was given doses of ceftriaxone and Levaquin. Upon arrival to the Medical Intensive Care Unit, the patient reported mild abdominal pain, but denied shortness of breath. There was a report of greenish sputum produced in the Emergency Department. However, the patient denied chest pain or trouble breathing. PAST MEDICAL HISTORY: 1. Multiple sclerosis 2. Neurogenic bladder with chronic indwelling Foley 3. Congestive heart failure 4. Seizures 5. Multiple admissions for urosepsis 6. Multiple admissions for community acquired pneumonia 7. History of kidney stones ALLERGIES: TEGRETOL TRANSFER MEDICATIONS: 1. Lasix 40 mg po q day only on Monday, Wednesday, Friday 2. Vasotec 2.5 mg po qd 3. Dilantin 300 mg po qd 4. Neurontin 200 mg po tid 5. Reglan 5 mg po tid 6. Sinemet 25/250 1 tablet po tid 7. Macrodantin 50 mg po q hs 8. KCL 10 milliequivalents po q day 9. Colace 100 mg po bid 10. Milk of Magnesia 30 cc po prn 11. Ceclor 200 mg po qd 12. Roxanol 20 mg per ml q2h prn 13. Probanthine 15 mg po bid SOCIAL HISTORY: The patient lives in the nursing home and has been institution bound for over 40 years. He is divorced. He does not use tobacco or alcohol. ADMITTING PHYSICAL EXAMINATION: VITAL SIGNS: Temperature current 100.2??????, heart rate 82, blood pressure 113/51, respiratory rate 15, oxygen saturation 100% on 2 liters. GENERAL: Elderly, frail white male in no acute distress. HEAD, EARS, EYES, NOSE AND THROAT: Mucous membranes mildly dry. HEART: Regular rate and rhythm with occasional beats, S1 and S2 audible with S4 gallop. LUNGS: Coarse breath sounds bilaterally. ABDOMEN: Soft with mild periumbilical tenderness to palpation (appropriate given suprapubic tube), nondistended, no masses. Active bowel sounds. EXTREMITIES: Calf soft, nontender. NEUROLOGIC: Alert and oriented to person, but not place or time. ADMITTING LABORATORY DATA: White blood cell count 9.0, hematocrit 41.5. Sodium 141, potassium 5.1, chloride 102, bicarbonate 27, BUN 29, creatinine 0.9, glucose 106, INR 1.2, PTT 28. Urinalysis notable for leukocytes, large blood, large protein 30, red blood cells 21 to 50, white blood cells greater than 50, epithelial cells 0, bacteria many. RADIOLOGIC: Electrocardiogram - sinus tachycardia at 124 with left axis deviation, left anterior fascicular block. Qs in 3, F, V5 and V6 without acute change compared to [Month (only) ] of '[91]. Chest x-ray with a right lower lobe opacification, increased bilateral interstitial markings with mild hilar engorgement. Chest CT with bibasilar opacifications, right greater than left, atelectasis versus aspiration versus pneumonia, distal aortic aneurysm. Abdomen and pelvis CT distal nonobstructive IVC thrombus without evidence of free air or fluid. HOSPITAL COURSE: 1. Cardiovascular/Hemodynamic: The patient was admitted to the Medical Intensive Care Unit with a presumed diagnosis of sepsis from a likely urinary tract infection and potentially a pneumonia. Upon arrival to the Intensive Care Unit in the Emergency Department, the patient's blood pressure remained quite labile often cycling from a systolic of 80 to 130 over the course of several minutes. During these cycling episodes, even with low blood pressure, the patient remained tachycardic with no change in his mental status or oxygenation. It was concluded that his highly labile blood pressures could very likely be secondary to underlying autonomic dysfunction given his multiple sclerosis with urinary and gastrointestinal involvement. As a result, the patient's pressors were weaned off very quickly and required minimal fluid boluses for blood pressure control. During this admission, the patient appeared to tolerate a systolic blood pressure in the 80s without tachycardia or symptoms. During this admission, his Lasix and his Vasotec was held. 2. Pulmonary: The patient remained on minimal supplemental oxygenation without desaturation. 3. Infectious disease: The patient defervesced over the course of his admission. His urinalysis revealed a urinary tract infection and is felt to be the most likely source of his bacteremia, given his genitourinary manipulation and pneumonia was also diagnosed on chest x-ray. At the time of this dictation, all cultures remained negative. The patient was changed to Levaquin po for coverage of his community acquired pneumonia and urinary tract infection. Because of potential for bacterial seeding of his genitourinary tract, he was recommended to complete a 14 day course. 4. Hematologic: A distal IVC thrombus was noted in the patient as an incidental finding on his abdominal CT. This was felt by the radiology interpretation to be chronic rather than acute. Given the patient's multiple comorbidities an desire for minimal amounts of treatments and potentially invasive procedures, Coumadin or any kind of anticoagulation will be deferred at this time. 5. Neurological: The patient was continued on his Neurontin, Sinemet and Dilantin. 6. Fluids, electrolytes and nutrition: The patient tolerated a soft pureed diet with thickened liquids and was to remain on aspiration precautions. 7. Genitourinary: The patient's suprapubic tubes remained in place. As per the urology service, this will remain in place for six weeks until he will follow up in urology clinic with Dr. [Last Name (STitle) 8872], ([Telephone/Fax (1) 24252]. 8. Disposition/Code status: After extensive discussions were held with the patient's doctor, Mrs. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], and her husband, along with the patient's primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 24253], the patient's code status was confirmed as DNR/DNI. Because of his age, multiple comorbidities, very frequent hospital admissions and the desire to minimize any and all invasive and/or stressful procedure, the decision was made that should the patient be hospitalized again he specifically request that he not be transferred to the Intensive Care Unit and not have any central lines placed. DISCHARGE DIAGNOSES: 1. Sepsis 2. Urinary tract infection 3. Community acquired pneumonia 4. Urinary obstruction 5. Deep venous thrombosis DISCHARGE MEDICATIONS: 1. Dilantin 300 mg po q day 2. Neurontin 200 mg po tid 3. Reglan 5 mg po tid 4. Sinemet 25 250 1 tablet po tid 5. Potassium chloride 10 milliequivalents po q day 6. Colace 100 mg po bid 7. Milk of Magnesia 30 cc po qid and prn 8. Multivitamin 1 tablet po q day 9. Probanthine 15 mg po bid 10. Levaquin 250 mg po q day, discontinue following [2204-9-21]. Ceclor 200 mg po q day, may start on [9-22] or as per Dr. [Last Name (STitle) 24253]. 12. Macrodantin 50 mg po q hs, may start on [9-22] or as per Dr. [Last Name (STitle) 24253] 13. Roxanol 20 mg per ml 1 to 2 cc sublingual pr q2h prn 14. Lasix 40 mg po q day Monday, Wednesday, Friday to be resumed when patient taking adequate po. Please note that the patient's Vasotec was discontinued. FOLLOW UP: The patient will follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 24253], and with urology ([Telephone/Fax (1) 24252], the latter of which in six weeks time. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437], M.D. [MD Number(1) 2438] Dictated By:[Last Name (NamePattern1) 9280] MEDQUIST36 D: [2195-9-9] 14:04 T: [2195-9-9] 14:17 JOB#: [Job Number 24254]	[ "0389", "5990", "486", "4280" ]
Admission Date: [2117-3-18] Discharge Date: [2117-3-23] Date of Birth: [2056-1-27] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1561] Chief Complaint: RLL nodule Major Surgical or Invasive Procedure: VATS right lower lobe superior segmentectomy History of Present Illness: 60- year-old woman, with a significant history of smoking and weight loss, who has been found to have a 1.7 cm ground-glass spiculated nodule within the right lower lobe. She underwent metastatic workup which demonstrated mild avidity within the lesion but no FDG uptake elsewhere. An MRI of the brain showed no evidence of metastasis. A short-term follow-up CT scan showed no change within the lesion. We discussed her case at the thoracic oncology multi-disciplinary conference, and it was the consensus of group that we should move forward with surgical resection. Therefore, due to the patient's poor pulmonary function, we elected to do a segmentectomy versus a right lower lobectomy should it end up being a lung cancer. Past Medical History: PMH: CHF (EF 40%), V-tach, s/p AICD, PVD Pertinent Results: [2117-3-18] 08:07PM CK(CPK)-438* [2117-3-18] 08:07PM CK-MB-6 [2117-3-18] 01:12PM GLUCOSE-131* UREA N-21* CREAT-0.5 SODIUM-141 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-26 ANION GAP-11 [2117-3-18] 01:12PM estGFR-Using this [2117-3-18] 01:12PM CK(CPK)-416* [2117-3-18] 01:12PM CK-MB-8 cTropnT-<0.01 [2117-3-18] 01:12PM CALCIUM-8.9 [2117-3-18] 01:12PM WBC-14.3* RBC-3.45* HGB-11.1* HCT-32.9* MCV-95 MCH-32.2* MCHC-33.8 RDW-13.6 [2117-3-18] 01:12PM PLT COUNT-275 Brief Hospital Course: The patient was admitte for her procedure which was 1. Thoracoscopic right superior segmentectomy. 2. Wedge excision of right lower lobe lesion. 3. Mediastinal nodal dissection. 4. Flexible bronchoscopy. The patients post operative CXR showed [3-19] CXR w/small R. apical PTX, small effusions [3-20] CXR w/slightly more SC air [3-22] CXR's w/o PTX The patient's R chest tube pulled on [3-21] and left [Doctor Last Name ] left placed to bulb then removed [3-22] The patient was discharged in stable condition on POD5 Medications on Admission: ASA, plavix, toprol XL, lisinopril, norvasc, lovastatin Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:80 Tablet(s) Refills:0 2. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Right lower lung nodule CHF (EF 40%), V-tach, s/p AICD, PVD Discharge Condition: stable Discharge Instructions: Call Dr.[Name (NI) 1816] office [Telephone/Fax (1) 170] if you develop chest pain, shortness of breath, fever, chills, redness or drainage from your chest incision. You may shower tomorrow. After showering, remove the dressing and cover with clean bandaid until healed. Please call your cardiologist to have an appointment to go over your medications Followup Instructions: Please call Dr[Name (NI) 1816] office for a follow up appointment [Telephone/Fax (1) 170] Completed by:[2117-5-27]	[ "4280", "496" ]
Admission Date: [2183-6-10] Discharge Date: [2183-6-16] Date of Birth: [2108-11-14] Sex: F Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old woman who was doing water aerobics on the day of admission, felt weak and dizzy after getting out of the pool, went home and then developed left sided headache. Signs and symptoms were gradual in onset and in the lateral afternoon she began having difficulty talking. Speech was confused. She was brought to an outside hospital. A CT scan showed a left parietal bleed and the patient was transferred to [Hospital6 1760] for further management. PHYSICAL EXAM: VITAL SIGNS: The patient was afebrile. Blood pressure was 155/83, heart rate 81, respiratory rate 18. CARDIAC: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended. NEUROLOGIC: Awake and alert with some aphasia. Speech was fluent with multiple paraphasic errors. Comprehension relatively intact with simple but no complex commands. Pupils equal, round and reactive to light. EOMs full. Face was symmetric. Mild right pronator drift. Formal strength testing difficult secondary to her lack of comprehension. Reflexes were symmetric and toes were downgoing bilaterally. IMAGING: CT at the outside hospital showed a large right parietal intraparenchymal bleed. HOSPITAL COURSE: The patient was admitted to the neurosurgery service and scheduled for an MRI with contrast to rule out an underlying lesion. She was monitored in the Intensive Care Unit overnight and transferred to the regular floor on [2183-6-11]. On [2183-6-12], the patient was still densely aphasic with right upper extremity weakness, moving the lower extremities bilaterally, left greater than right, awake, but somewhat more lethargic than on the previous day. The patient had a stat head CT which showed increased hemorrhage and edema. The patient was taken to the Operating Room for left parietal evacuation of intraparenchymal hemorrhage without intraoperative complication. Postoperative, the patient was awake and alert, not following commands, moving all extremities, left greater than right. The patient was seen by the speech and swallow service, but was found to be unable to take po's secondary to lethargy. On [2183-6-14], the patient was easily arousable, attentive to examiner, spoke a few words, poor fluency of speech, but face was symmetric and again moving her extremities, left greater than right. She was seen by physical therapy and occupational therapy and found to require rehabilitation prior to discharge home. On [2183-6-15], she was awake and alert, following commands. Her dressing was clean, dry and intact. She was much improved. On the 20th, her mental status was even more improved. She was speaking more fluently, although having some word finding difficulties. She was awake and alert, oriented to her name and following some simple commands with continued improved strength, still somewhat weaker on the right than on the left. She was stable and ready for transfer to rehabilitation on [2183-6-16]. DISCHARGE MEDICATIONS: 1. Dilantin 100 mg po q8h 2. Zantac 150 mg po q 12 hours 3. Levofloxacin 500 mg po q 24 hours x3 days 4. Percocet 1 to 2 tablets po q4h prn pain The patient was discharged to rehabilitation in stable condition with follow up with Dr. [Last Name (STitle) 6910] in three to four weeks' time. The patient should have her staples removed on postoperative day #10. Her surgery was on [2183-6-12]. The patient was in stable condition at the time of discharge. [Name6 (MD) 6911] [Name8 (MD) ], MD [MD Number(1) 6913] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2183-6-16] 11:57 T: [2183-6-16] 12:02 JOB#: [Job Number 41784]	[ "4019" ]
Admission Date: [2179-8-27] Discharge Date: [2179-8-31] Date of Birth: [2098-8-18] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1973] Chief Complaint: Acute Renal Failure, Urinary Obstruction, Coagulopathy, Atrial Fibrillation with Rapid Ventricular Response Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 10528] is an 81 year old Male with atrial fibrillation on coumadin, benign hypertension, who presents with 4 days of constipation and abdominal pain. He describes the abdominal pain as diffuse, mild, [2180-4-13]. Also has noted that his urine has been "backed up" for the past few days. Denies fever, chills, chest pain, SOB. He does have a cough productive of dark, thick sputum but this is chronic for years and unchanged. Denies dysuria. He did have some difficulty with constipation a couple weeks ago but that resolved more quickly. Usually, his stools are regular. In the ED, initial vs were: T 99.2, P 152, BP 138/85, R 20, O2 sat 96% RA. Exam was notable for a JVP of 8cm and an enlarged, firm prostate on rectal exam, guaiac negative. For his afib with RVR, he received 5 IV metoprolol with no effect and then was put on a diltiazem drip with HR down to 120s. Labs revealed a WBC of 26 with left shift and new acute renal failure with creatinine 5.5 (from 1.1 on [8-3]). Also had a coagulopathy with INR of 11.1. Pt denies recent antibiotic use or decreased PO intake. CT abd/pelvis without contrast revealed a massively dilated bladder (22cm) and enlarged prostate (5.2cm) and bilateral hydronephrosis/hydroureter. Pt has a known enlarged prostate with recent PSA increase from 2.1 in [Month (only) 956] to 11 in [Month (only) ] of this year and had an upcoming appointment with Dr. [Last Name (STitle) ] [Last Name (STitle) ] urology on [2179-9-8]. Urology was called and recommended placement of a coude catheter. After catheter placement, over 3L of fluid was drained with notable improvement in his symptoms. Urine was initially clear and then became bright red. The CT scan had also revealed a small to moderate pericardial effusion. Cardiology was called and bedside echo revealed an "inconsequential" pericardial effusion without evidence of hemodynamic compromise. He was given 1g IV ceftriaxone. Admitted to the [Hospital Unit Name 153] for monitoring and further management. He was discharged to the floor, as he had markedly improved. He had continued improvement of his renal failure. His coumadin was held with resolution of his coagulopathy. A bone scan and renal ultrasound were performed. Past Medical History: Benign Hypertension Paroxsysmal Atrial fibrillation on coumadin s/p Bilateral cataract removal Surgical resection for unknown Head & Neck cancer, requiring removal of Right jugular vein, right and left submandibular nodes and all of his mandibular teeth and subsequent radiation Social History: Lives with his wife. Retired, formerly worked for Eastern Airline in the cargo, mail, and freight department. Smoked 3ppd x 30+ years, quit in [2151]. Quit EtOH in [2151]. No illicit drug use. Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: T: 99.3, BP: 148/83, P: 134, R: 22, O2: 96% 4L General: Alert, oriented, pleasant elderly male in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, edentulous Neck: supple, JVP elevated to ear lobe, no LAD, markedly contracted skin with radiation telangectasias Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild RUQ tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 1+ distal pulses, trace ankle edema Pertinent Results: [2179-8-31] 06:05AM BLOOD WBC-10.9 RBC-3.49* Hgb-10.1* Hct-31.4* MCV-90 MCH-28.9 MCHC-32.1 RDW-14.0 Plt Ct-402 [2179-8-30] 05:10AM BLOOD WBC-11.9* RBC-3.62* Hgb-10.7* Hct-33.4* MCV-92 MCH-29.4 MCHC-31.9 RDW-14.4 Plt Ct-375 [2179-8-29] 04:09AM BLOOD WBC-13.0* RBC-3.49* Hgb-10.5* Hct-31.9* MCV-92 MCH-30.0 MCHC-32.8 RDW-14.4 Plt Ct-358 [2179-8-28] 12:02PM BLOOD WBC-16.8* RBC-3.53* Hgb-10.3* Hct-31.7* MCV-90 MCH-29.1 MCHC-32.5 RDW-14.1 Plt Ct-360 [2179-8-27] 11:22PM BLOOD WBC-21.1* RBC-3.51* Hgb-10.2* Hct-31.7* MCV-90 MCH-29.0 MCHC-32.1 RDW-14.5 Plt Ct-354 [2179-8-27] 12:10PM BLOOD WBC-26.6# RBC-3.74 Hgb-11.0* Hct-34.0* MCV-91 MCH-29.3 MCHC-32.2 RDW-13.8 Plt Ct-435 [2179-8-27] 11:22PM BLOOD Neuts-87.5* Lymphs-5.0* Monos-6.7 Eos-0.7 Baso-0.1 [2179-8-30] 05:10AM BLOOD PT-17.7* PTT-29.7 INR(PT)-1.6* [2179-8-28] 06:48PM BLOOD PT-21.3* PTT-35.0 INR(PT)-2.0* [2179-8-27] 11:22PM BLOOD PT-76.0* PTT-58.3* INR(PT)-9.0* [2179-8-27] 12:10PM BLOOD PT-90.4* PTT-52.7* INR(PT)-11.1* [2179-8-31] 06:05AM BLOOD Glucose-95 UreaN-24* Creat-1.2 Na-141 K-3.8 Cl-103 HCO3-30 AnGap-12 [2179-8-30] 05:10AM BLOOD Glucose-97 UreaN-33* Creat-1.5* Na-140 K-3.9 Cl-103 HCO3-28 AnGap-13 [2179-8-29] 04:09AM BLOOD Glucose-89 UreaN-47* Creat-2.1* Na-143 K-3.9 Cl-108 HCO3-26 AnGap-13 [2179-8-28] 06:48PM BLOOD Glucose-100 UreaN-49* Creat-2.5* Na-141 K-4.2 Cl-104 HCO3-24 AnGap-17 [2179-8-28] 12:02PM BLOOD Glucose-147* UreaN-53* Creat-2.9* Na-143 K-4.2 Cl-105 HCO3-26 AnGap-16 [2179-8-27] 11:22PM BLOOD Glucose-111* UreaN-60* Creat-3.9# Na-142 K-4.0 Cl-105 HCO3-23 AnGap-18 [2179-8-27] 12:10PM BLOOD Glucose-122 UreaN-68* Creat-5.5# Na-139 K-4.9 Cl-102 HCO3-22 AnGap-20 [2179-8-27] 11:22PM BLOOD CK(CPK)-25 [2179-8-27] 06:00PM BLOOD CK(CPK)-30* [2179-8-27] 12:10PM BLOOD ALT-13 AST-22 CK(CPK)-48 AlkPhos-69 TotBili-0.4 [2179-8-27] 12:10PM BLOOD Lipase-13 [2179-8-27] 06:00PM BLOOD cTropnT-<0.01 [2179-8-27] 12:10PM BLOOD cTropnT-<0.01 [2179-8-31] 06:05AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.5* [2179-8-29] 04:09AM BLOOD Calcium-7.7* Phos-3.3 Mg-1.8 [2179-8-27] 11:22PM BLOOD Calcium-8.2* Phos-5.1# Mg-2.1 [2179-8-27] 11:22PM BLOOD TSH-4.9 [2179-8-27] 11:22PM BLOOD Free T4-0.83* [2179-8-28] 12:02PM BLOOD PSA-18.0* [2179-8-27] 12:52PM BLOOD Lactate-0.8 [2179-8-29] 01:25PM URINE Color-Straw Appear-Hazy Sp [Last Name (un) ]-1.008 [2179-8-27] 02:45PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 [2179-8-29] 01:25PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2179-8-27] 02:45PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2179-8-29] 01:25PM URINE RBC-112* WBC-16* Bacteri-FEW Yeast-NONE Epi-<1 [2179-8-27] 02:45PM URINE RBC-21-50* WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [2179-8-27] 12:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): [2179-8-27] 2:45 pm URINE Site: CATHETER FINAL REPORT [2179-8-28] URINE CULTURE (Final [2179-8-28]): NO GROWTH. [2179-8-27] 7:45 pm MRSA SCREEN Site: NARIS (NARE) FINAL REPORT [2179-8-30] MRSA SCREEN (Final [2179-8-30]): No MRSA isolated. ECG Study Date of [2179-8-27] 11:52:30 AM Atrial fibrillation with a mean ventricular rate of 152. Compared to the previous tracing of [2178-7-17] cardiac rhythm is now atrial fibrillation with a rapid ventricular rate. Portable TTE (Complete) Done [2179-8-27] at 4:19:18 PM Conclusions Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Compared with the findings of the prior study (images reviewed) of [2177-5-23], a small circumferential pericardial effusion is now present; no evidence of cardiac tamponade. CHEST (PORTABLE AP) Study Date of [2179-8-27] 12:32 PM IMPRESSION: Appearances could represent enlargement of the large paraesophageal hernia which contains bowel loops or possibly a pericardial effusion. Mild upper lobe venous diversion and lower lobe airspace opacification with mild pulmonary edema. The enlargement of the paraesophageal hernia which contains bowel loops in the setting of leucocytosis could indicate strangulation of the hernia. CT PELVIS W/O CONTRAST Study Date of [2179-8-27] 1:15 PM IMPRESSION: 1. Bladder outlet obstruction with bilateral hydronephrosis and hydroureter 2. Prostatic enlargement. 3. Bilateral right greater than left small pleural effusions. 4. Small to moderate-sized pericardial effusion that measures simple fluid. 5. Large hiatal hernia with an organoaxial in orientation rotation of the herniated stomach and now herniated loops of large bowel. 6. Cholelithiasis without evidence of cholecystitis. BONE SCAN Study Date of [2179-8-30] IMPRESSION:Degenerative changes in the L1 vertebra with no evidence of metastatic disease. RENAL U.S. Study Date of [2179-8-30] 5:57 PM IMPRESSION: Marked improvement in previously visualized hydronephrosis, hydroureter, with only minimal residual prominence of the right collecting system. The bladder is decompressed by a Foley, with marked bladder wall thickening, consistent with history of obstructive uropathy. A superimposed malignancy or infection cannot be excluded on this study. Brief Hospital Course: 1. Atrial fibrillation with Rapid Ventricular Rate: The patient has a history of paroxysmal atrial fibrillation and presented with RVR. The patient remained hemodynamically stable. The patient was started on a diltiazem drip in the ED, which was changed to an amiodarone drip with a loading and maintenance dose which controlled his rate in the [Hospital Unit Name 153]. He was then switched to IV Lopressor and subsequently PO Lopressor which controlled his rate to around 110s. Although tachycardic, the patient remained asymptomatic. He has no history of structural heart disease and an unremarkable echocardiogram. A suppressed TSH ruled out hyperthyroidism as an organic cause of his atrial fibrillation. His oral lopressor was uptitrated and he had a normal rate at time of discharge. An echocardiogram was performed as above. Coumadin was held and will need to be restarted in the outpatient setting. 2. Severe Acute Renal Failure due to Total Urinary Obstruction: The patient presented with a creatinine of 5.5 in the setting of an enlarged prostate. He was found to have a bladder outlet obstruction leading to bilateral hydronephrosis and hydroureter. Urology inserted a coude catheter and his creatinine returned towards baseline and was normal at time of discharge. Dosing was renally adjusted. 3. BPH With Obstruction, Probable Malignant Neoplasm Prostate: The patient's PSA has been increasing from 2 to 11 over a four month period earlier this year and was 18 during this admission. Urology saw the patient and recommened continuing Ciprofloxacin to treat prostatitis. In addition, urology requested a bone scan and renal ultrasound. Both are listed above. The patient is being discharged on tamsulosin and with the indwelling catheter. He had leg bag teaching. He will follow up with Dr. [Last Name (STitle) ] [Last Name (STitle) 767] urology as previously scheduled. The bone scan did not identify other disease. He is noted with a thickened bladder wall, and this will be addressed in urology. 4. Coagulopathy: The patient had an INR=11.1 on admission, likely due to poor PO intake. His INR was reversed with Vitamin K and his INR is currently sub-therapeutic. He was discharged off coumadin as he will have a possible biopsy upcoming along with his continued workup. 5. Constipation: The patient was very constipated and upon arrival on the floor, had still not had a bowel movement. He was given 17g of polyethelene glycol with resoltution of his constipation. Medications on Admission: (Per chart, pt only mentioned 2 meds) Metoprolol 12.5mg PO BID Lisinopril 10mg PO daily HCTZ 25mg PO daily Protonix 40mg PO daily Coumadin 6mg PO daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:135 Tablet(s) Refills:2 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Atrial Fibrillation with Rapid Ventricular Response Acute Renal Failure Complete Urinary Obstruction Probable Malignant Neoplasm Prostate Septicemia Coagulopathy Leukocytosis Conspitation Discharge Condition: Good Discharge Instructions: You are being discharged with a urinary catheter in place with a leg bag. You will have a visiting nurse come to the house a few times to make sure it is functioning appropraitely. It is very important to note leaking, the bag no longer filling, pain or fever as these may be signs of a blocked catheter and either return to the hospital or contact the visiting nurse. Return to the hospital with fever/chills, chest pain, shortness of breath, nausea or vomitting. The scans did not find any evidence of prostate cancer that had spread. This does not mean there is none inside your prostate, but Dr. [Last Name (STitle) ] [First Name (STitle) ] help to determine this. Your metoprolol dosing has changed. Your coumadin (warfarin) has been held, check with your primary care doctor [First Name (Titles) ] [Last Name (Titles) 9533] this. Followup Instructions: Provider: [First Name8 (NamePattern2) 161] [Name11 (NameIs) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2179-9-8] 4:00	[ "42731", "0389", "5849", "V5861" ]
Admission Date: [2112-2-24] Discharge Date: [2112-3-9] Date of Birth: [2035-12-1] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Niacin / Lisinopril / Lorazepam Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Aortic valve replacement with a 25-mm [Doctor Last Name ] Magna bioprosthesis, Coronary artery bypass grafting x1, with left internal mammary artery to left anterior descending coronary artery, subtotal pericardiectomy from phrenic to phrenic due to constrictive pericarditis. [2112-3-2] permanent pacemaker History of Present Illness: Mr. [Known lastname 4660] is a 76 year old gentleman with a history of DM, ESRD on HD, AS who called EMS for substernal chest pain refractory to treatment with aspirin. Ruled in for MI. At [Hospital 5279] Hospital he underwent a cath revealing single vessel CAD (90% LM) and aortic stenosis. He presented for surgical evaluation. Cardiac Catheterization: Date: [2112-2-24] Place: [Hospital 5279] Hospital 90% Left Main, nml LV, mild AS. Cardiac Echocardiogram:[4-19] at [Doctor First Name 5279]: LVEF 55, trivial MR, AS with [Location (un) 109] 1.4, peak gradient of 26 Past Medical History: Past Medical History: CAD, AS, PVD, DM, DM neuropathy, DM retinopathy, DM nephropathy, hyperlipidemia, HT, glaucoma, hx of pericardial effusion w tamponade, CHF, chronic iron dificiency anemia, agranulcytosis, recurrent pleural effusion s/p thoracentesis '[07], '[08], '[09] now w chronic left pleural effusion, ESRD on HD, hx of GI bleed, chronic constipation, hx of CVA, s/p left forefoot amputation, cataract surgery, pericardiocentesis, umbilical hernia, tonsillectomy, right carotid endartarectomy Past Surgical History: s/p left forefoot amputation, cataract surgery, pericardiocentesis, umbilical hernia, tonsillectomy, right carotid endartarectomy Social History: Race:caucasian Last Dental Exam:edentulous Lives with:wife Occupation:retired Tobacco:quit at age 43, smoked 25 years and 2 ppd ETOH:seldomly drinks beer Family History: Non contributory Physical Exam: Pulse: 71 Resp: 14 O2 sat: 97% RA B/P Right: Left: 118/64 Height: 5'7" Weight:158 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] Left forefoot amputation Neuro: Grossly intact: gait disturbance, but strength 5/5 throughout Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ PT [Name (NI) 167]:1+ Left:1+ Radial Right:2+ Left:2+ Left upper arm fistula with thrill Pertinent Results: [2112-2-24] 08:00PM PT-12.1 PTT-28.1 INR(PT)-1.0 [2112-2-24] 08:00PM PLT COUNT-212 [2112-2-24] 08:00PM WBC-7.8 RBC-3.77* HGB-11.1* HCT-32.9* MCV-87 MCH-29.4 MCHC-33.7 RDW-15.0 [2112-2-24] 08:00PM %HbA1c-5.6 [2112-2-24] 08:00PM ALBUMIN-3.7 CALCIUM-8.1* PHOSPHATE-3.7 MAGNESIUM-2.3 [2112-2-24] 08:00PM LIPASE-54 [2112-2-24] 08:00PM ALT(SGPT)-8 AST(SGOT)-12 LD(LDH)-164 ALK PHOS-96 AMYLASE-115* TOT BILI-0.2 [2112-2-24] 08:00PM GLUCOSE-126* UREA N-51* CREAT-7.5* SODIUM-134 POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-26 ANION GAP-19 [2112-3-7] 09:26AM BLOOD WBC-9.2 RBC-3.86* Hgb-11.2* Hct-34.5* MCV-89 MCH-29.0 MCHC-32.4 RDW-14.9 Plt Ct-215 [2112-3-7] 09:26AM BLOOD Plt Ct-215 [2112-3-1] 03:19AM BLOOD PT-14.6* PTT-39.1* INR(PT)-1.3* [2112-3-5] 06:55AM BLOOD Glucose-169* UreaN-32* Creat-5.1# Na-140 K-3.6 Cl-98 HCO3-29 AnGap-17 [Hospital1 18] ECHOCARDIOGRAPHY REPORT LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic function. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS (area 0.8-1.0cm2). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: No pericardial effusion. Pericardium appears thickened. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) 914] was notified in person of the results on [2112-2-25] at 1430 . POST CPB: 1. Preserved [Hospital1 ]-ventricular systolic function. 2. Bioprosthesis in aortic position. Well seated and stable with good leaflet excursion. 3. Trace AI. PG = 18 mm MG = 8 mm Hg. 4. Intact aorta. 5. Dynamic mitral regurgitation, transiently [2-13] + with fluid administration without any hemodynmaic instability, wmas'S or change in SVO2 CHEST (PA & LAT) Study Date of [2112-3-3] 2:45 PM [Hospital 93] MEDICAL CONDITION: 76 yo man with heart block. Asess atrial and ventricular lead s/p PPM Final Report REASON FOR EXAMINATION: Evaluation of the pacemaker placement. PA and lateral upright chest radiographs were reviewed in comparison to [2112-2-28]. The pacemaker leads terminate in the expected location of right atrium and right ventricle allowing the technical quality of the study. The patient is after replaced aortic valve. Cardiomegaly, large left and small right pleural effusion are unchanged as well as there is no change in mild-to-moderate pulmonary edema. No pneumothorax is currently present. DR. [First Name4 (NamePattern1) 2618] [Last Name (NamePattern1) 2619] Brief Hospital Course: The patient is a 76-year-old gentleman with a history of acute myocardial infarction admitted to [Hospital 5279] Hospital. Echo revealed moderate aortic stenosis. The patient had a cardiac catherization and found to have severe left main disease and was, therefore, transferred down from [Hospital 5279] Hospital in [Location (un) 3844] to [Hospital1 771] for coronary artery bypass grafting and possible aortic valve replacement. He was taken to the operating room on [2112-2-26] and had an aortic valve replacement with a 25-mm [Doctor Last Name ] Magna bioprosthesis, coronary artery bypass grafting x1, with left internal mammary artery to left anterior descending coronary artery and subtotal pericardiectomy from phrenic to phrenic due to constrictive pericarditis. See operative note for full details. He was transferred to the intensive care unit in stable condition. He was extubated on post operative day 1 and continued on Neosynephrine for hypotension. Postoperatively he was transiently in sinus rhythm, then went into a complete heart block and was pacer dependent. Attempts to decrease pacing rate results in unreliable underlying ventricular escape rhythm (up to 30 bpm, occasional not present at all). EP was consulted for need for PPM placement. He lost 100% sensing and capture with the epicardial pacing wires and a temporary ventricular wire was placed with good capture. He was taken on [2112-3-2] for a permanent pacemaker placement. See procedure note for full details. He was being 100% paced with good capture and weaned off Neosynephrine after placement. Of note, the patient has a history of chronic left pleural effusion. Thoracic surgery was consulted and recommended a formal decortication. He needs to follow up with Dr. [Last Name (STitle) 11482] [Name (STitle) ] in [3-16] weeks to determine the timing for the decortication. He continued to be followed by the renal team and dialyzed 3 times per week via left upper extremity fistula. Transplant surgery was consulted for a concern in the exam of his LUE fistula. Reportedly prior to surgery the graft had a strong thrill and postoperatively found to have only a weak pulse. Access was found to be patent. Last hemodialysis treatment was [2112-3-7]. Chest tubes and pacing wires were removed per cardiac surgery protocol. He was transferred to the step down unit on post operative day 8 in stable condition. Physical therapy continued to work with him for increased strength and endurance. A bedside swallowing was performed due to coughing while taking thin liquids. It was suggested a diet of thin liquids and soft consistency solids with 1:1 supervision during meals secondary to mental status. Of note, patient did have episodes of sundowning, for which he received Haldol with good results. Once on the step down unit, Mr. [Known lastname 4660] [Last Name (Titles) 27836] well. He was working with physical therapy, tolerating a full po diet and his incisions were healing well. It was felt that he was safe for transfer to rehab at this time. He was discharged to rehab following hemodialysis on POD 13. Medications on Admission: ASA 81mg daily, insulin sliding scale, imdur 60mg daily, lopressor 25mg daily, prilosec 20mg daily, renvela 8--mg TID, Travatan opthalmic solution, Vitamin B complex/vitamin C/folic acid 1 capsule daily, crestor 20mg daily, repaglinide 2mg daily, fligrastim 300 mcg SC Saturdays Allergies:Sulfa, niacin, lisinopril, lorazepam (disorientation) Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 7. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Travoprost 0.004 % Drops Sig: One (1) gtt Ophthalmic QHS. 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Nephrocaps 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 15. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): dose according to sliding scale. Discharge Disposition: Extended Care Facility: [Hospital3 17921] Center - [Location (un) 5450], NH Discharge Diagnosis: Coronary Artery Disease, Aortic Stenosis-s/p AVR/CABG/pericardiotomy PMH::CAD, AS,PVD,DM europathy/retinopathy/nephropathy,hyperlipidemia, HT, glaucoma, hx of pericardial effusion w tamponade, CHF,anemia, granulcytosis, recurrent pleural effusion s/p thoracentesis w chronic left pleural effusion,ESRD on HD, hx of GI bleed, chronic constipation, hx of CVA, s/p left forefoot amputation, cataract surgery,umbilical hernia, tonsillectomy, RT CEA Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal wound healing well-CDI Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Surgeon Dr [Last Name (STitle) 914] in 2 weeks [Telephone/Fax (1) 170] [4-5] at 1:30 PM Please call to schedule appointments Primary Care Dr. [First Name8 (NamePattern2) 38748] [Name (STitle) ] in [2-13] weeks [Telephone/Fax (1) 74598] Cardiologist Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 39975] in 4 weeks Thoracic Surgeon [Last Name (un) 11482] [Doctor Last Name ] in [3-16] weeks to follow up pleural effusion [Hospital ] clinic for PM follow up in 2 weeks Completed by:[2112-3-9*]	[ "41071", "40391", "9971", "5119", "4241", "41401", "4280" ]
Admission Date: [2177-9-26] Discharge Date: [2177-10-7] Date of Birth: [2119-1-26] Sex: M Service: CARDIOTHORACIC Allergies: metformin Attending:[First Name3 (LF) 1406] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: Cardiac cath [2177-9-29] Aortic valve replacement(221mm St. [Male First Name (un) 923] mechanical), Coronary artery bypass graft x 3 (Left internal mammary artery to left anterior descending, Saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) [2177-9-30] History of Present Illness: Mr. [Known lastname ] is a 58 year old gentleman with a past history of insulin-dependent diabetes, hyperlipidemia, minimal aortic stenosis (valve area 1.7) and aortic insufficiency, who has been experiencing intermittent chest pain for several weeks and was admitted after a positive stress echocardiogram. The patient has been experiencing an "ache" in the center of his chest with exertion during his work as a landscaper since [Month (only) 547] [2177]. It is [5-25] in intensity. This pain resolves within one minute of resting (standing or sitting); lying down exacerbates the pain. He has also felt increasingly short of breath, especially with the pain. Episodes of pain occurred zero to multiple times per day, based on level of exertion. He has had no associated diaphoresis, nausea, vomiting, abdominal pain, radiation to arm or jaw. He has no history of acid-reflux. After evaluation by his PCP [Last Name (NamePattern4) ] [2177-9-16], he was instructed to take nitroglycerin for chest pain. On [2177-9-26], the patient saw his cardiologist for a stress/Echo, during which he walked for 3:05 and achieved 82% maximum predicted heart rate. He experienced moderate chest pain during the test. EKG showed [Street Address(2) 2051] depressions (downsloping), with many PVCs and ventricular bigeminy. He had a "borderline drop in blood pressure" during the test Chest pain lasted 30 minutes into recovery. Echo showed mild anteroseptal hypokinesis and global LV dysfunction with predominantly inferolateral, lateral and anterior ischemia. Patient's cardiologist urged him to go to the [Hospital1 18] ED for a diagnostic catheterization. Past Medical History: Aortic regurgitation Insulin dependent diabetes mellitus Hyperlipidemia Diverticulosis Colonic polyps h/o testicular cancer(remote) Social History: Married (wife is [Name2 (NI) ], with two daughters ([Name (NI) 636] 18 at [University/College 23925] for Architecture and [Doctor Last Name ] 15). Owns a landscaping company. -Tobacco history: Never smoker -ETOH: 4 beers per week -Illicit drugs: none ever Family History: Father with hypertension, [Doctor Last Name 2320] and Hodgkin's disease, deceased at 66 years old. Mother and sister with [Name (NI) 2320]. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse:78 SR Resp:16 O2 sat: 96% 2LNP B/P Right: 100/75 Left: Height: 5'8" Weight: 74.8Kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade _2/6SEM Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: cath Left: 2+ Carotid Bruit -none Pertinent Results: INTRAOP TEE:[9-30] PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild to moderate ([2-16]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results at the time of surgery POST-BYPASS: There is a well-seated, well-functioning mechanical prosthetic valve in the aortic position. No aortic regurgitation is seen aside from the small washing jets typical for this type of mechanical valve. No aortic stenosis is seen. Biventricular function is unchanged. Mitral regurgitation is unchanged. The ascending aorta, aortic arch, and descending aorta are intact. . Cath [2177-9-29]: 1. Selective coronary angiography of this right dominant system demonstrated one vessel coronary artery disease. The LMCA had a 95%ostial stenosis. The LAD had a mid 30% and 30% ostial D1 stenosis. The LCX had a proximal 50% stenosis. The RCA had a proximal 70% stenosis. 2. Limited resting hemodynamics revealed low systemic arterial pressure at the aortic level at the begining of the case. 3. Patient had a vaso-vagal episode at the begining of case with mild nausea, diaphoresis and hypotension with systolic blood pressure dipping into the SBP 60mmHg. This was reversed with administraation of IV fluids and atropine. After left coronary angiography patient developed anginal chest pain which resolved after administration of IV nitroglycerine and metoprolol. [2177-9-26] 03:30PM BLOOD WBC-8.9 RBC-4.82 Hgb-14.2 Hct-40.8 MCV-85 MCH-29.5 MCHC-34.8 RDW-14.0 Plt Ct-181 [2177-10-1] 02:10AM BLOOD WBC-8.7 RBC-3.37* Hgb-10.0* Hct-29.1* MCV-86 MCH-29.7 MCHC-34.4 RDW-14.0 Plt Ct-109* [2177-10-7] 06:50AM BLOOD WBC-8.1 RBC-3.07* Hgb-9.0* Hct-25.6* MCV-84 MCH-29.4 MCHC-35.2* RDW-13.6 Plt Ct-366 [2177-9-26] 06:15PM BLOOD PT-12.9 PTT-25.1 INR(PT)-1.1 [2177-10-2] 12:10PM BLOOD PT-15.6* PTT-31.4 INR(PT)-1.4* [2177-10-7] 06:50AM BLOOD PT-26.7* INR(PT)-2.6* [2177-9-26] 03:30PM BLOOD Glucose-68* UreaN-22* Creat-1.3* Na-144 K-4.6 Cl-108 HCO3-28 AnGap-13 [2177-10-3] 09:29AM BLOOD Glucose-181* UreaN-28* Creat-1.1 Na-136 K-3.9 Cl-97 HCO3-30 AnGap-13 [2177-10-7] 06:50AM BLOOD Glucose-71 UreaN-28* Creat-1.2 Na-137 K-3.9 Cl-93* HCO3-38* AnGap-10 [2177-9-27] 06:23AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.4 [2177-10-6] 05:58PM BLOOD Calcium-9.3 Phos-4.8* Mg-2.3 Brief Hospital Course: After admission Mr. [Known lastname ] [Last Name (Titles) 1834] a cardiac catheterization which revealed 95%left main disease as well as 70% proximal right and 50% circumflex disease. He was referred for surgical evaluation given his echo findings of aortic stenosis/regurgitation and a positive stress echocardiogram with significant coronary disease at catheterization. Following cath he was admitted to the CVICU for medical management prior to surgery. He [Last Name (Titles) 1834] the usual preoperative workup and on [9-30] [Month/Year (2) 1834] coronary artery bypass graft x 3 and aortic valve replacement (see operative note for details). Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated. The pressor was weaned off on post-op day one and Coumadin was started for his mechanical valve. Pacing wires were discontinued on post-op day two, however, chest tubes remained in place due to high output. On post-op day three his chest tubes were removed and he was transferred to the step-down floor for further care. Physical Therapy was consulted for mobility and strength assistance. [Last Name (un) ] service was also consulted for improved diabetes management. On post-op day seven he was doing well and discharged home with VNA services with the appropriate medications and follow-up appointments. His Coumadin for his mechanical valve with be managed by his PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 2411] [Last Name (NamePattern1) 12997]. Medications on Admission: 1.) Simvastatin (unknown dose); was prescribed Rosuvastatin 5 mg PO daily for one week then 10 mg PO daily, but has not taken yet 2.) Nitroglycercin 0.3 mg SL [Last Name (NamePattern1) ], PRN chest pain 3.) Glyburide 5 mg PO BID 4.) Pioglitazone 30 mg PO daily 5.) Insulin glargine 25 units SC qHS 6.) Aspirin 81 mg PO daily 7.) was prescribed Metoprolol tartrate 12.5 mg PO BID (started today after stress test) Discharge Medications: 1. aspirin 81 mg [Last Name (NamePattern1) 8426], Delayed Release (E.C.) Sig: One (1) [Last Name (NamePattern1) 8426], Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. ranitidine HCl 150 mg [Last Name (NamePattern1) 8426] Sig: One (1) [Last Name (NamePattern1) 8426] PO BID (2 times a day). Disp:60 [Last Name (NamePattern1) 8426](s) Refills:2 4. warfarin 1 mg [Last Name (NamePattern1) 8426] Sig: [Name8 (MD) ] MD [First Name (Titles) 8426] [Last Name (Titles) ] DAILY (Daily) as needed for mechanical valve. Disp:100 [Last Name (Titles) 8426](s) Refills:0 5. glyburide 5 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO BID (2 times a day). Disp:60 [Last Name (Titles) 8426](s) Refills:2 6. pioglitazone 15 mg [Last Name (Titles) 8426] Sig: Two (2) [Last Name (Titles) 8426] PO DAILY (Daily). Disp:60 [Last Name (Titles) 8426](s) Refills:2 7. tramadol 50 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO Q4H (every 4 hours) as needed for pain. Disp:50 [Last Name (Titles) 8426](s) Refills:0 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:60 Capsule, Ext Release 24 hr(s) Refills:2 9. metoprolol tartrate 50 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO three times a day. Disp:90 [Last Name (Titles) 8426](s) Refills:2 10. potassium chloride 20 mEq [Last Name (Titles) 8426], ER Particles/Crystals Sig: Two (2) [Last Name (Titles) 8426], ER Particles/Crystals PO once a day for 2 weeks. Disp:28 [Last Name (Titles) 8426], ER Particles/Crystals(s) Refills:0 11. warfarin 2.5 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO ONCE (Once) for 1 doses: Take on day of discharge, [10-7]. Disp:1 [Month/Year (2) 8426](s) Refills:0 12. Lasix 40 mg [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO once a day for 2 weeks. Disp:14 [Month/Year (2) 8426](s) Refills:0 13. rosuvastatin 10 mg [Month/Year (2) 8426] Sig: One (1) [Month/Year (2) 8426] PO once a day. Disp:30 [Month/Year (2) 8426](s) Refills:2 14. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous once a day. Disp:qs units Refills:2 15. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous once a day as needed for hyperglycemia: per sliding scale (see attached). Disp:qs Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Aortic insufficiency and Coronary artery disease s/p aortic valve replacement and coronary artery bypass graft x 3 Past medical history: Hyperlipidemia Insulin dependent diabetes mellitus h/o testicular cancer Colonic polyps Diverticulosis Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Edema: 1+ (L)LE Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]on [10-30] at 1:30pm [Last Name (un) 2577] Building [Last Name (NamePattern1) ], [Hospital Unit Name ] Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2177-11-19] at 9:20am Please call to schedule appointments with: Primary Care: Dr.[First Name11 (Name Pattern1) 2411] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 12997] ([Telephone/Fax (1) 86132]) in [5-20] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication: mechanical heart valve Goal INR 2.5-3.0 First draw [2177-10-8] Results to: PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 86132] Completed by:[2177-10-7]	[ "41401", "5849", "5119", "2720", "2859", "4019", "V1582", "V5867" ]
