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Admission Date: [2201-4-13] Discharge Date: [2201-4-17] Date of Birth: [2138-10-23] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: new murmur on physical exam/ asymptomatic Major Surgical or Invasive Procedure: s/p Mitral Valve repair [2201-4-13] (P2resection with 30 mm ring) History of Present Illness: 62M found to have murmur on physical exam. Echo revealed severe Mitral Regurgitation. He denies dyspnea on exertion, chest pain, lightheadedness, lower extremity swelling. He is referred for surgical evaluation. Past Medical History: Mitral Regurgitation hypertension Benign prostatic hypertrophy h/o nephrolithiasis- passed stones Social History: Lives with: wife and 2 adopted children (9yo and 13yo) Occupation: works part-time repairing watches, seeking FT employment in his desired field of electronics Tobacco: denies ETOH: 1-2 beers/month Family History: noncontributory Physical Exam: Pulse: 60 Resp: 18 O2 sat: B/P Right: 170/98 Left: Height: 6'0" Weight: 94kg General: NAD 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 4/6 systolic murmur, loudest at apex, +thrill Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Onychomycosis of toe-nails 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: Left: radiation of cardiac murmur Pertinent Results: [2201-4-15] 04:40AM BLOOD WBC-11.8* RBC-3.40* Hgb-11.0* Hct-30.6* MCV-90 MCH-32.3* MCHC-35.9* RDW-13.2 Plt Ct-116* [2201-4-13] 10:48AM BLOOD WBC-10.0 RBC-3.25# Hgb-10.5# Hct-29.2# MCV-90 MCH-32.4 MCHC-36.0* RDW-13.2 Plt Ct-133* [2201-4-13] 10:06PM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1 [2201-4-13] 10:48AM BLOOD PT-15.5* PTT-27.9 INR(PT)-1.4* [2201-4-17] 04:35AM BLOOD UreaN-12 Creat-0.6 Na-136 K-4.2 Cl-102 [2201-4-13] 10:48AM BLOOD UreaN-16 Creat-0.6 Na-138 K-4.5 Cl-110* HCO3-25 AnGap-8 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 89786] (Complete) Done [2201-4-13] at 11:08:53 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2138-10-23] Age (years): 62 M Hgt (in): 70 BP (mm Hg): / Wgt (lb): 200 HR (bpm): BSA (m2): 2.09 m2 Indication: mitral valve replacement for mitral valve flail segments ICD-9 Codes: 424.0 Test Information Date/Time: [2201-4-13] at 11:08 Interpret MD: [Name6 (MD) 3892] [Name8 (MD) 3893], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3893], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 5.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm Left Ventricle - Diastolic Dimension: 6.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 65% >= 55% Aorta - Ascending: 3.0 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.0 cm Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Partial mitral leaflet flail. Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic 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. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. 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 partial P 2mitral leaflet flail. Severe (4+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results prior to surgery start POST-BYPASS: Intact thoracic aorta. Normal RV systolic function. LVEF 50%. The mitral ring is stable and functioning well and mean gradient across is 3 mm of Hg. There is a chordal [Male First Name (un) ] with no demonstrable hemodynamic abnormalities in various hemodynamic situations with a pressure of 80 to 120 systolic. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 3892] [Name8 (MD) 3893], MD, Interpreting physician [Last Name (NamePattern4) ] [2201-4-16] 16:20 ?????? [2193] CareGroup IS. All rights reserved. Brief Hospital Course: On [2201-4-13] Mr.[Known lastname ] was taken to the operating room and underwent Mitral Valve repair with a P2 resection # 30 mm ring with Dr.[Last Name (STitle) ]. Please refer to operative report for further surgical details. Cardiopulmonary Bypass time= 74 minutes. Cross Clamp Time= 46 minutes. He tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. He awoke neurologically intact and was extubated without incident.He was weaned off pressors and Beta-blocker/Aspirin/Statin and diuresis was initiated. All lines and drains were discontinued per protocol. POD#1 He was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. He continued to progress. The remainder of his hospital course was essentially uneventful. On POD# 4 he was cleared by Dr.[Last Name (STitle) ] for discharge to home with VNA. All follow up appointments were advised. Medications on Admission: Lisinopril 40mg daily Atenolol 25mg daily Lasix 20mg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 5. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 5 days. Disp:20 Tablet Extended Release(s) Refills:0 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:5 Tablet(s) Refills:0 7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: severe Mitral Regurgitation s/p Mitral Valve repair [2201-4-13] Secondary: hypertension BPH h/o nephrolithiasis- passed stones Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. No edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[Last Name (STitle) ] at [Hospital3 1280] Heart Center on [2201-5-14] at 9am Cardiologist:Dr.[First Name8 (NamePattern2) 3924] [Last Name (NamePattern1) 20222] at [Hospital3 1280] Heart Center on [2201-5-28] at 2:30pm Wound check at [Hospital1 18]-[Hospital Ward Name ] [Hospital Unit Name ] on [2201-4-22] with [Doctor First Name ] at 10 AM Please call to schedule appointments with your Primary Care Dr.[Last Name (STitle) ],[First Name3 (LF) ] [Telephone/Fax (1) 7401] in [1-18] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2201-4-17]	[ "4240", "4019" ]
Admission Date: [2199-5-30] Discharge Date: [2199-6-13] Date of Birth: [2199-5-30] Sex: M Service: Neonatology HISTORY: [Known lastname ] [Known lastname 122] [Known lastname 49240] is a 3,270 gram 35 week newborn who is admitted for management of respiratory distress. This infant was born to a 40-year-old gravida 3 para 1 mom. Prenatal screens: Blood type O negative, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, group beta Strep status unknown. Maternal history of [Name Prefix (Prefixes) ] [Last Name (Prefixes) 4585]. Prior history of infant born at 36 weeks and with shoulder dystocia. This pregnancy was notable for cerclage placement and RhoGAM administration for RH negative type, but otherwise unremarkable until preterm premature rupture of membranes and preterm labor leading to delivery. The infant was delivered by cesarean section due to history of shoulder dystocia and mother's previous delivery at 36 weeks. Apgar scores seven at one minute and eight at five minutes of age. The infant was taken to the NICU for further care due to poor color and respiratory distress. PHYSICAL EXAMINATION: Weight 3,270 grams (90th percentile), length 48.5 cm (75th-90th percentile), head circumference 35 cm (greater than 90th percentile). Infant: Dusky appearing, although saturations in mid 90s on room air. Contribution from some acrocyanosis and perhaps some mild bruising. Positive molding. Anterior fontanel is soft and flat. Ears small and thick, but normally placed. Eyes features normal, positive red reflex OU. Neck is supple, without lesions. Lungs: Positive grunting and retractions. Fair aeration with coarse crackles, equal breath sounds. Heart: Regular, rate, and rhythm, no murmur, +2 femoral pulses. Abdomen is soft. Genitourinary: Normal male genitalia. Testes down bilaterally. Patent anus, no sacral anomalies. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Infant was placed on CPAP for respiratory distress shortly after admission to the Newborn Intensive Care Unit. Respiratory distress continued and escalated requiring endotracheal intubation. He received two doses of surfactant and was weaned to CPAP on day of life one. He weaned to nasal cannula oxygen 25 cc 100% on day of life four, and then finally, to room air by day of life six with a respiratory rate in the 30s-60s range. He has remained in room air for the remainder of his hospitalization without significant desaturations or dusky spells. Cardiovascular: Infant's blood pressure has been normal for his entire hospitalization. No fluid boluses or pressors required. He was pink and well perfused upon examination. Fluids, electrolytes, and nutrition: Upon admission to the Newborn Intensive Care Unit, he was started on IV fluids of D10W at 60 cc/kg/day. His Dstix have been stable throughout his hospitalization ranging from the 60-80 range. Enteral feeds of Nutramigen were initiated on day of life four, and he successfully advanced to full volume feeds of Nutramigen by day of life seven. Nutramigen was initiated because of a history of cow's milk protein intolerance in the older sibling. He has been tolerating full volume feeds of Nutramigen, no feeding intolerance during this hospitalization. His discharge weight is 3200gm. Discharge length 50 cm. Discharge head circumference 34 cm. GI: Phototherapy was started on day of life four for a bilirubin of 15.2 with a direct bilirubin of 0.4. Phototherapy was discontinued on day of life six with a rebound bilirubin of 6.7 on day of life eight. Hematology: Patient's hematocrit upon admission to the NICU was 54%. He did not receive any blood products during his hospitalization. Infectious Disease: A complete blood count with differential and blood culture were drawn upon admission to the Newborn Intensive Care Unit. White blood cell count of 14,000, hematocrit of 54, platelet count of 331,000, with 18% neutrophils and 0% bands. Chest x-ray showed some asymmetry with increased density in the right middle lobe, could not rule out pneumonia. He received a seven day course of ampicillin and gentamicin. Blood culture remained negative. Neurology: Normal neurologic examination, no head ultrasound indicated. Sensory: Hearing screen was performed with automated auditory brain stem responses. He passed in both ears on [6-12]. Psychosocial: [Hospital1 69] Social Work has been involved with the family. The contact social worker can be reached at [Telephone/Fax (1) ]. Genitourinary: The infant underwent circumcision on [6-12]. The circumcision is healing nicely. CONDITION ON DISCHARGE: Stable taking in po feeds without difficulty. DISCHARGE DISPOSITION: To home with parents. Follow-up appointment with pediatrician is scheduled for [2199-6-14]. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 49241] in [Location (un) ], [Hospital ] [Hospital3 ], phone #[Telephone/Fax (1) 37887]. CARE AND RECOMMENDATIONS: Feeds at discharge: Ad lib demand feeds of Nutramigen. MEDICATIONS: None. CAR SEAT POSITION SCREENING: A carseat test was performed and passed without difficulty on [6-12]. STATE NEWBORN SCREEN: The last newborn screen was sent on [6-3]. No abnormal results had been reported. IMMUNIZATIONS RECEIVED: [Known lastname ] received his first hepatitis B immunization on day of life one for unknown maternal hepatitis B surface antigen status. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with plans for daycare during RSV season, with a smoker in the household, or with preschool siblings, or 3) with chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOWUP: Follow up has been arranged with [Company 1519], phone #1-[Telephone/Fax (1) 12065]. DISCHARGE DIAGNOSES: 1. Prematurity at 35 weeks gestation. 2. Large for gestational age. 3. Respiratory distress syndrome. 4. Presumed pneumonia. 5. Hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Name8 (MD) 37391] MEDQUIST36 D: [2199-6-13] 04:06 T: [2199-6-13] 07:04 JOB#: [Job Number 49242]	[ "7742", "V053" ]
Admission Date: [2156-7-11] Discharge Date: [2156-7-22] Date of Birth: [2094-8-27] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with a past medical history significant for diabetes mellitus type 2, chronic renal insufficiency on hemodialysis with a history of congestive heart failure, status post A-V fistula placement, history of diverticulosis, status post partial colectomy, hypertension, and abdominal hernia. MEDICATIONS PRIOR TO ADMISSION: 1. Norvasc 20 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Metoprolol 50 mg p.o. b.i.d. 4. Nephrocaps q.d. 5. Quinine 325 mg p.o. q.d. 6. Renagel 240 t.i.d. 7. Lisinopril 10 mg p.o. q.d. 8. Glipizide 5 mg p.o. b.i.d. 9. Neurontin 300 mg p.o. b.i.d. 10. PhosLo with meals. 11. Aspirin 81 mg p.o. q.d. ALLERGIES: 1. Demerol. 2. Valium. 3. Codeine. This 61-year-old male was admitted to [Hospital1 190] on [2156-7-11] for increased shortness of breath. He was transferred from [Hospital3 16673], where he was admitted for severe shortness of breath. He was diuresed with Lasix with no change in symptoms at the outside hospital. Also at the time of his admission to the outside hospital, patient had a two week history of a cough nonproductive with a current chest cold, however, denying any fevers, chills, nausea, vomiting, or chest pain. Chest x-ray was done at the outside hospital, which revealed bilateral pleural effusions. EKG was performed, which revealed new T-wave inversions in leads I, aVL, and cardiac enzymes were performed as well showing a small increase in troponin to 0.7 with a CK MB of 10. The patient was treated in the Emergency Room with Heparin drip, beta blocker, and aspirin, and was transferred to [Hospital1 188] for cardiac catheterization. Cardiac catheterization was performed [2156-7-12], which revealed left main coronary artery disease and two vessel coronary artery disease. Patient underwent coronary artery bypass grafting x3 with the left internal mammary artery to the left anterior descending coronary artery. Reverse saphenous vein graft to the right posterior descending coronary artery, and reverse saphenous vein graft to the obtuse marginal coronary artery. On [2156-7-16], the patient was originally scheduled, however, to have surgery on the [7-15], but when the patient was brought to the holding area, the morning of the 10th, he was found to have an oxygen saturation of 85%, appearing short of breath, and was tachypneic. An EKG was performed at that time which showed slightly worse T-wave inversions laterally. ABG revealed respiratory acidosis with a large AA gradient, and the patient was postponed for surgery and transferred to the CCU. The evening of [2156-7-15], the patient had an intra-aortic balloon pump placed prophylactically. Patient was transferred to the CSRU after surgery on milrinone 0.4 mcg, 0.1 mcg of Levophed, 0.15 mcg of nitroglycerin, and 20 mcg of propofol. A Renal consult was called on the patient the day of his surgery and their plan was for hemodialysis the following day, and to D/C the patient's intra-aortic balloon pump if the patient remained hemodynamically stable. Postoperative day one, the patient still remained intubated on an insulin drip, a Levophed drip, as well as propofol drip. With a T max of 101.8 and sinus rhythm with an intra-aortic balloon pump still in place at 1:1. Patient was sedated due to his anxiety upon waking up at which time he would flail his arms causing his blood pressure to go up. Patient also received small doses of Versed as needed for his increased agitation upon waking. He had minimal urine output with a BUN of 23 and a creatinine of 5.8, and he was given Tylenol for his fever. His intra-aortic balloon pump was removed that same morning after which the patient received hemodialysis. A couple minutes into his hemodialysis, SVTs were noted on the monitor with a systolic blood pressure in the 90s. A crash cart was brought into the room for cardioversion. The patient rapidly deteriorated into V-tach and around 10:52 that morning, the patient was brought to the operating room. After several attempts to resuscitate the patient using closed chest resuscitative measures, the patient's chest was opened in the ICU for open cardiac massage before being brought to the operating room. At that time, a left femoral and a left arterial sheath was also placed in the left groin in an anticipation that the patient would probably need extracorporal membrane oxygenation. The patient underwent placement of the extracorporeal membrane oxygenator as well as another intra-aortic balloon pump, and underwent coronary artery bypass grafting x1 with a free left internal mammary artery to the left anterior descending coronary artery the morning of [2156-7-17]. The patient was transferred to the CSRU on vasopressin, amiodarone, and Levophed. Patient had chest tube output of 200 cc q 15 minutes for which he received constant infusion of blood products with a brief attempt at CVVH, which had to be stopped due to the fact that the patient was extremely volume sensitive causing the patient's ECMO to chatter. The patient had episodes V-tach and V-fib which required multiple defibrillations with the internal paddles as well as an extra bolus of amiodarone. The patient was able to open his eyes for his family, however, was maintained sedated on propofol. Postoperative day two status post the patient's original coronary artery bypass grafting, the patient was still on amiodarone drip as well as cisatracurium drip, Fentanyl drip, insulin drip, Levophed drip, Pitressin drip and remained sedated on propofol with a T max of 101.3, and the intra-aortic balloon pump on 1:1 ECMO in place on full ventilatory support. Multiple blood products were given for volume and a low hematocrit. The patient continued to have large amounts of chest tube drainage from one of his chest tubes. CVVH was restarted. The patient was started on bicarb drip, which was changed over to normal saline due to his increasing pH. On physical exam, the patient's right foot was cool, and his left foot and left calf were cold and slightly dusky. DP and PT pulses were present by Doppler on the right foot, however, not present on the left. The patient was unresponsive to verbal and physical stimuli. An increased number of premature atrial contractions were noted for which patient received another amiodarone bolus and around 5 o'clock that afternoon, the patient had a 17 beat run of V-tach as well as multiple episodes of atrial fibrillation with a heart rate as high as 140. Several doses of Lopressor were given intravenously, and the patient converted back to normal sinus rhythm. ECMO flow was maintained at 2.6 to 2.9 liters per minute throughout the day with a hematocrit being checked hourly by the perfusionist with a treatment of Heparin as needed. Intra-aortic balloon pump remained 1:1 with good wave form. Patient also underwent an infusion of platelets for a platelet count of 58,000. Multiple blood products as well as potassium were administered to keep the hematocrit greater than 60 and a potassium at 5. Patient had a V-fib arrest at 9:30 that evening of [2156-7-18] for which they were able to resuscitate to normal saline. However, the patient continued to be in rapid afib following the arrest. The following morning, postoperative day three, the patient was still continued on ECMO with the intra-aortic balloon pump at 1:1 on Levophed and vasopressin as well as amiodarone. On physical exam, the patient still had a cyanotic appearing left lower extremity with absent pulses and Dopplerable pulses on the right side. Hematocrit of 31.5. The patient remained in stable condition with only an increase in the Levophed drip for hypertension, and the patient's CVVH was stopped for transport to the Cardiac Cath Laboratory. Due to patient's refractory arrhythmias, cardiac catheterization revealed left main coronary artery disease as well as two vessel coronary artery disease with a patent LIMA to the left anterior descending artery, patent SVG to the OM, patent saphenous vein graft to the PDA. Patient was continued on his CVVH following his cardiac catheterization. On physical examination, there were noted to be two areas on the patient's abdomen overlying the patient's hernia, which had become dusky and mottled for which Surgery consult was obtained. General Surgery recommended providing the patient with antibiotic coverage, however, because of the patient's current condition, felt that the patient would not be able to tolerate any type of surgical procedure at that point. Postoperative day four, patient remained sedated and paralyzed on propofol, Fentanyl, cisatracurium, still on amiodarone, Pitressin and Levophed drip. Heart rate ranged between 110 and 125 in rapid afib with his intra-aortic balloon pump continuing at 1:1. Still on CVVH on full respiratory support. The patient went into V-fib and after multiple shocks returned to sinus rhythm. He was taken to the operating room that day for the removal of his ECMO, and the patient was transferred back to the CSRU in critical condition on Levophed, Pitressin, amiodarone, esmolol, and milrinone with his intra-aortic balloon pump at 1:1. A Swan was floated in the operating room and [Hospital1 1516] pads were placed on the patient's chest with the patient's chest remaining opened secured with Ioban dressing. Patient continued to have self-limiting runs of V tach for which he was treated with amiodarone bolus. CVVH was restarted. Patient had a BUN of 27, creatinine of 4.1, hematocrit of 28.2, and a white count of 16.7. While in the operating room for his ECMO removal, patient also had his left femoral vein and right femoral artery catheters removed for his ischemic left leg as well as having a left femoral thrombectomy. Postoperative day five, patient still on an insulin drip, propofol, milrinone, norepinephrine, vasopressin, Fentanyl, cisatracurium, and amiodarone drips. Afebrile with a white count of 17.5, hematocrit of 40, BUN of 29, and creatinine 3.9. With a failure of the CVVH early that morning, which was then restarted still with a heart rate in the 120s SVT and an intra-aortic balloon pump in place at 1:1. Cardiac index ranging between 2.8-3. On physical exam, the patient's left lower leg was still cold and very firm from mid calf down to his foot with his left toes cyanotic. Vascular was consulted, who felt that no intervention was necessary at this time. Patient's esmolol and levo drip needed to be increased to maintain an adequate blood pressure. The intra-aortic balloon pump was later weaned to [1-8] with stable hemodynamics, and the patient's Swan was changed over wire. Patient was transfused 2 units of red blood cells as well as 2 units of platelets for platelet count of 33,000 and 54,000. Patient continued on CVVH for the rest of that day. On postoperative day six, the patient was febrile to 101, still on the following drips: Insulin, propofol, milrinone, Fentanyl, cisatracurium, amiodarone, esmolol, vasopressin, and Levophed with a heart rate in the 110s to 130s in SVT on full ventilatory support. White count of 18, hematocrit of 43, BUN of 29, and creatinine of 3.8. CVVH was restarted that morning. Neurology was consulted to evaluate the patient's neurological status. They recommended a possible EEG and/or head CT to assess for hypoxia and ischemia as well as encephalopathy. Patient remained sedated that morning on propofol and Nimbex with a labile blood pressure requiring increased doses of Levophed. Patient had runs of V-tach that morning, treated with magnesium and calcium as well as an amiodarone bolus. Patient's mixed venous oxygen saturation dropping to the 50s with decreasing blood pressure. The patient's PEEP was increased as well as his FIO2 and he had V tach arrest shortly after noon that day. Several defibrillations were performed with the patient's rhythm varying between V tach and V fib and later bradycardia, and complete heart block. Continued defibrillation attempts were made without a return of the patient's rhythm, and the patient was pronounced at 12:44 p.m. The patient's family was present during the resuscitation. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Doctor Last Name 2011] MEDQUIST36 D: [2156-9-21] 10:35 T: [2156-9-23] 07:27 JOB#: [Job Number 16674]	[ "41071", "4280", "40391", "9971", "42731" ]
Admission Date: [2181-6-28] Discharge Date: [2181-7-10] Date of Birth: [2098-1-8] Sex: F Service: ORTHOPAEDICS Allergies: Fosamax / Prozac Attending:[First Name3 (LF) 8587] Chief Complaint: Left hip drainage Major [First Name3 (LF) 2947] or Invasive Procedure: [6-28]: I & D L hip, large haematoma evacuated [7-2]: I & D L hip, surface VAC + Hemovacs x2 thru VAC sponge History of Present Illness: 83yo F s/p L DHS (intertroch fx) on [4-28] c/b failed fixation by migration of screw & infection, s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [6-12] w/ Abx Spacer then s/p Left Hemi [6-18] w/ ORIF Greater Troch, now p/w increasing L hip pain. Past Medical History: -Coronary Artery Disease status post MI in [2180-12-24] (3VD on cardiac cath but managed non-operatively) -Depression -Anxiety -Atrial Fibrillation (not on anticoagulation) -Crohn's Disease -Chronic obstructive pulmonary disease -distant history of tonsillectomy and adenoidectomy -L hip ORIF [2181-4-28] Social History: Pt transported here from [Hospital6 ] Family History: She reports multiple family members with heart problems. Physical Exam: Gen: AFVSS HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [11-24]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [2181-6-27] 07:50PM SED RATE-48* [2181-6-27] 07:50PM CRP-68.1* [2181-6-27] 07:50PM WBC-20.8* RBC-3.54* HGB-10.7* HCT-32.7* MCV-92 MCH-30.2 MCHC-32.7 RDW-15.8* Brief Hospital Course: Mrs. [Known lastname 29878] is an 83 year old femaile who was admitted from [Hospital6 ] for increasing hip pain after being discharged on [6-20] for a presumed left hip infection, washout and hemiarthroplasty. Mrs. [Known lastname 29878] had numberous cultures drawn from her wound, but they never grew out anything. The patient was discharged to her rehab center on lovenox and her previous meds. She was then admitted for this hospital stay on [2181-6-28]. She was brought to the OR on [2181-6-28] for I&D of her left hip and a large hematoma was evacuated and a surface VAC was placed. On POD1 the patient was restarted on lovenox and home medications. The VAC produced 200-300cc of serosangous drainage per day and as a result was brought back to the OR on [7-2] for another washout and surface VAC placement. During her procedures, intra-op cultures were drawn but all returned negative. The infectious disease team was consulted and her medications were adjusted. It was felt taht dispite the negative cultures, we would aggresively treat this as an infection due to the high suspicion and aftermath of a missed infection. The wound continued to drain a large amount of serosangous fluid and on [7-7] the orthopaedic team decided to stop the patient's lovenox and begin the patient on low dose coumadin with an INR goal of 1.3-1.5 for DVT prophylaxis. On [7-9] the wound had completely stopped draining and she was felt stable to return to the rehab center. She is being discharged today back to her nursing home in stable condition. Medications on Admission: Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: Two (2) Puff Inhalation q6h PRN as needed for wheeze. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H PRN () as needed for sob, wheeze. Vancomycin 750 mg IV Q 24H Please restart Morphine Sulfate 0.5-2 mg IV Q4H:PRN pain Heparin Flush (10 units/ml) 2 mL IV PRN line flush Lovenox SQ 40mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). 12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 15. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)): INR goal: 1.3-1.5. Disp:30 Tablet(s) Refills:2 17. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: Two (2) Puff Inhalation q6h PRN as needed for wheeze. 18. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H PRN () as needed for sob, wheeze. 19. Vancomycin 750 mg IV Q 24H Please restart 20. Morphine Sulfate 0.5-2 mg IV Q4H:PRN pain 21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 22. Vancomycin 750 mg Recon Soln Sig: One (1) Intravenous once a day for 4 weeks. Disp:56 750mg soln Refills:0 23. Outpatient Lab Work Draw weekly: Vancomycin trough BUN and creatinine CBC w/diff Fax results to infectious disease: [Telephone/Fax (1) 432] Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Left hip hematoma s/p hemiarthroplasty Discharge Condition: stable Discharge Instructions: Keep dressing clean and dry. If you experience any shortness of breath, new redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. Please resume all of the medications you took prior to your hospital admission. Take all medication as prescribed by your doctor. You have been prescribed a narcotic pain medication. Please take only as directed and do not drive or operate any machinery while taking this medication. There is a 72 hour (Monday through Friday, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on Saturdays, Sundays, or holidays. Please plan accordingly. Physical Therapy: Left lower extremity is weight bearing as tolerated. PT daily for ambulation advance, no limits, patient currently OOBTC with assist. Fall precautions Treatments Frequency: please keep incision dry Take out stitches on POD#10 Followup Instructions: 2 weeks in orthopaedic trauma clinic with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP. Please call [Telephone/Fax (1) 1228] to schedule this appointment. Other Appointments: [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SPECIALTIES CC-3 (NHB) Phone:[Telephone/Fax (1) 274] Date/Time:[2181-7-25] 2:00 DR. [First Name (STitle) ] BLOOD Phone:[Telephone/Fax (1) 457] Date/Time:[2181-8-13] 10:00	[ "5990", "41401", "412", "496", "42731" ]
Admission Date: [2102-7-30] Discharge Date: [2102-8-1] Date of Birth: [2022-9-29] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8747] Chief Complaint: R arm, face, and leg weakness, and inability to speak Major Surgical or Invasive Procedure: tPA administration History of Present Illness: 79yo Cantonese-speaking woman with HTN, hyperlipidemia and otherwise active and healthy who presented with acute onset of right face, arm and leg weakness and global aphasia of known onset at 6:30pm today while playing cards. Arrived at ER at 8:30pm drowsy with eyes closed, moving left limbs spontaneously and no observed movement of right limbs to noxious stimuli. She was unresponsive to commands. . CT negative for acute bleed, ? hyperdense left MCA. Also showing a calcified mass in the ventricle that was determined to be of low bleeding risk by head of neuroradiology. . Pt without contraindications to tPA. Son consented and patient received 6.8mg bolus, then drip of 61.2mg was started of alteplase. Roughly 30min after infusion was started, pt was noted to become bradycardic to 40s and repeat EKG showed IW MI. Pt was intubated, as she was felt to have lost her gag reflex and tPA was stopped. Past Medical History: HTN Hyperlipidemia Social History: Lives independantly, family in the area Family History: non-contributory Physical Exam: Gen Elderly woman drowsy in NAD CV RRR Pulm CTAb Abd Benign Ext no edema . Neuro Mental status: Responds to voice by opening eyes and occasional turn of head to the left. Spontaneously moving left limbs. No spontaneous speech; unable to follow commands. Motor: No movement to noxious stimuli on right side, spontaneous movement of leg on left. Sensory: no facial griamcing or other response to noxious stimuli applied to the right side. She withdraws left side to stimulation. Gait: unable to assess Coordination: unable to assess on the right side. Pertinent Results: Admission Head CT: FINDINGS: No intracranial hemorrhage, mass effect, or shift of normally midline structures, or major vascular territorial infarct is apparent. There is slightly increased density in the left MCA. If there is a clinical concern for a left MCA territory infarct an MRI would be recommended. There is a 1.2 x 1.7 cm calcified lesion in the superior aspect of the right lateral ventricle. The etiology of this could also be further evaluated with MRI. Calcifications are seen within the basal ganglia bilaterally. There also is a small punctate calcification in the right temporal lobe and brainstem, which are likely vascular in nature. The bony structures are unremarkable. The visualized portions of the paranasal sinuses and mastoid air cells are well aerated. The surrounding soft tissue structures are unremarkable. . IMPRESSION: 1. No CT evidence of acute ischemia. 2. Increased density in the left MCA. If there is a clinical concern for left MCA territory infarct, an MRI would be recommended. 3. Calcified lesion in the right lateral ventricle, which may represent a calcified A-V malformation, among other possibilities. MRI could help in further workup. . NOTE ADDED AT ATTENDING REVIEW: Dr. [Last Name (STitle) ] discussed this study with Dr. [Last Name (STitle) ] at approximately 9 pm on [2102-7-30]. At that time, [Doctor Last Name ] offered the following discussion: There are several intraventricular calcifications, in addition to the mass near the foramen of [Last Name (un) 2044]. The differential diagnosis included an intraventricular neoplasm, such as a meninigioma, choroid plexus papilloma, oligodendroglioma, neurocytoma or giant cell astrocytoma. Some of these lesions arise from the choroid plexus, which is absent in the frontal [Doctor Last Name 534]. Thus, if this is a choroid-origin lesion, it may be pedunculated. There is also an abnormal calcification extending inferiorly into the suprasellar cistern. Although a craniopharyngioma may calcify and arise in the suprasellar cistern, invagination into the frontal [Doctor Last Name 534] would be unusual. The lesion does not appear to represent a neoplasm with a high bleeding risk, such as a metastasis or malignant glioma. It does not appear to be an arteriovenous malformation. MR [First Name (Titles) ] [Last Name (Titles) 15758] CT are much more sensitive than noncontrast CT for detecting early ischemia or infarction, but there is no evidence of hemorrhage. The slight increased density in the left MCA may represent calcification or thrombus. . Repeat Head CT, [7-30], after tPA administration: FINDINGS: Compared to prior study two hours earlier, there is now new right frontal subarachnoid hemorrhage. There is no significant associated mass effect or shift of normally midline structures. The ventricular system is stable in appearance. Otherwise, there has been no significant short interval change. . IMPRESSION: New right frontal subarachnoid hemorrhage. . NOTE ADDED AT ATTENDING REVIEW: There appears to be [Last Name (un) 940] of [Doctor Last Name 352]/white differentiation in the left MCA territory, suggesting early infarction. . Head CT [7-31]: FINDINGS: Comparison is made to [2102-7-30]. . There are multiple large intraparenchymal hematomas in the right cerebral hemisphere, the largest measuring approximately 6.7 x 5.4 cm. These hematomas are causing extensive right sided subfalcine, uncal, transtentorial, and bilateral cerebellar tonsillar herniations. . Hypodensity surrounding the hematomas were seen, consistent with vasogenic edema. . There is loss of the [Doctor Last Name 352]/white matter junction essentially diffusely throughout the brain, consistent with brain edema. There is a suggestion of possible left middle cerebral artery territory edema, which could indicate the clinically suspected evolving infarct originally requiring treatment, but imaging of this region is markedly limited by the marked generalized brain edema, noted previously. A 1cm linear area of hyperdensity is seen within the brain stem, which likely represents a Duret hemorrhage. Some subarachnoid hemorrhage along the right cerebral convexity surface is again noted. . No focal bony abnormalities are seen. The visualized orbits and paranasal sinuses are normal. . IMPRESSION: Since [2102-7-30], new massive right cerebral intraparenchymal hematomas causing subfalcine, uncal, transtentorial, and tonsillar herniation. Duret hemorrhage. Brief Hospital Course: The patient arrived to the ER within 3 hours of symptom onset. The clinical presentation highly suggested that she had an acute ischemic stroke of the left MCA territory and CT was showing evidence for left MCA occlusion. Given the additional findings on CT, a discussion was held with the head of neuroradiology prior to initiation of t-PA treatment. Given a potentially elevated risk from t-PA, the benefits versus risk of t-PA were discussed with the patient's son who gave consent to proceed with IV t-PA administered within three hours of symptom onset. After tPA administration, the patient developed bradycardia and respiratory distress, t-PA was discontinued and she was intubated prior to admission to the SICU for further monitoring. A repeat head CT showed subarachnoid hemorraghe in the right hemisphere without midline shift or parenchymal bleeding and there was further evidence for left MCA territory ischemic stroke. The following morning, she had developed new neuro findings concerning for brainstem damage (pinpoint, unreactive pupils, mute reflexes, negative oculocephalic reflexes, cold calorics, gag, and corneal reflexes) and the patient. was taken for urgent head CT. This showed evidence of known left MCA infarction. In the interim, the patient had also developed massive R hemispheric hemorrhage with subfalcine, uncal, transtentorial, and tonsillar herniation. The situation was discussed with the family including the patient's son from [State 3706] who decided that they would like the patient to be DNR/DNI. She developed bradycardia, cardiac arrest and expired, with family at the bedside. Medications on Admission: antihypertensive, antihyperlipidemia Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: L MCA infarction R hemispheric intracerebral hemorrhage with subfalcine, uncal, transtentorial, and tonsillar herniation Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[2102-8-2]	[ "4019", "2720" ]
Admission Date: [2173-10-1] Discharge Date: [2173-10-20] Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 5018] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: Intubation History of Present Illness: PER ADMITTING RESIDENT: Patient is a 87 yo man (handedness unknown) transferred from [Hospital3 ] with SDH and L temporal hemorrhage. Hx obtained only from transfer medical records given that unable to give own hx. Per records, patient was not heard from for > 24 hrs hence son asked neighbor to stop by. When the neighbor stopped by, patient was found sitting on the sofa but unresponsive hence EMS was called and patient was taken to [Hospital3 8834]. There were no signs of trauma or movements concerning for seizure. Of note, patient's initial INR was 4.0 and head CT revealed L temporal hemorrhage and para falcine SDH. He was given 3mg of IV vitamin K and FFP prior to transfer and repeat INR was 2.5 per records. En route to [Hospital1 18], patient vomited x2 and here, she was desatting down to 80's with NC. The only known medical hx of patient is that he is on Coumadin for PAF and he has a pacemaker. He appears to be on no other meds other than Coumadin. His son, [Name (NI) ] [Name (NI) ] was reached and he reports that his father would not have wanted heroic measures unless full-recovery was anticipated hence he does not want surgical intervention unless recovery is expected. However, he does not want supportive treatment only at this point - would like to assess prognosis in 24 hrs before making that decision. Past Medical History: 1. PAF on Coumadin 2. s/p pacemaker Social History: Lives alone - son, [Name (NI) ] [Name (NI) ] is HCP ([Telephone/Fax (1) 84452] or [Telephone/Fax (1) 84453]). Family History: Unknown Physical Exam: ON ADMISSION: BP 166/93 HR 110 RR O2Sat 88% with 5L NC Gen: Lying in bed, NAD HEENT: Has dentures Neck: No carotid or vertebral bruit CV: RRR, has a pacemaker. Lung: Clear Abd: +BS, soft, nontender Ext: No edema Neurologic examination: Mental status: Awake and alert - appears oriented to self but non-verbal other than occasional "[Last Name (un) 46536]", does not follow commands. Spontaneous arm movements bilaterally. CN: Pupils symmetric and reactive. Gaze deviation to L - does appear to cross midline to R on OCR. Blinks to visual threat bilaterally. Face appears symmetric and tongue movements intact. Motor: Spontaneous arm movements anti-gravity and withdraws to noxious stim in both legs. Increased tone in RLE. Reflexes: Trace and symm for biceps and [Last Name (un) ] but none for patellar or Achilles. Right toe upgoing and L downgoing. Pertinent Results: Laboratory Studies: WBC-9.4 RBC-4.54* HGB-14.1 HCT-44.1 MCV-97 PLT-209 NEUTS-88.1* LYMPHS-7.6* MONOS-3.5 EOS-0.3 BASOS-0.4 PT-19.0* PTT-25.8 INR(PT)-1.7* CK-MB-8 cTropnT-0.19* CK(CPK)-481* . Chest x-ray ([2173-10-1]) IMPRESSION: 1. Cardiomegaly, moderate left pleural effusion. 2. Right hilar possible infection and/or aspiration; correlate clinically. Repeat (2-view study in the radiology suite) may be helpful when clinically feasible. . CT HEAD W/O CONTRAST ([2173-10-1]) IMPRESSION: 1. Overall stable appearance to left temporal intraparenchymal hemorrhage, left parafalcine subdural hematoma causing slight mass effect, but no midline shift or herniation. Trace right occipital [Doctor Last Name 534] intraventricular hemorrhage, trace subarachnoid hemorrhage, and left occipital, parietal, and frontal subdural hematoma. 2. Stable ventricular size with slight deformity of the left lateral ventricle. . CT HEAD W/O CONTRAST ([2173-10-2]) IMPRESSION: No significant change from one day prior in the appearance of multifocal intracranial hemorrhage. The left temporal intraparenchymal hemorrhage demonstrates slight evolution with increased edema. There remains a global effacement of the left cortical sulci, secondary to mass effect, without significant midline shift or evidence of herniation. There is no new focus of hemorrhage identified. . CT HEAD W/O CONTRAST ([2173-10-6]): IMPRESSION: No appreciable change from four days prior in intraparenchymal, subarachnoid, and subdural hematomas with unchanged global effacement of left cerebral sulci and mass effect on the left lateral ventricle. . CT HEAD W/O CONTRAST ([2173-10-11]): 1. No significant change in the size and extent of subdural, subarachnoid, and intraparenchymal hemorrhages as described above. 2. Minimal new 2-mm rightward shift of normally midline structures. . EEG ([2173-10-8]): IMPRESSION: This is an abnormal routine EEG due to the slow background which is suggestive of a mild to moderate encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing although encephalopathies can obscure focal findings. There were no epileptiform features or electrographic seizures noted in this recording. . EEG ([2173-10-11]): IMPRESSION: This is an abnormal routine EEG due to the slow background with frequent voltage reduction and generalized bursts. These findings suggest a mild to moderate diffuse encephalopathy complicated by increased irritability emanating from subcortical structures or deeper midline structures. There were no frank epileptiform discharges or electrographic seizures. Brief Hospital Course: Mr. [Known lastname ] is an 87 yo man with paroxysmal atrial fibrillation on Coumadin s/p pacemaker placement who was brought to the [Hospital1 18] after being found unresponsive and was discovered to have a left temporal hemorrhage and a large parafalcine subdural hematoma (SDH) in the setting of a supratherapeutic INR. He was admitted to the Stroke Service from [2173-10-1] until ---- # Neuro/intraparenchymal hemorrhage: The patient was initially examined prior to sedation and intubation. He was alert and appeared oriented to self but did not appear to comprehend and did not follow any commands including miming. He appeared to have gaze deviation to left although with the oculocephalic reflex testing, eyes crossed beyond the midline to the right. He was intubated for airway protection. Repeat CT scans indicated some spread of the inital SDH, but the parietal-temporal hemorrhage remained stable. All anticoagulation was held. Neurosurgery was consulted but intervention was declined by the [Hospital 228] health care proxy. The patient remained stable in the ICU and was treated with 1 day of decadron for cerebral edema. He was extubated on [10-4] and tranferred to the floor on [10-5]. CT scans were periodically repeated and showed little change. However, the patient's neurological status deteriorated. By [2173-10-11], the patient was minimally responsive to stimulation, and demonstrated triple flexion to pressure on the great toe bilaterally. Increased rigidity was found in the left upper extremity. A repeat head CT demonstrated a new minimal (2mm) rightward shift of midline structures. # ID: In the course of the hospitalizaton, the patient developed fever. Repeated urine and blood cultures were negative. Chest x-ray was notable for a right lower lobe infiltrate for which vancomycin, cefepime, and ultimately clindamycin were started. Despite the broad empiric coverage, the patient continued to spike temperatures. The febrile illness was thought to reflect recurrent aspiration. The antibiotics were discontinued on [2173-10-13] when the patient's goals of care were transitioned from cure to comfort. # Cardiovascular/Afib. On admission the patient was noted to have a troponin of 0.19 in the absence of EKG changes. Given his large intraparenchymal hemorrhage, he was not a candidate for anticoagulation. Mr. [Known lastname 75208] pacemaker was interrogated by electrophysiology, and was found to be functioning appropriately. # METAB: Mr. [Known lastname ] developed a metabolic alkalosis of unclear etiology that continued to gradually worsen in the course of admission. # FEN. In the course of the hospitalization, Mr. [Known lastname ] developed hyponatremia. Urine and serum studies were thought to be inconsistent with SIADH. Hydration with IV fluids was continued as he was thought to be intravascularly dry. IV fluids were discontinued [2173-10-13] when the code status was transitioned to CMO. Following discussions with the patient's son, and health care proxy, [Name (NI) ] a decision was made to change the patient's code status from DNR/DNI to comfort measures only on [2173-10-13]. On [2173-10-15], Mr. [Known lastname ] was enrolled in inpatient hospice. Medications on Admission: 1. Coumadin 2.5mg daily Discharge Medications: 1. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for agitation, seizure. 2. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4H (every 4 hours) as needed for fever. 4. Atropine 1 % Drops Sig: Two (2) Drop Ophthalmic Q6HP () as needed for secretions. 5. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours). 6. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours). 7. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q2H (every 2 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Location (un) 11729] Home - [Location (un) 686] Discharge Diagnosis: Intraparenchymal hemmorrhage, infection Discharge Condition: occasional eye opening spontaneously, triple flexion to noxious stim of great toe bilaterally. Discharge Instructions: 1. Take all medications as directed. Followup Instructions: Hospice care. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2173-10-20]	[ "5070", "2761", "42731", "4019" ]
Admission Date: [2136-1-3] Discharge Date: [2136-1-29] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6378] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Video assisted thoracoscopic surgery and pleural biopsy Ultrasound guided pigtail catheter drainage of abdominal abscess Endotracheal intubation and ventilation Placement of central venous lines History of Present Illness: 85 y.o M with an extensive past medical hx including MDS, colon CA s/p resection, recent ileostomy revisions and takedown, cholecystectomy c/b MRSA and klebsiella pna and prolonged hospital course. Pt was hypotensive post-op requiring brief SICU stay when found to have pna and arf [1-11] hypotension. Pt then transfered to medicine team and received a course of Meropenem and Vanco (completed1/11). Pt found to have b/l pleural effusions R>L. Thorocentesis was negative for empyema. Pt also afebrile for entire admission except one low grade temp to 100.5. Pt went to rehab on [2135-12-19] where he was doing quite well until [2136-1-3] when pt awoke in resp distress. HE was transfered to OSH where he was found to have large L sided pleural effusion. Transferred to [Hospital1 18] for further treatment. Past Medical History: 1. PERIPHERAL EDEMA 2. DYSPHAGIA 3. Immune thrombocytopenic purpura 4. GBS like peripheral neuropathy 5. GASTROESOPHAGEAL REFLUX 6. NECK PAIN 7. CHRONIC CONJUNCTIVITIS 8. PERIPHERAL VASCULAR DISEASE 9. Hemorrhoids 10. SEROUS OTITIS 11. BENIGN PROSTATIC HYPERTROPHY 12. HYPERTENSION 13. Right Colon Cancer 14. Rectal ulcers 15. Myelodysplastic syndrome 16. colon cancer s/p colectomy [4-11], complicated by ileal perf leading to ileostomy placement 17. Chronic myelomonocytic leukemia on prednisone 18. adrenal insufficiency 19. abdominal abscess [10-12] Social History: Founder of Juliard String Quartet. No tobacco, no EtOH, generally lives with wife, however, recently at rehab. Family History: No colon cancer history. Physical Exam: MICU c/o exam VS 96.0 162/60 81 17 100% 4L NC GENERAL: Pt sitting with bed at 60 degrees. Mild tachypnea, speaking in ful sentences. NAD. NECK: Supple, JVP flat CARDIOVASCULAR: regular, nl S1, S2, II/VI systolic M LUNGS: Decreased breath sounds bilaterally with crackles ABDOMEN: Active bowel sounds, nontender, soft dressing/wound CDI, EXTREMITIES: Warm, 2+ pedal edema. Pertinent Results: [2136-1-11] 04:26AM BLOOD WBC-58.8* RBC-2.96* Hgb-9.0* Hct-26.8* MCV-90 MCH-30.5 MCHC-33.7 RDW-16.2* Plt Ct-77* [2136-1-11] 04:26AM BLOOD Neuts-59 Bands-2 Lymphs-6* Monos-17* Eos-0 Baso-0 Atyps-2* Metas-8* Myelos-6* [2136-1-11] 04:26AM BLOOD Plt Smr-VERY LOW Plt Ct-77* [2136-1-10] 07:10AM BLOOD Fibrino-363# [2136-1-11] 04:26AM BLOOD Glucose-124* UreaN-30* Creat-1.1 Na-146* K-3.7 Cl-117* HCO3-24 AnGap-9 [2136-1-10] 04:04PM BLOOD CK(CPK)-33* [2136-1-10] 02:44PM BLOOD ALT-12 AST-28 LD(LDH)-365* CK(CPK)-31* AlkPhos-117 TotBili-0.6 [2136-1-10] 07:10AM BLOOD ALT-12 AST-30 LD(LDH)-385* CK(CPK)-23* AlkPhos-137* TotBili-0.7 [2136-1-6] 01:53AM BLOOD Lipase-12 [2136-1-10] 04:04PM BLOOD cTropnT-0.08* [2136-1-11] 04:26AM BLOOD Calcium-6.3* Phos-3.9 Mg-2.2 [2136-1-10] 07:10AM BLOOD Albumin-2.4* Calcium-7.1* Phos-2.9 Mg-1.8 [2136-1-10] 04:04PM BLOOD Cortsol-34.7* [2136-1-10] 02:44PM BLOOD Cortsol-34.3* [2136-1-10] 07:10AM BLOOD Cortsol-45.6* [2136-1-10] 02:44PM BLOOD CRP-14.95* [2136-1-10] 07:10AM BLOOD Vanco-18.3* [2136-1-11] 04:28AM BLOOD Type-ART Temp-36.7 pO2-89 pCO2-42 pH-7.32* calHCO3-23 Base XS--4 Intubat-NOT INTUBA [2136-1-11] 04:28AM BLOOD Lactate-1.0 [2136-1-11] 04:28AM BLOOD freeCa-1.00* CT abd [2136-1-11] 1. Peribronchial consolidation which has developed since the prior examination are consistent with aspiration, predominantly involving the right middle lobe and the right lower lobe, but also with atelectasis at the left lower lobe. 2. Interval decrease in size of right upper quadrant fluid collection, with pigtail catheter in appropriate positioning. 3. Left-sided chest tube appears appropriately positioned in the left pleural space. GRAM STAIN (Final [2136-1-9]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. ENTEROCOCCUS SP.. SPARSE GROWTH. PRESUMPTIVE IDENTIFICATION DEFINITIVE IDENTIFICATION TO FOLLOW. BEING ISOLATED FOR SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- PND CEFTAZIDIME----------- PND CEFTRIAXONE----------- PND CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 2 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Brief Hospital Course: 86 yo male status post CCY/ileostomy takedown, MRSA/Klebsiella PNA status post completed treatment with vancomycin/meropenem returns with development of large left pleural effusion. * PLEURAL EFFUSIONs: Patient had on previous admission had known bilateral pleural effusions, R>L, and had undergone thoracentesis with removal of 2L of fluid from the right pleural space consistent with an exudate which was thought at the time to be secondary to parapneumonic effusion as the patient was still being treated for MRSA/Klebsiella pneumonia. Left-sided pleural effusion was not intervened upon. During this admission, patient underwent multiple procedures for removal of pleural effusions, however was immediately restarted on vancomycin/meropenem for empiric treatment of the previous klebsiella/MRSA pneumonia. Initially, patient underwent bedside thoracentesis, which was successful, but was only able to remove ~1.3L, secondary to loculation of the effusion. Serosanguinous fluid, although consistent with exudative effusion was sterile. A second attempt made under ultrasound guidance was only able to obtain 250cc of fluid, and radiologists commented upon loculations noted in the effusion, and repeat CT chest revealed continued massive pleural effusion despite initial thoracentesis. Thoracic surgery consultants then placed a chest tube, which drained an additional 1.2 liters, yielding an additional ~2L after two administrations of intrathoracic tissue plasminogen activator. Following placement of the chest tube, patient's blood pressure, creatinine, and lactic acid improved dramatically. However, patient continued to have return of pleural effusions causing respiratory distress and returned to OR for two additional chest tubes, complicated again by hypotension requiring several liters of fluid and several units of blood. Patient also underwent pleural biopsy which was unrevealing for a source of continued effusions. * LACTIC ACIDOSIS/HYPOTENSION: At the time of admission, patient's systolic blood pressure was approximately 100, which was significantly lower than his baseline, which normally required anti-hypertensives for control. While patient was initially given fluids for and blood to improve perfusion, patient became acutely hypoxic and short of breath overnight, concerning for congestive heart failure. Therefore, patient was then treated with diuresis and fluid restriction, which in turn induced hypotension and a rise in lactate, which peaked at 3.0. Transthoracic echocardiogram revealed left ventricular hypertrophy, with decreased filling, as well as possible decreased filling secondary to increased intrathoracic pressure due to the large left pleural effusion. Consistent with this, following placement of chest tube and blood transfusion, patient's blood pressures improved dramatically (to SBP 130's), lactate dropped below 1, and creatinine improved, suggesting that pleural effusion was impairing appropriate cardiac output. However, following administration of second dose of intrathoracic tPA and drainage of right upper quadrant abdominal abscess, patient became acutely hypotensive, concerning for sepsis. Patient was started on dopamine infusion and transferred to the MICU for further management. There, patient was found to have an extremely low central venous pressure, and patient was repleted with blood and fluids and responded appropriately. * ACUTE ON CHRONIC RENAL FAILURE: Serum creatinine at the time of admission was 2.2, which rose to a peak of 2.5 within the same day. Of note, patient's FeNa at different times during initial admission suggested both pre- and intra- renal failure. Given the fact that patient's lactate began to rise, it was felt that increased perfusion of tissues with fluid and blood support was necessary. Indeed, patient's creatinine improved dramatically (1.9->1.6) following placement of chest tube and administration of blood. However, patient became hypotensive secondary to blood loss following chest tube placement, and patient's creatinine was elevated and became oliguric. This responded well to fluid boluses and blood transfusion as expected. * ABDOMINAL ABSCESS: An air-fluid level was noted on multiple chest xrays at the time of admission, but was initially thought to be due to dilated loop of bowel on the right upper quadrant. However, oral contrast CT did not opacify the air/fluid level, and patient underwent ultrasound guided drainage. The fluid, however, was significant for only neutrophils, but no microorganisms. Ultimately, however, cultures grew out Klebsiella and vancomycin resistant Enterococci, and patient was treated with meropenem and linezolid with good effect. Cultures remained clear throughout rest of hospital course. On hospital day 24, following extensive invasive procedures, patient requested comfort measures only and transfer to home with hospice. Chest tubes were placed to water seal and removed without complications. All medications except those required for comfort were discontinued. Patient was discharged home with hospice care including morphine and lorazepam for comfort. Medications on Admission: Prednisone 10 mg Po QOD Latanoprost 0.005 % Drops Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic 3X/WEEK (MO,WE,FR). Percocet Q4-6. Combivent Nebs Dorzolamide-Timolol 2-0.5 % Drops Protonix 40 PO QD RISS Lantus 5U SC Qhs Lasix 80 mg QD Potassium Chloride 40 meq QD Discharge Medications: Morphine Ativan Discharge Disposition: Extended Care Facility: . Discharge Diagnosis: Chronic myelomonocytic leukemia Bacterial abdominal abscess Parapneumonic pleural effusions Acute on Chronic renal failure End-stage Myelodysplastic syndrome Discharge Condition: Poor Discharge Instructions: Comfort measures only. Continue Morphine and Ativan as needed for comfort. Followup Instructions: None - call primary care physician as needed for assistance with comfort medications [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6384] MD, [MD Number(3) 6385]	[ "5849", "5070", "2851", "4280", "51881", "4168" ]