Admission Date: [2181-8-29] Discharge Date: [2181-9-9] Date of Birth: [2112-4-2] Sex: F Service: C-MED HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old female with known coronary artery disease (status post myocardial infarction in [2174]; status post coronary artery bypass graft times three with a left internal mammary artery to the left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to right coronary artery in [2174]) who predominantly to the [Hospital 620] campus complaining of chest pain for three hours with the onset in the evening of [8-28] while at rest. This chest pain was associated with nausea and shortness of breath. The patient reported that earlier that day she was a restrained driver in an automobile accident in which her car was hit on the passenger side in the front. There was no airbag deployment, but after the accident the patient vomited once and developed chest discomfort with radiation to the right breast and arm. At that time, the patient reported that her chest pain was [10-26] in severity. On arrival to the [Hospital 620] campus, the patient's electrocardiogram showed 2-mm ST elevations in leads II, III, and aVF with 2-mm ST depressions in V5 and V6. Leads aVR, aVL, and V1 to V3 had inverted T waves. The patient was given aspirin and morphine and was started on heparin and Integrilin drips and was transferred to [Hospital1 1444] for emergent cardiac catheterization. During the cardiac catheterization, the patient had occasional episodes of hypotension and was started on atropine and dopamine. The patient was found to have bleeding from her groin after multiple access attempts. Her hematocrit was revealed to be 28 and a Swan-Ganz catheter showed low right atrial and pulmonary capillary wedge pressures. The patient was transferred to the Coronary Care Unit without having any interventional performed. The patient was transfused 2 units of packed red blood cells and given intravenous fluids. PAST MEDICAL HISTORY: 1. Coronary artery disease. (a) Status post myocardial infarction in [2174]. (b) Status post coronary artery bypass graft surgery in [2174] with a left internal mammary artery to the left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to right coronary artery. 2. Hypertension. 3. Osteoporosis. 4. Hypercholesterolemia. 5. Gastroesophageal reflux disease. 6. External hemorrhoids. 7. Negative colonoscopy in [2177-11-17]. 8. Anxiety. 9. Status post a ruptured appendix with partial cecectomy 30 years ago. 10. Status post hiatal hernia repair in [2177-10-17]. 11. Status post back surgery for scoliosis in [2175-10-18]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg by mouth once per day. 2. Atenolol 50 mg by mouth once per day. 3. Pravastatin 20 mg by mouth once per day. 4. Prilosec 20 mg by mouth every day. SOCIAL HISTORY: The patient is divorced. The patient does not smoke and does not drink. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient's temperature was 95.3 degrees Fahrenheit, her heart rate was 71, her blood pressure was 127/61, her respiratory rate was 18, and her oxygen saturation was 97% on room air. In general, a thin woman in no acute distress. The patient was confused. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. Sclerae were anicteric. The oropharynx was clear. The neck was supple. No masses. A right internal jugular triple lumen line was present. No jugular venous distention. The lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. A grade [1-22] to 2/6 systolic ejection murmur at the left lower sternal border. The abdomen was soft and mildly tender in the lower quadrants. No distention. Positive bowel sounds. There was a large epigastric ventral hernia. Groin revealed minimal oozing of blood in the left and right groin sites. Distal pedal pulses were intact. Neurologic examination revealed the patient followed commands. Extraocular muscles were intact. The level of consciousness initially varied. Cranial nerves II through XII were grossly intact. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data on admission revealed her white blood cell count was 10.6, her hematocrit was 36.7, and her platelets were 326. Mean cell volume was 92. Her sodium was 134, potassium was 4, chloride was 93, bicarbonate was 27.7, blood urea nitrogen was 22, creatinine was 1.1, and blood glucose was 119. Her calcium was 9.1. Her magnesium was 1.9. Her albumin was 3.8. Her ALT was 58. Her AST was 25. Troponin was 0.3. Creatine phosphokinase was 48. Her INR was 1.2. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm at a rate of 60. Normal axis. ST elevations of 2 mm in leads II, III, and aVF and V5 and V6. ST depressions in V1 to V3. Lead aVL with T wave flattening and inversion. A chest x-ray revealed no pneumonia or congestive heart failure with mild cardiomegaly. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. MYOCARDIAL INFARCTION ISSUES: The patient's creatine kinase peaked on [8-29] at 1641. The patient's initial cardiac catheterization was unsuccessful for any intervention and was complicated by a retroperitoneal bleed. The procedure was terminated at that time as the patient's hemodynamic instability and retroperitoneal bleed presented prevented further attempts at stent placement. After the patient's hematocrit stabilized, she was transferred out of the Coronary Care Unit to the Cardiology floor where she had occasional episodes of jaw pain and chest pain which were relieved with sublingual nitroglycerin. The patient underwent a Persantine MIBI on [9-7]; during which the patient had [5-26] chest pressure and chest pain with the infusion, but no electrocardiogram changes. The MIBI portion revealed moderate partially reversible defects involving the mid and lateral wall which extended to the apex and a hypokinetic lateral wall, with an ejection fraction of 62%. The following day, the patient developed an additional episode of chest pain while at rest. The patient was started on a heparin drip and given sublingual nitroglycerin. The pain resolved. The patient was to undergo a repeat cardiac catheterization on [9-10] with a planned intervention at that time. 2. RETROPERITONEAL BLEED ISSUES: After the multiple access attempts during the patient's initial cardiac catheterization the patient's hematocrit dropped, and she became hypotensive. The patient underwent an urgent abdominal and pelvic computerized axial tomography which revealed a large left-sided retroperitoneal hematoma in the pelvis, diverticulosis without evidence of diverticulitis, and no evidence of bowel obstruction. A ventral hernia containing nonobstructive loops of transverse colon. The patient was transfused with two units of packed red blood cells, and her hematocrit was followed serially. After several days, her hematocrit was found to be stable in the low 30s. In addition, a repeat abdominal computed tomography on [9-4] revealed a greatly decreased left pelvic wall hematoma. At this point, the patient's retroperitoneal bleed was felt to have resolved, and the patient's hematocrit was felt to be stable. The decision was made to proceed with cardiac catheterization on [2181-9-10]. 3. HYPOTENSION ISSUES: The patient had several episodes of hypotension while on the Cardiology floor. The patient's ACE inhibitor was discontinued as was her daily nitrate in order to maintain her systolic blood pressure around 100. The patient was given several boluses of intravenous fluids as needed and was continued on her daily Lopressor for rate control and for cardiac benefits. 4. URINARY TRACT INFECTION ISSUES: On [9-4], the patient was found to have developed a low-grade fever overnight and was complaining of dysuria that a.m. and mild suprapubic abdominal pain. The patient's urine culture revealed greater than 100,000 colonies of Escherichia coli which was pan-sensitive. The patient was started on 500 mg by mouth of Levaquin daily. 5. HYPERCHOLESTEROLEMIA ISSUES: The patient was continued on her daily Lipitor. 6. ANXIETY ISSUES: The patient was continued on her daily Paxil and trazodone at night. In addition, she was covered with Ativan as needed. The patient was found to have significant anxiety with an additional component borderline personality trait. She often had irrational fears regarding her medical care and her treatment by the staff and would frequently complain about hospital amenities, and hospital food, as well as nursing and physician [Name Initial (PRE) ]. The patient was continuously given reassurance by both nursing and physician staff, and the patient responded well to this increased attention and increased communication. NOTE: The remainder of the [Hospital 228] hospital course will be dictated by the covering intern taking over on [Last Name (LF) 766], [2181-9-10]. [Name6 (MD) ] [Last Name (NamePattern4) 5467], M.D. [MD Number(1) 5468] Dictated By:[Last Name (NamePattern1) 9609] MEDQUIST36 D: [2181-9-9] 10:38 T: [2181-9-12] 10:15 JOB#: [Job Number 108859]	[ "5990", "4019" ]
Admission Date: [2177-11-2] Discharge Date: [2177-11-11] Date of Birth: [2121-4-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4282] Chief Complaint: weakness Major Surgical or Invasive Procedure: Intubation History of Present Illness: 56 year old Portuguese-speaking M with an inoperable pancreatic cystadenocarcinoma s/p recent admission for pneumonia now p/w increased abd pain, urinary frequency, confusion/disorientation, +/- weakness. Afebrile at home. He did have a slow fall to the ground at home yesterday but there was no head injury. Per pt, his daughter gives him pain medication 2 times a day (PO dilaudid prescribed q3H prn). Of note, celiac nerve block was attempted during last admission and was not able to be completed [1-28] anatomic difficulties w/cystic nature of CA. The patient was discharged on [10-30] on his home pain regimen, on which his pain was well controlled throughout his entire last admission. . Upon presentation to the ED, VS were: 100.2 103 148/99 18 100%. Exam was nonfocal; he was guiac negative. Labs were reportedly at baseline. U/A was negative for infection. CXR and CT scan did not reveal any new/acute changes from prior. While in the ED, he did have a T of 100.2. He was cultured and given vanco and zosyn along with 2L NS. He is being admitted for pain control and respite for his family. VS prior to d/c 99 102 110/70 20 100% RA. . Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea or abdominal pain. No dysuria. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: Mr. [Known lastname ] has a history of chronic pancreatitis and pseudocyst development. He underwent a cyst jejunostomy with Roux-en-Y in [Country 4194] in [2177-2-24] and was hospitalized following this for acute on chronic pancreatitis with pseudocyst formation. He was given TPN and supportive treatment while awaiting maturation of the pseudocyst and potential surgical intervention. During that admission a CT of the abdomen/pelvis was reported to show a 16 x 8.6 x 16cm multi-loculated cystic mass essentially replacing the entire pancreas. He was transfered to [Hospital1 18] for further evaluation and management. It was determined that this lesion was inoperable due to encasement of the blood vessels. He underwent EUS and had an FNA [2177-9-11], which demonstrated atypical cells, concerning for a mucinous neoplasm. He underwent ERCP on [2177-9-17] which showed malignant cells consistent with adenocarcinoma. Tissue biopsy has not been feasable due to the location/nature of the mass. . Other Past Medical History: - [2170] - cholecystectomy for gallstone pancreatitis and subsequently developed a pseudocyst. - [2-/2177] he was reported to have undergone cyst jejunostomy with Roux-en-Y in [Country 4194]. - Hypertension - Splenectomy secondary to trauma, [2146] Social History: Mr. [Known lastname ] is married and has three children. He has been employed as a publicist for a television station in [Country 4194]. He reports having used alcohol socially up until two years ago. He denies tobacco or illicit drug use. He lives near [Location (un) 86] with his wife and daughter. Family History: No known family history of pancreatic disease. No family history of disease he reports. Physical Exam: VS: 97.5, 145/90, 103, 16, 99% RA GEN: Chronically ill appearing gentleman, laying in bed in NAD, A&Ox2 (self, hospital, year [2166], month [Month (only) 359]) HEENT: EOMI, PERRLA. MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 normal. Crescendo systolic murmur best heard at RUSB, no gallops/rubs. Pulm: CTAB, no crackles or wheezes appreciated. Abd: Firm abdominal mass palpable in epigastric region. No apparent organomegaly. NT, appears distended, tympanitic; no rebound. Skin: no rashes or bruising Neuro/Psych: CNs II-XII intact with exception of visual field testing which was deferred but no gross abnormalities in vision appreciated. Pertinent Results: Imaging: [2177-11-2] CXR: No acute cardiopulmonary process. . [2177-11-2] CT A/P: Large multiloculated known cystic neoplasm centered within the expected region of the pancreas, with replacement of the entire normal pancreatic parenchyma and extension into all of the adjacent organs, that overall is stable in both extent and size since examination from [2177-10-26]. Associated biliary dilation and obstruction with nonvisualization of the distal main portal vein, splenic vein and SMV. No new cystic areas that would be concerning for new abscess formation. . [2177-11-3] CXR: No evidence of acute process. . [2177-11-4] head MRI: 1. Sequelae of microvascular ischemia. 2. No evidence of intracranial lesions to suggest metastatic disease. . [2177-11-7] CXR: No acute cardiopulmonary abnormality. . Micro: [2177-11-10] MRSA-PENDING [2177-11-8] BLOOD CULTURE-PENDING [2177-11-8] BLOOD CULTURE- Blood Culture, Routine (Preliminary): ENTEROCOCCUS SP.. PRELIMINARY SENSITIVITY These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ R LEVOFLOXACIN---------- R VANCOMYCIN------------ R [2177-11-3] BLOOD CULTURE-NEG [2177-11-3] URINE CULTURE-NEG [2177-11-3] BLOOD CULTURE-NEG [2177-11-2] URINE CULTURE-NEG [2177-11-2] BLOOD CULTURE-NEG . Labs on admission: [2177-11-2] 01:24AM BLOOD WBC-10.9 RBC-3.34* Hgb-9.8* Hct-30.9* MCV-92 MCH-29.3 MCHC-31.7 RDW-17.0* Plt Ct-903* [2177-11-2] 01:24AM BLOOD Neuts-58 Bands-0 Lymphs-24 Monos-14* Eos-0 Baso-1 Atyps-3* Metas-0 Myelos-0 [2177-11-2] 01:24AM BLOOD Glucose-152* UreaN-6 Creat-0.5 Na-131* K-4.0 Cl-97 HCO3-23 AnGap-15 [2177-11-2] 01:24AM BLOOD ALT-20 AST-31 LD(LDH)-206 AlkPhos-557* TotBili-1.4 [2177-11-2] 01:24AM BLOOD Lipase-8 [2177-11-3] 07:10AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.8 [2177-11-2] 01:24AM BLOOD Osmolal-272* [2177-11-7] 09:00PM BLOOD Type-ART pO2-32* pCO2-42 pH-7.45 calTCO2-30 Base XS-4 [2177-11-2] 01:23AM BLOOD Lactate-2.3* Brief Hospital Course: 56 Portuguese-speaking M w/inoperable pancreatic cystadenocarcinoma s/p recent admission for PNA and pain control now p/w increasing abdominal pain with temp elevation noted while in the ED. Patient developed hypoxia, likely [1-28] aspiration event this [Hospital ] transferred to ICU where he was emergently intubated; unable to contact pt's wife immediately, pt made DNR after discussion w/Drs. [Last Name (STitle) ], [Name5 (PTitle) ] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] from ethics prior to reaching pt's wife. [Name (NI) 1094] wife was able to come in for family meeting this afternoon, pt made CMO. After made CMO, the patient was terminally extubated and was placed on a dilaudid drip. The patient's condition declined and he passed away on [2177-11-11] . # Suicidal ideation: Pt w/attempted suicide w/butter knife during admission. Psych consulted, they do not feel that pt is safe to go home as he states that he has been thinking of suicide for the past 2-3 months and is no longer afraid of dying. They recommend admission to hospice or psych hospital. Pt was started on ritalin and mirtazapine with improvement per psych recs. [Name (NI) 1094] wife was working on finding a private nurse to take care of pt while she was at work during the week. . # Transient hypoxia: Pt had episodes of hypoxia to 70s, improved to 90%s w/facemask. CXR negative, likely [1-28] aspiration. Had resolved until day of transfer to ICU w/ambulatory sats in 90s on RA. 85% on RA this AM prior to transfer. . # Fever: Tm 101.4 the evening of [11-8], pan cultured, 1/2 blood culture positive for VRE. Patient was recently discharged on home PO regimen of cefpodoxime 100 mg [Hospital1 ] and doxycycline 100mg [Hospital1 ] for 8 days for PNA seen on chest CT; d/c'd [2177-11-3]. UCx negative x 2, BCx +GPC from [11-8]. CXR neg. Vancomycin started on [2177-11-9]. Elevated LFTs noted on labs, however within the range of prior values. . # Abdominal pain: This is likely all related to disease, pain regimen was changed 4 days prior to last admission, pain poorly controlled at home, prn medications given [Hospital1 ] when prescribed q3H. Pt denied pain and nausea during his last admission; may be likely due to the fact that he was relatively inactive or the recent change in his pain regimen may have been in effect. We attempted to have GI place a celiac nerve block during last admission, as planned as an outpatient on [11-13]. However, upper GI endoscopy was performed without celiac block [1-28] to the cystic masses per GI. Pain well controlled on current regiment of increased home reg of fentanyl patch 175mcg/hr q72 hrs, gabapentin 400mg TID, started MS IR 15mg q4H prn and Tylenol 235mg TID with PPI and simethicone. Standing compazine with morphine sulfate to prevent nausea, zofran prn. We held dilaudid [1-28] concern for associated mental status changes . # Confusion: Pt's MS improved during admission, was A&O [1-29] prior to day of ICU transfer; likely [1-28] medication, infection, tumor. Change in MS the AM of ICU transfer likely [1-28] to hypoxia, bacteremia. MRI head was neg for any intracranial process. . # Weakness: Per pt's daughter, +/- weakness, stable from prior to last admission. Pt evaluated by PT, determined that pt did not need for PT upon discharge prior to ICU transfer. . # Pancreatic cancer: As per pt's primary oncologist, treating with Gemcitabine as an outpatient without available surgical or XRT options at time of admission. Per primary oncologist, would not continue chemotherapy at this time with current MS changes and frequent admissions for pain crisis. We continued Compazine, Zofran and Creon. Medications on Admission: 1. famotidine 20 mg Tablet [Hospital1 ] 2. fentanyl 100 mcg/hr Patch 72 hr apply with 50mcg patch for a total of 150mcg/hr 3. fentanyl 50 mcg/hr Patch 72 hr to be used with 100mcg/hr patch for total dosage of 150mcg/hr 4. gabapentin 300 mg PO three times a day. 5. hydromorphone 4 mg Tablet [1-29] tab PO Q3H as needed for pain. 6. lipase-protease-amylase 6,000-19,000 -30,000 unit Capsule, Delayed Release(E.C.) PO three times a day: with meals. 7. ondansetron HCl 4 mg Tablet PO every eight (8) hours. 8. polyethylene glycol 3350 17 gram/dose Powder PO Daily prn constipation. 9. prochlorperazine maleate 10 mg Tablet Q8H prn nausea. 10. zolpidem 10 mg qhs prn insomnia. 11. acetaminophen 325 mg 2 Tablet PO TID prn pain 12. docusate sodium 100 mg PO BID 13. senna 8.6 mg Tablet [Hospital1 ] prn constipation. 14. simethicone 80 mg Tablet [Hospital1 ] prn gas 15. cefpodoxime 100 mg [Hospital1 ] for 8 days. 16. doxycycline hyclate 100 mg [Hospital1 ] for 8 days. Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): apply with 75mcg patch for a total of 175mcg/hr. Disp:10 Patch 72 hr(s) Refills:2 3. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:qs 1 month Refills:2 4. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours). Disp:90 Tablet, Rapid Dissolve(s) Refills:2 5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. Disp:qs 1 month Refills:0 6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. Disp:90 Tablet(s) Refills:2 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for pain. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 10. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day as needed for indigestion. Disp:60 Tablet, Chewable(s) Refills:0 11. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): apply with 100mcg patch for a total of 175mcg/hr . Disp:10 Patch 72 hr(s) Refills:2 12. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 13. morphine 30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:180 Tablet(s) Refills:0 14. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Expired Discharge Diagnosis: Pt passed away Discharge Condition: Patient passed away Discharge Instructions: pt passed away Followup Instructions: patient passed away	[ "51881", "486", "2761", "4019" ]
Admission Date: [2148-10-29] Discharge Date: [2148-10-29] Service: CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is an 89 year-old female with a history of congestive heart failure and osteomyelitis of her left femur who presented with shortness of breath and decreased O2 saturations on room air in the setting of two days of foul smelling diarrhea. The patient lives at [Hospital3 2558] and was transferred today to [Hospital1 1444] Emergency Department, because she was noted to have persistent oxygen saturations in the low 90s and high 80s on 12 liters of oxygen. In addition to being hypoxic while in the Emergency Department she was noted to be hypotensive to 90/palpable with a temperature of 101.4. With the exception of the story of two days of foul smelling diarrhea there was no further documentation. While in the Emergency Department the patient was intubated for hypoxic respiratory failure, received 1 liter of normal saline and was started briefly on Dobutamine drip for her hypotension. In addition, she received Vancomycin, Flagyl and Ceftriaxone and transferred to [Hospital Ward Name 332] Intensive Care Unit for further management. PAST MEDICAL HISTORY: 1. Osteomyelitis of the left femur that has been chronic. The patient has been wheel chair bound for the last year. 2. Congenita one kidney status post nephrostomy tube in the left functional kidney with a history of urosepsis in the past. Her nephrostomy tube was changed in [2148-10-13]. 3. Hypothyroidism. 4. Congestive heart failure with a normal ejection fraction. Echocardiogram in [2147-2-13] showed moderate AS, mild MR, moderate TR, moderate pulmonary hypertension. 5. ITP plus Cipro exposure. 6. Depression. 7. History of C-diff colitis. 8. Dementia. ALLERGIES: Aspirin causing a rash. Penicillin causing difficulty breathing, codeine causes vomiting and Cipro causing ITP. MEDICATIONS ON ADMISSION: Iron 325 mg po q day, Levoxyl 50 mg po q day, vitamin B, vitamin E, vitamin C. Natural tears to the eyes. Zoloft 50 mg po q day, Megace 200 mg po b.i.d., Milk of Magnesia 30 mg po prn, Robitussin 5 ml po q 4 to 6 hours prn, Tylenol prn, Mylanta prn. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient lives in [Hospital3 2558] for the last eight years. Her daughter is heavily involved in her care and is her health care proxy. PHYSICAL EXAMINATION: Temperature 98.6. Pulse 109. Blood pressure 102/37 with a map of 60. O2 sat 100% on 40% oxygen vented at AC, 600 by 10 with a PEEP of 5. The patient was paralyzed and sedated. Her lungs were clear to auscultation bilaterally. Her heart was regular with faint heart sounds. There were no murmurs appreciated. Belly was soft and nontender. There were hyperactive bowel sounds. Extremities showed no clubbing, cyanosis or edema. However, they were cool to touch. There were good distal pulses. LABORATORIES ON ADMISSION: White blood cell count 3.2. Differential of 61 neutrophils, 3 bands, 34 lymphocytes, 2 monocytes, hematocrit 30.7, platelet count of 317, anion gap was 14. Chem 7 showed sodium of 143, potassium 4.8, chloride 115, bicarb of 14, BUN 40, creatinine 1.9, which is up from her baseline of 1, glucose 129. CK 53, troponin less then 0.3. Calcium 8.7, phosphate 3.5, magnesium 2.5. Her INR was 1.4, arterial blood gas 7.3, 28, 448, 100% O2. Chest x-ray showed ECT in left main stem, blunting of the left costophrenic angle - ECT tube was pulled back by 3 cm. CT of the abdomen showed atrophic right kidney with multiple stones. Percutaneous nephrostomy tube was in place in the left kidney. A small amount of air in the left kidney. There were bilateral pleural effusion noted. Her urinalysis showed red cloudy urine with specific gravity of 1.02. Serologic blood positive nitrites, more than 300 protein, negative glucose, trace ketones, small bili, pH of 7.5, large leukocyte esterase. Numerous red blood cells. Electrocardiogram showed sinus rhythm of 107, normal axis, normal intervals, Q wave in 3. No change from the prior. HOSPITAL COURSE: In summary, the patient is an 89 year-old female with a single kidney status post nephrostomy tube changed recently who presents with hypertension and hypoxia in acute renal failure. The patient's blood pressure remained stable at approximately 100 systolic overnight off of the pressors. She was continued on her antibiotics including Flagyl, Ceftriaxone and Vancomycin for coverage for urosepsis as well as C-diff. In the morning following admission the patient's blood pressure was noted to be very labile all the way to 40s. A family discussion was undertaken and based on the patient's poor prognosis as well as poor quality of life prior to the hospitalization the decision was made to withdraw care. The patient's antibiotics and fluids were stopped. She was extubated to room air. She passed away at 4:03 p.m. on [2148-10-29]. The family was present at bedside and her daughter [Name (NI) ] [Name (NI) ] refused postmortem examination. Her primary care physician was notified. DISCHARGE DIAGNOSES: 1. Probable urosepsis. 2. Hypoxic respiratory failure. 3. Acute renal failure. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ], M.D. [MD Number(1) 292] Dictated By:[Last Name (NamePattern1) 1762] MEDQUIST36 D: [2148-10-30] 11:18 T: [2148-11-5] 06:06 JOB#: [Job Number 9791]	[ "0389", "5849", "2762" ]
Admission Date: [2157-7-5] Discharge Date: [2157-8-4] Date of Birth: [2109-1-23] Sex: F Service: MEDICINE Allergies: Shellfish / Flexeril Attending:[First Name3 (LF) 949] Chief Complaint: # Lethargy # Confusion # Hyponatremia Major Surgical or Invasive Procedure: # MICU intubation # L arm PICC placement # Bedside [Last Name (un) ]-gastric tube placement # Fluoroscopy-guided [Last Name (un) ]-jejunal tube placement History of Present Illness: 48F h/o Hep C cirrhosis c/b ascites, encephalopathy and BLE edema, presented to clinic with lethargy, Na = 113. Pt reported that her mother, who helps pt manage her pills, also noted that pt was "making no sense" this morning. Pt denied any recent alcohol or drug intake, and reported that she had a productive cough with somewhat yellow sputum. Pt reported that she had not been having three bowel movements daily, and at least one day had no stools. . In the ED, she was oriented x 2, with positive asterixis. Pt received albumin 50g. . On first arrival to the floor, pt denied fever, vomiting, diarrhea, dysuria, bloody stool, joint pain, muscle pain, sore throat, or changes in vision. Pt endorsed hunger, fatigue, tremors, and dizziness. It was unclear whether pt endorsed or denied nausea as her account changed, and she was not focused during the interview. Pt conducted her admission interview with her eyes closed, and spoke in a shaky mumble throughout. Past Medical History: (1) Hepatitis C cirrhosis --Encephalopathy --Ascites --Edema s/p TIPS ([11-8]) --Hydrothorax --Thrombocytopenia --Hyponatremia (baseline 124-128) (2) Asthma (3) Adrenal insufficiency [1-7] ESLD (4) GERD (5) Anxiety Social History: # Recreational drugs: Past IV drug use with needle sharing, last use 7 years ago. Past drug-snorting. # Alcohol: Past alcohol use, last drink at age 46. # Tobacco: Past [Month/Day (2) 1818] with 10 pack-year history # Personal: Single with one child. Lives with mother, who manages medications # Employment: Former waitress, unemployed on disability. Family History: # Mother, 60s: DM2, HTN, hypercholesterolemia # Father, d. 51: COPD, alcohol-induced cirrhosis # Brother Physical Exam: VS = T 97.1, BP 106/50, HR 83, RR 26, O2 96%, FS 148 GEN: Tremulous in bed with covers pulled up and eyes closed throughout the interview HEENT: Scleral ictera, MMM, CN II-XII grossly normal CV: RRR, S1S2, III/VI SEM, no r/g PULM: CTA @ L, decreased breath sounds at R base, no rales/rhonchi/wheezes ABD: BS+, soft, NT, protuberant, no rebound. Tympanic. EXT: 3+ BLE edema. + asterixis. NEURO: Slow to respond. A&O x 3. Could not remember three words. Pertinent Results: Admission labs: . [2157-7-5] 12:19PM GLUCOSE-137* K+-4.3 [2157-7-5] 12:00PM GLUCOSE-155* UREA N-18 CREAT-0.8 SODIUM-113* POTASSIUM-4.4 CHLORIDE-89* TOTAL CO2-18* ANION GAP-10 [2157-7-5] 12:00PM estGFR-Using this [2157-7-5] 12:00PM ALT(SGPT)-54* AST(SGOT)-101* ALK PHOS-377* AMYLASE-69 TOT BILI-19.6* [2157-7-5] 12:00PM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-3.1 MAGNESIUM-1.9 [2157-7-5] 12:00PM ETHANOL-NEG bnzodzpn-NEG [2157-7-5] 12:00PM WBC-7.7# RBC-2.90* HGB-10.0* HCT-28.9* MCV-100* MCH-34.5* MCHC-34.5 RDW-19.4* [2157-7-5] 12:00PM NEUTS-83* BANDS-0 LYMPHS-10* MONOS-3 EOS-3 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [2157-7-5] 12:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-2+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-2+ BITE-OCCASIONAL ACANTHOCY-OCCASIONAL [2157-7-5] 12:00PM PLT COUNT-65* [2157-7-5] 12:00PM PT-23.8* PTT-50.5* INR(PT)-2.4* . # CXR [2157-7-9]: Multifocal patchy opacities seen in the left upper and lower lung zones, with cardiomegaly. This may represent asymmetric pulmonary edema; however, aspiration/pneumonia cannot be excluded. The ill-defined opacity in the right upper lung zone seen on the prior study has resolved. A TIPS shunt is present. . # ABD US [2157-7-8]: 1. Minimal intra-abdominal ascites. There was insufficient fluid to mark a location for bedside tap. 2. Patent appearance of the main portal vein. Measured TIPS velocities are similar to comparison examination. . # CXR [2157-7-22]: IMPRESSION: Improved aeration in the upper lobes. Persistent bilateral patchy opacities more confluent in the bases, greater on the right side. # CXR [2157-8-1]: FINDINGS: A PA and lateral of the chest were obtained and compared to the prior examination dated [2157-7-30]. Allowing for differences in technique, there is no significant interval change. The left subclavian PICC line is unchanged in position terminating within the expected region of the proximal superior vena cava. The enteric feeding catheter extends beyond the inferior margin of the film. The diffuse patchy opacities throughout both lungs are grossly unchanged. The left patchy opacity obscuring the left hemidiaphragm is unchanged. A persistent right pleural effusion is noted. Cardiomediastinal silhouette is unchanged. IMPRESSION: Stable examination as above. # RUQ Ultrasound [2157-8-3]: FINDINGS: Comparison is made to [2157-7-6]. The study is limited secondary to patient's inability to breath-hold. There is a large right pleural effusion. Color flow imaging demonstrates a patent TIPS with wall-to-wall flow though velocities cannot be measured secondary to respiratory motion. The right portal vein is patent and appears to be hepatofugal though evaluation markedly limited. There is trace ascites in the pelvis, but inadequate for paracentesis. IMPRESSION: 1. Limited exam. Patent TIPS with wall-to-wall flow. 2. Trace ascites. Brief Hospital Course: 48F h/o HCV cirrhosis, admitted to [Hospital Ward Name 121] 10 with hyponatremia, hepatic encephalopathy, and questionable respiratory symptoms. . # PNA: As pt reported syptoms of productive cough, admission CXR was obtained which demonstrated RUL infiltrate suspicious for infection. In light of her recent hospitalization, pt was started on ciprofloxacin 400mg IV q12H ([7-6]) for nosocomial PNA. To cover the possibility of aspiration PNA as pt's hepatic encephalopathy persisted, abx were broadened to vancomycin ([7-9])/pip-taz ([7-9])/azithromycin ([Date range (1) 11067]). Abx were discontinued on [7-18] given completed total abx course of approximately 10 days. Serial chest xrays every other day showed gradual interval improvement. . # Respiratory compromise: On admission, pt was ambulatory with no oxygen requirement, and pt was placed on home regimen of albuterol and fluticasone-salmeterol 100-50 mcg/dose [Hospital1 ]. On [7-8], pt received 1 unit PRBC for Hct = 20.9. On [7-9], HD#3, patient c/o increasing SOB, with RR = 30, PaO2 = 61 on 4L NC, PCO2 = 33, pH 7.44. Repeat CXR demonstrated new L upper and lower lung infiltrates and likely volume overload. Pt's acute respiratory compromise was considered to be possibly multifactorial, with contributions from asthma exacerbation, PNA, fluid overload, and possible TRALI. TTE performed in the MICU demonstrated hyperdynamic EF, enlarged LA, and no evidence of pulmonary HTN. Pt was intubated from [2163-7-13] to support respiratory capacity. On [7-21] transfer to floor, pt had been extubated for four days, with improved respiratory status and O2sat in the mid-90s on 4L. She was weened down to 3L, where she remained stable. . # Adrenal insufficiency [1-7] liver failure: Pt was initially maintained on her home regimen of prednisone 5 mg daily. Upon transfer to the MICU, stress dose steroids were administered in the setting of infection, respiratory compromise, and pt's background adrenal insufficiency. After transferring back to the floor, pt was transitioned ultimately to hydrocortisone to provide both glucocorticoid and mineralocorticoid activity. She is discharged on 20 mg hydrocortisone qday. . # Asthma: After pt's episode of respiratory insufficiency, pt was continued on standing albuterol and fluticasone-salmeterol nebs, with home regimen of montelukast held. She continued albuterol and fluticasone/salmeteral nebs throughout her stay. . # [Female First Name (un) 564] overgrowth: In the MICU, pt was started on casofungin x 4-5 days given yeast in sputum, as it was felt to be colonization. Repeat sputum and urine cultures, however, demonstrated continued heavy yeast colonization, with urine growing C. glabrata, and sputum growing C. albicans (sensitive to fluconazole) as well as another yeast organism with indeterminate speciation. Pt was started therefore on fluconazole 200mg daily on [7-26]. Per ID recommendations, fluconazole was stopped since yeast was likely colonizer and not reflecting true infection. . # HCV cirrhosis: On admission, pt's MELD was 27. On [2157-7-21], pt was removed from the transplant list given respiratory compromise but was relisted after transferring back to the floor. Pt's MELD remained in the 20s during this admission. She will need to have weekly MELD scores, reflected in weekly lab draws to be faxed to her hepatologist Dr. [Last Name (STitle) 497], as outlined in the discharge plan. . # Hepatic encephalopathy: Pt was given regular doses of rifaximin, lactulose PO, and lactulose PR, titrated to achieve four bowel movements daily. Pt's mental status was noted to wax and wane throughout admission, and therefore an NG tube, later a N-J tube, was placed to prevent aspiration. Pt was placed on pureed foods with sips of thin liquids only after a bedside speech and swallow noted no active aspiration, but the need for precautions. On day of discharge she was cleared by speech and swallow for a regular diet, but should be watched directly whenever she is eating to keep her from trying to swallow too much at once - one bit and sip at a time(per speech). Her encephalopathy showed improvement daily. . # Hyponatremia/hypernatremia: Pt initially presented with Na = 113 and total body water overload. Pt therefore was intially fluid-restricted and administered albumin, with furosemide and spironolactone initially held. Diuretics were later reintroduced. Pt was noted to become hypernatremic (Na = 155) in the MICU after aggressive diuresis, and therefore NGT free water was given with normalization of Na. Free water was stopped when her Na reached 130. On day of discharge, her Na was 130. . # DM2: Pt's blood glucose was controlled with HISS, with home regimen of glipizide first reduced and then ultimately held out of concern for hypoglycemia in the setting of hepatic dysfunction. Pt was placed on glargine 12 units at bedtime to provide basal glucose control, which was subsequently increased to 17 and then 20 on day of discharge to better control her glucose. . # Anemia: Hct was noted to drift downwards to a low of 20.9 on [7-8], and pt was therefore transfused 1 unit PRBC. On [7-9], pt was noted to have severe respiratory insufficiency, with PaO2 = 61, requiring transfer to MICU. There, pt was noted to have guaiac-positive stool in the setting of known hemorrhoids, no esophageal varices. Hct ultimately stablized in the high 20s, near pt's preadmission baseline. . # Hematuria: Pt presented with gross hematuria on [7-11], with INR = 3.4. Hematuria was considered to be due to spontaneous bleeding in the bladder given supratherapeutic INR and possible irritation from foley catheter. FFP 2 units were transfused with resolution of hematuria. On day of discharge, her Hct was 25.9. . # UTI: Pt was noted to have entercoccus in urine culture on [7-9], treated with vancomycin. Urinalysis on [7-29] grew pan-sensitive Klebsiella, and has been receiving a course of Ciprofloxacin, to complete on [8-8]. . # FEN: Pt was placed on a low Na diet. After extubation, pt was given NutrenPulmonary tube feeds at 60cc/hr, cycled from 1800 hrs to 1200 hrs, to increase her caloric intake, which was then changed to continuous 24 hr. She passed swallow and is cleared to take a full diet, but should be watched directly whenever she is eating to keep her from trying to swallow too much at once (per speech). . # Full code Medications on Admission: Lactulose 30 g q8H PRN Hydroxyzine HCl 25 mg q6H PRN for bilirubin-related itch Rifaximin 400 mg TID Albuterol PRN Ferrous Sulfate 325 mg daily Clotrimazole 10 mg Troche QID Montelukast 10 mg daily Oxybutynin Chloride 5 mg [Hospital1 ] Fluticasone-Salmeterol 100-50 mcg/dose [Hospital1 ] Pseudoephedrine HCl 30 mg q6H PRN Lidocaine 5 %(700 mg/patch) patch daily Lorazepam 0.5 mg [Hospital1 ] PRN Clonidine 0.1 mg [Hospital1 ] Prednisone 5 mg DAILY Pantoprazole 40 mg EC DAILY Glipizide 5 mg [Hospital1 ] Prochlorperazine 10 mg q8H PRN Spironolactone 50 mg daily Furosemide 20 mg daily Metoclopramide 10 mg TID PRN Discharge Medications: 1. Lactulose 10 g/15 mL Syrup [Hospital1 ]: Forty Five (45) ML PO TID (3 times a day). Disp:4050 ML(s) Refills:2 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Hospital1 ]: One (1) Inhalation Q4H (every 4 hours). 3. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours). 4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Hospital1 ]: One (1) Inhalation Q2H (every 2 hours) as needed for dyspnea. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 6. Rifaximin 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Last Name (STitle) ]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for Back pain. 8. Hydrocortisone 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 10. Furosemide 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 11. Spironolactone 25 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 12. Lactulose 10 g/15 mL Syrup [Last Name (STitle) ]: Forty Five (45) ML PO Q4H (every 4 hours) as needed. 13. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [Last Name (STitle) ]: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 14. Ciprofloxacin 250 mg Tablet [Hospital1 ]: One (1) Tablet PO Q12H (every 12 hours) for 4 days: Please give through [2157-8-8]. 15. Insulin sliding scale with glargine Finger sticks QACHS Glargine 20 Units qhs HISS per protocol attached 16. Heparin Flush 100 unit/mL Kit [Month/Day/Year ]: One (1) flush Intravenous once a day: Heparin flush for PICC. Flush daily and as needed. . 17. Outpatient Lab Work Lab work on [2157-8-9] and weekly thereafter. FAX results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] at [Telephone/Fax (1) 697]. Labwork: PT/INR, Chem-7 (sodium, potassium, chloride, bicarb, BUN, creatinine), AST, ALT, alk phos, total bilirubin. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary diagnosis: # Hyponatremia # Hypernatremia # HCV cirrhosis # Hepatic encephalopathy # Pneumonia # [Female First Name (un) 564] overgrowth # Adrenal insufficiency . Secondary diagnosis # Asthma Discharge Condition: Stable Discharge Instructions: You were admitted because you had a very low sodium level, and you were confused. We found that you had pneumonia and started antibiotics for you. You had a difficult time keeping your oxygen saturation normal, and therefore you had to go to the intensive care unit. There, you had to be intubated to breathe, and you continued receiving antibiotics. Afterwards, you were able to breathe on your own, and you returned to [Hospital Ward Name 121] 10. You continued to be very confused, so we gave you medications so that you could move your bowels. You were also found to have a urinary tract infection, and are currently on antibiotics for that. . We have given you some new medications: hydrocortisone 20mg daily folic acid 1mg daily ciprofloxacin 250mg every 12 hours until [2157-7-8] lactulose was increased to 45 ml three times titrated to 3 bowel movements with 45 ml as needed in addition. . You should be watched when you eat because of the potential to aspirate your food. You should eat one bite and one sip at a time. . You should return to the hospital or contact your primary care physician if you experience worsening concentration and mental status, increased bleeding, fever > 101.4 degrees F, worsening shortness of breath, or coughing up blood. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2157-8-10] 10:50	[ "5070", "2761", "5990", "2760", "2875", "25000", "49390", "2859", "53081" ]
Admission Date: [2184-1-21] Discharge Date: [2184-1-31] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: Lethargy, hypoxia. Major Surgical or Invasive Procedure: intubation History of Present Illness: The pt. is a [Age over 90 ] year-old gentleman with multiple medical problems, recently discharged from [Hospital1 18] after a hospital stay for CHF exacerbation and aspiration pneumonia, who presented from rehab with increasing lethargy. Pt. was noted to be "obtunded" at rehab facility on day of admission and ABG was performed which was consistent with hypercarbic and hypoxemic respiratory failure (7.25/96/26). Intubation was attempted at rehab without success. Pt. was also noted to be hypothermic (T=94F) and was given 1 gram of IV vancomycin and 1 gram of IV unasyn prior to transfer to the [Hospital1 18] ED. He was also given 100mg of IV lasix before transfer. In the ED, the pt. was noted to be tachypneic with respiratory rate in the upper 20's and ABG on presentation was 7.31/87/130. He was intubated and placed on mechanical ventilation shortly after presentation. He received a dose of levofloxacin and metronidazole for presumed aspiration pneumonia. He was also given a total of 2 liters of IV fluid and 40mg of IV lasix to which he put out approximately 800 cc of urine. According to the pt's. daughter, the pt. had been increasingly confused and lethargic for three to four days PTA. She also noted that his lasix dose had been recently reduced as it was felt that the pt. was "dry." Upon presentation to the MICU, the pt. was intubated and sedated. Past Medical History: -CAD s/p CABG x1 venous ([2165]) -PVD w/ RLE bypass -HTN -chronic afib s/p pacemaker -AVR (porcine [2165]) -AAA (7cm), awaiting repair -diastolic CHF; TTE ([11-2] at OSH) EF 55%, LAE, severe LVH, global HK esp. RV, MR, TR, severe pulmonary HTN -anemia of chronic inflammation -h/o aspiration pneumonia -S/P PEG placement, [12-3] -chronic subdural hematomas vs subdural hygromas of undeterminate age. -gastritis -Type III odontoid fx -cholelithiasis w/ hyperbilirubinemia -small septated cyst and granuloma in left liver lobe -cataracts Meds: -toprol XL 75mg po daily -lasix 60mg po daily -isordil 10mg po bid -heparin 5000units sc tid -lisinopril 10mg po daily -ASA 325mg po daily -digoxin 125mcg po daily -pantoprazole 40mg po daily -pramipexole 0.125mg po daily -docusate 100mg po bid -acetaminophen prn -albuterol prn -loperamide prn -senna prn Social History: The pt. is a resident of [Hospital3 ]. He is married. No use of tobacco or alcohol. Family History: Father (died of MI [Age over 90 ]yo) Mother unknown Physical Exam: Vitals: T: 100.3F P: 84 R: 15 BP: 145/61 SaO2: 97% on 70% FIO2 Vent: Mode: AC Vt: 500 RR: 16 PEEP: 5 FiO2: 0.7 General: elderly, cachectic male, intubated and sedated HEENT: PERRL, EOMI, MMdry, ETT in place Neck: C-collar in place Pulmonary: coarse breath sounds bilaterally Cardiac: RRR, S1S2, V/VI (+parasternal heave) HSM at LSB to axilla Abdomen: soft, NT/ND, hypoactive bowel sounds, no masses noted, PEG tube insertion site without erythema or drainage Extremities: warm, trace LE pitting edema bilaterally, 1+ DP pulses bilaterally Neurologic: Sedated, moving all extremities. Normal tone in all extremities. 1+ biceps and patellar DTRs bilaterally. Mute plantar response bilaterally. Skin: No rashes noted. Right heel ulcer noted with scant serosanguinous drainage. Pertinent Results: Labs on Admission: EKG: NSR at 66bpm, LAD, LBBB, no ST-T changes noted CXR: bilateral pleural effusions, marked cardiomegaly, perihilar haziness, apparent worsening of CHF in interval since [12-3] Brief Hospital Course: 1. Respiratory failure: Multifactorial and due to CHF exacerbation with possible aspiration event. ABG on admission c/w compensated chronic respiratory acidosis, improved with ventilatory support. 2. Hypotension: Differential includes sepsis vs. cardiogenic shock. The patient was maintained on pressors during his stay in the [Hospital Unit Name 153]. 3. Axis (C2) fx.: maintain hard collar at all times, pt. has f/u with orthopaedics in early [Month (only) 404]. 4. CAD: continue ASA 5. Comm: Daughter [Name (NI) 2155] [Telephone/Fax (1) 110927], son Dr. [Known lastname 8993] (internist, pg. [Telephone/Fax (1) 110930]) 6. Care plan: The paitne was clearly in pain and without a good prognosis given his aspiration risk and his C2 fracture. The family relied on the primary team and the ethics consult service for guidance in planning for Mr. [Known lastname 110931] care. In addition, Mr. [Known lastname 8993] had expressed to his wife the desire to not have his life prolonged by "machines". He was made CMO on [2184-1-30] and placed on a T-piece while still intubated. The patient passed away at 10:30 [2184-1-31]. Post-mortum was declined. Medications on Admission: -toprol XL 75mg po daily -lasix 60mg po daily -isordil 10mg po bid -heparin 5000units sc tid -lisinopril 10mg po daily -ASA 325mg po daily -digoxin 125mcg po daily -pantoprazole 40mg po daily -pramipexole 0.125mg po daily -docusate 100mg po bid -acetaminophen prn -albuterol prn -loperamide prn -senna prn Discharge Disposition: Expired Discharge Diagnosis: Congestive heart failure Discharge Condition: expired	[ "51881", "5070", "42731", "V4581" ]
Admission Date: [2188-2-1] Discharge Date: [2188-2-24] Date of Birth: [2188-2-1] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby girl [Known lastname 18937] is a 32 and [4-15]- week gestation female born to a 21-year-old G1/P0 (now 1) mother and weighing 1580 grams. Prenatal labs included blood type O+, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative and group B strep status unknown. MATERNAL HISTORY: Notable for Grave disease and hypothyroidism, which was treated with PTU; and chronic hypertension, which was treated with propranolol. This pregnancy was complicated by worsening maternal hypertension, resulting in admission on [1-23]. Evaluation for pre- eclampsia was negative. Mother received a course of betamethasone at that time and was betamethasone complete on [1-25]. On the evening prior to delivery mother was noted to have variable fetal decelerations. DELIVERY COURSE: She was monitored in labor and delivery overnight, and on the morning of delivery had a positive oxytocin challenge test, leading to the decision for C- section delivery. Membranes were intact at delivery, and mother was not in labor. At delivery, the infant emerged with moderate tone and a weak cry requiring vigorous stimulate and blow-by oxygen. Apgar's were 6 at one minute and 8 at five minutes of life. PHYSICAL EXAMINATION ON ADMISSION: Weight 1580 grams (25th to 50th percentile), head circumference 28.5 cm (10th to 25th percentile), length 42 cm (25th to 50th percentile). In general, baby girl [Name (NI) 18937] was a comfortable-appearing premature female, quiet but response to exam, in no distress. Her skin was warm, pink, with 1.5-second capillary refill, no bruising, and no rashes. HEENT exam revealed anterior fontanel that was soft and flat. Normal ears and nares. Intact palate. Red reflexes present bilaterally, and supple neck without lesions. Her chest was clear with moderate aeration; and no notable grunting, flaring or retracting. Her cardiac exam revealed a regular rate and rhythm without a murmur. Her abdomen was soft, with flat bowel sounds, no masses, and a 3-vessel cord present. Genitourinary exam revealed normal premature female infant with a patent anus. Her extremities were warm, and her hips and back were stable. Neurologic exam revealed appropriate tone with mildly diminished activity. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. RESPIRATORY: Baby girl [Known lastname 18937] was admitted to the neonatal intensive care unit in room air and never required any respiratory support during her stay. She did not suffer from apnea of prematurity and never required therapy with caffeine. She had rare bradycardic events with emesis. The last of these was on [2-18]; six days prior to discharge. 1. CARDIOVASCULAR: Baby girl [Known lastname 18937] required 1 normal saline bolus on admission for borderline low blood pressure, but thereafter was hemodynamically stable for the remainder of her stay. She was never noted to have a murmur or any other cardiac issues. 1. FLUIDS, ELECTROLYTES, AND NUTRITION: Baby girl [Known lastname 18937] was initially held n.p.o. for 24 hours; then was started on feeds. She advanced to full feeds of Premature [Known lastname 37112] or breast milk 20 calories per ounce by day of life 7; then was advanced to a maximum calorie density of 26 calories per ounce with ProMod. She was changed to [Known lastname 37112] 24 calories per ounce 1 day prior to discharge with no resulting weight loss. At the time of discharge, she had been taking all p.o. feeds for the past 4 days. Her weight at discharge was [2192] grams. 1. HEMATOLOGY: Baby girl [Known lastname 35729] initial hematocrit was 49.7%. She never required a transfusion with packed red blood cells but was supplemented with oral iron. She had hyperbilirubinemia which was treated with single phototherapy from days of life 2 to 10. Her maximum bilirubin level was 7.9 with a direct component of 0.4, and her rebound on day of life 11 was 4.5 with a direct component of 0.4. 1. INFECTIOUS DISEASE: Baby girl [Known lastname 18937] had an initial CBC that was reassuring but was treated with ampicillin and gentamicin secondary to her risk of infection. Blood cultures remained negative at 48 hours, and these antibiotics were discontinued. She never required further antibiotic therapy during her hospitalization. 1. NEUROLOGIC: Baby girl [Known lastname 18937] did not require a screening head ultrasound as her gestation was greater than 32 weeks. 1. SENSORY: Hearing screening was performed with automated auditory brain stem responses and was passed bilaterally. Baby girl [Known lastname 18937] did not require ophthalmologic exam for retinopathy of prematurity as her gestation was greater than 32 weeks. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home with mother. NAME OF PRIMARY PEDIATRICIAN: [Street Address(1) ]. CARE/RECOMMENDATIONS: 1. Feeds: At discharge, baby girl [Name (NI) 18937] is feeding [Name (NI) 37112] 24 calories per ounce ad lib well. 2. Medications: Her only medication is ferrous sulfate supplement. 3. She underwent car seat position screening and passed. 4. She has had newborn State screens sent on [1-31] and [2-3]. IMMUNIZATIONS RECEIVED: She received immunization with hepatitis B vaccine on [2-24]; prior to discharge. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: (1) born at less than 32 weeks; (2) born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or (3) with chronic lung disease. Baby girl [Known lastname 18937] did not meet any of these qualifications and did receive Synagis vaccine. 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 PLANS: Follow-up appointment is to be [Location 64882]Clinic in 2 to 3 days. The phone # for [Hospital1 ]Clinic is ([Telephone/Fax (1) 2535]. DISCHARGE DIAGNOSES: 1. Prematurity at 32 and 3/7 weeks gestation. 2. Rule out sepsis. 3. Hyperbilirubinemia. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Doctor Last Name 56593] MEDQUIST36 D: [2188-2-26] 15:29:54 T: [2188-2-26] 16:47:59 Job#: [Job Number 64883]	[ "7742", "V290", "V053" ]
Admission Date: [2140-1-11] Discharge Date: [2140-1-14] Date of Birth: [2100-4-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 458] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization Cold MI protocol History of Present Illness: 39m with no significant PMH or cardiac hx developed intense substernal chest pain on the morning of admission while lifting weights, was quickly transferred to [Hospital1 18] via EMS, was found to have an anterior ST-elevation MI, and was taken to the cath lab where an LAD stent was placed. He says outside of some mild, self-limited chest discomfort and dyspnea 3 days prior to admit, he's never had chest pain or exertional dyspnea before. He has been overweight for years but has lost about 60-70 pounds over the past 1-2 years by dieting and exercise. He walked for 3 miles two days before admit with no chest pain, lightheadedness, or dyspnea. On the morning of admit, the pain came on suddenly while exercising and was associated with significant dyspnea. EMS was called and he was brought to the ED, where an ECG showed ST elevations in I, aVL, V2-V6, with reciprocal inferior depressions. He was taken immediately to the cath lab where a discrete mid-distal LAD lesions was found and opened with a Cypher stent. He reported good resolution of his sx with the cath and was started on the COOL-MI protocol. Past Medical History: -Depression -Obsesity with good weight loss during [2138]-[2139] Social History: Lives with his wife. He's never smoked, only socially drinks etoh, and has never used illicit or injection drugs. He has been actively exercising over the past few years. Family History: Parents are healthy, has one sibling who's healthy. No known fhx of CAD. Physical Exam: PE: t 32.5 celsius, bp 113/76, hr 98, rr 14, spo2 100% 2Lnc gen- pleasant, well-appearing male, shivering, non-tox, nad heent- anicteric, op clear with mmm neck- lying flat so hard to assess jvp, no lad or thyromegaly cv- reg but tachy, no m/r/g pul- moves air well, no w/r/r abd- soft, nt, nd, nabs extrm- no cyanosis/edema, warm/dry, full dp pulses bilaterally nails- no clubbing, no pitting/color changes/indentations neuro- a&ox3, no focal cn/motor deficits Pertinent Results: Admission [2140-1-11] 07:15AM: GLUCOSE-96 UREA N-18 CREAT-1.5* SODIUM-142 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-16* ANION GAP-30* . WBC-7.8 RBC-5.12 HGB-15.6 HCT-45.3 MCV-89 MCH-30.5 MCHC-34.4 RDW-13.4 PLT COUNT-277 NEUTS-59.7 LYMPHS-28.1 MONOS-5.9 EOS-5.0* BASOS-1.3 . PT-11.3 PTT-19.4* INR(PT)-1.0 . Cholesterol panel: Total 111, Trig 43, HDL 34, LDLcalc 68, LDLmeas 71. . HgbAlc 5.2% . Cardiac Enzymes: [2140-1-11] 07:15AM CK(CPK)-86 CK-MB-NotDone cTropnT-LESS THAN [2140-1-11] 03:19PM CK(CPK)-815* CK-MB-64* MB INDX-7.9* [2140-1-11] 11:29PM CK(CPK)-963* CK-MB-50* MB INDX-5.2 [2140-1-12] 06:05AM CK(CPK)-797* CK-MB-36* MB INDX-4.5 [2140-1-13] 06:04AM CK(CPK)-727* CK-MB-31* MB INDX-4.3 . Cath Report [2140-1-11]: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated single vessel disease. The LMCA, LCX, and RCA were free of angiographic lesions. The LAD was totally occluded at mid vessel. 2. Limited hemodynamic assessment revealed low-normal systemic blood pressure (92/55 mmHg) and markedly elevated LVEDP (25 mmHg). Right heart catheterization was deferred. 3. Left ventriculography demonstrated 4. Successful delivery of the Radiant cooling catheter. 5. Successful PCI of the mid LAD using a 2.5x18mm Cypher drug eluting stent. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal ventricular function. 3. Acute anterior myocardial infarction managed by PCI of the left anterior descending coronary artery. . Echo [2140-1-12]: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the mid to distal anterior wall, septum, and apex. The remaining segments contract normally. A left ventricular mass/thrombus cannot be excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Focal hypokinesis of the mid to distal anterior wall, septum, and apex consistent with coronary artery disease. Mild pulmonary artery systolic hypertension. . Discharge labs significant for Creatinine of 1.3. (trend had been 1.5 to 1.0 and up to 1.3 upon starting aceI). Brief Hospital Course: #STEMI/CAD -- Patient presented with STEMI. Patient went immediately to cath and a 100% LAD lesion was found and stented with a DES. Cath showed no other evidence of stenosis in the other coronary vessels. CK peaked at 963. Unclear why this young, otherwise healthy male who seems to be active, exercising (with great exercise tolerance), and has no major risk factors would have an MI. One theory is that he developed CAD during the period when he was overweight (and perhaps had some element of hyperlipidemia and glucose intolerance) with the development of athersclerotic plaques at the time and ruptured one today while exerting himself. Other possibilities would be familial hypercholesterolemia, hyperhomocysteinemia, or other metabolic abnormality. His cholesterol panel was within guidelines and HgbA1c of 5.2%. He was started on aspirin 325 QD, clopidogrel 75mg QD, atorvastatin 80mg QD, metoprolol XL 50mg QD, and lisinopril 5mg QD. He was scheduled to follow up with cardiology (Dr. [Last Name (STitle) ]). . # ARF -- Patient had admission creatinine of 1.5. It decreased to 1.0 and was thought to be secondary to pre-renal effect. It increased to 1.3 on the day after lisinopril was started. He should be seen by his PCP in the next week and have chemistries rechecked in setting of starting aceI. . #Depression -- He was continued on lamotrigine and quetiapine. Medications on Admission: Lamotrigine 400mg qAM Quetiapine 50mg qPM Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): It is important that you take this medication every day. . Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Lamotrigine 100 mg Tablet Sig: Four (4) Tablet PO QAM (once a day (in the morning)). 5. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed): You may take 1 pill up to 3 times for chest pain every five minutes. If you are having any chest pain call 911. Disp:100 Tablet, Sublingual(s) Refills:2 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: STEMI Secondary: Depression Discharge Condition: Stable. Discharge Instructions: You had a major heart attack. Please take all medications as prescribed. MOST IMPORTANTLY you must take the aspirin and plavix (also called clopidigrel) every day! If you do not, you could have another major heart attack. Please take all of your other medications as prescribed. You were started on three other medications, Toprolol XL (also called metoprolol), Lisinopril and Atorvastatin (also called lipitor). . Please follow up with your PCP and cardiologist (info below). . Please follow all recommendations about activity. . Please seek medical attention for chest pain, lightheadedness, swelling in your feet, difficulty breathing or anything else that is concerning to you. Followup Instructions: Please see your PCP in the next 7-10 days. Please have them check your chemistries after starting lisinopril. . Please follow up with your cardiologist, Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2140-1-27] 1:20 ([Hospital Ward Name 23] Building [Location (un) 436]).	[ "5849", "2762", "41401" ]
Admission Date: [2100-7-14] Discharge Date: [2100-7-21] Date of Birth: [2016-5-13] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2297] Chief Complaint: Dyspnea, pneumonia, Acute on Chronic CHF exacerbation Major Surgical or Invasive Procedure: Diagnostic and Therapeutic thoracentesis of right hemithorax History of Present Illness: Patient is an 84yo male with PMH of systolic CHF (EF 40%, with recent TTE 30%), esophageal CA s/p gastroesophagectomy, CAD s/p CABGx4, admitted for hypoxia, increasing SOB, now with transfer to the MICU for hypoxia and hypotension. He was recently admitted for an aspiration PNA and discharged on Augmentin. He was then readmitted, and started on Vanc/ZOsyn and flagyl briefly for HCAP. He continues to have a leukocytosis despite abx. He had tapped pleural effusion that is transudative, thought to be [2-10] CHF. He had a repeat TTE which showed worsening EF from 40% to 30%. He was being diuresed with IV lasix 40mg [Hospital1 ], with inital improvement in hypoxia. However, this was limited by now worsening renal failure. He is making only ~300cc of urine in the last hour. His hospitalization has also been complicated by hypernatremia, likely [2-10] decreased free water access, not given back free water yet. This evening, he became hypotensive to 82/56, mentating well A&Ox3, hypoxic 6L NC with 55% facemask at 97%?. He had been hypoxic the evening prior, with desats to 81% on 4LNC, iwht improvement with duonebs & facemask. Since 0300 on the morning prior to transfer, pt was on on 4LNC + 50%FM. For the hypotension, he was bolused 250ccx2 and then 500cc later this evening, with minimal BP response. A code discussion was had between the patient and his daughter, and the decision was made to reverse his code status to full code. . Currently, he feels SOB, but that it has not changed in the last couple of hours. He says that he started to feel worse this afternoon after the thoracentesis was done. He denies any chest pain or pain anywhere else. He has had a dry, non-productive cough. . ROS: As above. last BM was today, brown per pt report. He also always feels cold, which is unchanged. Denies fever, chest pain, productive cough, abdominal pain, diarrhea, bloody or black bowel movements. Past Medical History: CAD s/p CABGx4 ([2085]) systolic CHF (EF 40% on echo [2099-1-19]) Esophageal CA s/p chemo, radiation, gastroesophagectomy [2088] PUD, GERD, Barrett's, h/o GI bleed HTN BPH depression narcolepsy osteoarthritis microvascular strokes without sequelae h/o C. diff colitis spinal stenosis Social History: Per medical floor team history The patient does not smoke any cigarettes but did during WWII and the Korean War. He smoked a pipe/day until his CABG in [2085]. He drinks a glass of red wine per day. He is currently living alone while his wife is in rehab. They have no children together but wife does from a previous marriage. His stepdaughter [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] is very involved in his care. Family History: Notable for cardiac disease in mother and father (died of heart disease age 45). Brother died recently of complications secondary to DM. Physical Exam: On admission: VS - Temp 98.8F, BP140/70 , HR88 , R20 , O2-sat 93% 4LNC GENERAL - comfortable, appropriate, cachectic HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear, palate raises evenly NECK - supple, no thyromegaly, JVD 3cm above sternal notch LUNGS - prominent rhonchi throughout lung fields, breath sounds heard at bases but difficult to discern level with prominent rhonchi HEART - RRR, no M/R/G ABDOMEN - NABS, scaphoid, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - 2+ pitting edema bilaterally SKIN - dry scale over feet with black pinpoint lesion of right great toe LYMPH - no cervical LAD NEURO - awake, A&Ox3, diffusely weak Pertinent Results: On admission: . [2100-7-14] 01:53PM BLOOD WBC-17.6# RBC-2.80 Hgb-9.3* Hct-27.6* MCV-98 MCH-33.3* MCHC-33.9 RDW-14.2 Plt Ct-226 [2100-7-14] 01:53PM BLOOD Neuts-91.3* Lymphs-5.4* Monos-2.7 Eos-0.4 Baso-0.3 [2100-7-14] 01:53PM BLOOD Glucose-86 UreaN-42* Creat-2.3* Na-144 K-4.4 Cl-108 HCO3-29 AnGap-11 [2100-7-14] 01:53PM BLOOD proBNP-[Numeric Identifier ]* [2100-7-15] 05:50AM BLOOD Albumin-2.0* Calcium-7.8* Phos-3.8 Mg-1.8 [2100-7-15] 08:40AM BLOOD Vanco-30.4* . On day of death: . [2100-7-21] 02:49AM BLOOD WBC-25.0* RBC-2.54* Hgb-8.1* Hct-24.8* MCV-98 MCH-32.0 MCHC-32.9 RDW-15.3 Plt Ct-153 [2100-7-21] 02:49AM BLOOD Glucose-58* UreaN-66* Creat-4.5* Na-150* K-4.0 Cl-110* HCO3-22 AnGap-22* [2100-7-21] 02:49AM BLOOD Calcium-8.0* Phos-6.0* Mg-2.3 Brief Hospital Course: Patient is an 84yo male with PMH of Esophageal CA s/p gastroesophagectomy with stomach pull-through, CAD s/p CABGx4, and CHF with previous ejection fraction of 40% who presented from rehab with acute shortness of breath from acute on chronic CHF exacerbation, and aspiration pneumonia. Patient was recently hospitalized for aspiration pneumonia, and chronically aspirates even when following recommendations from speech and swallow recommendations. Pt was transferred to the MICU for hypoxia and hypotension. Hypoxia was attributed to multifactorial etiology of pulmonary edema from heart failure, pleural effusions and pneumonia. He was persistently hypotensive, in part likely [2-10] hypovolemia, but mostly thought to be secondary to systolic heart failure. A code discussion was had with the family and pt was made DNR/DNI with the decision not to pursue invasive treatments with lines, pressors, etc. During the admission he was made CMO and expired. . #. Shortness of breath/cough: Given patient's history of aspiration event in the past with worrisome s+s eval and history of acutely worsening dyspnea, patient likely had another aspiration event. Concern for aspiration pneumonia vs. aspiration pneumonitis. HCAP and atypical pneumonia remain possibilities as well and were treated. He was also in heart failure. Discussion was held with the patient and family, and given the irreversibility of his heart failure and acute worsening of his condition, he was made CMO and expired 7 days after admission. . #. ARF: Patient with BUN/Cr suggestive of prerenal azotemia. Possibly due to poor forward-flow in setting of CHF exacerbation. However, worsening with diuresis. Creatinine continued to worsen until his death. Medications on Admission: tylenol 650mg PO Q4H prn pain or fever MOM 30ml po daily daily prn constipation Zofran 4mg po Q4H prn nausea ferrous sulfate 325mg po daily finasteride 5mg po daily opium tincture 10mg/5 drops po q6h prn dumping syndrome carvedilol 6.25mg po bid aspirin 81mg po daily mirtazapine 7.5mg omeprazole 40mg po daily amoxicillin 500/125mg PO q12H (3 more days to completion) Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Aspiration pneumonia Acute on chronic CHF exacerbation Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a	[ "5070", "5849", "2760", "4280", "53081", "311", "4019", "V4581" ]
Admission Date: [2127-2-23] Discharge Date: [2127-4-25] Date of Birth: [2065-12-24] Sex: M Service: MEDICINE Allergies: Ativan Attending:[First Name3 (LF) 3918] Chief Complaint: syncope Major Surgical or Invasive Procedure: CT guided liver biopsy PICC line placement, removed IVC filter placed R IJ triple lumen catheter History of Present Illness: This is a 61-year-old man with a history of diffuse large B-cell lymphoma status post six cycles of R-CHOP between [6-/2126] and [10/2126] and also status post five cycles of high-dose methotrexate and one dose of intrathecal methotrexate, who presents with symptoms cough, shortness of breath, mild chest discomfort, generalized weakness, and possible syncopal episode at his rehab facility today. The patient is a somewhat poor historian, but per notes from [Hospital1 ], the patient was found by the staff at rehab to be hypotensive (SBP 60's)and minimally unresponsive after having had a bowel movement earlier this morning. Given that he had recently been admitted to [Hospital1 18] for similar symptoms, the rehab staff was concerned that he had again experience a syncopal episode, and sent him to [Hospital1 ] ED for further evaluation. The patient states that he does not recall losing consciousness earlier today, but cannot elaborate any further and cannot say if he forgot any of the events which occurred earlier this morning. He does describe that he had mild chest discomfort and left thigh pain that made him feel short of breath and unable to talk, but that he is currently pain free. He also states that he has had symptoms of a cough and shortness of breath for a few days, but that his shortness of breath today was worse. While at [Hospital1 ], the patient was found to tachycardic to the 120's, afebrile, with a BP of 96/64. He had radiographic evidence concerning for a RUL PNA on CXR. He was also noted to be coughing with thick secretions that improved with humidified air. A head CT was unremarkable. EKG showed non specific lateral T wave changes, as well a troponin level of 0.26, however, upon arrival there, the patient denied having any symptoms of chest discomfort earlier in the day. His tachycardia improved to the 90's after receiving 2L of IVF. The patient was given 2gm of IV Ceftazidime for his pneumonia and transferred to [Hospital1 18] for further care per the request of his family. In arrival to [Hospital1 18] ED, initial vitals: T- 98.5, BP 115's/70's, HR 110's, O2 99% RA. Troponin was found again to be slightly elevated (0.39), but lower than when he was recently discharged. 1L IVF given and the patient's HR improved to 100. In the [Name (NI) ], pt remained afebrile, with stable BP (135-94), RR 18, O2 97% RA, upon transfer to the floor. Of note, the patient was recently admitted to the [Name (NI) 3242] service on [2127-2-11] for nausea and abdominal pain. He underwent a work up which included a CT of the abdomen and pelvis which showed colitis involving the distal portion of the transverse colon, descending colon, and proximal sigmoid colon. A new 2cm right hepatic lesion concerning for lymphoma was also identified on that scan. The patient also underwent an EGD that was unremarkable, Sigmoidoscopy which confirmed pseudomembranous colitis, and an upper GI study which showed dysmotility in the lower third of esophagus, but no evidence of stricture or mass. During that admission, the patient was ultimately found to be [Date Range ] positive, treated with PO vancomycin, and discharged back to his [Hospital1 1501] on [2127-2-17] with improvement in his symptoms. Shortly after discharge, the patient returned to the ED after being found by EMS to have altered mental status, junctional bradycardia with HR 20-30's, and hypotension with systolic BP's in the 80's. The patient was observed on the [Hospital Unit Name 196] service, underwent a TTE which showed a normal LVEF, mild MR but otherwise no significant valvular abnormalities, and no overall interval change from previous TTE in [2126-12-19]. The patient was evaluated by EP and determined to have had experienced a vasovagal episode. Troponins during that admission were mildy elevated, but were determined to be secondary to demand ischemia, with flat CKs as well. . Past Medical History: Past Oncologic History: Mr. [Known lastname ] initially presented to an outside hospital in [6-25] with a 30-pound weight loss over the prior 6 months. He was worked up and found to have a soft tissue mass in the cardiac ventricles involving the myocardium and extending into the interatrial septum. He was also noted to have multiple pulmonary nodules, bilateral pleural effusions, a pericardial effusion, large bilateral adrenal masses, and diffuse soft tissue masses involving both kidneys. The [Hospital 228] hospital course was complicated by the development of tamponade physiology, and the patient ultimately underwent a pericardial window. A renal biopsy on [2127-7-23] confirmed diffuse large B-cell lymphoma (Stage 4B), and a pericardial biopsy on [2127-7-25] also was consistent with large B-cell lymphoma. He was diffusely immunoreactive for CD20 and co-expressed Bcl-2 and Bcl-6. CD43, CD5, TdT, Bcl-1, S100 were negative. LMP for EBV was negative. CD10 and CD30 were weekly expressed. In addition, a bone marrow biopsy demonstrated bone marrow involvement by lymphoma. The patient was initiated on R-CHOP on [2126-7-26] and received six cycles between [7-/2126] and [10/2126] and is also status post five cycles of high-dose methotrexate and one dose of intrathecal methotrexate. Past Medical History: # Large B Cell lymphma as above # Recent C Diff Colitis # DVTs, on Lovenox # Strep viridans bacteremia (1 bottle; PICC-associated? treated w/ ceftriaxone/PCN/ceftriaxone x4 weeks total) # Erythema nodosum, right forearm ([8-/2126]) # Nephrolithiasis # Anemia # Gerd . Past Surgical History: # Amputation of right 2nd digit after electrical accident 45 years ago Social History: Social History: (Per OMR) The patient is married and has one son. [Name (NI) ] is a retired engineer. + 60 pk year history of tobacco, but quit in [Month (only) 205] of [2125], just prior to his diagnosis of lymphoma due to symptoms of profound weakness. Drinks socially, ~ 2 drinks per month. No illicit drug use. One son is alive and healthy, and is also a physician. [Name10 (NameIs) ] has been able to accomplish basic ADLs with minimal assistance, but is dependent on advanced ADLs. Family History: FHx: Family History: (per OMR) Father - died of [Name (NI) ] Mother - SLE, DM, CAD; died age 75 Brother - cardiac arrythmias Brother - prostate CA Son - healthy Physical Exam: Physical Exam on Admission: V/S: T- 97.8, BP 142/77, P 103. R 20, O2 99% RA GEN: Thin, cachetic appearing, pale, and sleepy but easily arousable, in NAD HEENT: PERRL, EOMI, mucous membranes dry, oropharynx clear NECK: No lymphadenopathy PULM: No evidence of respiratory distrses, lungs clear to auscultation without wheezes, rhonchi or rales CV: Tachycardic, nl s1, s2, no murmurs or extra heart sounds appreciated ABD: soft, flat, non-tender, non distended, hyperactive bowel sounds, no hepatosmplenolmegaly EXT: Warm, well perfused without lower extremity edema. Non-tender calves, 2+ distal pulses bilaterally NEURO: Follows commands, oriented x 3. . Physical Exam on Discharge: VS: T 97.2 BP 104/64, HR 92, RR 18, 99% RA GEN: thin man, cachetic, NAD HEENT: PERRLA, EOMI, MMM, OP clear NECK: R IJ in place supple PULM: CTA B/L CV: regular rate and rhythm, no murmurs, rubs and gallops ABD: soft, non-tender, non-distended, no HSM EXT: diffuse peripheral edema, 3+ pitting edema of bilateral lower extremities, RUE > LUE swelling NEURO: alert and oriented X 3, cranial nerves II-XII intact, [4-22] muslce strenth Pertinent Results: CXR on admission: FINDINGS: In comparison with the study of [1-3], the left subclavian catheter has been removed. Little change in the appearance of the heart and lungs. Right apical pleural thickening and scarring persists. No definite acute focal pneumonia. [2127-2-27] BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son[Name (NI) 867] of the right and left common femoral, superficial femoral and popliteal veinswere performed. On the right, there is a small amount of intraluminal material in the right mid superficial femoral vein where the vein does not compress completely, consistent with a very small amount of residual thrombus. The distal portion of the right SFV and both popliteal veins are now compressible (previously were not compressible). Aside from the focal abnormality in the mid right superficial femoral vein, deep veins of the right and left lower extremities are patent and compressible, with normal waveforms and augmentation. IMPRESSION: Mild residual thrombus is present in the mid right superficial femoral vein, which is not fully compressible at this time. Elsewhere, the veins are patent and compressible. Unilateral Extremity Ultrasound (L leg): IMPRESSION: Occlusive DVT involving the left common femoral vein and superficial femoral vein in its proximal and mid portions. CT Scan: [3-16] IMPRESSION: 1. Marked bowel wall thickening and edema involving the cecum and ascending colon, consistent with typhlitis. Additionally, inflammatory changes surround the transverse, descending and sigmoid colon, and rectum, but to a lesser degree than the cecum and ascending colon. No evidence of perforation. 2. Cholelithiasis with unchanged prominent CBD measuring 11 mm and proximal pancreatic duct measuring 5 mm. 3. Heterogeneous hypodensities of the inferior poles of the right kidney, adjacent to the inflamed bowel and mesentery, likely reactive inflammation. 4. Unchanged atherosclerotic disease with stable mild aneurysmal dilatation of the right common iliac artery. 5. Previously noted right hepatic lesion not well visualized. CT Scan: [3-21] IMPRESSION: 1. Near-complete interval resolution of left chest wall mass, with decreased cardiac masses, consistent with improvement in lymphoma. 2. Circumferential wall thickening and inflammatory change involving the proximal ascending colon, suspicious for colitis which may be infectious or inflammatory in nature. 3. Stable right upper lobe consolidation with central cavitation, with multiple additional nodular opacities which are stable to minimally decreased in size, as described. 4. Multiple peripheral renal hypodensities bilaterally, which may reflect infection, small regions of infarct, or may be related to the patient's known lymphoma. Multiple regions of scarring are also present within the left kidney. Recommend clinical correlation. 5. Cholelithiasis. 6. Fullness of the adrenal glands bilaterally. This is slightly more prominent at the lateral aspect of the left adrenal gland, but no definite focal adrenal lesion is seen. 7. Extensive atherosclerotic disease of the distal aorta with bilateral common iliac artery aneurysms measuring up to 2.5 cm in size on the right. CT Scan [2127-4-1]: 1. Unchanged colonic wall thickening particularly of the cecum, and ascending colon. The transverse, descending, and sigmoid colonic wall is also thickened, although to a lesser degree. These findings may be consistent with typhlitis, a diffuse colitis, or Clostridium difficile colitis. 2. Patent abdominal arterial vasculature including the arterial and venous systems. 3. Sigmoid diverticulosis without diverticulitis. 4. New abdominal and pelvic ascites. 5. Dilation of the left femoral vein compared to the right raising concern for a thrombus within the left femoral vein and would recommend further evaluation with ultrasound. 5. Stable aneurysmal dilation of the right and left iliac arteries. Echo [2127-3-27]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal inferior wall. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2127-3-10], the heart rate is much lower. Overall ejection fraction has improved with now only very mild hypokinesis of the basal inferior wall. The other findings are similar. Head MRI [2127-4-16]: 1. No acute intracranial abnormalities. No evidence of intracranial neoplastic disease. No significant change compared to [Month (only) 958] [2126]. 2. Stable appearance of remote left basal ganglia lacunar infarcts and chronic small vessel ischemic disease U/S RUE [2127-4-22]: IMPRESSION: Expansile right extremity DVT extending through the majority of the right subclavian, as well as the entire axillary and brachial veins. There is also a probable thrombus in the basilic vein, although examination was technically difficult. The cephalic vein was not identified. Lab Results on Discharge [2127-4-25]: WBC 9.1 98% N, 2%L, 0%M, 0%E ANC 8918 HCT 23.5 (received 1 unit PRBCs after this result) Platelets 63 . Na 141 K 3.5 Cl 108 CO2 28 BUN 23 Creat 0.5 Glucose 81 Calcium 7.4 Mg 1.5 Phos 2.4 ALT 17 AST 20 LDH 220 Alk Phos 60 T. Bili 0.5 Brief Hospital Course: 61 y/o M with hx of DLBCL who presents with second syncopal episode in one week, with continued elevated troponins and unclear etiology of syncope. Transferred from [Hospital1 ] for concern of RUL pneumonia. Received 3 courses of ESHAP and intrathecal chemotherapy during this hospitalization. Hospital course complicated by fever and neutropenia secondary to clostridium difficile infection, typhlitis, and atrial fibrillation with rapid ventricular rate. Hospital course by problem list: # RUL PNA: On admission, patient with symptoms cough and shortness of breath, and noted to have thickened sputum production at [Hospital ] hospital with portable CXR concerning for pneumonia. Was covered with zosyn initially here. Repeat PA and lat CXR here did not show a pneumonia and the zosyn was stopped after two days because he did not clinically appear infected. Was not neutropenic. Then had an episode of aspiartion while in the CCU and found to have aspiration pneumonitis v. aspiration pneumonia on CXR. Was treated with a 8 day course of flagyl/levo and stopped. His cough and symptoms improved. # Pre-syncope: Episode very similar to previous episode of syncope, occuring after pt had BM, with associated transient hypotension and bradycardia. By time of admission, the patient was normotensive, without bradycardia, and alert. Calcium channel blocker discontinued last admission, which was initially started for achlasia. During admission he was asymptomatic and monitored on telemetry for four days. He had no alarms. He had orthostatic hypotension with daily vitals. We did try a bolus challenge and after 500 cc NS, his orthostatics improved slightly but quickly returned on recheck several hours later. His syncope was thought to be either secondary to vaso-vagal syncope associated with BMs or orthostasis. We did not start beta blocker because of orthostasis. We started captopril for hypertension while lying down and wanted to optimize his cardiac standpoint. Then on [2-28] at 11am, pt had an episode of syncope. He stood up, walked to the chair, sat down for a few minutes then felt dizzy and became unresponsive. His BP was 60s/30s, responsive to IVFs, HR btw 70s and 120s. EKG showed new T wave inversions. He was incontinent of stool during this episode. He regained responsiveness after only two to three minutes and was A+Ox3 but lethargic. He complained of SOB and O2 was 98% on RA. He said it felt similar to his other episodes. Cards was reconsulted and he was transferred to CCU for possible EP study as arrhythmia as possible cause of syncope. CCU Course: Pt did not have any further episodes of syncope or arrhythmia while monitored on telemetry on the cardiology floor. No EP study was performed since pt did not have any further episodes despite having several BMs on the floor. He was later found to have lymphoma involvement of the heart based on CT scan, which was likely the cause of the syncope. We started chemo as outlined below. He had no more syncopal episodes. # Diffuse Large B-Cell Lymphoma: Patient is s/p 6 cycles R-CHOP + Methotrexate, completed in [10-26]. However, recent CT abdomen showed evidence of new liver lesion concerning for disease recurrence. Had CT guided liver biopsy on [2127-2-26]. The biopsy was positive and on workup of other disease, was found to have involvement in his heart, chest wall and retropharyngeal space. He also was assumed to have it in his CSF, even though the first LP had only one aytpical cell. He received a total of 3 cycles of ESHAP chemotherapy and two doses of intra-thecal ARA-C. His last cycle of ESHAP was [Date range (1) 79455]. No discrete hepatic lesions noted on CT abdomen on [3-21]. Flow cytometry showed indefinite evidence of lymphomatous involvement of the CSF. He was followed by neuro-oncology in-house who recommended no further IT ARA-C and to follow his neurologic symptoms clinically, and to re-refer him back to his outpatient neuro-oncologist (Dr. [Last Name (STitle) 79456] if he had any worsening confusion or neurologic symptoms. # Febrile neutropenia - Patient had fever and neutropenia, and was treated with IV and oral vancomcyin, cefepime, flagyl, ciprofloxacin and micafungin. Likely source was C. difficile infection (see below). # h/o C Diff colitis: Pt with episode of diarrhea at rehab, and with loose stool here. Last stool sample on [2127-2-20] negative for [Name (NI) ], pt has been on PO vanc for positive stool culture on [2-12]. Had continued diarrhea while inpatient and was started on PO flagyl. It seemed to improve slightly, but still was present. Eventually two more c.diff samples were negative and the meds were stopped. When he became neutropenic, his diarrhea started to be more severe and he had abdominal cramping and a positive c.diff again on [2127-3-12]. He was treated with PO vancomycin and IV/PO flagyl. He did not tolerate PO Vancomycin and was continued on IV Flagyl on discharge. Diarrhea has slowed down dramatically and C. difficile toxin assay was negative x3 on discharge. His IV Flagyl should continue until [2127-5-8] to complete a 14 day course after all other antibiotics were stopped. # Typhlitis: Noted in the setting of chemotherapy. Treated with IV/PO Vancomycin, Cefepime, and IV/PO Flagyl. Noted to have stable cecal and ascending colon thickening on serial CTs. PO Vancomycin discontinued due to nausea. These antibiotics were discontinued at the time of discharge and he was discharged on IV Flagyl for his C. Diff. # DVTs - was initially on lovenox for DVT diagnosed in [Month (only) ]. Lovenox was held for liver biopsy and repeat B leni's showed no further DVT, so it was decided to not continue lovenox. Then his L leg swelled again and he had another DVT in his left common femoral vein diagnosed on [2127-3-10]. An IVC filter was placed in lieu of anticoagulation because of his low platelets from chemotherapy. On [2127-4-22], swelling of the right upper extremity was noted. This was the site of his PICC line. An ultrasound showed extensive clot in the subclavian and axillary veins. He was started on Lovenox, 1mg/kg [Hospital1 ] (60mg SC BID). His platelets should be transfused > 50 while on Lovenox. # Elevated Troponin / likely CAD: Troponin found to be slightly elevated during last admission and determined to be from demand ischemia, as patient was asymptommatic. Earlier today, pt complained of mild chest discomfort, and troponins still slightly elevated, but trending down from last admission. Plan was for stress test as outpatient and started aspirin. No statin because of liver lesion. # Atrial fibrillation with rapid ventricular rate: Patient had a history of this, then multiple episodes of AF w/ RVR while inpatient. Patient was transferred to the MICU twice for AF w/ RVR and hemodynamic instability. During both admissions, he converted to sinus rhythm with either IV metoprolol or IV diltiazem. He had 2 episodes of AF w/ RVR in the setting of being diuresed, one requiring ICU transfer for hemodynamic instability. He was converted with diltiazem again and returned to the floor on an increased dose of metoprolol. He was followed by cardiology who recommended aggressive electrolyte repletion (K > 4, Mg > 2 at all times), no further diuresis with lasix as he was intravascularly dry, (leg elevation and [Male First Name (un) ] stockings for his lower extremity edema) and rate control with Toprol XL PO daily. He has had intermittent atrial fibrillation with hemodynamic stability, blood pressures in the 100s-110s systolic. His Toprol XL dose was increased to 200mg PO daily. He was stable in normal sinus rhythm but had another episode of afib on [2127-4-25] in the morning, lasting for 4 hours. This broke with his Toprol XL dose. He should be given an extra dose of Metoprolol Tartrate 50mg PO at midnight to prevent atrial fibrillation in the morning. #) VRE urosepsis: Noted to have VRE urosepsis on [2127-4-8] with positive blood and urine cultures. Remained hemodynamically stable. Started on Daptomycin on [2127-4-10]. Surveillence blood cultures were drawn and were negative on [2127-4-11] and [2127-4-12]. He remained afebrile. TTE showed no evidence of endocarditis. He completed a 14 day course of daptomycin which ended on [2127-4-24]. Weekly CKs were checked and were stable. He had no other evidence of blood infection, fevers or hemodynamic instability after Daptomycin was stopped. #) Platelet refractoriness: Was noted to not be adequately increasing platelet count after transfusions during neutropenic nadir. HLA typing (panel reactive antibody) typing was negative. Recovered and began responding to platelet transfusions once out of neutropenic nadir. # Back pain- Patient complained of chronic backpain and had decreased rectal tone on exam so L-S MRI ordered but pt refused. L-S plain films showed no evidence of fracture, no evidence of lytic or sclerotic lesions. Minimal dextroscoliosis with no otherwise gross abnormality. The sacroiliac joints are unremarkable. Calcified aorta is noted on the lateral view. There are dense areas in the right upper abdomen most likely representing diverticula. We had the pain service see him and he was switched to methadone 5 mg TID and morphine for breakthrough pain. # Double vision: Seen by opthalmology, has 6th cranial nerve palsy. No evidence of lymphomatous involvement causing palsty. Wear eye patch over L eye. Should be seen in outpatient clinic to be fitted for prizm glasses. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ Instructions for Rehab: Please pretreat with Tylenol 650 mg PO x1 and Benadryl 50 mg PO x1 prior to all blood transfusions. 1. Pt should be monitored on telemetry for atrial fibrillation. If having frequent episodes, Toprol XL can be increased or Metoprolol Tartrate given to help keep pt in sinus rhythm. 2. Pt should have CBC checked daily for the next 7-10 days or until stable. Transfusion parameters are as follows: HCT< 25, transfuse 1 unit PRBCs HCT< 21, transfsue 2 untis PRBCs Platelets <50, transfuse 1 bag platlets, recheck in 1 hour This patient should have platlets maintained over 50 while on Lovenox. 3. Electrolyte Parameters. The patient should have magnesium and potassium repletion on a daily basis. His magnesium and potassium levels should be checked every day and given repletion on the follow scale: Mg < 2.0, give 2gm IV Magnesium Mg < 1.4, give 4gm IV Magnesium K < 4.0, give 40meq Potassium (PO or IV) K < 3.6, give 60meq Potassium (PO or IV) K < 3.2, give 80meq Potassium (PO or IV) 4. Wound Care: Patient has a pressure ulcer on sacrum: Turn patient side to side while in bed off back. If OOB, limit sit time to 1 hr and sit on a ROHO cushion. Please apply a thin layer of DuoDerm Gel to the coccyx ulcer and apply Mepilex sacral border dressing over the area. (Do not use a small Mepilex dressing) Change every 3 days or prn. 5. Triple Lumen catheter: x-ray on [2127-4-23] confirms R IJ triple lumen catheter in SVC. Please provide line care. 6. Neupogen: The patient was started on Neupogen on [2127-4-24] in anticipation of WBC count dropping due to ESHAP. His WBC was 9.1 with ANC of 8918 on [2127-4-25] (after 1 dose). He was given a dose of Neupogen on [2127-4-25]. He should have his WBC and absolute neutrophil count (ANC) checked on [2127-4-26]. If ANC is > [2117] for 2 days, neupogen can be stopped. 7. Antibiotics: IV Flagyl should continue until [2127-5-8] which is 14 days after other antibiotics stopped to treat C. Diff infection. 8. Lasix: IV LASIX WILL CAUSE THIS PATIENT TO GO INTO ATRIAL FIBRILLATION. Swelling should be treated with leg elevation and [Male First Name (un) ] stockings. If Lasix is clinically indicated, small doses of PO Lasix can be used with caution. Medications on Admission: Enoxaparin 60mg Subcutaneous Q12H Fentanyl Patch 100 mcg/hr Q72H Vancomycin 250 mg PO Q6H through [2-28] Metoclopramide 10 mg PO QID Protonix 40 mg PO once a day. Multivitamin one capsule PO daily. Hydromorphone 4 mg - 8mg PO Q6H prn pain Acetaminophen 325 mg PO Q6H prn Simethicone 80 mg PO Q8 PRN Gas pain. Compazine 10 mg PO Q8 PRN nausea. Colace 100 mg PO twice a day PRN constipation. Zolpidem 5mg po QHS prn Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply near back. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed: On aspiration pre-cautions, please brush onto tongue. 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO every six (6) hours as needed for nausea: ONLY GIVE IF PATIENT COMPLAINS OF NAUSEA. 5. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H (every 24 hours): give until ANC > [2117] for 2 consecutive days. 7. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed for pain: hold for RR < 9, sedation. 8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Eight (8) mg Injection Q6H (every 6 hours) as needed for nausea. 9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 11. Magnesium Sulfate 4 % Solution Sig: [1-22] grams Injection once a day as needed for as directed: Per sliding scale below: Magnesium <1.2: 4 gm and [Name8 (MD) 138] MD Magnesium 1.2-1.5: 4 gm Magnesium 1.6-1.7: 2 gm Magnesium 1.7-2.0: 2 gm . 12. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. Potassium Chloride 20 mEq/50 mL Piggyback Sig: 40-60 mEQ Intravenous once a day as needed for per sliding scale: Sliding Scale: Potassium 4.0 - 3.6: 40 mEq Potassium 3.5 - 3.3: 60 mEq Potassium 3.2 - 3.0: 80 mEq Potassium < 3.0: Notify HO . 14. Potassium Phosphate Dibasic 3 mMole/mL Parenteral Solution Sig: Fifteen (15) mMole Intravenous PRN (as needed) as needed for per sliding scale: Sliding Scale: Phosphate >= 1.5 < 2.4: 15 mmol Phosphate < 1.5: Notify HO . 15. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 18. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). 19. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 20. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 21. Metoclopramide 10 mg IV BID:PRN nausea, dry heaving 22. Chlorpromazine 25 mg/mL Solution Sig: Ten (10) mg Injection Q4H (every 4 hours) as needed for wretching, dry heaves. 23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 14 days: last dose on [2127-5-8]. 24. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 25. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 1110] Discharge Diagnosis: Primary Diagnosis: 1. Diffuse Large B-cell Lymphoma 2. Deep Vein Thrombosis in lower and upper extremities 3. Atrial Fibrillation with Rapid Ventricular Rate, intermittent 4. Cardiogenic Syncope 5. Clostridium difficile infection 6. Febrile neutropenia 7. Typhlitis 8. VRE Urosepsis Discharge Condition: afebrile, hemodynamically stable, in normal sinus rhythm Discharge Instructions: You were admitted for fainting, it was likely due to the lymphoma in your heart. We monitored you closely, and then started chemotherapy. You received 2 doses of ESHAP chemotherapy and intrathecal ara-C as well. Your cancer showed some improvement with this chemotherapy. You had a rapid heart rate known as atrial fibrillation with rapid ventricular rate. This was controlled with medications and you are currently on oral metoprolol to control this heart rate. You had fevers while your counts were low. You also had clostridium difficile infection again, and an infection of the colon known as typhlitis. Both of these conditions, we treated with antibiotics. You remain on Flagyl IV on discharge. The following changes were made to your home medications. 1. Your enoxaparin, fentanyl patch, hydromorphone, tylenol, compazine, and zolpidem were stopped. 2. You were started on methadone 5 mg by mouth three times a day, morphine, and lidocaine patch for pain control. 3. You should continue on flagyl IV for 14 days, last day 4. Zyprexa was added as needed for nausea only. 5. Metoprolol 150 mg XL daily was added for control of your heart rate. It is extremely important that you do not miss taking this medication. 6. Please take neupogen until directed by your outpatient oncologist to discontinue this medication. 7. Your as needed compazine for nausea was switched to zofran. 8. You were started on acyclovir and fluconazole for prophylaxis against viral and fungal infections during your neutropenic phase. 9. Phosphate, Potassium, and Magnesium Sliding Scales as directed. Please return to the hospital or call your primary oncologist if you experience fevers greater than 100.4, chills, night sweats, worsening abdominal pain, worsening diarrhea, inability to tolerate good oral intake of food and fluids, loss of consciousness, or any other symptoms not listed here concerning enough to warrant physician [Name Initial (PRE) 2742]. Followup Instructions: Hematology/Oncology: Dr. [Last Name (STitle) ] and [First Name8 (NamePattern2) 3742] [Last Name (NamePattern1) 41684], NP on [2127-5-2] at 3:30pm. Please call optholmology at ([Telephone/Fax (1) 253]) to arrange an outpatient appointment to get fitted for prizm glasses at your convenience. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 3922]	[ "5070", "5990", "2760", "2875", "42731" ]