Admission Date: [2106-11-1] Discharge Date: [2106-11-9] Date of Birth: [2038-10-7] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Salmon Oil / Nut Flavor Attending:[First Name3 (LF) 4748] Chief Complaint: AAA Major Surgical or Invasive Procedure: [2106-11-2] open AAA repair History of Present Illness: 68 yo F with hypertension, PVD, COPD not on home O2, with significant DOE, who has an AAA incidentally found in [2103] during workup for cholecystitis. On follow up scans, the abdominal aneurysm has expanded to 5.1 cm with small leak per patient. She now presents for AAA repair. Past Medical History: HTN COPD not on home O2 with DOE (50 ft with walker) Depression Obesity peripheral vascular disease AAA and bilateral ICA occlusion Urinary incontinence Obesity PSH: CCY, appy, perforated ulcers x3, hysterectomy, bilateral total knee replacements, Social History: NC Family History: NC Physical Exam: VS: 98.4 53 125/73 16 94 % sat on 2L NC Gen: AAOx3, NAD Neck: No masses, Trachea midline, No carotid bruits B/L Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Abdomen: Obese, Non distended, No masses, No hepatosplenomegally. Incision intact, staples clipped and steri stripped. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RLE DP: P. PT: P. LLE DP: P. PT: P. Pertinent Results: [2106-11-9] 03:50AM BLOOD WBC-13.1* RBC-3.72* Hgb-12.2 Hct-36.2 MCV-97 MCH-32.7* MCHC-33.5 RDW-13.0 Plt Ct-383 [2106-11-8] 07:45AM BLOOD WBC-13.5* RBC-3.86* Hgb-12.3 Hct-37.0 MCV-96 MCH-32.0 MCHC-33.4 RDW-13.7 Plt Ct-339 [2106-11-9] 03:50AM BLOOD Neuts-68.8 Lymphs-21.6 Monos-5.7 Eos-3.3 Baso-0.6 [2106-11-9] 03:50AM BLOOD Plt Ct-383 [2106-11-9] 03:50AM BLOOD Glucose-99 UreaN-21* Creat-0.7 Na-134 K-3.6 Cl-96 HCO3-32 AnGap-10 [2106-11-9] 03:50AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9 ECG Study Date of [2106-11-1] 1:51:44 PM Sinus rhythm. Left axis deviation. Non-specific ST-T wave changes. Compared to the previous tracing the Q-T interval is shorter. CHEST (PRE-OP PA & LAT) Study Date of [2106-11-1] 3:22 PM IMPRESSION: 1. No radiographic evidence of pneumonia or edema. 2. Bilateral hilar prominence, recommend further evaluation with chest CT to exclude hilar lymphadenopathy. TEE (Complete) Done [2106-11-2] at 3:10:31 PM FINAL Conclusions The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. 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. There is no pericardial effusion. Dr.[Last Name (STitle) 59718] and [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1391] was notified in person of the results on [Known firstname ] [Last Name (NamePattern1) 111123]. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [2106-11-2] 1:48 PM IMPRESSION: 1. No evidence of aortic arch aneurysm. 2. Prominent left hilar lymph node, could be reactive. 3. Bilateral atelectasis. 4. Atherosclerotic disease involving aortic arch. The study and the report were reviewed by the staff radiologist Brief Hospital Course: [2106-11-1] Patient admitted to Vascular Surgery/Dr. [Last Name (STitle) 1391] service. Pre-oped and consented for open AAA repair. Routine labs, ECG and CXR. Made NPO after MN and IV hydrated. [Date range (1) 111124] Patient taken to OR and underwent open AAA. Was line pre-op in the holding room. Patient tolerated procedure, was transferred to the CVICU, patient had trouble extubating so remianed intubated and on pressors overnight. Was extubated the next day, transferred to [Hospital Ward Name 121] VICU. Placed on AAA pathway. [2106-11-4] POD2: No overnight events, started to diurese. Continued AAA pathway. Pain managed w/ PRN meds. Remains hypertensive-getting Hydralazine IV to keep SBP <140's. Started sips w/ meds. [Date range (1) 111125] POD3-4: No acute events. PAP elevated, got better w/ diuresis, eventually removed. Continued AAA pathway. PO meds. Physical therapy referral, OOb w/ assist. [Date range (1) 111126] POD5-6: No acute events. Resumed PO meds. Contued w/ AAA pathway. Physical therapy following-recs. Rehab- screening requested. UA came back w/ E-coli, started on Cipro (for 5 days). [2106-11-9] POD7: No acute events. Bed offer for rehab. Patient discharged in good condition. Will FU w/ Dr. [Last Name (STitle) 1391] in [3-31] weeks. Will continue Cipro till [2106-11-12]. Medications on Admission: advair [Hospital1 ] celexa 40' nabumetone 500 [Hospital1 ] trazadone 50 qhs triameterene/HCTZ 37.5/25 chantix 0.5 [Hospital1 ] spiriva qhs asa 325 Discharge Medications: 1. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Capsule PO once a day. 2. Nitroglycerin in D5W 400 mcg/mL Solution Sig: One (1) Intravenous TITRATE TO (titrate to desired clinical effect (please specify)). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): D/C when out of bed as tolerated. 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): Need to FU w/ PCP . 12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days: for UTI. 17. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 18. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 19. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1 doses. 20. Regular Insulin Sliding Scale Breakfast Lunch Dinner Bedtime Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-65 mg/dL [1-29] amp D50 [1-29] amp D50 [1-29] amp D50 [1-29] amp D50 66-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-140 mg/dL 2 Units 2 Units 2 Units 2 Units 141-160 mg/dL 4 Units 4 Units 4 Units 4 Units 161-180 mg/dL 6 Units 6 Units 6 Units 6 Units 181-200 mg/dL 8 Units 8 Units 8 Units 8 Units 201-220 mg/dL 10 Units 10 Units 10 Units 10 Units 221-240 mg/dL 12 Units 12 Units 12 Units 12 Units 241-260 mg/dL 14 Units 14 Units 14 Units 14 Units 261-280 mg/dL 16 Units 16 Units 16 Units 16 Units 281-300 mg/dL 18 Units 18 Units 18 Units 18 Units 301-320 mg/dL 20 Units 20 Units 20 Units 20 Units 321-340 mg/dL 22 Units 22 Units 22 Units 22 Units 341-360 mg/dL 24 Units 24 Units 24 Units 24 Units 361-380 mg/dL 26 Units 26 Units 26 Units 26 Units 381-400 mg/dL 28 Units 28 Units 28 Units 28 Units Discharge Disposition: Extended Care Facility: Life Care [Location 15289] Discharge Diagnosis: AAA UTI- found on admission on routine UA pre-op, treated w/ Cipro x 5 days History of: HTN COPD not on home O2 with DOE (50 ft with walker) Depression Obesity peripheral vascular disease AAA and bilateral ICA occlusion Urinary incontinence Obesity PSH: CCY, appy, perforated ulcers x3, hysterectomy, bilateral total knee replacements, Discharge Condition: Good Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm Repair Discharge Instructions ACTIVITIES: - [Month (only) 116] shower pat dry your incision, no tub baths - No driving till seen in FU by Dr. [Last Name (STitle) 1391] - No heavy lifting for 4-6 weeks - Resume activities as tolerated, slowly increase activiy as tolerated - Expect your activity level to return to normal slowly - Ambulate as tolerated DIET: - Diet as tolerated eat a well balanced meal - Your appetite will take time to normalize - Prevent constipation by drinking adequate fluid and eat foods [Doctor First Name ] in fiber, take stool softener while on pain medications WOUND: - Keep wound dry and clean, call if noted to have redness, draining, or swelling, or if temp is greater than 101.5 MEDICATIONS: - Continue all medications as instructed - We started you on new medications, please FU w/ your PCP to discuss further need to continue them. FU APPOINTMENT: - Call Dr.[Name (NI) 1392] office for FU appointment. Phone: [Telephone/Fax (1) 1393] Followup Instructions: Call Dr.[Name (NI) 1392] office for FU appointment. Phone: [Telephone/Fax (1) 1393] Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7145] ORTHOPEDIC PRIVATE PRACTICE Phone:[Telephone/Fax (1) 11262] Date/Time:[2107-2-23] 1:30 Completed by:[2106-11-9]	[ "5990", "5180", "2762", "2859", "496", "4019", "311" ]
Admission Date: [2142-9-14] Discharge Date: [2142-10-3] Date of Birth: [2081-10-27] Sex: M Service: [Doctor First Name 147] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: s/p house fire, carboxyhemoglobinemia Major Surgical or Invasive Procedure: intubation left chest tube placement bilateral myringotomies CVL/Swan Ganz catheter placement A line placement bronchoscopy x2 percutaneous tracheostomy post-pyloric feeding tube placement x2 History of Present Illness: Mr. [Known lastname 95189] is a 60 year old man found down after a house fire at his home [9-14], during which his wife was killed. An attempt at intubation by EMT in the field was unsuccessful and an LMA was placed. He was intubated in the [Hospital1 ] ED, and a thoracostomy tube was placed in the left chest for decreased breath sounds. A carboxyhemoglobin level was 49%, and Mr. [Known lastname 95189] was transferred to [Hospital1 2025] for hyperbaric O2 therapy. After this, he was returned to [Hospital1 ] for intensive care. Past Medical History: bilateral myringotomies ([2142-9-14] at [Hospital1 2025] prior to hyperbaric O2 tx) Social History: Lives in [Name (NI) ] Corner Wife died in [2142-9-14] house fire no etOH, no cigs Family History: noncontributory Physical Exam: T=99.8, HR 99, BP, 78/43, 90% Intubated, paralyzed NC/AT, 1cm bump on forehead 2mm pupils, equal & reactive RRR Bilateral coarse breath sounds L chest tube to suction, no leak Soft, NT, ND No CCE Pertinent Results: On return from [Hospital1 2025]: [2142-9-14] 10:15PM O2 SAT-87 CARBOXYHB-1 [2142-9-14] 09:30PM WBC-28.2* RBC-4.89 HGB-14.4 HCT-41.8 MCV-86 MCH-29.4 MCHC-34.4 RDW-13.4 [2142-9-14] 09:30PM PLT COUNT-258 [2142-9-14] 09:30PM PT-14.7* PTT-38.0* INR(PT)-1.4 [2142-9-14] 09:30PM GLUCOSE-126* UREA N-14 CREAT-0.9 SODIUM-145 POTASSIUM-4.1 CHLORIDE-117* TOTAL CO2-19* ANION GAP-13 [2142-9-14] 06:51AM TYPE-ART PO2-206* PCO2-43 PH-7.18* TOTAL CO2-17* BASE XS--11 [2142-9-14] 09:30PM CK(CPK)-1432* [2142-9-14] 09:30PM CK-MB-14* MB INDX-1.0 cTropnT-0.30* At initial ED presentation: [2142-9-14] 05:30AM TYPE-ART PO2-556* PCO2-58* PH-6.83* TOTAL CO2-11* BASE XS--26 [2142-9-14] 05:30AM HGB-15.9 calcHCT-48 O2 SAT-50 CARBOXYHB-49* Brief Hospital Course: On return from [Hospital1 2025], Mr. [Known lastname 95189] was admitted to the T-SICU for further care on the evening of [9-14]. Pressors were continued to maintain an adequate blood pressure. He was continued on CMV to correct his respiratory acidosis. He responded well to treatment and his vitals stabilized. He gradually improved with respect to his CV & respiratory status. A perc trach was done on [9-20], and he was weaned off the ventilator over the next 2 weeks. He was transferred to the MICU on [9-27], and then was discharged to [Hospital ] Rehab Hospital on [2142-10-3]. Neuro: At initial presentation, a neurology consult was obtained to evaluate for anoxic brain injury & the possibility of brain death. Neuroimaging did not reveal any ischemic injury to the brain & an EEG was not consistent with brain death, although he was heavily sedated at this time. The neurology team continued to follow the patient, but signed off as he woke up & was able to follow commands, move all extremities and communicate clearly. CV: After his initial CV shock, which required triple pressor therapy, he was weaned off these pressors. Early attempts to wean sedation were met with hypertension & tachcardia, which have been controlled with beta blockade & hydralazine. He will be discharged on oral labetalol & hydralazine. Resp: His respiratory acidosis improved in the first few days of this admission. On [9-19], a bronchoscopy was performed, which revealed significant mucosal burning & carbonaceous secretions. Because of his severe smoke inhalation injuries, it was decided that he would require a tracheostomy to wean from the vent. A perc trach was performed on [9-20]. About HD 10, his lungs acutely decompensated, requiring additional vent assistance. A chest CT showed bilateral effusions & intrinsic lung injury, and espohageal balloon manometry revealed that he required additional PEEP. At this time, endotracheal cultures revealed the presence of xanthomonas maltophila in his sputum. With diuresis & 1 week of antibiotics, his resp status improved. By the time of discharge, he is ventilating on his own via his tracheostomy. A Passey Muir valve was placed on [10-1] and he is able to speak as well. FEN/GI: After initial fluid resuscitation, Mr. [Known lastname 95189] was significantly volume overloaded (about 20 kg at one point). He was diuresed with lasix & diamox to his baseline weight by the time of discharge. In addition, his electrolyte abnormalities were corrected and his nutritional status was sustained with enteral tube feedings. HEME: He had several episodes of anemia, which required multiple RBC transfusions. ID: He was treated for a urinary tract infection on admission. He had ventilator associated xanthomonas pneumonia, which was treated. All other cultures were negative. Incidentally, he had a nasal swab which grew out MRSA. ENDO: His blood sugars were controlled with a sliding scale of regular insulin. MSK: His first degree burns on his lower back were treated with topical bacitracin. His initial rise in CK & troponin was secondary to muscle breakdown and resolved spontaneously. After the trauma, his spine was cleared radiographically. TOXIC: The presenting carbon monoxide intoxication resolved after hyperbaric O2 treatment, dropping to 1% immediately. There were no sequelae. A possible cyanide poisoning was empirically treated with thiocyannate. Medications on Admission: none Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: carboxyhemoglobinemia smoke inhalation injury first degree skin burns hypovolemic shock hemodynamic instability/monitoring via swan-ganz, arterial line volume overload hypokalemia hyperkalemia hypocalcemia hypomagenesemia UTI vent-assoc pneumonia sinusitis hypertension MRSA colonization xanthomonas pneumonia acute lung injury ARDS pleural effusions pneumothorax Discharge Condition: improved Discharge Instructions: Continue your care at [Hospital1 ] as directed. Followup Instructions: Contact Trauma Clinic at [Telephone/Fax (1) 2359] to arrange a follow up appointment in 2 weeks. Completed by:[2142-10-2]	[ "5990", "5119", "486" ]
Admission Date: [2103-3-30] Discharge Date: [2103-4-11] Date of Birth: [2032-7-18] Sex: M Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1481] Chief Complaint: T3, N0 distal esophageal cancer Major Surgical or Invasive Procedure: [2103-3-30] Minimally-invasive esophagectomy. History of Present Illness: Mr. [Known lastname 106187] is a 70-year-old gentleman with a T3, N0 distal esophageal cancer. He was treated with neoadjuvant chemotherapy and radiation and had a good response and presents for resection. Past Medical History: POncHx # Diagnosis: [11-28] EGD demonstrated bleeding 1.5 x 3 cm GE junction mass with partial obstruction. Biopsy demonstrated moderately differentiated adenocarcinoma at the GE junction. Gastric body polyp, antrum, duodenum benign per biopsy. # PET CT [2102-12-7]: Mural thickening, FDG avidity at distal esophagus in the GE junction. No FDG avid nodal disease noted distally. Multiple non-FDG avid lucent foci with sclerotic margins at pelvic bones. FDG avidity at L thyroid without mass # EGD/EUS [2102-12-14]: 2 cm mass at GE junction and cardia, staged T3, N0 lesion with invasion beyond muscularis and no abnormal nodes # Cisplatin/5FU: Cycle 1 @ [2103-1-9], cycle 2 @ [2103-2-5]. . PMH # Prostate cancer ([6-/2101]) --PSAs [2-24], bx [Doctor Last Name ] 3+3 in [1-31] cores. --CyberKnife [10/2101] # DM2 s/p chemotherapy # Hypercholesterolemia # Hypothyroidism # Renal insufficiency # Chronic hematuria # Sleep apnea # s/p B cataract surgery Social History: # Personal: Lives with his wife # Professional: Attorney # Tobacco: Never # Alcohol: Rare Family History: # Mother: Esophageal cancer # Sister: [Name (NI) ] cancer Physical Exam: afebrile hemodynamically stable A+Ox 3 NAD RRR no MRG S NT ND no HSM CTAB MAE B LE and UE [3-26] Pertinent Results: [2103-4-7] 05:50AM BLOOD WBC-8.9 RBC-2.82* Hgb-8.7* Hct-25.9* MCV-92 MCH-30.7 MCHC-33.4 RDW-16.4* Plt Ct-511* [2103-4-6] 03:11AM BLOOD WBC-9.2 RBC-2.86* Hgb-8.9* Hct-25.9* MCV-91 MCH-31.1 MCHC-34.3 RDW-16.1* Plt Ct-441* [2103-4-5] 02:21AM BLOOD WBC-8.4 RBC-3.00* Hgb-9.3* Hct-27.2* MCV-91 MCH-31.0 MCHC-34.1 RDW-16.1* Plt Ct-394 [2103-4-4] 02:16PM BLOOD WBC-7.1 RBC-2.86* Hgb-9.0* Hct-26.0* MCV-91 MCH-31.3 MCHC-34.4 RDW-16.1* Plt Ct-326 [2103-4-4] 01:28AM BLOOD WBC-8.3 RBC-3.01* Hgb-9.3* Hct-26.9* MCV-90 MCH-30.9 MCHC-34.6 RDW-16.3* Plt Ct-369 [2103-4-3] 02:49AM BLOOD WBC-7.9 RBC-3.37* Hgb-10.3* Hct-30.9* MCV-91 MCH-30.5 MCHC-33.4 RDW-16.5* Plt Ct-415 [2103-4-2] 08:47PM BLOOD WBC-7.8 RBC-3.42* Hgb-10.7* Hct-31.0* MCV-90 MCH-31.3 MCHC-34.6 RDW-16.4* Plt Ct-366 [2103-4-2] 09:13AM BLOOD WBC-8.7 RBC-3.35* Hgb-10.3* Hct-30.3* MCV-91 MCH-30.6 MCHC-33.8 RDW-16.4* Plt Ct-300 [2103-4-2] 02:32AM BLOOD WBC-8.3 RBC-2.89* Hgb-9.2* Hct-26.3* MCV-91 MCH-31.9 MCHC-35.1* RDW-16.6* Plt Ct-262 [2103-4-1] 08:18PM BLOOD WBC-6.9 RBC-2.82* Hgb-9.0* Hct-25.6* MCV-91 MCH-32.0 MCHC-35.3* RDW-16.7* Plt Ct-238 [2103-4-1] 02:24PM BLOOD WBC-6.4 RBC-2.88* Hgb-9.2* Hct-26.0* MCV-90 MCH-31.9 MCHC-35.4* RDW-16.9* Plt Ct-234 [2103-4-1] 12:54AM BLOOD WBC-6.7 RBC-2.71* Hgb-8.6* Hct-25.6* MCV-95 MCH-31.5 MCHC-33.4 RDW-16.4* Plt Ct-277 [2103-3-31] 02:40PM BLOOD Hct-27.5* [2103-3-31] 03:11AM BLOOD WBC-4.5 RBC-2.68* Hgb-8.5* Hct-24.7* MCV-92 MCH-31.8 MCHC-34.5 RDW-16.4* Plt Ct-245 [2103-3-30] 05:11PM BLOOD WBC-7.8# RBC-2.76* Hgb-9.0* Hct-26.0* MCV-94 MCH-32.4* MCHC-34.4 RDW-16.4* Plt Ct-269 [2103-4-2] 08:47PM BLOOD Neuts-84* Bands-7* Lymphs-2* Monos-6 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2103-4-2] 08:47PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-1+ [2103-4-9] 06:00AM BLOOD PT-14.4* PTT-31.6 INR(PT)-1.3* [2103-4-8] 06:02AM BLOOD PT-14.5* PTT-106.1* INR(PT)-1.3* [2103-4-7] 05:50AM BLOOD Plt Ct-511* [2103-4-7] 05:50AM BLOOD PT-14.0* PTT-78.7* INR(PT)-1.2* [2103-4-6] 09:06PM BLOOD PTT-61.7* [2103-4-6] 03:11AM BLOOD Plt Ct-441* [2103-4-6] 03:11AM BLOOD PT-13.4 PTT-69.9* INR(PT)-1.2* [2103-4-5] 08:56PM BLOOD PT-13.4 PTT-80.7* INR(PT)-1.1 [2103-4-5] 02:41PM BLOOD PT-13.5* PTT-59.8* INR(PT)-1.2* [2103-4-5] 05:20AM BLOOD PTT-50.2* [2103-4-4] 09:59PM BLOOD PTT-54.5* [2103-4-4] 02:16PM BLOOD Plt Ct-326 [2103-4-4] 02:16PM BLOOD PT-13.5* PTT-60.7* INR(PT)-1.2* [2103-4-4] 10:00AM BLOOD PTT-67.8* [2103-4-4] 02:57AM BLOOD PTT-75.9* [2103-4-4] 01:28AM BLOOD Plt Ct-369 [2103-4-3] 07:20PM BLOOD PTT-60.2* [2103-4-3] 12:27PM BLOOD PTT-55.0* [2103-4-3] 06:30AM BLOOD PT-12.4 PTT-43.4* INR(PT)-1.0 [2103-4-3] 02:49AM BLOOD Plt Ct-415 [2103-3-30] 10:00AM BLOOD PT-20.2* PTT-150* INR(PT)-1.9* [2103-3-30] 05:11PM BLOOD Plt Ct-269 [2103-3-31] 03:11AM BLOOD Plt Ct-245 [2103-3-31] 08:21PM BLOOD Plt Ct-214 [2103-4-1] 12:54AM BLOOD Plt Ct-277 [2103-4-1] 02:24PM BLOOD Plt Ct-234 [2103-4-1] 08:18PM BLOOD Plt Ct-238 [2103-4-8] 03:20AM BLOOD Glucose-140* UreaN-34* Creat-1.3* Na-141 K-4.3 Cl-105 HCO3-25 AnGap-15 [2103-4-6] 03:11AM BLOOD Glucose-142* UreaN-31* Creat-1.1 Na-136 K-3.9 Cl-102 HCO3-24 AnGap-14 [2103-4-5] 02:21AM BLOOD Glucose-148* UreaN-25* Creat-1.0 Na-137 K-3.9 Cl-102 HCO3-26 AnGap-13 [2103-4-4] 02:16PM BLOOD Glucose-127* UreaN-26* Creat-1.1 Na-137 K-3.8 Cl-100 HCO3-28 AnGap-13 [2103-4-4] 01:28AM BLOOD Glucose-212* UreaN-30* Creat-1.3* Na-134 K-3.6 Cl-99 HCO3-24 AnGap-15 [2103-4-3] 12:28PM BLOOD Creat-1.2 Na-136 K-4.2 [2103-4-3] 02:49AM BLOOD Glucose-164* UreaN-27* Creat-1.3* Na-137 K-4.2 Cl-98 HCO3-29 AnGap-14 [2103-4-2] 08:47PM BLOOD Glucose-186* UreaN-21* Creat-1.2 Na-137 K-4.2 Cl-100 HCO3-26 AnGap-15 [2103-4-2] 09:13AM BLOOD UreaN-18 Creat-1.1 Na-135 K-3.9 [2103-4-2] 02:32AM BLOOD Glucose-150* UreaN-17 Creat-1.0 Na-136 K-4.3 Cl-104 HCO3-27 AnGap-9 [2103-4-1] 02:24PM BLOOD UreaN-16 Creat-1.0 Na-136 K-4.0 [2103-4-1] 12:54AM BLOOD Glucose-177* UreaN-19 Creat-1.2 Na-137 K-4.3 Cl-104 HCO3-27 AnGap-10 [2103-3-31] 08:21PM BLOOD Glucose-140* UreaN-20 Creat-1.1 Na-138 K-4.0 Cl-104 HCO3-27 AnGap-11 [2103-3-31] 03:11AM BLOOD Glucose-109* UreaN-27* Creat-1.2 Na-140 K-4.3 Cl-108 HCO3-25 AnGap-11 [2103-3-30] 05:11PM BLOOD Glucose-207* UreaN-33* Creat-1.3* Na-141 K-4.3 Cl-107 HCO3-19* AnGap-19 [2103-3-30] 05:11PM BLOOD estGFR-Using this [2103-4-4] 01:28AM BLOOD CK(CPK)-71 [2103-4-1] 12:54AM BLOOD CK(CPK)-219* [2103-3-31] 08:21PM BLOOD CK(CPK)-258* [2103-4-4] 01:28AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2103-4-2] 09:13AM BLOOD cTropnT-<0.01 [2103-3-31] 08:21PM BLOOD CK-MB-3 cTropnT-<0.01 [2103-4-8] 03:20AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.5 [2103-4-7] 05:50AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.0 [2103-4-6] 03:11AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0 [2103-4-5] 02:21AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.4 [2103-4-4] 02:16PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0 [2103-4-4] 01:28AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.2 [2103-4-3] 12:28PM BLOOD Mg-2.0 [2103-4-3] 02:49AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1 [2103-4-2] 08:47PM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0 [2103-4-2] 09:13AM BLOOD Mg-2.4 [2103-4-2] 02:32AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1 [2103-4-1] 08:18PM BLOOD Mg-2.4 [2103-4-1] 12:54AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.4 [2103-3-31] 08:21PM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0 [2103-3-31] 03:11AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.3 [2103-4-9] 06:00AM BLOOD Vanco-13.0 [2103-4-8] 06:02AM BLOOD Vanco-17.0 [2103-4-7] 05:56PM BLOOD Vanco-12.7 [2103-4-7] 05:50AM BLOOD Vanco-23.7* [2103-4-5] 05:20AM BLOOD Vanco-14.2 [2103-4-7] 05:50AM BLOOD Digoxin-0.9 [2103-4-5] 02:21AM BLOOD Digoxin-1.2 [2103-4-5] 03:24PM BLOOD Type-ART pO2-68* pCO2-34* pH-7.52* calTCO2-29 Base XS-4 [2103-4-4] 05:06AM BLOOD Type-ART pO2-105 pCO2-34* pH-7.53* calTCO2-29 Base XS-6 [2103-4-3] 12:40PM BLOOD Type-ART Temp-37.8 Rates-/25 FiO2-100 O2 Flow-15 pO2-195* pCO2-35* pH-7.52* calTCO2-30 Base XS-6 AADO2-509 REQ O2-82 Intubat-NOT INTUBA [2103-4-2] 11:34PM BLOOD Type-ART pO2-68* pCO2-36 pH-7.51* calTCO2-30 Base XS-5 [2103-4-2] 04:06PM BLOOD pH-7.47* Comment-PLEURAL FL [2103-4-2] 09:27AM BLOOD Type-ART pO2-66* pCO2-35 pH-7.51* calTCO2-29 Base XS-4 Intubat-NOT INTUBA [2103-3-30] 02:38PM BLOOD pO2-103 pCO2-56* pH-7.24* calTCO2-25 Base XS--4 [2103-4-5] 03:24PM BLOOD K-4.2 [2103-4-4] 05:06AM BLOOD Lactate-1.5 K-4.1 [2103-4-2] 11:34PM BLOOD Lactate-2.2* [2103-4-2] 09:27AM BLOOD Lactate-1.2 [2103-3-30] 02:38PM BLOOD Hgb-9.8* calcHCT-29 [2103-4-5] 03:24PM BLOOD freeCa-1.16 [2103-4-5] 06:13AM BLOOD freeCa-1.04* [2103-4-4] 05:06AM BLOOD freeCa-1.08* [2103-4-2] 11:34PM BLOOD freeCa-1.06* [2103-3-30] 02:38PM BLOOD freeCa-1.11* Brief Hospital Course: Patient was admitted with the cancerous lesion noted in the HPI and worked up as an outpatient for his surgery here at the [Hospital1 18]. The patient had no immediated complications post-op and was transferred to the Surgican Intensive Care Unit for monitoring. While in the unit the patient suffered a pulmonary embolus and suffered from recalcitrat atrial fibrillation, not responsive various changes of medications. An optimal regimen was suggested and institutded by the cardiology consult team, and the patient was stable for transfer to the floor. While on the floor, the patient's course proceded well, and he was examined and found fit for discharge to home with visitng nurse services. he is to continue his levofloxacin course for one week while at home, and he is to utilize cycled tube feeds to supplement his oral diet Medications on Admission: lipitor 80', synthroid 100', prilosec 20', colace, senna Discharge Medications: 1. Amiodarone 200 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 2. Levofloxacin 250 mg Tablet [Hospital1 ]: Three (3) Tablet PO DAILY (Daily) for 1 weeks. Disp:21 Tablet(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Hospital1 ]: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:350 ML(s) Refills:0 4. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 6. Digoxin 125 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 8. Ascorbic Acid 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 9. Atorvastatin 80 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 10. Levothyroxine 100 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed. 13. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO BID (2 times a day). 14. Enoxaparin 80 mg/0.8 mL Syringe [Last Name (STitle) ]: One (1) Subcutaneous Q12H (every 12 hours). Disp:40 syringes Refills:2 15. Warfarin 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO ONCE (Once) for 1 doses. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: esophageal ca s/p chemo pulmonary embolus respiratory insufficiency atrial fibrillation pleural effusion Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. Diet Instruction: (after Nissen Fundoplication or [Doctor Last Name ] Myotomy) Please AVOID carbonated beverages and hard foods (bread, cake, coarse cereals, seeds/nuts, dried fruits, crackers, & tough meat) until your follow-up appointment with your surgeon. * Any serious change in your symptoms, or any new symptoms that concern you. Incision Care: You may shower. Pat incision dry. Avoid swimming and baths until further instruction at your followup appointment. Leave the steri-strips on. They will fall off on their own, or be removed during your followup. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. JP Drain Care: Please look at the site every day for signs of infection (increased redness, swelling, tenderness, odorous or purulent discharge). Maintain the bulb deflated to provide adequate suction. Note color, consistency, and amount of fluid in drain. Call doctor if amount increases significantly or changes in character. Be sure to empty the drain frequently and record the output. Maintain the site clean, dry, and intact. Keep drain attached safely to body to prevent pulling and possible dislodgement. Followup Instructions: You are to call Dr.[Name (NI) 1482] office ASAP for a follow-up appointment. You are to call your primary care physician's office ASAP for a follow-up appointment.	[ "9971", "5119", "5180", "42731", "5859", "25000", "2720", "2449", "2724" ]
Admission Date: [2114-8-9] Discharge Date: [2114-8-20] Date of Birth: [2041-6-6] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 425] Chief Complaint: xfer for ICD placement Major Surgical or Invasive Procedure: BiV/ICD placement on [8-14] History of Present Illness: Pt is a 73 year old woman with a history of non-ischemic cardiomyopathy EF 15%, pulm HTN, AF (not on coumadin) and schizophrenia who is here for CHF management and BiV ICD placement. She had originally presented to [Hospital6 33] on [8-6]. . At [Hospital3 ] BNP was 6300. It was managed with digoxin 0.125, lisinopril 2.5mg, and carvedilol 3.125mg twice daily. She was diuresed 2L and her Cr rose to 1.6. She was seen by [Doctor First Name 28239] [Doctor Last Name 13177] there and the decision was made to have a BiV ICD placed. . Arrived at [Hospital1 18], where she was noted to be hypoxic and orthopneic. Also complaining of abdominal pain. She got 40 lasix, however was only net negative 300 because of significant fluid intake. . She went down for procedure on admission but was unable to lie flat therefore she was transferred to CCU for diuresis and further management. Prior to arrival in the CCU, patient received 60 mg of IV Lasix. Upon arrival to the CCU, she was able to lie flat with O2 sat of 95%. Past Medical History: Non-ischemic cardiomyopathy CHF Class IV EF 15% Atrial fibrillation (pt off coumadin for unclear reasons since [12/2112]) mod-severe pulmonary HTN mod-severe MR [Name13 (STitle) ] TR Schizophrenia Dementia UTI Renal insufficiency Type II diabetes mellitus Social History: Pt has been living in a [Hospital1 1501]. She has an involved family, her HCP is her son. Family History: Noncontributory Physical Exam: VS: T 97 HR 83 BP 123/64 RR 18 Sat 77% RA 99% 2L Gen: Pleasant elderly woman in no apparent distress HEENT: OP clear, MMM, cataracts bilaterally, sclerae anicteric Neck: JVP to jaw CV: Normal s1/s2, +s3, RRR Pul: Decreased BS at bases, crackles 1/3 up Abd: Soft, distended, +BS, nontender. no rebound or guarding. Ext: Chr venous stasis, trace edema. Pertinent Results: ECG: NSR, LBBB, QRS 170. . [8-10] Echo: Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with mild free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with marked elevation of left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderately dilated LV cavity with severe global systolic dysfunction. Moderate mitral regurgitation. Mild pulmonary hypertension. . [8-10] CXR IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Enlargement of the cardiac silhouette is severe accompanied by mild pulmonary edema, small bilateral pleural effusions and mediastinal vascular engorgement. No pneumothorax. Fibrillator pads project over the heart. . Micro: Blood cultures negative, Urine cultures negative. Stool culure positive for Clostridium difficile . [2114-8-9] 06:55PM PT-12.3 PTT-27.3 INR(PT)-1.1 [2114-8-9] 06:55PM PLT COUNT-118* [2114-8-9] 06:55PM MACROCYT-3+ [2114-8-9] 06:55PM NEUTS-64.9 LYMPHS-25.1 MONOS-6.5 EOS-1.4 BASOS-2.1* [2114-8-9] 06:55PM WBC-5.0 RBC-3.94* HGB-13.6 HCT-40.4 MCV-103* MCH-34.5* MCHC-33.6 RDW-15.6* [2114-8-9] 06:55PM TSH-3.9 [2114-8-9] 06:55PM ALBUMIN-4.4 CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-2.5 [2114-8-9] 06:55PM proBNP-8030* [2114-8-9] 06:55PM ALT(SGPT)-30 AST(SGOT)-22 LD(LDH)-297* ALK PHOS-76 TOT BILI-0.6 [2114-8-9] 06:55PM GLUCOSE-216* UREA N-43* CREAT-1.5* SODIUM-145 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-31 ANION GAP-15 [2114-8-9] 07:25PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2114-8-9] 07:25PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.015 Brief Hospital Course: Ms. [Known lastname 68525] is a 73 year old with multiple medical problems including non-ischemic cardiomyopathy who presented from an OSH with pulmonary edema and plan for BiV ICD placement which was put on hold given hypoxia prior to procedure. . Cardiac: Pump: Ms. [Known lastname 68525] has a history of recurrent NYHA stage IV CHF and was transferred to [Hospital1 18] for BiV pacer/ICD placement in the hope that it would help to manage her refractory CHF (EF 15-20%). An echo was done on [8-10] which showed a moderately dilated LV cavity with severe global systolic dysfunction, moderate mitral regurgitation and mild pulmonary hypertension. Prior to the procedure the patient was unable to lie flat due to hypoxia/ pulmonary edema and was transferred to the CCU for diuresis. While in the CCU she received multiple doses of 120mg IV lasix with resultant good urine output. Spironolactone was added as well, however her creatinine began to rise and her Na and K became elevated. Spironolactone was then held and she was given a small amount of free water to normalize her sodium levels. As her oxygenation had improved, she underwent [Company 1543] ICD, Concerto C154DWK placement on [8-14]. Given her low EF, the device was not tested post-procedure. She developed a hematoma over the site of ICD placement. A pressure dressing was applied to the site to prevent further hematoma. A line was delineated around the hematoma site to monitor for increasing size of hematoma, which was not noted. She was intubated electively for the procedure and returned to the CCU with the ETT tube in place. She was successfully extubated the following morning and was started on a low dose of captopril and eventually switched to lisinopril 2.5mg daily. Carvedilol was also started and was well tolerated. On [8-17] she was transferred to a regular floor. Her wound remained stable. She will follow up with EP Dr. [Last Name (STitle) 68526] for an ICD check 1wk from discharge. She was discharged on an aspirin and statin. The patient denied any lightheadedness, chest pain, site tenderness or palpitations. . Rhythm: The patient presented in atrial fibrillation, however she was not on coumadin for unclear reasons. After BiV placement, it was felt that anticoagulation was unnecessary. . Renal: The patient presented with renal insufficiency, likely secondary to her diabetes mellitus. Her creatinine increase was reported at [Hospital1 34] likely due to diuresis. A UA done on admission was negative for infection. She had minimal hematuria which resolved after her foley was d/c'd. Her creatinine peaked at 2.1, however on the day of discharge it had normalized to 1.1 which appeared to be her baseline. She had adequate urine output. . Pulm: As above the patient was electively intubated for ICD placement. She was successfully extubated and was satting well on RA with no shortness of breath. CXR on [8-18] showed no interval change, mild pulmonary edema consistent with CHF. . ID: The patient was placed on vancomycin for 5 days post ICD placement. In addition, as she developed diarrhea a C. diff toxin was sent which was positive. She was started on a 14 day course of flagyl and was placed on contact precautions. She remained afebrile and her WBC count remained wnl. . Hematologic: Ms. [Known lastname 68525] had a gradual decrease in platelet count since admission (admission 118, low 81 on [8-17]). Her platelets had trended up to 171 prior to discharge. Heparin antibodies were sent which were negative, however heparin was d/c'd and she was given pneumoboots. It was also noted that she was anemic. Studies did not show iron deficiency or hemolysis and she was guaiac negative. It was felt that she likely had anemia of chronic disease. She did not require transfusions. . Endocrine: She was placed on 70/30 insulin 48U in AM, 20U in PM. Her BG were monitored for hypoglycemia. . Psych: Ms. [Known lastname 68525] was maintained on her outpatient regimen of aricept and depakote. . F/E/N: She was placed on a heart healthy, diabetic diet. Electrolytes were checked twice daily while she was being diuresed and repleted as needed. Medications on Admission: Insulin 70/30 24u qAM 15u qPM RISS Coreg 3.25 twice daily SLNTG prn Protonix 40mg twice daily ASA 325mg Lovastatin 40mg daily Aricept 5mg qs Depakote 750daily Levaquin (x3days last [8-7] for UTI) (Digoxin 0.125mg discontinued) Lasix 20 mg [Hospital1 ] at home, (held [8-8], restarted [8-9]) got 40-60 IV x3 doses in past 24 hours Lisinopril (2.5 mg held [8-9]) Lovenox (?) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:30 Tablet(s) Refills:0 10. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension Sig: Forty Eight (48) units Subcutaneous qAM. 12. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension Sig: Twenty (20) units Subcutaneous prior to dinner. Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary: CHF class IV s/p BiV/ICD placement Non-ischemic cardiomyopathy Atrial fibrillation Mod-severe pulm HTN Mitral regurgitation Tricuspid regurgitation Secondary: Schizophrenia Dementia DM, type 2 Discharge Condition: Stable. The patient is hemodynamically stable. Discharge Instructions: You have a diagnosis of heart failure. You need to weigh yourself every morning, and [Name8 (MD) 138] MD if weight increases by > 3 lbs. Please adhere to 2 gm sodium diet. Some of your medications have changed. You are now taking metronidazole, an antibiotic, for an infection in your GI tract. You need to take 10 more days of this medication. In addition, you will only be taking Lasix 20mg ONCE per day, instead of twice daily. You have been restarted on digoxin. Please keep all outpatient appointments as listed below. If you begin to experience any chest pain, shortness of breath, palpitations, or pain or swelling at the site of the ICD please Followup Instructions: You have an appointment with the Device clinic on [2114-8-28] at 2:30 for evaluation of your BiV/ICD. Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 68527] within the next two weeks. [0-0-]	[ "42731", "5859", "5849", "2875", "4240", "4168", "V5867" ]
Admission Date: [2187-4-22] Discharge Date: [2187-4-25] Date of Birth: [2117-10-17] Sex: F Service: MEDICINE Allergies: Percocet / Iron / Latex Attending:[First Name3 (LF) 2901] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 69 yo F w/PMHx sx for PVD, COPD who presents with shortness of breath over the course of the last several days. Patient states that she developed a nonproductive cough last week, and saw her PCP who diagnosed her with bronchitis and treated her with ciprofloxacin and guaifenesin with codeine, and then with albuterol inhalers. She states that the symptoms did not improve, and she developed SOB at rest, with marked worsening over the last two days, to the point that she has had to sleep upright in a chair. She denies any fevers, chills, night sweats. She states that she develops some chest pain with coughing, but does not have chest pain at rest. She also notes nausea and vomiting after fits of coughing. She has never had these episodes before. . Patient was initially seen in the ED where her initial VS were T97.0 BP 123/60 HR 119 RR 28 O2sat 90% RA. She was felt to have a pneumonia and CHF, and was given azithromycin, nitro paste, nebulizers, ceftriaxone, furosemide 40 mg IV, aspirin 325, zofran, and morphine. Her initial EKG showed sinus tachycardia with 2 mm STE in V3. She had a CTA which showed bilateral pleural effusions and GGO c/w pulmonary edema, and she developed worsening respiratory distress and was placed on BiPap, with good resolution of her symptoms. Her first set of CE were positive. . Per patient report, she had a recent chemical stress test at her cardiologist's office 3 weeks ago, which was negative. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She does note exertional calf pain, as well as the development of a hematoma at the time of prior bypass surgery. All of the other review of systems were negative. . * Cardiac review of systems is notable for chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea. She denies ankle edema, palpitations, syncope or presyncope. Past Medical History: Hypertension Hyperlipidemia Peripheral vascular disease s/p multiple interventions Retroperitoneal hematoma in setting of PVD fem bypass Tobacco use Hx osteomyelitis of left heel Thyroid resection with resultant hypoparathyroidism Abdominal aortic aneurysm Chronic diarrhea Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension Social History: She lives alone, and continues to work part time as a cashier. She has a 40 pack year smoking history, quit sometime this year. Drinks socially. Denies any illicit drugs. Has a son in the area who is involved. Family History: Has 13 siblings, one with MI < 60 years of age. Physical Exam: VS: T97.0, BP 133/69, HR 113, RR 24, O2 100% on BiPap Gen: well appearing, frail elderly appearing female in mild respiratory distress on BiPap HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP to tragus. CV: PMI located in 5th intercostal space, tachycardic. Normal S1/S2. 2/6 SEM at RUSB. I/IV soft diastolic murmur at RUSB. Chest: No chest wall deformities, scoliosis or kyphosis. Increased WOB. Dull at bases. Inspiratory crackles bilaterally [12-7] both lung fields. Expiratory wheezing. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: Trace edema at ankles. Cool, hairless. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 1+ with bruit; Femoral 1+ with bruit; 1+ DP Left: Carotid 1+ without bruit; Femoral 1+ with bruit; 1+ DP Pertinent Results: [2187-4-22*] 02:00PM BLOOD WBC-11.4 RBC-5.07 Hgb-14.6 Hct-43.5 MCV-86 MCH-28.8 MCHC-33.6 RDW-14.0 Plt Ct-374 [2187-4-23] 11:07PM BLOOD WBC-15.5* RBC-4.05* Hgb-11.7* Hct-34.0* MCV-84 MCH-28.8 MCHC-34.3 RDW-14.5 Plt Ct-253 [2187-4-24] 07:10AM BLOOD WBC-19.8* RBC-3.97* Hgb-11.8* Hct-33.6* MCV-85 MCH-29.8 MCHC-35.2* RDW-14.8 Plt Ct-271 [2187-4-24] 04:18PM BLOOD WBC-18.0* RBC-3.68* Hgb-10.7* Hct-31.7* MCV-86 MCH-29.1 MCHC-33.8 RDW-14.9 Plt Ct-235 [2187-4-24] 09:30PM BLOOD WBC-20.4* RBC-3.61* Hgb-10.4* Hct-31.4* MCV-87 MCH-29.0 MCHC-33.2 RDW-14.8 Plt Ct-222 [2187-4-23] 12:00AM BLOOD PT-13.5* PTT-66.2* INR(PT)-1.2* [2187-4-24] 09:30PM BLOOD PT-28.3* PTT-78.3* INR(PT)-2.9* [2187-4-22] 02:00PM BLOOD Glucose-120* UreaN-25* Creat-1.1 Na-136 K-5.4* Cl-96 HCO3-22 AnGap-23* [2187-4-23] 11:07PM BLOOD Glucose-111* UreaN-38* Creat-1.6* Na-139 K-4.2 Cl-101 HCO3-21* AnGap-21* [2187-4-24] 07:10AM BLOOD Glucose-153* UreaN-45* Creat-2.0* Na-137 K-4.9 Cl-97 HCO3-26 AnGap-19 [2187-4-24] 12:23PM BLOOD Glucose-134* UreaN-51* Creat-2.7* Na-135 K-5.8* Cl-96 HCO3-17* AnGap-28* [2187-4-24] 04:18PM BLOOD Glucose-149* UreaN-55* Creat-3.1* Na-134 K-5.3* Cl-92* HCO3-22 AnGap-25* [2187-4-24] 09:30PM BLOOD Glucose-287* UreaN-56* Creat-3.4* Na-128* K-5.5* Cl-87* HCO3-18* AnGap-29* [2187-4-22] 02:00PM BLOOD CK(CPK)-498* [2187-4-23] 12:00AM BLOOD CK(CPK)-656* [2187-4-23] 08:38AM BLOOD CK(CPK)-546* [2187-4-23] 11:07PM BLOOD ALT-130* AST-409* CK(CPK)-1299* AlkPhos-65 TotBili-0.4 [2187-4-24] 07:10AM BLOOD CK(CPK)-2391* [2187-4-24] 09:30PM BLOOD ALT-1597* AST-4489* CK(CPK)-2939* AlkPhos-61 TotBili-0.6 [2187-4-22] 02:00PM BLOOD cTropnT-0.91* [2187-4-22] 06:15PM BLOOD cTropnT-1.44* [2187-4-23] 12:00AM BLOOD CK-MB-59* MB Indx-9.0* cTropnT-1.92* [2187-4-23] 08:38AM BLOOD CK-MB-40* MB Indx-7.3* cTropnT-2.74* [2187-4-23] 11:07PM BLOOD CK-MB-73* MB Indx-5.6 cTropnT-7.73* [2187-4-24] 07:10AM BLOOD CK-MB-70* MB Indx-2.9 cTropnT-9.86* [2187-4-24] 09:30PM BLOOD CK-MB-43* MB Indx-1.5 cTropnT-11.87* [2187-4-23] 12:00AM BLOOD Calcium-8.7 Phos-7.2# Mg-1.6 [2187-4-24] 04:18PM BLOOD Calcium-8.5 Phos-9.4 Mg-2.5 [2187-4-24] 04:26PM BLOOD Type-ART pO2-126* pCO2-38 pH-7.33* calTCO2-21 Base XS--5 [2187-4-24] 04:54PM BLOOD Type-MIX pH-7.26* [2187-4-23] 03:09PM BLOOD Glucose-342* Lactate-3.2* Na-126* K-4.5 Cl-97* [2187-4-23] 05:54PM BLOOD Lactate-10.9* [2187-4-24] 09:40AM BLOOD Lactate-4.6* [2187-4-24] 04:26PM BLOOD Glucose-131* Lactate-6.7* . EKG: [2187-4-22] 16:10: Sinus tachycardia. [Apartment Address(1) ] mm in V3. [Apartment Address(1) ] mm V4. LVH. . 2D-ECHOCARDIOGRAM performed on [12-12] demonstrated: EF 45-50%. Moderate regional left ventricular dysfunction with moderate hypokinesis of the basal to mid inferior segments. Moderate to severe mitral regurgitation. Moderate aortic regurgitation. Moderate pulmonary artery systolic hypertension. . [2187-4-23] ECHO: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with mid to distal anterior, septal and apical hypokinesis - LAD territory). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. The aortic valve is not well seen. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild to moderate ([12-6]+) aortic regurgitation is seen. The aortic regurgitation vena contracta is >0.6cm. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. At least moderate (2+), eccentric mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. Compared with the prior study (images reviewed) of [2186-12-18], regional LV systolic dysfunction is new. . [2187-4-23] Cardiac cath: COMMENTS: 1. Selective coronary angiography of this right-dominant system demonstrated two vessel coronary artery disease. The LMCA was free from angiographically-apparent disease. The LAD was severely calcified proximally and had 99% stenosis at mid vessel. The LCX was mildly diseasd. The RCA was a smaller vessel (2.0 mm) with long 70% stenosis. 2. Resting hemodynamic assessmet revealed severely elevated left-sided filling pressure (mean PCWP 35 mmHg) and moderately elevated right-sided filling pressures (RVEDP 13 mmHg). The opening systemic arterial blood pressur was normal (104/56 mmHg) and the pulmonary arterial pressure was moderately elevated (52/31/41 mmHg). The cardiac output and cardiac index were low (2.06 l/min and 1.5 l/min/m2) indicative of cardiogenic shock. 3. Left ventriculography was deferred. 4. Unsuccessful attempt at PCI of mid LAD due to inability to deliver any devices to lesion. 5. Cardiogenic shock proceeding to PEA from worsening ischemia necessitating intubation and IABP. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Cardiogenic shock 3. Unsuccessful PCI. Brief Hospital Course: Ms. [Name14 (STitle) 56700] is a 69 yo F w/hx HTN, hyperlipidemia, PVD, and tobacco use who presents with SOB [1-6] pulmonary edema in the setting of an NSTEMI. . # CAD/Ischemia: Patient with severe PVD, no history of any cardiac catheterizations. On presentation she had isolated ST elevation in V3. Cardiac enzymes were positive and she ruled in for NSTEMI. She was given a Plavix load and started on Metoprolol, ASA 325mg, Atorvastatin 80mg, Heparin drip and integrillin. She was taken to the cardiac catheterization lab on [2187-4-23] which showed two vessel disease with a 99% LAD and 70% RCA. PCI was attempted on LAD but unsuccessful. Patient then suffered from a PEA arrest which resulted in cardiogenic shock. An Intra-Aortic Balloon pump was placed and the patient was transferred to the CCU for further care. While in the CCU she remained on IABP. She was hypotensive and required pressors for blood pressure support. The patient was DNR/DNI and the family agreed to not attempt aggressive measures and to not escalate care. The patient went into Ventricular Tachycardia on the morning of [2187-4-25] and expired from cardiac arrest. The family was present at the time of death and declined autopsy. Medications on Admission: Meprobamate 400 mg QID PRN Calcium lactate 10 mg - 4 tabs [Hospital1 ] Belladona 1 tab qam 2 tabs qpm Calcitriol 0.25 mcg QD Levoxyl 100 mg qd Nifedipine 30 mg qd Pravastatin 80 mg qd Cyanocobalamin 1000 mcg qmonth ASA 81 mg qd Discharge Disposition: Expired Discharge Diagnosis: ST- elevation MI Anuric renal failure Respiratory failure Suspected aspiration vs. hospital acquired pneumonia Discharge Condition: expired Discharge Instructions: expired Followup Instructions: none [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "41071", "9971", "5849", "5070", "486", "41401" ]
Admission Date: [2135-7-14] Discharge Date: [2135-7-17] Date of Birth: [2135-7-14] Sex: F Service: NB [Known lastname ] [Known lastname 23934] is a 3-day-old, former 34 3/7 weeks baby girl admitted to the Neonatal Intensive Care Unit because of prematurity. She was born by cesarean section to a 25-year- old G1 now P1 mother. She had prenatal screens of blood type O positive, antibody positive which was felt to be due to RhoGAM administration at 20 weeks, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, and GBS unknown. The pregnancy has been complicated by maternal fever of unknown origin for which she was admitted to the [Hospital1 346] on [2135-7-2] through [2135-7-10]. The workup for mom was negative including no evidence of chorioamnionitis, negative Monospot, HIV negative, IGM for CMV negative, toxoplasmosis negative, malaria negative, PPD negative, [Doctor First Name ] negative, rheumatoid factor negative, Lyme disease negative, Legionella negative, Listeria negative, and the test for the West [Doctor First Name ] disease is pending at this time. Mother was treated with vancomycin , Azithromycin, and Aztreonam. Mother remained afebrile after her discharge to home on [2135-7-10] until [2135-7-12] when she spiked a temperature to 103.3. She was admitted to the [Hospital1 346] at that time and had labor induced with Pitocin. Due to failure to progress and persistent fever, delivery was via cesarean section. Artificial rupture of membrane occurred at time of delivery with clear fluid. The baby was vigorous at birth with [Name (NI) 55924] of 9 and 9 at 1 and 5 minutes. She received bulb suctioning only and did not require blow by oxygen. PHYSICAL EXAMINATION UPON ADMISSION: Baby is [Name2 (NI) ], alert, and well appearing 34.5-week gestation infant. Her weight is 2.745 grams, the 80th percentile, length 46 cm, 50th percentile, and head circumference 34 cm, 90th percentile. Her temperature is 98.8, heart rate 160, respiratory rate 56, and blood pressure 48/31 with a mean of 39. Her oxygen saturation is 96 percent on room air. HEENT: Anterior fontanel soft and flat, small, mobile sutures, palate intact. Respiratory: Lungs are clear and equal; no retractions. Cardiovascular: S1, S2 normal intensity; no murmur; good perfusion. Abdomen: Soft with normal bowel sounds; no organomegaly. GU: Normal female. Hips stable. Neuro: Moving upper and lower extremities well. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The baby had mature lungs and was comfortable breathing on room air with respiratory rates 40s to 60s, saturations greater than 95 percent. She had no evidence of apnea or prematurity during her course in the Neonatal Intensive Care Unit. Cardiovascular: Baby remained cardiovascularly stable with normal blood pressures, AP ranging from 130s to 160s. Fluids, electrolytes, and nutrition: Initial dextrose stick upon admission to the NICU was 37 for which an intravenous was placed and a bolus of D10W was given. This was followed by a running intravenous of D10W at 60 cc per kilo and enteral feeds were begun with Enfamil 20. Baby was fed p.o. ad lib and was taking approximately 60 cc per kilo initially at time of transfer to the [Name2 (NI) ] Nursery, is taking approximately 100 cc per kilo total p.o. intake of Enfamil 20. Mother is planning on breast feeding. Blood sugars off of intravenous fluids have remained in the normal range with the last being 74 on the day of transfer to the [Name2 (NI) ] Nursery. She has had normal urine output and has passed meconium stool. Her weight at time of transfer is 2.625 kg, which is down 125 grams from birth weight. Gastrointestinal: Baby has had no evidence of jaundice, and a bilirubin has not been obtained at this point. Hematology: Baby's blood type is O negative. Coombs is negative. Her initial CBC included a white count of 17.3 with 56 polys, 0 bands, 35 lymphs, 7 monos, 2 eosinophils, and 1 nucleated red blood cell. Her hematocrit was 46.7 percent and platelets were 380,000. A blood culture was also obtained at the time of admission, and ampicillin and gentamicin were begun. A lumbar puncture was performed to rule out meningitis. The culture is pending. The gram stain is negative. There were 0 red cells, 0 white cells. Glucose and protein were both normal at 55 and 98, respectively. Baby received 48 hours of ampicillin and gentamicin and these were discontinued on [2135-7-16], and the infant has remained clinically well off of antibiotics. Neurology: Baby has been appropriate for gestational age. Sensory: Audiology: A hearing screening was performed with automated auditory brainstem responses and passed on [2135-7-17]. CONDITION AT TIME OF TRANSFER TO [Year (4 digits) ] NURSERY: Good. Name of primary pediatrician is unavailable at this time. CARE AND RECOMMENDATIONS AT TRANSFER: Feedings at this time are Enfamil 20 p.o. ad lib with a target of 100 cc per kilo per day. Breast feeding may be initiated. Medications are none at this time. Car seat position screening is being done at time of dictation and results are pending. State [Year (4 digits) ] Screen was sent on [2135-7-17]. Immunizations Received are Hepatitis B vaccine on [2135-7-17]. Immunizations recommended: Synergist RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: Born at less than 32 weeks, Born between 32 and 35 weeks with two of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, AOA abnormalities of school age siblings, those infants with chronic lung disease Influenza immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. FOLLOW-UP APPOINTMENTS RECOMMENDED: With the primary care pediatrician. DISCHARGE DIAGNOSES AT TIME OF TRANSFER: Prematurity at 34 3/7 weeks. Corrected gestational age at time of transfer is 35 weeks. Sepsis suspect ruled out. Baby will be managed by the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Service in the [Last Name (NamePattern1) ] Nursery. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2135-7-17] 17:08:12 T: [2135-7-17] 18:00:34 Job#: [Job Number 55925]	[ "V290", "V053" ]
Admission Date: [2185-9-6] Discharge Date: [2185-9-13] Date of Birth: [2112-5-16] Sex: M Service: This is a 73-year-old male who presented with history of coronary artery disease who had also had a abdominal aortic aneurysm and renal artery stenosis which required stenting. He was taken to the cardiac catheterization lab where he was found to have multi vessel disease. PAST MEDICAL HISTORY: 1. Coronary artery disease 2. Renal artery stenosis to the left 3. Hypertension 4. Arthritis 5. Diverticulosis 6. Abdominal aortic aneurysm 7. Question of transient ischemic attacks MEDICATIONS: 1. Enteric coated aspirin 325 po qd 2. Prinivil 40 mg qd 3. Lopressor 50 [Hospital1 ] ALLERGIES: He had no known drug allergies. EXAM: VITAL SIGNS: He was afebrile. His vital signs were stable. HEAD, EARS, EYES, NOSE AND THROAT: No jugular venous distention. LUNGS: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. EXTREMITIES: Warm and well perfuse, 1+ pedal pulses and no edema. ADMISSION LABS: Hematocrit was 39.0. Chem-7: Sodium 141, potassium 4.6, chloride 107, bicarbonate 27, BUN 26, creatinine 1.8, blood glucose was 108. The patient was taken to the Operating Room on [2185-9-9] where a coronary artery bypass graft was performed. During catheterization, it was found that his ejection fraction was 55%. The patient was taken to the Operating Room where coronary artery bypass graft x4 off pump was performed. The left internal mammary artery was used for the diagonal saphenous vein graft to PDA and also a saphenous vein graft was used for the OM and LPO. The patient did well postoperatively and was transferred to the Intensive Care Unit. His medications later were weaned. He was kept on his Plavix and he was transfused 2 units. He was fully weaned off of his ventilator and was able to be extubated. Physical therapy was consulted for ambulation and mobility. His diet was advanced. He continued to do well and his chest tubes were removed. His Foley was removed as well and he continued to improve. He was transferred to the floor and physical therapy continued to work with him. He cleared physical therapy on [2185-9-13], postoperative day #4, and was discharged home in stable condition, however the patient required home PT which he was given a referral for. The patient is discharged home in stable condition, instructed to follow up with his primary care physician in one to two weeks how is also a cardiologist, Dr. [Last Name (STitle) 24638]. DISCHARGE MEDICATIONS: 1. Plavix 75 mg po qd 2. Percocet 1 to 2 tablets po q4h prn 3. Enteric coated aspirin 325 po qd 4. Zantac 150 po bid 5. Colace 100 mg po bid 6. Potassium 20 milliequivalents po bid 7. Lasix 20 mg po bid 8. Lopressor 25 po bid The patient is discharged home in stable condition with home PT and instructed to follow up in one to two weeks with his primary care physician and cardiologist. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern4) 7148] MEDQUIST36 D: [2185-9-13] 11:26 T: [2185-9-13] 13:38 JOB#: [Job Number 24639]	[ "41401", "40390" ]
Admission Date: [2120-12-18] Discharge Date: [2120-12-22] Service: MEDICINE Allergies: Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) / Fish Product Derivatives Attending:[Doctor First Name 2080] Chief Complaint: Angioedema Major Surgical or Invasive Procedure: Intubation, mechanical ventilation History of Present Illness: 87 yo female with PMH Atrial fibrillation on coumadin, HTN on lisinopril , HL, eczema, recent drermatologic rashes, and recent facial/lip swelling presenting with new tongue swelling this AM. Pt called daughter around 10:45 am and speech sounded garbled and pt complained of new swollen tongue. She took 1 tab of benedryl this AM and called her PCP who referred her to the ED. Of note per her family pt had episodes of ichy skin this summer and was seen by Dr. [Last Name (STitle) 22342] in dermatology. Family also reports facial and periorbital swelling on and off since [Month (only) ] of unknown etiology. Some family members report voice sounding funny on and off. Also 2 wks ago had significant swelling of the lips that was thought to be associated with eating pineapple. She took benadryl for several days with improvement and had appointment with allergist for later this month. . PT took benedryl 25mg po at home and received 50mg IV in the ambulance. In the emergency department on arrival vitals were T98.2 HR73 BP139/65 RR16 98% RA. The patient had significant tongue swelling and was difficult to understand. The decision was made to intubate the patient due to difficulty speaking. EKG was done and reported to have mild depressions in inferior leads. In the ED he received solumedrol 125mg IV x1, pepcid 20mg IV x1, versed 2mg IV prn sedation. VSS stable on transfer. . Unable to obtain ROS given pt intubated. Family reported pt recently feeling well except for HPI. Past Medical History: Atrial fibrillation Hypertension Hyperlipidemia Osteoporosis Osteoarthritis s/p right hip replacement eczema Hayfever as a child Social History: Lives at an independent living facility. Walks with walker and is very active and does exercise program. Never smoker. 1 glass wine per week. No illicits. Family History: -1st cousin with peanut allergy developed in his 80s. -No FH of asthma or eczema Physical Exam: Physical Exam on Admission: T 97/8 BP 147/61 HR 78 RR 20 O2 100% RA GENERAL: sedated, arousable, able to open eyes on command but no squeeze hands HEENT: Markedly swollen tongue unable to visualize back of throat. No facial or periorbital swelling. Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA. MMM. CARDIAC: irregular rhythm. No murmurs, rubs or [Last Name (un) 549]. No JVD. LUNGS: CTAB, good air movement bilaterally anteriorly. ABDOMEN: +BS. Soft, NT, ND. No HSM EXTREMITIES: No edema, 2+ dorsalis pedis and radial pulses. SKIN: + macular papular rash with excoriations on right back and hip. NEURO: sedated, arousable, able to open eyes on command but no squeeze hands Pertinent Results: Labs on Admission: . [2120-12-18] 12:30PM BLOOD WBC-11.6* RBC-4.10* Hgb-12.4 Hct-37.1 MCV-91 MCH-30.2 MCHC-33.4 RDW-12.9 Plt Ct-266 [2120-12-18] 12:30PM BLOOD Neuts-69.0 Lymphs-24.5 Monos-4.6 Eos-1.6 Baso-0.4 [2120-12-18] 12:30PM BLOOD Plt Ct-266 [2120-12-18] 05:45PM BLOOD PT-27.3* PTT-30.3 INR(PT)-2.7* [2120-12-18] 12:30PM BLOOD Glucose-118* UreaN-28* Creat-1.0 Na-143 K-5.4* Cl-109* HCO3-21* AnGap-18 [2120-12-18] 12:30PM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1 . Labs during admission [2120-12-21] 04:55AM BLOOD PT-38.8* PTT-30.9 INR(PT)-4.0* [2120-12-21] 04:55AM BLOOD ESR-28* [2120-12-21] 04:55AM BLOOD ALT-32 AST-48* [2120-12-21] 04:55AM BLOOD TSH-0.096* [2120-12-21] 04:55AM BLOOD T3-PND Free T4-1.4 [2120-12-21] 04:55AM BLOOD Anti-Tg-PND antiTPO-PND [2120-12-18] 05:45PM BLOOD C4-43* . Cardiac Enzymes: [2120-12-18] 12:30PM BLOOD CK(CPK)-92 [2120-12-18] 05:45PM BLOOD CK(CPK)-57 [2120-12-19] 04:00AM BLOOD CK(CPK)-43 [2120-12-18] 12:30PM BLOOD CK-MB-3 cTropnT-<0.01 [2120-12-18] 05:45PM BLOOD CK-MB-3 cTropnT-<0.01 [2120-12-19] 04:00AM BLOOD CK-MB-2 cTropnT-<0.01 . EKG ([2120-12-18]): Atrial fibrillation, average ventricular rate 81. Right bundle-branch block. Diffuse non-diagnostic repolarization abnormalities. No previous tracing available for comparison. . CXR ([2120-12-18]): Endotracheal tube as above. For optimal placement, consider retraction by approximately 1 cm. A tortuous aorta with cardiomegaly and no signs of failure. . [2120-12-22] 07:20AM BLOOD WBC-11.8* RBC-4.42 Hgb-13.6 Hct-39.5 MCV-89 MCH-30.7 MCHC-34.4 RDW-12.2 Plt Ct-258 [2120-12-22] 07:20AM BLOOD PT-25.8* INR(PT)-2.5* [2120-12-22] 07:20AM BLOOD Glucose-125* UreaN-23* Creat-0.9 Na-138 K-3.5 Cl-98 HCO3-27 AnGap-17 [2120-12-21] 04:55AM BLOOD ALT-32 AST-48* [2120-12-21] 04:55AM BLOOD TSH-0.096* [2120-12-21] 04:55AM BLOOD T3-PND Free T4-1.4 [2120-12-21] 04:55AM BLOOD Anti-Tg-PND antiTPO-PND [2120-12-18] 05:45PM BLOOD C4-43* [2120-12-21] 04:55AM BLOOD CU INDEX (ANTI-FCER1 ANTIBODY)-PND [2120-12-18] 05:45PM BLOOD C1 INHIBITOR-PND Brief Hospital Course: 87 yo female with PMH Atrial fibrillation on coumadin, HTN on lisinopril , HL, eczema, recent drermatologic rashes, and recent facial/lip swelling, who presented with new tongue swelling and s/p intubation in the ED. Each of the problems addressed during this hospitalization are described in detail below: . Angioedema: The patient was intubated in the ED as was having trouble talking secondary to tongue swelling and was tranferred to ICU for further care. Although pt with recent facial and lip swelling on and off since end of [Month (only) ], this was first episode of tongue swelling. The patient also noted to have had hay fever as child. Allergies to fish and sulfa but no exposure recently. Of note, the patient was also recently followed by dermatologist for rash. Because of the high degree of suspicion that this was caused by Lisinopril, this medication was dicontinued and added to the list of allergies. The patient was continued on Benadryl 50mg IV q6hrs, IV Methylprednisolone 80mg q8hrs, pepcid 20mg IV BID, fexofenadine. The morning after admission, the patient was successfully extubated as the swelling had significantly improved. The patient had no further episodes of facial or tongue swelling, difficulty breathing while in the ICU. The patient was seen by Allergy service, who will follow up the patient as outpatient. As part of workup for allergy, C4 levels were normal, C1 inhibitor levels, TSH, Thyroglobulin antibody, CU Index (Anti-FCer1 Antibody), Anti-TPO Antibody, SED RATE, RAST, and RAST for pineapple, flounder, cod, haddock, salmon. The TSH was 0.096 and free T4 was 1.4. The T3 was pending. The patient was switched to PO Prednisone, H2 blocker, and antihistamine. She will continue Prednisone 40mg daily, as well as her H2 Blocker and antihistamine until follow up with allergy to decide a taper. . Low TSH: TSH was 0.096 with free T4 of 1.4. T3, antiTPO, antiTg pending at discharge. By review of systems and exam, there was no evidence of thyroid dysfunction. The case was discussed with endocrinology, who felt her low TSH was a result of her recent high dose steroids, vs sick euthyroid syndrome, unlikely contributing to her angioedema in the setting of her lisinopril. Her TFTs should be rechecked in [4-10] weeks, and her pending results followed up. . EKG changes: On admission, the patient was noted to have ST depression in inferior leads from EKG in ED. No EKG was available for comparison. No Aspirin as given on admission given angioedema. The patient had 3 sets of negative cardiac enzymes. She had no symptoms concerning for ACS. We continued home Metoprolol and Zocor. . Hypertension: Lisinopril was discontinued due to angioedema. We continued home Amlodipine and Metoprolol. She was started on hydralazine for a third hypertension [Doctor Last Name 360]. Her BP stabilized and she was discharged on higher dose metoprolol (50mg [Hospital1 ]) as well as her amlodipine. . Eczema: We continued outpatient Triamcinolone topical 0.1% 1 app QID . Hyperlipidemia: We continued Zocor. . Atrial fibrillation: INR was theraputic an arrival. Coumadin was re-started on the morning of extubation. INR then became supertherapeutic to 4 and coumadin was held. On the day of discharge her INR was 2.5. Her home warfarin was resumed and her INR should be rechecked on [2120-12-24] and adjusted accordingly. . Osteoporosis: Home calcium and vitamin D were re-started in the morning after extubation. Patient receives Fosamax q Wednesday. . Medications on Admission: Coumadin 2.5 mg 1 tab MWF;1/2tab all other days metoprolol 50 mg [2-9] tab am; 1 tab pm Claritin 10 mg 1 tab(s) once a day triamcinolone topical 0.1% 1 app QID Norvasc 10 mg 1 tab(s) once a day calcium and vitamin D combination 600 mg-200 units 1 tab(s) TID Fosamax 70 mg 1 tab(s) 1X/W lisinopril 10 mg 1 tab(s) once a day Zocor 20 mg 1 tab(s) once a day (at bedtime) Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): to continue until your allergist appointment. DO NOT stop this medication abruptly. Disp:60 Tablet(s) Refills:0 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for itchiness: apply to affected area. 9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every Wednesday). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please resume your normal coumadin dosing and check your INR on [2120-12-24]. Discharge Disposition: Home Discharge Diagnosis: Angioedema secondary to ACE inhibitor Atrial Fibrillation Hypertension, benign Sublcinical Hyperthyroidism Eczema Discharge Condition: Good Discharge Instructions: You were admitted with swelling of the tongue (angioedema), and were briefly intubated to protect your airway. With steroids and anti-inflammatory medication, you condition improved. This was most likely caused by your Lisinopril. Please DO NOT take this medication or similar medications (ACE inhibitors) in the future. You ill be prescribed anti-inflammatory medications to treat your condition. . It is very important that you follow up with the Allergist on [2120-12-24], to decide a taper of your prednisone and to identify a cause. . Your thyroid test was abnormal, which may be a false value. You will need your thyroid tests checked in [4-10] weeks to further assess this value. . Resume all medications as prescribed. Your metoprolol has been increased to 50mg twice daily. Please resume your coumadin and recheck your INR on [2120-12-24] . Return to the hospital with recurrent lip/tongue swelling, shortness of breath, or any other concerning symptoms. Followup Instructions: Allergist appointment Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9703], [Name12 (NameIs) 280] Phone:[Telephone/Fax (1) 9316] Date/Time:[2120-12-24] 2:00 . Please follow up with PCP: [First Name8 (NamePattern2) 3296] [Last Name (NamePattern1) 3297],[Name12 (NameIs) 3295] I. [Telephone/Fax (1) 608], in [3-13] weeks	[ "42731", "2724", "V5861" ]