Admission Date: [2122-2-28] Discharge Date: [2122-3-3] Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old man with a history of coronary artery disease, status post coronary artery bypass graft in [2102], with an ejection fraction of 20%, history of lower gastrointestinal bleed, now with multiple episodes of bright red blood per rectum. Most recently admitted in [2121-9-21] with a lower gastrointestinal bleed. A colonoscopy at that time revealed multiple nonbleeding diverticula. He was transfused 4 units of packed red blood cells and treated with fresh frozen plasma at that time. He has been doing well until 10 a.m. on the morning of admission when he began to have loose bloody bowel movements. He states that he had approximately one bowel movement an hour since [30] a.m. In the emergency department he had 300 cc of bloody bowel movements with clots. He was otherwise without complaints. He denies chest pain, dizziness, orthostasis or abdominal pain. The patient has been taking Plavix and aspirin. He refuses NG lavage. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft in [2102], status post myocardial infarction in [2119], when he had a thrombus in saphenous vein graft to D1. 2. Prostate cancer. 3. History of gastrointestinal bleed in [2113] with diverticulosis, also in [2121-9-21]. Colonoscopy in [2121-9-21] showed multiple nonbleeding diverticula. 4. Congestive heart failure with an ejection fraction of 25% in [2120-5-21] by echocardiogram. 5. Neural endocrine tumor, status post pancreatectomy and splenectomy in [2117]. 6. Status post hernia repair. 7. Status post cholecystectomy. 8. Hypertension. 9. Buerger's disease. 10. Cerebrovascular accident in [2119]. 11. Diabetes mellitus. MEDICATIONS ON ADMISSION: Aspirin 162 mg p.o. q.d., Plavix 75 mg p.o. q.d., Lopressor 25 mg p.o. b.i.d., digoxin 0.25 mg p.o. q.d., Lasix 40 mg p.o. four times a week, Zocor 40 mg p.o. q.d., folate 1 mg p.o. q.d., vitamin B12 1 tablet p.o. q.d., Betoptic 1 drop both eyes b.i.d., lisinopril 30 mg p.o. q.d., Glucovance 5/500. ALLERGIES: RELAFEN which causes bleeding. PROCAINAMIDE. SOCIAL HISTORY: The patient is a retired pharmacist. No alcohol. No tobacco. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.1, heart rate 75, blood pressure 155/93, breathing comfortably on room air. Generally, a pleasant man in no apparent distress. HEENT revealed the patient had cataracts. Extraocular muscles were intact. No icterus. No jugular venous distention. Lungs revealed dry rales at the bases bilaterally. Heart had a regular rate and rhythm, 2/6 systolic ejection murmur at the apex. Abdomen revealed well-healed scars, hyperactive bowel sounds, nontender, and distended. Extremities had no edema, 2+ dorsalis pedis pulses and posterior tibialis pulses bilaterally. Neurologically, alert and oriented times three. Strength was [4-25] throughout. Rectal examination revealed bright red blood per rectum. LABORATORY ON ADMISSION: White blood cell count 15.7, hematocrit 40 (which dropped to 35 in the emergency department with hydration), platelets 290. Differential revealed 69 neutrophils, 21 lymphocytes, 7 monocytes. INR 1.1, PTT 27.9. Sodium 141, potassium 4, chloride 105, bicarbonate 23, BUN 27, creatinine 0.9, glucose 87. Electrocardiogram showed normal sinus rhythm at a rate of 70. Normal axis. Q waves in V1 and V3. No change from electrocardiogram on [2121-10-12]. ASSESSMENT: The patient is an 81-year-old male with significant cardiac disease and recurrent gastrointestinal bleeding, now with bright red blood per rectum. HOSPITAL COURSE: 1. GASTROINTESTINAL: The patient was admitted to the medical intensive care unit for close observation. The patient had a tagged red blood cell scan which showed evidence of bleeding in the sigmoid colon. The patient was transfused 2 units of packed red blood cells to establish a stable hematocrit of 38 to 39 until the day of discharge. The patient was seen by interventional radiology for proposed intervention to embolize the bleeding artery; however, the patient's bleeding stopped spontaneously, and the patient refused any further interventions. The patient continued to have dark brown stools which were extremely OB positive; however, his hematocrit remained stable. He refused any further workup of this at this time unless he became unstable. He was to have his blood drawn two days post admission to be faxed over to Dr. [Last Name (STitle) 12167] who was covering for his primary doctor, Dr. [Last Name (STitle) ]. Also, he will call Dr. [Last Name (STitle) 1940] who is his primary gastroenterologist if there were any problems. The patient's cardiologist, Dr. [First Name8 (NamePattern2) ] [Known lastname ], was also notified, and he agreed that at this time it was prudent to withhold the patient's aspirin and Plavix. 2. DIABETES MELLITUS: The patient's Glucophage was held while in the hospital but will be restarted upon discharge. DISCHARGE STATUS: To home. CONDITION AT DISCHARGE: Good. MEDICATIONS ON DISCHARGE: 1. Multivitamin 1 tablet p.o. q.d. 2. Vitamin B12. 3. Nitroglycerin 0.4 mg sublingual every five minutes p.r.n. 4. Prilosec 20 mg p.o. b.i.d. 5. Betoptic 2.5% 1 drop both eyes b.i.d. 6. Lopressor 25 mg p.o. b.i.d. 7. Digoxin 0.25 mg p.o. q.d. 8. Lasix 40 mg p.o. four times a week. 9. Lisinopril 30 mg p.o. q.d. 10. Zocor 40 mg p.o. q.d. 11. Folate 1 mg p.o. q.d. 12. Glucovance 5/500 p.o. q.d. FOLLOWUP: The patient should have his hematocrit and hemoglobin drawn on [2122-3-5], and results faxed to Dr. [Last Name (STitle) 12167]. The patient should have followup with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 12167] per his office, and follow up with Dr. [Last Name (STitle) 1940] per his office, and Dr. [Known lastname ] per his office. DISCHARGE DIAGNOSES: 1. Lower gastrointestinal bleed, resolved spontaneously. 2. Diabetes mellitus. 3. Coronary artery disease. [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 15074] Dictated By:[Name8 (MD) 24585] MEDQUIST36 D: [2122-3-3] 16:38 T: [2122-3-4] 07:48 JOB#: [Job Number 103285] cc:[Known lastname 103286]	[ "41401", "25000", "V4581" ]
Admission Date: [2144-8-22] Discharge Date: [2144-9-3] Date of Birth: [2066-5-28] Sex: F Service: MEDICINE Allergies: Captopril / Iodine / Amiodarone Hcl / Morphine Attending:[First Name3 (LF) 689] Chief Complaint: hypercarbia, hypoxemia Major Surgical or Invasive Procedure: CVL placement History of Present Illness: 78yoW h/o chronic back pain, spinal stenosis, Afib, BOOP, obesity hypoventilation, CO2 retention, amiodarone toxicity, OSA, and CHF, transferred today from [Hospital6 28728] Center with hypercarbia, somnolence, transferred now to ICU with hypercarbia, hypoxemia. She was admitted to [Hospital1 18] [Date range (1) 37820] for low back pain and found to have L2 and L3 compression fracture. Hospital was complicated by ICU transfer for hypotension and concern for sepsis. No infectious etiology found. She presented to [Hospital 1121] Hospital [2144-8-11] with anemia (Hct 25) and somnolence, thought to be due to methadone and Ativan. Her INR on admission was 13.4. She was treated with narcan, BiPap, diuresed with Lasix, and rate controlled with digoxin and metoprolol. She was also treated for pneumonia with Zosyn and underwent thoracentesis [2144-8-18] which showed transudative effusion (protein 2.0). She may have been treated with steroids. Last ABG: [2144-8-20]: 23:15- 7.41/72/59 on 50% FiO2 from 7.44/57/74 on 50% FIo2 on [2144-8-16]. She was transferred to [Hospital1 18] for further management. On arrival to the floor she was somnolent, tachypneic 40s, and saturating 90s on 50%ventimask. ABG 7.45/70/62. On presentation she is somnolent but arousable. She c/o SOB and pain, but denies chest pain, abdominal pain, c/o back pain. Past Medical History: CHF w/ diastolic dysfunction (EF >55%) Hypertension Atrial fibrillation Reactive airway disease h/o amiodarone toxicity obesity hypoventilation Pulmonary Hypertension h/o BOOP Polymyalgia rheumatica Spinal stenosis Lower back pain Anxiety/depression h/o dye allergy Osteopenia, did not tolerate fosamax, declines Rx Anemia of chronic disease Pseudogout of right knee Social History: Lives at home with her daughter. [Name (NI) ] tobacco or ETOH. Orginally from [Country 2559]. Family History: asthma Physical Exam: T 98.4 HR 68 BP 100/52 RR 20 97% 50%hi flow mask 71kg GEN: sitting up, lethargic but arousable HEENT: PERRL, anicteric, MMM, OP clear Neck: supple, right IJ, JVP <10cm CV: RRR, no mrg Resp: bilateral crackles, poor inspiratory effort, decreased bilateral breath sounds R>L, no egophany, no accessory muscle use Abd: +BS, soft, NT, ND, no masses Ext: 3+ bilateral pitting edema Neuro: arousable, oriented to person only (although oriented x3 for floor resident earlier tonight), sensation intact bilateral UE, LE, DTR 1+ bilateral knee, ankle. Pertinent Results: [2144-8-15] CT scan of chest: Diffuse b/l infiltrates, b/l pleural effusions with b/b atelectasis CXR: bilateral instertial opacity, left effusion with increased opacity, tracheal deviation, elevated left hemidiaphragm [2144-8-22] 01:37AM TYPE-ART PO2-62* PCO2-70* PH-7.45 TOTAL CO2-50* BASE XS-19 [2144-8-22] 01:46AM PT-19.5* PTT-40.1* INR(PT)-1.9* [2144-8-22] 01:46AM PLT COUNT-232 [2144-8-22] 01:46AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL ENVELOP-OCCASIONAL [2144-8-22] 01:46AM NEUTS-86.2* BANDS-0 LYMPHS-8.2* MONOS-2.4 EOS-2.9 BASOS-0.3 [2144-8-22] 01:46AM WBC-13.0# RBC-3.24 HGB-9.5* HCT-31.1* MCV-96 MCH-29.5 MCHC-30.7* RDW-16.2* [2144-8-22] 01:46AM CALCIUM-8.6 PHOSPHATE-3.4 MAGNESIUM-2.0 [2144-8-22] 01:46AM GLUCOSE-98 UREA N-32* CREAT-1.1 SODIUM-153* POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-47* ANION GAP-9 [2144-8-22] 01:54AM LACTATE-1.6 [2144-8-22] 01:54AM TYPE-MIX COMMENTS-GREEN TOP [2144-8-22] 04:07AM O2 SAT-87 [2144-8-22] 04:07AM GLUCOSE-109* LACTATE-1.1 K+-4.2 [2144-8-22] 04:07AM TYPE-ART TEMP-37.2 PO2-59* PCO2-78* PH-7.42 TOTAL CO2-52* BASE XS-20 [2144-8-22] 06:36AM TYPE-ART PO2-87 PCO2-67* PH-7.42 TOTAL CO2-45* BASE XS-14 [2144-8-22] 07:00AM PT-19.3* PTT-27.5 INR(PT)-1.8* Brief Hospital Course: 78yo woman with h/o BOOP, chronic back pain d/t compression fracture, diastolic CHF, Afib, PMR. Pt went into hypercarbic respiratory failure and died. #For her respiratory failure, she is a known CO2 retainer due to chronic lung disease, thought to be secondary to amiodarone-induced BOOP. She required intubation and was ultimately found to have a pneumonia. She was treated with vancomycin and levaquin, as well as stress-dosed steroids. Once her BP stabilized, she was diuresed and extubated on [2144-8-28]. # Back pain: known compression fractures; on chronic steroids without treatment for osteopenia b/c did not tolerate bisphosphonate. continued neurontin # Metabolic alkalosis: no history vomiting or diarrhea; likely contraction alkalosis from diuresis, although not hypochloremic as would be expected. diuretics were held. # Hypernatremia: likely intravascularly depleted; free water deficit 3.3L. replete with D5W . # Anemia: baseline Hct 36, now 32; guiaic negative. previous iron studies [7-/2144] most consistent with anemia of chronic inflammation . # HTN: holding losartan, atenolol given hypotension in ICU . # Atrial fibrillation: dofetilide continued. holding atenolol as was hypotensive # PMR: continued steroids and plaquenil per outpt regimen . # Anxiety/depression: continued Zoloft . # PPX: anticoagulated, PPI, pneumoboots . # Communication: daughter HCP [Telephone/Fax (1) 37821]; [Name2 (NI) ] [Telephone/Fax (1) 37822] . # Code status - full(discussed with patient and daughter) Medications on Admission: Protonix 40 mg daily Hydroxychloroquine 400 mg po daily Zoloft 50 mg po daily Vit D 800 units daily Prednisone 5 mg po daily Cozaar 25 mg po daily Ceftazadime 1 gm daily Advair daily Albuterol Atenolol 150mg daily Atrovent Aoumadin 2.5mg daily Lasix 40mg daily Lidoderm 5% patch , remove in AM Ativan 1mg prn Metamucil MVI Neurontin 200mg QHS KCL 20mEQ daily Colace Tikosyn 0.125mg [Hospital1 ] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Patient died Discharge Condition: Death Discharge Instructions: none Followup Instructions: none Completed by:[2144-12-17]	[ "42731", "2760", "486", "0389", "78552", "32723" ]
Admission Date: [2123-5-22] Discharge Date: [2123-6-7] Date of Birth: [2044-10-23] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / hydrochlorothiazide / Enalapril Attending:[First Name3 (LF) 30] Chief Complaint: resp failure Major Surgical or Invasive Procedure: intubation RIJ History of Present Illness: 77 yo F with PMHx of L CVA BIBA from her nursing facility for increasing respiratory distress. Per report, she had no h/o CHF or asthma. Staff noticed difficulty breathing, SOB, and coughing. No reported fevers. Pt unable to give history. EMS bagging her on arrival but breathing on own. 60-70s RA->5L in 80s. IO put in ambulance. Per sister, visited by sister in law, found to be in USOH this am. Pt has been in NH since stroke three years ago but has normal mentation. . Upon arrival to the ED, BP 80s. Intubated with etomidate and succ. CXR: RML pna. RIJ. Lactate normal. Not requiring pressors. Got 2L of fluids, given vanc/zosyn. On propofol and fentanyl. Gap 15 and bicarb 18. Last labs improving. Thick secretions, yellow, ?aspiration pna. Unclear baseline mental status. 22 R foream. Prior to transfer, 99.9 rectal 91 122/77 100% Fio2, TV 500x16 PEEP of 5. . Upon arrival to ICU, patient was intubated and sedated. Appeared comfortable. In speaking with sister, then only thing new was that pt had right side pain that she was receiving ultram periodically for. She was intubated, placed with a RIJ, and transferred to the ICU for further management. . On admission, her CXR was consistent with a RML infiltrate, which ultiamtely ended up growing MRSA, BETA STREPTOCOCCI, NOT GROUP A, and rare GNRs. . In the ICU, she was started on Vancomycin and Zosyn, and ultimately did require pressor support with alternating norepinephrine and vasopressin. Eventually was weaned off pressors, and antibiotic overage was narrowed to Vancomycin. She received several IV boluses of fluid, such that upon her discharge from the ICU, she was noted to be 13 L positive. She was also briefly on Cipro, as well. Ultimately, she ended up requiring IV Furosemide diuresis, at first with a lasix gtt, and then by discharge 10 mg IV Lasix daily. . Also on admission, was noted to to have a possible SVT, initially controlled with IV metoprolol, now tolerating home atentolol, and appears to be in a sinus rhytym. . On [2123-5-24] she was noted to have a large R sided pleural effusion, which was tapped 2 days later revealing 1.4 L of serous fluid, with a pgitail in place initially, but ultimately removed. She was extuabated on [2123-5-27], but in [2123-5-28] was noted to have difficulty bringing up her secretions, and failed a S&S evaluation. . Vitals prior to transfer: 98.3 120/63 77 99% 2L . ROS (patient is unable to relay secondary to garbled speech at baseline secondary to stroke) Past Medical History: -L CVA with right sided hemipareisis, in NH since stoke three years prior -HTN -HL -GI bleed -depression -hypothyroidism -?lung ca->treated at [Hospital1 3278] s/p chemo/radiation 5 years ago Social History: Ex-smoker, live in NH after stroke . Family History: unable to obtain Physical Exam: Physical Exam on Admission: VS: Temp:100.7 BP: 98/66 HR:89 RR: 20 O2sat hard to obtain CMV 500X16 5 100% FiO2 CVP on admission 0mmHG GEN:intuabted sedated comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: bronchial b/s b/l with transmitted mechanical BS CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, cool extremities SKIN: no rashes/no jaundice/no splinters NEURO: sedated, could not be assessed, arousable to painful stimuli like suctioning Physical exam on Discharge: Pertinent Results: Labs: CBC: [2123-5-21] 11:50PM BLOOD WBC-5.8 RBC-3.84* Hgb-9.7* Hct-30.3* MCV-79* MCH-25.2* MCHC-31.9 RDW-17.3* Plt Ct-416 [2123-5-22] 05:14AM BLOOD WBC-3.5* RBC-3.59* Hgb-8.8* Hct-29.4* MCV-82 MCH-24.6* MCHC-30.0* RDW-17.3* Plt Ct-314 [2123-5-23] 04:52AM BLOOD WBC-5.2 RBC-2.83* Hgb-7.0* Hct-23.1* MCV-82 MCH-24.7* MCHC-30.3* RDW-17.7* Plt Ct-254 [2123-5-24] 03:40AM BLOOD WBC-8.3# RBC-2.76* Hgb-6.8* Hct-22.1* MCV-80* MCH-24.8* MCHC-30.8* RDW-17.7* Plt Ct-298 [2123-5-25] 03:24AM BLOOD WBC-12.5# RBC-3.04 Hgb-7.5* Hct-24.1* MCV-79* MCH-24.7* MCHC-31.2 RDW-18.3* Plt Ct-408 [2123-5-26] 01:10AM BLOOD WBC-8.0 RBC-3.17* Hgb-7.9* Hct-24.7* MCV-78* MCH-25.1* MCHC-32.1 RDW-18.5* Plt Ct-383 [2123-5-26] 06:43PM BLOOD WBC-6.2 RBC-3.19* Hgb-7.8* Hct-25.0* MCV-78* MCH-24.5* MCHC-31.3 RDW-18.5* Plt Ct-365 [2123-5-27] 04:01AM BLOOD WBC-6.5 RBC-3.16* Hgb-7.6* Hct-24.9* MCV-79* MCH-24.1* MCHC-30.6* RDW-18.4* Plt Ct-353 [2123-5-28] 05:08AM BLOOD WBC-7.4 RBC-3.40* Hgb-8.3* Hct-26.3* MCV-77* MCH-24.5* MCHC-31.6 RDW-18.6* Plt Ct-347 [2123-5-29] 04:54AM BLOOD WBC-8.6 RBC-3.23* Hgb-7.8* Hct-24.7* MCV-77* MCH-24.0* MCHC-31.4 RDW-19.0* Plt Ct-383 [2123-5-30] 05:54AM BLOOD WBC-9.6 RBC-3.00* Hgb-7.4* Hct-23.2* MCV-77* MCH-24.6* MCHC-31.8 RDW-18.8* Plt Ct-376 [2123-5-31] 05:56AM BLOOD WBC-12.6* RBC-2.98* Hgb-7.1* Hct-22.9* MCV-77* MCH-23.8* MCHC-30.9* RDW-18.7* Plt Ct-396 [2123-6-1] 05:43AM BLOOD WBC-13.0* RBC-2.94* Hgb-7.0* Hct-22.7* MCV-77* MCH-23.9* MCHC-31.0 RDW-18.8* Plt Ct-463* [2123-6-2] 11:30AM BLOOD WBC-10.5 RBC-2.79* Hgb-6.6* Hct-21.3* MCV-76* MCH-23.8* MCHC-31.2 RDW-18.5* Plt Ct-430 [2123-6-3] 12:35AM BLOOD WBC-10.1 RBC-3.22* Hgb-8.1* Hct-24.9* MCV-77* MCH-25.2* MCHC-32.5 RDW-18.0* Plt Ct-425 [2123-6-3] 05:37AM BLOOD WBC-9.8 RBC-3.16* Hgb-7.9* Hct-24.6* MCV-78* MCH-25.0* MCHC-32.1 RDW-18.2* Plt Ct-361 [2123-6-4] 06:17AM BLOOD WBC-8.1 RBC-3.11* Hgb-7.9* Hct-24.3* MCV-78* MCH-25.3* MCHC-32.4 RDW-18.5* Plt Ct-429 [2123-6-5] 06:00AM BLOOD WBC-8.1 RBC-3.07* Hgb-7.9* Hct-24.1* MCV-78* MCH-25.8* MCHC-32.9 RDW-19.2* Plt Ct-531* [2123-6-6] 06:00AM BLOOD WBC-7.6 RBC-3.01* Hgb-7.5* Hct-23.7* MCV-79* MCH-25.0* MCHC-31.7 RDW-19.0* Plt Ct-432 [2123-6-7] 05:54AM BLOOD WBC-6.7 RBC-2.94* Hgb-7.3* Hct-23.4* MCV-80* MCH-24.7* MCHC-31.0 RDW-18.9* Plt Ct-402 Diff: [2123-5-21] 11:50PM BLOOD Neuts-61 Bands-6* Lymphs-27 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 [2123-5-22] 05:14AM BLOOD Neuts-66 Bands-6* Lymphs-19 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-0 [2123-5-25] 03:24AM BLOOD Neuts-91.0* Lymphs-6.0* Monos-2.6 Eos-0.2 Baso-0.2 [2123-5-26] 01:10AM BLOOD Neuts-83.9* Lymphs-11.8* Monos-3.6 Eos-0.4 Baso-0.3 [2123-5-31] 05:56AM BLOOD Neuts-88.9* Lymphs-7.9* Monos-2.3 Eos-0.4 Baso-0.5 [2123-6-1] 05:43AM BLOOD Neuts-86.5* Lymphs-8.5* Monos-4.6 Eos-0.2 Baso-0.2 [2123-6-2] 11:30AM BLOOD Neuts-84.8* Lymphs-10.7* Monos-4.0 Eos-0.4 Baso-0.1 [2123-6-3] 05:37AM BLOOD Neuts-85.9* Bands-0 Lymphs-9.5* Monos-3.7 Eos-0.8 Baso-0.1 Red Cell Morphology: [2123-5-21] 11:50PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Tear Dr[Last Name (STitle) ]1+ Bite-OCCASIONAL [2123-5-22] 05:14AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear Dr[Last Name (STitle) 833] [Name (STitle) 4486] [2123-6-3] 05:37AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+ Stipple-OCCASIONAL Tear Dr[Last Name (STitle) ]2+ Ellipto-1+ Coags: [2123-5-21] 11:50PM BLOOD PT-14.9* PTT-23.9 INR(PT)-1.3* [2123-5-23] 04:52AM BLOOD PT-18.1* PTT-41.7* INR(PT)-1.6* [2123-5-23] 06:15AM BLOOD PT-17.9* PTT-37.5* INR(PT)-1.6* [2123-5-24] 03:40AM BLOOD PT-14.7* PTT-36.3* INR(PT)-1.3* [2123-5-25] 03:24AM BLOOD PT-13.1 PTT-30.5 INR(PT)-1.1 [2123-5-31] 05:56AM BLOOD PT-12.4 PTT-29.9 INR(PT)-1.0 [2123-6-1] 05:43AM BLOOD PT-12.7 PTT-27.3 INR(PT)-1.1 [2123-6-2] 09:15AM BLOOD PT-11.9 PTT-21.7* INR(PT)-1.0 [2123-6-3] 05:37AM BLOOD PT-12.1 PTT-25.1 INR(PT)-1.0 [2123-6-4] 06:17AM BLOOD PT-12.7 PTT-26.2 INR(PT)-1.1 Fibrinogen: [2123-5-23] 01:05PM BLOOD Fibrino-564* Reticulocyte Count: [2123-6-1] 05:43AM BLOOD Ret Aut-2.3 Electrolytes: [2123-5-21] 11:50PM BLOOD Glucose-131* UreaN-23* Creat-1.0 Na-146* K-5.1 Cl-113* HCO3-18* AnGap-20 [2123-5-22] 05:14AM BLOOD Glucose-118* UreaN-20 Creat-0.9 Na-144 K-4.5 Cl-114* HCO3-18* AnGap-17 [2123-5-22] 02:05PM BLOOD Glucose-107* UreaN-17 Creat-0.7 Na-145 K-3.9 Cl-115* HCO3-18* AnGap-16 [2123-5-23] 04:52AM BLOOD Glucose-142* UreaN-13 Creat-0.6 Na-146* K-4.2 Cl-119* HCO3-17* AnGap-14 [2123-5-23] 06:15AM BLOOD Glucose-151* UreaN-14 Creat-0.6 Na-144 K-4.2 Cl-118* HCO3-19* AnGap-11 [2123-5-24] 03:40AM BLOOD Glucose-130* UreaN-13 Creat-0.6 Na-143 K-3.9 Cl-116* HCO3-19* AnGap-12 [2123-5-25] 03:24AM BLOOD Glucose-118* UreaN-10 Creat-0.6 Na-137 K-4.0 Cl-108 HCO3-18* AnGap-15 [2123-5-26] 01:10AM BLOOD Glucose-115* UreaN-11 Creat-0.9 Na-144 K-4.2 Cl-114* HCO3-20* AnGap-14 [2123-5-26] 06:43PM BLOOD Glucose-98 UreaN-11 Creat-0.9 Na-144 K-4.1 Cl-113* HCO3-22 AnGap-13 [2123-5-27] 04:01AM BLOOD Glucose-123* UreaN-11 Creat-0.9 Na-146* K-3.7 Cl-115* HCO3-23 AnGap-12 [2123-5-27] 05:51PM BLOOD UreaN-11 Creat-0.8 Na-143 K-4.0 Cl-111* [2123-5-28] 05:08AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-142 K-4.2 Cl-109* HCO3-25 AnGap-12 [2123-5-29] 04:54AM BLOOD Glucose-123* UreaN-10 Creat-0.9 Na-143 K-3.5 Cl-108 HCO3-25 AnGap-14 [2123-5-29] 05:17PM BLOOD Glucose-113* UreaN-11 Creat-0.9 Na-145 K-3.8 Cl-107 HCO3-26 AnGap-16 [2123-5-30] 05:54AM BLOOD Glucose-101* UreaN-12 Creat-0.9 Na-145 K-3.9 Cl-106 HCO3-28 AnGap-15 [2123-5-31] 05:56AM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-144 K-3.8 Cl-104 HCO3-31 AnGap-13 [2123-5-31] 04:55PM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-145 K-4.8 Cl-104 HCO3-29 AnGap-17 [2123-6-1] 05:43AM BLOOD Glucose-118* UreaN-16 Creat-0.8 Na-145 K-4.6 Cl-105 HCO3-30 AnGap-15 [2123-6-2] 11:30AM BLOOD Glucose-97 UreaN-19 Creat-0.9 Na-141 K-5.1 Cl-101 HCO3-32 AnGap-13 [2123-6-3] 05:37AM BLOOD Glucose-94 UreaN-18 Creat-0.9 Na-141 K-4.9 Cl-101 HCO3-33* AnGap-12 [2123-6-4] 06:17AM BLOOD Glucose-78 UreaN-16 Creat-0.9 Na-140 K-4.9 Cl-100 HCO3-29 AnGap-16 [2123-6-5] 06:00AM BLOOD Glucose-114* UreaN-15 Creat-0.9 Na-140 K-4.3 Cl-99 HCO3-29 AnGap-16 [2123-6-6] 06:00AM BLOOD Glucose-98 UreaN-19 Creat-1.0 Na-136 K-4.3 Cl-98 HCO3-31 AnGap-11 [2123-6-7] 05:54AM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-141 K-4.2 Cl-103 HCO3-31 AnGap-11 Enzymes and Bilirubin: [2123-5-23] 04:52AM BLOOD ALT-9 AST-18 AlkPhos-77 TotBili-0.2 [2123-5-23] 06:15AM BLOOD ALT-9 AST-20 AlkPhos-82 TotBili-0.2 [2123-5-26] 01:10AM BLOOD ALT-12 AST-18 LD(LDH)-328* AlkPhos-124* TotBili-0.2 [2123-6-1] 05:43AM BLOOD LD(LDH)-611* TotBili-0.1 DirBili-0.1 IndBili-0.0 [2123-6-2] 11:30AM BLOOD LD(LDH)-599* [2123-6-3] 05:37AM BLOOD LD(LDH)-533* [2123-6-4] 06:17AM BLOOD LD(LDH)-497* [2123-6-5] 06:00AM BLOOD LD(LDH)-482* [2123-6-6] 06:00AM BLOOD LD(LDH)-453* [2123-6-7] 05:54AM BLOOD LD(LDH)-423* proBNP: [2123-5-21] 11:50PM BLOOD cTropnT-<0.01 proBNP-2766* [2123-5-25] 03:24AM BLOOD proBNP-[Numeric Identifier ]* Elements: [2123-5-21] 11:50PM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.3 Mg-1.8 [2123-5-22] 05:14AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.5* [2123-5-22] 02:05PM BLOOD Calcium-8.0* Phos-2.4* Mg-3.1* [2123-5-23] 04:52AM BLOOD Calcium-7.0* Phos-1.9* Mg-2.0 [2123-5-23] 06:15AM BLOOD Calcium-7.4* Phos-2.0* Mg-2.0 [2123-5-24] 03:40AM BLOOD Calcium-7.6* Phos-1.7* Mg-1.8 [2123-5-25] 03:24AM BLOOD Calcium-8.3* Phos-3.4# Mg-2.3 [2123-5-26] 01:10AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 [2123-5-26] 06:43PM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0 [2123-5-27] 04:01AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.0 [2123-5-27] 05:51PM BLOOD Mg-1.9 [2123-5-29] 05:17PM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9 [2123-5-30] 05:54AM BLOOD Calcium-7.7* Phos-3.1 Mg-1.9 Iron-14* [2123-5-31] 05:56AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0 [2123-5-31] 04:55PM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9 [2123-6-1] 05:43AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2 [2123-6-2] 11:30AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0 [2123-6-3] 05:37AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0 [2123-6-4] 06:17AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9 [2123-6-5] 06:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2 [2123-6-6] 06:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.1 [2123-6-7] 05:54AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.1 Iron Studies: [2123-5-30] 05:54AM BLOOD calTIBC-168* Ferritn-317* TRF-129* [2123-6-1] 05:43AM BLOOD Hapto-530* TSH: [2123-5-24] 03:40AM BLOOD TSH-1.0 Cortisol: [2123-5-24] 02:33PM BLOOD Cortsol-19.8 [2123-5-24] 03:10PM BLOOD Cortsol-36.3* [2123-5-25] 03:24AM BLOOD Cortsol-32.6* Vancomycin Troughs: [2123-5-24] 03:40AM BLOOD Vanco-10.2 [2123-5-25] 07:06PM BLOOD Vanco-30.6* [2123-5-26] 06:03AM BLOOD Vanco-25.0* [2123-5-26] 06:43PM BLOOD Vanco-25.7* [2123-5-27] 06:18AM BLOOD Vanco-23.5* [2123-5-27] 05:51PM BLOOD Vanco-18.4 [2123-5-29] 04:54AM BLOOD Vanco-19.2 [2123-5-30] 05:54AM BLOOD Vanco-12.3 [2123-5-31] 11:46AM BLOOD Vanco-17.7 [2123-6-1] 10:50AM BLOOD Vanco-11.7 [2123-6-3] 12:44PM BLOOD Vanco-14.4 Microbiology: Right Pleural Fluid ([5-26]): 4+ PMN, NGTD Sputum Culture ([5-22]): MRSA heavy growth, Beta Streptococcus heavy growth, sparse GNR Blood cultures ([5-25], [5-22], [5-21]): NEGATIVE Urine Culture ([6-1], [5-25], [5-22]): Negative Urine Legionella ([5-23]): Negative RRV Swab: Negative Stool sample ([6-6]) C. Diff NEGATIVE Imaging: ECG Study Date of [2123-5-31] 7:56:42 AM Moderate baseline artifact. Sinus tachycardia, rate 103, with occasional ventricular premature beats. Poor R wave progression. Low voltage in the standard leads. Non-specific ST-T wave changes. Compared to the previous tracing of [2123-5-26] the precordial voltage is much higher and the ST-T wave changes noted at that time are less prominent. CXR ([5-31]): As compared to the previous radiograph, there is a mild decrease in lung volume. However, no typical signs of aspiration are seen. Unchanged minimal bilateral areas of atelectasis, persistent right upper lobe atelectasis and atelectatic opacities in the retrocardiac lung areas. The presence of minimal bilateral pleural effusions cannot be excluded. No pulmonary edema. The monitoring and support devices are unchanged, except for a newly placed left PICC line with a tip projecting over the inferior SVC. EKG: NSR at 91 bpm, NA, NI, no STTW changes with no baseline comparison CXR: ET tube 7cmm above carina, OG at GE junction, advance 10cm. RIJ. RUL collapse. Perihilar infiltrates. CXR ([5-29]): There is a right IJ central venous catheter with distal lead tip in the mid to proximal SVC. There is a nasogastric tube whose tip and side port are well below the gastroesophageal junction. There is an unchanged persistent left retrocardiac opacity. There is increased opacity within the right upper lobe which may be due to collapse. CXR ([5-28]): The tip of the nasogastric tube and side port are well below the gastroesophageal junction. The tip is within the distal body. Cardiac silhouette is enlarged. There is some volume loss within the right upper lobe. This may represent atelectasis. There is a right IJ central venous catheter with distal lead tip in the distal SVC. The right lung base is clear. There is a left retrocardiac opacity. CXR ([5-27]): As compared to the previous radiograph, the monitoring and support devices, including the endotracheal tube are unchanged. The opacities at the left lung base have minimally increased, the presence of a minimal left pleural effusion cannot be excluded. Otherwise, the radiograph is unchanged. The position of the right pleural drain is constant. CXR ([5-26]): Uniform opacification in the right lower lung is probably severe right lower lobe consolidation or atelectasis. Right upper lobe remains collapsed and right pleural effusion is moderate to large, increasing slowly over the past several days. Heterogeneous consolidation has developed in the left lower lobe since [5-22], probably a second region of pneumonia. ET tube is in standard placement. Right jugular line ends in the mid to low SVC. Nasogastric tube ends in the stomach. No pneumothorax. TTE ([5-26]): The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. with depressed free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. KUB ([5-24]): Nasogastric tube not well seen, although it follows the expected course, coiling over the expected location of the stomach on the chest radiograph from four minutes earlier. Abdominal Xray ([5-24]): No obstruction or ileus. CXR ([5-22]): In comparison with the earlier study of this date, the tip of the endotracheal tube lies at the mid clavicular level, approximately 6 cm above the carina. Nasogastric tube extends well into the stomach beyond the lower margin of the image. There is continued opacification in the right upper zone consistent with right upper lobe collapse. Patchy opacification in the right mid and lower zones is again seen. CXR ([5-21], day of admission): IMPRESSION: 1. Complete right upper lobe collpase, raising question of endobronchial plug or mass. 2. Perihilar right lung opacity could represent asymmetric edema versus pneumonia. 3. Enteric tube could be further advanced. Brief Hospital Course: A/P: 77 yo F with PMHx of L CVA BIBA from her nursing facility for increasing respiratory distress now s/p intubation for respiratory failure [1-20] aspiration PNA. #Respiratory failure: The patient presented with fever and hypoxic respiratory failure secondary to aspiration PNA. CXR supportive of RLL/RML infiltrate as well as left retrocardiac opacity which became apparent as the patient was diuresed and has been stable. She was initially on Vanc/Zosyn for broad coverage, which was switched to Vanc/[Last Name (un) ] and then transitioned to Vanc/Levo before ultimately being placed on Vanc for a 14 day course in order to treat her MRSA PNA. The patient also had a large right sided pleural effusion which progressed during her initial hospital course and which was believed to be contributing to her difficulty weaning off the vent. She underwent a thoracentesis by IP, draining 1.4 L serous fluid, and had a pigtail catheter placed which was pulled prior to leaving the MICU. Pleural fluid showed 4+ PMNs without growth and was negative for malignant cells, consistent with a parapneumonic effusion. She was successfully extubated on antibiotics and with aggressive diuresis, and her respiratory status continued to improve, such that on discharge she was on room air. Of note, the patient also has right upper lobe collapse which may be old given history of lung Ca; the patient's records regarding her prior chest CT should be compared to see if there any evidence of change or progression of this collapse. #Hypotension: The patient's hypotension was likely [1-20] sepsis from aspiration pneumonia. She initially given significant IVF with good response, and was on pressors which were subsequently weaned when the patient's blood pressure stabilized on antibiotics and with discontinuation of sedation for mechanical ventilation. Her home Atenolol, which was initially held, was re-started prior to call-out from the MICU, and was continued upon her discharge. # NUTRITION: The patient had a Dobhoff placed for nutrition once it became clear that she was aspirating her oral intake. She was evaluated by speech and swallow team twice in hospital, and both times was recommended to remain NPO. Given these findings, in discussion with both the patient and the healthcare proxy, it was agreed to go forward with a PEG tube placement, which the patient underwent without complication on [2123-6-3]. The patient should be monitored in the future for possible further trial of S&S as she had had a PEG tube in the past, and her swallowing has improved such that it could be removed. #Elevated BNP: Patient's elevated BNP likely [1-20] volume overload and acute CHF exacerbation given the significant volume of IVF she received on initial presentation with sepsis. She has been improving clinically and by CXR from a respiratory standpoint with aggressive diuresis with IV Lasix. An ECHO performed in house showed a normal LVEF, moderate pulmonary artery systolic hypertension, as well as a small pericardial effusion, which was echo dense, consistent with blood, inflammation or other cellular elements. There was no echocardiographic signs of tamponade. On discharge from the ICU, she was noted to be 20 L positive secondary to fluid resuscitation during sepsis; throughout her stay on the floor, she continued to received 10 IV Lasix for diuresis. Upon discharge, she went home with 40 mg PO Lasix, to be discontinued at such time as her total body edema resolves. Upon her discharge, her bicarbonate was noted to be trending up, consistent with a metabolic alkalosis from contraction, which should continue to be monitored. #Rapid Heart Rate: The patient had an episode of HR 170's, and then episodes of HR 140's-150's on telemetry concerning for SVT vs afib, less likely sinus tachycardia vs accelerated junctional rhythm. EKGs were only obtained with HR's in the 90's and one EKG with HR 119, and these showed sinus tachycardia vs less likely accelerated junctional rhythm, although somewhat difficult to assess consistently due to low voltages. She was started on Metoprolol with improved heart rates. She was switched from Metoprolol to her home Atenolol prior to call-out from the MICU and tolerated that well with HR in the 90's-100's. Repeat EKGs on the floor and monitoring on telemetry continued to show only sinus tachycardia, again improved with the home dose of Atenolol. #Anemia: Microcytic anemia has been stable in-house, unclear baseline. No signs of active bleed, most likely marrow suppression from critical illness vs antibiotics. Continued home iron and trended hct in-house. On the floor, her HCT did nadir as low as 21, for which she received 1 uPRBC transfusion, with an appropriate bump in her HCT to 24. Her anemia should continue to be monitored as an outpatient. Hemolysis labs were negative, although the patient was noted to have an elevated LDH. Her iron studies were consistent with an anemia of chronic inflammation. #Elevated LDH: The patient was noted to have elevated LDH at a peak of 600 at one point during her hospitalization, trending down to the 400s. Etiologies considered where inflammation and cell turnover from her PNA, which was actually improving at the time these labs were drawn. In addition, there was concern that this elevation in LDH could represent recurrence of her small cell lung cancer; her CT at Tuft's will need to be reviewed, with consideration towards possible treatment/diagnosis of small cell lung cancer. #s/p stroke: Residual right hemiparesis. Continued home simvastatin, plavix. #Hypothyroidism: Continued home synthroid. #Depression: Continued home mirtazapine. # History of lung cancer: The patient was previously followed for this at [Hospital 3278] Medical Center. Records obtained from that institution documented small cell lung cancer of the right upper lobe s/p cisplatin 4 cycles in [2119]. Question of recurrence based on current CXRs, and reportedly had CT chest at [Hospital1 3278]. This will need to be followed as an outpatient. Contact:[Last Name (NamePattern4) ] in [Name (NI) 9012] ([First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] -proxy)[Telephone/Fax (1) 103891] sister in law in [Name (NI) 86] ([First Name8 (NamePattern2) ] [Name (NI) 103892]) [Telephone/Fax (1) 103893] Code: full code confirmed Medications on Admission: -levothyroxine 50mcg daily -albuterol/ipratropium prn -bisacodyl 10 mg Rectal Suppository Rectal Once Daily prn -Mapap (acetaminophen) 325 mg Tab Oral 2 Tablet(s) Every [3-24] hrs, as needed -loperamide 2 mg prn-mylanta prn -simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily -gabapentin 300 mg at bedtime -omeprazole 40mg daily -atenolol 25mg qday -mvi -plavix 75mg daily -spiriva 18mcg IH daily -iron 32mg dialy -colace/senna -mirtazapine 30mg qhs -ultram 25mg q8h prn pain Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ipratropium bromide 0.02 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 5. Mapap (acetaminophen) 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 6. loperamide 2 mg Capsule Sig: One (1) Capsule PO three times a day as needed for diarrhea. 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 15. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 18. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U Injection every eight (8) hours. Disp:*qs for 1 month Refills:0 19. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - Heathwood - [Location (un) 55] Discharge Diagnosis: Primary Diagnosis: - MRSA Pneumonia - Aspiration Secondary Diagnosis: - Stroke - Hypertension - Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Ms. [Known lastname ], It was a pleasure taking care of you in the hospital. You were admitted to us from your nursing home because your were having a hard time breathing. You were having such a hard time breathing that you needed to come to our intensive care unit to have a tube placed down your throat. We found a pneumonia which we think was the reason you were having trouble breathing. This pneumonia was likely the result of food and fluid which you were swallowing going into the wrong tube and down your lungs; we call this "aspiration." In the ICU, we placed a needle near your lungs to help take off some fluid which had accumulated there. We also were able to take the tube out of your throat, and you breathed well on your own. We treated you for your pnuemonia with antibiotics, and you got better. However, our speech and swallow specialists saw you twice, and both times felt that it was unsafe for you to continue to eat foods by mouth, because of the risk of aspiration. For this reason, we placed a "PEG" tube, which helps give you nutrition directly to your stomach. When you leave the hospital: - START Furosemide 40 mg Daily (continue to take this until your body swelling improves) - START heparin 5000 U subcutaneously every eight (8) hours - STOP Gabapentin 300 mg at night (you did not require this medication while in the hospital) We did not make any other changes to your home medications, so please continue to take them as you normally have been. Followup Instructions: Please have your nursing home make you an appointment with your primary care doctor, Dr. [Last Name (STitle) ], by calling [Telephone/Fax (1) 10688], within a week of your discharge from the hospital. Please have your nursing home contact your primary lung cancer doctor as well to discuss the results of your CT Scan at [Hospital1 3278].	[ "5070", "51881", "78552", "5119", "99592", "4019", "2724", "311", "2449", "4280" ]
Admission Date: [2179-3-4] Discharge Date: [2179-3-17] Date of Birth: [2158-5-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2145] Chief Complaint: Scrotal swelling Major Surgical or Invasive Procedure: Foley catheter repositioning in the OR PICC line placement Bronchoscopy History of Present Illness: This is a 20 year-old paraplegic male with a chronic indwelling foley who was transfered from an outside hospital for new scrotal swelling and fevers. A CT scan demonstrated that the balloon was inflated in the prostatic urethra with extravasation of fluid in the soft tissue. He was intubated in the emergenyc department for respiratory distress. He was taken to the OR for repositioning of the foley catheter. He was started on broad spectrum antibiotics for presumed urosepsis. Past Medical History: 1. Paraplegia status post being a pedestrian struck by a drunk driver. He sustained a C1 fracure. Also, had a splenectomy. 2. History of DVT and PE and is on coumadin. 3. History of MRSA bacteremia 4. History of Pseudomonal, klebsiella, and MRSA pneumonia 5. History of illicit drud use. Social History: He lives with his father. [Name (NI) ] has been smoking for the past 4 years. He also smokes crystal meth. He denies alcohol or other drug use. Family History: Noncontributory. Physical Exam: Vitals: Temperature:99.6 Pulse:111 Blood Pressure:118/67 Respiratory Rate:18 General: Lying in bed, intubated. HEENT: Pupils equal and reactive, extraoccular movements intact, moist mucous membranes. Neck: Supple. No cervical, submadibular, supraclavicular lymphadenopathy. Cardiac: Regular rate and rhythm, s1, s2 without murmurs, rubs, gallops Pulmonary: Decreased breath sounds at right base about halfway up with occasional end-expiratory wheezes Abdomen: Normoactive bowel sounds, soft, nontender, nondistended, large midline surgical scar. Extremities: Warm and well perfused with pneumoboots and multipodis boots intact. Neuro: Cranial nerves grossly intact, decreased strength in upper extremities, paraplegic in lower extremities, impaired lower extremity sensation. Genitial: Erythematous, firm, enlarged scrotum (about [6-24] inches in diameter), foley intact. Pertinent Results: Hematolgy: [2179-3-17] 06:30AM BLOOD WBC-13.1* RBC-4.41* Hgb-11.7* Hct-35.7* MCV-81* MCH-26.6* MCHC-32.9 RDW-16.9* Plt Ct-1189* . Chemistries: SODIUM-135 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-24 UREA N-23 CREAT-1.0 GLUCOSE-127 LACTATE-2.4 [2179-3-17] 06:30AM BLOOD Glucose-82 UreaN-3* Creat-0.5 Na-138 K-4.2 Cl-102 HCO3-28 AnGap-12 . Liver Function Tests: ALT(SGPT)-58 AST(SGOT)-38 CK(CPK)-241 ALK PHOS-95 AMYLASE-19 TOT BILI-1.0 LIPASE-11 . Coagulation: PT-23.4 PTT-30.1 INR(PT)-2.3 Imaging: 1. Chest x-ray: Right lower lobe atelectasis verse pneumonia. Right main stem intubation. 2. CT torso: Large amount of low attenuation fluid and stranding in the scrotum and associated inflammatory stranding of the suprapubic soft tissues. A Foley catheter balloon is seen expanded within the mid penile urethra, and lack of visualization of the right lateral wall of the urethra at this level may represent disruption. These findings likely represent urethral trauma with extravasation of urine to the scrotum. Alternatively, the fluid and stranding could be related to an infectious process. Left gluteal ulcer extending to the ischial tuberosity without associated fluid collection. Developing sinus tract in the right posterior subcutaneous tissues at the L3 level. No PE. Right lower lobe collapse and left lower lobe subsegmental atelectasis. Fatty liver. . [2179-3-11]: Repeat CT Scan: Again seen are opacities in the right lower lobe consistent with aspiration, slightly improved compared to prior study. There is also evidence of linear atelectasis in the left lower lobe. Small pericardial effusion is noted. There again appears to be fatty infiltration of the liver. No focal masses are identified within the liver. The gallbladder, pancreas, and adrenal glands appear unremarkable. Multiple small dense foci are seen within the right kidney, possibly representing tiny stones or vascular calcifications. No evidence of hydronephrosis. The patient is status post splenectomy. The large and small bowel appear within normal limits. No pathologically enlarged mesenteric or retroperitoneal lymphadenopathy is identified. There is no evidence of free fluid or free air within the abdomen. CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum and sigmoid colon appear unremarkable. Air is seen within the bladder, likely secondary to repositioned Foley catheterization. Again seen is marked suprapubic cutaneous stranding. Peri- penile, urethral, and scrotal stranding appears slightly improved from prior study. Again seen are large inguinal lymph nodes bilaterally. No pathologically enlarged pelvic lymphadenopathy is identified. There is no evidence of free fluid within the pelvis. Again seen is evidence of a sinus tract in the right posterior subcutaneous tissue. The scrotum is not completely imaged on today's study. BONE WINDOWS: No suspicious lytic or blastic lesions are identified. Again seen is right transverse process fracture of L1. IMPRESSION: 1. Slight decrease in peri- penile, urethral, and scrotal stranding. 2. Suprapubic cutaneous stranding, relatively unchanged from prior study. 3. Air is seen within the bladder, likely secondary to repositioned foley catheter within the bladder. 4. Partial clearing of right lower lobe opacities consistent with aspiration. 5. Unchanged appearing sinus tract in right posterior subcutaneous tissue. 6. Fatty liver. . Brief Hospital Course: This is a 20 year-old paraplegic admitted for presumed urosepsis secondary to malpositioned foley catheter. . 1. Scrotal swelling: He presented with marked scrotal swelling and was found to have the balloon of his foley inflated within the prostatic urethra with extravasation of fluid into the surrounding tissues. The urology team took him to the OR for repositioning of the foley. His scrotum was cellulitic without evidence of an abscess. He was initially maintained on borad spectrum antibiotics with vancomycin, levofloxacin, and zosyn. Urine cultures from the outside hospital grew out greater than 100,000 each of providencia rettgeri, pseudomonas, serratia marcescens, enteroccoccus faecalis. Based on antibiotice sensitivities, his antibiotic coveraged was changed to zosyn and levofloxacin. A repeat CT scan demonstrated decreased stranding. With treatment, his urine bacterial cultures cleared, but then grew out yeast. His catheter has been changed again. He continued to spike fevers and had a persistent leukocytosis and eosinophilia while on zosyn and levo. We suspected possible drug allergy to zosyn, and his antibiotic regimen was changed to his current regimen of levofloxacin, metronidazole,and vancomycin with resolution of fever and improved WBC count. He did have a significant reactive thrombocytosis which has stabilized. He was followed very closely by the infectious disease team throughout his hospitalization, as well as wound care and urology. His scrotal edema is improving, though he still has areas of necrotic tissue with active drainage of yellow pus, in particular the inferior portion of his scrotum. He is to continue on antibiotics for an additional 4 weeks (from start date of his current regimen [3-13]) and follow-up with ID and urology in 3 weeks. The team gave him and his family explicit instructions to return for medical attention sooner if he develops any worsening edema, pain, discharge, fever, chills. Additionally, we have emphasized the importance of staying away from illicit drugs. We spent extensive time speaking to both his mother and father regarding his discharge instructions, as Mr. [Known lastname 45670] has seemed emotionally unable at times to act in his own best interests (threatening to leave AMA on multiple occasions despite his life-threatening infections, including immediately post-extubation; crying when we advised that he needed additional hospitalization for close monitoring of his severe scrotal infection; shouting that his parents would take him home AMA if he asked them, which was not in fact true). . He was discahrged to home with outpatient urology follow-up. Once his infection clears, he plans to have a suprapubic catheter placed. ID requested follow up MRI of scrotal area to assess for continued infection. The MRI was ordered and the PCP was called: Dr. [Last Name (STitle) 50167] will complete the pre-certification necessary to have the MRI and make sure the study is done. . 2. Fevers: Initially his fevers were attributed to urosepsis. No other sources of fever were identified. He continued to spike temperatures despite broad spectrum antibiotic treatments. A repeat CT scan and scrotal ultrasound did not demonstrate any abscess. His fevers were thought to be secondary to drug fevers, especially since he had an eosinophilia as mentioned above and his antibiotic regmien was altered. ALl of his blood cultures showed no growth and he was afebrile by discharge. . 3. Hypoxia: He was intubated for respiratory distress in the emergency department and was extubated successfully on hospital day 2. His chest x-ray demonstrated right lower lobe collapse thought to be from mucous plugging. After extubation, he required 6L nasal canula to maintain his oxygenation. A repeat x-ray demonstrated complete white out of the right lung. He underwent a bronchoscopy for clearing of mucous plugs with subsequent aeration of his right lung. He was successfully weaned from supplemental oxygen. . 4. Reactive thrombocytosis: During previous admissions, he developed a reactive thrombocytosis that resolved with treatment of his infections. During this admission, he had a similar thrombocytosis which stabilized by discharge. . 5. History of PE/DVT: He became supratherapeutic on coumadin so his dose was decreased and eventually held for a few days. His dose was adjusted to maintain an INR between [2-19]. He will continue to have close follow up of his INR given the changes made in the hospital. . 6. Paraplegia: He was maintained on his outpatient baclofen and neurontin. . 7. History of substance abuse: He has a history of substance abuse. Since it was not feasible to discharge him on an oral antibiotic regimen, he was discharged with a PICC line. His family is taking responsibility for the line. 8. Prophylaxis: Coumadin, bowel regimen. . 9. Code: He remained full code throughout his admission. Medications on Admission: Medications on Transfer: Levofloxacin 500 mg IV Q24H Piperacillin-Tazobactam Na 4.5 gm IV Q8H Vancomycin HCl 1000 mg IV Q 12H Oxycodone 15 mg PO Q6H:PRN Pantoprazole 40 mg PO Q24H Acetaminophen 325-650 mg PO Q4-6H:PRN Baclofen 20 mg PO TID Docusate Sodium 100 mg PO BID Senna 1 TAB PO BID:PRN Gabapentin 800 mg PO BID Lorazepam 1-2 mg PO Q4-6H:PRN Warfarin 2 mg PO DAILY Zolpidem Tartrate 5 mg PO HS traZODONE HCl 100 mg PO HS:PRN Medications on Admission: Macrobid 100 QD Senna tiweek Dulcolax tiweek Lexapro 10 mg po qd Alprazolam 2 mg po bid Ambien 10 mg po QOD (per OSH records) Diazepam 10 mg po qod Neurontin [Age over 90 ] m gpo [Hospital1 ] Baclofen 20 mg po tid Protonix 40 mg po qd Ditropan 10 mg po qd Clonidine 0.1 po BID Discharge Medications: 1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Senna 8.6 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. 7. Glycerin (Adult) 3 g Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:qs 1 Refills:2 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 23 days. Disp:23 Tablet(s) Refills:0 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 23 days. Disp:69 Tablet(s) Refills:0 13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 9 days. Disp:45 gram Refills:0 14. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. Oxycodone 15 mg Tablet Sig: Three (3) Tablet PO every six (6) hours as needed for pain. Disp:60 Tablet(s) Refills:0 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 19. Outpatient [Hospital1 ] Work CBC, vancomycin level, BUN, creatinine weekly starting [2179-3-23]. Please Fax results to Dr. [Last Name (STitle) ] [Telephone/Fax (1) 1419] 20. Outpatient [Name (NI) ] Work PT, INR first draw [2179-3-19]. Susequent draws per Primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 50167] Please fax results to Dr. [Last Name (STitle) 50167]. 21. PICC line care Please provide PICC line care per protocol 22. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Personal Touch in londondery home care Discharge Diagnosis: Urinary tract infection Scrotal cellulitis Right lung collapse Paraplegia Discharge Condition: Afebrile > 24 hours, stable respiratory status, hemodynamically stable. Discharge Instructions: Please take all medications as prescribed. . Seek medical attention for worsening fevers, chills, nausea, vomiting, shortness of breath, chest pain, increased scrotal swelling or drainage from your scrotal wounds, or anything else that you find worrisome. Please be sure to keep all of your follow up appointments. Followup Instructions: Please keep your urology appointment on [4-8] at 3:40pm with Dr. [Last Name (STitle) 770] [Telephone/Fax (1) 277]. [Hospital Ward Name 23] Building, [Location (un) 470]. If you have any problems keeping this appointment plase call to reschedule. You have a follow up appointment with Dr. [Last Name (STitle) 50167] on [3-24] at 2:20 PM. If you have any difficulty keeping this appointment please call Dr. [Last Name (STitle) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 50168] as you need to follow up with him in the next 1-2 weeks. You will need to have your INR checked in 2 days. Since you are on antibiotics that affect your coumadin dosing you may need alteration in your dosing. These results will be follow by your primary doctor. You need to have an MRI to evaluate for any infection remaining in your scrotum. Your primary care physician will arrange this study. This appointment should be kept as the results will need to be reviewed by Dr. [Last Name (STitle) ] prior to you appointment with her on [2179-4-9]. You have the following appointment with the infectious disease clinic: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [First Name (STitle) ] Phone:[Telephone/Fax (1) 457] Date/Time:[2179-4-9] 11:30. It is essential that you follow up with them as they need to assess your wounds and to be sure that your infection is improving. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "0389", "51881", "99592", "5180", "49390" ]
Admission Date: [2172-11-29] Discharge Date: [2172-12-4] Date of Birth: [2094-4-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2145] Chief Complaint: Change in mental status, hematemesis Major Surgical or Invasive Procedure: EGD Central line History of Present Illness: Ms. [Known lastname 71441] is a 78 year-old woman with a history of a recent left-sided stroke with subsequent left carotid stenting and initiation of warfarin therapy for atrial fibrillation who was brought in from [Hospital 100] Rehab today for deteriorating mental status. She is intubated and sedated, and thus unable to provide her own history. Per EMS records, she was noted by staff this morning to be unresponsive around 8am this morning. She had a FSBG that was >600 at that time, and other labs were significant for a hematocrit of 19.6 from a baseline of 27, a creatinine of 3.8 and PT of 23.6. She was noted at that time to be responsive only to painful stimuli with a pinpoint right pupil (midline, reactive left pupil) and left facial droop. When her labs returned to, EMS was called. When EMS attempted intubation, she had a gag reflex and vomitted a small amount of coffe ground material. . Upon arrival to the ED, her heart rate was in teh 80s with a BP of 100/60 and an O2 Sat of 100%. She was intubated for airway protection and, per the ED resident, the patient had a difficult intubation in that she had episodes of bradycardia requiring atropine. GI was called and a gastric lavage via her PEG revealed coffe ground material without any fresh blood. She received 2 units of fresh frozen plasma, 4 units of PRBCs, and 10 mg of SC phytonadione. A femoral line was placed for emergent IV access. She was also given ampicillin/sulbactam for a dirty urinalysis. . Of note, during her recent hospitalization, she was noted to drop her hematocrit from 32.8 on admission down to a nadir of 24.1; this responded to 29.3 with 2 units of PRBCs on [2172-11-9]. Two days later, her hematocrit had drifted down to 26.9 and she was given an additional 2 units of PRBCs with a response up to 35.0. By the time of discharge, her hematocrit was back down to 27.2, though stable. . . Review of Systems: unable to obtain from patient due to sedation/intubation; per son, no [Name2 (NI) ], hematochezia, fevers Past Medical History: - hypertension - recent left MCA stroke [10/2172] - left ICA stent placed [2172-11-9] - operative PEG placement [2172-11-18] following failure of swallow eval - paroxysmal atrial fibrillation, recently started on warfarin - reported COPD; no PFTs in [Hospital1 18] records - chronic renal failure, baseline creatinine approx 2.6 with secondary hyperparathyroidism - chronic diastolic CHF - hyperlipidemia - type 2 diabetes mellitus - depression - morbid obesity Social History: Up until her recent hospitalization, Ms. [Known lastname 71441] lived with her son for several decades; upon discharge from [Hospital1 18] last week, she was sent to [Hospital 100] Rehab. She is a former smoker with a ~50 pack-year history; she quit approximately 10 years ago. She has a history of rare alcohol use without any active use at this time. Family History: One sister died of heart disease at age [Age over 90 ]; another sister has heart disease. Her brother died of colon cancer at age 68. Three of her four children have died, one from AIDS, one from drowning and one from ?choking. Physical Exam: T 97.7 BP 156/68 HR 83 RR 22 Sat 100% Vent: AC Vt 450cc RR 16 PEEP 5 FiO2 0.50 General: sedated, grimacing to pain, resisting opening of her eyelids HEENT: PERRL, no icterus, (+) ETT Neck: obese, supple, no lymphadenopathy detected Chest: clear to auscultation throughout, no w/r/r CV: rrr, nl s1s2, no murmurs Abdomen: obese, (+) PEG, nondistended, no HSM Extremities: 1+ edema to mid-shins, 1+ DP pulses, right femoral line Neuro: sedated, PERRL (5mm -> 3mm), grimacing and gagging to suctioning, moving all four extremities and wthdrawing to pain, opening eyes slightly to verbal command, 1+ patellar reflexes, plantar response equivocal bilaterally Pertinent Results: ECG ([2172-11-29]): Normal sinus rhythm at 91 bpm, normal axis, normal intervals, no obvious ST segment changes, though unsteady baseline may be obscuring subtle ST segment changes. . Head CT w/o contrast ([2172-11-29]): No evidence of intracranial hemorrhage. Marked mucosal thickening within the nasal cavity and ethmoid air cells without fluid levels to suggest the presence of acute sinusitis. Small-vessel angiopathy as described. . CXR ([2172-11-29]): The lung volumes are diminished. No focal consolidation, pneumothorax or pleural effusion is detected. The cardiomediastinal contour is within normal limits. ET tube terminates 1.5 cm above the carina. NG tube enters the stomach. The tip has been excluded. . [11-30] EGD: Impression: Normal mucosa in the esophagus Blood in the fundus There was some superficial ulceration with a small amount of oozing from around the G tube. No other bleeding site seen. Patent rotated for maximum visability given presence of large clot. Normal mucosa in the duodenum Otherwise normal EGD to second part of the duodenum . Recommendations: serial hematocrits [Hospital1 ] proton pump inhibitor Repeat EGD if acutely rebleeds AP CHEST 10:05 P.M, [12-2] HISTORY: Increased wheezing, crackles and dyspnea, assess for aspiration or pneumonia. IMPRESSION: AP chest compared to [11-29]: Lung volumes are very low, and the anatomic detail in the lungs is obscured by respiratory motion, but there appears to be new consolidation in the right mid and upper lung consistent with pneumonia due to aspiration. Moderate cardiomegaly has increased also and there is no mediastinal vascular engorgement suggesting cardiac decompensation, though I doubt that edema is present. Pleural effusion if any is small, decreased since [11-29]. No pneumothorax. Discharge labs [2172-12-4] 06:48AM BLOOD WBC-9.6 RBC-3.13* Hgb-9.4* Hct-29.0* MCV-93 MCH-29.9 MCHC-32.3 RDW-15.6* Plt Ct-285 [2172-12-4] 06:48AM BLOOD Neuts-77.8* Lymphs-15.6* Monos-4.4 Eos-2.1 Baso-0.2 [2172-12-4] 06:48AM BLOOD Plt Ct-285 [2172-12-4] 06:48AM BLOOD PT-13.0 INR(PT)-1.1 [2172-12-4] 06:48AM BLOOD Glucose-144* UreaN-109* Creat-2.7* Na-150* K-4.2 Cl-115* HCO3-26 AnGap-13 [2172-12-4] 06:48AM BLOOD Mg-2.1 Brief Hospital Course: Ms. [Known lastname 71441] is a 78 year-old woman with a recent left-sided ischemic stroke and subsequent left internal carotid stenting who presents with altered mental status following a large GI bleed in the setting of recent initiation of aspirin, clopidogrel, and warfarin. . ## Acute blood loss anemia secondary to GI blood loss: Hct on admission was as low as 15. She was admitted to the MICU and monitored with serial Hcts. She received 4 units of PRBCs intially with Hct rise to 29. She received an EGD which showed blood in the fundus and superficial ulceration surrounding the G tube but no active bleeding. She was continued on [Hospital1 ] PPI. Her aspirin, plavix, and coumadin were initially held. The following day her plavix and aspirin were restarted. Aspirin was decreased to 81 mg. Her coumadin was held and should likely not be restarted in the future given multiple episodes of significant GI bleeds. Following her EGD, her Hct continued to slowly trend down to 25 and she received another unit of PRBCs with appropriate response to 30. Upon transfer to the floor her vital signs were stable and her hematocrit remained between 28-30. She was scheduled follow up with Dr. [First Name (STitle) 572] of GI on [12-7] and neurology to decide on restarting coumadin weighing the risks of GIB and recurrent stroke. . ## Altered mental status: Unclear cause. Had evidence of UTI on admission. Also potentially secondary to hypoperfusion in the setting of profound anemia. Also possible contribution of uremia given concurrent renal failure. Head CT without any acute change. Toxicology screen negative. Her baseline prior to last discharge was reportedly interactive. However, after discussions with physicians at her rehab, it seems that her baseline there upon arrival was minimally verbal and minimally interactive. Her mental status improved with blood transfusions and improvement in her renal failure. Her mental status at discharge was occasional one word answers and nodding yes or no. Acoording to her son and HCP this has been her baseline since she suffered the CVA in [Month (only) ] of this year. . # Respiratory failure: She was intubated for airway protection in the setting of hematemesis and altered mental status. She was quickly weaned from the vent and was extubated without complication. Her mental status remained poor following extubation and there was concern for her respiratory status in this setting but her ABGs continued to be excellent not requiring further intervention. On the medical floors her oxygen ranged from 84-93 on room air, she was discharged on 1 liter NC saturating at 92-94 percent. Her oxygen requirements decreased with the addition of furosemide to her regimen which had been held during her ICU course. She had a chest x-ray on [12-3] which was consistent with volume overload and possible aspiration. She was not treated for aspiration pneumonia given she remained afebrile and WBC count was normal, her oxygen requirements also decreased with addition of furosemide. . ## Urinary tract infection: Evidence of UTI on U/A and received Unasyn in ED. On her recent hospitalization, she had a urine culture that grew our Enterococcus which was senstive to both vancomycin and ampicillin. She was started empirically on ampicillin and cipro. Unfortunately, urine culture was not sent prior to antibiotic administration and repeat urine culture grew only yeast. She was changed from ampicillin/cipro to augmentin. Her renal function and leukocytosis improved over the course of admission. She completed a course of Augmentin which was stopped upon transfer to the floor. . ## Acute on chronic renal insufficiency: acute exacerbation is most likely due to prerenal azotemia in the setting of massive GI blood loss. Her baseline Cr was ~2.3-2.7. On admission, Cr 3.8 and BUN significantly elevated to 168 from her last value prior to discharge of 68. Urine lytes were consistent with prerenal etiology. She was volume resuscitated with NS and renal function improved. Unclear if followed by renal as an outpatient. Will need to be seen by renal if not already seen by a nephrologist. At discharge her creatinint was back at baseline of 2.7. . ## Hypernatremia: Treated with free water through PEG tube, discharged on 400cc Q4H until hypernatremia resolves. Will need daily electrolytes until this resolves. . ## Recent left-sided ischemic stroke; s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 3098] stenting. Her aspirin was decreased to 81 mg but she was otherwise continued on both aspirin and plavix. . ## Chronic diastolic CHF: Her metoprolol and lasix were initially held. With stability following her EGD, her metoprolol was restarted and uptitrated. Her lasix was held in the setting of her ARF and restarted upon transfer to medical floor. She was discharged on furosemide 60mg [Hospital1 ], this will need to be titrated up to dose of 100mg [Hospital1 ] which she was on as outpatient. She needs close I/O and daily weights to determine her volume status. . ## Atrial fibrillation: Remained in in sinus rhythm. Recently started on warfarin for her atrial fibrillation which was discontinued in the setting of her GI bleed. Her beta blocker was initially held but was quickly restarted. Decision to restart coumadin will be made by GI, neurology, and her PCP. [Name10 (NameIs) ] up within the next few weeks was arranged with all three. . ## Type 2 diabetes mellitus, uncontrolled with complication. She had significantly elevated FSBGs while in house despite holding her tube feeds. Her glargine was titrated and she was continued on insulin sliding scale. Will need to increase glargine and adjust sliding scale as indicated. . ## Hypertension: antihypertensives intially held given significant bleeding but then restarted as above. Titrate up metoprolol as needed for hypertension. [Month (only) 116] need addition of another [Doctor Last Name 360], consider ACE inhibitor if creatinine allows given her diabetes. . ## Hyperlipidemia: continued on statin . ## Depression: continued on citalopram . ## FEN: TFs were restarted following EGD and extubation. TFs residuals were >100 on day prior to discharge, this resolved with as needed reglan. Continue with as needed prokinetic [Doctor Last Name 360] to keep gut motility adequate. . ## DVT Prophylaxis: pneumoboots . ## Communication: son [Name (NI) ] [Name (NI) 18915] ([Telephone/Fax (1) 98454] who is HCP . ## Code: Full, per son who is HCP. Medications on Admission: (per discharge summary from [2172-11-24]; patient and son unable to verify) citalopram 20 mg daily atorvastatin 80 mg daily nitroglyerin patch q6h ipratropium nebulizer q4h prn albuterol nebulizer q4h prn clopidogrel 75 mg daily aspirin 81 mg daily ferrous sulfate 325 mg daily calcitriol 0.25 mcg daily lansoprazole 30 mg daily furosemide 100 mg [Hospital1 ] docusate 100 mg daily metoprolol 50 mg tid insulin glargine 14 units qhs insulin lispro sliding scale warfarin 2 mg qhs bisacodyl prn acetaminophen prn ondansetron prn Discharge Medications: 1. Atorvastatin 80 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Calcitriol 0.25 mcg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 4. Citalopram 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Hospital1 ]: One (1) Inhalation Q4H (every 4 hours) as needed. 6. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 9. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 10. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours). 11. Insulin Glargine 100 unit/mL Cartridge [Last Name (STitle) ]: Twenty Two (22) units Subcutaneous at bedtime: titrate as blood sugars indicate. 12. Humalog 100 unit/mL Cartridge [Last Name (STitle) ]: One (1) Subcutaneous four times a day: sliding scale as directed. 13. Furosemide 80 mg Tablet [Last Name (STitle) ]: 1 and [12-24] Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Gastrointestinal bleed Secondary: Heart failure h/o CVA Diabetes type II Atrial fibrillation Hypernatremia Acute renal failure COPD UTI Discharge Condition: Stable, hematocrits stable>96 hours, mental status at baseline Discharge Instructions: You were admitted for a bleed likely originating from your stomach. This was likely caused by a combination of gastritis along with being on several blood thinner medications. Your blood counts stabilized. . Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4465], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2172-12-7] 1:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, MPH[MD Number(3) 708]:[Telephone/Fax (1) 7976] Date/Time:[2172-12-8] 11:30 Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2172-12-9] 2:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2172-12-16] 11:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "51881", "5849", "2760", "2851", "5990", "4280", "42731", "40390", "5859", "496", "2724", "311", "V5861" ]
Admission Date: [2178-2-11] Discharge Date: [2178-4-9] Date of Birth: [2103-2-27] Sex: F Service: CSU [First Name8 (NamePattern2) ] [Known lastname ] is a 74-year-old woman with known aortic stenosis followed by serial echocardiograms referred to [Hospital1 346] for an outpatient catheterization on [2178-1-14]. The echo at that time showed no coronary disease with an aortic valve area of 0.5 cm with a mean gradient of 45, an EF of 59 percent, an LVEDP of 10, aortic valve heavily calcified. She had no coronary disease. Right common iliac stenosis of 70 percent and subtotal left common iliac stenosis. HISTORY OF PRESENT ILLNESS: Patient with known aortic stenosis followed with serial echocardiograms. Echocardiogram from one year prior to catheterization showed an aortic valve area of 0.75 cm2. Repeat echo done in [12/2177] showed left ventricular hypertrophy with significant aortic calcification and aortic valve area of 0.4 to 0.5 cm2 with a peak gradient of 70 mm/Hg. Patient states dyspnea with exertion, such as climbing a flight of stairs. No complaints of angina. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Aortic stenosis. 4. Hiatal hernia. 5. PVD with aortoiliac disease. 6. Arthritis. 7. Degenerative disc disease. 8. Stress incontinence. PAST SURGICAL HISTORY: 1. Right hip replacement in [2165]. 2. Right carpal tunnel release over 15 years ago. 3. Cesarean sections in the past. ALLERGIES: Patient has no known drug allergies. MEDICATIONS: Her medications prior to catheterization include: 1. Lipitor 10 mg q.d. 2. Ditropan 5 mg b.i.d. 3. Omeprazole 20 mg q.d. 4. Avapro 300 mg q.d. 5. Hydrochlorothiazide 25 mg q.d. 6. Vitamin B supplements. 7. Multivitamin. 8. Calcium carbonate. 9. Glucosamine. SOCIAL HISTORY: Lives with daughter and son-in-law in [Name (NI) 3320], [State 350]. Planning to move to [Doctor First Name 26692] following aortic valve surgery. Denies alcohol use. Denies tobacco use. Denies any other recreational drug use. FAMILY HISTORY: Father died of an MI in his 80s and patient's mother died in her 90s. REVIEW OF SYMPTOMS: No diabetes, no thyroid disease, no CVA, no TIA, no seizures, no peptic ulcer disease, no hematochezia, no melena, no COPD, no asthma, no fevers, chills, sweats, or constitutional systems. Posterior PVD, pain in thighs with walking; relieved with rest. LABORATORY DATA: White count 6.8, hematocrit 35.9, platelets 242, PT 12.9, INR 1.1. Sodium 139, potassium 4.2, chloride 105, CO2 24, BUN 28, creatinine 0.6, glucose 105. ALT 13, AST 17, alkaline phosphatase 62, amylase 56, direct bilirubin 0.1, albumin 4.0. Chest x-ray showed mild enlargement of the cardiac silhouette with no evidence of CHF. EKG: A left bundle branch block at a rate of 80 with Q wave in Lead III as well as V2 through 3, an ST depression in Lead I, aVL, and V6. UA was pending, and dental clearance was provided by the patient prior to surgery. PHYSICAL EXAMINATION: Height 5 feet, 0 inches, weight 146 pounds. Vital signs: Heart rate 85, blood pressure 137/68, respiratory rate 14, O2 saturation 100 percent on room air. General: Lying comfortably in bed. HEENT: Pupils equally round and reactive to light with extraocular movements intact; anicteric, noninjected. Mucous membranes moist. Normal mucosa. No erythema or exudates. Neck is supple; no lymphadenopathy or thyromegaly; no JVD, with a radiating murmur. Respiratory: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm; S1, S2 with a III/VI blowing murmur. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm with no clubbing, cyanosis, or edema; no varicosities. Pulses: Carotid 2 plus with murmur bilaterally, radial 2 plus bilaterally, femoral 1 plus with a dressing on the right, and dorsalis pedis by Doppler bilaterally. Neurologically: Alert and oriented times three and nonfocal exam. Patient was a direct admission to the Operating Room on [2178-2-11] where she underwent aortic valve replacement. Please see the OR report for full details. In summary, the patient had a difficult operative course. She had an aortic valve replacement with a #19 mosaic valve. Her bypass time was 93 minutes with a cross clamp time of 66 minutes. The patient showed evidence of right heart failure following a wean from the bypass pump. Her chest was left open with a rubber [Doctor Last Name ] and she was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient's mean arterial pressure was 96. Her CVP was 17 with a PAD of 19. She was in a sinus tachycardia at 130 beats per minute with Levophed at 0.4 mcg/kg per minute, milrinone at 0.75 mcg/kg per minute, Amiodarone at 1 mg per minute, Neo-Synephrine at an undisclosed dose, epinephrine at 0.5 mcg/kg per minute, Vasopressin at 2.4 units per minute, and Lidocaine at 2 mcg per minute as well as propofol at 30 mg per hour. Upon arrival in the Intensive Care Unit the patient was placed on a _______ infusion as well as Ativan and Fentanyl infusions. On postoperative day one the patient remained hemodynamically unstable, and she returned to the Operating Room, at which time a right ventricular assist device was placed. Please see the OR report for full details. In summary, the patient had an RVAD placed, and following the procedure she was again returned to the Cardiothoracic Intensive Care Unit, again, with an open chest. Over the next several days the patient remained in critical condition in the Cardiothoracic Intensive Care Unit. She remained paralyzed and sedated with full ventilatory support. She was slowly weaned from her vasoactive medications. She had flow rates of 4 to 4.5 liters per minute with her right ventricular assist device. She was seen by the Renal Service to assist in fluid removal. Additionally, the patient was seen by the Heart Failure Service for assist in patient care management. On postoperative day seven the patient returned to the Operating Room, at which time she had her chest closed. On postoperative day eight the patient was brought to the Cardiac Catheterization Lab for a diagnostic catheterization which showed a tight right coronary artery lesion which was stented at that time. Please see the cath report for full details. Following the stenting to the RCA the patient returned to the Cardiothoracic Intensive Care Unit. She remained hemodynamically stable with her RVAD in place and the paralytics were slowly weaned to off so that by postoperative day nine all paralytics had been weaned off. By that point the patient had also been weaned from her epinephrine, significantly weaned from her Pitressin. The milrinone had been weaned down. The Lidocaine had been discontinued, and the Levophed was also weaned to off. Patient did well over the next several days. However, she was noted to have an elevated white blood cell count. She was pancultured and Infectious Disease was consulted at that time. By [2178-2-27] the patient was beginning to have an ARDS type picture by chest x-ray, and at that time she was bronched by the Interventional Pulmonary Service. The bronchoscopy showed diffuse blood in the airways with bleeding from the right upper lobe. Following the bronch the patient's Heparin was discontinued. The patient remained stable over the next several days with good right ventricular assist device flows. She was further weaned from her cardioactive IV medications, and on [2178-3-3] she again returned to the Operating Room, at which time her right ventricular assist device was removed. Please see the OR report for full details. Following RVAD removal the patient was again transferred to the Cardiothoracic Intensive Care Unit. At that time, she had two new mediastinal tubes, mean arterial pressure of 92 with a CVP of 19. She was in a sinus rhythm at 110 beats per minute with milrinone at 0.75 mcg/kg per minute, epinephrine at 0.5 mcg/kg per minute, Levophed at 2 mcg/kg per minute, Vasopressin at 1.2 units per hour, Amiodarone at 0.5 mg per hour, and propofol at 30 mg per hour. Again, the patient's chest was left open with a rubber [Doctor Last Name ] in place. The patient did well over the next three postoperative days, and on [2178-3-6] she again returned to the Operating Room, at which time her chest was closed. Patient tolerated the closure well. Following closure she was returned again to the Cardiothoracic Intensive Care Unit. She had a mean arterial pressure of 92. She was in a sinus rhythm at 106 beats per minute with a CVP of 23 and PAD of 24. Her Levophed had been weaned off, milrinone is at 0.75 mcg/kg per minute, epinephrine at 0.6 mcg/kg per minute, Vasopressin at 0.6 units per hour, Amiodarone at 0.5 mg per hour, as well as an insulin and Ativan drip. In addition to the services that had been previously consulted at this point, Plastic Surgery and the Intensivist Service had also been consulted. Over the next week the patient continued to make slow progress at weaning from her vasoactive IV medications as well as slow progress in weaning from the ventilator. She continued to be followed by the Infectious Disease Service as her white count had been greater than 20 since the implantation of the right ventricular assistive device. On [2178-3-8] a culture of the [MD Number(3) 52953] was positive for yeast. It turned out to be [Female First Name (un) 564] Torulopsis glabrata. Following identification the patient was switched from Fluconazole to caspofungin. During this period the patient's sedation was also discontinued. She continued to make progress, weaning from the ventilator. However, she remained too weak to adequately protect her airway, and on [2178-3-23] she again was brought to the Operating Room, at which time she underwent tracheostomy. Please see the OR report for full details. In summary, she had a 7 mm percutaneous Portex trach with a small amount of superficial bleeding. Following placement of the tracheostomy the patient returned to the Cardiothoracic Intensive Care Unit, and over the next two days, started on trach collar trials, which she tolerated well. Patient did exceedingly well with her trach collar trials. She was spending most of the day off of the ventilator, only being rested at night. On [2178-3-27] she had a video swallow evaluation which she passed. At that point her tube feeds were changed to be cycled in the nighttime hours only, and she was able to take oral food during the course of the daytime. Additionally, the patient was noted to have some sternal wound drainage. She was seen by the Plastic Surgery Service for incision. Distal incision was superficially debrided and a VAC dressing applied. However, by [2178-4-2] the incision showed necrotic tissue in the base of the wound and her sternum was felt to be unstable. At that point she was brought to the Operating Room for additional sternal debridement as well as a pec flap advancement and closure. Following her sternal debridement the patient was again begun on trach collar trials, and within two days she was successfully weaned from the ventilator and has been without ventilator support since [2178-4-3]. The patient's oral diet was advanced over the next week with shorter and shorter periods of tube feed cycles at night, and by [2178-4-8] she was on a full oral diet. Also on [2178-4-8] the patient's trach was downsized to a number 6 Portex fenestrated cuff. It is felt at this time that the patient will be ready for transfer to [Hospital 4820] rehabilitation center within the next day. At this time the patient's physical exam is as follows. Vital signs: Temperature 97.7, heart rate 91, sinus rhythm, blood pressure 128/53, respiratory rate 22, O2 saturation 99 percent on 35 percent trach collar. LABORATORY DATA: White count 10.7, hematocrit 31, platelets 290, sodium 138, potassium 4.4, chloride 102, CO2 27, BUN 29, creatinine 0.4, glucose 84. PHYSICAL EXAMINATION: Neurologically alert and oriented times three; moves all extremities, although remains weak. Breath sounds clear to auscultation bilaterally. Cardiac: Regular rate and rhythm. Sternal incision clean, dry, and intact. Abdomen is soft, nontender, with positive bowel sounds. Extremities are warm with no edema. DISCHARGE DIAGNOSES: 1. Aortic stenosis status post aortic valve replacement with number 19 mosaic valve. 2. Hypertension. 3. Hypercholesterolemia. 4. Peripheral vascular disease. 5. Arthritis. 6. Degenerative disc disease. 7. Stress incontinence. 8. Hiatal hernia. 9. Right hip replacement. 10. Right carpal tunnel release. 11. Cesarean section. 12. Right heart failure. 13. Status post right ventricular assist device placement and removal. 14. Status post tracheostomy. 15. Status post sternal debridement and pec flap advancement and closure. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q. day. 2. Albuterol one to two puffs q. 4 hours as needed. 3. Miconazole powder t.i.d. as needed. 4. Pantoprazole 40 mg q.d. 5. Potassium chloride 20 mEq b.i.d. 6. Amiodarone 200 mg q.d. 7. Plavix 75 mg q.d. 8. Fluconazole 200 mg q.d. 9. Captopril 100 mg t.i.d. 10. Lasix 20 mg b.i.d. 11. Colace 150 mg b.i.d. 12. Ceftazidime 1 gram q. 8 hours times three weeks. 13. Bisacodyl suppository, one, q.d. as needed. 14. Benadryl 25 mg q. h.s. as needed. 15. Acetaminophen 325 to 650 mg q. 4 hours for a temperature greater than 38.0 C. 16. Toprol XL 25 mg q.d. DISCHARGE INSTRUCTIONS: 1. Patient is to have follow up with Dr. [Last Name (STitle) ] of the Plastic Surgery Service in one week. 2. Rehabilitation center is to call [Telephone/Fax (1) ] for an appointment. 3. She also is to have follow up with Dr. [Last Name (STitle) 70] in six weeks, to call [Telephone/Fax (1) ] for an appointment. 4. Follow up with Dr. [First Name (STitle) ] of the Infectious Disease Service on [2178-5-18] at 9:30 a.m.; please call [Telephone/Fax (1) ] for directions. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] M.D. [MD Number(1) 75] Dictated By:[Doctor Last Name 52954] MEDQUIST36 D: [2178-4-8] 21:10:52 T: [2178-4-8] 23:46:55 Job#: [Job Number 52955]	[ "4241", "9971", "4280" ]
Admission Date: [2152-10-20] Discharge Date: [2152-11-2] Date of Birth: [2091-1-16] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 61 year old female was admitted to an outside hospital one day prior with the complaints of intermittent exertional chest pain times three to four days. She complained also of diaphoresis and shortness of breath associated with chest pain. She denies worsening paroxysmal nocturnal dyspnea, orthopnea, edema, nausea, vomiting or syncope. Her cardiac enzymes were negative at the outside hospital. A spiral CT was negative for pulmonary embolus. Stress test in [2152-6-29] showed normal ejection fraction and no inducible ischemia. She was transferred to the [Hospital1 69] for catheterization which showed two vessel coronary disease with an ejection fraction of 60 percent, left main 50 percent lesion, left anterior descending coronary artery 80 percent lesion, circumflex 40 percent, 95 percent lesion of the second obtuse marginal and the right coronary artery was normal. The patient was referred to Dr. [First Name (STitle) ] [Name (STitle) ] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Carotid artery stenosis. 4. Asthma. 5. Noninsulin dependent diabetes mellitus. 6. Fatty liver. 7. Anxiety. 8. History of nonsustained ventricular tachycardia. 9. Gallstones. PAST SURGICAL HISTORY: Is remarkable only for hysterectomy. ALLERGIES: She was allergic to aspirin which caused gastrointestinal upset and Percocet which has caused her to hallucinate. MEDICATIONS AT HOME: Diovan 80 mg P.O. daily, Klonopin 0.5 mg P.O. twice a day PRN, Celexa 40 mg P.O. daily while at the outside hospital. At home she was taking Lexapro. Plavix 75 mg P.O. daily. Lasix dose was [10-20] in the morning. Fosamax 1 tablet P.O. every Sunday. Singulair 10 mg P.O. daily. Multivitamin 1 tablet P.O. daily. Metformin 500 mg P.O. B.I.D, Lescol 80 mg P.O. once daily and calcium 1 tablet P.O. daily. Patient also took vitamin D. SOCIAL HISTORY: Patient lives with her husband. She works at home. Is active. Had no history of tobacco use and used alcohol only rarely. She has a positive family history for coronary artery disease with the mother having a myocardial infarction in her 40s and her bother dying of myocardial infarction at 53. PHYSICAL EXAMINATION: She admitted to a 20 pound weight gain over the past month and was sleeping very poorly at the time. Her height was 5, 1. Her weight was 160 pounds. Blood pressure 133/80, heart rate 82, respiratory rate 22, saturation 95 percent on room air. She was lying flat in bed on examination in no apparent distress. She was alert and oriented times three and appropriate. She had carotid bruits bilaterally. Her lungs were clear bilaterally. Her heart was regular rate and rhythm with S1, S2 tones and no murmur, rub or gallop. Abdomen was soft, obese, nontender, nondistended with positive bowel sounds. Her extremities were warm and well perfused with no edema or varicosities. On the right she had 2 plus radial, 1 plus dorsalis pedis and 1 plus posterior tibial pulses. On the left 1 plus radial, 1 plus dorsalis pedis, and 1 plus posterior tibial pulses. PREOPERATIVE LABORATORY DATA: White count 7.1, hematocrit 37.1, platelet count 185,000. PT 13.9, PTT 23.8, INR 1.2. Sodium 135, potassium 4.4, chloride 99, bicarb 23, BUN 14, creatinine 0.7 with a blood sugar of 260, anion gap 17, total bilirubin 0.5, amylase 57, alkaline phosphatase 100, ALT of 96, AST 89, albumin 4.0. HBA1C 9.7 percent, significantly elevated. Preoperative carotid ultrasound study showed less than 40 percent right internal carotid artery stenosis and no left internal carotid artery stenosis. Preoperative electrocardiogram showed sinus tachycardia at 103 with occasional ventricular ectopy, diffuse nonspecific ST-T wave abnormalities. Please refer to the official report on [2152-10-21]. HOSPITAL COURSE: Patient's Plavix was discontinued. Patient was referred to Dr. [Last Name (STitle) ] and over the course of the next couple of days as the carotid ultrasound was done the patient was followed by cardiology daily in preparation for her surgery on Monday morning. Patient was seen by cardiology daily and was seen also by the case manager and on [10-23] the patient underwent coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending coronary artery, a vein graft to the second obtuse marginal and a vein graft to the diagonal which is a Y graft off the saphenous vein graft to the obtuse marginal. Patient was transferred to cardiothoracic Intensive Care Unit in stable condition on a Neo-Synephrine drip at 0.24 mcg per kilograms per minute and a propofol drip at 10 mcg per kilogram per minute. On postoperative day one the patient had been extubated in the early morning hours, was in sinus rhythm at 97 with a blood pressure of 97/61, saturating 97 percent on 3 liters of nasal cannula with a cardiac index of 2.29. She was alert and oriented times three. Heart was regular rate and rhythm. She had decreased breath sounds bilaterally. Otherwise lungs were clear. Abdomen was soft, nontender. Chest tubes were in place. She had 1 plus peripheral edema bilaterally. Lasix intravenous diuresis was begun. Swan-Ganz was discontinued. Neo-Synephrine wean was begun. Postoperative laboratories as follows: White count 17.4, hematocrit 32.4, platelet count 207,000. Potassium 4.7, BUN 8, creatinine 0.6 with an INR o 1.2. Patient needed for Neo- Synephrine for tone on the following morning, postoperative day two remained at 1.0. Beta blockade was held. Neo- Synephrine was continued. The following day the blood pressure was 110/64 with a heart rate of 111. Patient was saturating 94 percent on 5 liters nasal cannula. Patient remained tachycardic. Examination was otherwise unremarkable. The Neo-Synephrine wean continued. Chest tubes were discontinued. Foley was discontinued. Hematocrit rose to 28.3. Creatinine was stable at 0.6. Patient was eligible to go to the floor as soon as the Neo-Synephrine was weaned off but was allowed to be out of bed in the room. On postoperative day three chest tubes were discontinued. Neo- Synephrine was off. Patient was in sinus rhythm in the 90s. Blood pressure 95/68. Examination was unremarkable. Incisions were clean, dry and intact with 1 plus peripheral edema. Creatinine stabilized at 0.5, hematocrit 27.4, potassium 3.8, beta blockade was begun with Lopressor 25 mg P.O. B.I.D Chest x-ray was repeated, Lasix diuresis continued. On postoperative day four the patient had a 10 beat run of supraventricular tachycardia in the morning which was monomorphic. No chest pain. Patient had been transferred out to the floor. Patient continued with perioperative Kefzol and continued to get Combivent and Singulair to help her for her asthma. Her pacing wires were discontinued. She was encouraged to do aggressive pulmonary toilet, cough and deep breath. She was placed on Kefzol for her sternum which had minimal erythema. She continued to work on the floor with physical therapy. Patient had some complaints of palpitations overnight but maintained a good blood pressure of 104/58. On postoperative day five she was in the sinus rhythm in the 90s with blood pressure of 116/65. She had no erythema of her sternal wound. Otherwise her examination was unremarkable with trace peripheral edema. She was stable and afebrile with a maximum temperature of 99.8. On postoperative day seven the patient had no overnight events but was still desaturating with ambulation. Her saturations were 93 percent on 2 liters nasal cannula. Her hematocrit was 27, her potassium 3.7, and magnesium 1.8. Her oral Metformin was started again. She had a few bibasilar crackles, still had 1 plus peripheral edema. Also the patient had an episode of rapid atrial flutter today with a heart rate of 150 and a stable blood pressure. Patient was give 5 mg intravenous of Lopressor twice and magnesium 2 grams and patient converted to sinus rhythm. The plan was the patient would be able to be discharged home if the O2 saturations were greater than 90 percent with ambulation. The patient continued to work with physical therapy and the nursing staff to achieve this. Early in the morning at approximately 4:15 A.M. on [10-31] the patient was found on the floor in the bathroom. By report she woke up to go to the bathroom. She was found on the bathroom floor. When asked if she had any pain or complaints of pain she said she slipped on her slipper and onto the floor. She was assisted back to the bed without any complains of headache, hip pain, nausea, vomiting, back pain. Patient was reminded to use the call bell for assistance,. On examination she was resting comfortably. Her neurologic examination was grossly normal. She has no obvious deformities noted. Patient was observed closely for any potential injury but appeared to be doing fine. On postoperative day eight the patient was on day five of a seven day course of Keflex for the sternal erythema. The sternal incision had no erythema at that time. She continued to increase her activity. A repeat chest x-ray was done. Lasix was increased to 20 intravenous B.I.D for 24 hours with plans to discharge her the following morning. She did have a temperature of 101 overnight which was brought to 99 in the morning. Her white count rose slightly to 14.6. Lopressor was increased to 75 B.I.D The patient was encouraged to use her incentive inspirometer. She was alert and oriented. On postoperative day nine she had rapid atrial fibrillation that began the day prior. She was started on Coumadin and amiodarone for her atrial fibrillation. She converted back to sinus rhythm with a blood pressure of 90/56 and a heart rate of 77. Her white count dropped slightly to 12.6. Her creatinine was stable at 0.7. Her examination was otherwise unremarkable and the plan was she would be to be discharged home if she had 24 hours of no arrhythmias. On postoperative day nine her lungs had decreased breaths on the left side [1-1] of the way down. Her sternum was stable with no drainage or erythema. She had bowel sounds. She had no peripheral edema. Her leg incisions bilaterally were clean, dry and intact. Patient did level five, was instructed to follow up with Dr. [Last Name (STitle) ] in the office for postoperative surgical visit in four weeks and to see Dr. [Last Name (STitle) 284], her cardiologist, in four to six weeks. Patient was also instructed to get blood drawn for INR checks on [11-3] and [11-6] and have results called to Dr. [Last Name (STitle) ], phone number [Telephone/Fax (1) 11554] who is responsible for following her Coumadin dosing and INR level management. DISCHARGE MEDICATIONS: Colace 100 mg P.O. B.I.D, 81 mg enteric coated aspirin P.O. daily, Dilaudid 2 mg tablet, 1 tablet P.O. q 4 to 6 hours PRN for pain, Metformin 500 mg P.O. B.I.D, escitalopram oxalate 20 mg P.O. daily, Montelukast sodium 10 mg P.O. daily, albuterol/ipratropium 103-108 mcg actuation aerosol 1 to 2 tabs inhalation every six hours as needed, Lasix 20 mg P.O. B.I.D for one week, then Lasix 20 mg P.O. daily times one week, Lipitor 40 mg P.O. daily, fluticasone/salmeterol 100-50 mcg dose disk with device, 1 disk with device inhalation 2 times a day, potassium chloride 20 mEq P.O. B.I.D times one week, Keflex 500 mg P.O. q.i.d. times five days, metoprolol tartrate 75 mg P.O. B.I.D, amiodarone 400 mg P.O. t.i.d. times one week, then amiodarone 400 mg P.O. B.I.D times one week, then amiodarone 200 mg P.O. daily. Coumadin 3 mg for that single dose on the evening of discharge with a goal INR of 2 to 2.5 and INR checks scheduled with Dr. [Last Name (STitle) ] on [11-3] and [11-6]. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting times three. 2. Hypertension. 3. Hyperlipidemia. 4. Carotid artery stenosis. 5. Asthma. 6. Noninsulin dependent diabetes mellitus. 7. Fatty liver. 8. Anxiety. 9. Nonsustained ventricular tachycardia. 10. History of atrial fibrillation. 11. Gallstones. Again the patient was given the previously mentioned discharge instructions and was discharged to home with [Hospital6 407] services on [2152-11-2]. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2152-11-24] 13:32:25 T: [2152-11-24] 14:53:10 Job#: [Job Number 57623]	[ "41401", "9971", "42731", "25000", "4019", "2724", "49390" ]