Admission Date: [2138-12-26] Discharge Date: [2139-1-2] Date of Birth: [2060-8-14] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 2597] Chief Complaint: Aorto-illiac disease Major Surgical or Invasive Procedure: Open Aorto-bifemoral bypass with [Female First Name (un) 899] reimplantation History of Present Illness: Pt is a 78 year old man who presents with thigh claudication who comes to the hospital today for aorto-bifemoral bypass Past Medical History: Aorto-illiac disease CABG HTN Social History: Married, one child, retired electrician No ETOH or Tobacco Family History: Mother with esophageal CA Sister with MI Physical Exam: 98.6 74 16 131/40 96%RA AOx3 NAD RRR CTA Abd: soft, non-tender, no mass ext: warm, well perfused Pertinent Results: [2138-12-26] 06:51PM BLOOD WBC-9.8 RBC-3.51* Hgb-10.9# Hct-32.5 MCV-93 MCH-31.0 MCHC-33.5 RDW-13.1 Plt Ct-624* [2138-12-26] 06:51PM BLOOD Plt Ct-624* [2138-12-26] 06:51PM BLOOD PT-16.0* PTT-46.2* INR(PT)-1.6 [2138-12-26] 06:51PM BLOOD Glucose-164* UreaN-21* Creat-0.5 Na-140 K-4.6 Cl-111* HCO3-26 AnGap-8 [2138-12-26] 06:51PM BLOOD Calcium-8.0* Phos-3.3 Mg-1.4* Brief Hospital Course: The patient was left intubated post operation due to some concerns of hypotenstion. This resoled quickly and he was extubated. He was extubated by the AM of POD1. He did well postoperativly. He had epidural anesthesia, which provided good pain control. He was moved to the VICU on POD1. His diet was held until flatus was passed. His INR was revered with Vit K. A bleeding time was done to assess coagulation, which was normal. His swan catheter was changed to cvl on POD 3 due to stable cardiac function. In the OR, a stomach mass was found, so Dr.[Name (NI) 1482] service was consulted, he will f/u as an outpt. He was found to have a weak left deltoid, and neurology was consulted. After extensive radiological study, no definate cause for his weakness was found, but it had almost complealty resolved by the time of discharge. Otherwise his diet advanced without incident and he did well from a PT persepective. He was d/c'ed on POD 7 on coumadin to be followed by his PCP. Medications on Admission: Lipitor 40' verapamil 180' altace 5' asa 81mg' mvi lasix 20' doxycycline 100" vit E Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Verapamil HCl 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 9. Outpatient Lab Work Please Draw PT/INR Three times a week Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: abdominal aortic aneurysm Discharge Condition: Good Discharge Instructions: Notify your MD if you experience increasing pain in the abdomen or back, pain, coldness or discoloration of either of your feet or any other sign that is concering to you. Get yor INR checked three times a week through your PCP Followup Instructions: Call both Dr. [Last Name (STitle) ] and your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 5456] for follow up. Call Dr.[Name (NI) 56701] office as soon as you get home to set up your first blood draw Also, call Dr.[Name (NI) 1482] office for follow up regaring stomach mass Completed by:[2139-1-2]	[ "42731", "496", "2720", "V4581" ]
Admission Date: [2145-11-3] Discharge Date: [2145-11-23] Date of Birth: [2075-7-6] Sex: M Service: CSURG Allergies: Diamox Sequels Attending:[First Name3 (LF) 1283] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: sp resection of complex distal arch/proximal descending aortic aneurysm w/ deep hypothermic circulatory arrest [2145-11-3]. sp tracheostomy/bronchoscopy [2145-11-17] History of Present Illness: 70 M p/w shortness of breath X 2 years. Upon work-up, CXR ? mediastinal "vascular" mass and B upper lobe pulmonary nodules. CT [8-2] revealed 5.8X4.9 saccular aneurysm of the proximal descending aorta, calcified atherosclerotic descending aorta. Past Medical History: NIDDM OSA on BIPAP obesity CAD sp stent X 2 hypercholesterolemia HTN remote malaria remote spontaneous pneumothorax BPH h/o hemorrhoids Social History: Tobacco: 1 ppd X 30 [Month/Year (2) 1686], quit 25 [Month/Year (2) 1686] ago. Rare ETOH. Family History: Father dies in 50's-CAD/MI Mother alive @ [Age over 90 ] [Name2 (NI) 1686] old. Physical Exam: Obese, slightly uncomfortable from shortness of breath PERRLA, EOMI No JVD/bruits CTAB RRR obese, NT/ND warm, well perfused CN II-XII Pertinent Results: [2145-11-22] 04:26AM BLOOD WBC-8.3 RBC-3.39* Hgb-10.6* Hct-32.3* MCV-95 MCH-31.3 MCHC-32.8 RDW-15.0 Plt Ct-408 [2145-11-16] 03:39AM BLOOD WBC-15.5* RBC-3.95* Hgb-12.2* Hct-37.3* MCV-94 MCH-30.8 MCHC-32.7 RDW-14.3 Plt Ct-422 [2145-11-15] 04:30AM BLOOD WBC-12.5* RBC-4.08* Hgb-12.7* Hct-38.1* MCV-93 MCH-31.0 MCHC-33.2 RDW-14.2 Plt Ct-385 [2145-11-4] 02:45AM BLOOD WBC-5.4 RBC-2.96# Hgb-9.0# Hct-25.8* MCV-87 MCH-30.3 MCHC-34.8 RDW-15.4 Plt Ct-177 [2145-11-8] 02:40AM BLOOD WBC-7.9 RBC-3.59* Hgb-11.3* Hct-32.7* MCV-91 MCH-31.4 MCHC-34.6 RDW-14.4 Plt Ct-153 [2145-11-18] 02:44AM BLOOD PT-13.1 PTT-25.5 INR(PT)-1.1 [2145-11-3] 05:27PM BLOOD PT-17.8* PTT-33.0 INR(PT)-2.0 [2145-11-3] 06:25PM BLOOD Fibrino-194 [2145-11-22] 04:26AM BLOOD Glucose-187* UreaN-41* Creat-0.8 Na-147* K-4.6 Cl-108 HCO3-28 AnGap-16 [2145-11-4] 02:45AM BLOOD Glucose-119* UreaN-20 Creat-1.0 Na-143 K-4.5 Cl-109* HCO3-25 AnGap-14 [2145-11-16] 03:39AM BLOOD ALT-134* AST-56* AlkPhos-115 Amylase-102* TotBili-0.6 [2145-11-17] 09:46PM BLOOD Type-ART Temp-38.2 PEEP-10 O2-40 pO2-164* pCO2-38 pH-7.44 calHCO3-27 Base XS-2 Intubat-INTUBATED Vent-IMV [2145-11-3] 09:07AM BLOOD Type-ART Tidal V-800 O2-100 pO2-308* pCO2-54* pH-7.33* calHCO3-30 Base XS-1 AADO2-363 REQ O2-64 Intubat-INTUBATED Vent-CONTROLLED [2145-11-16] 05:04AM BLOOD Lactate-2.3* Brief Hospital Course: [11-3]: Admitted to OR (see operative report for details), post-op to CSRU, initially kept paralyzed and sedated to facilitate oxygenation and ventilation. Had intrathecal catheter for first few post-op days for drainage and pain control. [11-4]: bronchoscopy for thick secretions [11-5]: antihypertensives initiated Neurology consult obtained due to decreased level of responsiveness/movement after sedation/paralytics stopped. Head CT's X 2 ([11-5] & [11-7]) showed no acute bleed nor stroke. MRI on [11-8] showed multiple embolic subacute infarcts, Left > Right. Pt. continued with decreased movement despite becoming "more awake" over next week. MRI of TLS spine revealed no cord compression nor intrinsic abnormality. Multiple attempts to wean vent over next few days were unsuccessful, Tube feeding was initiated as pt. was not able to be extubated. Had elevated temp., with hypotension requiring neo-synephrine for a few days. Treated epirically w/Vancomycin & Levofloxacin. Had 1 positive blood culture (out of 4, felt to be contaminated, subsequent blood cultures were negative). Tracheostomy performed on [11-17] due to need for continued vent. support, and slow nature of vent. weaning. Pt. had become more responsive, but still with significant decrease in movement. PICC line placed on [11-19] for IV access. Has been tolerating tube feedings well through Dobhoff feeding tube. Pt. had remained stable for a number of days, on slowly decreasing vent. support. Spiked temp to 101.8 again (off antibiotics) on [11-21]. While chest x-ray was unremarkable, he had copious amt. of thick sputum. Previous sputum culture was positive for pan-sensitive staph. Repeat sputum was the same. Pt. was re-started on Levaquin for positive sputum (without x-ray evidence of infiltrate, or elevated WBC). Temp. has decreased, and pt. now ready for rehab. Medications on Admission: ASA 325', metformin 1000", pravachol 20', isosorbide 60', lopressor 100", accupril 40", HCTZ 25', Doxazosin 2", MVI' Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Ranitidine HCl 15 mg/mL Syrup Sig: One [Age over 90 1230]y (150) mg PO QD (once a day). 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QD (once a day) as needed. 6. Trazodone HCl 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: started [11-22]. 8. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) Injection four times a day: as per sliding scale. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed) as needed for K<4.4 and CR<2.0. 14. Humalog 100 unit/mL Solution Sig: One (1) vial Subcutaneous every four (4) hours: Sliding scale humalog insulin coverage Q 4 hours: BS 121-140=3Units s/c BS 141-160=6U s/c BS 161-180=9U s/c BS 181-200=12U s/c BS 201-220=15U s/c BS 221-240=18U s/c BS >240=21U s/c . Disp:1 vial Refills:2 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) vial Subcutaneous every twelve (12) hours: 30 Units s/c Q 12 hours. Disp:1 vial Refills:2 Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: proximal descending aortic aneurysm Discharge Condition: stable Discharge Instructions: Please call physician if experiencing fever/chills, nausea/vomiting, redness/drainage from the wound site, chest pain/shortness of breath. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 1290] in 3 weeks; call the office for an appointment. Please follow up with Dr. [Last Name (STitle) ]; call the office for an appointment. Please follow up with your PCP/cardiologists within 1-2 weeks regarding new medications. Completed by:[2145-11-23]	[ "25000", "2720", "4019", "V4582" ]
Admission Date: [2107-2-13] Discharge Date: [2107-2-15] Date of Birth: [2076-8-17] Sex: M Service: MEDICINE Allergies: ceclor / compazine Attending:[Known firstname 2751] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 30 year old male with PMH of barrett's esophagous s/p nissen fundoplication in [2093], emergent splenectomy in [2099] s/p snow boarding accident, metastatic soft tissue fibrosarcoma s/p small bowel resection in [2104] at [Hospital1 2025], started chemo in [Month (only) ] with transition to temador chemotherapy (last dose during first week of [Month (only) ]), who presents with fevers to 102, crampy abdominal pain, and watery, nonbloody diarrhea. . Two-three weeks prior to admission, patient originally admitted to [Hospital1 18] [Location (un) 620] with fevers, abdominal pain, and watery diarrhea. Found to be c. diff positive, initially treated with PO vanco and IV flagyl X 2 days before he was transferred to [Hospital1 2025], the location of most of his care. At [Hospital1 2025], he was treated with flagyl monotherapy and discharged with instructions to complete 10 day course of flagyl, which he completed 5 days prior. He had full resolution of his symptoms with good PO intake, until this morning, when he developed fevers to 102, crampy abdominal pain, and watery diarrhea similar to his prior presentation. He denies any recent travel, sick contacts. . Of note, patient sees Dr. [Last Name (STitle) 12262] at [Hospital1 2025] for his oncologic care and reports receiving temador chemotherapy during the first week of [Month (only) ]. During his prior admission, patient also found to have a clot in his right jugular vein and started on coumadin as an outpatient. . In the ED, initial vitals were T: 101.8, BP: 108/73, HR: 123, RR: 18, O2sat: 100% on 2L. Labs notable for leukocytosis of 23.8, plt of 602, lactate of 1.6, INR of 3.1. ECG demonstrated sinus tachycardia with rate of 121 and without signs of ischemia. Guiac positive. CT abdomen with contrast demonstrated colitis and multiple mesenteric masses and right pararenal mass consistent with patient's history of low-grade fibrosarcoma. At [Hospital1 18] [Location (un) 620], patient was given flagyl 500mg IV X 1, toradol 30mg IV X 1, and 1 gram tylenol PO X 1. On arrival to [Hospital1 18], patient was given vancomycin 500mg PO X 1, morphine 4mg IV X 1, 1mg ativan IV X 1 for rigors, 600mg motrin PO X 1 and tylenol 1gram PO X 1. Was given 3L NS. Past Medical History: - barrett's esophagous s/p nissen fundoplication in [2093] at [Hospital3 1810] [Location (un) 86] - emergent splenectomy in [2099] s/p snow boarding accident - metastatic soft tissue fibrosarcoma s/p small bowel resection in [2104]. Oncologist at [Hospital1 2025] is Dr. [Last Name (STitle) 12262]. S/p temador chemotherapy during the first week of [2106-12-13]. - right IJ clot [3-16] port, on coumadin Social History: Denies any smoking history. Consumes on average 3 drinks per week. Family History: Endorses history of strokes in his family. Physical Exam: VS: Temp: 102, BP: 107/65, HR: 108, RR: 20, 98% RA GEN: anxious, diaphoretic HEENT: PERRL, EOMI, anicteric, dry mucous membranes. No supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: tachycardic, S1 and S2 wnl, no m/r/g ABD: Midline vertical scar from prior surgeries. +BS in all 4 quadrants. Tender diffusely to deep palpation. No g/r/r. EXT: no c/c/e SKIN: Right sided port. No rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps STOOL: Guiac positive. Pertinent Results: Labs on Admission: [2107-2-13] 04:57PM URINE HOURS-RANDOM [2107-2-13] 04:57PM URINE UHOLD-HOLD [2107-2-13] 12:20PM URINE HOURS-RANDOM [2107-2-13] 12:20PM URINE GR HOLD-HOLD [2107-2-13] 12:20PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.013 [2107-2-13] 12:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2107-2-13] 11:16AM COMMENTS-GREEN TOP [2107-2-13] 11:16AM LACTATE-1.6 [2107-2-13] 11:00AM GLUCOSE-99 UREA N-12 CREAT-0.9 SODIUM-138 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17 [2107-2-13] 11:00AM estGFR-Using this [2107-2-13] 11:00AM ALT(SGPT)-97* AST(SGOT)-48* ALK PHOS-72 TOT BILI-0.6 [2107-2-13] 11:00AM LIPASE-29 [2107-2-13] 11:00AM WBC-23.8* RBC-4.38* HGB-13.3* HCT-38.1* MCV-87 MCH-30.3 MCHC-34.8 RDW-15.3 [2107-2-13] 11:00AM NEUTS-86.6* LYMPHS-5.5* MONOS-7.4 EOS-0.1 BASOS-0.5 [2107-2-13] 11:00AM PLT COUNT-602* [2107-2-13] 11:00AM PT-30.8* PTT-33.9 INR(PT)-3.1* Labs on Discharge: [2107-2-15] 06:25AM BLOOD WBC-7.7# RBC-4.22* Hgb-12.8* Hct-37.6* MCV-89 MCH-30.4 MCHC-34.1 RDW-15.6* Plt Ct-571* [2107-2-15] 06:25AM BLOOD Neuts-53 Bands-0 Lymphs-23 Monos-17* Eos-0 Baso-0 Atyps-6* Metas-0 Myelos-1* [2107-2-15] 06:25AM BLOOD Glucose-100 UreaN-4* Creat-0.7 Na-139 K-3.4 Cl-103 HCO3-28 AnGap-11 [2107-2-15] 06:25AM BLOOD ALT-60* AST-30 LD(LDH)-152 AlkPhos-60 TotBili-0.3 [2107-2-15] 06:25AM BLOOD Mg-1.9 EKG: ECG demonstrated sinus tachycardia with rate of 121 and without signs of ischemia. Normal axis, normal intervals. . Imaging: . [2107-2-13]: Chest radiograph ([Hospital1 18] [Location (un) 620]): No acute cardiopulmonary process. . [2107-2-13]: CT Abdomen/Pelvis with Contrast ([Hospital1 18]): PRELIM READ: 1. mildly thickened colonic wall may represent resolving infectious colitis 2. multiple mesenteric masses and R pararenal mass c/w pt's hx of low-grade fibrosarcoma Brief Hospital Course: #. Fever/abdominal pain/diarrhea: In lieu of recent hospital discharge from [Hospital1 2025] for c. diff infection and recurrence of symptoms with cessation of flagyl therapy, symptoms most consistent with recurrent c. diff infection. CT abdomen with evidence of colitis but without other nidus for infection. C Diff toxin returned positive which , given his symptoms, is consistent with a relapse of his prior infection. He was started on PO vancomycin and IV flagyl in the ICU. He remained afebrile and his abdominal pain resolved. Initially a fever workup was started given his asplenia and blood cultures revealed no growht to date in the hospital. Stool cultures did not reveal any of CAMPYLOBACTER, O&P, VIBRIO, YERSINIA, OR E. COLI 0157:H7. The patient was ultimately discharged on a total 14 days course of PO Vanomycin and PO Metronidazole. Major risk for initial C. Diff infection is chemo and PPI therapy, and major risk for recurrent severe C. Diff colitis is PPI therapy during first treatment course. Consideration to be given by PCP for discontinuation of PPI if can tolerate. . #. Tachycardia: Likely secondary to underlying infection and hypovolemia secondary to diarrhea. Responded to IV resuscitation. HR on discharge was in the 80s. . #. Leukocytosis: Likely secondary to underlying infection as above. Trended down to 7.7 upon discharge with antibiotics . #. Metastatic Fibrosarcoma: CT abd/pelvis demonstrates multiple mesenteric masses and R pararenal mass. Patient will follow up with his outpatient oncologist and will have CT scan on CD to show his doctor at his next outpatient appt. . #. Right IJ Clot: secondary to intervention during last hospitalization. Patient on coumadin as an outpatient which was held initially as INR was supratherapeutic and patient was started on abx. INR prior to d/c was 2. He will follow up with his outpatient providers to have INR monitoring while on antibiotics. . #. Asplenia: fully vaccinated as outpatient. Unclear if has prophylactic abx prescription at home but did not take it when he was febrile prior to admission. Will need f/u with PCP [Last Name (NamePattern4) ]:antibiotics for ppx in the future. Fever workup as above revealed no source other than C. Diff for infection. . #. Barrett's Esophagous: Stable, continued home PO PPI, though consideration for discontinuing this should be given since PPI don't affect transformation of Barrett's epithelium into adenoca. . #. Code: Full . #. Outstanding Labs for follow-up: [2106-2-13] MRSA Screen - PND [2106-2-13] Blood Culture - PND . #. Active Issues on Discharge: - Metastatic Fibrosarcoma (continued treatment per O/P oncologist) - Reccurence of C. Diff (to discuss with PCP the need for further PPI therapy) - Transaminitis (Patient found on discharge to have a slighly elevated ALT, with remaining liver enzymes WNL; encouraged PCP f/u for further eval as needed). Medications on Admission: - coumadin 7mg Monday, Thursday, Sat - coumadin 6.5mg Tues, Wed, [Last Name (LF) 2974], [First Name3 (LF) 1017] - prilosec 40mg PO BID Discharge Medications: 1. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO every six (6) hours for 13 days. Disp:104 Capsule(s) Refills:0 2. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 13 days. Disp:39 Tablet(s) Refills:0 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please use 5 mg tablet in combination with 1 mg tablets to create the appropriate warfarin dosing per your anticoagulation nurses. Disp:30 Tablet(s) Refills:2 5. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please use 5 mg tablet in combination with 1 mg tablets to create the appropriate warfarin dosing per your anticoagulation nurses. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Clostridium Difficile Colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 12263], you were admitted to the hospital because you had an infection of your gastrointestinal tract known as Clostridium Difficile. You have had this infection before in the past, and on your current admision you were started on two different antibiotics to help treat Clostridium Difficile. When you leave the hospital: 1. START taking Vancomycin 500 mg every 6 hours for the next 8 days 2. START taking Metronidazole 500 mg every 8 hours for the next 8 days Please continue taking your other medications as you normally do. Please follow-up with your anticoagulation nurses to determine your optimal dosing of warfarin Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] M. Address: [Last Name (un) 12264] 555 WACC, [Location (un) ],[Numeric Identifier 10614] Phone: [Telephone/Fax (1) 12265] Appointment: [Telephone/Fax (1) 2974] [2107-2-18] 11:45am Name: [Last Name (LF) ],[Name8 (MD) ] MD Address: [Street Address(2) 12266], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 12267] Appointment: Thursday [2107-2-17] 1:40pm for lab work 2:40pm with Dr. [Last Name (STitle) 12262].	[ "V5861" ]
Admission Date: [2154-12-14] Death Date: [2154-12-15] Service: MEDICINE/[Doctor Last Name 1181] HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old male with a history of encephalitis, oral cancer, presenting to Intensive Care Unit with shortness of breath and hypoxia secondary to a large pleural effusion. While in the Intensive Care Unit, the patient had transient hypotension and had a large O2 requirement secondary to the large effusion and multiple pulmonary nodules almost certainly representing metastatic disease. The patient was stabilized with IVF and supplemental O2. The medical situation including presumed widely metastatic cancer with likely malignant effusion was discussed with the patient. Mr. [Known lastname 1182] firmly delined further diagnostic interventions or therapies to work up and treat this. Based on his firmly expressed opinion, his code status was made DNR/DNI and primary driver changed to maintaining comfort. On [2154-12-15], the patient was stable for transfer to floor for further care. He remained with a high supplemental FiO2 requirement in order to maintain borderline sats. Mr. [Known lastname 1182] frequently removed his face mask saying that he just wanted to be comfortable. He expressed understanding that going without supplemental Oxygen would put him at risk for respiratory or cardiac arrest. On [2154-12-15] at 11:05 pm, the senior resident was called to see patient for unresponsiveness. The patient had continued to refuse oxygen during the day into the evening. He had only intermittently complied with wearing the mask secondary to comfort concerns. as he had done in the MICU, and earlin the On evaluation by the sernior resident, the patient had no respirations. The patient had no response to voice or sternal rub or other painful stimuli. The patient had no heart sounds. Pupils were fixed and dilated. The patient was pronounced dead. The Attending was notified and family contact[Name (NI) ]. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-948 Dictated By:[Last Name (NamePattern1) 1183] MEDQUIST36 D: [2155-2-12] 10:54 T: [2155-2-12] 11:12 JOB#: [Job Number 1184]	[ "486", "5849" ]
Admission Date: [2153-7-30] Discharge Date: [2153-8-24] Date of Birth: [2080-5-20] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5810] Chief Complaint: C. diff diarrhea, abdominal pain Major Surgical or Invasive Procedure: Colonoscopy, flexible sigmoidoscopy Exploratory Laparotomy History of Present Illness: 73 yo F with hypertension, asthma and newly diagnosed PUD and Crohn's and multiple recent admissions for persistent diarrhea and abdominal pain who is transferred from [Hospital3 25357] after presenting [2153-7-25] with abdominal pain and diarrhea again and found to have C.diff colitis without improvement on vancomycin and metronidazole. . Patient was initially admitted [Date range (3) 90587] at [Hospital3 25357] with abdominal pain, diarrhea and fever though to be secondary to infectious gastroenteritis treated with metronidazole and levofloxacin x 14 days. Stool cultures were negative. Also found to have peptic ulcer disease on EGD (duodenal and prepyloric ulcer - reportedly large and deep) and started on PPI (biopsies negative for H.pylori or malignancy and revealed benign gastric antral type mucosa with chronic superficial gastritis and lymphoid folicular formation with foveolar hyperplasia per discharge summary [2153-7-30]). . Hospitalized again at [Hospital1 189] from [Date range (1) 90588] with RLQ abdominal pain, early satiety and weight loss. CT on admission showed thickening of cecum and ascending colon concerning for inflammatory versus infectious colitis. Also showed heavy calcified plaque at the origins of the celiac artery and SMA. Gastroenterology was consulted, colonoscopy performed [2153-7-13] and per discharge summary consistent with Crohn's disease (biopsy per [2153-7-30] discharge summary was negative for malignancy but showed inflamed granulation tissue with foreign body giant cells). Started on mesalamine. Stool studies negative for infection (negative c.diff and O/P per discharge summary). Of note, last colonoscopy was in [2151] but incomplete study due to anatomy. Discharge summary from [2153-7-14] does not mention antibiotics however discharge paperwork from today references that patient was treated with ciprofloxacin and metronidazole (patient unable to recall). . Patient re-presented to [Hospital6 204] on [2153-7-25] with diffuse abdominal cramping (acute on chronic), rigors, low grade fever, diarrhea and poor po intake with relative hypotension to 100/70. Her labs were significant for leukocytosis of 21.5K. Patient was started on high dose methylprednisolone, levofloxacin and metronidazole for presumed Crohn's flare. C.diff was positive in the stool (per discharge summary, no results reported) and methylprednisolone was discontinued (unclear when d/c'ed). CT abdomen and pelvis on [2153-7-29] was obtained which showed inflammatory changes in the colon unchanged from [2153-7-10]. Also showed subacute infarcts of spleen. Heme/onc was consulted which recommended MRI or doppler ultrasound to rule out splenic vein thrombosis. Hypercoagable work-up significant for low protein C activity. Given that patient continued to have abdominal pain, poor po and diarrhea and white count has not improved, decision made to transfer to [Hospital1 18] for second opinion. . Patient reports she continues to have diffuse ache-like abdominal pain with sitting and intermittent sharp periumbilical pain (which is new x 3 days). Continues to have 3-4 episodes of watery non-bloody diarrhea per day which she states has been going on for months. Reports very poor po intake due to lack of appetite and bad taste in mouth. Endorses weight loss however unable to quantify (Atrius note states 28 lbs since [Month (only) 116]). No nausea or vomiting. No fever or chills. No history of blood clots. Denies history of a.fib. . - General: No fevers, chills, sweats, + weight loss - HEENT: no changes in vision or hearing, no rhinorrhea, nasal congestion, headaches, sore throat - Lungs: no cough, shortness of breath, dyspnea on exertion - Cardiac: no chest pain, pressure, palpitations, orthopnea, PND - GI: + abdominal pain, no nausea, vomiting, + diarrhea, - constipation, -BRBPR, -melena - GU: no dysuria, hematuria, urgency, frequncey - MSK: no arthralgias or myalgias - Neuro: no weakness, numbness, seizures, difficulty speaking, changes in memory. Past Medical History: PUD - duodenal and prepyloric ulcers on EGD [6-11] HTN Asthma Social History: Lives with husband - four children and four grandchildren all healthy. Retired 1.5 years ago - teacher aid at an elementary school Quit tobacco 22 years ago, 1 ppd No heavy alcohol in the past, sometimes one cocktail a day but around the time of her granddaughter's death she reports having 'a couple' of cocktails per day. She has not had any alcohol in the last few months since the GI symptoms worsened. No history of drug use or IVDU Family History: Father - prostate and bladder cancer Grandmother - colon cancer Physical Exam: Admission Exam: VS: 96 105/67 86P 20RR 97RA Gen: alert, NAD, pleasant, resting comfortably in bed Heent: anicteric, eomi, perrl, op clear s lesions, mmd Neck: supple, no LAD, no JVD Cv: +s1, s2 -m/r/g Pulm: clear bilaterally Abd: soft, nt, nd, +bs Extr: no edema, 2+ dp/pt, no calf ttp Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Discharge Exam: VS: Tc/m 99.3, HR 106, 140/68, 16, 94% 1L and 92% on RA General: pleasant, NAD lying in bed smiling and interactive with dobhoff in and tube feeds running EENT: PERRL, EOMI, dry mucous membranes, no thrush CV: RRR, nml S1/S2, no murmurs, rubs, gallops Pul: CTAB. good air entry, good chest expansion with encouragement GI: stapled 6inch incision which is clean/dry/intact with some dried blood around staples, normoactive bowel sounds, soft, nondistended, diffusely tender, worse around incision site MSK: no joint swelling or erythema Extremities: warm and well perfused, 2+ edema to the knees bilaterally. LYMPH: no cervical lymphadenopathy SKIN: no rashes, no jaundice, some erythema of left forearm improved from yesterday NEURO: awake, alert and oriented x3 Pertinent Results: [8-2] K 3.3 after repletion, normal Bun/Creat, normal LFTs phos low at 1.9 WBC down to 11.4, Hct 35.2, plts 460 [Hospital1 18] micro: neg cdiff, neg stool cx and O+P, blood cx neg to date, H pylori serology P . Reviewed outside labs in chart: protein C level 72 (normal range 77-173), this value is not diagnostic or even suggestive of true protein C deficiency, other hypercoag labs including Factor V leidin, anti-thrombin III, lupus anticoagulant, anti-cardiolipin, factor II mutation are negative. . C diff toxin positive on [7-27], stool cultures are negative. albumin low to 2.1 on [7-28], PM cortisol level 19.4, CK 26, CRP 5.4, WBC high of 37.5 with 14% bands on [7-28]. . Recent study reports: kub with non-specific bowel gas pattern splenic vein duplex with splenic infarcts, intact venous/arterial flow [2153-7-30] OSH Labs: 138 107 9 -----------< 76 4.2 22 0.3 29.3> 12.8/37.2 <316 WBCs: 24 -> 37.5 -> 26.8 -> 29.3 Hct: 38 -> 45 -> 36 -> 37 . OSH Imaging: . [2153-7-25] AXR: diffuse colitis with marked mural thickening, no pneumatosis or abnormal gaseous distension of bowel . [2153-7-26] CT abdomen and pelvis with contrast: probable subacute splenic infarcts; inflammatory and/or infectious change of colon unchanged or slightly improved since [2153-7-10] study (thickening of the wall of ascending colon and cecum, mild to moderate wall thickening in descending colon and splenic flexure) . [2153-7-10] CT abdomen and pelvis enterography: mural thickening cecum and proximal ascending colon, hypervascularity in adjacent mesentery; heavy calcified plaques at origins of both celiac artery and SMA; no occlusion of these vessels, no venous obstruction; no abscess or perforation; multiple peripheral foci of transient hepatic attenuation differences consistent with areas of shunting within liver ... IMAGING DURING [Hospital1 18] ADMISSION: [2153-7-31] Spleen Ultrasound: Splenic infarcts with patent splenic vein. . [2153-8-1] KUB: No evidence of megacolon . [2153-8-3] CXR: Right PICC line terminates at mid SVC. Both lungs are well expanded. Minimal pleural effusions seen bilaterally wit mild atelectasis in the left lung base. There is no lung consolidation. Heart size is normal. Mediastinal and hilar contours are stable and unchanged since prior radiograph. Anterior wedge compression fracture of T9 vertebral body seen involving one-third of the vertebral height. Degenerative changes are seen at multiple thoracic vertebral body levels. . [2153-8-6] CXR: Compared to the prior exam there is no significant interval change. . [2153-8-6] CT ABD & PELVIS: 1. Trans-mesocolic small bowel internal hernia without secondary signs of ischemia. 2. Watery colonic wall thickening consistent with diagnosis of C. difficile colitis. 3. Near-complete splenic infarction with a small viable portion remaining medially, with associated splenic vein thrombosis. The portal vein and SMV are patent. 4. The SMA and celiac origins are severely calcified and fill poorly with contrast, though this is not an arterial phase CT. 5. Abdominal ascites. 6. Hiatal hernia. 7. Small bilateral pleural effusions with bibasilar atelectasis. 8. Anasarca. . [2153-8-6] Portable Abdomen: Normal diameter of the transverse colon. . [2153-8-17] Colonic mucosal biopsies, two: A. 45 cm: Colonic mucosa with crypt regeneration and focal edema of the lamina propria. B. 20-35 cm: 1. Features consistent with ischemic-type colitis with focal fibrinopurulent exudate, suggestive of early pseudomembrane formation; see note. . [2153-8-20] Abd and pelvis CT: 1. No evidence of intra-abdominal abscess. 2. Persistent splenic infarcts with unresolved splenic vein thrombosis. 3. Resolved intra-abdominal ascites. 4. Mild improvement in bibasilar pleural effusions. 2. AFB stain is negative for acid fast bacilli. No viral inclusions are identified on H&E; CMV immunostain will be performed at the request of the clinician and results will be reported in an addendum. [2153-8-22] URINE URINE CULTURE-negative INPATIENT [2153-8-22] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2153-8-22] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2153-8-20] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2153-8-20] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2153-8-19] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [2153-8-18] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [2153-8-14] BLOOD CULTURE Blood Culture, Routine-negative [2153-8-14] BLOOD CULTURE Blood Culture, Routine-negative [2153-8-7] PERITONEAL FLUID GRAM STAIN-negative; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-negative INPATIENT [2153-8-5] Immunology (CMV) CMV Viral Load-negative [2153-8-5] Blood (CMV AB) CMV IgG ANTIBODY-negative; CMV IgM ANTIBODY-negative [2153-8-3] STOOL FECAL CULTURE-negative; CAMPYLOBACTER CULTURE-negative CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2153-8-1] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST negative [2153-7-31] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST negative [2153-7-31] BLOOD CULTURE - negative [2153-7-31] BLOOD CULTURE - negative Brief Hospital Course: 73 yo F with hypertension, asthma transferred from outside hospital to [Hospital1 18] on [7-31] for further evaluation of acute on chronic diarrhea, abdominal pain, and weight loss. #. DIARRHEA/ C. DIFF COLITIS: Her OSH hospital course was significant for gastric ulcerations seen on EGD and colitis suggestive of Crohn's on colonoscopy and biopsy. Her outside path slides from gastric, colon biopsies performed prior to admission were reviewed by [Hospital1 18] pathologist and they confirmed colitis, but could not confirm or refute a diagnosis of Crohn's especially as she could have had partially treated or undiagnosed cdiff at that time. Additionally, GI states the biopsies were taken from an ulcer, which cannot acurrately diagnose Crohn's disease. During her most recent admission to the OSH, she was found to have a leukocytosis of 35 and her stool was positive for C. Diff. Her white count improved with treatment of her C. Diff, however her stool output continued to be at least 2 L/day. As such she was transferred to [Hospital1 18] for further work-up. Here, she was continued on oral vancomycin and IV flagyl. She underwent colonoscopy on [8-2] that showed pseudomembranes and active cdiff, the [Last Name (un) ] was not complete as edema/inflammation resulted in a stricture through which the colonoscopy could not pass. She was also seen by infectious disease who agreed with her management. On [2153-8-3], a Dobbhoff tube was placed in order to start tube feeds. She initially tolerated this well and there was no change in her stool output. However, early in the morning of [2153-8-6], she developed severe abdominal pain and these were stopped. She underwent an abdominal CT that suggested splenic vein thrombosis and a large splenic infarct, as well as a possible internal hernia of the small bowel. Surgery was consulted prior to the abdominal CT results and they ultimately decided to take her to surgery, as they felt she had an acute abdomen. Ex-lap did not show a surgical pathology for her abdonimal pain. Acute pain may have been [1-3] to her infarcted spleen. Patient was transferred back to medicine, after a short stint in the SICU for prolonged paralytic effect during the surgery, and her treatment for c. diff was continued (PO and PR vancomycin, as well as a shorter stint of IV flagyl). Repeat flex sig on [2153-8-17] showed improved but persistent pseudomembranes and colonic biopsies showed crypt regeneration, pseudomembranes, without evidence of crohn's in the portion of the colon biopsied. Notably, celiac serologies were performed and these were negative. At time of discharge frequency of bowel movements was significantly improved but she still required qod dosing of oral vancomycin which she should continue for one week. If patient is to develop fever or worsening idarrhea, please check Cdiff. . Other ACTIVE ISSUES: #Splenic infarct: visualized on OSH imaging as well as CT abdomen here. Hypercoag workup negative, although initially protein C level noted to be slightly lower than normal range, though this value is not suggestive of clinical protein C defeciency that could cause increased risk of thrombosis. Splenic infarcts were present on abdominal ultrasound. Repeat CT showed persistent splenic vein thrombosis and splenic infarction (with increased viable tissue), but no abscess. Anticoagulation was started with LMWH and coumadin. Platelet counts continued to rise (up to 900s), likely a result of recent spleen infarction. Anticoagulation should continue for minimum 3 months for treatment of splenic thrombosis and can be readdressed by primary care/GI teams. Pt will need immunizations given new asplenic state as outpatient, particularly meningiococcal vaccine and Hemophilus influenza vaccination. Should she become febrile prophylactic antibiotics should be considered though this could further exacerbate cdiff symptoms. . #Anorexia/weight loss/severe malnutrtion: This is likely related to her underlying illness, worsened by her distaste for food [1-3] flagyl use. For her nutrition, she was trialed on tube feeds, however this worsened her diarrhea and there was concern for malabsorption given her high outout. She ultimately received TPN, which increase her albumin from 1.9 to 3.0 over a week. Oral nutrition was encouraged and Ensure chocolate supplements were given. Pt continues to be week and requires rehabilitation given deconditioning and malnutrtion as a result of her prolonged illness. Discharge home is felt to be unsafe at this time. . Chronic ISSUES: . #PUD: duodenal and prepyloric ulcers by EGD in [Month (only) 205], biopsies negative for malignancy or h.pylori. At [Hospital1 18], stool h. pyroli antigen was negative. She was continued on her proton pump inhibitor. . #HTN: stopped her home enalapril on admission. She did not require antihypertensives during her admission. . COPD/asthma: pt required no treatmetn during her hosptialization. To Do: - Meningococcal vaccine, hemophilus influenza vaccine - check cdiff if fevers - monitor INR qod, adjust dose to maintain INR [1-4], until INR stable. - TPN to be discontinued per GI teams. Medications on Admission: Meds on transfer from OSH: Percocet 1-2 tabs q6h prn Metronidazole 500mg IV q8h ([2153-7-25]) Vancomycin 250mg q6h ([2153-7-28]) Mesalamine 1500mg daily Lovenox 40mg SQ daily Folic acid 1mg daily Thiamine 100mg po daily Reglan prn MVI Protonix 40mg iv BID Zofran prn Acetaminophen 650mg q4h prn Benadryl prn Ambien prn Discharge Medications: 1. Align 4 mg Capsule Sig: One (1) Capsule PO once a day: or equivalent probiotic. 2. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for breakthrough pain. 6. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 10. vancomycin 250 mg Capsule Sig: One (1) Capsule PO twice a day. 11. TPN Pt will need continued TPN Most recent order at [Hospital1 18] on [2153-8-24]: Volume(ml/d) Amino Acid(g/d) Dextrose(g/d) Fat(g/d) [2141] 110 370 40 NO Trace Elements will be added daily Standard Adult Multivitamins NaCL NaAc NaPO4 KCl KAc KPO4 MgS04 CaGluc 125 0 0 45 25 30 12 14 Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: Primary Diagnosis: C. diff diarrhea splenic infarction Secondary Diagnosis: PUD - duodenal and prepyloric ulcers on EGD [6-11] HTN Asthma/COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname ], You were hospitalized for treatment of an infection of your gastrointestinal tract which causes profound diarrhea. The infection is called Clostridium Difficile (C. Diff). At one point, there was concern for a a serious problem in your abdomen and you were taken to surgery for exploration. The surgery did not show evidence of any dead tissue or infection outside of your intestine. On imaging, we noted that you had a blood clot in a vein causing your spleen to become infarcted. Surgery did not feel your spleen had to be removed however. You remained in the hospital for treatment of the c. diff infection in your colon and for nutrition, which you largely got through your veins. The following changes were made to your medications: CONTINUE to take Vancomycin by mouth for 7 days. START Align or similar probiotic. START Dronabinol for appetite. Please continue to take your other home medications as prescribed. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [2153-8-28] at 3:00 PM With: [Name6 (MD) 2606] [Name8 (MD) 2607], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Completed by:[2153-8-24]	[ "42789", "4019" ]
Admission Date: [2186-4-19] Discharge Date: [2186-5-2] Date of Birth: [2112-1-6] Sex: F Service: CARDIOLOGY DATE OF DISCHARGE: To be determined pending rehabilitation placement. CHIEF COMPLAINT: Chest pain. HISTORY OF THE PRESENT ILLNESS: Ms. [Known lastname ] is a 74-year-old female with a history of coronary disease and congestive heart failure, who presented to [Hospital3 3834] [Hospital3 ] complaining of substernal chest pain. She required oxygen, IV Morphine and heparin to control her pain. She was transferred here for cardiac catheterization after her pain continued. When she arrived at [Hospital1 ] she was found to be anticoagulated with INR of 3.3. She was also felt to be in mild congestive heart failure and she was diuresed, but upon initial evaluation she was felt to be comfortable and without shortness of breath, chest pain, abdominal pain, lower extremity edema, melena, or bright red blood per rectum. PAST MEDICAL HISTORY: History is notable for the following: 1. Glaucoma. 2. Hypertension. 3. Paroxysmal atrial fibrillation. 4. Congestive heart failure with ejection fraction of 20%. Last echocardiogram was [2185-9-29]. 5. Coronary artery disease, status post multiple LAD interventions. 6. Aortic stenosis and aortic regurgitation. MEDICATIONS: 1. Plavix, recently discontinued. 2. Amiodarone 200 mg p.o.b.i.d. 3. Kerlone 20 mg p.o.b.i.d. 4. Coumadin 2 mg p.o. for five days a week and 4 mg p.o. for the other two days. 5. Zestril 40 mg p.o.q.d. 6. Aspirin 325 mg p.o.q.d. 7. Digoxin 0.25 mg p.o.q.d. 8. Protonix 40 mg p.o.q.d' 9. Lipitor 20 mg p.o.q.d. 10. Xalatan 1 drop to both eyes q.h.s. or 1 drop OU q.h.s. ALLERGIES: The patient states that she is ALLERGIC TO NOVOCAINE AND TO NITROGLYCERIN, WHICH MAKES HER HYPOTENSIVE WITH BRADYCARDIA. SOCIAL HISTORY: The patient denies any history of smoking. She is a widow who lives alone. She denies any alcohol use. PHYSICAL EXAMINATION: On physical examination the temperature is 96.0, pulse 52, blood pressure 130/50, respiratory rate 16, saturations 100% on two liters. GENERAL: The patient is awake, alert, and in no acute distress. Extraocular muscles are intact. Oropharynx clear. Mucous membranes moist. Lungs: Demonstrated crackles bilaterally at the bases. She does have 9 cm of JVD. CARDIOVASCULAR: Regular rate and rhythm with 3/6 systolic ejection murmur that radiates to her carotids and a [1-4] holosystolic murmur at the apex. ABDOMEN: Soft, nontender, and nondistended with normoactive bowel sounds. EXTREMITIES: Extremities are without edema, but have faint pulses. They are, otherwise, warm and pink. LABORATORY DATA: Labs on admission revealed the following: White count 8.1, hematocrit 35.8, platelet count 287,000. PT 21.6, PTT 150, INR 3.3, sodium 141, potassium 4.2, chloride 101, bicarbonate 26, BUN 14, creatinine 1.1, and glucose 162. She reportedly has a baseline creatinine of 0.7 to 0.8. HOSPITAL COURSE: The patient was admitted to the Cardiology Service with a diagnosis of chest pain. She was originally sent for cardiac catheterization, but this was delayed due to her elevated INR. She had a stress test that demonstrated a time of 7 minutes, maximum heart rate 51%. The test was stopped for fatigue. During this time, she had an EKG, which was not interpreted. Ejection fraction was less than 30% and she global hypokinesis and septal dyskinesis with reversible apical and inferior defects. She also had an echocardiogram that demonstrated an ejection fraction of less than 20% with an aortic gradient of 50 in addition to 2+ aortic regurgitation, 2+ mitral valve regurgitation and 1+ to 2+ tricuspid regurgitation. The patient ultimately had a cardiac catheterization that showed disease in multiple vessels. She was referred to the cardiac surgery team for intervention. On [2186-4-25], the patient was taken for a three-vessel coronary artery bypass graft and tissue aortic valve replacement. She had a LIMA to LAD, saphenous vein graft to diagonal, and saphenous vein graft to the right coronary. She also had a 21-mm tissue pericardial valve replaced. All of this was done for her diagnosis of aortic stenosis and coronary artery disease. The patient's procedure itself was remarkable for a cardiac bypass time of 148 minutes and cross-clamp time of 127 minutes. The patient was taken postoperatively to the cardiac surgery ICU on Milrinone, Levophed, and Propofol drips. While in the Intensive Care Unit, she had episodes of bradycardia to the 30s. During this time she appeared to be in a junctional rhythm. Attempts were made to pace the patient through her atrial wires, but there was no capture. The patient was, therefore, paced ventricularly to a rate of 80 and electrophysiology consultation was obtained. During her first day in the Intensive Care Unit, she was weaned from the ventilator and extubated without incident. She was also transfused with one unit of packed red blood cells. The electrophysiology team felt that given the need for continued therapy with beta blockers and Amiodarone, in light of her absence of sinus activity, she would benefit from an insertion of implantable pacemaker. On [2186-4-28], the patient was taken to the Electrophysiology Laboratory, where she had a [Company 1543] dual-chamber rate-responsive pacemaker inserted. It was left in DDD mode with a lower rate of 60. Following her procedure, she did have four doses of Vancomycin for prophylaxis against infection. In addition, she had a urinary tract infection, which was discovered prior to her pacemaker insertion and this was subsequently found to be E.coli. She was initiated on a ten-day course of Levaquin before her pacemaker was inserted. Within a few days after all of these events, the patient was stable on the Cardiac Surgery Floor. She did complain of some nausea and some pain around her pacemaker site. The pain was adequately controlled with Toradol and Tylenol and occasional Percocet. In addition, she was started on Reglan and p.o. Zofran to control her nausea. By her 7th postoperative day, [2186-5-2], the patient was feeling much improved. She was medically ready to be transferred to rehabilitation. The patient was asked to followup in pacer clinic in one week for interrogation. In addition, she is to followup with her primary care physician and cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11493] in two weeks. In addition, she is to followup with Dr. [First Name (STitle) ] [Last Name (Prefixes) ] in four weeks. The patient was transferred to rehabilitation on the following medications: DISCHARGE MEDICATIONS: 1. Reglan 10 mg p.o.q.i.d. times remaining two days. 2. Aspirin 325 mg p.o.q.d. 3. Colace 100 mg p.o.b.i.d. 4. Protonix 40 mg p.o.q.d. 5. Amiodarone 400 mg p.o.b.i.d. times four days; 400 mg p.o. q.d. times seven days; 200 mg p.o.q.d., thereafter. 6. Lopressor 25 mg p.o.b.i.d. 7. Xalatan one drop OU q.h.s. 8. Levaquin 500 mg p.o.q.d. times six days. 9. Lasix 20 mg p.o. b.i.d. times seven days. 10. Potassium chloride 20 mEq p.o. b.i.d. times seven days. 11. Percocet 1 to 2 p.o.,q.4h. to 6h.p.r.n. 12. Serax 10 mg q.h.s.p.r.n. 13. Tylenol 650 mg p.o.q.4h. to 6h.p.r.n. 14. Lipitor 20 mg p.o.q.d. 15. Coumadin 2 mg p.o.q.d. times five days of the week and 2 mg p.o.q.d.times two days of the week. We request that that rehabilitation staff draw a PT/INR in approximately two days and call the result to. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office. He can be reached at area code: [Telephone/Fax (1) 16827]. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Aortic stenosis now status post coronary artery bypass grafting times three and tissue aortic valve replacement. 3. Bradycardia now status post pacemaker. 4. Paroxysmal atrial fibrillation. 5. Congestive heart failure. 6. Hypercholesterolemia. 7. Glaucoma. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 9638] MEDQUIST36 D: [2186-5-2] 10:43 T: [2186-5-2] 11:03 JOB#: [Job Number 36008]	[ "4241", "41401", "4280", "42731", "5990", "42789", "4019" ]
Admission Date: [2180-6-30] Discharge Date: [2180-7-4] Date of Birth: [2132-12-28] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 896] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: Ms. [Known lastname ] is a 47yo chinese speaking female with past medical history significant for GERD, cognitive delay, and anemia (vitamin B12 deficiency), who presented to the emergency room complaining of epigastric pain for 4 days acompanied with dark brownish colored vomitus x2 at home over past 24 hours. She also had one episode diarrhea yesturday. Mild waves of intermittent nausea as well. Sister explains that patient c/o "dark black" stools over past month. No NSAIDs per family. In the ED, initial VS were: T 97.8F, HR 100, BP 129/85, RR18 and 100% RA. She had an OG lavage which showed coffee ground materials mixed with clots, a total of 250cc lavaged. No associated hypotension despite GI bleeding. One month ago patient had HCT of 41 and it is now 33 on ED labs. Rectal exam in ED was guaiac negative. She was given 2L NS IVFs, morphine 2mg for abdominal pain, 80 IV Protonix and then Protonix drip started. GI service consulted and advised close ICU monitoring overnight with plan for blood transfusions to keep HCT goal >30 with plan for EGD early in morning. Urinalysis in ED also remarkable for +blood, +bacteria, moderate leuks and >50 WBCs which was concerning for UTI. Patient has no fevers, chills, flank area pains but does endorse mild lower abdominal pain at suprapubic area. On arrival to [Hospital Unit Name 153], she appeared to be in no acute distress and was accompanied by her mother. Initial vital signs were : T 99.6F, BP 114/87, HR 92, RR 19 and O2 sat 98%. Past Medical History: -GERD -cognitive delay /anoxic brain injusry from birth -Anemia -Vit B12 deficiency -Torticollis -surgery in past to remove left ovary / ?cyst per sister Social History: She lives with her sister [Name (NI) ]. [Name2 (NI) ] with her sister [Name (NI) ] as well and mother lives nearby. Moved to US with her parents several years ago. She does not use drugs, drink, or use any tobacco. She is unemployed. Walks with lean to right side at baseline per sister. Family History: Mother with HTN, hyperlipidemia in her father. [Name (NI) ] family history of neurologic disorders. Physical Exam: Vitals: T 99.6F, BP 114/87, HR 92, RR 19 and O2 sat 98%. General: patient alert to person only, no acute distress, unable to speak english, posture with right sided torticollis-like positioning at times HEENT: PERRLA,EOMI. Gaze is disconjugate and left eye with slight lower eye lid as compared to right. Sclera anicteric, dry MM, poor dentition but oropharynx otherwise clear, nares clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft. Tender with palpation over epigastric area and mildly tender to palpation over left lower abdomen at suprapubic border, non-distended, bowel sounds present and normoactive x 4 quadrants, no rebound tenderness or guarding, no organomegaly (guaiac negative in ED) GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2180-7-1] Upper Endoscopy: Ulcer in duodenal bulb H.pylori: POSITIVE BY EIA. HCT trend: 32 -> 24 -> 34 -> 38 (discharge) Ferritin: 11 Brief Hospital Course: 1. Duodenal ulcer: Admitted to ICU with upper GIB. Endoscopy showed duodenal ulcers and h.pylori returned positive. She was treated at endoscopy and received 2 units of pRBC. Her HCT improved and was 38 at the time of discharge. A prescription for triple therapy was called into her pharmacy as these results turned positive after discharge. 2. Anemia: Mostly due to acute blood loss, though ferritin of 11 suggests some underlying iron deficiency. Repeat HCT and ferritin may be of value long-term. Medications on Admission: 1. Omeprazole 20mg [Hospital1 ] 2. Calcium/Vitamin D supplement Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Calcium Oral 3. Vitamin D Oral Discharge Disposition: Home Discharge Diagnosis: Duodenal ulcer GI bleed Discharge Condition: Hemodyamically stable with a stable hematocrit Discharge Instructions: You were admitted and found to have an ulcer in the duodenum. To help this heal, we are proscribing a new medications (pantoprozole). Please be sure to take this until you are seen in follow-up. Followup Instructions: We are working on an appointment for you to see your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. The office will contact you with an appointment. If you have not heard from them, please call [Telephone/Fax (1) 10349].	[ "2851", "5990", "53081" ]
Admission Date: [2122-2-23] Discharge Date: [2122-3-27] Date of Birth: [2098-2-9] Sex: F Service: HEPATOBILIARY SURGERY SERVICE DIAGNOSIS: Bile duct injury/obstruction, status post laparoscopic cholecystectomy. The patient is a 24 year old female status post laparoscopic cholecystectomy on [2122-2-18], at outside hospital who presented with jaundice and elevated total bilirubin level, ERCP performed at [Hospital1 69] demonstrating a single short stricture seen at the common hepatic duct, distal to the hilum. There was moderate postobstructive dilation. Surgical clips were in the area concerning for clip across common hepatic duct. These findings are compatible with postcholecystectomy injury and obstruction. A 12 cm x 10 French plastic biliary stent was placed successfully into the left intrahepatic bile duct. There was normal pancreatic duct. PAST MEDICAL HISTORY: High blood pressure. PAST SURGICAL HISTORY: Laparoscopic cholecystectomy on [2122-2-18]. MEDICATIONS: On admission, none. ALLERGIES: OxyContin. PHYSICAL EXAMINATION: The patient is afebrile, vital signs stable. No acute distress. Lungs clear to auscultation bilaterally. CVS: Regular rate and rhythm, no murmurs. Abdomen: Obese, nontender, nondistended, but soft. HOSPITAL COURSE: The patient was kept NPO. On [2122-2-24], a HIDA scan was performed demonstrating likely persistent bile leakage. Labs that morning, [2122-2-24], were the following: WBC of 2.9, hematocrit of 33.3, platelets 406,000. Sodium 133, potassium 3.3, chloride 95, bicarbonate 23, BUN 3, creatinine 0.7, glucose 156. AST 137, ALT 292, alkaline phosphatase 930, amylase 1649 and lipase 3905. INR 1.2. On [2122-2-24], the patient had an ultrasound of her hypoechoic fluid collection in the gallbladder fossa measuring 65 x 31 x 32. Fluid collection in the gallbladder fossa could not be accessed by ultrasound via submucosal approach. The patient was brought to the CT scanner for pigtail catheter placement. The same day the patient did have a CT guided placement of an 8 French [Last Name (un) 2823] catheter in the subhepatic fluid collection. On [2122-2-25], the patient had decreased pain, afebrile, vital signs stable. Total bilirubin had decreased. Drain had put out 75 cc. On [2122-2-25], the patient had an ultrasound of the abdomen demonstrating patent hepatic venous and pleural venous system with flow in the appropriate direction. Normal Doppler arterial waveform in the liver. There was no significant residual fluid seen in the gallbladder fossa after placement of a drainage catheter and no free fluid seen in the abdomen. On [2122-2-25], the patient went to interventional radiology for a right-sided percutaneous transhepatic cholangiography which was unsuccessful after multiple attempts. Left-sided intrahepatic biliary tree is not dilated. Contrast passes from the left-sided biliary tree through the stent into the bowel. The patient had a NG placed on admission, continued to be NPO. Positive flatus on [2122-2-27]. On [2122-2-27], her labs that day were the following: WBC of 16.8, hematocrit of 23.9, platelets 263,000. Sodium 139, potassium 3.0, chloride 101, bicarbonate 30, BUN 6 and creatinine 0.6 with a glucose of 90. Amylase and lipase had decreased significantly to 424 and 444. AST was 49, ALT 106, alkaline phosphatase 416. INR was 1.4. The decreased hematocrit prompted a CT abdomen and pelvis to be obtained which demonstrated active bleeding from the anterior liver causing a large hematoma in the right upper quadrant with extension of the hematoma into the pelvis. There was evidence of mass backed by the hematoma displacing the liver more centrally. There was fluid around the tail of the pancreas which may be consistent with the patient's history of pancreatitis. Biliary catheter is seen in the porta hepatis. No significant fluid collection in the gallbladder fossa. There is a small left pleural effusion and atelectasis. Urgent angiogram was performed of the liver demonstrating superselective angiogram of the hepatic arteries demonstrating an area of acute extravasation in the anterior segment of the right lobe of the liver. There was successful coiling of the bleeding vessel using two 0.018/0.5 cm straight coils. Of note, during her hospitalization, the patient had episodes of aggressive behavior where she would suck her thumb, infantile speech, would not get out of bed. The patient was placed on Unasyn since the time of admission on [2-23], when she received 3 mg IV q.6 and eventually finished a 16 day course of antibiotics which was discontinued on [2122-3-10]. On [2122-3-3], the patient had a CT abdomen and pelvis demonstrating interval development of a large geographic area of hypodensity in the right hepatic lobe. Given the recent hepatic artery embolization, this is reasonable for hepatic necrosis or developing abscess. Parenchymal hematoma is also less likely. There is no evidence of active contrast extravasation. Decrease in the amount of perihepatic abdominal and pelvic fluid. There was a small left pleural effusion. Since the patient was NPO, the patient had been started on TPN. She was at goal. Social work was consulted. Foley was in place throughout this early hospitalization. The patient was out of bed walking with physical therapy. Nutrition was consulted and made recommendations on TPN. On [2122-3-9], the patient had an ERCP demonstrating the previous stent placed in the biliary duct was found in the major papilla. This was removed. The postcholecystectomy structure was seen in the common hepatic duct. There was moderate postobstructive dilatation. Left intrahepatic ductal system was dilated as well as compared to the branches seen in the right system. The forceful injection was performed and the patient was rotated for optimal visualization, appeared we were in fact viewing both a nondilated right and a moderately dilated left system. No biliary leak was seen. A 12 cm x 10 French Contin [Doctor Last Name ] biliary stent was placed successfully in the left main hepatic duct. On [2122-3-10], the patient continued to be afebrile, vital signs stable with WBC of 8.8, hematocrit of 31.0, platelets 322,000. Sodium 134, potassium 4.3, chloride 102, bicarbonate 24, BUN 15, creatinine 0.6, and glucose of 95. AST was 132, ALT 279, alkaline phosphatase 492, total bilirubin 1.9 which had decreased significantly. Amylase and lipase 221 and 137 which was also decreased. On [2122-3-16], the patient went to the OR for an end to side roux-en-y hepaticojejunostomy over a 5 French feeding tube; evacuation of subcapsular hematoma performed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and Dr. [Last Name (STitle) ]. Please see operative note from [2122-3-16], for more details about the operation. Postoperatively, the patient had an epidural for pain control. On [2122-3-18], the patient had a T-max of 102.2, had NG tube continued to be in place, good urine output, T tube put out 270. The patient had 2 J-P drains, one put out 270 and the other 10. Her labs that day were WBC of 12.8, hematocrit of 24.1, platelets 295,000. Sodium 133, potassium 3.9, chloride 101, bicarbonate 26, BUN 11 and creatinine 0.5, glucose 121. AST was 110, ALT 199, alkaline phosphatase 242, total bilirubin 1.3. Temperature was worked up which included a UA, UC, blood cultures which were all unremarkable. The patient was transfused blood for a hematocrit of 24.1. The patient was placed on vancomycin postoperatively and received a total of 8 days of vancomycin 1 gram IV q.12. At discharge, physical therapy was reconsulted. On [2122-3-19], epidural catheter was removed. Tip was intact. There were no complications. The patient was placed on IV medications for pain control. The patient continued to be NPO, continued on TPN. The patient was out of bed. Fingersticks were within range of 105 to 139. On [2122-3-23], the patient had a T-tube cholangiogram demonstrating gravity T-tube cholangiogram demonstrating emptying of contrast into the jejunum. There is dilation of the left hepatic duct as noted, unchanged compared to the ERCP on [2122-3-9]. On [2122-3-24], the patient's diet was advanced. Continued to ambulate well with physical therapy and physical therapist thought that she could go home, that it would be safe for her to go home. On [2122-3-26], CT abdomen and pelvis was performed because of persistent nausea and vomiting which demonstrated no evidence of bowel obstruction or other acute gastrointestinal pathology. Decrease in size of intrahepatic subcapsular collection. There was a 5.9 x 4.6 x 3.4 cm focus in the gallbladder fossa of low attenuation mixed with air. This may represent surgical packing, however, an abscess could not be excluded. So the patient was receiving Keflex for a small area of her incision that was possible infection. After receiving the CAT scan and speaking with the patient, Dr. [Last Name (STitle) ] felt that all unnecessary medications should be stopped which included antibiotic Keflex, which she had been treated with 1 day of Keflex. Protonix was discontinued. Dilaudid was discontinued. On [2122-3-27], the patient was on no antibiotics. She had no overnight events. She was afebrile and vital signs were stable. Blood sugars were excellent. Weight was 68.9 kilograms, relatively good [Name (NI) ] and O's. Urine output was good. Labs on the 24th, were the following: WBC of 9.5, hematocrit of 26.8, platelets 336,000. Sodium 134, potassium 4.3, chloride 99, bicarbonate 26, BUN 11 and creatinine 0.7, and glucose 71. Calcium, phosphorus and magnesium were 9.0, 4.5, 1.8. AST 38, ALT 113, alkaline phosphatase 350. So at that point, the patient was only taking Tylenol p.r.n. The patient was discharged to home with physical therapy and VNA. She went home on the following medications: Tylenol 325 mg 1-2 tabs q.4-6hours p.r.n. and Dilaudid 2 mg 1 tablet every 8 hours p.r.n. if needed. The patient is to call transplant surgery immediately at [Telephone/Fax (1) 64549] if any fevers, chills, nausea, vomiting, increased abdominal pain, any redness around her PTC catheter which was capped. MAJOR SURGICAL INVASIVE PROCEDURES: 1. [2122-2-23], endoscopic retrograde cholangiopancreatography. 2. [2122-2-26], unsuccessful attempted right sided percutaneous transhepatic angiography despite multiple attempts. 3. [2122-2-27], superselective angiogram. 4. [2122-2-25], CT guided placement of drain catheter. 5. [2122-3-3], right IJ catheter in the superior vena cava. 6. [2122-3-14], another endoscopic retrograde cholangiopancreatography. 7. [2122-3-16], end to side roux-en-y hepaticojejunostomy over a 5 French feeding tube and evacuation of subcapsular hematoma. The patient postoperatively had 3 drains, 2 J-P drains and 1 T-tube. On postoperative day 2, one of the J-P drains were removed and on [2122-3-23], postoperative day 8, second J-P drain was removed. So the patient only has 1 T- tube which has been capped. RECOMMENDED FOLLOW-UP APPOINTMENTS: Dr. [Last Name (STitle) ] on [2122-4-1], at 11:00 a.m. Please call [Telephone/Fax (1) 57640] if there are any questions about the appointment. DISCHARGE DIAGNOSES: The patient is a 24 year old female with hypertension, history of pulmonary embolism 2 years ago, with bile duct injury/obstruction, status post laparoscopic cholecystectomy. Secondary diagnoses subcapsular hematoma of the liver, hypertension. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD,PHD[Numeric Identifier ] Dictated By:[Last Name (NamePattern1) 4835] MEDQUIST36 D: [2122-4-1] 19:39:03 T: [2122-4-1] 21:47:46 Job#: [Job Number 64550]	[ "4019" ]
Admission Date: [2156-8-15] Discharge Date: [2156-8-27] Date of Birth: [2070-4-17] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Neosporin Scar Solution / Ampicillin / Tobrex Attending:[First Name3 (LF) 1145] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Placement of a R IJ dialysis catheter CVVH History of Present Illness: Ms. [Known lastname 82252] is an 86yoF with history of severe aortic stenosis, CAD s/p CABG in [2154] and RCA stents x3 in [2148] recently hospitalized here from [Date range (1) 52084] for acute pulmonary edema who now is TF from OSH for management of recurrent pulmonary edema. For details of her initial presentation see Dr.[Name (NI) 62137] admission note from [2156-8-12]. Briefly, she presented to OSH with 10/10 chest pain not relieved by nitro x4 and SOB that developed at rest. She was transferred to [Hospital1 18] and had an echo which showed severe aortic stenosis ([Location (un) 109] <0.8cm2) with preserved systolic function, AR (1+), MR (2+), TR (2+) and severe PAH. Unclear whether she was evaluated as inpatient by CT surgery but was to follow up with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 5076] as outpatient re need for open AVR vs TAVI. . On the evening she was discharged to her ALF, she again developed acute chest pain and SOB. She described the pain as [10-11] and radiating to her L arm, and associated with diaphoresis. She notes that the chest pain was the same as the chest pain that she initially presented with, but the SOB was more severe. She did not use NG as advised by the medical team on discharge. She called EMS and she was transported back to OSH. When she arrived she was noted to be in severe respiratory distress and was started on BiPAP. She received IV lasix 20mg x1. Labs were notable for Creat 3.35 (up from 2.31 on [8-11]), BNP 702, CK 153, trop 0.64. EKG showed sinus tach. She was admitted to the ICU. After further diuresis her O2sats improved to 94% on 3L. Cards was c/s and felt that CP was likely related to aortic stenosis and not ACS. She was transferred to [Hospital1 18] for further treatment and surgical evaluation. . On transfer, she feels well w/o complaints. She states that her chest pain has resolved and her breathing is comfortable on the BiPAP. She notes orthopnea c/w her baseline (requires 2 pillows), denies worsening peripheral edema. She believes she is 3lbs over her dry weight. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes (Insulin-dependent for 27 years), + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: off-pump CABG x 2: Saphenous vein grafted to LAD and saphenous vein graft to PDA -PERCUTANEOUS CORONARY INTERVENTIONS: PCI and stentx3 (?BMS) to RCA ([2145]) PTCA to LAD ([2138]) Aortic stenosis Carotid stenosis status post right carotid endarterectomy [2137] Chronic kidney disease (unknown baseline Creat) Left subclavian steal syndrome Glaucoma Sleep apnea (no longer uses CPAP) Past surgical history: Tonsillectomy, Left ankle repair, Right carpal tunnel release, Total abdominal hysterectomy, Laser eye surgery, CABG as above Social History: Non-smoker, rare brandy, no drugs. Lives in [Hospital3 ] in [Hospital1 487]. Three sons, local. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Mother and father died from cancer. Brother passed away from GI bleed and PUD and another with liver cirrhosis. One sister passed away from cancer, another sister passed as a child. Physical Exam: Admission Physical Exam: VS on transfer: T= 96.1 BP= 152/61 HR=88 RR=19 O2 sat= 95% on CPAP (50% FIO2) GENERAL: Pleasant, comfortable-appearing, in no acute distress. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with 10cm JVP . surgical scar s/p right endartrectomy CARDIAC: s/p CABG, RRR, 4/6 systolic crescendo murmur loudest at LUSB radiating to carotids, No r/g. LUNGS: Bibasilar crackles to mid lung, faint expiratory wheezes. Resp were unlabored, no accessory muscle use. ABDOMEN: Hysterectomy scar, abd is Soft, non-tender, non-distended. EXTREMITIES: WWP, no clubbing/cyanosis, trace pedal edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Discharge Physical Exam: Patient delirious, not oriented. On high flow face mask with good oxygen saturations Cardiac exam unchanged. Lungs continue to be wheezy on exam with elevated JVP Pertinent Results: Admission labs: WBC 5.6 Hgb 9.6 Hct 27.5 Plts 211 PT 11.4 PTT 25.7 INR 0.9 Na 140 K 4.7 Cl 99 CO2 23 BUN 70 Cr 4.2 Gluc 209 Ca 8.4 Mag 2.2 Phos 5.2 CK 164 CKMB 12 Trop-T 0.53 ALT 17 AST 32 Alk phos 133 T bili 0.4 Admission studies: CXR: Moderate pulmonary edema, worsened in comparison to prior study from [2156-8-12]. Otherwise, no significant change. EKG: Sinus rhythm, LVH, 1-2mm ST depressions in I, II TTE [2156-8-16]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild focal LV systolic dysfunction with antero-lateral hypokinesis. The remaining segmetns are hyperdynamic and thus overall left ventricular ejection fraction is preserved (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is mild functional mitral stenosis (mean gradient 8 mmHg) due to mitral annular calcification. At least moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2156-8-12], no change (the [Location (un) 109] was slightly underestimated and regional antero-lateral hypokinesis was present but not commented on for the prior study). CXR [2156-8-24]: Diffuse hazy opacification with cardiomegaly are consistent with pulmonary edema, unchanged in appearance from the prior examination. A small left pleural effusion is not significantly changed. No pneumothorax is seen. A previously seen right central venous line has been removed with no resulting hematoma or mediastinal widening. Median sternotomy wires are unchanged. Pertinent Labs: Renal function pre-CVVHD: [2156-8-18] 07:08PM BLOOD UreaN-98* Creat-6.4* Renal function Post-CVVHD: [2156-8-20] 09:59AM BLOOD UreaN-23* Creat-2.0* [2156-8-21] 05:15AM BLOOD UreaN-33* Creat-3.0* [2156-8-23] 03:57AM BLOOD UreaN-55* Creat-3.7* [2156-8-24] 05:16AM BLOOD UreaN-65* Creat-4.0* [2156-8-25] 05:45AM BLOOD UreaN-78* Creat-4.6* [2156-8-26] 04:59AM BLOOD UreaN-86* Creat-5.0* Brief Hospital Course: Primary Reason for Hospitalization: 83yoF with h/o severe aortic stenosis and [Hospital ] transfered from OSH for SOB [2-4] flash edema from AS. # Acute on chronic diastolic heart failure - Due to both severe aortic stenosis and mitral regurgitation. She was initially requiring BiPAP to maintain O2sats >90%, but this improved and by discharge she was maintaining O2 sats >90% on NC at 15L/min, with occasional episodes of SOB requiring face mask. She was continued on her home BP meds to reduce afterload, with her metoprolol tartrate increased to 100mg [Hospital1 ]. Her Imdur was initially increased to 90mg daily but then decreased to her home dose of 60mg daily. She was diuresed with IV lasix and metolazone. She was also treated with IV morphine to increase pulmonary venodilation and improve her sensation of dyspnea. This was later changed to IV dilaudid due to concern for poor clearance in setting of renal failure. She was evaluated by CT surgery, who felt that she was not an appropriate candidate for open AVR given her comorbidities. She was then considered for TAVI, but there was concern that she may not be a candidate for the procedure given her known atherosclerosis of femoral vessels and h/o difficult access for cardiac cath. Patient opted to start CVVH to optimize her renal function, in order to pursue balloon valvuloplasty. Review of her echo demonstrated that her MR was more significant than AS and she would likely get little benefit from intervention on her aortic valve. Patient clearly expressed her wishes to not pursue further invasive treatments and to focus on her comfort at a hospice facility. A family meeting was held with the patient's sons, palliative care, social work, and the primary team, and it was agreed that the patient's expressed wishes could best be served in a hospice house. The following day, however, she appeared to be very uncomfortable and it was thought that interventions at hospice may not be enough to keep her breathing more comfortably. She died at 11:40 PM on [8-27], family was contact[Name (NI) ] and autopsy was offered and declined. . # CAD - On admission pt c/o chest pain, thought most likely [2-4] demand ischemia, low suspicion for ACS given history and absence of ischemic changes on EKG. She was initially continued on aspirin 325mg, metoprolol, atorvastatin and clopidrogel. ACEi was held in the setting of renal failure. Her isosorbide mononitrate CR was initally increased to 90mg daily, then reduced to 60mg daily as above. Chest pain did not recur. # Acute on chronic RF: Creat increased from 2.2 on previous admission to 4.2, and continued to increase to 6.4. Patient was started on CVVH on HD3 and tolerated this well. On HD5 CVVH was held when her dialysis line malfunctioned and renal function did not improve. Creatinine continued to trend upwards and patient continued to have poor urine output. She did respond to bolus doses of 200 mg IV lasix and metolazone with some improvement in respiratory status. The renal service discussed the possibility of resuming dialysis with the patient, but she elected not to continue as she did not want to be on dialysis long-term. # Hypertension: BP stable on home amlodipine, and metoprolol. Imdur dose modified as described above. These meds were continued after goals of care transitioned to CMO in hopes of improving patient's respiratory status. # Hypercholesterolemia: Atorvastatin was initially continued throughout hospitalization but discontinued on changing goals of care to CMO. # Diabetes Mellitus: Patient's blood sugar was well controlled throughout admission on home lantus and insulin sliding scale. She was contined on ISS in hopes that glucose control would improve her mental status and quality of life. Patient passed at 11:40pm on [2156-8-27]. Family was notified. Medications on Admission: 1. Lantus 100 unit/mL Solution Sig: As directed units Subcutaneous at bedtime: Please take 14 - 16 units at bedtime. . 2. Humalog 100 unit/mL Solution Sig: As directed units Subcutaneous Before meals: As directed by your primary care doctor: 4-6 units prior to meals. 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO As directed: Take 40 mg daily on sunday, tuesday, thursday, and saturday. Take 40 mg twice a day on monday, wednesday, and friday. 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: N/A Discharge Disposition: Expired Facility: Hospice of the [Location (un) 1121] Discharge Diagnosis: Critical aortic stenosis Coronary artery disease s/p CABG Anemia Moderate Mitral Reguritation Acute on chronic renal failure Hypertension Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A	[ "51881", "5849", "4280", "40390", "5859", "2720", "2859", "25000", "V4582", "V4581" ]
Unit No: [Numeric Identifier 66398] Admission Date: [2180-1-30] Discharge Date: [2180-2-12] Date of Birth: [2180-1-21] Sex: F Service: NBB HISTORY: This infant was born at 32-2/7 weeks gestation, was admitted to the Neonatal Intensive Care Unit at [Hospital1 ] on day 9 of life from the [Hospital3 1810] where she was transferred shortly after birth from [First Name8 (NamePattern2) ] [Hospital3 66399] labor and delivery unit for lack of bed availability in the Neonatal Intensive Care Unit at [Hospital1 188] at the time of her birth. The infant was born to a 31 year-old gravida I, para 0, now I woman with prenatal screens that were blood type B positive, antibody negative, HBSAG negative, rubella immune, RPR nonreactive, GBS unknown. This pregnancy was complicated by poor fetal growth and oligohydramnios. In addition, fetal imaging revealed a liver echogenic foci throughout and thought to be a hemangioma. The infant was delivered by cesarean section due to the intrauterine growth retardation and oligohydramnios and had Apgar of 8 and 9. The hospital course while at [Hospital3 1810] in the Neonatal Intensive Care Unit: Respiratory: The infant has always maintained room air with no additional respiratory support. Has had mild apnea but required no methylxanthine. Cardiovascular: Was stable without concern or need for support. Fluid, electrolytes and nutrition: Steady feeding advance, progressed to full volume feeds on [2180-1-27]. She was discharged from the [Hospital3 1810] on day of life 9 at 5272 grams. Follow up abdominal ultrasound confirmed echogenic foci in the dome of the left lobe of the liver thought not to be hemangioma. KUB revealed calcifications overlying this area. Follow up abdominal ultrasound was recommended by [Hospital3 18242] radiologist at that time. That was on [2180-1-26]. Phototherapy was given from [2180-1-23] to [2180-1-26]. A spinal ultrasound was done due to sacral dimple and found to be normal on [2180-1-26]. Elemental iron was initiated at the [Hospital3 1810]. PHYSICAL EXAMINATION: On admission to the Neonatal Intensive Care Unit showed General: A well appearing preterm infant with normal facies, cry, activity, no edema. Skin normal. Head and neck: Normal. Ears, nose and throat were normal, intact palate. Lungs clear and equal to auscultation. No retractions. No heart murmur. Normal pulses. Abdomen soft, rounded, no hepatosplenomegaly, no masses. Genitalia: Normal for gestational age female. Patent anus. Trunk and spine straight with sacral dimple. Extremities: Normal. Reflexes normal. Infant's birth weight was 1540 grams which is 25th to 50th percentile, length 41 cm which is 25th percentile. Head circumference 28.5 cm which is 10th to 25th percentile. SUMMARY OF HOSPITAL COURSE BY SYSTEMS AT THE [Hospital3 ]: RESPIRATORY: The infant has remained stable on room air since admission to the Neonatal Intensive Care Unit at the [Hospital1 ] and has had rare apnea bradycardic episodes with the most recent episode being on [2180-2-2]. She has required no methylxanthine therapy. CARDIOVASCULAR: She has remained hemodynamically stable without a murmur, has had normal heart rate and blood pressure and well perfused. A murmur was noted on the day of discharge. CXR was normal as was a hyperoxia test, 4 extremitiy blood pressures and EKG. Plan for routine follow-up of murmur in pediatrician office. FLUID, ELECTROLYTES AND NUTRITION: She arrived at the Neonatal Intensive Care Unit on total fluids of 150 ml per kilo per day of 24 calorie breast milk or premature Enfamil. The caloric density was concentrated to 26 calories per ounce on [2180-1-31] and had good weight gain and growth on that. She was subsequently dropped back to 24 calorie per ounce breast milk with Enfamil powder on [2180-2-10]. She is presently all p.o. feeding and has been for the past 3 days of breast milk 24 with Enfamil powder and taking approximately 160 to 170 ml per kilo per day. Her most recent weight is She was started on multivitamins on [2180-2-10] and presently is on elemental iron of ferrous sulfate at .3 ml per day p.o. and baby multivitamins of 1 ml per day. GASTROINTESTINAL: She has had no further issues with hyperbilirubinemia since requiring phototherapy at [Hospital3 18242]. A follow up abdominal ultrasound was done at [Hospital1 ] [First Name (Titles) ] [2180-2-7] which showed a single 4 mm calcification in the dome of the liver with no associated soft tissue mass. A short term follow up is recommended. A calcification like this can be of no clinical significance or may be secondary to a prior area of ischemia. A repeat abdominal ultrasound is recommended in 1 month to 3 months of age. HEMATOLOGY: The most recent hematocrit was 51.9 on [2180-1-22]. No further hematocrits have been measured. The most recent platelet count was 239,000 also at that time. She has had no issues with sepsis or septic work ups while in the Neonatal Intensive Care Unit and [Hospital1 ]. NEUROLOGIC: She has maintained a normal neurologic examination and has had no cranial imaging. SENSORY: Audiology: Hearing screen was performed with automated auditory brain stem response on [2180-2-11] and she passed in both ears. PSYCHOSOCIAL: A [Hospital1 69] social worker has been in contact with the family. There are no ongoing social service concerns at this time but if there if there are any future concerns a [Hospital1 ] social worker can be reached at [Telephone/Fax (1) 8717]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home to the family. Name of primary pediatrician: [First Name4 (NamePattern1) 4115] [Last Name (NamePattern1) 42176], M.D. from [Hospital 1426] Pediatrics. Telephone #[Telephone/Fax (1) 37802]. Fax #[Telephone/Fax (1) 38332]. CARE RECOMMENDATIONS: 1. Feedings: Ad lib p.o. feedings of breast feeding or breast milk supplemented with 4 calories per ounce of Enfamil powder or 24 calorie per ounce Enfamil p.o. ad lib. 2. Medications: Elemental iron .3 ml p.o. per day of 24 mg per ml concentration. Pediatric multivitamin drops 1 ml per day. 3. The infant was screened in the car seat for positioning screening on 4. State Newborn Screens were done on the newborn day prior to transfer to the [Hospital3 1810]. Those results were all out of range. A repeat state screen was sent while at the [Hospital3 1810] on approximately day 3 of life. Those results are pending. In the following 2 weeks state screen was sent on [2180-2-4]. Those results are also pending. IMMUNIZATIONS RECEIVED: The hepatitis B vaccine was given on [2180-2-11]. IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for any infants who meet any of the following 3 criteria: 1) born at less than 32 weeks gestation; 2) born between 32 and 35 weeks with 2 of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings; or 3) with chronic lung disease. 2. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW UP: Appointments will be with the pediatrician on VNA visit on. DISCHARGE DIAGNOSES: 1. Appropriate gestational age premature female born at 32- 2/7 weeks gestation. 2. Echogenic foci in the liver, question etiology. 3. Hyperbilirubinemia. 4. Sepsis ruled out. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Doctor Last Name 65552] MEDQUIST36 D: [2180-2-11] 20:53:03 T: [2180-2-11] 22:46:29 Job#: [Job Number 66400]	[ "V053", "V290" ]
Admission Date: [2129-8-22] Discharge Date: [2129-8-25] Date of Birth: [2051-4-30] Sex: F Service: MEDICINE Allergies: Diltiazem / Lisinopril Attending:[First Name3 (LF) 1990] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: 78 year-old Mandarin-speaking female with history of atrial fibrillation on coumadin, amiodarone induced pulmonary fibrosis and CHF (EF on [First Name3 (LF) ] 55% with apical hypokinesis and 2+ MR in [2-16]) who presented to the ED with diarrhea for 8 days. She noted a sudden onset of the diarrhea with no inciting events. She made no recent dietary changes and had no recent sick contacts. She had no nausea, vomiting, fevers or chills. She noted blood on the toilet tissue but none in the bowl. Her VNA found her to be hypotensive and sent her to the ED. . In the ED, initial vital signs were T 98.3, HR 76, BP 94/57, RR 18, O2 Sat99. She received 3L of NS. A CT scan revealed mild colitis. She received Flagyl and Ciprofloxacin in the ED. (Of note, an incidental pulmonary nodule was detected at the right lung base.) A reaction developed at the site of Ciprofloxacin infusion and she was switched to Ceftriaxone upon transfer to the MICU. She was still hypotensive in the MICU and received further IVF. . The patient was transfered to the medicine team the following day ([8-23]). On transfer, the vital signs were T:97.0, HR:95, BP:108/60, RR:18, SO2:96% on RA. . Review of systems: (+) Per HPI (-) Denies: vomting, melena, changes in diet, fast-food intake, history of travel, sick contacts, family history of bowel disease inc. colon cancer. Past Medical History: CHF with EF 55% 2+ MR [First Name (Titles) ] [Last Name (Titles) ] [2-16] Amiodarone induced pulmonary fibrosis Paroxysmal atrial fibrillation, now status post AVJ ablation and permanent pacemaker implantation in [2126-10-7]. The pacemaker had previously been placed for tachybrady syndrome. On coumadin. Hypertension Hemorrhoids Gastritis Osteoarthritis Hypothyroidism Hyperlipidemia GERD Depression Tachy-bradycardia Syndrome s/p Pacemaker placement ([2125]) Social History: 1. Living: Lives alone and has VNA 2. Occupation: Used to work as a cook for an elderly woman. 3. Smoking: Used to smoke 1.5 packs per day but stopped approximately 1 year ago 4. Alcohol: None Family History: No family history of bowel disease or colon cancer Physical Exam: Vitals: T:98.6, BP:118/60, P:65, R:18, SO2: 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, moist mucus membranes, oropharynx clear Neck: supple, no JVD, no LAD Lungs: Minimal crackles at the bases but otherwise clear CV: RRR (paced), normal S1, S2, no murmurs, rubs, gallops Abdomen: soft, minimal TTP in lower abdomen Ext: warm, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact Pertinent Results: Labs: [2129-8-22] 03:00PM BLOOD WBC-9.7 RBC-3.85* Hgb-11.2* Hct-34.2* MCV-89 MCH-29.1 MCHC-32.7 RDW-14.0 Plt Ct-310 [2129-8-22] 03:00PM BLOOD Neuts-77.2* Lymphs-16.5* Monos-3.1 Eos-2.8 Baso-0.4 [2129-8-23] 06:26AM BLOOD WBC-6.2 RBC-3.41* Hgb-10.4* Hct-29.8* MCV-87 MCH-30.3 MCHC-34.8 RDW-13.9 Plt Ct-220 [2129-8-25] 07:44AM BLOOD WBC-7.9# RBC-3.50* Hgb-10.7* Hct-31.1* MCV-89 MCH-30.5 MCHC-34.3 RDW-14.3 Plt Ct-239 [2129-8-22] 08:26PM BLOOD PT-33.5* INR(PT)-3.4* [2129-8-23] 06:26AM BLOOD PT-30.0* PTT-31.9 INR(PT)-3.0* [2129-8-25] 07:44AM BLOOD PT-20.5* PTT-28.2 INR(PT)-1.9* [2129-8-22] 03:00PM BLOOD Glucose-85 UreaN-39* Creat-2.1* Na-135 K-4.0 Cl-100 HCO3-25 AnGap-14 [2129-8-23] 06:26AM BLOOD Glucose-81 UreaN-31* Creat-1.4* Na-142 K-4.1 Cl-112* HCO3-22 AnGap-12 [2129-8-25] 07:44AM BLOOD Glucose-108* UreaN-11 Creat-1.0 Na-138 K-4.2 Cl-108 HCO3-24 AnGap-10 [2129-8-22] 03:00PM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.7* Mg-2.0 [2129-8-25] 07:44AM BLOOD Calcium-8.6 Phos-2.0* Mg-1.8 . Micro: 1. UA negative 2. Blood cultures pending at discharge 3. C. diff toxin negative x one, repeat pending at discharge 4. Stool cultures pending at discharge . Images: CT Abdomen/Pelvis ([8-22]): 1. Mild stranding and minimal thickening of the ascending colon concerning for mild infectious/inflamatory colitis. 2. Cholelithiasis without cholecystitis. 3. 5mm pulmonary nodule in the right lung; if no risk factors follow up in 12 months. If risk factors 6-12 months. . Brief Hospital Course: 78 year old Mandarin-speaking female with CHF, amiodarone-induced pulmonary fibrosis, and AF on coumadin admitted with colitis and hypotension. . 1. Colitis: A bacterial etiology was assumed on admission given the duration of the diarrhea. Empirirc antibiotics, Ceftriaxone and Metronidazole, were initated with coverage for C. diff. Blood, urine and stool cultures (including C. diff toxin) were sent. Patient was C. diff toxin negative. In the initial course of her illness she reported close to 10 bowel movements per day. On admission she was only have 3 per day. Antibiotics were not continued upon transfer from the MICU to the medicine floor. The patient had one bowel movement per day while on the medicine service but no further diarrhea. A repeat C. diff toxin and stool cultures were pending at the time of discharge. Blood cultures were negative to date. Patient has GI follow-up as she has never had a colonoscopy. . 2. Hypotension: Patient received approximately 3.6L NS in the ED and MICU. Patient was normotensive on transfer to the medicine service and required no further intravenous fluid resuscitation. . 3. Acute Kidney Injury: Cr 2.1 on admission but returned to baseline of 1.0 following intravenous fluid resuscitation. No urine studies were pursued given fluid response and likelihood of prerenal etiology in the face of severe volume depletion. . 4. Heart Failure with Preserved EF: EF 55% in [2-16]. Patient's Furosemide, Metoprolol and Valsartan were held in the setting of hypotension and acute kidney injury. Patient was euvolemic at discharge and restarted on home medications. . 5. Anemia: Baseline hematocrit mid- to high-30s in months prior to admission. Patient has never received colonoscopy. No evaluation pursued during this admission but patient was scheduled with gastroenterology follow-up. . 6. Atrial Fibrillation: Patient on Coumadin for anticoagulation and Metoprolol tartrate for rate control. Metoprolol was initially held in the setting of hypovolemia and rate remained within normal limits. Metoprolol was restarted once euvolemic. INR 3.4 on admission. Coumadin was held until INR less than 3 and was reinitiated. Patient followed by [Hospital 197] clinic as an outpatient. . 7. Solitary Pulmonary Nodule: 5-mm pulmonary nodule in the right lung base detected on abdominal CT. Patient was a smoker at one point in her life but reported different pack-year histories. Of note, patient was reported to have Amiodarone-induced pulmonary fibrosis. Patient will need follow-up as an outpatient. [First Name8 (NamePattern2) ] [Last Name (un) 8773] guidelines, a followup chest CT at 12 months is recommended if there are no risk factors. If there are risk factors, then initial followup CT at 6 to 12 months is recommended. Medications on Admission: Medications - Prescription ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth every week on Wednesday CLONAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth three times a day FLUOXETINE - 20 mg Capsule - 1 Capsule(s) by mouth once a day Folate 1mg daily FUROSEMIDE [LASIX] - 20 mg daily LEVOTHYROXINE - 88 mcg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day NAPROXEN - 500 mg Tablet - 1 Tablet(s) by mouth Twice a day OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth Every morning and every night before dinner Take 30 minutes before breakfast, take 30 minutes before dinner PRAMIPEXOLE - 0.125 mg Tablet - 1 Tablet(s) by mouth hs SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day TIOTROPIUM BROMIDE - 18 mcg Capsule, w/Inhalation Device - 1 puff inh once a day WARFARIN - 1 mg Tablet - Take up to 5 tablets daily or as directed by coumadin clinic Trazodone 25mg daily at night . Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily CALCIUM CARBONATE - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth twice a day CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 400 unit Capsule - 1 Capsule(s) by mouth once a day - No Substitution FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth daily GLUCOSAMINE HCL-MSM-CHONDROITN - 500 mg-167 mg-400 mg Tablet - 1 Tablet(s) by mouth Three times a day Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO Every Week on Wednesday. 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ASDIR: Take up to 5 tablets daily, as directed by your coumadin clinic. . 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime. 11. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: Do NOT take this medication until you see your primary care physician.. 15. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day: No Substitution. 17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 18. Glucosamine HCl-MSM-Chondroitn [Telephone/Fax (3) 75495] mg Tablet Sig: One (1) Tablet PO three times a day. 19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 20. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day. 21. Outpatient Lab Work Please have your INR, CBC and Chem-10 checked in 4 days (Monday, [2129-8-29]). Please have the results sent to your PCP. [Name Initial (NameIs) ]: [Telephone/Fax (1) 250] Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: Primary Diagnoses: Diarrhea Secondary Diagnoses: Incidental Pulmonary Nodule Congestive Heart Failure Pulmonary Fibrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname 1255]: You were recently admitted to the hospital for severe diarrhea and low blood pressure. You received intravenous fluids and a short-course of antibiotics. Both your diarrhea and your blood pressure improved. It is likely that the cause of your diarrhea was a virus. You should follow up with your primary care physician as described below. No changes were made to your home medications with one exception. You should not take your Aspirin 81 mg until you see your new primary care physician in [Name9 (PRE) ]. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: RADIOLOGY When: TUESDAY [2129-8-30] at 1:30 PM With: RADIOLOGY [Telephone/Fax (1) 327] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GASTROENTEROLOGY When: THURSDAY [2129-9-8] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 18307], MD [Telephone/Fax (1) 1983] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: WEDNESDAY [2129-9-14] at 3:50 PM With: [Doctor First Name 5147] [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage You were incidentally found to have a nodule in your right lung. You should have a repeat CT-scan in [6-18] months to ensure that it is stable. Completed by:[2129-8-28]	[ "5849", "4280", "42731", "4240", "4019", "2449", "2859" ]
Admission Date: [2105-1-14] Discharge Date: [2105-1-21] Date of Birth: [2051-4-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3276] Chief Complaint: UGI bleeding Major Surgical or Invasive Procedure: Transfusions x 8 History of Present Illness: 53 y/o male with esophageal cancer and h/o PE's on Lovenox who presented to the ED after melena and an episode of coffee ground emesis at home. States that he had one episode of formed black stool approximately 3-4 days ago. No associated dizziness, CP/SOB. Two days ago he had 3 epidoses of dark stool, with the final one begin more diarrheal in nature. He never saw any BRB in or coating the stool. He admits to beginning to feel more fatigued and short of breath with minimal exertion, but denies orthostatic or presyncopal symptoms. Was still tolerated normal po intake without nausea, vomiting or abdominal pain. However, on the evening prior to admission he vomited approximately 200cc of "coffee ground" emesis at home. In total he vomited approximately 4-5 times per his wife. [Name (NI) ] [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 62047] or clots. Endorses pleuritic CP that was associated only with vomiting and coughing. Denied any radition of CP or associated nausea or diaphoresis. This AM, when his visiting nurse came, she stated that he looked pale, and upon hearing his story, placed a phone call to pt's oncologist Dr. [Last Name (STitle) 3274], who advised going to the ED. Of note, pt had a recent admission from [2104-12-31] to [2105-1-3] for UGIB, including an EGD on [1-1] without obvious upper etiology for bleeding. In the ED, vitals on presention were T 98.1 HR 124 BP 98/62 RR 20 99%RA. He was given 2 units of PRBCs and 2 liters of NS. Had rpt episode of coffee ground emesis. EKG was without any acute ST changes. 18G was placed in right hand and left chest port was accessed. He received 1mg Dilaudid for chest pain related to cough and vomiting. GI was consulted and he was admitted to the [Hospital Unit Name 153] for further care. Past Medical History: PMH: 1. Metastatic adenocarcinoma of esophagus. Five cycles of cisplatin and 5-FU completed [9-/2102], some with concurrent radiation therapy, followed by consolidation chemotherapy alone and also CyberKnife radiation therapy to left pelvic metastasis in [10-30]. Course c/b RUE DVT related to his line. In [7-/2103], Mr. [Known lastname 13144] began to experience difficulty swallowing, evaluation revealed local recurrence. He was referred to Dr. [Last Name (STitle) ] who removed as much of the mass as possible. Started irinotecan 65 mg/m2 day one and day eight and cisplatin 30 mg/m2 days one and day eight of three-week cycle [2103-10-23]. Developed PE [2103-11-18], since then is on Lovenox. Changed to Taxotere [1-1] due to insufficient palliative response in esophagus despite apparent systemic control; An esophageal stent was placed in [2104-1-24], however, he soon returned to the hospital with increased esophageal area pain and was found to have an abscess. During this hospitalization, he was diagnosed with atrial fibrillation and found to have a pericardial effusion which required drainage, balloon pericardiotomy and pericardial window. He was hospitalized from [2104-7-5] - [2104-7-15] for fever, shortness of breath, and enlarging pleural effusion. During this hospitalization he underwent talc pleurodesis of the right effusion. Cytology was negative. His primary oncologist is Dr. [Last Name (STitle) 3274]. 2. Hyperlipidemia 3. PE as above 4. h/o afib w/ rvr in setting of pericard effusion and window Social History: Married and lives w/ wife, 17 and 13-yo sons, works in IT, never smoked. occasional EtOH. Independent w/ ADLs at home. Family History: Mother had ovarian cancer at age 54, father MI age 48. Multiple family members on mother's side with 'cancers' 3 brothers/sisters in good health. Physical Exam: PE: T 98.3 BP 99/60 HR 97 RR 18 O2sat 97% 2L NC Gen: Pale, chronically ill appearing man in NAD HEENT: MM slighly dry, pale conjunctivae Neck: JVP 7cm, veins not distended, No cervical LAD appreciated CV: borderline Sinus tachy, no m/r/g appreciated Resp: No increased WOB noted. fine rales left lung base, no wheezes nor rhonchi Abd: +BS, soft, NT, ND Rectal: black stool guaiac positive Ext: WWP, 2+ DP/PT pulses b/l, no c/c/e Neuro: CN 2-12, strength, sensation grossly intact Pertinent Results: [2105-1-14] 11:51AM PT-13.9* PTT-31.3 INR(PT)-1.2* [2105-1-14] 11:51AM PLT SMR-NORMAL PLT COUNT-294 [2105-1-14] 11:51AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL SCHISTOCY-1+ [2105-1-14] 11:51AM NEUTS-88.7* BANDS-0 LYMPHS-7.4* MONOS-3.5 EOS-0.2 BASOS-0.1 [2105-1-14] 11:51AM WBC-8.9 RBC-2.26# HGB-6.7# HCT-20.0# MCV-88 MCH-29.6 MCHC-33.5 RDW-15.5 [2105-1-14] 11:51AM PHOSPHATE-3.6 MAGNESIUM-1.5 [2105-1-14] 11:51AM CK-MB-NotDone [2105-1-14] 11:51AM cTropnT-<0.01 [2105-1-14] 11:51AM ALT(SGPT)-20 AST(SGOT)-24 CK(CPK)-9* [2105-1-14] 11:51AM estGFR-Using this [2105-1-14] 11:51AM GLUCOSE-115* UREA N-20 CREAT-0.6 SODIUM-133 POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-30 ANION GAP-10 [2105-1-14] 08:38PM PT-13.8* PTT-26.4 INR(PT)-1.2* [2105-1-14] 08:38PM PLT COUNT-292 [2105-1-14] 08:38PM WBC-9.8 RBC-2.76* HGB-8.2* HCT-25.2# MCV-91 MCH-29.8 MCHC-32.6 RDW-15.0 [2105-1-14] 08:38PM CK-MB-1 cTropnT-<0.01 [2105-1-14] 08:38PM CK(CPK)-10 [2105-1-14] 08:38PM GLUCOSE-99 UREA N-16 CREAT-0.6 SODIUM-136 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13 . CXR [1-14]: 1. Dense left retrocardiac opacification possibly secondary to a combination of atelectasis and effusion, less likely pneumonia. 2. Persistent right mid lung opacity which may reflect sequela of chronic aspiration. Brief Hospital Course: A/P: 53 yo M with metastatic esophageal cancer and h/o GIB, h/o PE anticoagulated with lovenox on admission, presenting with 4 day h/o fatigue in association with melena and coffee ground emesis, admitted to ICU for management of GIB, then transferred to OMED, then back to the ICU and then back to OMED. Hospital Course by Problem: Upper GI Bleed: This is secondary to known fungating esophageal CA with gastric fundal extension of mass. GI consult team followed patient. He had EGD [1-1] without obvious source of bleeding. No intervention possible to stop bleeding from this mass. Has recieved total of 8U PBRC since admission, with hct dropping despite transfusions. He had continued episode of hematemesis and was taken to endoscopy again. He had substantial tumor burden in the esophagus and GE junction. The tumor is friable and was oozing blood at several sites. There is no endoscopic intervention which is effective in reducing the chance of bleeding. Per GI, it is likely his bleeding and occasional hematemesis will continue. They recommend against further endoscopies as they are unlikely to impact his management. Argon plasma coagulation was considered, but given the vascularity of tumor and location of stent, it is not a feasible option for him at this time. He was maintained on an IV PPI while in the hospital, PO on dischage. For the nausea, he was given compazine and zofran. His Hct was checked 2-3times/day, and he was transfused for Hct >25. The Lovenox for his hx of PE was discontinued given the persistent bleeding. Esophageal Cancer: Patient is s/p multiple rounds of chemotherapy, radiation and cyberknife. Per patient is not a candidate for further therapy given poor health status. No further intervention for tumor. For pain he had been on fentanyl patch 200mcg/hr q72h, and morphine IV prn, PO on discharge. H/o PE: He has a history of upper extremity DVT the embolized. He had been on Lovenox, but this is been discontinued in the setting of continued bleeding from esophageal mass. SVT: The patient has h/o atrial flutter to HR > 160. Patient's heart rate stable in metoprolol, but increases to 160 when even on dose of metoprolol is held. He had several episodes of SVT while on service tha twere trated with 5mg IV metoprolol pushes. they were generally controlled on this. He was continued on metoprolol TID, with a high threshold to hold completely. Patient also had tendency to become hypotensive with metoprolol IV pushes, so gets 500cc NS boluses with metoprolol. Gastroparesis: Patient on erythromycin which was initially held on admission. on [1-18] patient complained of early satiety and cramping in abdomen which resolved [1-19]. He was restarted on erythromycin. Hyperlipidemia: Initially held, continued on discharge Insomnia: Initially held po trazodone and remeron, but then readded with the addition of ativan PRN Medications on Admission: 1. Prochlorperazine 10 mg PO Q6H as needed. 2. Fentanyl 200 mcg/hr Patch q72 hr 3. Erythromycin 250 mg Tablet, Delayed Release PO TID. Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Mirtazapine 22.5 mg PO HS (at bedtime) as needed for insomnia. 5. Atorvastatin 10 mg Tablet PO DAILY 6. Lorazepam 1 mg Tablet PO HS 7. Lovenox 80 mg Subcutaneous twice a day. 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. 9. Pantoprazole 40 mg PO BID 10. Methylphenidate 5 mg Tablet PO twice a day. 11. Benzonatate 200 mg Capsule PO TID 12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr PO once a day. 13. Trazodone 50 mg PO QHS PRN insomnia 14. Maalox 225-200 mg/5 mL Suspension 15-30 MLs PO QID as needed. 15. Docusate Sodium 100 mg PO BID 16. Bisacodyl 10 mg Tablet PO BID 17. Liquid morphine 10-20 mg QID PRN pain 18. Zofran 4 mg PO TID PRN Discharge Medications: 1. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:10 Tablet(s) Refills:1 2. Remeron 15 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:30 Tablet(s) Refills:0 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Ritalin 5 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Benzonatate 200 mg Capsule Sig: Two (2) Capsule PO three times a day. 9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO once a day. 11. Maalox 200-200-20 mg/5 mL Suspension Sig: [11-26] PO once a day as needed for nausea. 12. Morphine 10 mg/5 mL Solution Sig: 10-20 mg PO every six (6) hours as needed for pain. 13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:10 Tablet, Rapid Dissolve(s) Refills:0 14. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 15. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous once a day. Disp:30 Flushes Refills:2 16. Normal Saline Flush 0.9 % Syringe Sig: One (1) Injection once a day. Disp:30 Flushes Refills:2 17. Other Sig: One (1) once a day: Please give POC Care per NEHT Protocol. . Disp:qs Other Refills:2 18. Needle (Disp) 20 G 20 x [1-27] Needle Sig: One (1) Miscellaneous once a week: To be used to access port weekly. . Disp:30 needle Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: Esophageal cancer Secondary: Hypotension, hyperlipidemia Discharge Condition: Hemodynamically stable & afebrile. Discharge Instructions: You were admitted for low blood counts and low blood pressure due to bleeding from you GI tract. You were treated with several blood transfusions. You had an endoscopy, the results of which were discussed with you. Please take all medications as prescribed. Your medications have not been changed while you were in the hospital. You will also be prescribed some anti-nausea medications. Please keep all your outpatient appointments. Please return to the hospital or seek medical advice if you notice new lightheadedness, bloody vomit, black or bloody stools, rapid heart rate, fever, chills or any other symptom for which you are concerned. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2105-1-27] 9:00 Provider: [First Name8 (NamePattern2) 251] [Name11 (NameIs) ], MD Phone:[0-0-] Date/Time:[2105-1-27] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6050], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2105-1-27] 10:00 [First Name8 (NamePattern2) 251] [Name8 (MD) ] MD [MD Number(1) 3282] Completed by:[2105-2-4]	[ "42731", "V5861", "2724" ]
Admission Date: [2131-5-4] Discharge Date: [2131-5-10] Date of Birth: [2048-9-20] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 82 year old female with significant PMH including DM type 2, HTN, atrial fibrillation, CAD, COPD and pulmonary fibrosis who is transferred from [Hospital 1562] Hospital for continued management of [Last Name (un) ], altered mental status, resolving sepsis and afib with recent digoxin toxicity. . History was obtained from chart as patient is unable to provide information. She initially presented to [Hospital 1562] Hospital on [4-24] with fever to 101, malaise and chills. She was seen in the ED there and was diagnosed with a UTI based on a mildly positive UA. She was put on Keflex PO for 2 days without improvement. Urine culture showed mixed flora. She re-presented with several days of loose stool and continued fevers to 101 and chills. She denied any localizing symptoms, but did endorse anorexia for 5 days. . At [Hospital1 1562], she was found to have a pseudomonal UTI and subequently developed hypotention, fever and presumed pseudomonal urosepsis. She was treated initially with doxy/levaquin prior to culture, then with Cefepime which was switched to Imipenem. On the second day of hospitalization, she developed acute respiratory failure requiring intubation and transfer to the ICU. This was thought to likley be flash pulmonary edema and cardiogenic in nature. She required pressors in the ICU and was extubated 6 days prior to transfer. She did not require further pressors. She was then transferred to the medical floor. She was found to be confused without focal neurologic deficits and was seen by Neurology who felt supportive care with MRI and possible EEG after stabilization would be indicated. She was also found to have an NSTEMI thought to be demand related as well as rapid afib treated with digoxin. This led to junctional bradycardia which was treated with digibind on the morning of transfer. She also developed acute renal failure with a peak creatinine of 3.8. She was treated with hydration. Nephrology at OSH thought this was likely ATN due to sepsis. This has begun to improve. She additionally has had intermittent nausea and vomiting as well as elevated lipase/amylase. No source was found on abdominal US. She had loose stools and a negative C. Diff x1; however, she was empirically started on PO vancomycin. And finally, she was found to have swelling in her left arm after infiltration of an IV and was found to have a DVT of L cephalic vein. Given thrombocytopenia, a HIT Ab was drawn which was equivocal and IgM APLA was positive, she was started on an Argatroban drip. She was given 2 units prbcs for a low Hct at 23%. . On the floor, the patient is alert but not oriented. She is weak but able to follow simple commands. She states she feels weak but denies any pain. . Review of sytems: Patient is unable to provide. Denies pain, shortness of breath. She does endorse weakness and malaise. Past Medical History: PMHx: -DM type 2 -GIB 2nd AVM -CAD with recent positive stress test (apical ischemia) -CKD, baseline Cr 1.2 -Pulmonary fibrosis -[Last Name (LF) 9215], [First Name3 (LF) ] 60% prior -PVD -COPD -Refractory HTN -Chronic low back pain -Old LBBB -Afib -Gout -Hyperlipidemia . [Hospital1 1562] hospitalization prior to transfer: -Pseudomonal urosepsis -Acute respiratory failure -Acute on chronic [Hospital1 9215] -NSTEMI -[Last Name (un) ] -Pancreatitis -?Type 2 HIT -+IGM APLA Social History: Independent with ADLs at home. Does not smoke, drink or use drugs. Family History: NC Physical Exam: Afebrile 108/75 75 20 98% on 1.5 L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: +mild bibasilar rales, significantly improving over past several days. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2131-5-4] 08:03PM BLOOD WBC-10.2 RBC-4.15* Hgb-12.5 Hct-38.1 MCV-92 MCH-30.1 MCHC-32.8 RDW-15.0 Plt Ct-202 [2131-5-8] 06:34AM BLOOD WBC-9.5 RBC-3.49* Hgb-10.4* Hct-32.1* MCV-92 MCH-29.7 MCHC-32.4 RDW-15.3 Plt Ct-127* [2131-5-9] 05:44AM BLOOD WBC-8.3 RBC-3.64* Hgb-10.9* Hct-33.2* MCV-91 MCH-29.8 MCHC-32.7 RDW-15.4 Plt Ct-123* [2131-5-10] 05:25AM BLOOD WBC-7.5 RBC-3.43* Hgb-10.2* Hct-31.1* MCV-91 MCH-29.8 MCHC-32.9 RDW-15.5 Plt Ct-124* [2131-5-7] 06:00AM BLOOD PT-14.0* PTT-81.5* INR(PT)-1.2* [2131-5-8] 06:34AM BLOOD PT-15.8* PTT-74.0* INR(PT)-1.4* [2131-5-9] 05:44AM BLOOD PT-18.8* PTT-32.2 INR(PT)-1.7* [2131-5-10] 05:25AM BLOOD PT-20.4* PTT-35.5* INR(PT)-1.9* [2131-5-5] 05:14AM BLOOD ACA IgG-PND ACA IgM-PND [2131-5-5] 05:14AM BLOOD Lupus-NEG [2131-5-5] 05:14AM BLOOD Glucose-250* UreaN-74* Creat-2.2* Na-146* K-4.0 Cl-117* HCO3-20* AnGap-13 [2131-5-8] 06:34AM BLOOD Glucose-231* UreaN-58* Creat-1.8* Na-142 K-4.1 Cl-113* HCO3-20* AnGap-13 [2131-5-9] 05:44AM BLOOD Glucose-148* UreaN-54* Creat-1.7* Na-145 K-4.0 Cl-114* HCO3-22 AnGap-13 [2131-5-10] 05:25AM BLOOD Glucose-138* UreaN-50* Creat-1.6* Na-144 K-3.9 Cl-113* HCO3-24 AnGap-11 [2131-5-4] 08:03PM BLOOD ALT-21 AST-22 LD(LDH)-474* AlkPhos-74 Amylase-592* TotBili-0.4 [2131-5-7] 06:00AM BLOOD ALT-14 AST-19 AlkPhos-61 Amylase-577* TotBili-0.3 [2131-5-7] 04:06PM BLOOD CK(CPK)-29 [2131-5-8] 01:37AM BLOOD CK(CPK)-31 [2131-5-8] 12:18PM BLOOD CK(CPK)-51 [2131-5-4] 05:08PM BLOOD Lipase-[2098]* [2131-5-4] 08:03PM BLOOD Lipase-[2124]* [2131-5-5] 05:14AM BLOOD Lipase-[2149]* [2131-5-6] 03:48AM BLOOD Lipase-1691* [2131-5-7] 06:00AM BLOOD Lipase-1631* [2131-5-7] 04:06PM BLOOD CK-MB-3 [2131-5-8] 01:37AM BLOOD CK-MB-3 [2131-5-8] 12:18PM BLOOD CK-MB-9 [2131-5-10] 05:25AM BLOOD Phos-2.9 Mg-1.8 [2131-5-6] 03:48AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.1 Mg-2.3 [2131-5-5] 05:14AM BLOOD VitB12-878 Folate-18.1 [2131-5-4] 08:03PM BLOOD TSH-1.5 [2131-5-5] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Equivocal EKG: Probable sinus tachycardia with atrial premature beats. Left bundle-branch block. No previous tracing available for comparison. CHEST PORT. LINE PLACEMENT [2131-5-5] IMPRESSION: PICC line at right SVC/RA junction. Cardiac Echo: Conclusions The left atrium is dilated. A small secundum atrial septal defect is present. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with moderate to severe hypokinesis of the inferior and inferolateral segments and of the mid to distal lateral segments. 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) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild focal LV systolic dysfunction consistent with CAD (inferior ischemia/infarction). Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. Small secundum ASD. Brief Hospital Course: 82 year old woman with PMH significant for HTN, DM type II, PVD, CAD, [Hospital 9215] transferred from OSH for continued management of hypertension, resolving sepsis, [Last Name (un) ], afib with RVR and diarrhea. . # Severe sepsis (at OSH): Appears to have been in the setting of pseudomonal UTI. Pt had been off of pressors and had been extubated for several days prior to transfer to [Hospital1 18]. The patient was continued on cefepime for pseudomonal coverage and has completed 13/14 days of IV Cefepime by the time of discharge from [Hospital1 18] to acute rehab. Culture data was obtained from [Hospital 1562] Hospital which showed pan-sensitive pseudomonas. Due to the fact that her course of antibiotics was nearing completion by the time culture data was available, it was decided to complete the entire coures on Cefepime. . # Acute on chronic diastolic heart failure Pt noted to have episode of flash pulmonary edema requiring intubation at [Hospital 1562] Hospital. Pt found to have acute decompensated [Hospital 9215] at [Hospital1 18] on [5-7] which responded well to Lasix 40 iv x 1. Pt was subsequently started on oral lasix which was uptitated to Lasix 60 mg po BID by the time of discharge, due to ongoing pulmonary bibasilar rales and mild oxygen requirement. Renal function has been improving despite diuresis. The lasix dose will need to be titrated on an ongoing basis, and her weight should be followed, as she is incontent of urine. Unfortunately, her dry weight is not currently known. . # Diarrhea: Pt had significant diarrhea throughout most of the hospitalization. C. Diff negative x1 but started empirically on PO vanco at [Hospital1 1562] and Flexiseal was placed. Repeat C.diff was negative at [Hospital1 18], so metronidazole and oral vancomycin were discontinued. She continued to have diarrhea at [Hospital1 18], which is thought likely an ADR to Cefepime; hopefully her diarrhea will improve after completion of her course. . # NSTEMI: Pt was found to have a Troponin up to 30 at [Hospital1 1562], likely in the setting of demand ischemia with known CAD as well as flash pulmonary edema/[Hospital1 9215]. Cardiac echo showed EF of 40-45% and mild focal LV systolic dysfunction consistent with CAD (inferior ischemia/infarction), mild mitral regurgitation, mild pulmonary artery systolic hypertension, and a small secundum ASD. She was continued on aspirin, carvedilol, and simvastatin. ACE inhibitor was held for acute kidney injury, and remains held at this time. ACE should be resumed once her renal funciton improves. If her blood pressure is too low to tolerate an additional blood pressure medication at that time, consider discontinuation of clonidine. . # Altered mental status/Acute delirium: Pt was found to have an acute delirium on admission, which was likely toxic-metabolic encephalopathy. Pt's mental status continued to improve throughout the hospitalization. . # Atrial fibrillation: Currently in sinus, but was tachy and irregular when arrived, in atrial fibrillation. She is being anticoagulated for DVT with heparin gtt bridge to warfarin, but it is not clear if she had documented atrial fibrillation prior to this admission. Heart rate was generally well controlled. The patient was started on warfarin, with a goal INR [1-17], given CHADS2 score of 4. INR was 1.9 upon transfer to the acute rehab. Warfarin dosing: pt has been given warfarin 5 mg po q 1600 [Date range (1) 83456]. Please see results section for corresponding INR values for past several days. . # Hypernatremia: Admission Na+ level 150. Likely from poor access to PO fluid. The patient was given multiple hypotonic fluid infusions to bring her serum [Na+] down. The hypernatremia resolved and did not recur. . # Elevated amylase/lipase: Pt was noted to have significantly elevated lipase/amylase, although pt denies abdominal pain, though the patient had reportedly been experiencing intermittent nausea/vomiting at that time. Her nausea and vomiting had resolved prior to admission. Amylase was measured in the high 500s and lipase around [2120] at [Hospital1 18], and trended down. Pt did not complain of any symptoms suggestive of pancreatitis during this admission. . # Thrombocytopenia: Negative but borderline HIT Ab. Patient was on argatroban from tranfer from [Hospital1 1562]. Argatroban was discontinued upon arrival, and the patient was restarted on heparin gttinstead. Platelets were monitored and remained stable; pt does not have HIT. . # Diabetes Mellitus, Type 2: Fingersticks were checked and glucose was controlled with insulin sliding scale. Pt was started on Lantus 8 units q HS on [5-9], and will need further titration as needed. . # Hypertension: Pt reportedly had a hypertensive emergency at [Hospital1 1562]. Is noted to have "refractory" HTN in admission notes. On lopressor, lasix, amlodipine, catapres and lisinopril at home. Upon arrival to [Hospital1 18], lopressor was held given reported digoxin toxicity with junctional bradycardia. Lisinopril was held given [Last Name (un) ]. Her clonidine and amlodipine were continued, and she was started on carvedilol. Her blood pressures were well controlled on the floor. Consider restarting ACE when renal function improves, as above. . # LUE DVT: Per report in the setting of infiltrated peripheral line. The patient had no personal or family history of prior clotting disorders. She was started on warfarin, and INR at time of transfer to rehab was 1.9. She should continue heparin gtt until INR is [1-17] x at least 48 hours. . # Digoxin toxicity: Pt reportedly had digoxin toxicity at [Hospital 1562] Hospital prior to transfer. THis resolved with one dose of digibind. . # Acute renal failure: Likely ATN in the setting of sepsis, hypotention. Creatinine continued to improve throughout the hospitalization, and was 1.6 at the time of dishcarge. . Code: Full DISP: discharge to LTAC for ongoing care. Medications on Admission: Medications on Transfer: Acetaminophen Liquid 640 mg Q6H prn Argatroban 3 mcg/kg/min Regular insulin SS Lopressor 5 mg IV Q4H 3L NC O2 Prilosec 20 mg daily Vancomycin 125 mg PO BID Allpurinol 100 mg QAM ?Imipenem . Medications at home: Prilosec 20 mg daily Lopressor 100 mg [Hospital1 ] Iron 325 mg daily Catapres 0.25 mg daily Simvastatin 40 mg daily Lasix 20 mg daily Allopurinol 100 mg daily Glipizide 5 mg PO BID Amlodipine 10 mg daily MVI daily Lisinopril 5 mg daily Tylenol 650 mg Q6H prn pain Discharge Medications: 1. Amlodipine 10 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 2. Simvastatin 40 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Clonidine 0.2 mg/24 hr Patch Weekly [Hospital1 ]: One (1) Patch Weekly Transdermal QFRI (every Friday). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 5. Nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO TID (3 times a day). 6. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 7. Warfarin 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAYS ([Doctor First Name ],MO,TU,WE,TH,FR,SA): Please monitor INR closely and titrate prn for goal INR [1-17]. 8. Carvedilol 12.5 mg Tablet [Month/Day (3) ]: One (1) Tablet PO BID (2 times a day). 9. Miconazole Nitrate 2 % Powder [Month/Day (3) ]: One (1) Appl Topical TID (3 times a day) as needed for fungal rash. 10. Acetaminophen 325 mg Tablet [Month/Day (3) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Furosemide 20 mg Tablet [Month/Day (3) ]: Three (3) Tablet PO BID (2 times a day): Please titrate as needed. 12. Cefepime 2 gram Recon Soln [Month/Day (3) ]: One (1) Recon Soln Injection Q24H (every 24 hours) for 1 doses: Pt's final dose is [2131-5-10] at 20:00. 13. Continue Heparin gtt as per sliding scale 14. 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. 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. 16. Insulin Glargine 100 unit/mL Solution [Month/Day/Year ]: Eight (8) units Subcutaneous at bedtime. 17. Humalog 100 unit/mL Solution [Month/Day/Year ]: As per sliding scale units Subcutaneous QACHS: as per sliding scale provided. 18. 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: [Hospital 5503] [Hospital ] Hospital - [Location (un) 5503] Discharge Diagnosis: # Severe sepsis due to pseudomonas urinary tract infection # Acute on chronic diastolic heart failure # NSTEMI at OSH # Acute delirium # Atrial fibrillation # Elevated pancreatic enzymes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted in transfer from [Hospital 1562] Hospital for multiple medical problems, including sepsis from a urinary tract infection, heart failure, atrial fibrillation, DVT, and confusion. You have gotten much better, but you still need ongoing medical care which you will receive at an acute rehab. Followup Instructions: Please continue to titrate Lasix dose as appropriate for [Hospital 9215]. Please continue heparin gtt for atrial fibrillation and DVT until INR is therapeutic ([1-17]) for at least 48 hours. Pt should receive her last dose of Cefepime 2 gm IV x 1 at 8 pm tonight. Please continue to increase her lantus dose as needed for improved glycemic control.	[ "5849", "41071", "2760", "99592", "4280", "2875", "25000", "4019", "42731", "496" ]