Admission Date: [2109-6-14] Discharge Date: [2109-6-20] Date of Birth: [2042-7-26] Sex: M Service: MEDICINE Allergies: Tetracycline Analogues Attending:[First Name3 (LF) 2195] Chief Complaint: Unable to void Major Surgical or Invasive Procedure: foley catheter changed History of Present Illness: Mr. [Known lastname ] is a 66 year old man with juvenile rheumatoid arthritis and an indwelling foley catheter secondary to an atonic bladder. He presented to the ED today with a one day history of inability to void and abdominal pain. He states that he uses a leg bag during the day and a larger bag at night, which are emptied by his two PCAs (each comes for 2 hours a day, morning and evening). He is not aware of any abnormal-appearing urine recently and has not had dysuria. He also reports that to his knowledge his leg ulcer is at baseline, not getting worse. . In the ED, initial vs were: 97.8 103 136/79 18 100%. His Foley was exchanged and drained 1 L of purulent-looking urine. This resolved his abdominal pain. He had very poor access, so labs were not able to be obtained. He had an intraosseous line placed in the right lower extremity and was given IL of IV fluids. While in the ED, he was noted to be hypotensive to SBP 40s-50s/P; however, his small arms and body habitus made a good [Location (un) 1131] difficult. BP in the leg was 90s/40s, and his mental status was clear throughout. His left lateral ankle was also noted to be malodorous. He received vancomycin (for leg cellulitis) and zosyn for antibiotics. . On the floor, patient reported complete resolution of abdominal pain. He reported discomfort at the IO site, as well as his chronic hip and knee pain because he did not receive home pain meds in ED. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - with chronic indwelling foley catheter - Juveile rheumatoid arthritis (no steroids in decades, but history of chronic steroids x 15 years) - Osteoporosis - GERD - Left venous stasis ulcer, chronic - Hemorroids - Chronic pain of knee, back, shoulder, hip - s/p C. difficile infection - Cellulitis/osteomyelitis of his calf - Multiple orthopedic surgeries (no hardware per patient) to ankles, knees, neck, right elbow Social History: Former smoker, 10 pack years. Rare alcohol. Retired neurohistologist (formerly worked at [Hospital1 ]). Lives alone in an apartment in [Location (un) ], two PCAs help him in the morning and evening. Uses an electric wheelchair to get around both at home and outside his home. Family History: Brother died of colon cancer in his 40s. Mother with alcoholism, cirrhosis, and heart attack. Sister alive and well. Father alive with hypertension. Physical Exam: Physical Exam on Admission to [Hospital Unit Name 153] Vitals: T: BP: 121/67 P: 91 R: 18 O2: 96% on RA General: Alert, oriented, no acute distress. Small body habitus with foreshortened extremities and small hands and feet. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult to assess given body habitus (large jowls), no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Small amount of purulent discharge at urethra, foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Superficial ulceration of left lower extremity with copious yellow exudative discharge and minimal surrounding erythema, slightly indurated. Pertinent Results: Labs on Admission: [2109-6-14] 04:20PM WBC-15.5# RBC-3.53 Hgb-6.9* Hct-23.4* MCV-66* Plt Ct-385 Neuts-83.8* Lymphs-11.6* Monos-3.8 Eos-0.5 Baso-0.3 PT-14.4* PTT-39.7* INR(PT)-1.2* Glucose-112* UreaN-30* Creat-0.8 Na-140 K-4.1 Cl-106 HCO3-26 AnGap-12 Calcium-7.7* Phos-2.8 Mg-1.9 URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.017 URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG URINE RBC-30* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 URINE WBC Clm-MANY Mucous-MANY Labs on Discharge: [2109-6-19] 01:04PM WBC-10.6 RBC-3.27* Hgb-6.4* Hct-22.9* MCV-70* Plt Ct-337 Glucose-113* UreaN-17 Creat-0.6 Na-139 K-4.1 Cl-104 HCO3-28 AnGap-11 Imaging: [2109-6-14] - Tib/Fib X -ray: Intraosseous catheter is seen with tip in the proximal tibial metadiaphysis beyond the cortical margin. Bones are diffusely osteopenic with ankylosis involving the hindfoot, midfoot and ankle. Extensive degeneration and distortion incompletely assessed at the knee. Extensive vascular calcifications are also seen. IMPRESSION: IO catheter in the proximal tibia. Microbiology: URINE CULTURE (Final [2109-6-19]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. WORK UP PER DR [Last Name (STitle) ].[Doctor Last Name ] [2109-6-15]. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. AMPICILLIN AND Penicillin Sensitivity testing performed by Sensititre. Daptomycin Sensitivity testing per DR [Last Name (STitle) ] #[Numeric Identifier 30694]. Daptomycin Sensitivity testing performed by Sensititre. SENSITIVE TO Daptomycin (MIC=1MCG/ML). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PROTEUS MIRABILIS \| \| ENTEROCOCCUS SP. \| \| \| AMPICILLIN------------ =>32 R 1 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- 8 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 2 I =>4 R DAPTOMYCIN------------ S GENTAMICIN------------ <=1 S 4 S LINEZOLID------------- 2 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S PENICILLIN G---------- 4 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ =>32 R Brief Hospital Course: Mr. [Known lastname ] is a 66 year old man with a history of JRA and bladder atony with chronic indwelling Foley who presents with one day of urinary retention and abdominal pain. # Urinary tract infection. Most likely [1-30] urinary retention from clogged/obstructed Foley catheter. Foley catheter was changed on [2109-6-14]. Last documented catheter change prior was in [Month (only) 547]. Upon admission to the ICU, hemodynamics were stable with improvement of his abdominal discomfort. His outpatient urologist was informed. Urine culture was significant for VRE and Psuedomonas, and the patient was placed on Macrobid and Meropenem initially, which was transitioned to Macrobid and Piperacillin-Tazobactam at discharge. A PICC was placed in the LUE for home antibiotics, and he will complete a total of 14 days of antibiotics. Safety labs to be sent on Wednesday, [6-26] and faxed to the ID division. Patient will susbsequently follow-up with his outpatient ID physician [Last Name (NamePattern4) ].[Last Name (STitle) ]. Patient remained afebrile, asymptomatic and hemodynamically stable throughout his stay on the general medicine service. # Urinary retention. [1-30] bladder atony with chronic indwelling Foley. Since the change of Foley catheter on admit, his abdominal discomfort improved, suggesting possible clogging in the catheter. Patient will have continued follow-up with his outpatient urologist. [Month (only) 116] need scheduled foley catheter changes, [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7986] (NP) and Dr.[Name (NI) 825] note on [2108-7-6] # Chronic leg ulcer, PVD: Baseline per patient. Patient has been followed by Dr. [Last Name (STitle) ] for his non-healing ulcer. Asa 162mg was continued, and QOD Aquacel silver dressings were ordered. Blood cultures remained negative. No antibiotics were given specifically for the wound infection. # Hypotension. Concerning for peri-sepsis initially, but apparently hypotension in the ED and borderline in the ICU. Unclear if this was due to poor cuff [Location (un) 1131] given his body habitus and use of a large cuff in the ED or if it recovered quickly after 1L of IVF. Using pediatric cuff, readings remained mostly in the 110s. # Microcytic Anemia: History of iron-deficient anemia. No evidence of acute bleed. Pt was continued on his home iron therapy. Iron studies were normal. HCT remained near his baseline during his admission. # Osteoporosis: Likely secondary to chronic steroid use. Has chronic pain related to multiple surgeries. Continued home Actonel (Mondays). Continued methadone and oxycodone for chronic pain Code Status: OK to intubate, defibrillate or cardiovert; no chest compressions Medications on Admission: FAMOTIDINE 40 mg qPM METHADONE 5 mg/5 mL Solution, 10 ml by mouth at 6pm OXYCODONE 10 mg q4 hours RISEDRONATE 35 mg every week ASPIRIN 162 mg daily FERROUS GLUCONATE 324 mg TID MULTIVITAMIN Discharge Medications: 1. famotidine 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. methadone 10 mg/mL Concentrate Sig: One (1) PO DAILY AT 6 () as needed. 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. risedronate 35 mg Tablet Sig: One (1) Tablet PO weekly on Monday () as needed for osteoporosis. 5. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 6. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 17 doses. Disp:17 Capsule(s) Refills:0 9. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1) dose Intravenous every six (6) hours for 8 days. Disp:8 day's supply Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: hypotension urinary tract infection-complicated atonic bladder with chronic foley L.leg chronic ulcer juvenile rheumatoid arthritis 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 intially admitted with abdominal pain and inability of your foley catheter to drain. For this, you had your foley catheter replaced. You were given antibiotics for a urinary tract infection. You will need to take Zosyn and Macrobid upon discharge through [6-28]. Medication changes: 1. Take Zosyn and Macrobid through [6-28] Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: Department: Primary Care Name: Dr. [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] When: Wednesday [2109-6-26] at 3:15 PM Address: [Street Address(2) 12840],[Apartment Address(1) 40744], [Location (un) 6017],[Numeric Identifier 12842] Phone: [Telephone/Fax (1) 40745] Department: INFECTIOUS DISEASE When: FRIDAY [2109-7-5] at 8:30 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: VASCULAR SURGERY When: WEDNESDAY [2109-12-4] at 11:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10107], NP [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "5990", "V1582", "2859" ]
Unit No: [Numeric Identifier 26877] Admission Date: [2124-1-12] Discharge Date: [2124-1-14] Date of Birth: [2096-2-27] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: A 27-year-old male with a history of depression, panic attacks and multiple suicide attempts was found down by his father on the day of admission. His father spoke to him at 7:00 a.m. that morning when he sounded groggy and had a slurred speech. He did not show up at work and that is when his father went to his apartment and found down with a bag over his head snoring. He called the emergency services. At that time, the patient started vomiting pills. The pill bottles were found with the patient. These were as follows: Seroquel 200 mg tablets last filled [2124-1-5], 28 tablets, no tabs left in the pill bottle, carisoprodol 350 mg tablets last filled [2124-1-5], 56 tablets were filled at that time, none left in the bottle, lorazepam 1 mg tablets last filled [2124-1-5], 42 tablets, none left in the bottle, cyclobenzaprine 10 mg tablets last filled [1-10], #30 in number, 10 left in the bottle, Cymbalta 60 mg tablets last filled [2123-12-17], 30 in number, only 4 left in the bottle. In the emergency department, his vitals were temperature of 35.2 with a bear hugger, initially it was unable to register, pulse of 79, blood pressure 90/59, after 4 liters of IV fluids. He was intubated for airway protection and given his vomiting. He received 50 grams of charcoal with sorbitol. He had a negative head CT and a C-spine CT as well. EKG was within normal limits. He was admitted to the intensive care unit for further care. PAST MEDICAL HISTORY: 1. Depression. He was discharged from a psychiatric facility 1 week ago. 2. Panic attacks. 3. Multiple suicide attempts. Per chart, he has had at least 7 suicide attempts since [2118], most recently 10 days ago by cutting himself. He has also tried to stab himself in [2123-10-24], with an Exacto knife, overdose with Seroquel, Zanaflex and Klonopin. MEDICATIONS: Seroquel, carisoprodol, lorazepam, cyclobenzaprine, Cymbalta. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He works at [Hospital3 1196] in nuclear medicine. No alcohol use. History of tobacco use. Has a girlfriend with bipolar disorder. PHYSICAL EXAMINATION: On admission, temperature was 97.8 without a bear hugger, blood pressure 108/67, pulse 76. These vitals were taken in the intensive care unit. He was saturating 100% on the ventilator. Good urine output. Appeared intubated, sedated but followed commands. Head and neck exam were mild pallor, NG tube and endotracheal tube were in place. The pupils were bilaterally reactive, equal. Neck: C-spine collar was in place. Lungs clear to auscultation bilaterally. Cardiovascular exam: Regular rate and rhythm, no murmurs, rubs or gallops. Abdomen soft, nontender, hypoactive bowel sounds. Extremities: No edema, 2+ distal pulses. Neurologic exam: PERRL, intermittently following commands. Skin warm and dry. LABORATORY DATA: On admission, he had a hematocrit of 29 that remained stable throughout the admission ranging from 27 to 29. There was 1 spurious value of 23.8, however, on repeating a few hours later it was back up to 29. Normal coagulation panel. Chem7 was unremarkable. ALT, AST were normal. Alkaline phosphatase was normal. Amylase was 318. Normal lipase. Cardiac enzymes remained normal. Calcium at admission was 7.9, however, it could be corrected with albumin of 3.3. Ionized calcium was normal at 1.16. Normal TSH, normal haptoglobin. Serum toxicology showed positive for tricyclics. Normal lactate. UA was normal. Urine toxicology was normal. Urine culture at the time of discharge was pending and was normal. Blood culture sent out the day prior to discharge was normal at the time of dictating this discharge summary. Chest x-ray, PA and lateral, showed no evidence of pneumonia. This was done the day prior to discharge. CT of the cervical spine revealed no fracture, anything suggestive of trauma. CT head revealed no signs of intracranial bleed or infarct or mass effect or fractures. Chest x-ray on admission did not reveal any infiltrate. PROCEDURES PERFORMED: Intubation, extubation. HOSPITAL COURSE: Severe depression and history of multiple suicide attempts: The patient after being initially intubated for airway protection he was extubated within less than 24 hours later and tolerated that well. He was given Charcoal in the emergency room. No EKG changes suggestive of Q-T prolongation were noted. No signs or symptoms suggestive of serotonin syndrome were noted. As well as toxicology followed the patient while in the intensive care unit. After stabilization, he was transferred to the floor with 1 to 1 sitter. He displayed ongoing suicidal ideation during the hospitalization. All further medications that he had overdosed on were withheld during the hospital course. Psychiatry evaluation was obtained who recommended inpatient psychiatry admission. He is eventually being discharged to an inpatient psychiatric facility ([Hospital1 ] 4) for further management of his severe depression and history of multiple suicidal attempts and the current ideation. Anemia. His hematocrit except for the spurious value of 23 remained stable between 27 and 29. There was no acute evidence of bleeding, however, what was noted was the patient had multiple bruises and cuts on his extremities in various stages of development. These probably were from past suicide attempts that could have led to chronic blood loss causing his anemia. There was no evidence of hemolysis on his blood work and no evidence of acute GI or other bleeding. His hematocrit should be followed up as an outpatient. There is no acute need for blood transfusion at the time of discharge. Fever. The day prior to discharge the patient had a fever up to 101.9. A fever workup was initiated. Chest x-ray revealed no pneumonia or infiltrate. Urinalysis was normal. Urine culture was normal at the time of discharge. Blood cultures were drawn as well which were normal at the time of discharge. The patient had no symptoms suggestive of any infection. The fever defervesced overnight with resolution. The patient was afebrile for 24 hours prior to discharge. Hypocalcemia. The initial blood tests revealed hypocalcemia, however, after correction with the low albumin this was correctable. His ionized calcium was also confirmed to be normal. There were no symptoms or signs suggestive of hypocalcemia but this could have been a spurious value. The patient is being be discharged for further care to the inpatient psychiatric facility. At the time of discharge, the patient was medically stable to be discharged for his further psychiatry needs. CONDITION ON DISCHARGE: Stable from medical point of view. DISCHARGE INSTRUCTIONS: Further care to be taken over by the physicians at the psychiatry unit. The patient should call and follow-up with the primary care physician after discharge. DISCHARGE MEDICATIONS: 1. Nicotine patch. 2. Sumatriptan subcutaneous dose once daily as needed for migraine headaches. 3. Naproxen 250 mg tablets, 2 tablets every 8 hours as needed for migraine headaches. 4. Pantoprazole 40 mg p.o. daily. DISCHARGE DIAGNOSES: 1. Severe depression. 2. Suicidal attempt, drug overdose. 3. Anemia. 4. Fever-resolved. [Name6 (MD) ] [Name8 (MD) 21386], MD [MD Number(2) 26878] Dictated By:[Name8 (MD) 26879] MEDQUIST36 D: [2124-1-14] 11:32:50 T: [2124-1-14] 12:56:47 Job#: [Job Number 26880]	[ "2851" ]
Admission Date: [2189-1-17] Discharge Date: [2189-1-21] Date of Birth: [2189-1-17] Sex: F Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby girl [Known lastname 1557], [Known lastname ], was born at 34 and 2/7 weeks gestation by cesarean section due to preterm labor with fetal heart rate decelerations. Mother is a 25 year-old gravida 1 para 0 now 1 woman. Prenatal screens are blood type O positive, antibody negative, Rubella immune, B strep unknown. The pregnancy was uncomplicated until 32 and 5/7 weeks when the onset of preterm labor with cervical shortening occurred. At that time the mother was treated with magnesium sulfate and received a complete course of betamethasone. She was discharged home on bed rest. She then presented with a question of rupture of membranes on the day of delivery. On evaluation the membranes were intact, but there were uterine contractions and the cervix was dilated and there were fetal heart rate decelerations. An attempt to induce with Pitocin was done, but there were fetal heart rate decelerations and therefore cesarean section was done. The infant emerged vigorous with spontaneous cry. Apgars were 9 at one minute and 9 at five minutes. Rupture of membranes occurred at delivery. There was no intrapartum fever and the mother did receive antibiotics prior to delivery. The birth weight was 2175 grams 50th percentile, birth length was 44 cm 30th percentile and the birth head circumference 31 cm 40th percentile. ADMISSION PHYSICAL EXAMINATION: Revealed a well appearing nondysmorphic preterm infant. Anterior fontanel open, soft and flat. Positive bilateral red reflex. Intact palette. Breath sounds slightly crackly. Good air entry, very mild intercostal retractions. Heart was regular rate and rhythm and no murmur. Abdomen benign. No hepatosplenomegaly. No masses. Three vessel umbilical cord. Normal external genitalia for gestational age. Stable hips. Skin pink and well perfuse. Appropriate tone and strength. The coccyx area has an area, which appears to be a contact dermatitis or perhaps a sebaceous nevi. HOSPITAL COURSE: Respiratory status: The infant has always remained in room air. She has had no apnea of bradycardia. On examination her respirations are comfortable. Lung sounds are clear and equal. Cardiovascular status: She has remained normotensive throughout her Neonatal Intensive Care Unit stay. There are no issues. Fluid, electrolyte and nutrition status: The infant began oral enteral feeds soon after admission to the Neonatal Intensive Care Unit and she is currently taking enfamil 20 calories per ounce or [Known lastname ] feeding on an ad lib schedule. Her weight at the time of discharge is 2075 grams. Gastrointestinal status: Her bilirubin on day of life number two was total 7.8, direct 0.4, repeated on day of life four, which was also the day of discharge and her total bilirubin is 8.8 with a direct of 0.3. She never received any phototherapy during her Neonatal Intensive Care Unit stay. Hematological status: [Known lastname ] has never received any blood product transfusion during her Neonatal Intensive Care Unit stay. At the time of admission her hematocrit was 50.7 and her platelets were 346,000. Infectious disease status: Blood culture was done at the time of admission and has remained negative and she has never received any antibiotics. Neurological status: There are no issues. Sensory status: Audiology, hearing screen was performed with automated auditory brain stem responses and the infant passed in both ears. Psycho/social status: The parents are married and have been very involved in the infant's care throughout her Neonatal Intensive Care Unit stay. DISCHARGE CONDITION: The infant is discharged in good condition. DISCHARGE STATUS: The infant is discharged home with her parents. Primary pediatric care will be provided by Dr. [Last Name (STitle) 43699] of Center of Pediatrics. RECOMMENDATIONS AT DISCHARGE: The infant is [Last Name (STitle) ] feeding or taking Enfamil 20 on an ad lib schedule. The infant is discharged on no medications. The infant passed a car seat position screening test. State screen was sent on [2189-1-19]. The infant received her first hepatitis B vaccine on [2189-1-20]. Recommended immunizations, Synagis RSV prophylaxis to be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following criteria, born at less then 32 weeks, born between 32 and 35 weeks with plans for day care during the RSV season, with a smoker in the household or with preschool siblings or with chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants wit chronic lung disease once they reach six months of age. Before this age the family and other care givers should be considered for immunization against influenza to protect the infant. Follow up appointments, the infant will have a visiting nurse [First Name (Titles) ] [Last Name (Titles) ] feeding support and weight checks. DISCHARGE DIAGNOSES: 1. Prematurity 34 and 2/7 weeks gestation. 2. Sepsis ruled out. 3. Status post mild transitional respiratory distress. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Last Name (NamePattern1) 46595] MEDQUIST36 D: [2189-1-21] 06:43 T: [2189-1-21] 07:06 JOB#: [Job Number 3644]	[ "V053", "V290" ]
Admission Date: [2182-6-24] Discharge Date: [2182-7-2] Date of Birth: [2103-1-20] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Cephalosporins / ciprofloxacin Attending:[First Name3 (LF) 1505] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Aortic valve replacement 25-mm Biocor apical tissue heart valve History of Present Illness: 79 year old male with moderate to severe aortic regurgitation with associated fatigue, dyspnea and neck pain was admitted preoperatively for an Aortic Valve Replacement on [2182-5-9]. He was placed on heparin drip for Coumadin washout for paroxysmal Atrial Fibrillation. Initial labs were drawn and revealed neutropenia and an elevated creatnine from baseline. Based on Mr.[Known lastname 101329] history of renal transplant, the Renal Transplant Service was consulted. His medications were reviewed and recommendations were made. His Cyclosporine and prednisone were continued. Azathioprine and Colchicine were discontinued per renal. Labs were monitored. His Creatnine drifted down to 1.5 and WBC ct=1.5 on [5-14]. The decision was made to rescreen Mr.[Known lastname 57554] for rehab with postponement of his AVR until his lab values trend towards normalizing. He returns to [Hospital1 18] today for heparin bridge preop AVR/? Asc.Ao.Replacement with normalizing lab values. Past Medical History: 1. Moderate-to-severe aortic insufficiency with dilating LV, currently be evaluated for valve replacement by cardiac surgery. 2. Recent cardiac catheterization showing no obstructive coronary artery disease, however, found to have elevated filling pressures, requiring diuresis. 3. Hypertension. 4. Kidney transplant in [2155] due to PCKD, the baseline creatinine approximately 1.6. 5. Hyperlipidemia. 6. Peripheral neuropathy. 7. Diverticulitis. 8. Pseudogout. 9. Osteoporosis. 10. Atrial fibrillation, currently on Coumadin for thromboembolic prophylaxis. Social History: Patient previously worked as an engineer for channel 5. He currently lives in a house himself. His wife passed away 9 years ago. Prior history of 3 ppd X 20 years, quitting 34 years ago. Occasional ETOH (few beers per week). No illicits. His daughters ([Name2 (NI) ] (daughter) - ([Telephone/Fax (1) 101330], [Female First Name (un) ] (daughter) [0-0-]) are very involved. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Physical Exam 97.6 131/60 64AFib 18 100%RA General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM []Limitied ROM Chest: Lungs clear bilaterally []crackles right base, o/w clear Heart: RRR [x] Irregular [] Murmur [x] grade _2/6 syst__ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds [x] Extremities: Warm [x], well-perfused [x] Edema []+2 lower ext edema _____ Varicosities: None [x] Neuro: Grossly intact [x] Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 1569] [Hospital1 18] [Numeric Identifier 101331] (Complete) Done [2182-6-27] at 12:31:50 PM FINAL GENERAL COMMENTS: Written informed consent was obtained from the patient. A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. Conclusions PRE-CPB: Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. The left ventricular systolic function is globally mildly depressed, estimated EF=45%. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with focal calcifications. Trivial mitral regurgitation is seen. There is a small pericardial effusion. There is a small left pleural effusion. Dr.[Last Name (STitle) ] was notified in person of the results at time of study. POST-CPB: The patient is on no vasopressors. A bioprosthetic valve is seen in the aortic position. The valve is well seated with normally mobile leaflets. There are no apparent paravalvular leaks. There is no AI. The peak gradient across the aortic valve is 13mmHg, the mean gradient is 6mmHg with CO of 3.8L/min. The inferior and inferoseptal segments of the left ventricle appears hypoknetic. This improves with time but is still more notable than pre-bypass. Overal left ventricular systolic function remains mildly depressed, estimated EF 40-45%. The RV systolic function remains normal. The MR remains trace. Other valvular function is unchanged. The small left pleural effusion remains. There is no evidence of aortic dissection. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Name8 (MD) 17792], MD, Interpreting physician [Last Name (NamePattern4) ] [2182-6-27] 15:58 ?????? [2172] CareGroup IS. All rights reserved. [2182-7-2] 04:41AM BLOOD WBC-5.4 RBC-3.25* Hgb-9.9* Hct-30.5* MCV-94 MCH-30.5 MCHC-32.5 RDW-18.1* Plt Ct-87* [2182-7-1] 06:27AM BLOOD WBC-5.8 RBC-3.09* Hgb-9.8* Hct-29.1* MCV-94 MCH-31.6 MCHC-33.6 RDW-18.6* Plt Ct-64* [2182-6-30] 02:32AM BLOOD WBC-10.9 RBC-2.90* Hgb-9.2* Hct-27.4* MCV-95 MCH-31.6 MCHC-33.4 RDW-17.7* Plt Ct-75* [2182-7-2] 04:41AM BLOOD PT-18.8* INR(PT)-1.8* [2182-7-1] 06:27AM BLOOD PT-16.3* PTT-26.9 INR(PT)-1.5* [2182-6-30] 02:32AM BLOOD PT-14.6* PTT-26.2 INR(PT)-1.4* [2182-6-29] 01:57AM BLOOD PT-15.9* INR(PT)-1.5* [2182-6-28] 04:09AM BLOOD PT-13.4* PTT-25.5 INR(PT)-1.2* [2182-6-28] 12:10AM BLOOD PT-13.0* PTT-26.3 INR(PT)-1.2* [2182-6-27] 09:58PM BLOOD PT-13.4* PTT-26.6 INR(PT)-1.2* [2182-6-27] 06:00PM BLOOD PT-14.4* PTT-27.5 INR(PT)-1.3* [2182-6-27] 02:48PM BLOOD PT-16.5* PTT-31.9 INR(PT)-1.6* [2182-6-27] 01:17PM BLOOD PT-19.1* PTT-30.3 INR(PT)-1.8* [2182-6-27] 11:30AM BLOOD PT-14.9* PTT-45.6* INR(PT)-1.4* [2182-6-27] 04:35AM BLOOD PT-15.6* PTT-25.6 INR(PT)-1.5* [2182-7-2] 04:41AM BLOOD Glucose-87 UreaN-63* Creat-1.4* Na-137 K-3.5 Cl-97 HCO3-34* AnGap-10 [2182-7-1] 06:27AM BLOOD Glucose-141* UreaN-71* Creat-1.6* Na-136 K-3.5 Cl-96 HCO3-32 AnGap-12 [2182-6-30] 02:32AM BLOOD Glucose-113* UreaN-66* Creat-1.9* Na-134 K-3.8 Cl-94* HCO3-30 AnGap-14 Brief Hospital Course: Pre-op MSSA screen was positive and the patient was treated with Mupirocin. Additionally, on admission his INR was supratherapeutic. He was given Vitamin K and FFP. INR would trend down and on [2182-6-27] Mr.[Name14 (STitle) 101332] was taken to the operating room where he underwent Aortic valve replacement 25-mm Biocor apical tissue heart valve with Dr.[Last Name (STitle) ]. Please see operative report for surgical details. He tolerated the procedure well and was transferred to CVICU intubated and sedated for invasive monitoring. He awoke neurologically intact and extubated. He weaned off pressor support and Beta-blocker/Statin/diuresis was initiated. Renal continued to follow the patient. Coumadin was resumed for chronic AFib. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Bay Point in [Hospital1 1474] in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Alendronate Sodium 70 mg PO QSUN 2. Benzonatate 100 mg PO TID:PRN cough 3. CycloSPORINE (Sandimmune) 100 mg PO DAILY 4. Diltiazem Extended-Release 120 mg PO DAILY 5. Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Lovastatin NF 20 mg Oral daily 8. Metoprolol Tartrate 75 mg PO TID 9. Furosemide 40 mg PO BID 10. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH [Hospital1 ] 11. PredniSONE 5 mg PO DAILY 12. Warfarin 2.5-3.75 mg PO DAILY 13. Aspirin EC 81 mg PO DAILY 14. Guaifenesin [4-25] mL PO Q6H:PRN cough 15. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Alendronate Sodium 70 mg PO QSUN 2. Aspirin EC 81 mg PO DAILY 3. Benzonatate 100 mg PO TID:PRN cough 4. CycloSPORINE (Sandimmune) 100 mg PO DAILY 5. Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] 6. Furosemide 40 mg PO BID 7. Metoprolol Tartrate 75 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. 8. PredniSONE 5 mg PO DAILY 9. Warfarin MD to order daily dose PO DAILY goal INR [1-18] for AFib 10. Acetaminophen 650 mg PO Q4H:PRN pain 11. Lovastatin NF 20 mg ORAL DAILY 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 13. Potassium Chloride 20 mEq PO DAILY Hold for K+ > 4.5 14. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH [Hospital1 ] 15. Guaifenesin [4-25] mL PO Q6H:PRN cough 16. Multivitamins 1 TAB PO DAILY 17. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Disposition: Extended Care Facility: [Hospital 27838] Rehabilitation & [Hospital ] Care Center - [Hospital1 1474] Discharge Diagnosis: Severe Aortic Insufficiency s/p Aortic valve replacement Secondary: 2. Paroxysmal atrial fibrillation. 3. Hypertension. 4. Kidney transplant in [2155] secondary to Polycystic Kidney Disease. 5. CRI with baseline creatinine of 1.2-1.4 6. Hyperlipidemia. 7. Peripheral neuropathy. 8. Diverticulitis. 9. History of pseudogout. 10. Osteopenia 11. Recent admission for dehydration and rabdomylysis 12. Recent UTI developed peripheral neuropathy from Cipro and switched to linezolid Past Surgical History: PCKD s/p renal transplant in [2155] (on immunosuppression) bilateral cataracts Inguinal hernia repair Right AV fistula in 80 which has been tied off Bronchitis Lactose intolerance BPH Bilateral rotator cuffs not repaired Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Followup Instructions: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2182-7-31] 2:20 Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2182-8-28] 2:00 The Cardiac Surgery Office will call you with the following: Surgeon: Dr.[Last Name (STitle) ] # [Telephone/Fax (1) 170] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] D. [Telephone/Fax (1) 3329] in [12-17] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation Goal INR:[1-18] First draw:[2182-7-3] Needs Coumadin follow up arranged prior to DC from Rehab Completed by:[2182-7-2*]	[ "4241", "5849", "42731", "V5861", "2724", "4168", "2875", "40390" ]
Admission Date: [2186-7-7] Discharge Date: [2186-7-11] Date of Birth: [2123-5-12] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 6565] Chief Complaint: Febrile neutropenia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname ] is a 63 yo woman with metastatic breast cancer with hepatic, pulmonary and bone mets who presented to the ED yesterday evening [2-15] fever (100.8F) following therapeutic paracentesis (2.5L). Prior to Thursday Ms. [Known lastname ] had noted fatigue since Sunday, but denied cough, SOB, changes in bowel habits or urination. Fevers/chills were absent until Thursday post-procedure She is currently recieving 4th line chemotherapy with Navelbine with ascites following 4 rounds. Also with leukopenia (WBC 2.3) and neutropenia (483). Ascites has been therapeutically tapped in [6-26] w/ 3L removed but with interval worsening of ascites. In the ED, initial vitals were T 99.0, HR 138, BP 118/69, RR 18, O2 100% on RA. She triggered for tachycardia and received a total of 4L IVF with minimal improvement. She had a clear CXR and negative U/A. She also received 1 g IV vanco and 2 g IV cefepime for febrile neutropenia and acetaminophen and motrin for fever. The oncology fellow was consulted and recommended against diagnostic paracentesis. Vitals on transfer were T 99.6 (Tmax in ED 100.4), HR 128, BP 122/88, RR 15, O2 sat 100% RA. On the floor, patient endorses abdominal pain, dyspnea, and malaise. She is somnolent and requests many questions be referred to her daughter. Past Medical History: -Stage I breast cancer, diagnosed by biopsy [2183-6-28], (negative mammogram in [12/2182]), on [2183-8-4] she had a right partial mastectomy with sentinel node biopsy for invasive carcinoma of the right breast (diagnosed by core biopsy) at [Hospital 882] Hospital. The pathology report showed that one of five radioactive lymph nodes contain a neoplastic cell in peripheral sinus, pN0 (i+). ERA 40%, PRA 2%, HER2 1+ out of 3+, Ki67 25%. -DM -Hypercholesterolemia Social History: She denies the use of tobacco, alcohol, or illicit drug use ever. She lives with her husband and 2 of her 5 daughters in [Name (NI) 3146]. She is a homemaker. Family History: The patient's sister had a suprasellar epidermoid cyst diagnosed [8-15] s/p right craniotomy [11-15]. CT brain showed it was a suprasellar based mass extending into the sella measuring 1.8x1.4x2.2 cm which may represent dermoid or teratoma. MRI showed suprasellar mass with fat and calcifications exerting some mass effect on the optic chiasm which is likely dermoid or teratoma. Her mother had breast cancer at 37, and also had Crohn's disease and a stroke, she died in her 70s. Her father had lymphoma and died in his early 70s. Her sister has DM. Physical Exam: EXAM ON ADMISSION: General: tired but oriented x3, HEENT: Dry MM, oropharynx w/ mucosal bleeding Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: sinus tachycardia, normal S1 + S2, no murmurs, rubs, gallops Abdomen: grossly distended abdomen w/ tenderness to palpation GU: Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Exam on Discharge: Vitals: Tmax 97.7, Tcurrent 96.8, BP 100/60, HR 88, RR 20, SO2 97 on RA GEN: NAD, AOX3 HEENT: PERRL Cards: RRR, No MRG Pulm: Lungs CTAB (poor effort), no dullness to percussion GI: Abdomen is distended and mildly tender to palpation in all 4 quadrants, no guarding or rebound tenderness Extremities: Mild non-pitting edema in LE's bilaterally Pertinent Results: Admission Labs: [2186-7-6] 11:20PM PT-16.4* PTT-24.9 INR(PT)-1.4* [2186-7-6] 11:20PM PLT SMR-NORMAL PLT COUNT-204 [2186-7-6] 11:20PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ [2186-7-6] 11:20PM NEUTS-21* BANDS-0 LYMPHS-45* MONOS-31* EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* [2186-7-6] 11:20PM WBC-2.3# RBC-3.70 HGB-10.8* HCT-32.7* MCV-89 MCH-29.3 MCHC-33.1 RDW-19.5* [2186-7-6] 11:20PM ALBUMIN-2.6* [2186-7-6] 11:20PM LIPASE-32 [2186-7-6] 11:20PM ALT(SGPT)-46* AST(SGOT)-225* ALK PHOS-396* TOT BILI-1.2 [2186-7-6] 11:20PM GLUCOSE-139* UREA N-13 CREAT-0.4 SODIUM-135 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15 [2186-7-6] 11:28PM LACTATE-3.1* K+-3.7 [2186-7-6] 11:28PM COMMENTS-GREEN TOP [2186-7-7] 01:40AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.005 [2186-7-7] 03:23AM LACTATE-3.2* [2186-7-7] 07:14AM GRAN CT-1140* [2186-7-7] 07:14AM PT-17.9* PTT-26.3 INR(PT)-1.6* [2186-7-7] 07:14AM PLT SMR-NORMAL PLT COUNT-184 [2186-7-7] 07:14AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-1+ [2186-7-7] 07:14AM NEUTS-41* BANDS-0 LYMPHS-33 MONOS-19* EOS-1 BASOS-0 ATYPS-0 METAS-4* MYELOS-2* NUC RBCS-2* [2186-7-7] 07:14AM WBC-2.8* RBC-3.67* HGB-10.7* HCT-32.9* MCV-90 MCH-29.2 MCHC-32.6 RDW-19.1* [2186-7-7] 07:14AM CALCIUM-8.6 PHOSPHATE-2.5* MAGNESIUM-1.5* [2186-7-7] 07:14AM ALT(SGPT)-43* AST(SGOT)-199* LD(LDH)-996* ALK PHOS-405* TOT BILI-1.8* [2186-7-7] 07:14AM GLUCOSE-115* UREA N-13 CREAT-0.5 SODIUM-139 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14 Imaging: CXR [2186-7-6]: FINDINGS: There is no pneumonia. There is no pleural effusion or pneumothorax. Hilar, mediastinal, and cardiac silhouette within normal limits. There is a Port-A-Catheter with tip at the cavoatrial junction. IMPRESSION: No pneumonia. ECG [2186-7-6]: Sinus tachycardia. Since the previous tracing no significant change on previously noted findings. [2186-7-7] Sinus tachycardia. Since the previous tracing no significant change on previously noted findings. Micro: [2186-7-6] - BCX - NGTD [2186-7-7] - BCX - NGTD [2186-7-7] - MRSA Nasal Swab Screen - Negative Discharge Labs: [2186-7-11] 06:29AM BLOOD WBC-4.3 RBC-3.06* Hgb-8.9* Hct-28.0* MCV-92 MCH-28.9 MCHC-31.6 RDW-18.4* Plt Ct-100* [2186-7-11] 06:29AM BLOOD Neuts-52 Bands-0 Lymphs-16* Monos-30* Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [2186-7-11] 06:29AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-2+ Schisto-1+ MacroOv-OCCASIONAL [2186-7-11] 06:29AM BLOOD Plt Smr-LOW Plt Ct-100* [2186-7-11] 06:29AM BLOOD Gran Ct-2484 [2186-7-11] 06:29AM BLOOD Glucose-116* UreaN-12 Creat-0.5 Na-137 K-4.0 Cl-105 HCO3-26 AnGap-10 [2186-7-11] 06:29AM BLOOD ALT-24 AST-95* LD(LDH)-310* AlkPhos-357* TotBili-1.5 [2186-7-11] 06:29AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.8 Brief Hospital Course: Ms. [Known lastname ] presented with febrile neutropenia following therapeutic paracentesis and was admitted to the medical ICU for tachycardia unresponsive to fluids in the ED. # Febrile Neutropenia. On arrival, the patient's ANC was < 500 and she was febrile to Tmax 100.4 in the ED. She was therefore started on broad-spectrum antibiotic coverage with vancomycin and cefepime. U/A and CXR were unremarkable, and blood cultures obtained at admission showed no growth at this time. Diagnostic paracentesis was considered to rule out the possibility of SBP, but no suitable fluid pocket could be identified for safe bedside paracentesis. Her fever resolved within 24 hours of admission and she remained afebrile throughout the remainder of her hospital stay. #Tachycardia: The patient was noted to be tachycardic to 130s-140s on arrival to the ED; after 4L of IVF, her HR remained in the 130s. 12-lead EKG was obtained which showed sinus tachycardia. This was felt likely secondary to fever/infection, as when her fevers resolved her heart rate decreased to 90s-100s. On review of her most recent clinic notes, her heart rate was nearly always > 90 bpm, so HR in 90s to 100s was felt to be her recent baseline. #Abnormal LFTs: Patient was noted to have a transaminitis as above. This was felt possibly secondary to known liver metastases vs. toxicity from recent chemotherapy. Transaminases trended down over the course of this admission. #Metastatic Breast Cancer: Ms. [Known lastname ] has undergone significant functional decline over the past few weeks. Prior to this admission, she had planned to visit [Company 2860] for a second opinion on treatment options and discussion of her prospects for involvement in a clinical trial. Her oupatient oncologist Dr. [Last Name (STitle) ] was called to consult during this admission, and was involved with her plan of care. At this juncture, it was felt that the patient has a relatively poor prognosis with life expectancy on the order of a few months. Ms. [Known lastname ] went out of the ICU to the oncology (OMED) service on hospital day #2, where she remained afebrile and normotensive and was discharged to home with services. #DMII: Metformin held while inpatient. Humalog ISS was implemented during this stay. Transitional Issues: - Follow up blood cultures. - Patient at higher risk for readmission due to reaccumulating ascites and ongoing issues with pain (although under better control than admission). Medications on Admission: diazepam 2mg 1-2x daily for insomnia/anxiety, simvastatin 40mg once daily, paroxetine 20mg once daily, docusate 100mg twice daily, OxyContin 30 mg [Hospital1 ] PRN pain, Metformin 1000 mg [Hospital1 ] Discharge Medications: 1. OxyContin 30 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO twice a day as needed for pain: Hold for sedation or Respiratory Rate < 12/min. Disp:60 Tablet Extended Release 12 hr(s) Refills:0 2. diazepam 2 mg Tablet Sig: 1-2 Tablets PO once a day as needed for Anxiety. 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Tablet(s) 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Febrile Neutropenia Hypotension Tachycardia Metastatic Breast Cancer Pancytopenia Type II Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], you were admitted with fever and low blood pressure. You were put on antibiotics, given fluids and given some medicines to help with your blood pressure. We also found that your white blood cell counts were low, but these have improved since the day of your admission. During your stay your blood pressure stabilized, you stopped having fevers and your pain came under better control. No changes were made to your medications. Followup Instructions: PCP [Name Initial (PRE) ]:WEDNESDAY [2186-7-19] at 10:15am Name: DR. [First Name (STitle) ] TIBA, an associate of your PCP, [Last Name (NamePattern4) ].[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [Doctor Last Name 79420] since your PCP is unavailable next week. Location: [Location (un) ] FAMILY HEALTH CENTER Address: [Street Address(2) 79421] [Apartment Address(1) 3745], [Location (un) ],[Numeric Identifier 26335] Phone: [Telephone/Fax (1) 78480] Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2186-7-19] at 3:00 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 7634], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2186-7-19] at 3:00 PM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 10280], PA [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name4 (NamePattern1) 2946] [Last Name (NamePattern1) ] MD [MD Number(1) 3218]	[ "25000", "2720" ]