Admission Date: [2132-4-8] Discharge Date: [2132-4-14] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: increasing SOB and LE edema Major Surgical or Invasive Procedure: [4-9] TVRepair (#30 CE Annuloplasty Band) History of Present Illness: 83 yo F with seere TR and increasing pulmonary [Month/Day (4) ]. Past Medical History: MI, [Month/Day (4) ], lipids, severe TR, pulm [Month/Day (4) ], OA, HOH, s/p R THR, TKR Social History: Lives with Son retired no tobacco no etoh Family History: premature CAD - son with MI at 52 Physical Exam: Elderly women in NAD Lungs CTAB RRR no M/R/G Abdomen benign Extrem warm with 2+ LE edema, BLE erythematous [2-8] edema DP/PT pulses non-palp, femoral 2+, radial 2+ Discharge Vitals 98.0, 64 SR, 141/77, 22, Sat 97% on 3l nc wt 60.2kg Neuro A/o x3 MAE R=L strength but generalized weakness Cardiac RRR, Sternal Inc healing no erythema/drainage, sternum stable Pulm Crackles right base, decreased left base Abd soft, NT, ND last BM [4-13] Ext warm +2 edema right calf with erythema - cellulitis resolving, pulses palpable Pertinent Results: [2132-4-13] 03:00PM BLOOD WBC-10.6 RBC-3.54* Hgb-10.1* Hct-30.9* MCV-87 MCH-28.6 MCHC-32.9 RDW-19.1* Plt Ct-191 [2132-4-12] 04:15AM BLOOD WBC-13.9* RBC-3.63* Hgb-10.4* Hct-31.3* MCV-86 MCH-28.7 MCHC-33.3 RDW-19.0* Plt Ct-156 [2132-4-9] 09:53AM BLOOD WBC-14.2* RBC-3.66* Hgb-10.3* Hct-31.3* MCV-86 MCH-28.3 MCHC-33.1 RDW-19.0* Plt Ct-223 [2132-4-13] 03:00PM BLOOD Plt Ct-191 [2132-4-11] 03:46AM BLOOD PT-13.2* PTT-30.6 INR(PT)-1.2* [2132-4-9] 09:53AM BLOOD Plt Ct-223 [2132-4-9] 09:53AM BLOOD PT-13.6* PTT-54.8* INR(PT)-1.2* [2132-4-9] 09:53AM BLOOD Fibrino-268 [2132-4-14] 09:50AM BLOOD Glucose-111* UreaN-15 Creat-0.8 Na-145 K-3.6 Cl-105 HCO3-32 AnGap-12 [2132-4-9] 10:46AM BLOOD UreaN-25* Creat-0.8 Cl-108 HCO3-25 [2132-4-14] 09:50AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9 [2132-4-10] 03:13AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.2 EKG Normal sinus rhythm. Left axis deviation. Probable left anterior fascicular block. Delayed R wave transition. Possible prior anteroseptal myocardial infarction. No change ST-T wave abnormalities. Compared to the previous tracing of [2132-4-9] no diagnostic interim change. Read by: [Last Name (LF) ],[First Name8 (NamePattern2) 2206] [Doctor Last Name ] Intervals Axes Rate PR QRS QT/QTc P QRS T 63 160 104 [Telephone/Fax (2) 70838] -54 23 CXR CHEST (PA & LAT) [2132-4-13] 10:25 AM CHEST (PA & LAT) Reason: evaluate effusions [Hospital 93] MEDICAL CONDITION: 83 year old woman with TR REASON FOR THIS EXAMINATION: evaluate effusions CHEST TWO VIEWS ON [4-13] HISTORY: Triscuspid regurg, check effusions. REFERENCE EXAM: [4-11]. FINDINGS: There is moderate cardiomegaly with moderate bilateral pleural effusions and pulmonary vascular redistribution consistent with CHF. There is fluid and azygos fissure. An incomplete ring of a valve replacement is seen overlying the spine on the frontal film and overlying the mid heart on the lateral film. The appearance of this incomplete ring was discussed with the cardiac surgeon on call (Dr. [Last Name (STitle) ]. IMPRESSION: Increased CHF. DR. [First Name (STitle) ] [Doctor Last Name ] Approved: SUN [2132-4-13] 12:28 PM\ ECHO PRELIMINARY REPORT PATIENT/TEST INFORMATION: Indication: Tricuspid Valve repair- Intra-op TEE Height: (in) 61 Weight (lb): 118 BSA (m2): 1.51 m2 BP (mm Hg): 112/54 HR (bpm): 42 Status: Inpatient Date/Time: [2132-4-9] at 12:09 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW000-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) 412] [Last Name (Prefixes) 413] MEASUREMENTS: Left Ventricle - Ejection Fraction: 55% (nl >=55%) INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. Cilated IVC (>2.5cm) with no change with respiration (estimated RAP >20 mmHg). LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall hypokinesis. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular calcification. No MS. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Severe [4+] TR. Eccentric TR jet. Severe PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) 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. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally post-bypass data Conclusions: PRE-BYPASS: The left atrium is markedly dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is >20 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated. There is mild global right ventricular free wall hypokinesis. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. POST-BYPASS: [Location (un) ] PHYSICIAN: Brief Hospital Course: Ms. [Known lastname ] came in for scheduled surgery on [4-8] however had eaten breakfast that morning. She was admitted to the floor and then taken to the operating room on [4-9] where she underwent a TV repair with a #30 CE annuloplasty ring. She was transferred to the ICU in critical but stable condition. She was seen by pulmonology post op for pulmonary [Month/Day (4) ]. Recommendations included outpatient w/u, as well as treatment for her diastolic dysfunction - diuresis, rate control and afterload reduction. Her vasoactive drips were weaned to off and she was extubated by POD #2. She was transferred to the floor on POD #2. She was seen by physical therapy and continued to progress. She was ready for discharge to rehab on POD 5. Medications on Admission: atenolol, imdur, ditropan, norvasc, lasix, prilosec, xocor, colace, MVI, K-dur, diovan, asa, oxygen prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Tablet, Delayed Release (E.C.)(s) 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO Q12H (every 12 hours). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks: for Right leg cellulitis. Tablet(s) 12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital 8629] Discharge Diagnosis: Severe TR s/p TV repair MI [Hospital ] lipids pulmonary [Hospital ] OA HOH s/p R THR, TKR Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incisions, 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 until follow up with surgeon. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] 4 weeks Dr. [Last Name (STitle) ] (PCP) [Last Name (un) ] discharge from rehab Dr. [First Name (STitle) 70839] (Cardiology) 2 weeks Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (Pulmonology) 1-2 months for pulmonary hypertension workup Completed by:[2132-4-14]	[ "4240", "4280", "4019" ]
Admission Date: [2169-9-27] Discharge Date: [2169-10-10] Date of Birth: [2112-10-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1377] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: None. History of Present Illness: 56 year old man with HIV, DM2, CAD, h/o seizures, alcoholic cirrhosis and known varices s/p banding on [2169-9-18] initially presented to OSH with bright red hematemesis. Initial VS: Temp 97.3F, BP 81/47, HR 111, R 22, SaO2 99% RA with initial Hct 31.6. He continued to have hematemesis with worsening hypotension (SBP 60s) despite IVF and PRBCs (7L NS + 5units PRBCs total). Femoral CVL placed and he was started on Dopamine and Octreotide gtts and given protonix 40mg IV. Endoscopy attempted but unsuccessful due to continued hematemesis. He was intubated and repeat endoscopy with successful sclerotherapy and placement of 2 bands (reportedly [4-24] bands fired). He was transferred here for further care and concern given passage of maroon stool per rectum. . In our ED, initial vs were: HR 108 113/56 on dopamine 20 100%. He was continued on versed and fentanyl added for sedation. Labs remarkable for HCT 32, INR 1.5 from 1.2. He had no further bleeding and received ceftriaxone 1g and 2 units FFP. Seen by GI who recommended octreotide and pantoprazole drips, ceftriaxone, q4hour HCT and plan for repeat scope in am. VS prior to transfer: 107 94/53 on dopa 75mcg/kg/min 12 100% AC 500x18 PEEP 5 satting 100%. Access includes 20g PIV, 18g PIV, femoral CVL. . On the floor, he is intubaetd and sedated but opens eyes to commands. . Review of systems: Unable to obtain Past Medical History: - EtOH cirrhosis, c/b esophageal varices, s/p banding [2169-9-18] - HIV, on Atripla - diabetes, on insulin - seizures - CAD s/p MI [2155] - HTN? - hypercholesterolemia? - depression/anxiety? Social History: Disabled. Reportedly heavy EtOH use with ongoing daily use, no tobacco or other drug use. Family History: Unable to obtain Physical Exam: On admission: Vitals: T: BP: P: R: 18 O2: General: Intubated, sedated, opens eyes to name and follows commands. HEENT: Sclera anicteric, MM with dried blood around ETT, no new blood, oropharynx otherwise clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, faint 2/6 systolic murmru LUSB. No rubs, gallops Abdomen: soft, non-tender, non-distended, hyperactive bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining dark yellow-[Location (un) 2452] urine Ext: cool, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKin: No plamar erythema. Faint spiders anterior torso and gynecomastia. No tremor of tongue or extremities On discharge: VS: Tm 98.4 Tc 97, 107/66 (103-137/65-79), 69 (65-80), 18, 95%RA General: Pleasant male lying in bed in NAD HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no m/g/r Abdomen: soft, non-tender, non-distended, normoactive bowel sounds present, no rebound tenderness or guarding. Ext: warm, well perfused, no clubbing, cyanosis, or edema Neuro: Alert and oriented x3. Motor strength and sensory grossly equal and intact bilaterally. No asterixis. Pertinent Results: On admission: [2169-9-27] 10:19PM HCT-35.6* [2169-9-27] 07:09PM TYPE-CENTRAL VE PO2-47* PCO2-44 PH-7.25* TOTAL CO2-20* BASE XS--7 [2169-9-27] 07:09PM LACTATE-1.7 [2169-9-27] 06:38PM HCT-33.0* [2169-9-27] 03:08PM PH-7.29* COMMENTS-GREEN TOP [2169-9-27] 03:08PM freeCa-1.03* [2169-9-27] 02:22PM GLUCOSE-189* UREA N-12 CREAT-0.5 SODIUM-141 POTASSIUM-4.2 CHLORIDE-117* TOTAL CO2-17* ANION GAP-11 [2169-9-27] 02:22PM CALCIUM-7.3* PHOSPHATE-2.9 MAGNESIUM-2.0 [2169-9-27] 02:22PM CALCIUM-7.3* PHOSPHATE-2.9 MAGNESIUM-2.0 [2169-9-27] 02:22PM PT-14.0* PTT-26.1 INR(PT)-1.2* [2169-9-27] 11:04AM TYPE-CENTRAL VE PO2-43* PCO2-47* PH-7.21* TOTAL CO2-20* BASE XS--9 [2169-9-27] 11:04AM LACTATE-1.5 [2169-9-27] 11:04AM freeCa-1.14 [2169-9-27] 10:30AM TYPE-ART RATES-/22 TIDAL VOL-500 O2-50 PO2-136* PCO2-37 PH-7.29* TOTAL CO2-19* BASE XS--7 INTUBATED-INTUBATED VENT-SPONTANEOU [2169-9-27] 10:30AM LACTATE-1.4 [2169-9-27] 10:30AM freeCa-1.14 [2169-9-27] 09:45AM HCT-28.8* [2169-9-27] 05:56AM TYPE-ART TIDAL VOL-500 PEEP-5 O2-50 PO2-82* PCO2-41 PH-7.22* TOTAL CO2-18* BASE XS--10 INTUBATED-INTUBATED [2169-9-27] 05:56AM LACTATE-1.5 [2169-9-27] 05:56AM freeCa-0.99* [2169-9-27] 05:53AM GLUCOSE-230* UREA N-11 CREAT-0.5 SODIUM-137 POTASSIUM-4.4 CHLORIDE-116* TOTAL CO2-15* ANION GAP-10 [2169-9-27] 05:53AM CALCIUM-6.1* PHOSPHATE-2.4* MAGNESIUM-1.6 [2169-9-27] 05:53AM CORTISOL-25.7* [2169-9-27] 05:53AM WBC-20.3* RBC-3.55* HGB-9.8* HCT-30.6* MCV-86 MCH-27.5 MCHC-31.9 RDW-18.8* [2169-9-27] 05:53AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL TEARDROP-OCCASIONAL [2169-9-27] 05:53AM PLT SMR-VERY LOW PLT COUNT-76* [2169-9-27] 05:53AM PT-16.3* PTT-25.8 INR(PT)-1.4* [2169-9-27] 03:21AM TYPE-ART RATES-/14 TIDAL VOL-500 PEEP-5 O2-100 PO2-181* PCO2-41 PH-7.18* TOTAL CO2-16* BASE XS--12 AADO2-491 REQ O2-83 INTUBATED-INTUBATED VENT-CONTROLLED [2169-9-27] 03:00AM URINE HOURS-RANDOM [2169-9-27] 03:00AM URINE GR HOLD-HOLD [2169-9-27] 03:00AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2169-9-27] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2169-9-27] 02:04AM LACTATE-1.4 [2169-9-27] 01:50AM GLUCOSE-261* UREA N-9 CREAT-0.5 SODIUM-137 POTASSIUM-4.7 CHLORIDE-117* TOTAL CO2-13* ANION GAP-12 [2169-9-27] 01:50AM estGFR-Using this [2169-9-27] 01:50AM ALT(SGPT)-17 AST(SGOT)-38 TOT BILI-1.9* [2169-9-27] 01:50AM LIPASE-67* [2169-9-27] 01:50AM ALBUMIN-2.7* CALCIUM-5.7* PHOSPHATE-2.3* MAGNESIUM-1.4* [2169-9-27] 01:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2169-9-27] 01:50AM WBC-18.2* RBC-3.81* HGB-10.3* HCT-32.6* MCV-86 MCH-27.1 MCHC-31.7 RDW-18.7* [2169-9-27] 01:50AM NEUTS-85.6* LYMPHS-8.7* MONOS-5.1 EOS-0.3 BASOS-0.2 [2169-9-27] 01:50AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL BURR-2+ [2169-9-27] 01:50AM PLT COUNT-150 [2169-9-27] 01:50AM PT-17.2* PTT-31.2 INR(PT)-1.5* Other Relevant Labs: [2169-9-28] 10:23AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HAV Ab-POSITIVE [2169-9-28] 10:23AM BLOOD Smooth-NEGATIVE [2169-9-28] 10:23AM BLOOD [Doctor First Name ]-NEGATIVE [2169-10-2] 02:45AM BLOOD WBC-6.6 Lymph-17* Abs [Last Name (un) ]-1122 CD3%-88 Abs CD3-991 CD4%-39 Abs CD4-440 CD8%-49 Abs CD8-555 CD4/CD8-0.8* Micro: [2169-9-27] Blood cx- [1-23] coag negative staph; [3-23] no growth [2169-9-27] Urine cx- no growth [2169-9-29] Blood cx- no growth [2169-10-1] SPUTUM Source: Induced. RESPIRATORY CULTURE (Final [2169-10-5]): SPARSE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. (pan sensitive) [2169-10-2] HIV-1 Viral Load/Ultrasensitive (Final [2169-10-3]): HIV-1 RNA detected, less than 48 copies/mL. [2169-10-3] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2169-10-4]): Feces negative for C.difficile toxin A & B by EIA. Studies: [9-27] Duplex Doppler Abd U/S: RIGHT UPPER QUADRANT LIVER/GALLBLADDER: The liver echotexture is coarse. This, and the inability of patient to hold his breath could obscure a focal lesion. The gallbladder is normal without evidence of stones. There is no intra- or extra-hepatic biliary ductal dilation. The common duct measures 5 mm. The kidneys are not well seen. The pancreas and aorta are obscured by bowel gas. The spleen is enlarged, measuring 15.4 cm. There is a small amountof ascites. DOPPLER EXAMINATION: Doppler examination is limited as patient was unable to hold his breath due to the intubated status. The main, right anterior, right posterior, and left portal veins are patent, with forward flow. The right, left, and main hepatic arteries are patent with appropriate waveforms demonstrating sharp systolic upstroke and preserved flow through diastole. The right, middle, and left hepatic veins are patent with appropriate direction of flow. Doppler evaluation of the IVC is limited. IMPRESSION: 1. Cirrhosis. 2. Splenomegaly. 3. Small amount of ascites. 4. Limited assessment of the pancreas, aorta and kidneys. 5. Normal Doppler examination of the liver. CXR [9-29]: Greater opacification in the left lower lobe is probably worsened atelectasis. Moderate-to-severe atelectasis in the right lower lung is stable or increased and small bilateral pleural effusions have increased as well. Lung apices are clear. Heart size is mildly enlarged, increased since the previous study. ET tube in standard placement. CXR [10-8] (s/p NGT placement): FINDINGS: As compared to the previous radiograph, the lung volumes have increased, likely to reflect an improved ventilation. Unchanged size of the cardiac silhouette. Minimal remnant retrocardiac atelectasis. Normally positioned right-sided PICC line. Unremarkable course of the nasogastric tube, the tip of the tube is not visualized on the image. No pleural effusions. No focal parenchymal opacity suggesting pneumonia. . [10-3] CT Head- No evidence of acute intracranial abnormalities. . [10-5] EEG- This EEG showed some low voltage patterns alternating with widespread alpha frequencies. Overall, it suggested an encephalopathy with some medication effect. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features. On discharge: [2169-10-10] 05:57AM BLOOD WBC-3.5* RBC-3.27* Hgb-9.3* Hct-27.6* MCV-84 MCH-28.5 MCHC-33.8 RDW-18.3* Plt Ct-124* [2169-10-10] 05:57AM BLOOD PT-15.1* INR(PT)-1.3* [2169-10-10] 05:57AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-138 K-3.7 Cl-111* HCO3-22 AnGap-9 [2169-10-10] 05:57AM BLOOD ALT-21 AST-36 AlkPhos-137* TotBili-0.5 Brief Hospital Course: 56yo man with HIV, DM, h/o seizures, CAD, EtOH cirrhosis c/b esophageal varices initially presenting to OSH with massive hematemesis [2-21] variceal hemorrhage now s/p successful endoscopic banding transferred to [Hospital1 18] for further management. # UGIB/Variceal bleed: Per report, source of UGIB felt to be variceal in nature from findings at endoscopy and hemostasis achieved with no further episodes of bleeding since banding on [9-18]. Passage of maroon stool (the reason for transfer) was felt to most likely represent blood in trasnsit from UGIB rather than separate source. GI was consulted and recommended octreotide and PPI gtt; on [9-28] was transitioned to daily PPI, octreotide drip d/c-ed on [10-2]. Repeat EGD was not performed as patient did not have further episodes of variceal bleeding. Patient received 5 days of CTX for SBP PPX. During ICU course received 3 units of pRBCs and 2 units FFP as there was some blood found in his ETT. He was transferred out of the ICU and his home nadolol was restarted and increased to 30 mg. He remained stable on the floor, with stable hct and no further episodes of bleeding. If the patient should rebleed in the future, it was felt that TIPS would be the next step in management. # Hypotension: Patient hypotensive on admission, likely secondary to hypovolemia and GIB. Blood pressure improved on arrival to ICU and dopamine was weaned. As hemodynamics stabilized, patient became hypertensive and was restarted on his home enalopril, HCTZ, and nadolol with good pressure control. # ETOH abuse c/b cirrhosis: At high risk for EtOH withdrawal given positive level at OSH, h/o seizures and reported daily use. Pt received banana bag and was put on a CIWA scale. Initially on fentanyl/versed for sedation while intubated, though was changed to propofol drip on [9-28]. NGT placed on [9-29] and tube feeds were started (the NGT was self d/c-ed on [10-6]). Propofol shut off on [9-30] and pt received valium only per CIWA protocol. CIWA was weaned. By the time of transfer to the floor patient was [Doctor Last Name ] zero on CIWA. Patient was started on lactulose secondary to altered mental status (see below). Home nadolol dose was increased as above. Social work was consulted and worked with the patient to find an appropriate rehab for alcohol abuse. He was instructed to follow up with his outpatient gastroenterologist Dr. [First Name (STitle) ] in [Location (un) ], NH and schedule an EGD to reassess his varices in the next 1-2 weeks. # Hospital acquired pneumonia- Patient developed hospital acquired pneumonia following extubation on [10-1]. Was treated with broad spectrum antibiotics and then coverage narrowed down to cefepime for 8 days to treat pan-sensitive pseudomonas. He required a brief period of reintubation ([Date range (1) 41932]) secondary to hypoxia and altered mental status (see below). On discharge, patient was breathing comfortably on room air and lung exam had cleared. # Delirium- Patient was noted to have altered mental status, with agitation requiring restraints. Was noted to have left gaze deviation and neurology was consulted. Recommended CT head (negative for acute process) and continuous EEG monitoring for seizures (drowsiness/mild encephelopathy, negative for seizures on [10-3] and encephelopathy w/ some medication effect on [10-5]). Patient was continued on his home keppra (has history of seizures). Delirium was attributed to prolonged ICU course, medications, and possible hepatic encephelopathy. He was started on lactulose, frequently reoriented, and symptoms gradually improved. He was alert and oriented x3 at the time of discharge. # Diabetes: On insulin at home. Was given glargine and humalog sliding scale while in house. # HIV: On HAART. HIV VL was checked and was undetectable. CD4 count 440. Patient was continued on his home atripla. # Seizures: Was continued on home keppra. Was monitored on EEG with no epileptiform activity. # Depression/Anxiety: Sertraline and seroquel were held while patient NPO, but restarted once he was taking POs. Medications on Admission: - Keppra 500mg PO BID - Gabapentin 300mg PO BID - Atripla - Pravastatin 40mg PO daily - Protonix 40mg PO daily - Sertraline 150mg PO daily - Seroquel 25mg PO BID - HCTZ 25mg PO daily - Nadolol 20mg PO daily - Enalapril 20mg PO BID - Novalog 70/30 10units daily Discharge Medications: 1. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:1000 ML(s) Refills:2 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Nadolol 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Efavirenz-Emtricitabin-Tenofov [Telephone/Fax (3) 567] mg Tablet Sig: One (1) Tablet PO once a day. 12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Ten (10) units Subcutaneous once a day. 13. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO every six (6) hours. Disp:120 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] homecare Discharge Diagnosis: Primary: Alcoholic cirrhosis, complicated by esophageal varices Alcohol abuse Pneumonia Delirium Secondary: HIV Diabetes mellitus Seizure disorder HTN Hypercholesterolemia Depression/anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 3549], It was a pleasure taking care of you at the [Hospital1 18]. You were admitted to the hospital because you were vomiting blood. You underwent endoscopy and banding of esophageal varices (enlarged blood vessels in your throat) at your local hospital in [Location (un) ] and were transferred here for further care. While you were here at the [Hospital1 18] you were treated for a pneumonia and delirium. It is important that you STOP drinking alcohol to prevent further damage to your liver and your health. You must also have a repeat upper endoscopy performed to evaluate your varices in the next 1-2 weeks- you can schedule that in [Location (un) ] or return here for this procedure as we discussed. Please also follow up with your gastroenterologist in [Location (un) ]. We have made the following changes to your medications: - please INCREASE your dose of nadolol to 30 mg daily - please START taking lactulose - please START taking sucralfate You may continue to take your other medications as you were previously. We wish you a speedy recovery. Followup Instructions: Please schedule follow up with your outpatient gastroenterologist Dr. [First Name (STitle) ]. You will also need to have a repeat endoscopy performed to evaluate the status of your esophageal varices. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] Completed by:[2169-10-10]	[ "51881", "5070", "2762", "2760", "25000", "V5867" ]
Admission Date: [2185-1-4] Discharge Date: [2185-1-14] Date of Birth: [2185-1-4] Sex: F Service: Neonatology HISTORY: Baby Girl [Known lastname 46379] [Known lastname 46380] delivered at 37-5/7 weeks gestation with a birth weight of 2705 grams and was admitted to the Intensive Care Nursery for a sepsis evaluation and management of respiratory distress. Infant was born to a 25-year-old gravida 6, para 3, now 4 mother with estimated date of delivery [2185-1-21]. Prenatal screens included blood type A positive, antibody screen negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, and group B Strep negative. Mother's medical history is notable for irritable bowel syndrome treated with dicyclomine and a history of horseshoe kidney. She presented in spontaneous labor. Rupture of membranes occurred three hours prior to delivery with clear amniotic fluid. The mother had a fever to 100.4 during labor. Intrapartum antibiotics were started six hours prior to delivery. On prenatal ultrasound, the infant was also noted to have a horseshoe kidney. The infant had a spontaneous cry at delivery. Was bulb suctioned and given free flow oxygen. Apgar scores were 7 and 8 at one and five minutes respectively. PHYSICAL EXAMINATION ON ADMISSION: Weight 2705 grams (25th-50th percentile), length 47 cm (25th-50th percentile), head circumference 32.5 cm (25-50th percentile). In general, an infant who has decreased perfusion, active. Skin without rashes or lesions. Head: Anterior fontanelle open and flat. Eyes, ears, nose, throat within normal limits. Respiratory: Grunting, flaring, retracting with fair aeration. Heart: regular, rate, and rhythm, no murmur, decreased perfusion. Abdomen: No hepatosplenomegaly, no masses. Genitalia: Normal female, patent anus, spine intact. Hips stable. Moro, grasp, and sucking present. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: Was grunting, flaring, retracting on admission, then tachypnea to low 100s for the first three days of life. Had an oxygen requirement. On admission required supplement oxygen by nasal cannula until day of life four. Chest x-ray was nonspecific, but clinical course suggested mild respiratory distress syndrome. She had intermittent desatuations through day 7. Now greater than 48 hours stable in RA with good saturations. At discharge, the infant was breathing comfortably on room air, respiratory rate 30s-60s. 2. Cardiovascular: A normal saline bolus was given on admission for poor perfusion. Has remained hemodynamically stable since without a murmur. Recent blood pressure 72/45 with a mean of 52. 3. Fluids, electrolytes, and nutrition: Remained NPO and on intravenous fluid until day of life four due to tachypnea. Feeds are started on day of life four. Has been ad lib feeding with Enfamil 20 with iron. Discharge weight 2470 grams. 4. GI: Was treated with phototherapy for indirect hyperbilirubinemia. Peak bilirubin total of 16.4, direct 0.4. Rebound bilirubin 11.3. 5. Hematology: Hematocrit on admission 53.4%. 6. Infectious Disease: Received 48 hours of ampicillin and gentamicin for rule out sepsis on admission. The complete blood count was benign. Blood culture was negative. Was started on amoxicillin 50 mg per day on day of life four for prophylaxis secondary to UPJ obstruction. 7. Urology: Was noted to have a horseshoe kidney on fetal ultrasound. The ultrasound done on day of life one revealed horseshoe kidney with the right measuring 4 cm, the left measuring 3.5 cm. The echotexture of the right kidney is normal. On the left, there is moderate pelviectasis and mild caliectasis to the left of the ureteropelvic junction. The bladder is unremarkable. The UPJ obstruction is moderate. She has been seen by the urology service and an outpatient VCUG and US have been scheduled for 1 month of age along with an appointment with Dr. [Last Name (STitle) 45267]. Amoxicillin prophylaxis is recommended at least until she is seen in follow up. 8. Neurology: Exam age appropriate. 9. Sensory: Audiology hearing screening was performed with automated auditory brainstem response. Infant passed both ears. 10. Psychosocial: The mother has a history of alcohol abuse and is currently residing at [First Name4 (NamePattern1) 36413] [Last Name (NamePattern1) ]. The infant will go to [First Name4 (NamePattern1) 36413] [Last Name (NamePattern1) ] with the mother at discharge. [Hospital1 1444] Social Work was involved with the family. The contact social worker is [Name (NI) 46381] [Name (NI) ], and she can be reached at [Telephone/Fax (1) 8717] if there is any questions. CONDITION ON DISCHARGE: Stable 10 day old infant. DISCHARGE DISPOSITION: Discharged to [First Name4 (NamePattern1) 36413] [Last Name (NamePattern1) ] with mother. NAME OF PRIMARY PEDIATRICIAN: Pediatric care will be given at [Hospital ] Community Health Center while mother is at [Name (NI) 36413] [Last Name (NamePattern1) ]. Telephone number [Telephone/Fax (1) 46382]. After discharge from [First Name4 (NamePattern1) 36413] [Last Name (NamePattern1) ] the pediatrician will be Dr. [Last Name (STitle) 46383] at [Hospital 5871] Pediatrics ([Telephone/Fax (1) 46384]. CARE AND RECOMMENDATIONS: 1. Feeds: Enfamil 20 with iron ad lib demand. 2. Medications: Amoxicillin 50 mg once a day. 3. Car seat position screening done and infant passed. 4. State newborn screen was sent on [1-7] and [1-14]. Results are pending. 5. Immunizations received: Received hepatitis B immunization on [2185-1-9]. FOLLOW-UP APPOINTMENT SCHEDULED RECOMMENDED: 1. Follow-up appointment with pediatric at [Hospital1 ]. Recommended within 2-3 days from discharge. 2. A VCUG and renal ultrasound has been scheduled at [Hospital3 1810] on [2185-2-7] at 8:40 in the morning, telephone number [Telephone/Fax (1) 45268]. 3. An appointment with Dr. [Last Name (STitle) 45267], the pediatric urologist at [Hospital3 1810], has been made for [2-9] at 9:15 am, telephone number [Telephone/Fax (1) 46385]. DISCHARGE DIAGNOSES: 1. AGA term female. 2. Respiratory distress resolved. 3. Rule out sepsis. 4. Horseshoe kidney with left ureteropelvic junction obstruction. 5. Indirect hyperbilirubinemia resolving. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37233], M.D. [MD Number(1) 36463] Dictated By:[Last Name (NamePattern1) 37803] MEDQUIST36 D: [2185-1-14] 00:31 T: [2185-1-14] 05:37 JOB#: [Job Number 46386]	[ "V290" ]
Admission Date: [2107-4-13] Discharge Date: [2107-4-17] Date of Birth: [2039-3-10] Sex: M Service: MEDICINE Allergies: Levofloxacin Attending:[First Name3 (LF) 2745] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 68 yo M with severe COPD p/w shortness of breath and subjective fevers and chills for the past five days. He states that he has not felt well and has been taking his inhalers as directed. Patient called EMS and received nebs. Patient denies any chest pain or dizziness associated with his shortness of breath. Patient has had multiple hospitalizations requiring intubation in the past for COPD. . On arrival to the ED, patient appeared better. Patient had an episode where he desaturated to the low 80s and received Mg, solumedrol, nebs. His VS were 119/43 HR 84 93% on NC 5L RR 25. Patient improved with these measures. He also had tranient altered mental status, that resolved while in the ER. Patient's CXR was c/w a RLL infiltrate and received ceftriaxone and azithro. . On arrival to [Hospital Unit Name 153], patient denies any nausea, vomiting. Admits to diarrhea over past several days and persistent lumbar pain. All other ROS is otherwise negative. Past Medical History: CAD s/p NSTEMI in [2101] - [4-10] cath showed 10% LMCA stenosis, TTE [8-10] showed mild RV enlargement and preserved BiV function COPD on baseline 4L NC, nightly BiPAP 12/5 Iron-deficiency anemia b/l Hct ~30% GERD Diverticulosis VRE and Pseudomonas UTI HTN Hyperlipidemia Chronic low back pain s/p L1-L2 laminectomy Bilateral cataract surgery BPH s/p TURP Social History: The patient currently lives in [Location 686] with his wife. [Name (NI) ] is initially from [Country 7936], now retired but previously employed as a mechanic for [Company 19015]. Tobacco: Patient quit 30 years ago, previous 20 pk-year history. ETOH: Rare social use Illicits: + Marijuana use up to 1 to 2 marijuana cigarettes daily, quit Family History: Mother w/ asthma, Alzheimer's disease. Father w/ [Name2 (NI) 499] cancer. Physical Exam: PHYSICAL EXAM GENERAL: Pleasant, well appearing male in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP not appreciated. LUNGS: Mild basilar crackles, poor air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [1-7]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [2107-4-13] 06:29PM WBC-16.5# RBC-4.12 HGB-11.0* HCT-34.9* MCV-85 MCH-26.6* MCHC-31.4 RDW-15.2 [2107-4-13] 06:29PM NEUTS-76.9* LYMPHS-11.5* MONOS-6.9 EOS-4.3* BASOS-0.5 [2107-4-13] 06:29PM PLT COUNT-335 [2107-4-13] 06:29PM CK-MB-4 [2107-4-13] 06:29PM cTropnT-0.02* [2107-4-13] 06:29PM GLUCOSE-86 UREA N-14 CREAT-0.6 SODIUM-134 POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-37* ANION GAP-13 [2107-4-13] 06:43PM LACTATE-2.0 [2107-4-13] 11:17PM TYPE-ART RATES-/18 O2 FLOW-4 PO2-65* PCO2-77* PH-7.32* TOTAL CO2-42* BASE XS-9 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2107-4-13] CXR The focus in the retrocardiac right lower lobe has increased in size. While this may be indicative of either a slowly-developing pneumonia or possibly aspiration, possibility of an underlying bronchoalveolar cell carcinoma cannot be dismissed. It is likely prudent to obtain a followup CT scan to compare with the one obtained on [2-16], [2107] soon as an outpatient. [2107-4-14] pCXR: COMPARISON: [2107-4-13]. FRONTAL CHEST RADIOGRAPH: The cardiomediastinal silhouette is within normal limits. The pulmonary vasculature is normal. In the right and left lower lobes there is mild tram tracking and bronchial wall thickening consistent with bronchiectasis. Patchy bibasilar opacities likely representing aspiration. No pleural effusion or pneumothorax. IMPRESSION: 1. Bibasilar bronchiectasis. 2. Patchy bibasilar opacities likely representing aspiration/aspiration pneumonia. Brief Hospital Course: 68 y/o M with a history of COPD who presents with COPD exacerbation and pneumonia. He was initially in the [Hospital Unit Name 153] on arrival, transferred to the hospitalist service on HD#2. . #. COPD: Patient is currently at basline, on 4L NC. Patient's last ABG was 7.32/77/65/42 and is consistent with his propensity to be a CO2 retainer. Patient's mental status was altered while he was in the ER, and may be related to either hypercapnea or hypoxia, but was resolved on presentation to the ICU. He is currently on his home oxygen requirement. He continued albuterol and ipratropium nebs, and changed from IV solumedrol to po prednisone on transfer to the floor. Given his frequent steroid requirement, he was continued on PCP prophylaxis with Bactrim DS MWF. On the medicine floor, the patient clinically improved and was discharged on a long steroid taper, completion of his levofloxacin and his home oxygen at 4-6 liters and outpatient pulmonary medication regimen. The patient was observed to be walking comfortably around the floor for 3 days prior to discharge. . #. Hospital Acquired Pneumonia, RLL: Patient had 5 days of subjective fevers and chills, has leukocytosis, and has hospitalization within past three months. Initiated coverage with Vancomycin, Cefepime, Levofloxacin. He was transferred to the floor on just Levaquin, but leukocytosis on HD#3 went from 7K to 26K so cefepime was resumed but subsequently discontinued. The patient was discharged to complete a 7 day course of levofloxacin. . #. CAD: Stable. Continued ASA, Statin, ACE-I . #. Glaucoma: Asymptomatic currently Continued eye drops . #. Hyperphosphatemia: On the day of discharge, the patient's phosphorus returned at 1.3. The patient had already left the hospital. He will need oral repletion with neutra-phos. Medications on Admission: Alendronate 70 mg Tablet qsunday. Calcium Carbonate 500 mg [Hospital1 ] Cholecalciferol 800 unit qday. Fluticasone-Salmeterol 250-50 mcg/Dose [Hospital1 ] Lorazepam 0.5 mg qHS prn. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4H prn Pravastatin 40 mg DAILY Sertraline 50 mg Daily Tiotropium Bromide 18 mcg Capsule Daily Aspirin 81 mg qday. Trimethoprim-Sulfamethoxazole 160-800 mg qMWF Prednisone 30 mg qDaily Prednisolone Acetate 1 % Drops [Hospital1 ] Lisinopril 5 mg qday. Albuterol Sulfate 2.5 mg /3 mL 2puffs Q4H Finasteride 5 mg qDaily Montelukast 10 mg qdaily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO every twelve (12) hours. 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 9. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing: Ideally use no more than 4 times a day, but may increase if having difficulty breathing. 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day. 12. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 13. BIPAP Sig: One (1) administration at bedtime: Use per home settings. 14. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 15. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 18. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO once a day. 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 20. Oxycodone-Acetaminophen 7.5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: This is a dangerous medication. Minimize using. 21. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual use as directed. 22. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) dose Inhalation once a day. 23. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 24. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 25. home oxygen Sig: 4-6 Liters continuously: Continuous home oxygen 4-6 liters. 26. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 27. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:2 Tablet(s) Refills:0 28. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day: Steroid Taper to prednisone 20 mg. Take 4 tablets by mouth once a day for 3 days and then decrease to 3 tablets a day for 5 days and then decrease to 2 tablets once a day and stay at 2 tablets a day. Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. pneumonia, hospital associated 2. COPD exacerbation Discharge Condition: stable, on home oxygen 4-5L O2 by nasal canula Discharge Instructions: You were hospitalized with pneumonia and an exacerbation of your COPD. Please take all medications as prescribed. Follow up with your doctors as previously [Name5 (PTitle) 1988], and as [Name5 (PTitle) 1988] below. If you have increased shortness of breath, fever greater than 101, chest pain, diarrhea or any other alarming symptoms, return to the emergency department. Do not drive if you take percocet. Followup Instructions: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2107-8-11] 10:10 Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2107-8-11] 10:30 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2107-8-11] 10:30	[ "486", "41401", "53081", "4019", "2724", "412" ]
Admission Date: [2130-4-16] Discharge Date: Date of Birth: [2130-4-11] Sex: F Service: NBB ID: Baby Girl [Known lastname 72714] is a 20 day old former 33 week infant being discharged from the [Hospital1 69] Neonatal Intensive Care Unit. She was born at the [Hospital1 18], and was initially transferred to [Hospital3 1810] NICU due to bed availability issues. She was then retro-transferred to [Hospital1 18] on [4-16]. HISTORY: Baby Girl [Known lastname 72714] was born at 33 weeks gestation to a 31-year-old G3, P0 now 1 mother. Prenatal screens: B-negative, antibody negative, hepatitis surface antigen negative, RPR nonreactive, GBS unknown. This pregnancy was uncomplicated until premature rupture of membranes and spontaneous preterm labor, which then progressed to vaginal delivery. ROM occured 15 hrs prior to delivery, and there was no maternal fever noted. Mother was treated with antibiotics beginning 11 hours prior to delivery. Infant emerged vigorous with Apgars [7-27]. HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant remained stable in RA from birth throughout hospitalization, without significant concerns for respiraotry insufficiency. Mild to moderate immaturity of respiratory control was noted, with occasional spells related to apnea and feeding. Last spell was noted on [4-26], and by time of discharge, she had been without spells for 5 days. She did not require methylxanthine therapy for her apnea and bradycardia. Cardiovascular: Infant remained hemodynamically stable throughout hospitalization. A systolic murmur was noted, which persisted at time of discharge. CXR, EKG, and 4-extremity blood pressures were performed on [4-27], and these were all within normal limits. Murmur is most consistent with PPS, and can be followed as an outpatient; if murmur persists, referral to a pediatric cardiologist can be considered. Fluid and electrolyte: Infant was initially maintained on IVF, and advanced to full enteral feeds without difficulty. Gavage feedings were transitioned gradually to oral feedings, and by time of discharge, infant has been ad lib feeding BM 24 calories/oz all PO for several days with adequate intake and weight gain. Birthweight was 2185 grams; weight at discharge was 2560 grams. Weight gain has been steady prior to discharge, so caloric density of breast milk may be able to be reduced in the near future. GI: Infant was noted to develop mild hyperbilirubinemia, with peak bilirubin level of 9.7 on [4-13], treated with several days of phototherapy. Infectious disease: CBC and blood cx were sent on admission; CBC was unremarkable, and blood cx were negative. Infant received ampicillin and gentamicin for 48 hours. Hematology: Initial Hct was 47. Infant was treated with iron supplementation. Neuro: Normal neurologic exam was maintained throughout admission. Hearing screen has been performed with automated auditory brainstem responses, and the infant passed in both ears. DISCHARGE EXAM: Wt 2560 grams. Infant in open crib, room air. Skin: Warm and dry with pink color. Anterior fontanel open, level. Sutures opposed. Chest: Breath sounds clear and equal. Cardiovascular: Regular rate and rhythm, no murmur. Normal S1, S2. Pulses +2 x4. Abdomen: Soft, no masses, positive bowel sounds. Cord site healed. GU: Normal external female genitalia. Extremities: Moves all extremities. Neuro: Alert, positive suck, positive grasp, symmetric Moro.CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) ], [Hospital1 47370] Pediatrics, [Telephone/Fax (1) 47371], fax # [Telephone/Fax (1) 72715]. CARE AND RECOMMENDATIONS: Continue ad-lib feeding breast milk 24 calories/oz, supplemented with similac powder. Medications: Continue ferrous sulfate of 0.2 mL p.o. daily and Tri-Vi-[Male First Name (un) ] 1 mL p.o. daily. Follow-up: VNA scheduled for 1 day after discharge, PMD scheduled for 2 days after discharge. Routine health care maintenance: Infant passed a 90 minute car seat position screening. State newborn screens have been sent per protocol and have been within normal limits. Infant received hepatitis B vaccine on [2130-4-20]. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2130-4-30] 21:09:25 T: [2130-5-1] 06:32:53 Job#: [Job Number 72716]	[ "7742", "V053" ]
Admission Date: [2173-2-5] Discharge Date: [2173-2-23] Date of Birth: [2117-9-26] Sex: M Service: NEUROSURGERY Allergies: Tetanus Toxoid Attending:[First Name3 (LF) 1271] Chief Complaint: fever Major Surgical or Invasive Procedure: 1. Deep Brain Stimulator placement 2. Fluoroscopy guided lumbar puncture 3. Deep Brain Stimulator removal History of Present Illness: The patient is a 55 yo M with s/p right DBS placement [2-2]. The patient reports that since yesterday morning he has felt very tired and "groggy". Yesterday morning he slipped and fell backwards into a laundry basket; denies hitting head, no LOC. He saw his neurosurgeon in clinic today for a head CT (which was stable). This evening he spiked a fever at home and per report his wife felt that he had altered mental status so he was brought to the ED. He reports that he has had headaches since the DBS. Denies blurry vision, neck pain, neck stiffness. Denies chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea. No URI like symptoms. No sick contacts. [Name (NI) ] [Name2 (NI) ] intake at home. . In the ED, initial vitals were 101.6 HR88 BP137/81 RR18 O299%RA. He received tylenol 650mg PO x 1. CXR and UA were unremarkable. Lactate 1.7. He was treated empirically with unasyn 3g IV x1 and vancomycin 1g IV x1. Neurosurgery evaluated the patient and recommened admission to medicine to r/o sepsis. Past Medical History: -- Tremors (per patient not Parkinson's disease) -- Anxiety disorder-the patient was treated with Klonopin. -- Sleep apnea -- Gout -- Dysphagia -- Hypercholesterolemia -- Stills disease Social History: Patient lives with his wife. Two children ages 22 and 19. Son is graduating from [Male First Name (un) ] this year. He has a Law practice. Denies smoking. ETOH 1x per week. Smoked pot on new years eve, otherwise no illegal drugs. Family History: non-contributory Physical Exam: Vitals - 98.8 120/70 77 20 94%RA General - middle aged male, sitting up in bed, able to answer questions, oriented x 3, conversant with slow deliberate speech, BUE tremors with R>L HEENT - PERRL, EOMI, + incision on scalp, well approximated, c/d/i Neck - supple, no rigidty CV - RRR; subcutaneous battery for DBS on left chest, no tenderness Lungs - CTA B/L Abdomen - soft, NT/ND Ext - no edema Pertinent Results: [2173-2-21] 07:05AM BLOOD WBC-6.0 RBC-4.55* Hgb-14.0 Hct-41.8 MCV-92 MCH-30.8 MCHC-33.6 RDW-12.5 Plt Ct-300 [2173-2-21] 07:05AM BLOOD Plt Ct-300 [2173-2-21] 07:05AM BLOOD Glucose-102 UreaN-13 Creat-0.8 Na-139 K-4.7 Cl-101 HCO3-30 AnGap-13 [2173-2-21] 07:05AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.4 [2173-2-15] 03:45AM BLOOD Vanco-15.8 [2173-2-21] 07:05AM BLOOD Phenyto-6.2* MR HEAD W & W/O CONTRAST Reason: f/u Contrast: MAGNEVIST [Hospital 93] MEDICAL CONDITION: 55 year old man with R DBS removed due to infection, L DBS deactivated REASON FOR THIS EXAMINATION: f/u CONTRAINDICATIONS for IV CONTRAST: None. MRI HEAD HISTORY: 55-year-old man with abscess surrounding right deep brain stimulator status post stimulator removal; here for reassessment. TECHNIQUE: Axial pre- and post-gadolinium MP-RAGE, GRE, and DWI images of the head were obtained. Regular head MR was not obtained as the spin echo and fast spin echo sequences would have gone over the [Female First Name (un) ] limit. FINDINGS: Comparison is made to prior MR of the head from [2173-2-12]. The previously seen right-sided deep brain stimulator has been removed. Again seen is a peripherally enhancing lesion consistent with an abscess involving the high right frontal lobe. This lesion measures approximately 2.5 x 1.6 cm in size, and appears smaller compared to the prior study. Enhancement along the prior deep brain stimulator tract is seen extending all the way down to the subthalamic region. There is surrounding T1 hypointensity, especially around the abscess consistent with edema. Overlying pachymeningeal enhancement is also seen as before. No abnormal enhancement is seen around the left-sided deep brain stimulator. There is no subependymal enhancement and no areas of slow diffusion within the ventricles to suggest ventriculitis or empyema. The ventricles and extra-axial CSF spaces are unchanged. There is minimal mass effect upon the right lateral ventricle as before. Enhancing fluid is seen within the right scalp, which may represent postoperative fluid versus infection. The visualized bone marrow signal appears normal. Within the right maxillary sinus, there is a mucous retention cyst. IMPRESSION: Since [2173-2-12], removal of right deep brain stimulator. Decrease in size of abscess within the high right frontal lobe with marginal enhancement along the deep brain stimulator tract still visualized with surrounding edema. Overlying pachymeningeal enhancement may represent postop change versus meningitis as before. There is no abnormal enhancement around the left deep brain stimulator nor is there enhancement or abnormal signal of the subependyma or ventricles. OBJECT: ee, digital eeg monitoring w/video, ekg, [2-11] to [2173-2-12]. REFERRING DOCTOR: DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1941] FINDINGS: ROUTINE SAMPLING: An [8-21] Hz posterior predominant rhythm is noted in the waking state. There were no regions of focal slowing and no epileptiform discharges noted. Of note, there was frequent tremor artifact at approximatley [4-17] Hz in a generalized distribution at times with a bilateral frontal or temporal predominance. This was correlated on video with tremors of bilateral arms. SLEEP: The patient progressed from wakefulness to sleep at appropriate times with no additional findings. CARDIAC MONITOR: A generally regular rhythm was noted. AUTOMATIC SPIKE DETECTION FILES: There were 40. These consisted primarily of electrode or movement artifact. No true epileptiform discharges were noted, however. AUTOMATIC SEIZURE DETECTION FILES: There were 25. These similarly consisted of electrode and movement artifact. No true electrographic seizures were noted, however. PUSHBUTTON ACTIVATIONS: There was a single pushbutton activation by the sitter on [2-11] at 12:03. A normal background is noted with some superimposed movement artifact associated with the patient's tremors. IMPRESSION: This is a normal 24-hour video EEG telemetry in the waking and sleeping states. There were no regions of focal slowing and no epileptiform discharges. There were no electrographic seizures noted. There was, however, tremor artifact noted on the EEG associated with the patient's bilateral arm and hand tremors. CAROTID SERIES COMPLETE [2173-2-12] 10:42 AM CAROTID SERIES COMPLETE Reason: CONFUSION, APHASIA [Hospital 93] MEDICAL CONDITION: 55 year old man with longstanding tremors, s/p DBS placement, now w/ confusion, intermittent aphasia REASON FOR THIS EXAMINATION: assess for evidence of carotid stenosis CAROTID ULTRASOUND ON [2173-2-12] CLINICAL HISTORY: Aphasia, confusion. FINDINGS: Grayscale and color Doppler ultrasound imaging of the neck with attention to the carotid vessels was performed. No priors available for comparison. There is normal color flow within the bilateral carotid vessels with normal velocities seen throughout. ICA and CCA ratios approximate one on the right, and 0.8 on the left. There is minimal visualized plaque. IMPRESSION: No hemodynamically significant stenosis, normal carotid ultrasound. Brief Hospital Course: Assessment and Plan: 55 yo M with parkinsons 2 days s/p DBS now with fevers to 102. . # Fever - unclear source. CXR and UA unremarkable. No clear localizing symptoms. Given his recent DBS concerning for infection stemming from that procedure. Other possibilites include viral infection. No evidence of cellulits, No RUQ pain. Initially had blood cultures drawn which remained negative. Following day pt continued to be febrile to 102 and had LP attempted on the floor, which was difficult and was started empirically on vanc, ctx for meningitis dosing. Next day LP done under fluror which revealed elevated wBC, gstain negative. ID consulted and started treatment with vanc and meorpenam. He continued to have vaxing and [Doctor Last Name 688] confusion. On [2-8] noted to have some ptosis of the right eye and incresed disorientation. Underwent head CT with contrast which showed acute midbrain hemorrhage and pt transferred to Neurosurg ICU. ID continued to follow the patient. Pt s/p surgical removal of DBS on [2-12] secondary to abscess and infection near electrode seen by MRI. Follow up images with decreasing edema, culture of abscess significant for enterobacter. Pt continues on Ertapenem for 6-10weeks. . # Tremor/Parkinsons - continued home meds, Left DBS currently on. . # Hypercholesterolemia - started simvastatin (unclear what med at home). Communication - patient and wife [Location (un) 1439] [Telephone/Fax (1) 106180]) Medications on Admission: -- Lipitor 10mg daily --> per patient changed to other statin, unsure which one -- Lexapro 10mg daily -- Nadolol 40mg three times daily -- Clonazepam 1mg three times daily -- Trihexyphenidyl 2mg three times daily -- Amantadine 100 mg twice daily Discharge Medications: 1. PICC line flushes Heparin 100 U/ml 3-5 cc SASH/PRN 2. PICC line flushes Normal Saline 5-10 cc SASH/ PRN 3. Ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q24h (). Disp:30 Recon Soln(s) Refills:2 4. Outpatient Lab Work weekly chem 7, LFT's, and CBC with differentail to be fax'd to the [Hospital ] clinic at [Telephone/Fax (1) ] Dr. [Last Name (STitle) 4427] 5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amantadine 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Trihexyphenidyl 2 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Meningitis from Deep Brain Stimulator placed for familial essential tremors Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F PLEASE CALL [Telephone/Fax (1) ] IF YOU NEED TO CANCEL YOUR SCHEDULED APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 6 WEEKS. YOU WILL NEED AN MRI OF THE BRAIN WITH and WITHOUT GADOLIDIUM Followup Instructions: MRI OF BRAIN WITH AND WITHOUT CONTRAST WHEN YOU ARE FINISHED WITH YOUR COURSE OF ANTIBIOTICS / CALL THE NEUROSURGERY OFFICE AT [Telephone/Fax (1) ] TO HAVE THIS ARRANGED. FOLLOW UP IN THE [Hospital ] CLINIC IN THE [Hospital Unit Name 106181] [3-5] AT 930aM WITH DR. [Last Name (STitle) ]..... CALL [Telephone/Fax (1) ] FOR CLARIFICATION/VERIFICATION/CONCERNS/DIRECTIONS [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2173-2-23]	[ "2720", "42789" ]
Admission Date: [2182-3-22] Discharge Date: [2182-3-28] Date of Birth: [2119-11-6] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 330] Chief Complaint: Transferred from [Hospital6 8283] for respiratory failure Major Surgical or Invasive Procedure: arterial line placement PICC line placement Intubation History of Present Illness: Pt is a 62 yo male with history of lung cancer (s/p RUL lobectomy), COPD O2 dependent (3 L), history of MRSA and psuedomonal PNA who is a transfer from [Hospital3 ]. Per EMS notes, last night they were called to patient's house for difficulty breathing which had been ongoing for 45 minutes. He was found to be sitting up in bed in stridorous and diaphoretic. He was unable to speak; albuterol neb treatments were tried without much success. He was brought to [Hospital6 ] where he was admitted to the ICU and started on BIPAP, IV solumedrol, and levaquin. He required increasing amounts of O2 on BIPAP and was tachypnic in the 30s. 7.30/45/63 on 60% BIPAP with O2 90%. Pt was intubated at 7:40 am on day of admission and transferred to [Hospital1 ]. BP 219/90 per report, HR 90-136. Post-intubation he was give 8 mg IV dilaudid, 4 mg ativan, 150 mcg fentanyl, 2 mg versed, and nitropaste. Also received fentanyl in med flight though records unavailable now. Pt was hospitalized at [Hospital6 ] [Date range (1) 56565] for shortness and breath and COPD exacerbation. He was given prednisone and levaquin. Most recent hospitalization at [Hospital1 ] was in [2181-12-20] for when he had a pneumothorax from his severe emphysema. Prior to that, in [2181-9-19] patient was in the ICU at [Hospital1 ] for MRSA and psedomonal pneumonia. The patient received linezolid for a 21 day course for MRSA PNA and cefepime for 21 day course for pseudomonas. Amikacin was added for synergy. This was all in the setting of a three week prior hospitalization for COPD/PNA with sputum growing MRSA and pseudomonas treated with bactrim and levaquin. Past Medical History: 1. Non-small cell lung cancer, s/p R upper lobectomy, partial R fifth rib resection c/b chronic pain. No chemo or radiation. 2. COPD w/ severely reduced DLCO, FEV1 42%, and FEV1/FVC ratio 59%; stage= moderate IIB 3. h/o MRSA and pseudomonas PNA 4 Ulcerative colitis - s/p multiple surgeries, most recently in late 80s. S/P total colectomy and ileostomy 5. Steroid induced hyperglycemia 6. PFO 7. h/o cardiomegaly 8. h/o depression 9. Spirometry [7-/2181] Actual Pred %Pred FVC 2.87 4.01 72 FEV1 1.21 2.86 42 MMF 0.70 2.87 24 FEV1/FVC 42 71 59 LUNG VOLUMES Actual Pred %Pred TLC 6.19 6.12 101 FRC 4.59 3.42 134 RV 4.09 2.12 193 VC 2.10 4.01 52 IC 1.60 2.70 59 ERV 0.50 1.31 38 RV/TLC 66 35 191 He Mix Time 0.00 DLCO Actual Pred %Pred DSB 6.62 25.62 26 VA(sb) 4.46 6.12 73 HB 12.70 DSB(HB) 7.02 25.62 27 DL/VA 1.58 4.19 38 Social History: Married, 2 daughters, lives on the [Name (NI) ]. Not current smoker, quit in [2177] w/ dx of lung cancer, 40 pack-yr history. Occasional EtOH use. Worked as a paiting contractor, retired after lung cancer surgery. Family History: F died of lung cancer; M died of Alzheimer's. Has 3 sisters, all older than him, healthy Physical Exam: Initial physical examination: VS: T: 95.0, BP: 94/55, HR: 64, AC 500/12/100/5 breathing at 15. O2: 94% Gen: Intubated, sedated HEENT: pinpoint pupils reactive 2-->minimal. Sclera anicteric. ETT in place. Neck: No LAD. No JVP at 30 degrees. CV: RRR S1S2. No M/R/G Lungs: diffuse rales and rhonchi bilaterally anteriorly. Scattered wheezes anteriorly. Abdomen: +colostomy bag in place. Many surgical scars bilaterally in lower abdomen. Soft, nondistended. Ext: no edema. DP 2+. PT 2+ Neuro: Cannot follow commands nor arouse. Biceps, brachio reflexes [12-21]. Patellar reflexes [12-21]. babinski equivocal. Pertinent Results: Labs on admission: [2182-3-22] 11:52AM BLOOD WBC-6.2 RBC-3.62# Hgb-10.3# Hct-31.7# MCV-88 MCH-28.4 MCHC-32.3 RDW-15.7 Plt Ct-244 [2182-3-22] 11:52AM BLOOD Neuts-73* Bands-14* Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-0 [2182-3-22] 11:52AM BLOOD PT-12.8 PTT-28.7 INR(PT)-1.1 [2182-3-22] 11:52AM BLOOD Glucose-243* UreaN-33* Creat-1.3* Na-145 K-6.1* Cl-113* HCO3-21* AnGap-17 [2182-3-22] 11:52AM BLOOD ALT-10 AST-10 LD(LDH)-169 AlkPhos-66 Amylase-117* TotBili-0.3 [2182-3-22] 11:52AM BLOOD Albumin-3.0* Calcium-7.8* Phos-4.8* Mg-1.4* [2182-3-22] 12:16PM BLOOD Type-ART Rates-12/ Tidal V-500 PEEP-5 FiO2-100 pO2-86 pCO2-59* pH-7.17* calTCO2-23 Base XS--7 AADO2-590 REQ O2-94 -ASSIST/CON Intubat-INTUBATED Labs on discharge: [2182-3-28] 04:52AM BLOOD WBC-9.9 RBC-3.46* Hgb-9.7* Hct-29.5* MCV-85 MCH-28.0 MCHC-33.0 RDW-16.6* Plt Ct-250 [2182-3-28] 04:52AM BLOOD Neuts-65 Bands-3 Lymphs-21 Monos-5 Eos-2 Baso-0 Atyps-0 Metas-3* Myelos-1* [2182-3-28] 04:52AM BLOOD PT-11.0 PTT-29.7 INR(PT)-0.9 [2182-3-28] 04:52AM BLOOD Glucose-155* UreaN-23* Creat-0.7 Na-138 K-4.2 Cl-98 HCO3-32 AnGap-12 [2182-3-27] 04:48AM BLOOD ALT-9 AST-11 LD(LDH)-187 AlkPhos-76 TotBili-0.2 [2182-3-28] 04:52AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.2 Other labs: [2182-3-27] 04:48AM BLOOD calTIBC-256* VitB12-690 Folate-8.6 Ferritn-304 TRF-197* [2182-3-22] 11:52AM BLOOD TSH-0.98 ___________________________________________ Microbiology: Sputum [2182-3-22]- FINAL REPORT [2182-3-27] GRAM STAIN (Final [2182-3-22]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. RESPIRATORY CULTURE (Final [2182-3-27]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE 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. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVE TO AMIKACIN (<=2MCG/ML). PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND COLONIAL MORPHOLOGY. SENSITIVE TO AMIKACIN (<=2). SENSITIVITIES: MIC expressed in MCG/ML _______________________________________________________ STAPH AUREUS COAG + \| PSEUDOMONAS AERUGINOSA \| \| PSEUDOMONAS AERUGINOSA \| \| \| CEFEPIME-------------- 2 S 2 S CEFTAZIDIME----------- 4 S 4 S CIPROFLOXACIN--------- =>4 R =>4 R CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S =>16 R =>16 R IMIPENEM-------------- =>16 R =>16 R LEVOFLOXACIN---------- =>8 R MEROPENEM------------- 4 S 4 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- <=4 S 8 S PIPERACILLIN/TAZO----- 8 S <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TOBRAMYCIN------------ =>16 R =>16 R VANCOMYCIN------------ <=1 S Blood culture [2182-3-22]- No growth Legionella urine ag [2182-3-23]- negative Sputum [2182-3-27] GRAM STAIN (Final [2182-3-25]): [9-12] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2182-3-27]): MODERATE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). RARE GROWTH. [2182-3-26]- urine culture- no growth [2182-3-28] blood culture x 2- No growth _______________________________ Radiology: Echo [2182-3-28] Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A Ratio: 0.67 Mitral Valve - E Wave Deceleration Time: 151 msec TR Gradient (+ RA = PASP): 40 to 45 mm Hg (nl <= 25 mm Hg) LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: LV not well seen. Cannot assess LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. Mild [1+] TR. Moderate PA systolic hypertension. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs of agitated normal saline, at rest, with cough and post-Valsalva maneuver. Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Suboptimal image quality - poor subcostal views. Conclusions: The left atrium is normal in size. The left ventricle is not well seen. Overall left ventricular systolic function cannot be reliably assessed. Right ventricular chamber size and free wall motion are normal. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Bubble study did not demonstrate any clear right-to-left shunting at the atrial level, but image quality is suboptimal. Compared with the findings of the prior study (images reviewed) of [2181-9-11], the findings are grossly similar but the technically suboptimal nature of both studies precludes definitive comparison. . Other radiology: [2182-3-24] CXR AP-Nasogastric tube and endotracheal tube have been removed. Cardiac silhouette appears larger than on the prior study and is accompanied by engorged pulmonary vessels and perihilar haziness, attributed to either CHF or volume overload. These findings are superimposed upon extensive emphysema, post-operative changes in the right upper lobe, and extensive areas of parenchymal scarring. Persistent left retrocardiac opacity, likely due to a combination of atelectasis and effusion, although underlying infection is not excluded in the appropriate clinical setting. [2182-3-22] CXR AP-FINDINGS: ET tube has been repositioned in the interval, and now terminates 5.7 cm above the [Month/Day/Year ]. The NG tube still is in a suboptimal positioning with the side port well above the expected location of the GE junction. Overall, the appearance of the chest is unchanged from today's radiograph, including status post right upper lobectomy with associated right-sided volume loss, opacities projecting over the right medial and lower hemithorax. There is no evidence of pulmonary edema. Small left-sided pleural effusion and left lower lobe atelectasis is unchanged. IMPRESSION: 1. Interval repositioning of the ET tube, now terminating 5.7 cm above the [Last Name (LF) ], [First Name3 (LF) ] be advanced 1-2 cm for more optimal placement. 2. Malpositioned nasogastric tube. Brief Hospital Course: Impression/Plan: 62 yo male with COPD on home O2 (3L), history of lung cancer, history of multiple PNAs (including MRSA) who is a transfer from [Hospital6 ] for respiratory failue and intubated. 1. Respiratory failure- Pt with severe emphysema/COPD. CXR with showed a possible RML opacity and left pleural effusion. We started solumedrol 80 mg IV q12 hours. We initially started patient on vancomycin for possible MRSA and cefepime to cover GNR and pseudomonal species. Sputum culture grew out MRSA (moderate growth) and pseudomonas (sparse growth) resistant to fluroquinolones (see attached micro data). Additionally, blood cultures from [Hospital6 ] grew out 2/2 bottles of streptococci pneumoniae sensitive to levaquin and penicillin. Patient was successfully extubated on [2182-3-23]. Additionally, combivent nebs were given around the clock while patient was vented. This was changed to tiopropium, fluticasone-salmterol, and albuterol when he was extubated. After extubation, patient was able to get to 6 L of NC and satting in low-mid 90%. However, whenever he was turn or exert himself in any manner, he would desaturate to as low as 70%. He would correct and return to oxygenating in the 90s after a few minutes. To further investigate this and to look for a shunt, a TTE was done, as one from [2179] showed a patent foramen ovale and right to left shunt but only when he maneuvered himself. A repeat bubble study echo on the day of discharge was suboptimal in quality. It showed moderate pulmonary artery systolic hypertension but no right-to-left shunting at the atrial level. Steroids were changed to prednisone after extubation and have been slowly tapered to 60 mg and patient is on 40 mg prednisone (day 2) on discharge. The plan will be for a two week steroid taper to usual dose(patient is on 10 mg po prednisone at home). He received a 10 day course of vancomycin (last day was day of discharge) for MRSA in sputum (? source of pneumonia). Also was initially on levaquin which was changed to cefepime, plan for a 14 day course. 2. COPD- as above. He has severe emphysema by DLCO. Medications as above. 3. Bacteremia- as above. Blood cultures at the outside hospital grew [12-21] strep pneumonia. He was on levaquin which was changed to cepepime as above. 4. Hypertension- initially on arrival to [Hospital1 18] pt was hypotensive and required fluid boluses, though never required pressors. He had received dilaudid, fentanyl, ativan, and other medications including nitropaste post-intubation. His blood pressures subsequently came up. In fact, patient was hypertensive here in the 160s systolic post-intubation. Captopril was started and uptitrated to 25 mg tid; we then changed him to lisinopril 20 mg to be started the am after discharge. 5. Chronic pain- patient has a history of chronic pain, mainly in lower back (also right ribs. We increased his oxycontin to tid dosing (20 mg tid). He required IV dilaudid for breakthrough pain. 6. Steroid induced hyperglycemia- Required ~30 units of insulin per day on day of discharge. He was initially on a regular insulin sliding scale. On dischare, he was changed to lantus pm with a humalog sliding scale. Insulin will need to be adjusted at rehab. 7. F/E/N- Got tube feeds while intubated. Then was on a regular diet. Nutrition saw patient and recommended ensure sedondary to nurtitional needs. 8. PPx- heparin sc and PPI while intubated 9. Code- Full Medications on Admission: Medications at home (per [Hospital6 56566]): Neurontin 300 mg po tid Spiriva 1 puff qday Prednisone 10 mg po qday Paroxetine 20 mg po qday Oxycontin 20 mg po bid Medications on transfer to [Hospital1 ] : Solumedrol 125 mg IV q 6 hours combivent nebs q4 hours Paroxetine 20 mg po qday Oxycontin 20 mg po bid Neurontin 300 mg po tid Levaquin 500 mg po IV qday Albuterol nebs q2 prn Ativan 1 mg IV qhs prn morphine 2 mg IV q2 prn Dilaudid 8 mg Iv x 1 am on admission versed 2 mg IV x 1 nitropaste 1 inch at 8:25 am morning of admission Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days: Last dose [2182-3-30]. 6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day: To start [2182-3-31]. Tablet(s) 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours): Hold for sedation or RR<8. 13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Hydromorphone 2 mg/mL Syringe Sig: 0.5 - 2 mg Injection Q4H (every 4 hours) as needed: Hold for sedation or RR<8. 17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 18. Cefepime 2 g Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours): Last day [2182-4-4]. 19. Insulin Lantus 10 units qhs with humalog insulin sliding scale 20. Oxygen On 6L NC on discharge Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Primary diagnosis: Respiratory failure s/p intubation Chronic obstructive pulmonary disease pneumonia Hypoxia hyperglycemia Hypertension bacteremia Secondary diagnosis: chronic pain Discharge Condition: Patient's vital signs are stable. His oxygenation is 90-95% on 6L NC and cool nebs. He desaturates when Discharge Instructions: Microbiology [Telephone/Fax (1) 4645] needs to be called to follow up on pending cultures in the hospital. Followup Instructions: You should call your pulmonologist, Dr. [Last Name (STitle) 14069*] for follow up.	[ "51881", "4019" ]
Admission Date: [2142-10-30] Discharge Date: [2142-11-10] Date of Birth: [2096-5-28] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: weakness Major Surgical or Invasive Procedure: right suboccipital craniectomy with decompression placement EVD transesophogeal echocardiogram History of Present Illness: HPI: Patient is a 46 yo man with history of obesity who who presented to [Hospital3 417] Medical Center [2142-10-29] with complaint of several days weakness, fatigue and falls. He had been feeling unwell for about three weeks and had been falling out of bed in the mornings. He was unable to stand [10-29] Am and father called EMS. Progressive weakness and lethargy for 3 weeks according to family. Had a head CT [10-29] at 21:22 showing cerebellar mass. MRI was performed this afternoon and showed large right cerebellar mass with areas of hemorrhage, significant mass effect and associated hydrocephalus. Report describes near effacement of the 4th ventricle and mass effect on the brain stem. There is striated enhancement of the lesion with the mass measuring 6.2 x 5.4 cm. Past Medical History: none Social History: Social Hx: Recently unemployed from computer work. Positive tox for marajuana, no tob. occasionaly ETOH. Family History: Family Hx: mother had stroke late in age. Father alive with HTN, PVD and DM. Physical Exam: PHYSICAL EXAM: O: T: 98.9 BP: 164/95 HR: 76 R 17 O2Sats 99 vented Gen: intubated, sedation with propofol just turned off HEENT: Pupils: [2-12] bilaterally EOMs: absent with Doll's maneuver Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: unresponsive to voice. Moves x 4 to noxious stimulation. Does not follow commands. Eyes closed. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. No blink to threat. III, IV, VI: Extraocular movements absent with Doll's manevuer. Eyes midline. V, VII: Face symmetric. Corneals absent bilaterally. VIII: unresponsive IX, X: weak gag to suction. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Antigravity x 4 to noxious stim and symmetric. Sensation: withdraws x 4. Reflexes: B T Br Pa Ac Right 0 0 0 0 0 Left 0 0 0 0 0 Toes upgoing bilaterally Coordination: could not assess Physical Exam on Discharge: A&Ox3 Pupils: 3-2mm bilaterally face symmetrical tongue midline Slight L pronator drift Motor: [4-17] throughout Incision: c/d/i Pertinent Results: Labs: 138 105 15 AGap=14 ------------< 323 4.3 23 1.0 Ca: 8.5 Mg: 2.2 P: 3.4 12.8 10.0 >< 235 38.8 CT/MRI: MRI from OSH shows: large right cerebellar mas with areas of hemorrhage, significant mass effect and associated hydrocephalus. Report describes near effacement of the 4th ventricle and mass effect on the brain stem. There is striated enhancement of the lesion with the mass measuring 6.2 x 5.4 cm. Brief Hospital Course: Pt was admitted to the hospital on neurosurgery service to ICU for close neurologic monitoring. He had placement of EVD with normal ICPs. He was readied for the OR including MRI wand study and on [10-31] went to OR where under general anesthesia he underwent right suboccipital craniectomy with excision of necrotic brain from infarct. He tolerated this procedure well, remained intubated and transferred back to ICU. Post op CT showed good decompression without new hemorrhage. His EVD continued to function and was clamped on POD#2 and removed the next day. He was extubated on POD#2 and tolerated this well although did have issues with sleep apnea requiring CPAP. His neurologic exam improved and he was following commands, conversant and full motor exam. His incision was clean and dry with staples. He was seen in consultation by the stroke neurolgy team. He underwent TTE which showed no vegetations and he underwent TEE which showed a PFO which will be followed up as an out patient by neurology. CTA of head and neck revealed no evidence of stenosis in the carotid or vertebral arteries. He was transferred to stepdown POD#4 and diet and activity were advanced. He was started on steroids for cerebral edema and these were weaned down post op; pt had elevated glucose and found to have HgA1C of 11.9 and seen in consultation by the [Last Name (un) ] team for insulin management. He had PT/OT evaluations that felt he was approprite for discharge to home. Diabetes teaching was done by nursing. He was refusing VS and lab work. He verbalized refusal to use CPAP at home. He was discharged to home with prescriptions for the next several days as well as prescriptions for his ongoing needs to bring to the free care clinic during the week. Medications on Admission: Home Meds: none Medications at transfer: Fentanyl gtt, Versed, propofol,nitropaste, lopressor IV, RISS, ASA 325 daily, lorazepam 1mg Q2hrs prn, Nexium 40mg daily, heparin 5000 SC q12, RISS, colace,acetaminophen Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 7. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO Q6H PRN as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: right cerebellar infarct newly diagnosed diabetic obstructive hydrocephalus obstructive airway disease morbid obesity Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in 7 days and fax results to [Telephone/Fax (1) 87]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[First Name (STitle) ] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST PLEASE CALL [Telephone/Fax (1) 657] TO SCHEDULE AN APPOINTMENT WITH NEUROLOGY IN ONE MONTH WITH DR. [Last Name (STitle) ] Completed by:[2142-11-15]	[ "25000" ]
Unit No: [Numeric Identifier 106961] Admission Date: [2180-5-12] Discharge Date: [2180-5-16] Date of Birth: [2100-2-3] Sex: F Service: [Last Name (un) ] ADMISSION DIAGNOSIS: Status post motor vehicle collision. DISCHARGE DIAGNOSIS: 1. Status post motor vehicle collision. 2. Left temporal subarachnoid and intraparenchymal hemorrhage, stable. 3. T1 tear drop fracture. 4. T2 burst fracture. 5. Hypertension. 6. Coronary artery disease. 7. Gastroesophageal reflux disease. 8. Blood loss anemia. HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old woman who initially presented to the emergency department having been brought in by EMS following a motor vehicle collision. The patient was a restrained driver and accidentally ran her car into her neighbor's house. There was significant damage to the car and house. The patient did not recall the events. It is unclear whether or not she lost consciousness before or after the event. PAST MEDICAL HISTORY: 1. Question of diabetes mellitus. 2. Depression. 3. Coronary artery disease. 4. Status post cardiac catheterization with stent placement. 5. Hypertension. 6. GERD. 7. Hypercholesterolemia. ALLERGIES: The patient has a significant IV contrast allergy which causes anaphylaxis. MEDICATIONS ON ADMISSION: 1. Plavix 75 mg daily. 2. Avapro 75 mg daily. 3. Toprol 25 mg daily. 4. Lipitor 20 mg daily. 5. Nexium 40 mg daily. 6. Lexapro 20 mg daily. 7. Digoxin 0.25 mg daily. 8. Magnesium Oxide 400 mg daily. 9. Multivitamin daily. 10. Cilium 1 tsp daily. 11. Imdur 30 mg daily. 12. Zetia 10 mg daily. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Unknown. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 100.4 degrees F, pulse 103, blood pressure 156/68, respiratory rate 24, oxygen saturation 100% on face mask. The patient had an initial GCS of 14HEENT: Pupils equal, round and reactive to light. Normocephalic. There was a small ecchymosis in the right temporal region. TMs clear bilaterally. Neck: Midline and with a cervical collar. Chest: Clear to auscultation bilaterally. There was some mild sternal chest tenderness to palpitation. Regular, rate, and rhythm without murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. There was some very mild gastric tenderness. FAST exam was negative. Rectal: Exam demonstrated normal tone and guaiac negative. Pelvis: Stable. Back: Examination was nontender and without deformity. Extremities: Warm and well perfused with no obvious injury. Neurologic: Although the patient had a GCS of 14, she was alert and oriented to person only. RADIOLOGY STUDIES: On admission chest x-ray was negative. Pelvis x-ray was negative. CT of the head demonstrated a small left subarachnoid, as well as very small left temporal intraparenchymal hemorrhage. CT scan of the cervical spine demonstrated T1 tear drop fracture, as well as a T2 burst fracture. CT of the chest, abdomen, and pelvis were all done without IV contrast and showed no gross abnormalities. HOSPITAL COURSE: The patient was admitted to the trauma intensive care unit for q.1 hour neurochecks and was followed closely by the neurosurgical service who also was the consult service for the spine. The patient had a repeat head CT scan done within 12 hours which demonstrated essentially no change of her intracranial bleed. The patient's mental status improved rapidly after being admitted. She was initially maintained with a goal systolic blood pressure of less than 150 which was easily done on Esmolol drip, as well as with IV beta-blockade. The patient, after restarting her home medications, had difficulty in maintaining a blood pressure below 150. MR of the cervical spine demonstrated no ligamentous injury, the patient was essentially pain free and also cleared clinically from having to wear the cervical collar. The neurosurgical service, which was consulting for spine surgery, felt that her T1 and T2 fractures were stable in nature, and that no additional braces or precautions were necessary. As also part of initial evaluation, given her cardiac history, the patient had an EKG that demonstrated approximately [Street Address(2) 4793] depressions from leads V4 through V6. Over the first 24 hours, the patient was ruled out for MI. Over the subsequent days, the patient had an uneventful ICU course. She was discontinued from invasive monitoring and continued to do well. She did have some difficulty with pulmonary toilet and had some coarse secretions. She also had a very mild oxygen requirement via face tent and nasal cannula. She was left in the ICU for aggressive chest physical therapy, as well as pulmonary toilet. Ultimately, on the day of discharge, she was tolerating a regular diet, had adequate pain control on p.o. pain medications, with no focal or neurologic findings. She had a GCS of 15 and was alert and oriented times three. The patient had by physical therapy and cleared for discharge with continued physical therapy requirements working with gait training, strengthening, as well as transfers. Syncopal work-up during her hospital stay included an echocardiogram which showed a normal ejection fraction of greater than 55%, but 2+ mitral regurgitation. No other structural abnormalities were seen. Carotid duplex bilaterally demonstrated no significant carotid stenosis. The patient was maintained on continuous telemetry throughout her stay and demonstrated no unusual arrhythmias which may have contributed to her syncopal episode. DISPOSITION: To rehabilitation facility. DIET: 1800 calorie diabetic diet, also low fat, supplemented with Ensure, Boost, or diabetic equivalent t.i.d.. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg p.o. q.4 hours p.r.n. 2. Lexapro 20 mg daily. 3. Protonix 40 mg daily. 4. Toprol XL 25 mg daily. 5. Lipitor 20 mg daily. 6. Imdur 30 mg daily. 7. Percocet [1-30] tab p.o. q.6 hours p.r.n. 8. Avapro 75 mg daily. 9. Digoxin 0.25 mg daily. 10. Heparin 5000 units subcue t.i.d. 11. Magnesium oxide 400 mg daily. 12. Insulin sliding scale. DISCHARGE INSTRUCTIONS: 1. The patient should follow-up with the trauma clinic, as well as with Dr. [Last Name (STitle) 66048] of the neurosurgery service in two weeks. 2. Encourage chest physical therapy, as well as pulmonary toilet to maintain excellent oxygen saturations. 3. The patient should continue to work with physical therapy in order to strengthen her gait mobility and balance. 4. If the patient has any focal neurologic findings, she should come back to the emergency department immediately and have a immediate neurologic work-up, including a head CT scan. [Doctor Last Name ] A. MD [Last Name (Titles) ] Dictated By:[Last Name (NamePattern1) 23688] MEDQUIST36 D: [2180-5-16] 10:34:16 T: [2180-5-16] 11:07:28 Job#: [Job Number 106962]	[ "4019", "53081", "V4582" ]
Admission Date: [2154-8-23] Discharge Date: [2154-9-6] Date of Birth: [2089-9-7] Sex: F Service: SURGERY Allergies: Demerol / Nsaids Attending:[First Name3 (LF) 4111] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Exploratory laparotomy, enterectomy, enteroenterostomy, ligation of AV malformation x2. enteroscopy History of Present Illness: This patient had previously been admitted with gastrointestinal bleeding and had had the AV malformation coiled to see whether or not it would be therapeutic. It was not and she was admitted with another GI bleed. Past Medical History: CAD, s/p MI DM2 s/p TIA [2152] - small, L posterior limb of the internal capsule; seen at [Hospital1 18] GI Bleeds since [2147] Migraines s/p CCY s/p lumbar surgery "fast heart rate" anemia 3 NSVD Social History: Lives at home with husband, 2 children, and grandchild. Works in medical billing. Quit smoking many years ago, no EtOH, no other drugs. Family History: Daughter with ulcerative colitis. Brother died of esophageal ca, father died of prostate ca, mother with "heart problems," siblings with diabetes. Physical Exam: 98.2 150/70 91 22 97% RA Gen- Pleasant lady resting comfortably in bed. no acute distress anicteric Cardiac- regular rate and rhythm. II/VI Systolic ejection murmur at LUSB. Pulm- Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Abdomen- Soft. nontender nondistended. Positive bowel sounds. Extremities- No clubbing cyanosis or edema. warm. Pertinent Results: [2154-8-23] 01:30PM BLOOD WBC-9.4 RBC-1.97# Hgb-6.3# Hct-18.6# MCV-95# MCH-31.8 MCHC-33.6 RDW-20.1 Plt Ct-241 [2154-8-24] 02:49AM BLOOD WBC-8.6 RBC-3.26# Hgb-10.4# Hct-29.3* MCV-90 MCH-31.9 MCHC-35.5* RDW-17.6* Plt Ct-179 [2154-8-24] 09:00PM BLOOD WBC-7.8 RBC-3.13* Hgb-10.0* Hct-27.8* MCV-89 MCH-31.8 MCHC-35.8* RDW-17.0* Plt Ct-188 [2154-8-25] 05:35AM BLOOD WBC-7.3 RBC-3.74* Hgb-11.5* Hct-33.2* MCV-89 MCH-30.8 MCHC-34.7 RDW-17.2* Plt Ct-186 [2154-8-26] 12:17AM BLOOD Hct-29.1* [2154-8-26] 01:11PM BLOOD WBC-16.8# RBC-3.62 Hgb-11.5* Hct-33.0* MCV-91 MCH-31.8 MCHC-34.9 RDW-17.4* Plt Ct-210 [2154-8-28] 07:03AM BLOOD WBC-9.1 RBC-3.36* Hgb-10.8* Hct-30.5* MCV-91 MCH-32.1* MCHC-35.4* RDW-16.7* Plt Ct-154 [2154-9-4] 03:07AM BLOOD WBC-7.8 RBC-3.01* Hgb-9.4* Hct-27.4* MCV-91 MCH-31.1 MCHC-34.2 RDW-15.6* Plt Ct-249 [2154-8-23] 01:30PM BLOOD PT-13.3 PTT-23.2 INR(PT)-1.2 [2154-9-1] 06:15AM BLOOD PT-13.6* PTT-56.2* INR(PT)-1.2 [2154-9-2] 02:50AM BLOOD PT-14.2* PTT-55.7* INR(PT)-1.4 [2154-9-3] 02:14AM BLOOD PT-14.2* PTT-49.1* INR(PT)-1.4 [2154-9-5] 06:05AM BLOOD PT-24.1* PTT-34.8 INR(PT)-4.2 [2154-9-2] 05:37PM BLOOD Thrombn-150* [2154-9-2] 05:37PM BLOOD ProtCFn-72 ProtSFn-67 ACA IgG-PND ACA IgM-PND [2154-8-23] 01:30PM BLOOD Glucose-188* UreaN-14 Creat-0.6 Na-143 K-3.8 Cl-110* HCO3-22 AnGap-15 [2154-8-28] 07:03AM BLOOD Glucose-207* UreaN-10 Creat-0.5 Na-137 K-4.1 Cl-105 HCO3-27 AnGap-9 [2154-9-4] 03:07AM BLOOD Glucose-154* UreaN-5* Creat-0.5 Na-143 K-3.9 Cl-108 HCO3-26 AnGap-13 [2154-8-23] 01:30PM BLOOD CK(CPK)-62 [2154-9-1] 05:53AM BLOOD ALT-24 AST-26 AlkPhos-92 Amylase-45 TotBili-0.2 [2154-9-1] 09:12AM BLOOD CK(CPK)-227* [2154-9-1] 05:53AM BLOOD Lipase-9 [2154-8-23] 01:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2154-9-1] 12:39AM BLOOD CK-MB-9 cTropnT-0.47* [2154-9-1] 09:12AM BLOOD CK-MB-6 cTropnT-0.15* [2154-9-1] 04:16PM BLOOD CK-MB-5 cTropnT-0.09* [2154-8-24] 02:49AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.7 [2154-8-28] 07:03AM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.1 Mg-1.6 Iron-18* [2154-9-1] 05:53AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.5 Mg-2.1 [2154-9-3] 02:14AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.6 Cholest-127 [2154-8-28] 07:03AM BLOOD calTIBC-265 Ferritn-84 TRF-204 [2154-9-3] 02:14AM BLOOD Triglyc-140 HDL-31 CHOL/HD-4.1 LDLcalc-68 [2154-9-2] 05:37PM BLOOD Homocys-4.5 [2154-9-1] 11:23AM BLOOD Ammonia-18 [2154-9-4] 12:00PM BLOOD Vanco-10.0* [2154-9-1] 05:53AM BLOOD Phenyto-6.9* [2154-9-5] 06:05AM BLOOD Phenyto-11.2 [2154-8-26] 09:00AM BLOOD freeCa-1.08* [2154-9-3] 03:29AM BLOOD freeCa-1.18 HELICOBACTER PYLORI ANTIBODY TEST (Final [2154-8-28]): NEGATIVE BY EIA. Reference Range: Negative. [2154-9-2] 12:05 am SPUTUM Site: ENDOTRACHEAL FINAL REPORT [2154-9-4] GRAM STAIN (Final [2154-9-2]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). [2154-9-2] 12:48 pm CATHETER TIP-IV Source: CVL. FINAL REPORT [2154-9-4] WOUND CULTURE (Final [2154-9-4]): No significant growth. [2154-9-1] 12:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM RADIOLOGY Final Report -59 DISTINCT PROCEDURAL SERVICE [2154-8-25] 7:30 PM Reason: evaluate for source of bleeding. embolize if possible. Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 64 year old woman with active GI bleed seen on enteroscopy but no site identified. REASON FOR THIS EXAMINATION: evaluate for source of bleeding. embolize if possible. INDICATION: History of recurrent active GI bleeding seen on enteroscopy, but no site identified. COMPARISON: Images from a prior mesenteric angiogram from [2154-8-9]. PHYSICIANS: The procedure was performed by Drs. [First Name (STitle) 4154] and [Name5 (PTitle) 4686], with Dr. [Last Name (STitle) 4686], the attending radiologist, being present and supervising throughout the procedure. Dr. [Last Name (STitle) 380] reviewed the exam. PROCEDURE: Prior to initiation of the procedure, written informed consent was obtained and a preprocedure timeout was performed. The right groin was prepped and draped in sterile fashion. A 19-gauge needle was used to access the right femoral artery, after which a 0.035 [Last Name (un) 7648] guide wire was advanced through the needle. The needle was exchanged for a 5 French sheath. A 4 French Cobra glide catheter was advanced over the needle, and the tip was positioned within the celiac artery. The wire was removed, and contrast injected with arteriogram demonstrating no areas of active extravasation arising from branches of the celiac artery. The catheter was then positioned within the SMA. Contrast was injected and SMA arteriogram was performed, and a focal area of contrast extravasation was identified, localized to a branch of the SMA adjacent to the embolized area on the prior exam. Based on the diagnostic findings, it was decided to proceed with embolization. A Fast Tracker microcatheter was then advanced through the Cobra catheter and positioned within the bleeding vessel. The vessel was then embolized with two 2 mm x 1 cm microcoils. Contrast was then injected demonstrating successful embolization of this bleeding vessel. However, bleeding was noted to have started from a new adjacent area, which could not be embolized. The catheters were then removed. The sheath was removed and manual compression was applied for 20 minutes until adequate hemostasis was achieved. ANESTHESIA: Local anesthesia was provided with 8 cc of 1% lidocaine. 2.5 mg of Versed and 125 mcg of fentanyl were also administered. CONTRAST: 100 mL of IV Optiray contrast was administered. COMPLICATIONS: No immediate complications. IMPRESSION: 1. Mesenteric angiogram demonstrated active contrast extravasation from a branch of the SMA adjacent to the area of the previously embolized vessel. This vessel was successfully embolized with two microcoils. 2. Subsequent injection after successful embolization demonstrated area of contrast extravasation adjacent to the embolized artery. Access could not be obtained to this vessel, and this could not be embolized. Results were discussed with the covering attending physician immediately after the procedure. RADIOLOGY Final Report GI BLEEDING STUDY [2154-8-25] GI BLEEDING STUDY Reason: [Doctor First Name ] EGD BUT CONTINUES TO HAVE MELENA INDICATION: 64-year-old woman with history of upper GI bleeding presenting with continued melena. A recent upper endoscopy was negative. INTERPRETATION: Following intravenous injection of autologous red blood cells labelled with technetium-[Age over 90 ]M, blood flow and dynamic images of the abdomen for 60 minutes were obtained. The flow images are limited, in that they represent posterior views. The dynamic blood flow images show bleeding, which begins in the distal duodenum or proximal jejunum, starting at 9 minutes, and then passing distally. The more likely source is the proximal jejunum. IMPRESSION: Evidence of active gastrointestinal bleeding, with the source either the distal duodenum or proximal jejunum. Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 57796],[Known firstname 8207] [2089-9-7] 64 Female [-3/3534] [Numeric Identifier 57797] Report to: DR. [Last Name (STitle) ]. [Doctor Last Name ] Gross Description by: DR. [Last Name (STitle) ]. [Doctor Last Name ]/dif SPECIMEN SUBMITTED: SMALL BOWEL--2 PARTS.. Procedure date Tissue received Report Date Diagnosed by [2154-8-26] [2154-8-26] [2154-9-2] DR. [Last Name (STitle) ] [Last Name (NamePattern4) 18795]/jip DIAGNOSIS: I. Segmental resection of small bowel #1 (A-F): 1. Focal fresh hemorrhage in the mucosa, submucosa, and muscularis propria. 2. Foci of abnormally large caliber thick and thin-walled blood vessels in areas of hemorrhage and non-hemorrhagic bowel wall. The vessels are in the submucosa and muscularis propria. 3. Fresh hemorrhage, focal, in the mesentery. II. Segmental resection of small bowel #2 (G-O): 1. Focal acute hemorrhagic mucosal ischemic infarctions. The resection margins contain focal mucosal hemorrhage, but no necrosis is identified. 2. Foci of abnormally large caliber thick and thin-walled blood vessels in areas of mural hemorrhage and in non-hemorrhagic bowel. These vessels are located primarily in the submucosa and muscularis propria, but focally involve the adjacent mesentery (slide O). a. Recent thrombi present in submucosal arteries (slides G, I). b. Organized thrombi in arterial vessels (slides G, N). 3. Focal fresh hemorrhage in the mesentery. RADIOLOGY Final Report MR CONTRAST GADOLIN [2154-8-31] 8:23 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Reason: MRI stroke protocol PLUS MRI with gadolinium Contrast: MAGNEVIST [Hospital 93] MEDICAL CONDITION: 64 year old woman with acute AMS s/p removal of RIJ CVL. Please eval acute stroke, seizure focus, etc. REASON FOR THIS EXAMINATION: MRI stroke protocol PLUS MRI with gadolinium CONTRAINDICATIONS for IV CONTRAST: None. MR HEAD CLINICAL INFORMATION: Acute AMS, status post removal of right internal jugular CVL. Evaluate for acute stroke. TECHNIQUE: Multiplanar, multisequence MRI of the head with DWI. 3D TOF MRA of the circle of [Location (un) 431]. FINDINGS: The DWI images demonstrate scattered foci of hyperintense abnormality along the expected region of the watershed territory of the ACA and MCA bilaterally (see series 10, image 410). The corresponding coronal T1 post-contrast images demonstrate subtle enhancement along the ACA/MCA watershed territories, more prominent on the left. These findings are in keeping of acute ACA/MCA watershed territory infarct. No further focus of abnormal enhancement is present. No additional T1 or T2 signal abnormalities within the cerebrum, cerebellum, or brainstem. Ventricular size and configuration are within normal limits. Basal cisterns are patent. [Doctor Last Name ]-white matter differentiation is otherwise preserved. The 3D TOF MRA images demonstrate somewhat narrowed A1 segments of the ACAs bilaterally, of uncertain significance. Otherwise, the circle of [Location (un) 431], and its principal branches demonstrate normal flow signal, with no critical stenosis, occlusion, or aneurysm greater than 3 mm is evident. No evidence of vascular malformation within the field of view. CONCLUSION: 1. MR features of acute ACA/MCA watershed territory infarcts bilaterally. 2. No additional signal abnormality, mass, or mass effect. 3. Hypoplastic A1 segments of the ACAs bilaterally, otherwise a normal cerebral MRA. RADIOLOGY Final Report CTA CHEST W&W/O C &RECONS [2154-8-31] 6:03 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Reason: please eval for PE Field of view: 36 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 64 year old woman with altered mental status and low O2 sat REASON FOR THIS EXAMINATION: please eval for PE CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Assess for pulmonary embolism. TECHNIQUE: CT examination of the chest utilizing contiguous axial imaging was performed with and without the administration of intravenous contrast bolus per CT pulmonary angiogram protocol. Images were reformatted in the sagittal and coronal planes. FINDINGS: No prior CT for comparison. Study is somewhat limited secondary to motion. No filling defect is identified within the main or segmental pulmonary arteries. No evidence of central pulmonary embolism. The thoracic aorta is normal in caliber throughout, without aneurysmal dilatation. The heart is not enlarged. There is no pericardial effusion. There are no enlarged mediastinal, hilar, or axillary lymph nodes. Small lymph nodes are seen within the prevascular and paratracheal distribution. The central airway is patent, without filling defect. Evaluation of the lungs reveals multiple ill-defined pulmonary nodules. Within the right middle lobe, there are two nodules measuring 4 and 5 mm respectively (images 42 and 52), within the right lower lobe measuring 6 mm (image 32), and within the left lower lobe abutting the major fissure measuring 5 mm (image 67). No dominant mass is identified. There is dependent atelectasis bilaterally. There is mild central venous engorgement, and mild prominence of the interlobular septum, findings most compatible with mild underlying pulmonary edema. Limited evaluation through the upper abdomen is grossly normal. There is degenerative change of the thoracic spine without lytic or sclerotic lesion. Incidental note is made of hypodensities within the left lobe of the thyroid, better evaluated with ultrasound. IMPRESSION: 1. No pulmonary embolism. 2. Multiple small pulmonary nodules as described. A followup CT examination is recommended in three months to further evaluate. 3. Incidental note of hypodense lesion within the left lobe of the thyroid, which would be better evaluated with ultrasound. 4. Mild pulmonary edema. RADIOLOGY Preliminary Report BILAT UP EXT VEINS US [2154-9-1] 10:26 AM BILAT UP EXT VEINS US Reason: eval carotids and subclavians (i.e. neck and upper chest) fo [Hospital 93] MEDICAL CONDITION: 64 year old woman with post/ant embolic infarcts on MRI REASON FOR THIS EXAMINATION: eval carotids and subclavians (i.e. neck and upper chest) for source INDICATION: This patient is a 64-year-old female with embolic infarcts on MRI. The patient had a line in the left subclavian vein. COMPARISONS: No comparisons are available. BILATERAL UPPER EXTREMITY DVT STUDY: Grayscale and Doppler son[Name (NI) 1417] of the bilateral internal jugular veins, subclavian veins, axillary veins, and brachial veins were performed. There is normal flow, compressibility, and augmentation of these vessels. No intraluminal thrombus was identified. IMPRESSION: No evidence of DVT. RADIOLOGY Final Report CAROTID SERIES COMPLETE PORT [2154-9-2] 12:56 PM CAROTID SERIES COMPLETE PORT Reason: POST/ANT EMBOLIC INFARCTS [Hospital 93] MEDICAL CONDITION: 64 year old woman with post/ant embolic infarcts on MRI REASON FOR THIS EXAMINATION: to evaluated for arterial stenosis HISTORY: Posterolateral embolic infarcts. FINDINGS/TECHNIQUE: B-mode, Duplex, and Doppler interrogation of the extracranial carotid arteries was performed. RIGHT SIDE: No calcified plaques were noted. Vertebral artery demonstrated antegrade flow. Peak systolic velocities were as follows: 76 cm/sec ICA, 75 cm/sec CCA, 77 cm/sec ECA, 55 cm/sec vertebral artery. ICA/CCA ratio was 1.01. LEFT: No calcified plaques were identified. Vertebral arteries demonstrated antegrade flow. Peak systolic velocities were as follows: 63 cm/sec ICA, 81 cm/sec CCA, 91 cm/sec ECA, 87 cm/sec vertebral artery. The ICA/CCA ratio was 0.77. IMPRESSION: No hemodynamically significant stenosis in the extracranial internal carotid arteries. REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.7 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.3 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 5.2 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.3 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%) Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.2 m/sec Mitral Valve - A Wave: 1.2 m/sec Mitral Valve - E/A Ratio: 1.00 INTERPRETATION: Findings: Lateral and septal e'=0.08m/s LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Apical LV aneurysm. Moderate regional LV systolic dysfunction. TVI E/e' >15, suggesting PCWP>18mmHg. No LV mass/thrombus. LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior - hypo; mid anteroseptal - hypo; mid inferoseptal - hypo; anterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex - hypo; apex - dyskinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Based on [2145] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the distal half of the inferior septum and akinesis of the distal third of the anterior septum, anterior wall, and inferior wall. The apex is mildly dyskinetic and anerysmal. No masses or thrombi are seen in the left ventricle. Tissue velocity imaging E/e' is elevated (>15) suggesting 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 structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid-LAD lesion). Compared with the study (images reviewed) of [2153-7-18], the left ventricular regional dysfunction is new. Based on [2145] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. RADIOLOGY Final Report MR HEAD W & W/O CONTRAST [2154-9-3] 12:57 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Reason: stroke protocol Contrast: MAGNEVIST [Hospital 93] MEDICAL CONDITION: 64 year old woman s/p ex-lap, coded ?stroke REASON FOR THIS EXAMINATION: stroke protocol MRI OF THE BRAIN WITH CONTRAST INDICATION: Stroke followup exam. Multiplanar T1- and T2-weighted images of the brain were obtained without and with intravenous gadolinium administration. Comparison is made to the prior examination from [2154-8-31]. There are persistent foci of restricted diffusion seen on diffusion images involving the right ACA and posterior watershed territory. A focal area of decreased diffusion is noted along the splenium of the corpus callosum. These most likely represent evolving a small infarct, which could be related to hypoperfusion. They could also be embolic in nature. There is T2 hyperintensity within the mastoid sinuses suggestive of fluid retention or inflammatory mastoiditis. There is T2 hyperintensity along the splenium of the corpus callosum and abutting the adjacent occipital lobes consistent with small evolving infarcts. T2 hyperintensity is also present along the posterior parietal lobes. There is no midline shift seen. Residual cytotoxic edema is present due to the evolution of multiple infarcts described previously. Signal flow voids are present. There is mucosal thickening within the ethmoid and sphenoid sinuses. No pathologic enhancement is seen within the brain following intravenous contrast administration. IMPRESSION: Multiple evolving subacute infarcts involving the occipital, posterior parietal, and right frontal lobes along the right ACA and posterior watershed zone distribution. These infarcts persist to be of decreased diffusion as noted on diffusion images. There is no intraparenchymal or subdural hemorrhage. Further follow should be based on clinical grounds. There is bilateral inflammatory mastoid sinus disease, which was not present on the previous exam. ENT correlation might be helpful. INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers. LEFT VENTRICLE: Overall normal LVEF (>55%). No LV mass/thrombus. AORTA: No atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or vegetations on aortic valve. MITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral valve. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). Local anesthesia was provided by benzocaine topical spray. The posterior pharynx was anesthetized with 2% viscous lidocaine. Contrast study was performed with 3 iv injections of 8 ccs of agitated normal saline, at rest, with cough and post-Valsalva maneuver. Echocardiographic results were reviewed with the houseofficer caring for the patient. Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall left ventricular systolic function is normal (LVEF>55%). The LV apex was not well seen. No masses or thrombi are seen in the left ventricle. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. Brief Hospital Course: This patient had previously been admitted with gastrointestinal bleeding and had had the AV malformation coiled to see whether or not it would be therapeutic. It was not and she was admitted about 72 hours ago on the medical service and underwent a series of studies including a push enteroscopy by Dr. [Last Name (STitle) 57798] which did not see any bleeding, followed by a labeled red cell scan which showed bleeding in the left upper quadrant and followed by an angiogram and coiling of an area which they thought showed extravasation. SHe also received A TOTAL OF 4u OF pRBCs with HCTs checked every 6 hours. She did, however, continued to bleed and therefore was taken to the ICU, surgery consult was obtained. SHe was stabilized overnight and the first thing in the morning, when the gastroenterologist would be available for the push enteroscopy in case we needed it, she was taken to the OR for exploratory laparotomy. Multiple AVMs were found, small bowel resection x 2 were performed with reanastamosis and ligation of AVMs x 3. Patient was extubated in the operating room and then taken to the SICU for overnight monitoring with an NGT and foley catherter. Patient did well post-op. POD 1 NGT was dc'd and patient was transferred to the floor. TPN was also started. H. Pylori cultures were sent which were negative. Central line was changed over a guidewire. POD 2 patient continued to improve. FOley catherter was dc'd and TPN advanced. POD 3 TPN was at goal, reglan and insulin started. POD 4, insulin was advanced, patient started on sips. POD 5 patient advanced to clears. However, on removal of RIJ, pt became hypoxic, desatted, and unresponsive x 2min--code called. responded with oxygen. pt c ?sz activity--loss of bladder and bowel. PE suspected-->CTPA neg. Pt eval for CVA by neurology c resultant sz in MRI requiring intubation, MRI demonstrative of b/l thromboembolic strokes. Tx to SICU, started heparin drip, propofol. POD 6 b/l UE US: neg venous thrombosis, CT hd x 2: unchanged, EEG: non-status. Patient had serial neuro exams throughout the day, improving in responsiveness and following commands. POD 7 was successfully extubated. Patient appeared to have normal mental status and pre-op motor ability later int he day without residual deficits. Echo done showed LVEF 35% with new dysfuction and no vegetations. POD 8 repeat MRI was unchangedshowing multiple evolving subacute ifracts in watershed distribution, patient was started on clears and advanced to soft solids. POD 9 repeat ECHO showed EF >55% and no new deficits, no asd or pfo, no thrombi. Patient was trasnferred to the floor in good condition. POD 10 patient was restarted on the remainder of her home meds. Patient was dischraged on POD 11 in good condition, on coumadin, dilatin and baby aspirin. Medications on Admission: Protonix, folate 1, FeSO4 325, 70/30 insulin 56/48, verapamil SA 180, Pravachol 20, ([Last Name (STitle) ]) Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 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). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Upper GI bleed Discharge Condition: good Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all follow up appointments. 3. Seek medical attention for fevers, chills, chest pain, shortness of breath, abdominal pain, black stools, dizziness, or any other concerning symptoms. 4. Please see you primary care physician tomorrow to have your INR checked and coumadin dose adjusted. You should have daily INRs checked for the next few days until you are on a stable coumadin regimen. Followup Instructions: Please call Dr[Name (NI) 6275] office for an appoitnemtn in about 2 weeks. [Telephone/Fax (1) 2359] Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 2574], neurologist) to schedule a follow up appointment which should be in [2-27] weeks. Continue taking dilantin and coumadin until then. Please see your primary care physician tomorrow to have your INR drawn and coumadin dose adjusted. Cardiology team will call you to arrange for your follow up and catherization. Completed by:[2154-9-6]	[ "2851", "41071", "25000", "412", "4019" ]
Admission Date: [2173-3-17] Discharge Date: [2173-3-26] Date of Birth: [2122-7-28] Sex: M Service: This dictation covers Mr. [Known lastname 19064] stay in the Intensive Care Unit from [2173-3-17] to [2173-3-26]. Please see separate dictation for Mr. [Known lastname 19064] admission to the Bone Marrow Transplant service on [2173-3-11] up until his transfer on [2173-3-17]. BRIEF SUMMARY OF HOSPITAL COURSE: On [2173-3-17], Mr. [Known lastname 9817] was transferred from the Bone Marrow Transplant service to the Fenard Intensive Care Unit for management of rapid atrial fibrillation up to a heart rate of the 150s that was unresponsive to po and intravenous Metoprolol. Mr. [Known lastname 9817] had been admitted to the Bone Marrow Transplant team for fever and neutropenia and started on Vancomycin and Cefepime. However, Mr. [Known lastname 9817] continued to spike fevers and was begun on Ampicillin, transitioned to Voriconazole and then restarted on Ampicillin and Caspofungin for possible fungal pneumonia. On chest CT Mr. [Known lastname 9817] was noted to have bilateral pulmonary opacities whose appearance appeared most consistent with a fungal process, especially given his continued fevers on broad-spectrum antibiotics. On transfer all of his microbiological diagnostic workup had been negative. MEDICATIONS ON TRANSFER: 1. Vancomycin 1 gram b.i.d. 2. Cefepime 2 grams intravenously t.i.d. 3. Caspofungin 50 mg intravenously q.d. 4. Digoxin 0.125 mg q.d. 5. Metoprolol 50 mg p.o. b.i.d. 6. Acyclovir 400 mg intravenously t.i.d. 7. Bactrim Monday, Wednesday, Friday. 8. Voriconazole which was changed to Caspofungin above. 9. Lasix 120 mg p.o. q. a.m., 60 mg p.o. q. p.m. 10. Imdur 60 mg q.d. 11. Zestril 40 mg p.o. q.d. 12. Lopressor 100 mg t.i.d. 13. Protonix 40 mg p.o. q.d. 14. Levofloxacin 250 mg q.d. REVIEW OF SYSTEMS: He denied mouth pain, sore throat. No chest pain. Felt his breathing was comfortable. EXAMINATION ON TRANSFER: Temperature is 97.4, T-max is 101.3 20 hours before transfer, his pulse ranges from 100 to 150s, blood pressure ranges 130s to 160s/60s to 70s, oxygen saturation is 91 to 94% on 40% face mask. In general, he appears to be frail and tachypneic, older than stated age. HEENT: His oropharynx is dry. His chest has fine, Velcro-like crackles throughout, occasional anterior wheezes. Cardiovascular exam is tachycardiac; irregularly irregular; no murmurs. Abdomen is soft, nondistended, nontender with active bowel sounds. Extremities are without edema. LABORATORY DATA ON TRANSFER: His labs on transfer were notable for white blood cell count of 0.4, platelet count of 20, hematocrit of 34.4, and an absolute neutrophil count of 240. His Chem-7 was notable for sodium 132, potassium 3.2, chloride of 96, bicarbonate 24, BUN 29, creatinine of 1.3, and glucose of 127. His repeat sodium and potassium are 134 and 4.0. His AST was 41, ALT 46, alkaline phosphatase 95, total bilirubin 1.0, albumin 3.5, calcium 8.5, phosphorous 2.7, magnesium 1.9, Vancomycin peak was 27.6. HOSPITAL COURSE IN THE SURGICAL INTENSIVE CARE UNIT: [Unit Number ]. Atrial fibrillation: On transfer Diltiazem drip was started for rate control. In addition, he was continued on Lopressor 100 mg p.o. t.i.d. His Digoxin level was subtherapeutic. Therefore, his Digoxin dose was increased to 0.5 p.o. q.d. Per Dr. [First Name8 (NamePattern2) 401] [Last Name (NamePattern1) ], Mr. [Known lastname 19064] outpatient cardiologist, recommendations, decision was made to hold off on Amiodarone. It was felt that his rapid atrial fibrillation was likely secondary to the pulmonary infiltrates noted on his chest CT scan and that the pulmonary process was causing his irregular rhythm. Therefore, decision was made to treat Mr. [Known lastname 19064] atrial fibrillation conservatively with a goal of rate control while trying to treat his underlying pulmonary infection. On [2173-3-19] he was transitioned from the intravenous Diltiazem drip to Diltiazem and Lopressor p.o. Unfortunately, Mr. [Known lastname 9817] became hypotensive with both blood pressure and rate control agents on board and these agents had to be discontinued. At that time Mr. [Known lastname 9817] was transitioned to Digoxin. He was Digoxin loaded according to renal parameters. On the morning of [2173-3-23] with the Digoxin on board, Mr. [Known lastname 9817] [Last Name (Titles) 19065] to normal sinus rhythm with the rate in the 60s. He continued in normal sinus rhythm throughout the remainder of the SICU stay up until [2173-3-26]. 2. Pulmonary infiltrates: At the time of transfer the Infectious Disease team thought that his infiltrates are likely fungal. His antibiotic coverage for fungal organisms was broadened with Ampicillin and Caspofungin for empiric Aspergillosis ......... treatment. Clinically, Mr. [Known lastname 9817] appeared to improve with decreasing respiratory rate and improved oxygen saturations with decreasing oxygen requirements. Oxygen enabled him to maintain oxygen saturations however, a repeat chest CT was done on [2173-3-23] to reassess a worsened chest x-ray. The chest CT scan on [2173-3-23] showed marked progression of bilateral ill defined pulmonary nodular opacities throughout all lobes becoming more confluent at the left base. Given the progression of the pulmonary infiltrates, the Infectious Disease service was concerned that his antibiotic coverage and fungal coverage were inadequate. Ceftriaxone 1 gram q.d. was added to cover for possible endocardia. At this point, given the progression of his pulmonary infiltrates, it was felt that tissue diagnosis was necessary. It was arranged for Mr. [Known lastname 9817] to have video-assisted thoracic surgery procedure done by the Thoracic Surgical service. Mr. [Known lastname 9817] [Last Name (Titles) 1834] his VATS on [2173-3-25]. He had a very small left apical pneumothorax post procedure. His chest tube was able to be pulled on [2173-3-26] without incidence. He was able to be weaned from face mask to nasal cannula oxygen post procedure without difficulty. At the time of the dictation the micro data from his VATS left upper lobe and left lower lobe lung biopsies was still pending. Please see next dictation for final pathology and microbiology data. 3. Right cerebrovascular accident: During his stay in the Intensive Care Unit Mr. [Known lastname 9817] was noted to have a new left facial droop. CT scan was done to evaluate for a hemorrhagic infarct. The head CT scan showed a subacute right MCA infarct. It was felt that Mr. [Known lastname 19064] right MCA infarct may have been caused by a left ventricular thrombus which had been diagnosed in [10/2172] for which he had been on Coumadin. Given that Mr. [Known lastname 9817] was thrombocytopenic with a platelet count of 14, his anticoagulation had been on hold. He was not receiving any aspirin or subcutaneous Heparin at the time of the right MCA infarct. The atrial fibrillation in the setting of his left ventricular thrombus made Mr. [Known lastname 9817] at high risk for throwing further emboli. The Neurology service was consulted for management. Per Neurology he was initially started on Neo-Synephrine with intravenous fluids to maintain his systolic blood pressure in the 140s. Further consult opinion could just slightly lower Mr. [Known lastname 19064] target blood pressure as long as his neurologic symptoms did not worsen. Over the next couple of days Mr. [Known lastname 9817] did not develop any further neurological deficits. He appeared to have slightly decreased left upper extremity strength, possible left pronator drift, and a very small left facial droop which seemed to improve slowly. 4. Splenic infarct: On the day following the right cerebrovascular accident on [2173-3-20] Mr. [Known lastname 9817] developed significant left upper quadrant pain. He had a CT of his abdomen which showed hypoattenuation in his spleen. This study was limited because Mr. [Known lastname 9817] was unable to drink oral contrast, and he could not have intravenous contrast at this time secondary to acute renal failure. It was felt that the hypoattenuated areas in the spleen could be secondary to infarct; however, they could not exclude lymphoma. Coupled with the progression of his chest CT, which was noted several days later, Infectious Disease service was also concerned that the hypoattenuation area could be invasive Aspergillosis. This was being investigated at the time of this dictation. Due to the concern for emboli to the spleen in the setting of a recent right MCA cerebrovascular accident, Mr. [Known lastname 9817] was started on intravenous Heparin. It was felt that this safe because his platelets at this point had increased above 50. 5. Acute renal failure: On transfer to the Intensive Care Unit Mr. [Known lastname 19064] creatinine was 1.3. During his hospital stay his renal function deteriorated with a creatinine up to 2.1. It was felt that this was possibly secondary to his AmBisome or possibly ATN from hypotension in the setting of receiving Lopressor and Diltiazem for control of his atrial fibrillation. The Renal service was consulted for assistance with the management of his acute renal failure. They felt that the etiology was likely multifactorial. Mr. [Known lastname 9817] continued to have gentle hydration of his kidneys, and his medications were renally dosed to minimize their toxicity. Over next several days his creatinine did improve to 1.7, which was the creatinine at the time of this dictation. 6. Coronary artery disease: Mr. [Known lastname 9817] has a history of myocardial infarction and coronary artery disease. He was initially off aspirin secondary to his thrombocytopenia. He did have a mild troponin weak in the setting of his rapid atrial fibrillation. During his hospital stay this troponin was noted to trend downward. This was also in the setting of acute renal failure which complicated interpretation of the troponin. Once his platelet count was over 50, Mr. [Known lastname 9817] was restarted on his aspirin for secondary prevention of coronary artery disease. 7. Congestive heart failure: Mr. [Known lastname 9817] had a history of congestive heart failure for which he was on Lasix and angiotensin-converting enzyme inhibitor as an outpatient. Secondary to his renal failure, his Lasix was held during his hospital stay in the Intensive Care Unit. In addition, his ACE inhibitor had been held secondary to hypotension. He should be restarted as his blood pressure improves and he stabilizes and his acute renal failure improves. 8. Mantle cell lymphoma status post chemotherapy: Mr. [Known lastname 19064] mantle cell lymphoma appeared to be in remission during his stay in the Intensive Care Unit. His platelets were monitored and he was transfused when his hematocrit dropped below 30 given that he had history of coronary artery disease. 9. Code status during his hospital stay in the Intensive Care Unit: Mr. [Known lastname 9817] remained Full Code. His family and wife were very involved and supportive of his care. Please see final dictation addendum for the remainder of Mr. [Known lastname 19064] hospital course. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4561] Dictated By:[Name8 (MD) 3482] MEDQUIST36 D: [2173-3-26] 22:59 T: [2173-3-28] 15:09 JOB#: [Job Number 19066]	[ "486", "5849", "4280", "42731" ]
Admission Date: [2121-3-18] Discharge Date: [2121-3-24] Date of Birth: [2057-2-19] Sex: F Service: CARDIOTHORACIC Allergies: Pollen Extracts Attending:[First Name3 (LF) 2969] Chief Complaint: Left lung cancer, status post chemotherapy and radiation therapy. Major Surgical or Invasive Procedure: [2121-3-18]: Flexible bronchoscopy with therapeutic aspiration, left intrapericardial pneumonectomy and a mediastinal lymphadenectomy. History of Present Illness: Ms. [Known lastname 81697] is a 64-year-old woman with over an 80-pack year history of smoking who was found to have a lung mass on chest x-ray during workup for shoulder pain. Subsequent workup found her to have a large left-sided hilar adenocarcinoma. She underwent chemotherapy and XRT and presented for subsequent pneumonectomy. Past Medical History: Removal of vocal cord polyp Hypercholesterolemia Peripheral Vascular Disease Goiter Face lift Tonsillectomy Social History: Married lives in [State 108]. Tobacco:80 pack year. Quit 12 months ago ETOH: [6-30] oz day Family History: Mother: colon cancer Physical Exam: VS: T: 98.1 HR: 75 SR BP: 146/80 Sats: 97% RA General: 64 year-old female no apparent distress HEENT: mucus membranes Neck: supple, no lymphadenpathy Card: RRR. normal S1,S2 no murmur/gallop/rub Resp: right breath sounds clear, left absent breath sounds GI: benign Extr: warm no edema Incision: Left thoracotomy site clean, dry, intact Neuro: non-focal Pertinent Results: [2121-3-20] WBC-7.6 RBC-2.94* Hgb-9.7* Hct-28.8* Plt Ct-232 [2121-3-19] WBC-9.6# RBC-2.84* Hgb-9.4* Hct-27.5* Plt Ct-245 [2121-3-17] WBC-4.8 RBC-2.98* Hgb-9.9* Hct-29.7* Plt Ct-301 [2121-3-23] Glucose-78 UreaN-16 Creat-0.9 Na-139 K-4.0 Cl-102 HCO3-27 [2121-3-22] Glucose-90 UreaN-21* Creat-1.0 Na-137 K-4.1 Cl-101 HCO3-25 [2121-3-20] Glucose-74 UreaN-29* Creat-1.4* Na-139 K-4.9 Cl-106 HCO3-25 [2121-3-18] Glucose-167* UreaN-19 Creat-1.2* Na-140 K-4.2 Cl-108 HCO3-22 [2121-3-17] UreaN-20 Creat-1.4* Na-140 K-4.2 Cl-102 HCO3-28 AnGap-14 [2121-3-17] ALT-10 AST-15 LD(LDH)-180 AlkPhos-71 Amylase-41 TotBili-0.4 CXR: [2113-3-24] FINDINGS: In comparison with the study of [3-22], there is little change. Again there is a long air-fluid level in the left hemithorax at the level of the hilum. The right pleural effusion has decreased. [2121-3-22] The fluid level in the left hemithorax has again slightly increased. No other changes in the left hemithorax. The right hemithorax has also unchanged appearance, including a minimal right basal pleural effusion. [2121-3-19]: Interval increase in amount fluid in the left pleural cavity. Expected elevated left hemidiaphragm. There is interval decrease of amount of subcutaneous gas in left chest wall. Unchanged appearance of right small pleural effusion. Right lung is clear. [2121-3-18]: Status post left-sided pneumonectomy. Only minimal left-sided mediastinal shift. Brief Hospital Course: Mrs. [Known lastname 81697] was admitted on [2121-3-18] for Flexible bronchoscopy with therapeutic aspiration, left intrapericardial pneumonectomy and a mediastinal lymphadenectomy. She was extubated in the operating and transferred to the SICU for further management. The NGT was to low-wall suction, left Penrose drain in place. Her pain was managed by the acute pain service with via Bupivacaine & Dilaudid epidural with good control. On POD1 she transferred to the floor, the penrose drain and NGT tube were removed. She was scoped by ENT for hoarness which showed a paretic left vocal cord with minimal glottic gap. On POD2 she had a video swallow which showed no aspiration. She was started on a regular diet which she tolerated and her home medications. On POD3 the epidural was removed and her pain was well controlled with PO pain meds. The foley was removed and she voided. She was maintained on a 1.0-1.5L liter restriction. Her electrolytes were monitored and repleted as needed. She was followed by serial chest films. She was re-scoped by ENT on POD5 which showed no change. They recommended no treatment at this time. She was seen by physical therapy. On POD6 she continued to do well and was discharged to the Holiday Inn with her husband and son. She will follow-up with Dr. [Last Name (STitle) ] in 1 week. Medications on Admission: fluticasone 110mc 2 puffs [Hospital1 ], docusate 100 mg [Hospital1 ], omeprazole 40 mg qam, pentoxyfylline 400mg tid, senna [Hospital1 ], lorazepam 0.5 qhs/prn Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:90 Tablet(s) Refills:0 4. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:0 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:90 Tablet(s) Refills:0 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO at bedtime. Disp:30 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. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day. 10. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO three times a day. 11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day. 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. Discharge Disposition: Home Discharge Diagnosis: Left lung cancer, status post chemotherapy and radiation therapy. Discharge Condition: stable Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 4741] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Incision develops drainage. Steri-strips remove in 10 days or sooner if start to come off. -You may shower. No tub bathing or swimming for 6 weeks -Take stool softners with narcotics. -No driving while taking narcotics -Walk for 10 mins intervals with goal of 30 mins a day Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 4741] [4-1] at 2:00pm in the [Hospital Ward Name 121] Building, [Hospital1 ] I Chest Disease Center. Report to the [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Completed by:[2121-3-24]	[ "2720" ]