Admission Date: [2164-5-28] Discharge Date: [2164-6-27] Date of Birth: [2080-10-18] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1257] Chief Complaint: Altered mental status, need for BiPAP Major Surgical or Invasive Procedure: Central line placement Arterial line placement Endotracheal intubation History of Present Illness: [Known firstname ] [Known lastname 40718] is an 83 yo female with morbid obesity, DMII, diastolic CHF, asthma, and pemphigus folleacious, and a recent 20-day [Hospital Unit Name 153] admission for complex wound care for worsening skin sloughing and bullae and severe pain, who is now transferred back from rehab for hypoventilation in the setting of narcotic administration. During her admission, her pemphigus skin lesions were thought due to CMV/HSV with psuedomonal superinfection, and she had chronic narcotic requirements (at one point was on dilaudid PCA in ICU). She was d/c'ed to [Hospital 100] Rehab on [5-22]. Of note, she was persistently hypothermic during her admission and was d/c'ed to rehab with a temp of 92.9. Since that time, she has continued to have lots of pain, possibly post-herpetic, with all turns, movements, etc. Per her daughter, she has been "getting too much pain medication." Today, with her turning and cleaning in bed, she got 2mg IV dilaudid, then 2mg again. After that she was noted to be hypopneic, altered/less responsive, and was referred to ED. . In ED, VS: hypothermic to 85.8, 62, 138/78, 6, 100% on BiPAP. Got 0.1mg narcan, with improvement in repsiratory rate to 18-20. Lungs were noted to be wheezy, but no crackles were heard. She was given a nebulizer treatment and solumedrol. CXR showed stable mild cardiomegaly with increased perihilar opacities reflecting volume overload and atelectasis. She complained of difficulty breathing and was placed on BiPAP 14/4/100%. ABG on these settings was 7.33/55/579, so FiO2 was decreased to 50%. Shortly thereafter, her SBP briefly dropped down to 90s, and she got 500cc bolus with reutn of BP's to 110s. EKG showed NSR at 70, NA/NI, diffuse TW flattening. No effusion was seen on bedside ultrasound. CE's negative. Other labs showed normal WBC count, stable anemia, and new thrombocytopenia to 109, as well as renal insufficieny (Cr 1.3, was 0.7 on d/c, but by report has CRI with baseline 1.3). Lactate was 3.6. Urine and blood cultures were sent and she was given vancomycin 1g and levofloxacin 750mg. Access is with her [Hospital1 18] PICC line. Most recent VS: rectal temp 88 67 14 108/71 100% on BiPAP. Hypothermia was only addressed later in her ED course, with plan to begin warming down in ED and to check TSH. Past Medical History: Chronic diastolic heart failure - repeat Echo with EF 75% Diabetes mellitus, type 2 on insulin Chronic kidney disease, stage 3, baseline Cr 1.3-1.5 Obesity Hypertension Colostomy for diverticulitis Asthma Pemphigus foliaceus diagnosed last admission, with CMV/HSV superinfection (in addition to disseminated CMV/HSV disease) Macrocytic anemia, unclear etiology Dyslipidemia Sacral decubitus ulcer, stage 2 Social History: Never smoked, no alcohol use. Retired from the [Location (un) 86] School District after 32 years. Family History: No history of any severe dermatologic issues. Physical Exam: Vitals: 31.5 (88.7) 66 121/59 10 100% on 2L General: Obese, eldery, anasarcic african american female, no acute distress, lethargic but rousable HEENT: anisocoria, L>R, with sluggush light reaction, adentulous Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: distant HS, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, + ostomy in LLQ, no organomegaly GU: foley in place. Ext: cold to touch, anasarcic Skin: diffuse hypopigmented lesions and desquamated skin rash most severe in intertriginous areas, as well as surrounding stoma, upper chest, face, and sacral area. Estimated that desquamation covers approx 30-40% BSA. None of the lesions appear infected. . On [Hospital Unit Name 196]: PHYSICAL EXAM VITALS: T97.1, BP116/41, HR86. RR18, O2sat100% on face mask, 96% on RA GEN: Alert and oriented X3, pleasant, NAD HEENT: EOMI, NCAT, normal oro/nasopharynx, moist mucus membranes NECK: Soft, supple, RIJ in place - c/d/i, no JVD but unable to assess clearly given body habitus CV: RRR, no murmurs, gallops, rubs, normal S1/S2 PULM: Scattered wheezes, bibasilar crackles but distant lung sounds - no rhonchi/rales ABD: Soft, +BS, non-tender, non-distended, morbidly obese, colostomy sink c/d/i with pink granulation tissue EXT: 1+ pitting edema bilaterally to above the knees, symmetrical, pulses intact Neuro: Moves arms and legs but with proximal weakness Skin: Pemphigus lesions (purplish papules with yellowish, hypopigmented reticular borders Pertinent Results: CBCs: [2164-5-28] 04:07PM BLOOD WBC-5.1 RBC-2.90* Hgb-8.6* Hct-31.2* MCV-108* MCH-29.8 MCHC-27.6* RDW-19.1* Plt Ct-109* [2164-5-29] 09:43AM BLOOD WBC-6.2# RBC-2.19* Hgb-6.8* Hct-22.4* MCV-103* MCH-31.3 MCHC-30.5* RDW-19.5* Plt Ct-81* [2164-5-31] 03:47AM BLOOD WBC-6.4 RBC-3.14* Hgb-9.7* Hct-30.9* MCV-98 MCH-30.9 MCHC-31.5 RDW-19.9* Plt Ct-81* [2164-6-3] 12:31AM BLOOD WBC-8.0 RBC-3.07* Hgb-9.8* Hct-29.8* MCV-97 MCH-31.9 MCHC-32.9 RDW-18.9* Plt Ct-55* . CHEMs: [2164-5-28] 04:07PM BLOOD Glucose-217* UreaN-30* Creat-1.3* Na-136 K-3.2* Cl-98 HCO3-30 AnGap-11 [2164-5-30] 03:20AM BLOOD Glucose-176* UreaN-28* Creat-1.1 Na-141 K-3.8 Cl-111* HCO3-25 AnGap-9 [2164-6-1] 02:44AM BLOOD Glucose-397* UreaN-39* Creat-1.2* Na-136 K-4.1 Cl-108 HCO3-23 AnGap-9 [2164-6-2] 02:43AM BLOOD Glucose-98 UreaN-47* Creat-1.5* Na-140 K-3.8 Cl-109* HCO3-25 AnGap-10 [2164-6-3] 12:31AM BLOOD Glucose-246* UreaN-54* Creat-1.3* Na-142 K-3.8 Cl-109* HCO3-25 AnGap-12 . ENDOCRINE: [2164-5-28] 04:07PM BLOOD TSH-4.9* [2164-5-28] 04:07PM BLOOD Free T4-0.49* [2164-5-29] 02:52AM BLOOD Cortsol-14.9 . MICRO: [2164-5-28] 4:15 pm BLOOD CULTURE FINAL REPORT [2164-6-3] Blood Culture, Routine (Final [2164-6-3]): PROTEUS MIRABILIS. FINAL SENSITIVITIES. ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. SENSITIVE TO Daptomycin (MIC =0.19 MCG/ML). Sensitivity testing performed by Etest. DR. [Last Name (STitle) 40719] ([Numeric Identifier 40720]) REQUESTED SENSITIVITIES TO CIPROFLOXACIN AND LEVOFLOXACIN [2164-6-3]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| ENTEROCOCCUS FAECALIS \| \| AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S =>8 R DAPTOMYCIN------------ S GENTAMICIN------------ <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S PENICILLIN G---------- 4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 1 S . [2164-5-28] 4:20 pm BLOOD CULTURE FINAL REPORT [2164-6-3] Blood Culture, Routine (Final [2164-6-3]): ENTEROBACTER CLOACAE. FINAL SENSITIVITIES. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [2164-5-29]): GRAM NEGATIVE ROD(S). . [2164-5-28] 4:49 pm URINE Site: CATHETER FINAL REPORT [2164-5-30] URINE CULTURE (Final [2164-5-30]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [2164-5-29] 9:43 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2164-5-30] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2164-5-30]): Feces negative for C.difficile toxin A & B by EIA ,. [2164-5-30] 3:20 am Immunology (CMV) Source: Line-aline. FINAL REPORT [2164-6-1] CMV Viral Load (Final [2164-6-1]): CMV DNA not detected. 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]. . IMAGING: [5-28] CXR: IMPRESSION: 1. Stable cardiomegaly, with findings suggestive of CHF. 2. Bibasilar atelectasis with bilateral pleural effusions. . [2164-5-29] ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Physiologic mitral regurgitation is seen (within normal limits). There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [2164-4-18], findings are similar. . [2164-5-29] CXR: FINDINGS: The new right CVP line tip is 1 cm above the cavoatrial junction. The NG tube passes below the diaphragm and out of view. Bilateral small pleural effusions are stable since the chest radiograph earlier on today; however a slight increase in peribronchial cuffing and perihilar haziness is due to new mild pulmonary edema. IMPRESSION: Stable bilateral pleural effusions with new mild pulmonary edema. . [6-1] CT CHEST IMPRESSION: Large bilateral pleural effusions with adjacent atelectasis. Right middle lobe and probably left upper lobe pneumonic consolidation. Cardiomegaly. Large hiatal hernia. . [6-1] CT HEAD IMPRESSION: There is no evidence of acute intracranial hemorrhage. Left mastoid air cells opacities, possibly related with an ongoing inflammatory process, please correlate clinically. Diffuse fat stranding is demonstrated in the soft tissues, likely related with the provided history of anasarca . EEG [2164-6-3] IMPRESSION: As noted above, this is a technically unsatisfactory study due to physiologic artifact of prominent and persistent muscle artifact. Although no evidence for non-convulsive status epilepticus was seen, the background was otherwise largely uninterpretable. . Brief Hospital Course: This is an 83 year old woman with a history of pemphigus foliaceous and a recent ICU admission for complex wound care, worsening skin sloughing, and HSV/CMV and pseudomonal skin superinfection who was admitted with altered mental status from polymicrobial sepsis and hypercapnic failure. She was intubated for apnea and CO2 retention. A CT of chest showed RML pneumonia (antibiotics as below). Bronchoscopy sowed edematous, collapsible airways. She was extubated on [2164-6-5]. Her altered mental status was multifactorial due to sepsis and over-narcosis from Dilaudid received during turning and maneuvering at nursing home. She was unable to tolerate LP due to body habitus, and MRI was unobtainable due to patient girth. EEG was technically unsatisfactory, but did not reveal status epilepticus. When she got extubated, she was very weak in the setting of steroids and anasarca without any focal deficits. Patient's mental status dramatically improved. In regards to her sepsis, blood cultures grew PROTEUS MIRABILIS, ENTEROCOCCUS FAECALIS, and ENTEROBACTER CLOACAE and urine culture grew ESCHERICHIA COLI. She initially received vancomycin, meropenem, and levofloxacin. She came off pressors on [2164-5-29] after fluid and blood transfusions. On TTE, there was no evidence of cardiogenic shock or tamponade (EF >75%), and serum cortisol was at normal range at 14.7. TTE did not show vegetations. Of note, she grew pansensitive Klebsiella in the sputum which was felt to be a colonizer. She finished a full course of vancomycin and levofloxacin x total 14 days. The patient had clinical anasarca, and was on a Lasix drip while in the ICU and then metolazone and oral Lasix. She developed significant contraction alkalosis (Bicarb >50) at some point but this has resolved. She also had acute kidney failure on chronic kidney disease, stage 3. Her renal function improved with Lasix discontinuation. In regards to the pemphigus foliaceus, she had HSV/CMV superinfection during previous admission with CMV viremia. She had a skin biopsy that was consistent with disseminated HSV and was treated with acyclovir and then valacyclovir. Skin lesions also grew pseudomonas and proteus which were felt to be colonizing and was treated with skin care including acetic acid only. Ophthalmology was also consulted and they recommended erythromycin and ciprofloxacin eye drops for pseudomonas given she had skin lesions abutting her eyes. [Date Range 2652] consult advised high dose oral steroids, continuing ganciclovir for CMV suppression, and monthly IVIG. She received her first course of IVIG which was complicated by mild hyponatremia. Since then her skin condition remained stable. She should be seen by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (immunobullous expert at [Hospital1 112]) to discuss any further IVIG and taper steroids gradually. The prednisone should be tapered over four months otherwise she is at risk for relapse. The patient developed thrombocytopenia that worsened in the setting of sepsis and ganciclovir. PF4 AB was negative. PPI was changed to H2 blocker. Platelets started to improve but she relapsed again. We could not stop ganciclovir as she is at risk for relapsed CMV/HSV infection. However, platelets have been stable at 70-80 without bleeding complications. There is no alternative for this medication per ID. However, it could be stopped if she develops bleeding or severe thrombocytopenia (benefit/risk ratio changes). Her metoprolol was held upon admission for sepsis and then for bradycardia. She had severe malnutrition and hypoalbuminemia. She initially received tube feeds (diabetic formulation) for poor PO intake. Speech and swallow evaluated the patient and started pureed solids and nectar thickened liquids. Her tube feeds then were discontinued. She had severe hyperglycemia and frequent hypoglycemia from prednisone and further worsened in the setting of tube feeds. [Last Name (un) ] was consulted and adjusted her Insulin (see printed SS)The patient was full code despite her chronic condition and acute illnesses. Her HCP, daughter [Name (NI) 123] [Name (NI) 40713] [Telephone/Fax (1) 40714], refused DNR/DNI and asked the patient remains in hospital despite resolution of acute medical problems. She was finally transfered to [Hospital 100] rehab after 2 family meetings 2 weeks apart. She will need follow up with both infectious disease ([Last Name (LF) ],[First Name3 (LF) ]) and [First Name3 (LF) 2652] (Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [First Name3 (LF) ] immunobullous expert at [Hospital1 112]). CMV viral load testing should be done every 2 weeks and next testing should be done with infectious disease appointment. CBC and chem 7 should be checked every 2-3 days. Discontinue diuretics if she develops alkalosis or acute renal failure. Please discontinue valganciclovir if severe thrombocytopenia or bleeding complications. She would need continuous wound care. Foley catheter last changed on [2164-6-22] (genital skin lesions). I discssed her case with rehab M.D/NP, [Year (4 digits) 2652], and ID upon discharge. Total discharge time 145 minutes. Medications on Admission: Medications per [5-22] d/c summary: Discharge Medications: 1. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) unit dose Inhalation every four (4) hours as needed for shortness of breath. 6. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 11. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection [Hospital1 ] (2 times a day). 12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 13. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 14. Hydromorphone 2 mg Tablet Sig: 1-2 mg PO Q3H (every 3 hours) as needed for Pain. 15. Hydromorphone in NS 2 mg/10 mL (0.2 mg/mL) Syringe Sig: 0.5 to 1 mg Intravenous Q2H (every 2 hours) as needed for For pain related to turning patient. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 19. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 21. Petrolatum Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for dry skin. 22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 23. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day). 24. Acetic Acid 0.25 % Solution Sig: One (1) Appl Irrigation [Hospital1 ] (2 times a day) as needed for to affected area for dressing changes: Use on areas with open blisters. 25. Insulin Fixed Dose and Sliding Scale NPH 20units Subcutaneous QAC breakfast and 10units QHS Humalog sliding scale, check accucheck QAC and QHS: Breakfast, Lunch, or Dinner, for BS: <70 give 1 amp of D50 or [Location (un) 2452] juice 70-120 give 0 units 121-170 give 6 units 171-220 give 8 units 221-270 give 10 units 271-320 give 12 units 321-370 give 14 units >371 give 16 units and [Name8 (MD) 138] M.D. For QHS bloodsugars, if BS: <70 give 1 amp of D50 or [Location (un) 2452] juice 70-220 give 0 units 221-270 give 3 units 271-320 give 5 units 321-370 give 7 units >371 give 9 units and [Name8 (MD) 138] M.D. 26. Prednisone 10 mg Tablet Sig: Seven (7) Tablet PO DAILY (Daily). 27. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): (through [2164-6-8]). 28. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: through [2164-5-28]. 29. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 30. Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig: One (1) PO BID (2 times a day). 31. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO BID (2 times a day). 32. IV fluids IV NS @ 100cc/hr Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 3. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 7. Petrolatum Ointment Sig: One (1) Topical TID (3 times a day) as needed for dry skin: Petrolatum NF 1 application Topical TID dry skin . 8. Bacitracin-Polymyxin B Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): Bacitracin-Polymyxin Ointment 1 Appl TP [Hospital1 ] open areas . 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-31] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 12. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): Please stop if patient develops bleeding complications or severe thrombocytopenia. 15. Prednisone 20 mg Tablet Sig: Eighty (80) MG PO DAILY (Daily): This medication should be tapered slowly over 4 months period starting [2164-6-17]. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Insulin Glargine 100 unit/mL Solution Sig: Please see printed paper Subcutaneous twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Mulitmicrobial sepsis Pemphigus CMV/HSV skin infection Pseudomonas skin colonization Acute renal failure Chronic Kidney disease Hyperglycemia with diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were treated for sepsis (blood infection) and skin infection. Your Penmphigus was treated with steroids and IV immunoglobulin. You may need monthly infusions of IV immunoglobulin if you and Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] agree. Your will need to decrease your steroid dose very slowly over 4 months period. Foley catheter has to be changed frequently to avoid infections. It was last changed on [2164-6-22]. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please call [Last Name (LF) ],[First Name3 (LF) ] S. [Telephone/Fax (1) 40715] for an appointment Please follow up with Dr. [Last Name (STitle) ],[First Name3 (LF) ], M.D with infectious disease. Please call [Telephone/Fax (1) 457] to schedule an appointment in [12-31] weeks for CMV viral load. You will have an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (an immunobullous expert at [Hospital1 756] and Women Hospital [Hospital1 112]) with possible plans to continue IVIG 5 days every month. Dr. [Last Name (STitle) 10270],[First Name7 (NamePattern1) 2191] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [First Name (Titles) 767] [Last Name (Titles) 2652] will call you to provide you with the details of your appointment.	[ "486", "51881", "5849", "78552", "5990", "2761", "5119", "4280", "2875", "25000", "V5867", "40390", "2859", "99592" ]
Admission Date: [2195-3-25] Discharge Date: [2195-3-31] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: Pneumonia, sepsis Major Surgical or Invasive Procedure: None History of Present Illness: 89M h/o HTN, hyperlipidemia and prostate CA presented with increased confusion, fever, lethargy with multiple falls for several days prior to admission. . In the ED, patient was febrile to 102F, and found to have a retrocardiac opacity concerning for pneumonia as well as a creatinine of 2.3 increased from his baseline of 1.2. Oxygen saturation on room air was in the low 80s, and the patient was found to have systolics in the 80s. The patient had a central line placed in the ED, received ceftriaxone and levofloxacin as well as volume resuscitation, and admitted to the MICU for sepsis. . On arrival to the MICU, patient had received 3L NS with improvement in SBP to low 100s, and therefore did not require pressors. No other source of fever was located and antibiotics were therefore tailored to levofloxacin for community acquired pneumonia. Influenza testing was negative. After stabilization, the patient was transferred to the floor. . On arrival to the floor, the patient had only mild dyspnea, and no other complaints. Past Medical History: Hypertension Hyperlipidemia Osteoarthritis Seasonal allergies Prostate cancer: IV tx q6 months Social History: # Personal: Russian speaker. Lives at home with wife. # Professional: Retired ship captain. # Tobacco, alcohol, recreational drugs: No current use Family History: Noncontributory Physical Exam: Vital signs: T 96.1, BP 144/80, HR 60, RR 16, O2sat 96% on 3L General: NAD HEENT: NCAT, EOMI, sclera anicteric. MM dry appearing Neck: No JVD, dressing over right neck s/p triple lumen Chest: CTAB at anterior fields, few rales at left base. CV: RRR, normal S1/S2, 3/6 SEM throughout precordium, loudest at apex Abdomen: RLQ healed scar. Soft, NT, NT +BS. Ext: No C/C/E Pertinent Results: Admission labs: . [2195-3-25] 04:45PM WBC-24.1# RBC-3.76 HGB-12.4* HCT-35.5* MCV-94 MCH-33.0* MCHC-35.0 RDW-12.6 [2195-3-25] 04:45PM NEUTS-92.8* BANDS-0 LYMPHS-4.7* MONOS-2.4 EOS-0 BASOS-0.1 [2195-3-25] 04:45PM GLUCOSE-137* UREA N-61* CREAT-2.3# SODIUM-134 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-23 ANION GAP-17 . Microbiology: . # UA: Small leukocytes, no bacteria . # Blood cultures no growth . STUDIES: # CXR [2195-3-25]: No definite consolidation however there is relatively [Name2 (NI) 15410] atelectasis in both lung bases worse on the left. There is an indistinct opacity adjacent to the superior mediastinum in the right apex. While this may be due to underlying aortic tortuosity, either airspace process, atelectasis, or possible underlying ground-glass nodule cannot be excluded on the basis of this examination. PA and lateral views may be of benefit however CT may be indicated given the multiple complaints listed in the history. . # CXR [2195-3-25]: Left lower lobe atelectasis/consolidation with worsening failure. Right upper lobe opacity is concerning for a mass, and should be further investigated with cross-sectional imaging. . # CT head: No intracranial hemorrhage . # CT chest [2195-3-27]: 1. Well marginated 3.5 cm mass abutting the pleura in the posterior segment of the right upper lobe corresponding with the region of abnormality seen on the previous chest radiograph. Further characterization with PET CT is recommended to exclude malignancy. If no FDG activity is seen within this lesion on PET imaging, a followup chest CT is recommended in three months to assess for temporal stability. 2. Bilateral small pleural effusions with adjacent relaxation atelectasis. 3. Calcified mediastinal lymph nodes suggesting previous granulomatous infection. 4. Moderately severe compression fractures of several mid thoracic vertebral bodies of unknown chronicity. Recommend correlation with outside imaging studies to assess stability. Brief Hospital Course: 89M Russian speaking h/o HTN, hyperlipidemia, prostate cancer, admitted to the MICU with CAP and sepsis, and found to have a mass in right lung apex. . # Community acquired pneumonia/sepsis: Given patient's admission x-ray, community acquired pneumonia was considered the most likely cause for his symptoms and hypotension. Blood and urine cultures were negative. Patient was begun on a 10 day course of levofloxacin and was discharged with good ambulatory oxygen saturations on room air. . # Acute renal failure: Patient was in acute renal failure with elevated creatinine of 2.3 on admission. He received IV fluids and antibiotics for septic pneumonia, and his creatinine returned to baseline. . # Falls: Patient's falls were considered likely secondary to infection and sepsis. CT head on admission was negative for ICH, and he received physical therapy while inpatient. . # Hypertension: Patient presented with hypotension, and his home regimen of antihypertensives were initially held. On transfer to the floor he was borderline hypertensive and outpatient antihypertensive regimen resumed including nifedipine. Atenolol stopped and he was changed to metoprolol given acute renal failure on admission. . # Lung mass NOS: CXR on admission revealed a rounded nodule at right apex concerning for malignancy. CT chest demonstrated a 3.5 cm mass abutting pleura in posterior segment of RUL. Radiology recommending characterization with PET CT. the patient was provided with a PET CT appointment and given instructions on preparing for the exam. Follow-up was arranged as an outpatient. . # Prostate cancer: Patient's history of known prostate cancer was considered a possible source of his new lung mass. Patient was continued on doxazosin, with PSA less than 0.1. . # Full code Medications on Admission: Atenolol 25mg [Hospital1 ] Nifedipine XR 30mg daily Atorvastatin 10mg daily Aspirin 81mg daily Doxazosin 2mg QHS Loratadine 10mg daily Calcium carbonate 500mg TID Magnesium 250mg daily Oxycodone/acetaminophen 10/325mg 1 tab Q6H Meloxicam 7.5mg daily Diazepam 2mg QHS PRN Zolpidem 10mg QHS PRN Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:30 Tablet Sustained Release(s) Refills:2 4. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Tablet(s) 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Tablet(s) 6. Diazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 7. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Magnesium 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 11. Endocet 10-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 12. Lidocaine HCl Topical 13. Meloxicam 7.5 mg Tablet Sig: One (1) Tablet PO daily (). Discharge Disposition: Home With Service Facility: family extended care Discharge Diagnosis: Primary Diagnoses: Community acquired pneumonia Acute renal failure Lung mass NOS . Secondary diagnosis: Hypertension Prostate cancer Discharge Condition: Stable. Ambulatory oxygen saturation 97% on room air. Discharge Instructions: You were admitted to the hospital because you were confused, falling and having fevers. You were found to have a pneumonia, you were treated with antibiotics, and you improved. You were also found to have kidney failure. Later, you were found to have a mass in your right lung. You had a CT scan that confirmed the mass and its location. We will be referring you to workup this mass as an outpatient; please see below for information on the appointments for the workup. . We have made no changes to your medications. . Please call your doctor or return to the hospital if you experience any concerning symptoms including chest pain, difficulty breathing, lightheadedness or fainting, fevers or any other concerning symptoms. Followup Instructions: We have made an appointment for you to get a PET CT scan on Tuesday, [2195-4-7] at 11:20am on the [Location (un) ] of the [Hospital Ward Name 23] building at [Hospital1 18]; their phone number is ([Telephone/Fax (1) 9595], if you have any questions. . Please go to [Hospital Ward Name 23] [Location (un) ] to get a 'clear scan' fluid that you will need to drink 3 hours before the scan. . Also you will need to follow a special PET diet prior to the scan. We have attached the information about this diet to your discharge paperwork. . We have made an appointment for you with your primary care doctor DR. [Last Name (STitle) ],[First Name3 (LF) 5106] at [Telephone/Fax (1) 5105] for Thursday, [2195-4-9] at 12pm; please call her if you have any questions or need to reschedule the appointment. . We have made an appointment for you to discuss the PET scan results with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on Tuesday, [4-14], at 10:30am on the [Location (un) ] of the [Hospital Ward Name 23] building at the [Hospital1 18]. If you have any questions in regard to this appointment, please contact his office at ([Telephone/Fax (1) 5562]. Completed by:[2195-4-1]	[ "0389", "486", "5849", "51881", "99592", "2724", "4019" ]
Admission Date: [2182-4-19] Discharge Date: [2182-5-10] Date of Birth: [2157-5-22] Sex: F Service: MEDICINE Allergies: Amoxicillin Attending:[First Name3 (LF) 613] Chief Complaint: Endocarditis Major Surgical or Invasive Procedure: TEE History of Present Illness: This is a 24 yof with history of IVDU who initially presented to [Hospital 4199] hospital on [4-18] with 2 days of right sided chest and abdominal pain, as well as difficulty breathing for 2 days. She reports haveing used about 1g of heroin/day as well as cocaine recently over the past 2.5 weeks. . Given her shortness of breath and tachycardia, a CT chest was obained on admission which showed no PE, but right middle and lower lobe air space opacities suggestive of multifocal consolidation, as well as multiple nodular densities in the right upper lobe, left upper lobe, and left lower lobe with associated central cavitation concerning for septic emboli. There was also evidence of mediastinal and axillary adenopathy. Due to her IVDU history and CT findings there was concern for endocarditis and was started on vanco/ceftriaxone. Of note, she has had history of MRSA cellulitis in the past. Echo was obtained showing 2 cm vegetation on the tricuspid valve, with potential concern for fungal vegetation. Blood cultures were drawn and are now growing out GPC clusters in [2-9] bottles. ID consult was obtained and abx were changed to vanc/cefepime. HIV and Hepatitis B and C serologies were sent given her IVDU and were pending on transfer. . Of note, given her subjective history of weightloss/fevers there was concern for TB, so PPD was placed. She remained tachycardic throughout admission presumed secondary to fevers, pain, and anxiety. . Given her endocarditis, she was transferred to [Hospital1 18] where she could have a cardiac surgery evaluation. . On arrival to the MICU, initial VS were 102.9 130 128/52 27 96% RA. She complains of significant chest pain that inhibits her taking a deep breath. She denies peripheral edema, n/v/d. She endorses night sweats and weight loss over the past several days . Review of systems: (+) Per HPI (-) Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -IVDU -Depression -MRSA cellulitis Social History: Lives at home with her dad, who was previously addicted to narcotics but sober x 15 yrs. Not working or in school. No ETOH, smokes [10-21] cigarettes/day, + heroin and cocaine abuse. Family History: Lung cancer in paternal GM with brain mets Mother with a h/o IVDU Physical Exam: Admission PE Vitals: 102.9 130 128/52 27 96% RA General: Alert, oriented, tachypenic, moderate distress HEENT: Sclera anicteric, PERRLA (3mm in diameter) MMM, oropharynx clear, EOMI Neck: supple, JVP not elevated, but difficult to interpret given tachypnia. no LAD CV: Tachy, regular, S1 + S2, difficult to appreciate murmur given tachycardia Lungs: Tachypenic, shallow breaths, clear to auscultation anteriorly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No splinters, oslers nodes, or [Last Name (un) ] lesions. Evidence of track marks over the arms. Some evidence of skin popping as well Neuro: CNII-XII intact, moving all extremities. Discharge PE: VS: 97.9 112/60 (110-112/68-83) 108 (104-116) 18 100RA General: Alert, oriented, laying comfortably in bed HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI Neck: supple CV: Tachy, regular, S1 + S2, soft systolic murmur at LLSB Lungs: clear to auscultation b/l, no wheezes/rhonchi/crackles Abdomen: soft, non-tender, non-distended, +BS Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Skin: slight petechiae over feet, resolving--> new petechiae scattered along LE b/l, nonblanching, nontender, ranging in size some pinpoint to 2 cm in diameter; slightly present on the lower back as well --> continuing to resolve, fading in color Neuro: CN 2-12 grossly intact, normal muscle strength and sensation throughout Pertinent Results: Admission labs: [2182-4-19] 08:20PM BLOOD WBC-11.3* RBC-3.25* Hgb-9.6* Hct-29.7* MCV-91 MCH-29.6 MCHC-32.5 RDW-12.9 Plt Ct-110* [2182-4-20] 03:38AM BLOOD WBC-14.2* RBC-3.12* Hgb-9.1* Hct-28.7* MCV-92 MCH-29.2 MCHC-31.7 RDW-12.9 Plt Ct-111* [2182-4-19] 08:20PM BLOOD Neuts-88.0* Lymphs-8.4* Monos-3.0 Eos-0.1 Baso-0.5 [2182-4-20] 03:38AM BLOOD Neuts-85.4* Lymphs-10.6* Monos-3.6 Eos-0.1 Baso-0.3 [2182-4-19] 08:20PM BLOOD PT-17.7* PTT-33.1 INR(PT)-1.7* [2182-4-19] 08:20PM BLOOD Fibrino-513* [2182-4-20] 03:38AM BLOOD FDP-10-40* [2182-4-20] 12:37PM BLOOD ESR-100* [2182-4-21] 04:57AM BLOOD Ret Aut-0.7* [2182-4-19] 08:20PM BLOOD Glucose-101* UreaN-6 Creat-0.4 Na-140 K-3.0* Cl-106 HCO3-31 AnGap-6* [2182-4-20] 03:38AM BLOOD Glucose-100 UreaN-6 Creat-0.6 Na-139 K-3.2* Cl-106 HCO3-25 AnGap-11 [2182-4-19] 08:20PM BLOOD ALT-13 AST-16 LD(LDH)-220 AlkPhos-70 TotBili-0.5 [2182-4-20] 03:38AM BLOOD ALT-13 AST-14 LD(LDH)-229 AlkPhos-64 TotBili-0.5 [2182-4-19] 08:20PM BLOOD Albumin-2.3* Calcium-7.2* Phos-1.7* Mg-2.0 [2182-4-20] 03:38AM BLOOD Calcium-7.1* Phos-2.6* Mg-1.9 [2182-4-23] 05:22AM BLOOD calTIBC-137* Hapto-352* Ferritn-349* TRF-105* [2182-4-20] 12:37PM BLOOD CRP-245.2* Discharge labs: [2182-5-9] 05:55AM BLOOD WBC-9.3 RBC-3.53* Hgb-10.1* Hct-33.6* MCV-95 MCH-28.7 MCHC-30.1* RDW-14.4 Plt Ct-918* [2182-5-10] 06:06AM BLOOD WBC-9.1 RBC-3.33* Hgb-9.5* Hct-31.5* MCV-95 MCH-28.5 MCHC-30.1* RDW-14.2 Plt Ct-871* [2182-5-10] 06:06AM BLOOD PT-12.5 PTT-30.1 INR(PT)-1.2* [2182-5-9] 05:55AM BLOOD Glucose-105* UreaN-17 Creat-0.7 Na-142 K-5.0 Cl-101 HCO3-32 AnGap-14 [2182-5-10] 06:06AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-142 K-4.5 Cl-102 HCO3-34* AnGap-11 [2182-5-10] 06:06AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.3 [2182-5-6] 09:16AM BLOOD Cryoglb-NO CRYOGLO [2182-4-19] 08:20PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [2182-4-19] 08:20PM BLOOD HCV Ab-POSITIVE* Studies: ECHO [2182-4-19]: IMPRESSION: Large tricuspid valve vegetation with mild (possibly underestimated) tricuspid regurgitation. No other valvular vegetations appreciated. Preserved biventricular regional and global left ventricular systolic function. Very small circumferential pericardial effusion. CT abd/pelvis: [2182-4-22] IMPRESSION: 1. New basilar consolidations concerning for septic emboli. 2. Increased bilateral pleural effusions since the reference study from [2182-4-18]. 3. New moderate ascites and body wall edema. TEE: [2182-4-23] IMPRESSION: There is a large vegatation on the tricuspid valve. Moderate to severe tricuspid regurgitation. Overall normal biventricular function. Very small pericardial effusion. RUQ u/s: [2182-4-23] IMPRESSION: -> No portal vein thrombosis identified. -> Trace of ascites in the pelvis. There are right and left pleural effusions noted. -> No focal collection is seen in either the spleen or liver. CT abd/pelvis: [2182-4-26] IMPRESSION: 1. Increasing bilateral pleural effusions and new moderate-sized pericardial effusion. Cavitating pulmonary nodules c/w septic emboli. 2. No evidence of septic emboli within the abdomen. 3. Moderate amount of free fluid in the dependent portion of the pelvis. CT chest [2182-4-27] IMPRESSION: 1. Worsening right upper and right middle lobe pneumonia with multiple bilateral septic emboli, many of which have cavitated, the most prominent of which appears to communicate with a branch of the right middle lobe bronchus and extends to the periphery, but given the lack of gas within the pleural space, bronchopleural fistula is not favored at this time. Findings discussed with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at 22:39 on [2182-4-27] by [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 11623] over the phone. 2. Pleural and pericardial effusions as described above. CT chest: [2182-5-1] IMPRESSION: 1. Right upper lobe noncavitary consolidation has improved since the recent study, and a few nodules show new cavitation. However, dominant wedge-shaped areas of cavitary consolidation in the right middle lobe and lingula are not appreciably changed. 2. Resolved left pleural effusion, decreased right pleural effusion, and persistent moderate pericardial effusion. Brief Hospital Course: 24 yof with history of IVDU, past MRSA cellulitis, presenting to [Hospital 4199] hospital with breathing difficulty and tachycardia. CT torso showed cavitary lesions suggestive of septic emboli, and echo with large tricuspid vegitation suggestive of endocarditis. # Right-sided Endocarditis with septic pulmonary emboli: transferred from an OSH with know tricuspid valve endocarditis, cultures eventually speciated to MSSA. CT scan at the OSH with cavitary lung lesions, consistent with septic emboli from her known endocarditis. She was seen in consultation by the infectious disease service and the cardiac surgery service, she underwent a TEE which showed a 1.7cm x 1cm tricuspid valve vegetation, no abscess formation, and no involvement of any other valves. Given the TEE findings the cardiac surgery service felt that no surgical intervention was needed at this time. She remained on vancomycin with a goal trough of over 20, when the cultures from the OSH returned MSSA it was decided to continue her on vancomycin given her history of throat closing with amoxicillin. However, the patient later developed a new LE rash, which initially was thought could be related to vanc. Vanc was stopped and the patient was briefly on dapto, when it was decided by ID that she should undergo PCN desensitization so she could be on the appropriate NAfcillin for her MSSA endocarditis. . On the floor, the patient was hemodynamically stable, though she continued to be tachypneic to 30-40s and tachycardic to 120-130s. Her daily EKG's did not show any evidence of conduction system disease. A PICC was placed with plans for a total of 6 weeks of antibiotics based on date of first negative cultures, which was on [2182-4-23]. End date will be [2182-6-4]. . The patient was found to have an increasing white count and repeat CT chest was done on [2182-5-1]. Thoracics was consulted re: potential for any operable/resectable areas that could be causing this white count. However, CT chest showed improvement compared to priors, and thoracics said no intervention was needed at this time. . # PCN desensitization: The patient was transferred to the MICU for PCN desensitization, which she tolerated without any issue. She also received Nafcillin without incident and was able to be called out to the floor without issue. It is VERY important that the patient should not miss [First Name (Titles) 691] [Last Name (Titles) 4319] given her recent desensitization. . # Fevers/weight loss: Prior to transfer given the septic emboli on her chest CT and fevers and weight loss there was concern for possible TB. A PPD placed at the OSH was negative and she had three sputums negative for AFB. The patient was also noted to be HIV negative at OSH. . # Tachycardia: CTA negative for PE prior to transfer, thought to be related to pain, fever and withdrawal symptoms, she was monitored on telemetry and remained in sinus tachycardia throughout her stay. . # IVDU: Pt with long history of IVDU likely precipitating her endocarditits, HIV antibody negative at the OSH on [2182-4-19]. Hepatitis C antibody positive here with a viral load of 173,401. Hepatitis B serologies showed immunity. Hepatology was curbsided and said pt could follow up in hepatology clinic at any time for HCV treatment if she desired this. However, it is not urgent so they recommended she finish endocarditis treatment first and no longer be using IV drugs. The patient was also given clonidine PRN for any withdrawal symptoms. . # abdominal pain: The patient had an episode of abdominal pain, with exam notable for rebound tenderness. Surgery was consulted, and KUB was done. KUB was negative for free air or any evidence of obstruction; lactate was normal. Surgery recommended NPO until abdominal pain resolves. The patient's diet was advanced slowly, and her abdominal pain resolved. Given her recent diagnosis of HSP (see below), it is possible that this acute episode of abdominal pain was intussuception that had self resolved. . # diarrhea: The patient reported having some intermittent diarrhea while in patient; was found to be Cdiff negative x2. . # Anemia: The patient was found to be iron deficiency on studies, with no evidence of hemolysis, and she was started on ferrous sulfate. . # new BLE pupura: The patient was found to have new LE rash, which was initially thought to be secondary to Vanc. There was some improvement after Vanc was stopped. Derm was consulted and punch biopsies were done. Path was consistent with leukocytoclastic vasculitis, with IgA deposits in vessel walls, consistent with Henoch-Schonlein Purpura. This was thought to be most likely secondary to her underlying bacterial endocarditis. . # thrombocytosis: The patient had a persistent thrombocytosis during this admission, likely reactive in the setting of her endocarditis. Upon discharge, it had started trending down. Transitional Issues: # new Hep C: The patient should follow up as an outpatient in liver clinic once treatment for endocarditis is finished. . # bacterial endocarditis: The patient will need to complete six weeks total of antibiotics starting from 1st negative culture; end date will be [2182-6-4]. She will be discharged on Nafcillin. . # LE purpura s/p punch biopsy: The patient had punch biopsy done on [2182-5-7]. The patient will need to have sutures removed from biopsy site in two weeks ([2182-5-21]). The patient will also need outpatient dermatology follow up. Please call [Telephone/Fax (1) 1971] to make an appointment. # infectious disease follow up: The patient will follow up in [Hospital 4898] clinic on [2182-5-21] 10a with Dr. [Last Name (STitle) ] and [6-4] 11.30a with Dr. [Last Name (STitle) ]. Please send weekly CBC w/diff, BMP, LFTs to [Telephone/Fax (1) 1419]. # HSP: Please get urinalysis once weekly to monitor for hematuria for two months. Medications on Admission: none Discharge Medications: 1. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day). 2. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for withdrawals. 4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: please hold for RR<12, altered mental status. 6. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 9. nafcillin 2 gram Recon Soln Sig: One (1) Intravenous every four (4) hours: PLEASE STOP [2182-6-4]. Discharge Disposition: Extended Care Facility: Tewsbury State Hospital Discharge Diagnosis: Primary: MSSA bacterial tricuspid endocarditis with pulmonary septic emboli intravenous drug use Hepatitis c Secondary: reactive thrombocytosis Henoch-Schonlein Purpura Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 35914], It was a pleasure taking care of you while you were hospitalized at [Hospital1 18]. You were transferred to [Hospital1 18] because you were found to have a bacterial infection in your blood, with bacteria on your heart valves and in your lungs. We started you on antibiotics to help treat this infection. Because you had an allergy to penicillin, we had to send you back to the intensive care unit for desensitization; you tolerated this well. It is VERY important that you do not NOT miss any of your [Hospital1 4319] of the antibiotic. We made the following changes to your medications: START Nafcillin 2 grams every four hours through your veins START Zofran 4 mg every 8 hours by mouth as needed for nausea START Sarna lotion, applied to your hands/feet, as needed for dry skin START Dilaudid 2-4 mg as needed for pain every 4 hours START clonidine 0.1 mg by mouth as needed every 4 hours START lorazepam 0.5 mg by mouth as needed for anxiety every fours hours START acetaminophen 650 mg as needed for fever/pain every 6 hours (do NOT exceed 2 grams daily) Followup Instructions: Please followup with your primary care physician [Name Initial (PRE) 176] [7-16] days regarding the course of this hospitalization. Please call [Telephone/Fax (1) 1971] to make an appointment to make an appointment with dermatology clinic. You will also have to follow up with the liver doctors as [Name5 (PTitle) ] outpatient, given your new diagnosis of Hepatitis C. Department: INFECTIOUS DISEASE When: TUESDAY [2182-5-21] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4593], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: TUESDAY [2182-6-4] at 11:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4091], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2182-5-10]	[ "486", "5119", "5180", "2875", "3051" ]