Admission Date: [2122-9-22] Discharge Date: [2122-9-30] Date of Birth: [2039-8-7] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 598] Chief Complaint: fell out of bed Major Surgical or Invasive Procedure: none History of Present Illness: 83 y/o female transferred from outside facility after a CT of the head revealed a SDH/SAH and punctate contusion. Per transfer notes patient fell from standing this morning at [Hospital3 ] while in the bathroom, it is unclear per the patient and per transfer notes whether this was a syncopal episode or a traumatic fall. Upon questioning the patient was alert and oriented but completely amnestic to the event. She states that she fell out of bed while sleeping. Past Medical History: Hypothyroidism Breast CA, s/p right mastectomy Social History: Lives in [Hospital3 ] with her husband Remote history of smoking Family History: non contributory Physical Exam: T:97 BP:119 /72 HR:98 R 13 O2Sats: 98% 2L Gen: WD/WN, comfortable, NAD. HEENT: Pupils:4-2mm b EOMs: intact Neck: Hard cervical collar Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: poor recall 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,4 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-21] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: [2122-9-22] 12:20PM WBC-10.7 RBC-4.46 HGB-13.7 HCT-41.0 MCV-92 MCH-30.7 MCHC-33.4 RDW-14.1 [2122-9-22] 12:20PM NEUTS-86.5* LYMPHS-9.0* MONOS-4.2 EOS-0.2 BASOS-0.1 [2122-9-22] 12:20PM PLT COUNT-140* [2122-9-22] 12:20PM PT-12.8 PTT-25.2 INR(PT)-1.1 [2122-9-22] 12:20PM GLUCOSE-129* UREA N-16 CREAT-0.8 SODIUM-141 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12 [2122-9-22] 12:20PM CK-MB-9 cTropnT-0.30* [2122-9-22] 08:23PM LACTATE-1.9 [2122-9-22] Head CT : 1. Small right frontoparietal subdural hematoma and subarachnoid hemorrhage with foci of subarachnoid bleed in the left parietal and left occipital suggesting contrecoup injury. No significant change since the prior study done at outside hospital. 2. No fractures identified. [2122-9-22] C Spine CT : 1. No acute C-spine fractures or abnormal alignment detected. Please note that MRI is more sensitive for ligamentous /cord injury. 2. Mild degenerative changes of the C-spine, without significant spinal canal stenosis. 3. Bilateral apical lung opacities. Correlate with dedicated chest imaging, either x-ray or CT. [2122-9-22] Chest/Abd ST : 1. Consolidation in the dependent portion of the lungs bilaterally, possibly due aspiration, atelectasis or infection. Small bilateral pleural effusions. 2. No evidence of traumatic injury to the remainder of the torso. 3. Moderate diverticulosis without diverticulitis. 4. Over-distention of the endotracheal tube balloon. 5. 6 mm enhancing lesion within the periphery of the left lobe of the liver is non-specific and may represent a flash-filling hemangioma, adenoma, or area of FNH. [2122-9-23] Cardiac echo : The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the distal 40 percent of the left ventricle. Estimated left ventricular ejection fraction is 30 percent. 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 moderately thickened. There is mild functional mitral stenosis (mean gradient 3 mmHg) due to mitral annular calcification. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [2122-9-24] Cardiac Echo : The left atrium is moderately dilated. The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is moderate to severe regional left ventricular systolic dysfunction with hypokinesis of mid left ventricular walls and akineisis of apical walls and apex. Overall left ventricular systolic function is severely depressed. Estimated ejection fraction is 25-30%. There is evidence of diastolic dysfunction. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is moderate pulmonary artery systolic hypertension. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2122-9-23], there is worsening of the of pulmonary artery systolic hypertension, which is now moderate. IMPRESSION: Severly depressed left ventricular systolic function, evidence of diastolic dysfunction with elevated PAWP (> 18 mmHg). Moderate [2+] tricuspid regurgitation, moderate pulmonary artery systolic hypertension. [2122-9-27] CXR : There are small bilateral pleural effusions, mildly decreased on the right since prior study. Clips are present in the right axilla. Heart and mediastinum are within normal limits. Lungs are otherwise grossly clear. Carotid duplex [9-29]: no stenosis Brief Hospital Course: Mrs. [Known lastname ] was transferred to [Hospital1 18] for further evaluation and management of her SDH. During her stay in the ER she desaturated to the mid 80's and was urgently intubated. A repeat Head CT was done which showed no change and she was subsequently transferred to the Trauma ICU. Her vital signs were stable and her neurologic status was evaluated off sedation. She was able to move all four extremities and responded appropriately to commands. She was extubated 24 hours later successfully and again her neuro exam was unchanged. She was then transferred to the Trauma floor for further management Unfortunately on [2122-9-24] she desaturated again and was transferred back to the ICU. She was in CHF and required vigorous diuresis and BIPAP. A cardiac echo was done which revealed diastolic heart failure, pulmonary hypertension and an EF of 25%. She subsequently developed atrial fibrillation and was placed on a diltiazem drip. She eventually converted to NSR and the cardiology service was consulted. Their recommendations included further diuresis then [Hospital1 ] Lasix, beta blockers for afib with discontinuation of diltiazem and starting an ACEI. A follow up echo is recommended in [5-25] weeks with her cardiologist and if her diastolic dysfunction improves then her ACEI may be able to be stopped. Their thought is that she may have Takotsubo's stress cardiomyopathy which may resolve in time. Carotid studies were normal. She was transferred back to the Trauma floor and was seen on multiple occasions by PT and OT. She was slowly making progress with ambulation. Her neurologic exam was unchanged and she will need to have a repeat non contrast head CT in 8 weeks followed by an appointment with Dr. [Last Name (STitle) ]. She received a 10 day course of phenytoin prophylactically and had no seizures. Mrs. [Known lastname ] was transferred to rehab on [2122-9-30] to increase her mobility and get her back to her baseline. Medications on Admission: Levoxyl 50 mcg Po daily ASA 81 mg PO Daily Calcium supplement Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day: hold SBP < 100 HR < 60. 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 9. Levolyl 50 mcg PO Daily Discharge Disposition: Extended Care Facility: [Hospital1 756] Manor Nursing & Rehab Center - [Location (un) 5028] Discharge Diagnosis: Right frontal/parietal subdural hematoma Small SAH CHF Atrial fibrillation Cardiomyopathy Discharge Condition: stable Discharge Instructions: ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Advil, or Ibuprofen etc. 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: Please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2359] for a follow up appointment in [1-20] weeks Call Dr. [Last Name (STitle) 41243] for a follow up appointment in [12-19] weeks Call Dr. [Last Name (STitle) ] ( Neurosurgery) at [Telephone/Fax (1) 1669] for a follow up appointment in 8 weeks. You will need a non contrast head CT before the visit. This can be booked when you call to make the appointment. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2122-9-30]	[ "41071", "4280", "42731", "2449", "41401", "412", "4240", "4019", "4168", "2859" ]
Admission Date: [2175-4-1] Discharge Date: [2175-4-7] Date of Birth: [2175-4-1] Sex: M Service: NB IDENTIFICATION: [First Name8 (NamePattern2) 66844] [Known lastname 66845] is a 6 day old former 35 [5-7] wk infant with feeding immaturity and neonatal abstinence syndrome being transferred from the [Hospital1 ] NICU to the [Hospital3 ] Special Care Nursery. HISTORY: [First Name8 (NamePattern2) 66844] [Known lastname 66845] was admitted to the NICU due to prematurity and respiratory distress. He was born at 35-5/7 weeks to a 27-year-old gravida 4, para [2-3] mother with past OB history notable for a SVD at 39 weeks in [2164] and a C- section at 35 weeks in [2171]; SAB x1. PAST MEDICAL HISTORY: 1. Charcot-[Doctor Last Name ]-Tooth disease. 2. [Doctor Last Name 13534]-Parkinson-White status post ablation. 3. Asthma. 4. Mitral valve prolapse. 5. Depression on paroxetine 30 mg per day and p.r.n. lorazepam. 6. Nephrolithiasis with chronic pain during pregnancy; initially treated with Percocet progressing to hydromorphone infusion at 2.5 mg per hour in the week prior to delivery. Also receiving dolasetron. PRENATAL SCREENS: Blood type A-positive, DAT negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, group B Strep status unknown. ANTENATAL HISTORY: Estimated date of delivery is [2175-5-1] for an estimated gestational age of 35-5/7 weeks. Pregnancy complicated by maternal conditions and medications as detailed above and by preterm labor at 25 weeks which was treated with magnesium sulfate and betamethasone at that time. Mother presented in spontaneous labor leading to a cesarean section under epidural anesthesia. Membranes were ruptured at time of delivery yielding clear amniotic fluid. There were no intrapartum fever or other clinical evidence of chorioamnionitis. She did not receive intrapartum antibiotic therapy. NEONATAL COURSE: Infant cried at delivery, orally and nasally bulb suctioned, dried. Free-flow oxygen administered. Apgars 7 and 9 at 1 and 5 minutes. In the NICU, infant was noted to have grunting respirations, intercostal retractions, and occasional apnea. PHYSICAL EXAM UPON ADMISSION: Birth weight 2.595 kilograms, OFC 34.5 cm, length was undocumented at that time. HEENT: Anterior fontanel is soft and flat, nondysmorphic. Intact palate. Mouth and neck: Normal. Nasal flaring. Red reflex visualized bilaterally. Chest: With grunting respirations, moderate intercostal retractions, improved with nasal CPAP. Clear breath sounds bilaterally with few scattered coarse crackles. Cardiovascular was well perfused with regular rate and rhythm. Femoral pulses: Normal. Normal S1, S2, no murmur. Abdomen: Soft nondistended. Liver 2 cm below the right costal margin. No splenomegaly, no masses. Bowel sounds: Active. Anus appears patent. GU: Normal penis. Testes descended bilaterally. CNS: Active, responsive to stimuli. Tone: Appropriate for gestational age and symmetric. Moves all extremities. Suck, root, and gag: Intact. Integument: Erythema toxicum over neck and trunk. Musculoskeletal: Normal spine, limbs, and hips and clavicles. HOSPITAL COURSE BY SYSTEMS: Respiratory: Due to increased work of breathing on CPAP, infant progressed to intubation and surfactant administration. Peak ventilator settings were 25/5 with a rate of 25 and 40% with a blood gas of 7.36, 40, 95, 24, and -2. He received 1 dose of surfactant and was extubated at 24 hours of age, and has been room air breathing comfortably since that time. There has been no evidence of apnea or prematurity. Currently breathing 30s-40s with O2 saturations 95-97%. Cardiovascular: Infant has remained hemodynamically stable throughout without need for cardiovascular support. FEN: Infant was initially NPO until cardiorespiratory stability was achieved, and had normal glucose screens and electrolytes. on IV fluid and normal electrolytes as well. Enteral feedings were introduced on day of life 2 with Enfamil 20, and advanced gradually to 120 cc/kg/day. Infant is currently feeding mostly PG with gradually improving PO intake. Breast feeding and breast milk were initially held due to maternal medication use, but could be initiated in the future if desired. Infant has been voiding and stooling normally, and ast electrolytes were on [4-5] with a sodium of 142, a K of 4.9, chloride 114, and a bicarbonate of 15. Further increase in feeding volumes and/or calories is anticipated. GI: A serum bilirubin was obtained on day of life 3 with a state screen which was 10.5/0.3. It peaked on day of life 4 at 13.5/0.3 at which time the baby was placed under phototherapy. The phototherapy remained in place for 24 hours and was discontinued for a bilirubin of 7.9/0.3, with a rebound level of 8.7/0.3 on the day of transfer. Due to concern for one mucousy stool and several heme-positive stools, a KUB was obtained on [4-6] which was reassuring, although with a paucity of bowel gas. Repeat KUB on [4-7] was normal. Physical exam revealed a soft, flat belly with no distention, active bowel sounds, and baby continued to feed without difficulty. Hematologic/ID: A CBC and blood culture were obtained upon admission due to the respiratory distress. The white blood cell count was 11.2 with 21 polys and 1 band, hematocrit 44.9 and platelets 359,000. The blood culture remains negative. The antibiotics of ampicillin and gentamicin were administered for 48 hours. Baby has remained clinically well since the discontinuation of the antibiotics. Neurologic: The baby was followed for neonatal abstinence syndrome in view of maternal narcotic use for chronic pain and due to increasing scores on day of life 2, the baby was started on neonatal opium solution (equivalent 0.4 mg morphine per mL) with the initial dose being 0.35 mL by mouth every 4 hours. This was increased to 0.4 mL every 4 hours later on day 2 of life due to persistently elevated NAS scores, but since then scores have remained stable at 4-6. Dose of neonatal opium remains 0.4 mL PO q 4 hours. On examination, Coltson had some irritability and some mild tremors, mildly increased tone, and a high-pitched cry. This has improved with the neonatal morphine. He does have an excoriated buttock. Social: Parents are married. Mother has a complex medical history and has a supportive family in place. Plans for transfer to [Hospital3 ] for continued convalescent care and weaning of neonatal morphine and maturation of feeding skills is planned, and parents are in agreement with that at this time. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Level II nursery at [Hospital3 38285]. NAME OF PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) 19267] [Last Name (NamePattern1) 1349] in [Location (un) 5028]. CARE AND RECOMMENDATIONS: Feedings currently are Enfamil 20 at 120 mL per kilogram. Medications are neonatal morphine, neonatal opium solution 0.4 mL p.o. PG every 4 hours which is a total dose of 0.9 mL per kilogram per day. Car seat position screening is recommended before discharge. State newborn screen was obtained on day of life 3 and was noted to have an increased 17OHP, and a repeat will be sent on [4-7] prior to transfer to [Hospital3 ]. Immunizations received are none to date. Immunizations recommended are 1. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks; 2) born between 32-35 weeks with 2 of the following: Daycare during RSV season, smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3) infants with chronic lung disease. 2. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the 1st 24 months, immunization against influenza is recommended for household contacts and out-of-home caregivers. Follow-up appointments scheduled will be primary care pediatrician after discharge. DISCHARGE DIAGNOSES: Prematurity at 35-5/7 weeks, surfactant deficiency, rule out sepsis, feeding immaturity and neonatal abstinence syndrome. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (NamePattern1) 55876] MEDQUIST36 D: [2175-4-7] 03:10:29 T: [2175-4-7] 05:38:51 Job#: [Job Number 66846]	[ "7742", "V290" ]
Admission Date: [2120-4-4] Discharge Date: [2120-4-30] Date of Birth: [2048-5-25] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Shellfish Derived Attending:[First Name3 (LF) 10323] Chief Complaint: SOB/weakness Major Surgical or Invasive Procedure: Thoracentesis (left side) Thoracentesis with pigtail drains (left and right) Pleurex catheter placement (left) History of Present Illness: 71 F with h/o Stage II pancreatic cancer diagnosed in [2118-6-7] s/p pancreatoduodemectomy and adjuvant radiation and Gemcitabine in [2118-10-7] p/w SOB and generalized weakness for several days, worse with exertion. pt is s/p IR thoracentesis on [3-29] w/ 2.5L of transudative effusion removed from the right side. After procedure went home and almost immediately began experiencing some SOB particularly with exertion and standing which worsened to the point where her oncologist referred her to the ED today. Pt noted lightheadedness and extreme weakness and palpitations when attempting to stand up with severe DOE of just several steps. States these symptoms are similar to what she experienced prior to pleurocentesis [3-29] but worse. Pt states she has been able to keep up with PO intake despite. Denies n/v but has had diarrhea for the last 3 weeks s/p antibiotic course w/ CTX for E.coli bacteremia, course ending [3-9]. Stool is now loose for the last week but no longer watery and never with blood. Denies abd pain/headaches. . OF note, during her recent hospitalization she had a thoracentesis. Fluid analysis showed transudate and path showed ?reactive. mesothelial cells (from ascitic tap). PT also with known portal vein thrombosis and at home on treatment dose lovenox. . ED course: Initial vitals: 97.8 106 88/43 20 97%. Triggered for hypotension but BP in the room was then 118/72. Did not receive IVF at that time. EKG: sinus rhythm at 94 bpm, no STE, low voltage diffusely CXR: bilateral pleural effusions. Labs pertinent for: Na 123, K 5.3 ?hemolyzed, BUN/CR 17/0.8, glucose 283. Hct 42 (up from 29 recent b/l) WBC 6 with PMNs 80%, LFTs with AST/ALT at 54/74 and alk phos stable but elevated at 362. IP was paged and will evaluate pt in the AM. . PT was admitted to the [Hospital Unit Name 153]. On arrival appeared comfortable on 3L NC with BP 110/84, 96, 98% 3LNC. Pt stated she felt fine with breathing improved. Denied pain of any kind. Drank some [Location (un) 2452] juice. Repeat labs in [Hospital Unit Name 153] showed Na of 128. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure. Denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - T2, N1, stage IIB pancreatic adenocarcinoma diagnosed in [1-/2118] on ERCP. s/p pylorus-preserving pancreaticoduodenectomy. s/p gemcitabine c/b thrombocytopenia and neutropenia. [3-17] CT showed bilateral lung nodules. [11-17] with development of ascites and CT with hypodensity in liver c/f mets vs perfusion abnormality. - Infectious IBS - Diabetes mellitus II - on oral hypoglycemics and insulin - Pancreatic insufficiency - on pancreatic enzyme replacement - Portal vein thrombosis - on lovenox at home Social History: Lives in [Location 686] alone. Her sister lives next door. She has a history of smoking many years ago and does not currently smoke. no ETOH or IVDU. Family History: Family history of DM in her mother and sister. Father died of cancer (unknown type) Physical Exam: ON ADMISSION: Vitals: T: AF BP:111/60 P:90 R:22 95% O2:2L NC General: Alert, oriented, no acute distress, cachectic female HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, without discernable JVD Lungs: diffuse crackles throughout inicreasing at the bases. Left lower lung field with decreased air movement. NO wheezing CV: Regular rate and rhythm, normal S1 + S2, ?splitting of S1 vs ?S4 no murmurs, rubs, gallops Abdomen: scaphoid soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. midline hernia adjacent to umbilicus easily reducible and nontender to palpation GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . ON DISCHARGE: Vitals: T: 98.4 BP:110/60 P:89 R:16 93% O2:RA General: Alert, oriented, no acute distress, cachectic female HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, without discernable JVD Lungs: Left lower lung field with decreased air movement. NO wheezing CV: Regular rate and rhythm, normal S1 + S2 Abdomen: scaphoid soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. midline hernia adjacent to umbilicus easily reducible and nontender to palpation GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: CXR [2120-4-4] FINDINGS: Single portable view of the chest is compared to previous exam from [2120-3-29]. When compared to prior, there has been significant interval enlargement of bilateral pleural effusions which are now moderate in size. Underlying airspace disease is also possible. Superiorly, however, the lungs are grossly clear. Cardiac silhouette is difficult to assess given the size of effusions. Osseous and soft tissue structures are unchanged. IMPRESSION: Significant interval increase in the bilateral pleural effusions since prior exam with possible underlying airspace disease not excluded. . EKG [2120-4-4] low voltage, SR at 90bpm no ST changes prior ECG without such low voltage in lateral precordial leads . [2120-4-15] CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST CT OF THE ABDOMEN: The visualized heart is normal. The pericardium demonstrates no evidence of effusion. Small left pleural effusion is decreased in size compared to the most recent prior examination. There has been interval resolution of right-sided pleural effusion. Bilateral pigtail drains are noted in appropriate position. A 6 mm nodule in the right lung base is present (series 2, image 1). Additional nodularity within the right lung base measuring approximately 10 mm (series 2, image 10) and 6 mm linear density within the right lung base (series 2, 8) represent atelectasis versus infectious process. Pleural-based nodularity at the left lung base measures approximately 6 mm. There is moderate intrahepatic bile duct dilation predominantly involving left lobe of the liver with new pneumobilia compared to [2120-3-6], which may be secondary to hepaticojejunostomy. A 12-mm enhancing focus in the right lobe of the liver demonstrates arterial enhancement and is isodense on the venous phase and may represent enhancing metastasis versus perfusion abnormality. Hypodense area involving the right and left lobes of the liver extending from the porta hepatis to the periphery is new since most recent prior examination and may represent infiltrative tumor or metastases versus perfusion abnormality. The patient is status post pylorus-preserving Whipple with hepaticojejunostomy. The gallbladder is surgically absent. The remaining pancreatic tail appears unremarkable. The spleen and bilateral adrenal glands appear unremarkable. Both kidneys enhance and excrete contrast symmetrically. The upper poles of bilateral kidneys demonstrate thinned cortex similar to [2120-3-6] and may represent prior ischemic injury. Persistent thrombus of the main portal vein, right and left portal veins, the upper portion of the superior mesenteric vein and the splenic vein is again noted. There is mild calcification at the origin of the celiac artery. There is minimal irregularity of the common hepatic artery. The SMA, [Female First Name (un) 899] and bilateral renal vessels appear unremarkable. There is stranding of the mesentery which may represent edema versus tumor involvement. There is no evidence of pneumoperitoneum. Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for pathology. CT OF THE PELVIS: The bladder, uterus is unremarkable. Pelvic lymph nodes do not meet CT size criteria for pathology. There is mild anasarca. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesions suspicious for malignancy are identified. IMPRESSION: 1. Bilateral pigtail catheters in appropriate position with resolution of right and improved small left pleural effusion. 2. 6 mm nodule at the right lung base. Additional nodular densities within the right lung base may represent atelectasis or infections. 3. Moderate intrahepatic bile duct dilatation especially in the left lobe, not significantly changed from [2120-3-6]. New pneumobilia within the left lobe of the liver may be secondary to hepatojejunostomy. 4. Persistent occlusion of main portal vein, right and left main portal veins, upper portion of the SMV and the splenic vein. 5. Large area of low density involving the right and left lobes of the liver extending from the porta hepatis to the periphery may represent infiltrative tumor or metastases versus perfusion abnormality. MRI is suggested for further evaluation. 6. Small enhancing focus in segment VI of the right lobe of the liver measuring 12 mm may represent enhancing metastases versus perfusion abnormality. 7. Stranding of the mesentery may represent edema versus tumor infiltration. 8. Mild anasarca. MRI ABDOMEN W/O & W/CON MRI Abdomen FINDINGS: The previously noted bilateral pleural effusions have resolved. There is small volume ascites. The patient is status post Whipple resection and reconstruction. There is persistent portal vein occlusion with nonenhancing thrombus seen extending into the right anterior, right posterior,left and main portal vein. The thrombus is also seen extending into the proximal portion of the SMV. The thrombus in the SMV is well demonstrated as a hyperintense structure on the T1-weighted imaging (8:74). No evidence of thrombus enhancement to suggest tumor thrombus. There is persistent biliary dilatation, more pronounced in the left hepatic lobe. This biliary dilatation has progressively increased over interval studies over the last 12 months. There are significant peribiliary varices, secondary to the portal vein occlusion, which may be contributing to some stenosis at the level of the hepaticojejunostomy (1002:62). There is pneumobilia (6:11), which suggests patency of the hepaticojejunostomy, however. On the post-contrast images, there is perfusional abnormality involving the left hepatic lobe. These areas are non-mass-like and likely reflect altered perfusion following the longstanding portal vein thrombosis. No evidence of a concerning mass-like hepatic lesion to suggest a metastasis. There is abnormal soft tissue, however, encasing the celiac axis and involving the SMA. This soft tissue extends along the proximal SMA as an abnormal soft tissue cuff (1002:65). The abnormal soft tissue is difficult to accurately measure, but abuts the left adrenal gland, abuts the IVC and extends into the porta hepatis. An approximate measurement is best estimated on the delayed post-contrast sequences ([Numeric Identifier 16105]:54) measuring 4.7 x 2 cm in maximal axial dimension. Narrowing and encasement of the celiac trunk is best appreciated on image (1001:50). The spleen is normal in size measuring 10 cm in long axis. Normal appearance of both kidneys, which enhance symmetrically. Incidental note is made of small Tarlov cysts in the lower sacrum (4:22). No concerning marrow abnormality identified in the thoracic or lumbar spine. IMPRESSION: 1. Thrombosis of the intra- and extra-hepatic portal vein and SMV. 2. Signal change in the liver following contrast likely reflects perfusion changes secondary to chronic portal vein thrombosis. 3. No evidence of metastatic tumor to the hepatic parenchyma. 4. Abnormal soft tissue encasing the celiac axis extending inferiorly to involve the SMA resulting in vessel narrowing. These features are highly concerning for local tumor recurrence. 4. Progressive, predominantly left-sided intrahepatic biliary dilatation with prominent peribiliary varices . Admission: [2120-4-4] 06:20PM BLOOD WBC-6.0# RBC-5.02# Hgb-12.7 Hct-42.9# MCV-85 MCH-25.3* MCHC-29.6# RDW-17.8 Plt Ct-367# [2120-4-5] 03:05AM BLOOD WBC-4.7 RBC-4.57 Hgb-12.0 Hct-37.8 MCV-83 MCH-26.3* MCHC-31.9 RDW-17.9* Plt Ct-237 [2120-4-4] 06:20PM BLOOD Neuts-80.6* Lymphs-8.5* Monos-8.1 Eos-1.5 Baso-1.2 [2120-4-4] 06:20PM BLOOD PT-13.3* PTT-40.8* INR(PT)-1.2* [2120-4-4] 06:20PM BLOOD Plt Ct-367# [2120-4-4] 06:20PM BLOOD Glucose-283* UreaN-17 Creat-0.8 Na-123* K-5.3* Cl-89* HCO3-24 AnGap-15 [2120-4-4] 06:20PM BLOOD ALT-54* AST-74* AlkPhos-362* TotBili-0.8 [2120-4-7] 07:49AM BLOOD ALT-42* AST-34 LD(LDH)-157 AlkPhos-314* TotBili-0.5 [2120-4-4] 06:20PM BLOOD Lipase-9 [2120-4-4] 06:20PM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.1 Mg-2.0 [2120-4-11] 06:55AM BLOOD Ferritn-51 [2120-4-18] 07:10AM BLOOD Triglyc-82 [2120-4-8] 06:45AM BLOOD Cortsol-32.4* [2120-4-29] 05:55AM BLOOD Cortsol-21.2* [2120-4-11] 06:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2120-4-11] 06:55AM BLOOD [Doctor First Name ]-NEGATIVE [2120-4-11] 06:55AM BLOOD IgG-794 [2120-4-11] 06:55AM BLOOD HCV Ab-NEGATIVE [2120-4-5] 05:06PM BLOOD pH-7.52* Comment-PLEURAL FL [2120-4-5] 03:20AM BLOOD Lactate-1.4 CA [27]-9 Test Result Reference Range/Units CA [27]-9 337 H <37 U/mL ON discharge: [2120-4-30] 06:55AM BLOOD WBC-3.3* RBC-3.56* Hgb-9.3* Hct-29.8* MCV-84 MCH-26.2* MCHC-31.3 RDW-18.5* Plt Ct-76* [2120-4-30] 06:55AM BLOOD Neuts-71.5* Lymphs-16.9* Monos-8.9 Eos-2.5 Baso-0.2 [2120-4-28] 07:05AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL [2120-4-18] 01:10PM BLOOD LMWH-0.62 [2120-4-30] 06:55AM BLOOD Glucose-195* UreaN-17 Creat-0.7 Na-132* K-4.5 Cl-102 HCO3-22 AnGap-13 [2120-4-30] 06:55AM BLOOD ALT-50* AST-30 AlkPhos-315* TotBili-0.7 [2120-4-30] 06:55AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 Brief Hospital Course: REASON FOR ICU ADMISSION Patient is a 71 y/o F h/o pancreatic cancer s/p Whipple, recent pleurocentesis with large volume fluid removal from R lung now presents with several days worsening SOB and generalized weakness found to have bilateral pleural effusions on CXR. HOSPITAL COURSE #pleural effusions/dyspnea - reaccumulation of pleural fluid in setting of known portal vein thrombosis with recurrent transudative ascites and pleural effusions. Left pleural effusion is new this admission. She was maintained on her home dose of diuretics after last discharge however she has reaccumulated fluid quickly. IP was consulted who originally placed bilateral pigtails with a massive amount of drainage on a daily basis from both. She would match out in her lungs whatever fluid was given through the IV or PO. She was tried on steroids empirically without resolution of drainage. As her lengthy hospital course continued, the output from her right drain decreased and this was pulled. However, her left drain continued with output, so a pleurex catheter was placed by IP. The etiology of her pleural effusions is unknown. Due to her portal hypertension, it was presumed secondary to hepatic hydrothorax, but throughout her admission we noted that she had minimal to no ascites and yet would put out 4-5 liters daily from the pleural space. We attempted to do an intraabdominal tracer study to prove hepatic hydrothorax, however the tracer was unintentionally injected into the bowel without any clinical consequences. Renal, cardiac and liver disease were ruled out. The pleural and ascitic fluid from previous taps over the last few months have all consistently been extremely transudative without any evidence of malignancy. When her pancreatic cancer was found to have reoccurred via MRI (done to better evaluate her portal vein thrombosis ?bland thrombus vs tumor thrombus), we felt that her effusions might have been related to a capillary leak paraneoplastic process, because after starting chemotherapy her effusions slowed. She will follow up with pulmonary as an outpatient to determine the ongoing need for a pleurex catheter. # stage IIB pancreatic adenocarcinoma ?????? CA [27]-9 had been rising as an outpatient for the past few months, without clear evidence of a recurrence. Finally MRI of the abdomen was done which showed a suspicious soft tissue mass in the resection bed. She started chemotherapy with gemcitabine on [2120-4-18]. Next chemotherapy is due on [2120-5-3]. # hypotension/volume status - A major issue and the main driver of her lengthy hospitalization. We were unable, through any intervention (colloid or crystalloid), to improve her volume status without causing significant pleural output into both lungs. She was placed on an octreotide drip for possible hepatorenal syndrome (noted due to orthodeoxia when standing, however after further analysis we noted that her orthodeoxia was more likely due to hypoperfusion because of extreme orthostasis (sbp in the 40s while standing)). Octreotide provided no benefit and so it was stopped. Cardiology, interventional pulmonary and liver were all consulted, who all agreed that her orthostasis was due to severe hypovolemia, so she was uptitrated to max dose florinef, salt tabs and midodrine. After taking these medications, she was able to stand without symptomatic hypotension and walk with minimal assistance. She will be discharged on florinef, salt tabs and midodrine and the patient was encourage to stand up slowly. She was also chronically hyponatremic throughout her hospital course, typically 128-132, despite the salt tabs. # [Last Name (un) ] - C/w likely somewhat pre-renal etiology although unusual that FeUrea is 45%. Still pt appears dry on exam and history c/w volume depletion (recent diarrhea and limited mobility/access to PO intake). She was volume resuscitated in the [Hospital Unit Name 153] with resultant worsening of her pleural effusions. Her creatinine stabilized. #pancreatic insufficiency - diabetes and enzyme deficiency. Issues with hyperglycemia when on steroids requiring aggressive uptitration of her insulin regimen. When off of steroids and after starting octreotide (an inhibitor of pancreatic function) she developed severe symptomatic hypoglycemia requiring discontinuation of her insulin. After stopping octreotide, she was restarted on an humalog insulin sliding scale. She also had large volumes of diarrhea due to her pancreatic enzyme deficiency s/p whipple. Her home zenpep was continued. #portal vein thrombosis - likely [2-8] hypercoagulability from malignancy. Has had asictes requiring taps over the last several months but no ascites on presentation. Liver was consulted who felt that she should not have portal hypertension without cirrhosis, however her cirrhosis workup was negative and she has known Grade II esophageal varices. Her factor Xa level was barely therapeutic after once daily dosing of lovenox, so she was switched to [Hospital1 ] dosing. We attempted to find an intervention to remove/lyse this clot, however in discussion with many different services found no options (the clot was present for too long to be lysed with TPA via IR, and would require an open abdominal surgery with reconstruction via vascular/transplant). Transitional Issues - Please continue to drain 500-1500cc of fluid from the pleurex catheter as needed for comfort. - She will need to return for follow up appointments with Hem-Onc (see appointment within this discharge summary) Medications on Admission: - enoxaparin 70 mg Subcutaneous DAILY - furosemide 40 mg PO DAILY - glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day. - insulin aspart Four (4) units SC three times a day: please use before meals . - insulin glargine 12 units Subcutaneous once a day - spironolactone 100 mg PO DAILY - lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Three (3) Cap PO QID (4 times a day). Discharge Medications: 1. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO four times a day. 2. Zenpep 20,000-68,000 -109,000 unit Capsule, Delayed Release(E.C.) Sig: Capsule, Delayed Release(E.C.) PO ASDIR (AS DIRECTED): 3 caps with meals 2 caps with snacks. 3. sodium chloride 1 gram Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). 7. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed for diarrhea. 8. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 9. opium tincture 10 mg/mL Tincture Sig: Four (4) drop PO every four (4) hours as needed for constipation. 10. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 11. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. 12. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for diarrhea. 13. insulin Please see attached Insulin Sliding Scale Discharge Disposition: Extended Care Facility: [Hospital1 ] at the [Doctor Last Name 1263] Discharge Diagnosis: Pleural effusions s/p pleurex catheter placement Portal vein thrombosis Pancreatic cancer (recurred) Orthostatic hypotension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [Hospital1 18]. You were admitted for shortness of breath and found to have a reaccumulation of the fluid around your right lung as well as a new fluid collection around your left lung. As you know, we had extreme difficulty preventing water from accumulating around your lungs; eventually we had to place a pleurex catheter in your left lung due to the speed of reaccumulation of fluid. You will need the pleurex catheter drained between 500-1500cc of fluid periodically for comfort. Extra vacuum bottles have been sent with you at discharge. Complicating this was your low blood pressure when standing. We gave you new medications to raise your blood pressure. Please note the following changes to your medications: STOP lasix spironolactone enoxaparin 70mcg START salt tabs 2g twice per day enoxaparin 40mg twice per day florinef 0.2mg daily midodrine 10mg three times per day, please take the last dose at least 4 hours before bed, and the first dose as soon as you wake up prior to standing Please see discharge summary for more details regarding your new medications. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2120-5-3] at 10:00 AM With: [First Name4 (NamePattern1) 2747] [Last Name (NamePattern1) 5780], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2120-5-10] at 10:00 AM With: [First Name4 (NamePattern1) 2747] [Last Name (NamePattern1) 5780], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY (please obtain a chest xray on the same day just prior to this appointment) When: THURSDAY [2120-5-16] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6543], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5990", "2761", "5849", "4168", "4280", "V5867" ]
Admission Date: [2191-6-15] Discharge Date: [2191-6-20] Date of Birth: [2125-3-4] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1835] Chief Complaint: Seizure, new Right parietal mass Major Surgical or Invasive Procedure: [2191-6-17] Right craniotomy for tumor resection History of Present Illness: 66 yo M hx pulmonary artery sarcoma s/p resection and pneumonectomy in [3-/2191] currently undergoing Raditaion treatments here at [Hospital1 18] who developed left facial numbness and left hand clumsiness around 7pm on [6-14]. Family initiated emergency services and upon EMS arrival the patient progressed to generalized seizure. He was givien ativan with good effect and brought to OSH where he became combative. He was subsequently intubated for combativeness and airway protection and taken for a head CT that showed right parietal lesion. Transferred to [Hospital1 18] for further evaluation. Past Medical History: PMH: Hyperlipidemia, Hx prostate CA s/p rsxn ([2188]) PSH: prostatectomy for early stage prostate cancer at [Hospital1 2025] ([9-/2189]), B/L inguinal hernia repair ([2191-1-5]) Social History: Married, lives with wife. [Name (NI) 1139] never. ETOH: 1 drink per week Family History: Father died age 73 of breast cancer. Brother has prostate cancer. Physical Exam: Intubated, sedated with propofol and Fentanyl. Pupils equal and brisk, 4mm to 3mm Does not follow. Spontaneous breaths over vent, Gagging occasionally on ET tube On discharge: slight left pronator drift, otherwise neurologically intact Pertinent Results: [6-14] CT head noncontrast: Right parietal lesion 2cm x 2cm with surrounding edema and 3-4mm midline shift. [6-15] MRI Head with and without contrast: IMPRESSION: 1. Enhancing hemorrhagic 2.2-cm intra-axial mass centered within the right parietal lobe with associated vasogenic edema that in the current clinical setting, most likely represents a metastasis. 2. Multiple small foci of signal loss scattered throughout the brain on gradient recalled echo sequences. This finding may relate to amyloidosis, with metastases not entirely excluded. [6-16] CT Torso: CHEST FINDINGS: Post-surgical changes consistent with left pneumonectomy and resection of left pulmonary artery sarcoma are redemonstrated. There is fluid within the pneumonectomy cavity with interval resolution of gas. There is no nodularity of the pleural surface which is minimally enhancing. Pericardial fluid or thickening along the left lateral margin is unchanged. There is soft tissue density in the mediastinum at the level of the left main bronchus resection, stable from the prior examination. A right paratracheal lymph node measuring 8 mm is slightly smaller from the prior examination (11m) (3:20). There are numerous left supraclavicular lymph nodes, none of which are pathologically enlarged by CT criteria or unchanged from the most recent examination, however, these were not present on the baseline examination. A few prominent paraesophageal lymph nodes near the diaphragmatic hiatus measure up to 7 mm, also essentially unchanged from the prior examination. Left pericardial lymph nodes measuring up to 6 mm are stable. There is no axillary lymphadenopathy. In the right upper lobe, there is an enlarging pulmonary nodule measuring 7 mm (previously 5 mm) (3:13). A second right upper lobe pulmonary nodule measuring 5 mm was present on preoperative examination and is essentially unchanged in size (3:22). No additional pulmonary nodules are present. There is no pleural effusion on the right. The heart is normal in size. Diffuse coronary artery calcifications are visualized. The heart and mediastinum are shifted to the left as a result of the left pneumonectomy. ABDOMEN FINDINGS: A vague 5-mm hypodensity in the right hepatic lobe, segment VII is visualized (3:52). This is not evident on the prior PET-CT, however, that was performed without contrast. The spleen (with small splenule), adrenal glands, pancreas and gallbladder are within normal limits. Bilaterally, the kidneys demonstrate subcentimeter hypodensities which are too small to accurately characterize. In addition, there is a 2.9 x 2.4 cm cyst in the right mid kidney with layering dependent milk of calcium. On delayed images through the kidneys, this does not collect contrast excluding a calyceal diverticulum. There is a nonobstructing 2-mm renal calculus in the right mid kidney. The kidneys demonstrate symmetric uptake and excretion of contrast. There is no hydronephrosis. There is no abdominal lymphadenopathy or free fluid. Scattered atherosclerotic calcifications are present within the normal caliber abdominal aorta. PELVIS FINDINGS: The prostate gland is not visualized. Bowel loops are normal in appearance without evidence of inflammation, mass or obstruction. There is no pelvic lymphadenopathy or free fluid. Air within the bladder presumably relates to foley catheter insertion. OSSEOUS STRUCTURES: There are no destructive osseous lesions. A vertebral body hemangioma is present within L1 and L5 vertebral bodies. IMPRESSION: 1. Post-surgical changes consistent with left pneumonectomy and resection of left pulmonary artery sarcoma. Pneumonectomy space is fluid filled with smooth pleural mild enhancement. 2. Enlarging right upper lobe pulmonary nodule measuring 7 mm, concerning for metastatic disease. 3. Stable soft tissue surrounding the trachea and left bronchial stump. Decreased size of right paratracheal node and left pericardial thickening/fluid. 4. Stable subcentimeter lymph nodes in the left supraclavicular, right lower paraesophageal and left pericardial regions. Continued followup is recommended as these were not present on the initial examination. 5. Ill-defined 5-mm hypodense lesion in the right hepatic lobe was not definitely present on the prior examinations. Again, metastatic lesion is possible and continued followup is recommended. [6-17] CT Head: IMPRESSION: Immediately status post right frontal craniotomy and resection of right frontoparietal mass, with expected post-craniotomy changes, including pneumocephalus and trace subarachnoid blood. There is persistent vasogenic edema with mild right convexity sulcal and lateral ventricular effacement, as well as 5 mm leftward shift of midline structures, unchanged since the pre-operative examinations. [6-19] MRI Brain: IMPRESSION: 1. Post-surgical changes in the right parietal lobe, with blood products in the surgical resection site and moderate surrounding vasogenic edema. A very tiny focus of enhancement may relate to post-surgical changes. However, consider followup evaluation to exclude residual tumor. Persistent mild leftward shift of midline structures and right-sided frontal and parietal edema. Evaluation for infarcts is limited given the confounding effects of blood products on the diffusion-weighted sequence. Brief Hospital Course: Pt was admitted to the ICU under the neurosurgery team for further care and workup of his new right parietal lesion. He remained intubated and was started on dilantin for seizure treatment. He underwent and MRI Head to further evaluate this mass which showed a lesion in the right posterior parietal region with surrounding vascogenic edema. He was extubated on the afternoon of [6-15] and remained stable overnight into [6-16]. On morning rounds he was seen and evaluated and his exam was nonfocal. He was evalauted by neuro and radiation oncology pre-operatively and had a speech and swallow evaluation. A CT of his torso showed an increase of a right apical pulmonary nodule 7 mm R increased from 4 mm on [2191-5-25] ct - size increase concerning for met. Dr[Name (NI) 90134] the patient's primary oncologist was notified and came to see the patient before his surgery. On [6-17] he went to the OR and underwent a right parietal craniotomy. Post-operatively, he was admitted to the ICU for monitoring and his exam remained stable. On [6-18], he had a post-op MRI with expected post-op findings. On [6-19] his ASA was restarted and he was transferred to the floor. He remained stable overnight into [6-20] and during the day worked with PT and OT as well as re-eval by speech and swallow. As a result of [Doctor Last Name ] evaluations he was dxeemed fit for discharge to homewithout services and was cleared for a regular diet. On the afternoon of [6-20] he was discharged to home with instructions for follow-up. Medications on Admission: aspirin 81mg daily, Pyridoxine 50mg daily, bensonatate 100mg TID, Hycodan PRN, Mtoprolol ER 75mg Daily, Omeprazole 20 mg daily, pravastatin 40mg daily, tylenol PRN, Vit D daily, glucosamine-chondroitin daily, MVI, Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper: Take 3mg (1.5 tabs) every 6 hours on [6-20], Take 2mg (1 tab) every 6 hours on [6-21], then take 2mg (1 tab) [Hospital1 ] on [6-22] and continue until followup . Disp:90 Tablet(s) Refills:0 7. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metoprolol ER 75 Sig: Seventy Five (75) mg once a day. Discharge Disposition: Home Discharge Diagnosis: Right Parietal Mass Seizure (new onset) Lung nodule Cerebral Edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [5-29] 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 on [2191-6-27] 1130am. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. Completed by:[2191-6-20]	[ "2724", "4019", "2720" ]
Admission Date: [2131-3-16] Discharge Date: [2131-3-26] Date of Birth: [2065-6-28] Sex: M Service: MEDICINE Allergies: Oxycontin Attending:[First Name3 (LF) 6021] Chief Complaint: hematuria, abd pain Major Surgical or Invasive Procedure: Cystoscopy History of Present Illness: 65 Russian-only speaking M with metastatic colon ca on Cycle 1, Day 6 experimental drug (unknown action) of Reata clinical trial, history of extensive PE, presents with SOB and hypoxemia. He was vomiting tonight and desatted to 80% RA and 94% FM on two episodes that followed each other within minutes. ABG on FM: 7.41 / 47 / 315. CXR shows diffuse fluffy infiltrates indicative of pneumonitis but no indication for hypoxemia. He was given lasix with unknown UO (nurses did not monitor), levo/flagyl x 1, and he stabilized to 100% NRB without improvement. CK 69, MB 3, Trop 0.02. During these episodes, patient had sinus tach to 120s, which was not treated. He has a history of extensive PEs but has been compliant with lovenox 100 per day. Over the last day, his WBC increased from 9.9 to 14.8, Hct decreased from 33 to 25.1, Cr increased from 1.2 to 2.0. . He was admitted today with hematuria, abdominal pain, repeated vomiting. Patient has a history of hematuria and has ureteral invasion of his tumor on prior imaging. He was seen in epi clinic on [3-5] for gross hematuria in which his lovenox was decreased from 120 to 100 mg qd and he was given levaquin for treatment of a UTI based off of a positive UA. The pt noticed a slight decrease in his hematuria and was feeling relatively well when he began to have repeat gross hematuria with clots beginning last pm at 8:30. This was associated with a dull, achy pain in the suprapubic area. He initially refused to go to the ED for evaluation; however he was up all night with urinary urge and gross hematuria that he presented for evalution early this am. He denies associated dysuria, flank pain, back pain, fevers, chills, night sweats, n/v/d. The pt reports his last BM was 7 days ago. . In the ED, the pt was seen by urology to placed a 3-way catheter for CBI. He was given mag citrate and fleets enema for large amt of stool seen on KUB and had one small BM. UA was positive with glucose > 1000, ketones positive. . He has been on an experimental drug made by Reata pharmaceuticals called RTA-402, which is an inhibitor of IKK. The drug would thus inhibit NFkB. On the Reata site, states no overt side effects to the drug in administration for 28 days to baboons, but no side effects noted in humans. Past Medical History: PAST ONC HISTORY: The patient initially presented in [2125] for evaluation of mild hematuria when a CT abd showed thickening of the sigmoid colon. A sigmoidoscopy showed a large non-bleeding mass and he underwent sigmoid colectomy which showed moderately differentiated ulcerated adenocarcinoma reaching the serosa with [5-18] lymph nodes were positive for metastasis. Since his initial presentation of stage III colon CA, he has progressed to metastatic disease to the lung, liver, abd wall, ureter. 1. He is status post 5-FU, leucovorin as adjuvant therapy. 2. He is status post 5-FU, irinotecan, and Avastin with disease progression. 3. Status post oxaliplatin and Xeloda. 4. He is status post Erbitux and irinotecan. 5. He is status post Avastin, 5-FU, and mitomycin. He has not received therapy in several months. He has progressed on all these therapies. 6. He developed a PE in [9-17] and is being anticoagulated with Lovenox daily. 7. He was recently placed on a phase 1 Reata clinical trial, which has since been held due to progression of disease. . PMH: 1) Metastatic colon cancer as above 2) HTN 3) Hypercholesterolemia 4) Depression 5) CRI 6) GERD Social History: Lives with wife in [Location (un) ] apt with elevator. Has a home aide. Smokes [5-17] cig/day for the past 50 yrs. Previously was a heavier smoker, up to 1 PPD. Denies EtOH, illicits, IVDA. Family History: No family h/o colon CA. Aunt with rectal CA at the age of 85. Physical Exam: VS: 96.8 / 92 / 113/93 / 24 / 92% NRB General: Responds in broken English, NAD, pleasant male, thin HEENT: No JVD, no LAD, sclerae anicteric, MMM, OP clear LUNGS: CTA b/l HEART: RRR, +s1/s2, no m/r/g ABD: Firm to palpation over epigastric and suprapubic areas (per onc fellow note, this is not new), normoactive BS in all 4 quadrants, distended, no hsm EXTR: No LE edema, +2 DP pulses b/l Pertinent Results: LABS ON ADMISSION: [2131-3-15] 09:55AM WBC-9.6 RBC-3.95* HGB-12.0* HCT-34.5* MCV-87 MCH-30.4 MCHC-34.8 RDW-16.0* [2131-3-15] 09:55AM NEUTS-78.0* LYMPHS-16.3* MONOS-4.5 EOS-1.0 BASOS-0.3 [2131-3-15] 09:55AM PLT COUNT-488# [2131-3-15] 09:55AM PT-13.0 PTT-29.5 INR(PT)-1.1 [2131-3-15] 09:55AM FIBRINOGE-423 [2131-3-15] 09:55AM RET AUT-2.4 [2131-3-15] 09:55AM TOT PROT-6.8 ALBUMIN-3.9 GLOBULIN-2.9 CALCIUM-9.7 PHOSPHATE-2.4* MAGNESIUM-2.0 URIC ACID-5.5 [2131-3-15] 09:55AM ALT(SGPT)-19 AST(SGOT)-16 LD(LDH)-152 ALK PHOS-123* TOT BILI-0.3 [2131-3-15] 09:55AM GLUCOSE-130* UREA N-18 CREAT-1.0 SODIUM-136 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-21* ANION GAP-16 [2131-3-15] 11:00AM URINE COLOR-Red APPEAR-Cloudy SP [Last Name (un) 155]-1.015 [2131-3-15] 11:00AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-TR [2131-3-15] 11:00AM URINE RBC->50 WBC-[1-1]* BACTERIA-RARE YEAST-NONE EPI-[4-16] . KUB [3-16]: Large amount of stool within the large bowel with no evidence of obstruction. . CXR [3-16]: No free air is seen under the diaphragms. In comparison with [2131-1-12], the cardiomediastinal silhouette appears stable. Again noted are innumerable bilateral pulmonary nodules consistent with the patient's history of metastatic colon cancer. No additional focal consolidations or effusions are seen. There is no pneumothorax. . Renal US [3-17]: 1. Moderate-to-severe hydronephrosis in the right kidney with associated parenchymal thinning, not significantly changed from previous CT dated [2131-1-26]. 2. Small amount of echogenic material within the bladder which is consistent with patient's history of intraluminal bladder hematoma. 3. Large mass identified within the region of the bladder likely corresponding to patient's known anterior abdominal wall metastatic disease. . Ureteral mass [3-19]: path pending . Cystoscopy [3-19]: There were noted clots within the proximal urethra and a notably high bladder neck that was also hypervascular. Once in the bladder we were immediately confronted by a large space occupying bladder clot occupying likely [4-15] of the bladder, which was evacuated. A large papillary frondular mass emanating from the right ureteral orifice of approximately 3 x 2 cm, high grade appearing, was resected and sent for pathology. . CT abd/pelvis without contrast [3-20]: 1. No evidence of bowel obstruction. 2. Extensive metastatic disease including innumerable pulmonary nodules, pleural mass, hepatic lesions, omental and abdominal wall disease. The pleural disease and hepatic metastasis appears increased from prior examination. 3. Tiny non-obstructing stone in the left proximal ureter. Otherwise, stable appearance of the kidneys. Irregularity of the bladder is likely related to the prior day's cystoscopy. . CXR [3-22]: 1. Right-sided PICC catheter with tip likely within superior right atrium. Recommend repositioning. 2. Patchy basilar opacities, best appreciated within the right lower lobe are suspicious for areas of aspiration pneumonia or pneumonitis given clinical history. Metastatic burden appears stable/ 3. Probable small bilateral pleural effusions. Brief Hospital Course: 65 yo M with metastatic colon CA and h/o PE presents who presented with hematuria and abdominal pain. The pt was evaluated by urology in the ED who placed a 3 way Foley and a CBI was begun with return of dark, and then bright red urine. He was also given magnesium oxide and lactulose in the ED with 1 small BM. The CBI and a more aggressive bowel regimen were continued on the night of admission when the pt developed emesis and subsequently desated down to the upper 70s on RA. He was placed on a NRB with improvement in sats to the low to mid 90s. An EKG was performed without any ischemic changes. He was transferred to the MICU and started on vancomycin and cefepime for aspiration PNA. There was also a question of whether or not capillary leak could be a side effect from the pt's clinical trial drug, Reata; however, no literature suggesting this was found. Based off of CXR, it was most likely that the pt's hypoxia was secondary to aspiration PNA vs. an aspiration pneumonitis. As the CXR was also significant for vascular congestion, his IVFs were limited and he was diuresed with IV lasix. . While in the MICU, it was noted that the pt continued to have gross hematuria and large blood clots in spite of continuous bladder irrigation. His Hct also fell from 34.5 to 22.3 and his Cr climbed from 1.4 to 3.6. Renal was consulted who felt that the cause of his ARF was most likely post-renal in nature given his known h/o a R ureteral mass and ongoing hematuria. Urology took the pt for cystoscopy in which a large blood clot occupying [4-15] of the bladder was evacuated and a large, high grade appearing R ureteral mass was biopsied and resected. He was transfused a total of 8 U pRBC in the MICU for decreasing Hct, which eventually stabilized out to the upper 20s, low 30s on the floor. . The pt's oxygen requirement was weaned down to 4L NC and he was called out to the floor. As his urine had cleared s/p cystscopy, his CBI was d/c'd and a Foley was placed. Lovenox was titrated up from 40 to a treatment dose of 80 mg SQ qdaily without any increase in hematruia or Hct drop. The pt was also further diuresed and was switched to po levaquin for treatment of PNA. His oxygen requirement was weaned off and he was sating in the mid 90s on RA by time of discharge. Of note, the pt had two seperate urinary void trials without success prior to d/c (bladder scan with 450 cc, 400 cc respectively). He was discharged to rehab with a Foley in place and will f/u with urology in 2 wks time to have the foley removed. He will follow-up with Dr. [Name (STitle) ] for further oncologic care. During the hospital course, Reata was d/c'd given demonstrated progession of disease . Code status: Full Medications on Admission: Ambien 5 mg qhs prn LAC-HYDRIN 12 %--Apply to heels at bedtime Lisinopril 40 mg qd Ativan 0.5 mg [2-13] pills qhs Lovenox 100 mg SQ qd Miralax qd MS Contin 100 mg [Hospital1 ] Oxycodone 5 mg po q4h prn Protonix 20 mg qd Lactulose prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:15 Tablet(s) Refills:0 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:1 Tablet(s) Refills:0 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:400 ML(s) Refills:0 8. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) units Subcutaneous QDAILY (). Disp:1 month supply Refills:2 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 11. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:2 12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:60 Tablet, Chewable(s) Refills:0 13. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO Q8H PRN () as needed for hiccups. Disp:30 Tablet(s) Refills:0 14. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary Diagnosis: Hematuria s/p removal of R ureteral orifice Aspiration PNA Secondary Diagnosis: Metastatic Colon CA HTN Hypercholesterolemia Depression CRI GERD Discharge Condition: Good, ambulating, breathing well on room air, eating regular diet. Discharge Instructions: You were admitted for hematuria, or blood in your urine. A cytoscopy was performed in which a large blood clot was evacuated from the bladder and a mass was removed and biopsied from the R ureteral orifice. You will need to complete a 7 day course of levaquin as an outpatient for treatment of pneumonia. Please take all of your other medications as prescribed. You are being discharged with a Foley catheter in place. You will need to follow-up with urology in 2 weeks to remove the Foley. The phone number for the urology clinic is ([Telephone/Fax (1) 18591]. Please call your physician or return to the emergency room if you experience any of the following: increasing hematuria, abdominal pain, diarrhea, cough, shortness of breath. Followup Instructions: You have the following appointments: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1879], M.D. Date/Time:[2131-3-28] 10:20 Provider [First Name11 (Name Pattern1) 5445] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5446], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2131-4-11] 10:20 Provider [First Name8 (NamePattern2) 161] [Name9 (PRE) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2131-4-23] 10:30 Completed by:[2131-3-26]	[ "5070", "5859", "5849", "2851", "2720", "40390", "53081" ]