Admission Date: [2169-11-18] Discharge Date: [2169-11-22] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 602] Chief Complaint: Hypoxia/respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ]F nursing home resident with severe dementia, s/p stroke with resultant dysphagia, recently treated for PNA (last dose CTX [11-16]) p/w dyspnea. Per EMS, found to be tachypneic, saturating in high 80's no RA, with only minimal improvement on nasal canula. She improved to high 90's on NRB w/ EMS with RR in 40's. . In the ED inital vitals were, 140/80, 103, 36, 100% 15L NRB. CXR showed infiltrate in RML and RLL. EKG: sinus tach @ 101, NA/LBBB, TWI I, AVL V5/6. Labs significant for lactate 1.6, Na 152, and WBC 12 with left shift but no bandemia. She was given IVF, tylenol 650mg PR, levofloxacin, ceftriaxone, and vancomycin and was placed on BiPAP due to concern over work of breathing and documented DNR/DNI in chart. Her Access is: 24G L arm, 20 R forearm. On transfer to the ICU, VS 99.4 104 140/65 40 100% Non-Rebreather. . In the ICU, patient follows simple directions. Says, "I feel good." Denies pain. Per daughter, her mental status is much improved and she has "perked up" since last PM when she was less interactive. Notes she has had less PO intake. . Review of systems: (+) Per HPI Unable to obtain full ROS per patient, but denies pain. Past Medical History: OSA HTN severe dementia hyperlipidemia DM with neuropathy COPD s/p stroke with resultant dysphagia uterine prolapse OA Social History: - Tobacco: Distant for many years, quit 30 yrs ago per daughter - Alcohol: Daughter Denies - [Name2 (NI) 3264]: Daughter Denies Family History: Significant for diabetes Physical Exam: On admission to ICU: Vitals: 97.9 116/63 98 26 94%NRB General: no acute distress, follows simple commands. when asked questions of orientations, asks us to refer to her daughter. dysphasic [Name2 (NI) 4459]: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP low, no LAD Lungs: Tachypnic, crackles up to right mid lung field CV: tachycardic, regular 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 Discharge Exam: PHYSICAL EXAM: VS: Tm AFebrile Tc HR 80s BP 100-130s/60s RR 22-36 SaO2 98% 3LNC FSG I/O GENERAL: [x] NAD [] Uncomfortable. Pleasant Eyes: [] anicteric [] PERRL ENT: [x] MMM [] Oropharynx clear [] Hard of hearing NECK: [] No LAD [] JVP: CVS: [x] RRR [x] nl s1 s2 [x] no MRG [x] no edema LUNGS: [] No rales [x] No wheeze [x] comfortable. Scattered crackles ABDOMEN: [x] Soft [x]nontender []bowel sounds present []No hepatosplenomegaly SKIN: []No rashes []warm []dry [] decubitus ulcers: LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD NEURO: [] Oriented x3 [x] Fluent speech [x] demented. Psych: [x] Alert [x] Calm [x] Mood/Affect: good mood Pertinent Results: On admission: [2169-11-18] 09:12AM BLOOD WBC-12.0* RBC-4.41 Hgb-13.5 Hct-39.5 MCV-89 MCH-30.5 MCHC-34.1 RDW-15.3 Plt Ct-161 [2169-11-18] 09:12AM BLOOD Neuts-86.5* Lymphs-10.6* Monos-2.4 Eos-0.3 Baso-0.3 [2169-11-18] 11:05AM BLOOD PT-13.6* PTT-28.6 INR(PT)-1.2* [2169-11-18] 09:12AM BLOOD Glucose-134* UreaN-21* Creat-1.0 Na-151* K-4.6 Cl-112* HCO3-28 AnGap-16 [2169-11-18] 09:12AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0 [2169-11-18] 09:25AM BLOOD Lactate-1.6 [2169-11-18] 09:30AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2169-11-18] 09:30AM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2169-11-18] 09:30AM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-OCC Epi-<1 [2169-11-18] 09:30AM URINE CastGr-1* CastHy-1* CXR [2169-11-18]: FINDINGS: A portable semi-upright frontal view of the chest was obtained. Consolidation in the right mid and lower lungs is likely pneumonia. A moderate right pleural effusion is also likely present. Increased opacity in the left mid lung field may be developing focus of infection. There is no large pneumothorax. Pulmonary vascular is engorged. Evaluation of heart size is limited due to consolidation. The bones are diffusely osteopenic. IMPRESSION: Mild pulmonary edema with moderate right pleural effusion. Right lung opacification may be due to pneumonia, or possibly asymmetric pulmonary edema. There may be a developing focus of infection in the left mid lung. Labs on Discharge: [2169-11-21] 07:15AM BLOOD WBC-10.9 RBC-4.16* Hgb-12.2 Hct-37.6 MCV-90 MCH-29.3 MCHC-32.4 RDW-15.3 Plt Ct-195 [2169-11-22] 07:55AM BLOOD Glucose-138* UreaN-11 Creat-0.9 Na-143 K-4.4 Cl-106 HCO3-30 AnGap-11 [2169-11-20] 07:30AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0 [2169-11-21] 07:15AM BLOOD Vanco-12.3 Studies pending at discharge: None Brief Hospital Course: [Age over 90 ]yo F with severe dementia admitted from Nursing home facility ([Hospital3 537]) with right middle and right lower lobe pneumonia, encephalopathy, hypernatremia, and hypoxemia . #Hypoxemia/Health care associated pneumonia: The patient was initially admitted to the intensive care unit with high oxygen requirement requiring oxygen via a non-rebreather. She was treated for health care associated pneumonia as she is a nursing home resident with Vancomycin and Zosyn to complete an 8 day course to end [11-27] with vancomycin trough goal of 15-20. She was also given Solumedrol in the ICU but this was not continued when she was transferred to the medical floor. Her oxygen requirements improved and she was maintained on 2-3L of oxygen by nasal canula through most of her hospitalization. . #Aspiration: Given the location of the pneumonia and her encephalopathy and severe dementia she was evaluated by speech pathology who felt that the patient would always be at risk for aspiration, but that she should be monitored with 1:1 supervision and have a pureed dysphagia with thin liquids and all pills crushed in applesauce diet. The risk of recurrent aspiration and pneumonina was discussed with the health care proxy [Name (NI) ] (daughter). . # Hypernatremia/Fluids/Electrolytes/Nutrition: Na was 151 on admission and peaked at 153. This was felt to be due to the patient's poor oral intake on top of infection. Throughout the hospitalization the patient continued not to eat and was maintained on IV fluids. Her sodium remained stable and improved slightly each day on D51/2NS +/- K depending on potassium at 75ml/hr without complications of volume overload. Nutrition was discussed with the patient's family including daughter and health care proxy [Name (NI) ] [Name (NI) 91472] ([Telephone/Fax (1) 91473]) who said that the patient would not want a feeding tube of any kind or TPN. They understood that this may lead to undernourishment but re-stated that they did not want tubes or TPN for feeding/nutrition. . # Severe Dementia/Encephalopathy: Her mental status improved slowly over hospitalizatoin. She was able to answer questions and interact on discharge but was not always oriented and unclear if she comprehended completely. Daughter said patient was close to her mental baseline prior to discharge. . # DM: Patient was managed on insulin sliding scale . # Diabetic neuropathy: gabapentin and tramadol were continued . # Code: DNR/DNI . #Acces: A midline IV was placed for IV antibiotics. . #Goals of care: The issue of aspiration and nutrition were discussed with the [Hospital 228] health care proxy [Name (NI) ] (phone number above) prior to discharge. She confirmed that feeding tubes and TPN were not wanted. They understood that she may be reliant on IV fluids and even with this she may be undernourished if she continued not to eat. She also understood that with feeding she was at high risk for pneumonia and hypoxemia. The issue of "do not hospitalize" was discussed, but a decision was not made at the time of discharge, but the HCP understood that this was an option and will consider further depending on how the patient does at her [Hospital1 1501]. Medications on Admission: per [Hospital3 537] records Ceftriaxone stopped [11-16] (7 day course) MVI Tramadol 75mg QAM, 100mg QPM gabapentin 100mg daily at 2pm, 300mg at morning and at bedtime senna daily colace tylenol prn ca-vit D Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. insulin lispro 100 unit/mL Solution Sig: as directed units Subcutaneous ASDIR (AS DIRECTED). 3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. tramadol 50 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)). 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 7. Vancomycin 750 mg IV Q 12H 8. Piperacillin-Tazobactam 2.25 g IV Q6H 9. 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. 10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold if diarrhea. 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold if diarrhea. 17. Labs Please check a Vancomycin trough just prior to his evening Vancomycin dose on [2169-11-23] to confirm trough is at goal of 15-20. If not at goal trough, please adjust accordingly. Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: Health care associated pneumonia Hypernatremia 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 because of a pneumonia which probably occurred because of aspiration. You were treated with antibiotics and are being discharged to complete an 8 day course to end [11-27]. You were also found to be at risk for aspiration. Therefore, it is very important that you are supervised closely and given instruction while eating. You should also make sure to eat well to maintain your nutrition. Since you have required IV fluids to maintain your hydration and keep your electrolytes in the normal range this should be continued at your nursing facility and your labs should be checked every day or every other day to make sure your electrolytes are in the appropriate range. Followup Instructions: Please follow up with your doctor [First Name (Titles) ] [Hospital3 537]	[ "5070", "2760", "5119", "496", "4019", "2720", "32723", "V1582" ]
Admission Date: [2193-6-27] Discharge Date: [2193-7-23] Date of Birth: [2193-6-27] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 58109] was the 1335 gm product of a 32 [3-29] week gestation born to a 28 year old gravida 1, para 1 woman with obstetrics history notable for infertility and bicornuate uterus. Past medical history was unremarkable. Prenatal screens are as follows - Blood Group B positive, DAT negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune, Gonococcus negative, Chlamydia negative and Group B Streptococcus unknown. Pregnancy complicated by subchorionic hematoma and vaginal hemorrhage in the first trimester and by intrauterine growth retardation, 9th percentile, on [6-21] ultrasound, low amniotic fluid index and absent end diastolic flow, first noted on ultrasound on [2193-6-21]. Mother was admitted at that time and received a full course of Betamethasone. Diastolic flow was subsequently normal with biophysical profile of 8 out of 8, but doppler abnormalities returned on day of delivery leading to breech cesarean section under spinal anesthesia. Ruptured membranes at delivery yielded clear amniotic fluid, no labor noted. No intrapartum fever or other evidence of chorioamnionitis. The infant cried at delivery, orally and nasally bulb suctioned. Blow-by oxygen provided. Heart rate was well maintained. Apgars were 7 at one minute and 8 at five minutes. The infant was transferred to the Neonatal Intensive Care Unit. PHYSICAL EXAMINATION ON ADMISSION: Birth weight was 1335 gm, 10th percentile to 25percentile. Head circumference was 28 cm, 10th percentile to 25th percentile. Length 39 cm, 10th percentile to 25th percentile. Anterior fontanelle was soft and flat, nondysmorphic palate intact. Neck, mouth normal. Normocephalic. CPAP in place. Mild retractions on CPAP, good breath sounds bilaterally, no crackles. Cardiovascular, well perfused, regular rate and rhythm. Femoral pulses normal. S1 and S2 normal. No murmur. Abdomen soft, nondistended, no organomegaly and no masses. Bowel sounds active. Anus patent, three vessel umbilical cord. Normal female genitalia. The infant was active and alert, responds to stimulation. Axial and appendicular tone slightly decreased but symmetric. Moves all extremities. Suck/root/gag intact. Grasp symmetric. Spontaneous eye opening. Nevus squamous over eyelid. Normal spine, limbs, hips and clavicles. HOSPITAL COURSE: Respiratory - [Location (un) 31910] initially was placed on CPAP for approximately 24 hours at which time she transitioned to room air. She has been stable on room air for the remainder of the hospital course. She has not required any Methylxanthine therapy for treatment of apnea and bradycardia. Cardiovascular - She has been stable throughout the hospital course without any further issues. Fluids, electrolytes and nutrition - Birthweight is 1335 gm. Discharge weight is 1755 grams. The infant was initially started on 80 cc/kg of D10/W. Enteral feedings were started on day of life #1. The infant reached full enteral feedings by day of life No. 7. Maximum caloric intake was 150 cc/kg/day of breast milk or Special Care Formula concentrated to 30 calories with extra ProMod. She is currently ad lib feeding, breast milk 26 calorie, taking in excess of 140 cc/kg/day. Gastrointestinal/genitourinary - Her peak bilirubin was on day of life No. 3, 7.3/0.3. She received phototherapy for five days and she has since resolved. Hematology - Hematocrit on admission was 58.3. She has not required any blood transfusions during this hospital course. Infectious disease - A complete blood count and blood culture were obtained. Complete blood count was benign. Blood culture remained negative. The infant did not receive any antibiotics during this hospital stay. Neurology - Head ultrasound performed at one week of age was within normal limits, and the infant's examinations have been reassuring. Sensory - Audiology screening has been performed with automated auditory brain stem responses and the infant passed both ears. Ophthalmology, not applicable. Psychosocial - Involved family. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) 553] [First Name8 (NamePattern2) 58110] [Name8 (MD) ], MD. Telephone number [Telephone/Fax (1) 58111]. CARE/RECOMMENDATIONS: Feeding - Continue ad lib feedings. Breast milk 26 calorie, concentrated with corn oil, 2 calories with corn oil and 4 calories with NeoSure and ad lib breastfeeding. Medications - Continue Fer-In-[Male First Name (un) ] supplementation. Carseat position screening - Performed and the infant passed. State newborn screens - Sent, most recent specimen from [7-17] has been within normal limits. Immunizations received - Infant received a hepatitis B vaccine on [2193-7-22]. DISCHARGE DIAGNOSIS: Premature female born at 32 5/7 weeks. Mild respiratory distress syndrome, status post rule out sepsis. Mild hyperbilirubinemia. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2193-7-22] 23:10:24 T: [2193-7-23] 08:24:10 Job#: [Job Number 58112]	[ "7742", "V290", "V053" ]
Admission Date: [2159-10-14] Discharge Date: [2159-10-16] Date of Birth: [2077-3-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 983] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy and biliary stent placement History of Present Illness: 82M with PMH CHF, T2DM, prostate CA, s/p CCY who presents from [Hospital1 1562] ED with concern for cholangitis. Pt states that he began to have epigastric pain last night [6-22] 'steady' pain not associated with food and without radiation. Pain eventually went away on its own, but returned this am and didn't go away, leading to presntation to [Hospital1 1562] ED. Per [Hospital1 1562] records, he had nausea and dry heaves and was febrile to 102. Upright x-ray showed no free air, large stool. Ultrasound showed dilated CBD and intrahepatic ducts, distal and CBD large impacted gallstone 1.8cm, with proximal duct measuring 1.6cm. He had WBC to 15.7. He was given Morphine 8mg IV, ZOfran 4mg IV, 500mg Flagyl and 500mg Levaquin. . In the ED inital vitals were, 99.9 104 136/59 18 97%. He appeared confused, stating "2nd" "[Month (only) 1096]" "11" for year, initially states "[Hospital3 ]" for location. He is aware that he is confused. Abdomen was distended with +BS, TTP RUQ, epigastrium, and LUQ without rebound or guarding. Labs were notable for WBC of 18.6, TBili of 3.1, DBili of 2.3, AST and ALT 609 and 265 and AP of 167. Lactate was 2.4. GI was consulted who recommended urgent ERCP with admission to the [Hospital Unit Name 153]. . On the floor, patient is in no current pain. He admits to nausea earlier without emesis. He did note chills yesterday. He denies shortness of breath or dizziness. He has had no bloody bowel movements. He did have his gallbladder removed approximately 8 years ago, associated with similar pain 'but worse' at that time. Review of systems is otherwise unremarkable Past Medical History: -CHF (although patient denies) -DM -prostate CA s/p CCY -s/p cholecystectomy approximately 8 years ago -s/p splenectomy for 'low platelets' -s/p two knee replacements -'lung procedure' for a 'virus around the lung' approximately 3 years ago at [Hospital3 ] Hospital Social History: Retired propane truck driver. Lives in [Hospital1 1562] with his wife of 52 years. 2 daughters and 1 son. - Tobacco: Quit 45 years ago - Alcohol: Occasional - Illicits: Denies Family History: NC Physical Exam: Admission: Vitals: T:98.4 BP:107/55 P:77 R:16 O2:95% 2LNC General: Alert, oriented to person, hosptital, year and president. No acute distress, watching football. HEENT: Sclera mildly icteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Soft breath sounds. Mild crackles at bases bilaterally. Nonlabored. CV: Soft heart sounds. 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. No [Doctor Last Name ] sign. Scars c/w prior splenectomy and cholecysctectomy. Ext: warm, well perfused, 2+ pulses. Rt chronic venous stasis changes. 1+pitting edema to mid shins, prominently over ankles. 2 scars over knees c/w prior surgery. Discharge Exam: VSS GEN: Patient lying comfortably in bed nad a+ox3 HEENT: MMM oropharynx clear NECK: supple no thyromegaly CV: rrr no m/r/g RESP: ctab no w/r/r ABD: soft nt nd bs+ no rebound or guarding EXTR: no le edema good pedal pulses bilaterally DERM: no rashes, ulcers or petechiae neuro: cn 2-12 grossly intact non-focal PSYCH: normal affect and mood Pertinent Results: Admission Labs: [2159-10-14] 04:19PM BLOOD WBC-18.6* RBC-4.52* Hgb-14.3 Hct-41.5 MCV-92 MCH-31.7 MCHC-34.6 RDW-13.7 Plt Ct-209 [2159-10-14] 04:19PM BLOOD Neuts-90.5* Lymphs-6.0* Monos-2.7 Eos-0.5 Baso-0.4 [2159-10-14] 04:19PM BLOOD PT-14.4* PTT-22.5 INR(PT)-1.2* [2159-10-14] 04:19PM BLOOD Glucose-199* UreaN-15 Creat-0.8 Na-138 K-3.6 Cl-103 HCO3-23 AnGap-16 [2159-10-14] 04:19PM BLOOD ALT-465* AST-609* AlkPhos-167* TotBili-3.1* DirBili-2.3* IndBili-0.8 [2159-10-14] 04:19PM BLOOD Lipase-16 [2159-10-14] 10:40PM BLOOD Albumin-3.5 Calcium-8.3* Phos-3.4 Mg-1.9 [2159-10-14] 04:19PM BLOOD Digoxin-0.9 [2159-10-14] 04:21PM BLOOD Lactate-2.4* [2159-10-14] 04:19PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 [2159-10-14] 04:19PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-SM Urobiln-4* pH-5.5 Leuks-NEG URINE Site: CLEAN CATCH FINAL REPORT [2159-10-15] URINE CULTURE (Final [2159-10-15]): NO GROWTH. ERCP: A large periampullary diverticulum was noted. There was pus drainage from the ampulla Successful biliary cannulation was achieved with the sphincterotome. Partial opacification of the biliary tree was performed because of the clinical evidence of cholangitis There was significant dilation of the CBD up to approximately 18 mm in the mid CBD with evidence of at least two large stones, measuring up to 18mm in size Successful placement of a 7cm x 10Fr biliary stent for drainage Otherwise normal ERCP to 3rd part of duodenum. RUQ U/S: FINDINGS: The liver demonstrates a normal-appearing echotexture, with minimal prominence of the intrahepatic biliary ducts. The portal vein is patent with directionally appropriate flow. The distal CBD is markedly distended up to 1.8 cm. A 2.3-cm echogenic shadowing stone is demonstrated within the distal CBD. Limited views of the pancreatic head and body show no pancreatic duct dilatation. IMPRESSION: 2.3-cm stone in the distal CBD with marked extrahepatic and mild intrahepatic biliary dilatation. CXR: Hyperinflation of the lungs and the configuration of the diaphragm suggest COPD. Thickening of the lower lateral and posterior costal pleural margins could be due to thickening or small effusions. There is pleural parenchymal scarring at both lung apices, right greater than left. Heart size is normal and there is no evidence of central adenopathy. Any prior chest radiograph should be obtained to see if there are new findings warranting further investigation. Discharge Labs: [2159-10-16] 06:45AM BLOOD WBC-10.8 RBC-4.09* Hgb-13.0* Hct-39.0* MCV-95 MCH-31.7 MCHC-33.3 RDW-13.7 Plt Ct-179 [2159-10-16] 06:45AM BLOOD PT-14.8* PTT-28.2 INR(PT)-1.3* [2159-10-16] 06:45AM BLOOD Glucose-172* UreaN-13 Creat-0.8 Na-139 K-3.9 Cl-105 HCO3-28 AnGap-10 [2159-10-16] 06:45AM BLOOD ALT-227* AST-103* AlkPhos-155* TotBili-2.1* Brief Hospital Course: # Cholangitis: ERCP evaluated pt in ED and recommended ICU admission with plan for ERCP on night of admission. He underwent sphincterotomy with purulent drainage and CBD stones were seen. NO extraction was performed and biliary stent was placed with improvement in symptoms. His diet was advanced and he should have repeat ERCP for stent removal, sphincteroplasty and stone extraction in [3-16] weeks(plan for [11-2]). He was started on Unasyn post-procedure. Cultures from osh were sensitive to cipro and he was discharged to complete a 2 week course(Complete on [10-28]). He will follow up with his PCP, [Name10 (NameIs) ] THAT VISIT PLEASE CHECK LFT'S(WHICH WERE DOWNTRENDING ON DISCHARGE) AND CBC(LEUKOCYTOSIS HAD NORMALIZED ON DISCHARGE). GI WILL BE CALLING THE PATIENT TO GIVE A TIME FOR THE PROCEDURE ON [11-2]. . # GNR bacteremia: OSH blood cultures grew e.coli in 2 bottles which were sensitive to cipro. Unasyn was d/c and he was started on po cipro. He will complete his course on [10-28]. . # DM: Insulin dependent. Metformin held and Lantus initially held, started on ISS. Patient discharged to restart his home lantus and metformin. . # CHF? vs afib: Patient stated he was on digoxin for an arrhythmia not chf as previous notes stated. Dig level 0.9. Lasix was initially held and restarted post ERCP. Digoxin and lasix were continued on discharge. . . TRANSITIONAL ISSUES: -repeat ERCP 3-4 weeks -Cipro PO until [10-28] Medications on Admission: KCl ER 750mg daily Furosemide 20mg daily Digoxin 25mcg daily Metformin 500 [Hospital1 ] ASA 81 Insulin (unsure type, suspect lantus) 28 units qhs Discharge Medications: 1. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:24 Tablet(s) Refills:0 6. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28) units Subcutaneous at bedtime. 8. potassium chloride Oral Discharge Disposition: Home Discharge Diagnosis: 1. Acute cholangitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You presented with abdominal pain and fevers and were found to have cholangitis-this is an obstruction/infection of the bile ducts. You were treated with antibiotics and an ERCP to relieve the obstruction. When discharged you will be on antibiotics for a total of 2 weeks and will follow up with the gastroenterologists for a repeat ERCP. Followup Instructions: 1) Primary care physician follow up: Name: [Last Name (LF) 18365],[First Name3 (LF) ] W. Address: [Street Address(2) 90881], [Hospital1 ],[Numeric Identifier 23859] Phone: [Telephone/Fax (1) 20997] Appt: [10-23] at 3:15pm 2) You will have a follow up ERCP on [11-2]. The gastroenterology clinic will call you with a time in [1-14] weeks.	[ "25000", "42731" ]
Admission Date: [2168-9-28] Discharge Date: [2168-10-1] Service: Medicine, [Doctor Last Name ] Firm HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old female with a history of hypertension, gastroesophageal reflux disease, and Alzheimer's dementia who presents with symptoms of presyncope and a decreased hematocrit. Three weeks prior to presentation, the patient developed a decreased appetite and fatigue. The patient is currently living with her daughter in [Name (NI) 86] where the patient was lethargic and not her usual self. The patient was seen by her daughter's primary care physician and found to have a hematocrit of 23.2 and was sent to the [Hospital1 190] for further evaluation. The patient denied any recent nausea, vomiting, diarrhea, constipation, change in stool color/size/caliber, bright red blood per rectum, and melena. The patient does note an 8-pound to 10-pound weight loss over the past few weeks in concordance with her symptoms. The patient denies any chest pain, shortness of breath, cough, sputum, or dysuria. The patient does not know when her last colonoscopy was. In the Emergency Department, the patient was found to be tachycardic. Two large bore intravenous lines were placed. The patient was transfused 3 units of packed red blood cells with resolution of her tachycardia. The patient was seen by Gastroenterology and found to be guaiac-positive and had melena in the Emergency Department; although, by report, not at home. The patient's hematocrit appropriately bumped after the blood transfusion, and the patient was sent to the medical floor. PAST MEDICAL HISTORY: (The patient's past medical history includes) 1. Hypertension. 2. Gastroesophageal reflux disease. 3. Alzheimer's disease. 4. Anemia. 5. Hypothyroidism. 6. Neurogenic bladder. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Medications on admission included aspirin 81 mg p.o. q.d., Aricept 5 mg p.o. q.d., Oxybutynin chloride 5 mg p.o. q.d., Accupril 10 mg p.o. q.d., Premarin 0.3 mg p.o. q.d., Levoxyl 5 mcg p.o. q.d. SOCIAL HISTORY: The patient lives in [State 4565]. She is visiting her daughter in [Name (NI) 86]. The patient denies any intravenous drug use or tobacco but reports alcohol occasionally. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 98.9, blood pressure was 130/64, pulse was 60, respiratory rate was 20. The patient was 99% on room air. In general, a pleasant elderly white female in no apparent distress. Head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive to light. No oropharyngeal lesions. Heart had a regular rate and rhythm. Normal first heart sound and second heart sound. No murmurs, gallops or rubs. Lungs were clear to auscultation bilaterally. No wheezes, crackles, or rhonchi. The abdomen was soft, nontender, and nondistended. Bowel sounds were present. Guaiac-positive by report. Extremities were warm. Dorsalis pedis pulses were 2+. No edema. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed white blood cell count was 14.7, hematocrit was 23.2, platelets were 302 (neutrophils of 86.2%, lymphocytes of 9.4%, monocytes of 6.6%, eosinophils of 0.3%, basophils of 0.5%). Chemistry revealed sodium was 138, potassium was 4.2, chloride was 102, bicarbonate was 25, blood urea nitrogen was 44, creatinine was 1.1, and blood glucose was 139. The patient's thyroid-stimulating hormone was 4.7, and her free T4 was 1.3. ASSESSMENT: This is an 84-year-old white female who presents with a 3-week history of anorexia and presyncope; found to have a hematocrit of 23. The patient was seen in the Emergency Department and found to guaiac-positive with frank melena. HOSPITAL COURSE BY SYSTEM: 1. GASTROINTESTINAL SYSTEM: The patient presented with a decreased hematocrit and guaiac-positive stools. The patient was treated for an upper gastrointestinal bleed with the usual two large bore intravenous lines and was transfused 3 units with a stable post transfusion hematocrit. The patient's hematocrit was monitored serially with appropriate stabilization. The patient was scheduled for an esophagogastroduodenoscopy as well as a colonoscopy while she was in house. The patient's colonoscopy revealed an extremely tortuous colon with very many tight angles. The procedure was stopped secondary to the tortuosity of the colon and the patient's pain during the procedure. The patient also had an esophagogastroduodenoscopy done which showed erythema and friability of the tissue in the pyloric region with some outlet obstruction. The differential diagnosis included infiltrating tumor versus inflammatory changes related to an ulcer. A biopsy was taken at this region, and the patient was recommended to follow up regarding the results of this. Given the patient that the patient's hematocrit remained stable status post transfusion for over 24 hours, and the patient was tolerating her proton pump inhibitor, it was recommended that she follow up with her primary care physician regarding the results of the biopsy and for further management. 2. CARDIOVASCULAR SYSTEM: The patient has a history of hypertension; however, given her recent bleed, her Accupril was held. In addition, the patient's aspirin was held secondary to her gastrointestinal bleed. The patient was recommended to hold off on restarting her aspirin and Accupril until she followed up with her daughter's primary care physician four days after discharge. 3. NEUROLOGIC/PSYCHIATRIC SYSTEM: The patient has a history of Alzheimer's disease. She was continued on her Aricept while in house with no complications. 4. GENITOURINARY SYSTEM: The patient has a history of incontinence with spasmodic bladder. The patient was continued on her oxybutynin without recourse. 5. ENDOCRINE SYSTEM: The patient has a history of hypothyroidism and was continued on her Levoxyl without problems. 6. HEMATOLOGY: The patient has a history of anemia; although, she presented with a hematocrit of 23.2. The patient was transfused 3 units and tolerated the transfusion well with stabilization of her hematocrit status post transfusion. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE DIAGNOSES: Upper gastrointestinal bleed; likely secondary to infiltrating tumor versus inflammatory secondary to an ulcer in the pylorus of her stomach. MEDICATIONS ON DISCHARGE: (The patient's discharge medications included). 1. Aricept 5 mg p.o. q.d. 2. Oxybutynin chloride 5 mg p.o. q.d. 3. Premarin 0.3 mg p.o. q.d. 4. Levoxyl 5 mcg p.o. q.d. 5. Protonix 40 mg p.o. q.d. The patient was instructed to hold on her aspirin 81 mg p.o. q.d. as well as her Accupril 10 mg p.o. q.d. until she went and followed up with her primary care physician four days after discharge to assess both her hematocrit and her blood pressure at that time. DISCHARGE FOLLOWUP: The patient was to follow up with her daughter's primary care physician after discharge regarding the biopsy results, and also for a hematocrit check, as well as a blood pressure check. [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Name8 (MD) 9633] MEDQUIST36 D: [2168-10-3] 18:46 T: [2168-10-4] 08:31 JOB#: [Job Number 32871]	[ "2851", "4019", "53081", "2449" ]
Admission Date: [2110-3-28] Discharge Date: [2110-4-9] Date of Birth: [2052-12-2] Sex: M HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old male with a history significant for hypertension who presented initially to [Hospital3 15174] with neck pain and was found to have 2-mm to 4-mm anterior [Hospital ] Medical Center for primary percutaneous transluminal coronary angioplasty. The patient initially developed neck pain while exercising on a treadmill at approximately 4 p.m. today with progressive substernal heaviness and left arm pain along with significant sweating. There was some mild nausea and shortness of breath, but no fevers or chills. No lightheadedness or dysuria. The patient presented to anterior ST elevations with new onset right bundle-branch block. The patient was placed on heparin, nitroglycerin and TNK and immediately transported to [Hospital1 188] for primary intervention. On arrival, the patient's diagnostic angiogram was notable for diffuse left anterior descending artery disease with slow flow consistent with thrombus. Thus, the patient underwent proximal left anterior descending artery intervention. After having a left anterior descending artery stent placed, the patient was hemodynamically stable. He was noted to have increased filling pressures, with a pulmonary capillary wedge pressure of 26, pulmonary artery pressure of 56%. After catheterization he was transferred to the Coronary Care Unit. The patient was enrolled in the Cool myocardial infarction study. Aside from hypertension and age, the patient denies any cardiac risk factors. Currently, the patient denies any chest pain, lightheadedness, nausea, diaphoresis or shortness of breath. PAST MEDICAL HISTORY: Past Medical History significant for hypertension. MEDICATIONS ON ADMISSION: Zestril 10 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No tobacco, positive alcohol use. No recreational drug use. FAMILY HISTORY: Family history was negative for coronary artery disease. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed vital signs with temperature of 96, heart rate of 92, blood pressure of 138/96. The patient's oxygen saturation was 92% to 96%, respiratory rate of 19. The patient's head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light and accommodation. Extraocular movements were intact. Neck was supple. No lymphadenopathy. No bruits, lying flat. Chest was clear to auscultation anteriorly. Cardiovascular examination revealed distant heart sounds. Normal first heart sound and second heart sound. No murmur, rubs or gallops. Abdomen was soft and nontender, positive bowel sounds. Extremities revealed no edema. Distal pulses were weakly palpable bilaterally. Neurologic examination was nonfocal. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories from Emergency Department revealed white blood cell count of 14, hematocrit of 41.6, platelets of 260. Differential showed 87 neutrophils, 10 lymphocytes, 2 monocytes. Sodium of 140, potassium of 4.1, chloride of 103, bicarbonate of 25, blood urea nitrogen of 24, creatinine of 1.2, and glucose of 149. The patient's PT was 15.8, PTT of 150. Calcium of 7.7, magnesium of 1.5, albumin of 3.5, phosphorous of 4.6. Creatine kinase was 6106, MB of 683, MB index of 11.2. The patient's blood gas was pH of 7.35, PCO2 of 43, and PO2 183. Liver function tests were pending. RADIOLOGY/IMAGING: The patient's electrocardiogram revealed tachycardic, 2-mm to 4-mm ST elevations in V2 through V5, 2-mm to 5-mm ST depressions in I, II, and aVF. Right bundle-branch block, leftward axis, frequent ectopy. Q waves in V1 through V5. Status post catheterization the patient had normal sinus rhythm, right bundle-branch block, some resolution of ST elevations, resolution of ST depressions, large Q waves across precordium. In the morning, further resolution of ST elevations. The patient's cardiac catheterization showed coronary angiography was right dominant, 2-vessel coronary artery disease, left main coronary artery was normal, left anterior descending artery had 70% ulcerative plaque with TIMI-II flow. Left circumflex had mild luminal irregularities. The right coronary artery had a 50% distal lesion. Resting hemodynamics demonstrated an initial narrow pulse pressure with a blood pressure of 100/80, improved during his gait. He had elevated left-sided filling pressures with a wedge of 25, cardiac index was 1.7. The patient had an intra-aortic balloon pump placed via left femoral access. A cooling catheter was placed for the Cool myocardial infarction protocol which was in the left femoral vein. ASSESSMENT AND PLAN: In summary, Mr. [Name14 (STitle) 38782] is a 57-year-old male with a history of hypertension who now presents with an acute anterior myocardial infarction complicated by increased filling pressures. Now, is status post left anterior descending artery stent and intra-aortic balloon pump placement. 1. The patient is status post left anterior descending artery intervention. Would like to stabilize the patient in the Coronary Care Unit. Magnitude of infarct is high. Evidence indicates that left anterior descending artery lesion was the culprit.Continue temperature regulation as per Cool myocardial infarction protocol; which is to cool the patient's core temperature down to 33 degrees Centigrade, continue the patient on aspirin, Plavix, and heparin. No Integrilin, and no 2B3A inhibitor is indicated here due to his lytic usage. We will monitor CK/MB, add a cholesterol battery. We will start Lipitor pending cholesterol. We will get serial electrocardiograms. 2. PUMP: Based on filling pressures, the patient's left ventricular function is significantly depressed. Of great concern is his index. His cardiac index was 1.7. The patient looks well. We will continue to monitor. We will continue with intra-aortic balloon pump and re-address its use every day. We will hold the ACE inhibitor due to his blood pressure being low, and we will start a low-dose beta blocker. We will consider a repeat echocardiogram in the next couple of days. We will get a chest x-ray in the morning. 3. RHYTHM: The patient's anterior myocardial infarction places the patient at risk for both arrhythmias and high-grade ABB. He already demonstrates evidence of new right bundle-branch block. If indicated, we will start a beta blocker. A temporary pacing wire may be indicated. 4. PULMONARY: The patient did not appear to be in pulmonary edema at this time. We will monitor his saturations and use oxygen monitor, and we will use oxygen supplement as needed to keep saturations greater than 95%. 5. HEMATOLOGY: The patient was on a major anticoagulation regimen. We will need to monitor his hematocrit and platelets and watch for bleeding. 6. RENAL: Given contrast load and acute decrease in his cardiac output the patient was at risk for renal injury. We will follow his urine output, follow his blood urea nitrogen and creatinine and his electrolytes. We will consider sending urine studies if indicated. 7. FLUIDS/ELECTROLYTES/NUTRITION: The patient appeared dry The patient was treated for nausea with Compazine. 8. PROPHYLAXIS: The patient is on heparin, aspirin, Plavix, and Protonix. 9. LINES: The patient has an intra-aortic balloon pump with sheath. He has a venous sheath, peripheral lines, Foley catheter. 10. CODE STATUS: The patient is a full code. HOSPITAL COURSE: As outlined in the History of Present Illness, the patient received cardiac catheterization with a stent to the left anterior descending artery and intra-aortic balloon pump placement. The patient did well and was stable. The patient had a slightly low urine output on the first day of admission. After his cardiac catheterization, he was given some Lasix and then continued to diurese well. The patient had no clinical evidence of pulmonary congestion or heart failure. The patient's intra-aortic balloon pump was removed. The patient remained stable. The patient's heparin was weaned to off. The patient was started on Coumadin and Lovenox as a bridge until the Coumadin was therapeutic. The patient was placed on ACE inhibitor (captopril) and continued on beta blocker (Lopressor). The patient did not need Lasix. He had no clinical signs of congestive heart failure. The patient continued to do well and was transferred to a regular floor with telemetry monitoring for one day. The patient did have an episode of nonsustained ventricular tachycardia in the Coronary Care Unit; which was concerning due to a large anterior myocardial infarction with the possibility of arrhythmias. An electrophysiology study was performed. The patient's electrophysiology study showed he was not inducible. No implantable cardioverter-defibrillator was required. A request for a recheck with an echocardiogram in six weeks was recommended; which will be done in follow up with his cardiologist, Dr. [Last Name (STitle) 11493]. The patient's echocardiogram performed on [2110-4-1] showed left atrium was mildly dilated, moderate symmetric left ventricular hypertrophy, severe regional left ventricular systolic dysfunction. Apex, anterior, septal, apical, and distal lateral walls of the left ventricle were akinetic. Left ventricular contraction was best preserved at the [Doctor First Name ], inferior, and lateral walls. Small circumferential pericardial effusion with fiber deposits on the surface of the heart. The patient's creatine phosphokinases peaked at 10,126 and were trending downward. Last checked on [2110-3-31] at 692. The patient's CK/MB peaked at 1187; last checked on [2110-3-31] was down to 19. The patient was trending down to normal. In light of large anterior myocardial infarction, the patient will go home on Coumadin. His INR level on discharge was 2.1. He was sent out on 7 mg of Coumadin per night. His INR level will be checked in two days (on Friday); per the visiting nurse and the results to be called into to Dr. [Last Name (STitle) 11493] who will then inform the patient on if he needs any changes in his Coumadin level dose. The patient did have elevated liver function tests, status post his large anterior myocardial infarction. They did trend toward normal. Lipitor was started at 20 mg p.o. q.d. The patient's liver function tests then started to increase on discharge. The patient's liver function tests were slightly elevated with an AST level of 108, with an ALT level of 140. The Lipitor was discontinued. His liver function tests will be checked by the [Hospital6 407] to see if this will continue to trend downward; as the possible cause of increased liver function tests and transaminase might be due to the Lipitor as well as the antibiotics the patient was on, or from the recent stress of his heart attack. These will be followed as an outpatient each week. On [2110-4-1], the patient developed a low-grade fever which was monitored. The patient was blood cultured at that time. The patient was given Tylenol and had no other symptoms of infection. The patient's blood cultures then grew out Staphylococcus aureus in [7-9] bottles. The patient was started on vancomycin; then sensitivities were finalized, and the patient was put on oxacillin and gentamicin to cover for possible endocarditis. The patient had a transesophageal echocardiogram which ruled out vegetations on the heart and showed a continued small pericardial effusion; not suspected to be from an infectious source. The patient also had a CT of his abdomen with contrast to rule out an infection, fluid collection or hematoma. The patient had no retroperitoneal fluid collection, no abscesses, and no hematoma. Of note, on the abdominal CT the patient had a 2-cm narrowing in the sigmoid region; which, when discussed with Radiology, was felt most likely strictly peristalsis and not concerning, but the patient will have a follow-up colonoscopy as an outpatient and will make this appointment for a normal preventative care colonoscopy in six weeks. Blood cultures were drawn daily. The patient has had no growth to date from blood culture dating [2110-4-6]. The patient then had a peripherally inserted central catheter line placed for long-term antibiotic use due to sensitivities and due to recent stent placement. Infectious Disease would like to consider this infection similar to a valve replacement type coverage that is needed for Staphylococcus aureus. The patient will go home on a 6-week course of oxacillin 12 g per day in divided doses of 2 g q.4h. intravenously. The patient will also take rifampin 300 mg p.o. b.i.d. for coverage. The patient was also positive for Clostridium difficile and was treated with Flagyl 500 mg p.o. t.i.d. for a total of 14 days. The patient has a follow-up appointment with Dr. [Last Name (STitle) 11493] on Monday, [2110-4-14]. The patient also has a follow-up appointment with Infectious Disease, Dr. [First Name8 (NamePattern2) 1059] [Last Name (NamePattern1) 1057], on [2110-5-2] at 9:30 a.m. in the [Doctor Last Name 780] Building. The patient was to have his INR, liver function tests, complete blood count, blood urea nitrogen, and creatinine all checked via the [Hospital6 407] each week; especially while on rifampin and oxacillin. The patient was aware that when done with his six weeks of rifampin he will need to closely monitor his INR, as it will increase since rifampin is competitive with the P450 enzyme system in the liver, increasing Coumadin requirements while on rifampin. The patient was told that when the rifampin is stopped his INR will probably elevate and he will need less Coumadin, and he knows to be aware of this. The patient's creatinine remained stable during this hospitalization, status post cardiac catheterization. His hematocrit on discharge was 31.5 and trending upward. His INR (as before) was 2.1; which was therapeutic between 2 and 3. The patient's blood urea nitrogen, creatinine, and sodium were all within normal limits. The patient's alkaline phosphatase and total bilirubin were within normal limits. The patient's chest x-ray on the day of discharge showed his peripherally inserted central catheter line was in the normal position in the superior vena cava just beyond the brachiocephalic junction. The patient did speak with a [Hospital6 407] nurse. He is aware of how to administer the intravenous antibiotics and was given a special pump for continuous intravenous antibiotic administration into his peripherally inserted central catheter line. The patient knows to discuss the issue of his slightly elevated liver function tests with his primary care physician/cardiologist, Dr. [Last Name (STitle) 11493], and the decision will be made whether to restart Lipitor based on the re-checked liver function test values. The patient with a normal white blood cell count on the day of discharge. The patient had been afebrile for the past three days. Follow-up appointments as above. MEDICATIONS ON DISCHARGE: 1. Zestril 10 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Coumadin 7 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. 5. Aspirin 325 mg p.o. q.d. 6. Oxacillin 2 g q.4h. intravenously. 7. Rifampin 300 mg p.o. b.i.d. times six weeks. 8. Flagyl 500 mg p.o. t.i.d. times 10 days. CONDITION AT DISCHARGE: Condition on discharge was stable and improved. DISCHARGE DIAGNOSES: 1. Anterior myocardial infarction. 2. Hypercholesterolemia. 3. Hypertension. 4. Staph sepsis 5. Cardiogenic shock [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8227] Dictated By:[Last Name (NamePattern1) 4724] MEDQUIST36 D: [2110-4-9] 14:13 T: [2110-4-11] 14:55 JOB#: [Job Number 38783] cc:[Numeric Identifier 38784]	[ "41401", "4019" ]

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