Admission Date: [2193-5-10] Discharge Date: [2193-5-16] Date of Birth: [2126-5-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 45] Chief Complaint: palpitations Major Surgical or Invasive Procedure: none History of Present Illness: 66 YOF with h/o alcohol use, afib on coumadin, systolic CHF with EF 30%, HTN, presented with palpatation x3 days, worsening dyspnea with exertion, increased peripheral edema with abdminal ascites over past week. Reports difficulty sleeping due to dyspnea and palpatations, sleeping recumbant on 1 pillow. Speaks full sentences in ED in no obvious respiratory distress. Recently decreased her verapamil to 120 daily, questionable if PCP is [Name Initial (PRE) ]. Has not had a drink since late [Month (only) ]. . In the ED, patient's HR in 130s in Afib with good BPs. Given 10mg IV dilt x2. Admitted to [Hospital Unit Name 196] for diuresis and rate control. . On floor, patient was found resting in bed. Became tearful with discussing regarding her medical condition. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. 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 paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope. . Past Medical History: Cardiac Risk Factors: Diabetes, + Dyslipidemia, + Hypertension . Cardiac History: CABG: none Percutaneous coronary intervention: none Pacemaker/ICD: none Social History: She is divorced, lives with her son. She works with historical manuscripts. She does smoke two packs of cigarettes a day. Was drinking 10 glasses of wine per day but quit four month ago. No recreational drugs, does not do any regular exercise, or follow a particular diet. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - 97.7 112/83 84 18 99% 3L NC Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 10 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [1-12] murmur no r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. poor air movement, decreased breath sound b/l, wet crackles on right base, no wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2193-5-10] 03:05PM BLOOD WBC-5.8 RBC-4.15* Hgb-12.9 Hct-39.0 MCV-94 MCH-31.1 MCHC-33.1 RDW-13.8 Plt Ct-202 [2193-5-16] 05:40AM BLOOD WBC-6.4 RBC-4.06* Hgb-12.7 Hct-38.6 MCV-95 MCH-31.4 MCHC-33.0 RDW-14.7 Plt Ct-195 [2193-5-10] 03:05PM BLOOD PT-42.1* PTT-39.6* INR(PT)-4.5* [2193-5-16] 05:40AM BLOOD PT-18.4* PTT-42.8* INR(PT)-1.7* [2193-5-10] 03:05PM BLOOD Glucose-105* UreaN-16 Creat-0.9 Na-134 K-3.1* Cl-98 HCO3-23 AnGap-16 [2193-5-16] 05:40AM BLOOD Glucose-95 UreaN-18 Creat-1.0 Na-138 K-3.7 Cl-97 HCO3-29 AnGap-16 [2193-5-10] 03:05PM BLOOD ALT-10 AST-25 AlkPhos-59 TotBili-1.5 [2193-5-12] 03:30AM BLOOD ALT-11 AST-19 LD(LDH)-174 AlkPhos-47 TotBili-1.3 [2193-5-10] 03:05PM BLOOD cTropnT-0.02* proBNP-[Numeric Identifier 47330]* [2193-5-11] 12:06AM BLOOD CK-MB-4 cTropnT-0.02* [2193-5-11] 08:15AM BLOOD CK-MB-3 cTropnT-0.01 [2193-5-11] 12:06AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2 [2193-5-16] 05:40AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.5* [2193-5-12] 03:30AM BLOOD TSH-2.0 [2193-5-10] 03:05PM BLOOD GreenHd-HOLD [2193-5-12] 12:19PM URINE Hours-RANDOM UreaN-502 Creat-202 Na-25 K-74 Cl-47 [2193-5-12] 12:19PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-[10-26] [2193-5-12] 12:19PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-5.0 Leuks-NEG [2193-5-12] 12:19PM URINE Color-Amber Appear-Clear Sp [Last Name (un) ]-1.018 2D-ECHOCARDIOGRAM performed on [2193-5-11] demonstrated: L atrium dilation. Moderate global left ventricular hypokinesis (LVEF = 30-35%). RV moderately dilated with moderate global free wall hypokinesis. No AS or AR. Moderate to severe (3+) MR, Moderate to severe [3+] TR. The estimated pulmonary artery systolic pressure is normal. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] Small pericardial effusion with no signs of tamponade. [2193-5-16] Cardiology ECHO No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %). Right ventricular chamber size is normal. with moderate global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta and aortic arch. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion, most prominent near the inferior wall. There are no echocardiographic signs of tamponade. IMPRESSION: Mild left atrial appendage spontaneous echo contrast with depressed ejection velocities. No left atrial/appendage thrombus seen. Hypokinetic LV with moderate mitral regurgitation. Brief Hospital Course: 66 YOF with Afib on coumadin, systolic CHF with EF 30%, HTN, who presented with palpatations and found to be in Afib with RVR, and heart failure, treated in the CCU with dopamine drip for hypotension/bradycardia likely associated to IV diltiazem + other nodal agents. TEE and DCCV planned for [5-16]. . Mrs [Known lastname 99458] had episode of hypotension secondary to low cardiac output in the setting of bradycardia as the result of multiple nodal agents for RVR control (received 40 IV dilt + 20 PO dilt + home metoprolol + 240 verapamil CR). She had a repeat ECHO showed small pericardial effusion, EF stable (EF 30-35%) with 3+ MR, 3+ TR. She was transiently maintained on dopamine, amiodarone, atropine, calcium gluconate. Antihypertensives were held. She was continued on amiodarone and started on metoprolol for her atrial fibrillation. She was diuresised aggressively and was placed on standing lasix for her heart failure. She underwent DCCV after TEE, after which she was in sinus rhythm. After the cardioversion, she was discharged in stable condition with significant modification in her medications. She will follow up with her PCP and cardiologist. . # Code status: presumed full Medications on Admission: hydrochlorothiazide 12.5 mg a day Cozaar 50 mg a day metoprolol succinate 50 mg a day verapamil 240 mg a day warfarin Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:20 Tablet(s) Refills:0 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Please start after you have completed the 10 day course of twice a day dosing. Disp:30 Tablet(s) Refills:2 3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 6. Outpatient Lab Work [5-18] CHEM10 (Na/K/Co2/Cl/BUN/Cr/Ca/Mg/Phos/glucose), Coagulation (PT/INR) and send to PCP [Name Initial (PRE) ] [Name10 (NameIs) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Fax: [Telephone/Fax (1) 97841] Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Congestive Heart Failure Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came with heart failure and were in atrial fibrillation. You were treated with diuresis and given medication to control your heart rate. We were able to help you get rid of fluids to make you feel much better. You were discharged in stable condition. Please follow up with the following doctors. Please note we have made the following changes to your medications. STOPPED: Hydrochlorothiazide 12.5 mg a day Cozaar 50 mg a day Metoprolol succinate 50 mg a day Verapamil 240 mg a day Warfarin 5mg a day STARTED: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Please start after you have completed the 10 day course of twice a day dosing. 3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. It was a pleasure taking care of you. We wish you a speedy recovery. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 62] Date/Time:Friday [2193-5-24] 2:30PM. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], MD Phone:[Telephone/Fax (1) 5068] Date/Time:[2193-5-21] 10:15; [Location (un) ]. PCP [Name Initial (PRE) 2169]: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 41966] [Street Address(2) ], 4W, [Location (un) ], [Numeric Identifier 822]. Date/Time: [2193-5-21] 3:30PM. New PCP if you prefer: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 815], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2193-5-22] 2:35 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [Doctor First Name 63]	[ "5849", "4280", "42731", "42789", "4240", "4019", "2724", "V5861" ]
Admission Date: [2122-12-7] Discharge Date: [2122-12-10] Date of Birth: [2063-5-1] Sex: M Service: BONE MARROW TRANSPLANT HISTORY OF PRESENT ILLNESS: 59-year-old male with a history of chronic lymphocytic leukemia who presents with two- to three-week history of worsening short-term memory problems and mild ataxia. Patient describes difficulty remembering day of the week and inability to complete tasks at work, some clumsiness and coordination problems. [Name (NI) ] denies headache, visual changes, nausea, vomiting, diarrhea, fevers, chills. He notes slight right arm weakness with lifting and has been bumping into items on his left side recently. Patient notes history of a fall on [2122-11-12] after consuming alcohol at a party. Patient presented to [Hospital 10908] on [2122-12-4] complaining of the symptoms mentioned above. There, he had a head CAT scan, head MRI, and a lumbar puncture. Evaluation has shown a new brain mass in the region of the corpus callosum extending into subependymal region and involving the fornix. Patient presents for further workup of this new mass. PAST MEDICAL HISTORY: 1. Chronic lymphocytic leukemia diagnosed [2117] status post a single course of Chlorambucil and Prednisone course finished 06/[2121]. Patient was first treated in [8-/2121] for constitutional symptoms, night sweats, increased lymphadenopathy, and splenomegaly on presentation. 2. Hyperlipidemia. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Lipitor 10 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Decadron 6 mg p.o. q.i.d. 4. Ativan 1 mg p.o. intravenously q. 6 hours p.r.n. 5. Regular insulin sliding scale. 6. Metamucil, one package, p.o. q.d. p.r.n. SOCIAL HISTORY: Works in a brokerage firm; lives alone; divorced male currently with girlfriend. [Name (NI) ] has three children aged 26, 30, and 33. Lives in [Location 86]. Denies tobacco use. Drinks alcohol, approximately 12 drinks per week. No history of intravenous drug or illicit drug use. He did serve in [Country 3992] in the past. PHYSICAL EXAMINATION: Well appearing, well nourished, appearing stated age. Vital signs: Temperature 98.1, heart rate 60, blood pressure 144/88, respiratory rate 17. HEENT: Extraocular muscles intact; pupils equal, round, reactive to light and accommodation; anicteric sclerae. Tongue and uvula midline. No nystagmus. Neck: Supple; no lymphadenopathy. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm; normal S1, S2. Abdomen: Soft, nontender, nondistended; positive bowel sounds; no hepatosplenomegaly. There is no clubbing, cyanosis; full range of motion; 2+ distal pulses. Neurologic: Cranial nerves II-XII intact; alert and oriented times three; 5/5 strength in the upper and lower extremities; finger-to-nose testing within normal limits; mildly unsteady gait; negative Romberg. Mental status: Alert and oriented times three; difficulty with serial 7s; [12-29] item short-term recall; long-term distant memory intact. Skin: Without rash or lesions. LABORATORY DATA ON ADMISSION: White count 95,000, 7% neutrophils, 0% bands, 91% lymphocytes, 2% monocytes, 0% eosinophils, 0% basophils, 0% atypicals, metamyelocytes. Hematocrit 37.7, platelet count 211. Electrolytes: Sodium 137, potassium 4.0, chloride 101, bicarbonate 27, BUN 21, creatinine 0.8, glucose of 166. Liver function tests within normal limits on presentation. Lumbar puncture from outside hospital on [2122-12-6]: Gram stain showed no micro-organisms, 4+ lymphocytes. Cell count from lumbar puncture 560 red blood cells, 46 nucleated cells, 97% lymphocytes. Protein 68, glucose 117. CT of the head at outside hospital: Right temporoparietal enhancing density with minimal surrounding edema. MRI of the head [2121-12-5] from [Hospital 4415]: Abnormal signal in the region of the corpus callosum extending into the subependymal region and involving the fornix. HOSPITAL COURSE: 1. Brain mass: The etiology of the brain mass was unclear at the time of presentation. Although the patient does have a history of chronic lymphocytic leukemia, it rarely presents in this manner. Therefore, other possibilities such as infection, a new primary malignancy, a metastasis, or perhaps a demyelinating process, were considered in the differential. Neurosurgical consultation was obtained on the day of presentation. Also, the neuro-oncologist was consulted for further recommendations. Human immunodeficiency virus testing, toxoplasmosis, and cryptococcus testing was initiated shortly after admission, all of which came back negative. Decadron was continued initially but then was stopped on [2122-12-8] out of concerns that steroid administration prior to the biopsy could interfere with the biopsy results. Due to scheduling difficulties the brain biopsy was delayed until [2122-12-9], at which time patient underwent stereotactic brain biopsy completed by Dr. [First Name (STitle) ] without complication. Patient had subsequent neuro checks q. 6 hours, and his Decadron and insulin sliding scale were restarted. At the time of discharge the patient's brain biopsy results were pending. He was discharged on a course of Decadron with instructions to follow up with Dr. [First Name (STitle) 1557] the following Monday to review the pathology. 2. Infectious Disease: An infectious cause of the patient's new brain mass was considered. The patient did have HIV serology testing upon presentation which did come back negative. Cryptococcal and toxoplasmosis testing also was negative. An infectious cause was largely ruled out at the time of discharge. 3. Cardiovascular: Patient continued Lipitor for history of hyperlipidemia. 4. Endocrine: While on a course of Decadron the patient was on a regular insulin sliding scale for blood sugar control. 5. Neurology: On presentation the patient had no focal neuro deficits but did have some difficulty on mental status examination especially in regard to short-term memory and mild cognitive deficits. These symptoms did improve during his hospital stay. At the time of discharge he was neurologically intact with a steady gait and had a markedly improved mental status exam. Patient was discharged on a course of Decadron 6 mg p.o. q.i.d. to address edema associated with his brain mass. DISCHARGE CONDITION: Hemodynamically stable, afebrile, alert and oriented times three, ambulating without difficulty, improved mental status exam. DISPOSITION: To home with supervision from family member or friend for the next 24 to 48 hours. DISCHARGE DIAGNOSES: 1. Brain mass. 2. Chronic lymphocytic leukemia. 3. Hyperlipidemia. DISCHARGE MEDICATIONS: 1. Acetaminophen 325 mg, one to two tablets, p.o. q. 4 to 6 hours as needed for pain. 2. Dexamethasone 4 mg, one tablet, p.o. q. 6 hours. 3. Lipitor 10 mg, one tablet, p.o. q.d. DISCHARGE INSTRUCTIONS: 1. The patient was advised to contact Dr.[Name (NI) 6168] office to schedule an appointment for Monday, [2122-12-14]. He was advised to discuss the length of course of his Dexamethasone medication. 2. Patient was advised to schedule a follow-up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of Neurosurgery in one week to be evaluated and to have staples from the brain biopsy site removed. 3. Patient was advised to abstain from taking a bath for two weeks. Avoid taking a shower for 48 hours. Keep the are of the incision dry. DR.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557], M.D. Dictated By:[Last Name (NamePattern1) 1615] MEDQUIST36 D: [2123-1-16] 18:20 T: [2123-1-17] 14:05 JOB#: [Job Number 10909]	[ "2720" ]
Admission Date: [2167-5-21] Discharge Date: [2167-5-29] Date of Birth: [2108-9-15] Sex: F Service: SURGERY Allergies: Codeine / Ampicillin / Tetracycline / Lactose Attending:[First Name3 (LF) 148] Chief Complaint: 1. Severe left-sided hydronephrosis 2. Chronic pancreatitis Major Surgical or Invasive Procedure: [2167-5-21]: 1. Distal pancreatectomy with splenectomy. 2. Left nephrectomy History of Present Illness: Ms. [Known lastname ] is a 58-year-old woman who has a recent history of pancreatitis. She was treated with laparoscopic cholecystectomy a number of months ago. She seems to have been floundering for 4 or 5 months since then with failure to thrive. She has had fevers and chills as well as poor p.o. intake, nausea and occasional vomiting. She was worked up and found to have an usual mass in the distal tail of the pancreas in the setting of a prior gallstone pancreatitis problem. [Name (NI) ] this most likely represented focal effects of pancreatitis this was not certain for sure. An endoscopic ultrasound was performed of this lesion and a mass was found which was irregular. It was biopsied and found to be atypical. Furthermore, she had a very large obstructed left kidney from a prior operation on that organ. This was recently drained in that it was 20 cm in size and basically nonfunctional from chronic atrophy. This was drained with a percutaneous nephrostomy tube. Past Medical History: PAST MEDICAL HISTORY: Pancreatitis, hypertension, GERD, chronic kidney disease (baseline creatinine 1.7), anemia. PAST SURGICAL HISTORY: Cholecystectomy [2167-1-19], left dismembered pyeloplasty, pilonidal cyst drainage. ALLERGIES: Codeine causes abdominal cramps Ampicillin causes rash Tetracycline causes nausea and vomiting Lactose intolerance. MEDICATIONS: Lisinopril, citalopram, oxazepam, Percocet, multivitamin, and iron. Social History: noncontributory Family History: noncontributory Physical Exam: On Discharge: VS: 99.9, 79, 172/76, 16, 96% RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: neck is not rigid CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: soft, normal tenderness along left subcostal incision. incision covered by steri strip and c/d/i. old Jp site with dry dressing c/d/i ext: no edema Pertinent Results: [2167-5-21] 06:23PM WBC-22.8# RBC-4.63# HGB-11.7# HCT-37.2# MCV-80* MCH-25.3* MCHC-31.4 RDW-16.5* [2167-5-21] 06:23PM GLUCOSE-195* UREA N-19 CREAT-1.5* SODIUM-138 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-19* ANION GAP-13 [2167-5-21] PATHOLOGY: Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 85938],[Known firstname 539] [2108-9-15] 58 Female [-9/2247] [Numeric Identifier 85939] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] GOODELL/mtd SPECIMEN SUBMITTED: Spleen and distal pancreas, Left Kidney. Procedure date Tissue received Report Date Diagnosed by [2167-5-21] [2167-5-22] [2167-5-26] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/ttl DIAGNOSIS: I. Distal pancreas and spleen, distal pancreatectomy (A-H): - Chronic pancreatitis with pseudocyst, extensive necrosis, and foreign body giant cell reaction, no malignancy identified. - Spleen, unremarkable. - Nine unremarkable lymph nodes. II. Left kidney, nephrectomy (I-P): - Diffuse acute and chronic interstitial nephritis with tubular atrophy, interstitial fibrosis consistent with chronic obstructive pyelonephritis. - Arteriosclerosis and focal glomerular sclerosis consistent with history of hypertension. [2167-5-23] EEG: IMPRESSION: This is an abnormal routine EEG due to a moderately slow and disorganized background consisting mostly of theta frequencies reaching up, at times, to 7 Hz. The patient was noted to have microblinks at times and there were no discharges associated with these. There were no areas of prominent focal slowing and there were no epileptiform features. Overall, this background is suggestive of a moderate encephalopathy. Amongst the most common causes of encephalopathy are metabolic derangements, medications, infection, and anoxia. [2167-5-23] EKG: Sinus tachycardia, rate 111. Otherwise, normal tracing. Compared to the previous tracing of [2167-5-5] normal sinus rhythm has given way to sinus tachycardia. [2167-5-23] HEAD CT: IMPRESSION: No evidence of acute intracranial abnormality. In case of clinical concern for acute infarction/ etiology of seizure, an MRI can be obtained if not contra-indicated. [2167-5-23] CHEST XRAY: Cardiomediastinal contours are normal. Aside from linear atelectasis in the left retrocardiac area, the lungs are clear. There is no pneumothorax or pleural effusion. NG tube tip is out of view below the diaphragm. Right IJ catheter tip is in the upper to mid SVC. [2167-5-27] 01:10PM BLOOD WBC-17.6* RBC-3.66* Hgb-10.3* Hct-31.2* MCV-85 MCH-28.1 MCHC-33.0 RDW-17.1* Plt Ct-401 [2167-5-27] 01:10PM BLOOD Glucose-97 UreaN-8 Creat-1.5* Na-134 K-3.6 Cl-95* HCO3-29 AnGap-14 [2167-5-27] 01:10PM BLOOD Calcium-8.6 Phos-4.7* Mg-1.7 Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment. On [2167-5-21], the patient underwent distal pancreatectomy with splenectomy and left nephrectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids and antibiotics, with a foley catheter, and Bupivacaine/Hydromorphone for pain control. The patient was hemodynamically stable. Neuro: The patient received Bupivacaine/Hydromorphone via epidural catheter with good effect and adequate pain control. On [2167-5-23] AM found to be unresponsive, on epidural was immediately stopped. She was given narcan 0.4 with minimal improvement. She was seen with fluttering eyes earlier which subsided. On exam she is unresponsive to verbal stimuli, she grimaces to noxious stimuli, she makes significant resistance against me opening her eyes, pupils are equal and reactive, normal doll's and corneal, she is hyperreflexic throughout. Patient was transferred into ICU, head CT was obtained and was normal. In ICU patient's metabolic derangements was corrected. Patient mental status improved on [5-24] to baseline. Patient stayed in ICU until [5-25] for observation, and remained stable. She was transferred back on the floor to continue postsurgical recovery and treatment. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: On [5-23] patient developed onset of tachycardia, which was corrected with Hydralazine. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced to clears on [5-24], which was well tolerated. Currently patient on regular diabetic diet and tolerated well. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Patient's Creatinine 1.4-1.8 within patient's baseline. Patient voiding without difficulties and independently. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Patient's WBC was 22.8 on admission and went up post operatively to max 30.8. Urine cultures were negative, blood cultures still pending. Patient remained afebrile during hospitalization. On discharge WBC was 17.6. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Lisinopril, citalopram, oxazepam, Percocet, MVI, and iron Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Ascorbic Acid 500 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for anxiety. Discharge Disposition: Home With Service Facility: CareGroup VNA Discharge Diagnosis: 1. Nonfunctional chronically obstructed left kidney with recent infection and a history of chronic pancreatitis, fibrotic atrophic left kidney. 2. 2.1. Pancreatic tail mass. 2.2. Chronic pancreatitis. 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 resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-27] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call your doctor or nurse practitioner if you experience the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 1231] Date/Time:[2167-6-12] 9:30 [Hospital Ward Name 23] 3, [Hospital Ward Name 516] . Please follow up with Dr. [Last Name (STitle) 11950] (PCP) in [1-21] weeks after discharge . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8941], MD Phone:[Telephone/Fax (1) 4537] Date/Time:[2167-6-12] 10:00 [Hospital Ward Name 23] 3, [Hospital Ward Name 516] Completed by:[2167-5-28]	[ "5180", "40390", "53081", "5859", "42789", "2859" ]
Admission Date: [2114-3-10] Discharge Date: [2114-3-21] Date of Birth: [2038-2-1] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2114-3-16] Coronary artery bypass graft x3 (left internal mammary artery > left anterior descending, Saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) and aortic valve replacement ( 25 mm [First Name8 (NamePattern2) ] [Male First Name (un) ] tissue valve) [2114-3-12] Cardiac catherization History of Present Illness: Mr. [Known lastname 81021] is a 76 year old male who presented to outside hospital on [3-8] for revision of left hip prosthesis and underwent surgery. He was doing well post-operatively, ambulated with physical therapy today without symptoms, however when he returned to bed he developed crushing substernal chest pain with radiation to bilateral arms and the back of his neck. He had never experienced pain like this before. It was associated with shortness of breath and diaphoresis. He did not have nausea. He was treated with nitro paste, morphine, aspirin, and IV metoprolol. He believes the morphine relieved the chest pain. CXR reportedly showed pulmonary vascular congestion. Labs returned with CK 771, Trop 3.63, Hct 27.7. He has been pain free since the original episode aside from a 20 second period of shortness of breath which occurred at 4PM and resolved on its own. He is transferred for further evaluation. Past Medical History: Hypertension Aortic stenosis Aortic insufficiency THR left [2107] - developed recurrent pain in [2111]. Failed medications, PT. THR right [2111] Degenerative joint disease benign prostatic hypertrophy Social History: Mr. [Known lastname 81022] social history is significant for the absence of current tobacco use. He quit smoking 50 years ago. He smokes an occasional cigar. There is no history of alcohol abuse. He drinks two times per week, two drinks at a time. He is a classical ballet dancer, teaches, and lives alone. Family History: Noncontributory Physical Exam: VS BP 112/61, HR 89, RR 12, O2sat 96% on 2L Gen: WDWN older 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 7cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [2-9] decrescendo diastolic murmur and [3-9] systolic ejection murmur. 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, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . 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: [2114-3-21] 04:38AM BLOOD WBC-10.4 Hct-29.5* Plt Ct-391 [2114-3-20] 04:30AM BLOOD PT-16.3* INR(PT)-1.5* [2114-3-21] 04:38AM BLOOD Glucose-109* UreaN-32* Creat-1.3* K-4.3 Cl-96 HCO3-30 [2114-3-17] 07:15PM BLOOD Glucose-125* Lactate-1.2 Na-130* K-5.1 Cl-100 Brief Hospital Course: Transferred from [Hospital6 ] after ruling in for non ST elevation myocardial infarction. He was found to have epitaxis with integrilin and ENT was consulted, nose was packed and no further occurence with intergrilin stopping. Was also noted to have hematoma at left hip and orthopedic surgery was consulted, it remained stable, required no surgical intervention and no evidence of sciatic nerve dysfunction. He underwent cardiac catheterization which demonstrated extensive three vessel disease as well as aortic stenosis. He underwent surgical evaluation for cardiac surgery. On [2114-3-16] he was brought to the operating room and underwent coronary artery bypass graft surgery and aortic valve replacement. See operative report for further details. He received vancomycin for perioperative antibiotics. He was transferred to the intensive care unit for hemodynamic monitoring. He required inotropes due to systolic heart failure but were weaned off in the first twenty four hours postoperatively. He was also weaned from sedation, awoke neurologically intact, and was extubated. He remained in the intensive care unit for hemodynamic monitoring, and had atrial fibrillation post operative day one at night, treated with betablockers and amidarone which after a few hours converted to normal sinus rhythm. He was transferred to the floor for the remainder of his care. He had intermittent episodes of atrial fibrillation and was started on coumadin for anticoagulation. On post-operative day three he was found to have a right forearm phlebitis. Further, there was a small amount of sero-sanguinous drainage from his mediastinal incision. He was placed on Vancomycin and ciprofloxacin. On the following day the sternal drainage abated. The forearm had improved, but because Mr. [Known lastname 81021] has a new aortic valve, a PICC was placed and a plan was set for 2 weeks of IV Vancomycin and oral ciprofloxacin. Vanco troughs should accordlingly be followd along with the progress of these wounds. On the Physical therapy worked with him on strength and mobility. He continued to progress and was ready for discharge to rehab on post operative day four. Medications on Admission: Multivitamin Lisinopril 10mg daily Terazosin 2mg daily Glucosamine plavix 75 mg daily, 300 mg on [3-10] ASA 325 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Terazosin 2 mg Capsule Sig: One (1) Capsule PO once a day. 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 2 weeks. 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. 11. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: or until at pre-op weight. 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 15. 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. 16. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: goal inr 2-2.5 for post-operative atrial fibrillation, resolved. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital 745] Health Care Center Discharge Diagnosis: Aortic stenosis s/p aortic valve replacement coronary artery disease s/p coronary artery bypass graft surgery Acute on chronic systolic heart failure Post operative atrial fibrillation Post operative - non ST elevation myocardial infarction at NEBH Epitaxis Hypertension degenerative joint disease benign prostatic hypertrophy s/p left hip revision [2114-3-8] at NEBH s/p left total hip repl. [2107] s/p right total hip repl. [2111] s/p left knee scope Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Monitor right arm phlebitic area for increasing redness or lack of improvement. Place warm packs to site four times per day. Complete 2 week course of intravenous Vancomycin and oral ciprofloxacin started on [2114-3-20]. Vanco troughs should be checked weekly. PICC in place, flush with normal saline two times per day. Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule all appointments Dr. [First Name (STitle) ] after discharge from rehab Dr. [First Name (STitle) 7049] after discharge from rehab Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] appointment - [4-18] at 1200 - ([Telephone/Fax (1) 81023] Labs: PT/INR for coumadin dosing - indication atrial fibrillation with goal INR 2.0-2.5 Completed by:[2114-3-21]	[ "41071", "9971", "4241", "41401", "4280", "42731", "4168", "4019" ]
Admission Date: [2189-7-21] Discharge Date: [2189-7-24] Date of Birth: [2126-5-23] Sex: F Service: MEDICINE Allergies: Hydrochlorothiazide / Sesame Oil Attending:[First Name3 (LF) 7333] Chief Complaint: Acute Cardiac Tamponade Major Surgical or Invasive Procedure: Pulmonary vein isolation Pericardiocentesis with drain placement Arterial line placement Blood transfusion - 1 unit packed red blood cells History of Present Illness: 63 yo F h/o HTN, PAF underwent PVI today and during procedure acutely developed hypotension with bradycardia in AF which ultimately lead to losing her pulse. CPR was initiated, with two rounds of epinephrine and one round of atropine. With immediate concern for acute cardiac tamponade, a blind pericardiocentesis was attempted, but did not illicit blood. A bed-side echo was performed which showed a large pericardial effusion with tonic compression of the right atrium and right ventricle. Pericardial drain was initiated and 700 cc of blood removed from pericardial space. Echo then confirmed no active bleeding. O2 sat on blood was c/w arterial saturation. A dopamine gtt was initiated with sbp >100. Patient was given protamine to reverse heparin and did not require any blood products. The right femoral vein sheeth was removed, but the left femoral vein line remained. An arterial line was placed. Patient was intubated for the procedure and ultimately extubated prior to transfer to the CCU. She was also given 1 gram of Ancef prior to transfer. . Upon admission to the CCU, initial vitals were: 97.3 66 20 95% on face mask, sbps in the 70s on dopamine. (initially at 8 mcg, however given acute decrease in sbp, dopamine was increased to 10 mcg and bp was >100.) Was also given 1.5 liter bolus of IVFs. She c/o [9-27] pleuritic chest pain. Given 30 mg IV toradol with minimal relief and IV morphine prn for further pain control. She also c/o nausea and vomited x 1. Resolved with IV zofran. . Patient has had a history of palpitations for several years, however, only recently diagnosed with paroxysmal atrial fibrillation in [2189-2-16]. At that time, she presented in sustained atrial fibrillation and DC cardioversion. She was started on Propafenone and then developed recurrent afib 8 weeks later. She returned for a second DC cardioversion. Then 3 weeks later she again developed recurrent atrial fibrillation and had another DC cardioversion in [Month (only) ]. She stopped Propafenone in [Month (only) ] and started Flecainide. She subsequently reverted back to afib on Flecainide and this was stopped in early [Month (only) 205] and started Amiodarone [2189-6-25]. She has had continued afib since [2189-6-14] and ultimately underwent PVI. . . On review of systems, s/he denies any prior history of, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: Hypertension Lacunar infarct: non-embolic per CT scan done in [2188-12-19] Osteoarthritis Infertility surgery Breast biopsy,lumpectomy (benign) C cection Cholecystectomy Knee arthroscopy Exploratory lapartomy/appendectomy Social History: Married. Works part time as a physical therapist. ETOH: Denies Tobacco: Denies Illicit drugs: none Family History: Father died of an MI in his 60s. Mother died of renal failure in her 80s. Brother with diabetes. 2nd Brother had diabetes and died of lung cancer. One sister who has palpitations. Physical Exam: Discharge Physical Exam Afebrile, vital signs stable GENERAL: middle aged female, no acute distress, comfortable HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with no JVD appreciated. CARDIAC: PMI located in 5th intercostal space, midclavicular line. IIRR, normal S1, S2. slight 2 component rub appreciated. No thrills, lifts. No S3 or S4. Pericardial drain site bandaged, c/d/i. 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. + bowel sounds EXTREMITIES: No c/c/e. No femoral bruits. no hematomas, induration, no back tenderness. minimal tenderness to deep palpation at left femoral cath site. 2+ DP/PT pulses bilaterally Pertinent Results: [2189-7-21] 10:30AM BLOOD WBC-5.2 RBC-4.48 Hgb-13.7 Hct-40.1 MCV-90 MCH-30.6 MCHC-34.2 RDW-13.5 Plt Ct-213 [2189-7-21] 04:50PM BLOOD Hct-34.7* [2189-7-21] 06:10PM BLOOD WBC-16.7# RBC-4.12 Hgb-12.5 Hct-37.7 MCV-92 MCH-30.4 MCHC-33.2 RDW-13.4 Plt Ct-237 [2189-7-21] 11:00PM BLOOD Hct-35.9* [2189-7-22] 03:49AM BLOOD WBC-8.5 RBC-3.82* Hgb-11.7* Hct-34.8* MCV-91 MCH-30.5 MCHC-33.5 RDW-13.5 Plt Ct-223 [2189-7-23] 05:19AM BLOOD WBC-10.0 RBC-2.67# Hgb-8.3# Hct-24.2# MCV-91 MCH-31.1 MCHC-34.4 RDW-13.5 Plt Ct-160 [2189-7-23] 08:10AM BLOOD Hct-23.3 [2189-7-23] 02:37PM BLOOD WBC-9.6 RBC-2.99* Hgb-9.3* Hct-27.3* MCV-91 MCH-31.2 MCHC-34.2 RDW-14.2 Plt Ct-169 [2189-7-24] 05:40AM BLOOD WBC-7.4 RBC-2.82* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.4 MCHC-33.5 RDW-14.2 Plt Ct-163 [2189-7-24] 10:33AM BLOOD Hct-26.2* [2189-7-21] 10:30AM BLOOD PT-33.0* PTT-32.0 INR(PT)-3.3* [2189-7-21] 06:10PM BLOOD PT-34.5* PTT-40.6* INR(PT)-3.5* [2189-7-22] 03:49AM BLOOD PT-31.9* PTT-37.0* INR(PT)-3.2* [2189-7-23] 05:19AM BLOOD PT-39.0* PTT-36.5* INR(PT)-4.1* [2189-7-24] 05:40AM BLOOD PT-26.3* INR(PT)-2.5* [2189-7-21] 10:30AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-141 K-4.0 Cl-103 HCO3-31 AnGap-11 [2189-7-21] 06:10PM BLOOD Glucose-162* UreaN-12 Creat-0.9 Na-145 K-4.0 Cl-110* HCO3-25 AnGap-14 [2189-7-23] 05:19AM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-137 K-3.8 Cl-108 HCO3-25 AnGap-8 [2189-7-24] 05:40AM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-139 K-4.1 Cl-108 HCO3-27 AnGap-8 [2189-7-21] 06:10PM BLOOD CK(CPK)-90 [2189-7-23] 05:19AM BLOOD ALT-58* AST-31 LD(LDH)-183 AlkPhos-55 TotBili-0.3 [2189-7-21] 06:10PM BLOOD CK-MB-6 cTropnT-0.24* [2189-7-21] 06:10PM BLOOD Calcium-8.0* Phos-3.6 Mg-1.9 [2189-7-21] 06:10PM BLOOD Calcium-8.0* Phos-3.6 Mg-1.9 [2189-7-22] 03:49AM BLOOD Calcium-7.5* Phos-3.3 Mg-2.5 [2189-7-23] 05:19AM BLOOD Albumin-2.8* Calcium-7.1* Phos-2.5* Mg-2.1 [2189-7-24] 05:40AM BLOOD Calcium-7.6* Phos-1.8* Mg-2.1 MRSA SCREEN (Final [2189-7-24]): No MRSA isolated. Echo [7-21]: pre-pericardiocentesis: large pericardial effusion with tonic compression of the right atrium and right ventricle post-pericardiocentesis: no residual pericardial effusion [7-22]: The left atrium is dilated. The right atrium is dilated. 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 effusion appears loculated. A catheter is seen in the pericardial space. There are no echocardiographic signs of tamponade. IMPRESSION: Two small pockets of pericardial fluid are seen behind the left and right atria. No echo signs of tamponade. Normal biventricular systolic function. Compared with the prior study (images reviewed) of [2189-7-21], the findings are similar to the post-procedure images from that study EKG [7-21]: Atrial fibrillation. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [2189-7-13] findings are similar. [7-21]: Atrial fibrillation. Diffuse non-specific ST-T wave changes. Compared to tracing #1 there is no change. [7-22]: Atrial fibrillation with rapid ventricular response. Diffuse non-specific ST-T wave changes, particularly in the anterior leads, may be due to myocardial ischemia. Clinical correlation is suggested. Compared to tracing #2 the rate is increased and the ST-T wave changes are more accentuated on the currenttracing although this may reflect the higher rate rather than an ischemic process CXR [7-21]: COMPARISON: No comparison available at the time of dictation. FINDINGS: Mildly enlarged cardiac silhouette with drain in situ. Mild blunting of the left costophrenic sinus, potentially suggesting a small left pleural effusion. Mild retrocardiac atelectasis. No focal parenchymal opacity suggesting pneumonia. No evidence of pneumothorax. Brief Hospital Course: 63 yo F h/o recently diagnosed PAF s/p DCCV x3 and failed propefenone and flecainide, currently on amiodarone and s/p PVI today c/b acute cardiac tamponade leading to hemodynamic compromise on dopamine s/p percardial drain. # Cardiac Tamponade - During the patient's PVI, she became hypotensive due to acute cardiac tamponade. She was pulseless for a short period and underwent chest compressions as well as 2 rounds of epinephrine and 1 dose of atropine. A pericardiocentesis with pericardial drain was performed with immediate return of ~700cc of oxygenated blood and return of pulse. The patient was started on dopamine and transported to the CCU for monitoring. Pulsus paradoxus was monitored with an arterial line and was < 12. Overnight, the drain put out 45cc of fluid, so the drain was pulled the following morning. The dopamine was able to be discontinued the following afternoon and blood pressures remained stable with IVF hydration, with SBP in the 100s-110s. Her Hct was followed and she was noted to have a 10 point Hct drop overnight. This was thought to be primarily dilutional as the day before, she received 5.5L of IV fluids. She received 1 unit of PRBC and had an appropriate increase in Hct. Her repeat hematocrit checks were stable and she needed no more transfusions. She received 2 days of antibiotic prophylaxis with Ancef for her lines. Her metoprolol and dilitazem were held as her pressure and rates were controlled and did not require addition of more agents at the time of discharge. She had follow-up appointments made with her outpatient cardiologist on [Last Name (LF) 766], [7-27] and her PCP on Wednesday, [7-29]. Dr.[Name (NI) 29750] office was to get back with her regarding EP follow-up. She was also instructed to have a hematocrit checked on [7-27]. # Atrial fibrillation - The PVI was not able to be completed due to the tamponade. She remained in atrial fibrillation during the hospitalization. She was restarted on amiodarone and a lower dose of digoxin. Her heart rates were ranging from 90-115 on those medications. She was evaluated by physical therapy and her heart rate did not increase while she was walking. She was not started on her home metoprolol or diltiazem per Electrophysiology recommendations. Her coumadin was held as her INR was elevated. She was instructed to restart her coumadin at 2.5mg daily, and to have an INR checked on [7-27], then to continue her coumadin per her cardiologist recommendations. # Chest pain - The patient did complain of sternal chest pain after being admitted to the CCU. Her pain was initially controlled with IV morphine; she was then started on indomethacin 25mg TID for 7 days for post-tamponade pericarditis. She also developed left sided pleuritic chest pain which improved greatly by the day of discharge and was also controlled with indomethacin. Medications on Admission: Amiodarone 200 mg [Hospital1 ] Digoxin 250 mcg daily (PM) Diltiazem 240 mg daily (AM) Metoprolol succinate 100 mg [Hospital1 ] Coumadin 2.5 mg MWF, 5 mg all other days Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO three times a day for 5 days. Disp:15 Capsule(s) Refills:0 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Outpatient Lab Work Please draw INR and Hematocrit. Have results faxed to Dr. [Last Name (STitle) ] and to Dr. [Last Name (STitle) 3321]. 5. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Please take until your INR check on [7-27], then take as directed by your cardiologist. Discharge Disposition: Home Discharge Diagnosis: Primary: Cardiac tamponade, atrial fibrillation Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 20296], It was a pleasure taking care of you during your hospitalization. You were admitted to undergo a Pulmonary Vein Isolation, a procedure to treat your atrial fibrillation. During the procedure, you had blood fill the sac the heart sits in, which made it difficult for your heart to beat. You had CPR performed which kept blood moving through your body. A catheter was placed in the sac and drained the blood which relieved the pressure around your heart. You were started on a medication, dopamine, that helps increase blood pressure and were monitored in the Cardiac Care Unit. We were able to stop the dopamine and your blood pressure remained stable. Your blood levels were decreased so we gave you a blood transfusion. This was likely because of you getting fluids through your IV that diluted your blood. The physical therapists saw you and cleared you to go home. We CHANGED two medications: --> decreased your Digoxin to 125mcg by mouth once a day --> decreased your Coumadin to 2.5 mg by mouth daily --> Please have your INR checked on [Known lastname 766] [7-27] and then take your coumadin as instructed by your cardiologist. We ADDED one medication: Indomethacin 25mg by mouth three times a day for 5 days We STOPPED two medications: --> Metoprolol --> Diltiazem These medications were stopped per EP recommendations as your heart rate was fairly controlled, ranging from 90-120. Please follow up with your scheduled appointments. If you have any concerns this weekend, you can call Dr. [Name (NI) 71181] office to reach the covering physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Dr.[Name (NI) 29750] office number is [Telephone/Fax (1) 1536]. Followup Instructions: Dr.[Name (NI) 29750] office will call you on [Name (NI) 766] to schedule your follow-up appointment. If you don't hear back from them, please call his office at [Telephone/Fax (1) 1536]. Please follow-up with Dr. [Last Name (STitle) ] on [Last Name (LF) 766], [7-27] at 10:45am. Please follow-up with Dr. [Last Name (STitle) 3321] on Wednesday, [7-29] at 9:15am. Completed by:[2189-7-26]	[ "42731", "9971", "4019" ]
Admission Date: [2110-6-19] Discharge Date: [2110-6-28] Date of Birth: [2063-6-19] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 12174] Chief Complaint: CHIEF COMPLAINT: transfer for hepatic encephalopathy Major Surgical or Invasive Procedure: EGD with 2 bands placed IR guided paracentesis History of Present Illness: Mr. [Known lastname ] is a 46 y/o male with ETOH cirrhosis, previous hepatitis C infection with spontaneous clearance in [2109] (recent HCV VL undetectable), polysubstance abuse with a one-year abstinence per notes who is transferred from OSH with acute kidney injury, ascites, and acute encephalopathy. He initially presented in liver decompensation with variceal bleeding, ascites, and encephalopathy in [2109-6-2], and recently established care with the transplant center in [2110-5-4]. His endoscopies have shown isolated gastric varices and esophageal varices (grade II) which have been banded x 3. Of note, in [2110-5-4] while establishing care at our liver center, he was on lasix and aldactone for ascites. His Cr was normal at 0.6 at that time. He has also had h/o three large volume paracentesis, partly felt to be due to poor compliance with low salt diet. At that time, he had mild hepatic encephalopathy and was on lactulose, having [4-6] BM per day. He has a long history of alcohol and substance abuse- having consumed 1 bottle of vodka daily for many years before stopping last [Month (only) 116] upon his diagnosis of cirrhosis. He has used prescription drugs, heroin, and methadone in the past, though has been clean for a year. He is enrolled in AA. Patient is currently transferred from [Hospital ] hospital. Per Dr [First Name (STitle) 3636] (pager [Telephone/Fax (1) 110689]), patient presented the night of [6-17] with dizziness, hepatic encephalopathy, abdominal pain, n/v and [Last Name (un) ]. She reports that he has not had a bowel movement in "a day or so" and he was given lactulose X5 yesterday and only had 1 BM. Per d/w patient's fiancee, he had been having abdominal pain, nausea, and bilious vomiting 2 days PTA. 1 week PTA patient did have tooth infection and was given amoxicillin as well as motrin. He has been taking motrin 1x per day. Fiancee reported that he has been adherent to medications and denied dietary indiscretion. He has been taking aldactone 200 mg 2x/day and lasix 80 mg qAM and 40 mg qPM at home prior to admission. He has had 5 admissions at RIH in past 2 mo for liver decompensation. Also, at RIH, renal was consulted and felt that [Last Name (un) ] was pre-renal in etiology given FEurea 12.39%. He was started on IVF and diuretics were held. On [6-18], he underwent diagnostic and therapeutic 5L paracentesis. This did not show SBP. RUQ and RUS were performed, with results showing, "cirrhosis, portal htn, reversal of portal venous flow, varices, and splenomegaly, mild to moderate residual ascites s/p paracentesis, kidneys without hydronephrosis." Lactulose was unable to be given on date of transfer and was held due to AMS. NGT was reportedly unsuccessful due to AMS. On transfer, he is arousable but combative and they have started lactulose enema's in order to prevention aspiration. Creat was 4.35. No other labs available due to poor access, but T-bili 2.8, INR 1.5, Creat 4.35. Of note, pt is in the transplant evaluation process. On the floor, patient is acutely agitated and without PIV access. He is not oriented to self or place. ROS: unable to be obtained [3-6] acute hepatic encephalopathy. Past Medical History: 1. Right knee surgery almost 15 years ago. 2. Hypertension. 3. ETOH Cirrhsosis, c/b varices, encephalopathy, and ascites requiring recurrent large-volume paracenteses 4. Grade II esophageal varices, grade I gastric varices, portal gastropathy 5. History of hepatitis C, which cleared spontaneously. 6. Variceal UGIB [12/2109] s/p banding x 3 7. Hx of IVDU 8. Recurrent pancreatitis Social History: He lives alone. He has a fiancee who checks on him every day. Mom is the HCP. The patient has one son. [Name (NI) ] is unemployed applying for disability. He used to work as salesperson. He has VNA three times a week. He has past history of drug use such as Percocet and OxyContin nonprescribed as well as methadone. He also used IV heroin in the past. He has been clean from drugs for over a year per notes. He smokes cigarettes almost one-half pack per day. Family History: Negative for liver cancer, GI cancer or liver Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.2, 125/80, 71, 16, 99 RA, BG 184 GENERAL: agitated male, looks older than stated age, in restraints, not oriented to self or place HEENT: mild scleral icterus. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, S1 S2 without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: moderately distended but soft, umbilical hernia present which is reducible, non-tender to palpation, mild to moderate ascites, hepatomegaly appreciated [3-7] fingerbreaths below costal margin, ? splenomegaly, spider angiomas present EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. Minimal non-pitting LE edema bilaterally. NEURO: patient not cooperative with exam, in restraints, agitated, not oriented to self or place, not following commands, asterixis unable to be tested DISCHARGE PHYSICAL EXAM: VS: 98.3 110/75 75 20 97%RA GENERAL: Sitting up in bed, appropriate, NAD. AOx3 HEENT: NC/AT, mild scleral icterus. NECK: L IJ in place CARDIAC: PMI located in 5th intercostal space, midclavicular line. regular rate, S1, S2 without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB without crackles, wheezes or rhonchi. ABDOMEN: Moderately distended but soft, umbilical hernia present which is reducible, nontender, hepatomegaly appreciated [3-7] fingerbreaths below costal margin, spider angiomas present. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. NEURO: A&Ox3, no asterixis Pertinent Results: [2110-6-19] 08:55PM BLOOD WBC-5.1 RBC-3.61* Hgb-12.0* Hct-36.5* MCV-101* MCH-33.3* MCHC-32.9 RDW-13.8 Plt Ct-106* [2110-6-20] 09:00AM BLOOD WBC-4.6 RBC-3.39* Hgb-10.9* Hct-34.1* MCV-101* MCH-32.3* MCHC-32.1 RDW-13.7 Plt Ct-105* [2110-6-21] 05:55AM BLOOD WBC-5.0 RBC-3.62* Hgb-12.3* Hct-36.3* MCV-100* MCH-33.9* MCHC-33.8 RDW-13.7 Plt Ct-108* [2110-6-22] 05:10AM BLOOD WBC-11.1# RBC-3.62 Hgb-12.2* Hct-37.3* MCV-103* MCH-33.7* MCHC-32.7 RDW-14.0 Plt Ct-97* [2110-6-22] 05:01PM BLOOD WBC-9.1 RBC-3.05* Hgb-10.3* Hct-31.0* MCV-102* MCH-33.8* MCHC-33.3 RDW-14.1 Plt Ct-93* [2110-6-22] 09:00PM BLOOD WBC-8.1 RBC-3.40* Hgb-11.4* Hct-34.3* MCV-101* MCH-33.7* MCHC-33.4 RDW-14.8 Plt Ct-80* [2110-6-23] 02:01AM BLOOD WBC-7.2 RBC-3.20* Hgb-10.7* Hct-31.9* MCV-100* MCH-33.5* MCHC-33.5 RDW-15.2 Plt Ct-80* [2110-6-23] 08:22AM BLOOD WBC-7.7 RBC-3.23* Hgb-11.0* Hct-32.3* MCV-100* MCH-34.0* MCHC-34.0 RDW-15.3 Plt Ct-78* [2110-6-23] 05:00PM BLOOD WBC-7.7 RBC-3.23* Hgb-10.7* Hct-31.8* MCV-99* MCH-33.0* MCHC-33.5 RDW-15.1 Plt Ct-83* [2110-6-24] 12:30AM BLOOD WBC-6.4 RBC-3.23* Hgb-10.8* Hct-32.3* MCV-100* MCH-33.3* MCHC-33.3 RDW-15.9* Plt Ct-75* [2110-6-24] 04:00AM BLOOD WBC-6.3 RBC-3.06* Hgb-10.2* Hct-30.4* MCV-99* MCH-33.4* MCHC-33.6 RDW-15.8* Plt Ct-85* [2110-6-24] 03:50PM BLOOD WBC-6.3 RBC-3.20* Hgb-10.7* Hct-31.9* MCV-100* MCH-33.4* MCHC-33.4 RDW-15.8* Plt Ct-92* [2110-6-25] 05:00AM BLOOD WBC-4.7 RBC-3.08* Hgb-10.0* Hct-30.7* MCV-100* MCH-32.6* MCHC-32.7 RDW-16.0* Plt Ct-88* [2110-6-26] 03:45AM BLOOD WBC-8.1# RBC-3.37* Hgb-11.3* Hct-34.9* MCV-104* MCH-33.6* MCHC-32.4 RDW-17.0* Plt Ct-99* [2110-6-28] 04:58AM BLOOD WBC-6.0 RBC-3.30* Hgb-10.9* Hct-33.0* MCV-100* MCH-33.2* MCHC-33.2 RDW-16.8* Plt Ct-88* [2110-6-19] 08:55PM BLOOD PT-16.5* INR(PT)-1.6* [2110-6-20] 09:00AM BLOOD PT-19.2* PTT-37.2* INR(PT)-1.8* [2110-6-21] 05:55AM BLOOD PT-18.1* PTT-38.2* INR(PT)-1.7* [2110-6-22] 05:10AM BLOOD PT-22.4* PTT-38.9* INR(PT)-2.1* [2110-6-22] 05:01PM BLOOD PT-24.7* PTT-60.8* INR(PT)-2.4* [2110-6-23] 02:01AM BLOOD PT-21.1* PTT-44.7* INR(PT)-2.0* [2110-6-25] 05:00AM BLOOD PT-25.5* PTT-59.3* INR(PT)-2.4* [2110-6-26] 03:45AM BLOOD PT-23.9* INR(PT)-2.3* [2110-6-27] 05:20AM BLOOD PT-23.0* PTT-47.3* INR(PT)-2.2* [2110-6-28] 04:58AM BLOOD PT-21.6* PTT-42.2* INR(PT)-2.1* [2110-6-19] 08:55PM BLOOD Glucose-99 UreaN-32* Creat-1.7* Na-136 K-4.6 Cl-102 HCO3-21* AnGap-18 [2110-6-20] 09:00AM BLOOD Glucose-120* UreaN-32* Creat-1.7* Na-141 K-4.5 Cl-104 HCO3-23 AnGap-19 [2110-6-21] 05:55AM BLOOD Glucose-113* UreaN-27* Creat-1.3* Na-143 K-4.1 Cl-109* HCO3-21* AnGap-17 [2110-6-22] 05:10AM BLOOD Glucose-164* UreaN-30* Creat-1.2 Na-139 K-4.0 Cl-104 HCO3-18* AnGap-21* [2110-6-22] 05:01PM BLOOD Glucose-114* UreaN-29* Creat-0.9 Na-140 K-4.1 Cl-108 HCO3-19* AnGap-17 [2110-6-23] 02:01AM BLOOD Glucose-116* UreaN-23* Creat-0.9 Na-139 K-3.7 Cl-103 HCO3-21* AnGap-19 [2110-6-24] 04:00AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-137 K-3.4 Cl-103 HCO3-23 AnGap-14 [2110-6-25] 05:00AM BLOOD Glucose-103* UreaN-15 Creat-0.9 Na-136 K-3.2* Cl-99 HCO3-25 AnGap-15 [2110-6-26] 03:45AM BLOOD Glucose-115* UreaN-16 Creat-1.1 Na-137 K-3.6 Cl-102 HCO3-16* AnGap-23* [2110-6-27] 05:20AM BLOOD Glucose-99 UreaN-14 Creat-1.0 Na-136 K-3.5 Cl-100 HCO3-23 AnGap-17 [2110-6-28] 04:58AM BLOOD Glucose-93 UreaN-12 Creat-0.8 Na-135 K-3.7 Cl-97 HCO3-23 AnGap-19 [2110-6-19] 08:55PM BLOOD ALT-30 AST-49* LD(LDH)-240 AlkPhos-87 TotBili-3.5* [2110-6-20] 09:00AM BLOOD ALT-29 AST-44* AlkPhos-71 TotBili-4.2* [2110-6-21] 05:55AM BLOOD ALT-29 AST-46* AlkPhos-77 TotBili-4.3* [2110-6-22] 05:10AM BLOOD ALT-27 AST-39 AlkPhos-63 TotBili-4.6* [2110-6-23] 02:01AM BLOOD ALT-24 AST-34 LD(LDH)-185 AlkPhos-52 TotBili-7.3* DirBili-2.1* IndBili-5.2 [2110-6-24] 04:00AM BLOOD ALT-22 AST-33 LD(LDH)-174 TotBili-5.7* [2110-6-25] 05:00AM BLOOD ALT-22 AST-34 AlkPhos-56 TotBili-4.9* [2110-6-26] 03:45AM BLOOD ALT-23 AST-38 LD(LDH)-210 CK(CPK)-42* AlkPhos-65 TotBili-4.3* [2110-6-27] 05:20AM BLOOD ALT-24 AST-40 LD(LDH)-201 AlkPhos-69 TotBili-4.2* [2110-6-28] 04:58AM BLOOD ALT-28 AST-44* AlkPhos-81 TotBili-3.9* [2110-6-22] 05:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2110-6-22] 05:10AM BLOOD CEA-5.9* [2110-6-28] 04:58AM BLOOD HIV Ab-NEGATIVE [2110-6-22] 05:10AM BLOOD HCV Ab-POSITIVE* [2110-6-22] 05:14PM BLOOD Lactate-3.1* [2110-6-22] 09:12PM BLOOD Lactate-2.9* [2110-6-23] 02:30AM BLOOD Lactate-2.2* [2110-6-26] 04:01AM BLOOD Lactate-10.6* [2110-6-26] 09:42AM BLOOD Lactate-1.7 [2110-6-22] 05:10AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name [2110-6-19] 11:58PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [2110-6-26] 06:10AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2110-6-19] 11:58PM URINE RBC-6* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 [2110-6-19] 11:58PM URINE Hours-RANDOM UreaN-862 Creat-148 Na-30 K-45 Cl-12 [2110-6-19] 11:58PM URINE Osmolal-520 [2110-6-23] 04:30PM ASCITES WBC-160* RBC-790* Polys-35* Lymphs-8* Monos-0 Mesothe-2* Macroph-55* [2110-6-23] 04:30PM ASCITES TotPro-1.3 Glucose-131 LD(LDH)-71 Amylase-10 TotBili-1.2 Albumin-1.0 KUB [6-20]: IMPRESSION: Nonspecific bowel gas pattern with mild small bowel dilation. Early or partial obstruction cannot be excluded. RUQ U/S [6-20]: IMPRESSION: Cirrhosis with findings of portal hypertension. Reversal of flow within the left portal vein and antegrade flow within the main portal vein. KUB [6-22]: IMPRESSION: Supine and left decubitus views show there is no pneumoperitoneum. However moderate generalized distention of large and small bowel has progressed since [6-20], and appreciable wall thickening particularly in the transverse colon and in small bowel loops in the left lower abdomen is new. This is not a pattern of obstruction, but of ileus and requires careful attention for the possible contribution of ischemia. CT Abdomen [6-22]: IMPRESSION: 1. Diffuse small bowel wall thickening and dilation most likely secondary to ascites, portal hypertension, and hypoalbuminemia. There is no evidence of small-bowel obstruction. 2. There is no flow within the intrahepatic portal veins, despite adequacy of bolus timing. Doppler ultrasound from two days ago did show flow in the intra-hepatic branches (reversed on the left), but the waveforms were not robust. Further evaluation is recommended with multi-phasic CT or abdominal MRI to confirm the suspicion of portal vein thrombosis 3. Nodular liver contour, extensive splenic and esophageal varices consistent with cirrhosis and portal hypertension. CXR [6-26]: FINDINGS: As compared to the previous radiograph, there is no relevant change. Low lung volumes. Normal size of the cardiac silhouette. Normal hilar and mediastinal structures. No pleural effusions. No pneumonia, but areas of atelectasis at the left lung base. No pneumothorax. The monitoring and support devices are constant. CT Head [6-26]: IMPRESSION: No acute intracranial hemorrhage or mass effect. Correlate clinically to decide on the need for further workup. CT Neck [6-26]: IMPRESSION: 1. No acute cervical spine fracture. No canal or foraminal stenosis. Correlate clinically to decide on the need for further workup. 2. A 2.1x1.8cm mass lesion in right parotid- ? node/neoplasm-correlate with ultrasound/soft tissue MRI neck on a non-emergent basis. Brief Hospital Course: 46 y/o male with ETOH cirrhosis, previous hepatitis C infection with spontaneous clearance in [2109] (recent HCV VL undetectable), polysubstance abuse with a one-year abstinence per notes, who is transferred from OSH with acute encephalopathy, acute kidney injury, and ascites. On [6-22] had tachycardia and hematochezia/[Hospital 58799] transferred to the MICU and found with portal gastropathy/duodenopathy and esophageal varices which were banded. Stablized and transferred from the unit. On [6-25], the patient had a fall from a likely seizure with elevated lactate to 10 and transferred to the MICU. Again, he was stabilized in the ICU and called out to the floor on [6-26], without any change in his previous management. # Seizure: On [6-26] patient was witnessed to fall by roommate with associated convulsions and bowel incontinence. The patient was post-ictal afterwards and had an elevated lactate to 10, which downtrended back to 1 prior to discharge. He had a normal head CT and neck (only small parotid gland mass noted). Neuro was consulted who recommended 24 hour EEG, which by report showed no epileptiform activity however final read is pending at the time of discharge. The patient has report of seizure-like activity by fiance in the past when withdrawing from alcohol, but otherwise has no seizure history. Neurology ultimately recommended outpatient MRI of the brain to rule out intracranial mass and felt that there was no indication for AEDs at this time. # Upper GIB: On [6-22] was noted to be sinus tachycardic to 120-130 with hematochezia, transferred to the unit for emergent EGD. Bleed likely [3-6] esophageal varices (3 cords of grade II varices) and severe portal gastropathy/duodenopathy. Varices banded x2. Placed on octreotide gtt with transition to nadolol upon discharge. HCTs stable after 2u PRBC and 2u FFP till time of discharge without any further episodes of hematemesis or hematochezia. # Hepatic encephalopathy: Transferred from [Hospital 792]Hospital for dense encephalopathy and acute renal failure. Attempt was made to clear the patient with PO lactulose however this produced no effect. On admission here it was felt that the patient's distended abdomen and nausea/vomiting to any PO was consistent with an obstructive process, so KUB was performed which showed a likely small bowel ileus. The encephalopathy was managed with PR lactulose initially with some clearing of mental status. Eventually when ileus resolved was switched to PO lactulose with good effect and had stable normal mental status upon discharge. # Acute renal failure: Resolved after albumin resuscitation. Cr reportedly 4.35 at RIH. Renal was consulted and felt that [Last Name (un) ] was pre-renal in etiology given FEurea 12.39%. RUS was without obstruction and no hydronephrosis noted. He was started on IVF/albumin and diuretics were held, with improvement in Cr back to baseline. # Suspected portal vein thrombosis: Suspicion for this based on CTA on [6-22]. From scans it was unclear whether this was a true thrombosis so anticoagulation was deferred in setting of GIB. # Ileus: Initially presented with nausea/vomiting at home for 2 days prior to presentation. After 5L paracentesis at OSH, it was noted that his abdomen continued to be tense and tympanic to percussion. KUB was consistent with early ileus vs SBO. CT abdomen ruled out SBO definitively but did note dilated and edematous loops of bowel. Eventually his ileus resolved with standard of care therapy, at which time he was transitioned from PR to PO lactulose with good effect. # ETOH cirrhosis: c/b grade II esophageal varices, ascites, encephalopathy. 5 admissions at RIH in past 2 mo for liver decompensation. On this admission, complicated by encephalopathy and GIB, ascites not an issue after restarting home diuretics. The transplant workup continued. Outstanding tests include further imaging studies of the parotid mass noted on CT neck (per radiology, evaluate with ultrasound or MRI) as well as PFTs. Transitional Issues: - possible MRI brain for seizure workup - MRI vs ultrasound of parotid mass for transplant workup - PFTs for transplant workup - possible MRI for portal vein thrombosis workup Medications on Admission: - docusate 100 mg [Hospital1 ] - lactulose titrate to 4 BM per day - lasix 40 mg qPM - lasix 80 mg qAM - nexium 40 mg daily - oxycontin 40 mg q12 hrs - prochlorperazine prn - propanolol 10 mg tid - aldactone 200 mg [Hospital1 ] - tramadol 50 mg q6 hrs prn Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): titrate up or down to 3-4 bowel movements daily. 3. furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 1 months. Disp:120 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Hepatic encephalopathy Small bowel ileus versus obstruction Acute renal failure Upper GI bleeding Suspected Seizure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred from [State 792]Hospital for further management of multiple issues. You had encephalopathy, acute renal failure, decompensation of cirrhosis, small bowel ileus, acute gastrointestinal bleeding and had what was likely a seizure. We treated all of this and you improved. Note the following changes to your medications: STOP Propranolol Oxycontin - you did not need this while hospitalized here, instead just use tramadol for pain Compazine START Rifaximin 550mg by mouth twice per day Nadolol 20mg by mouth once per day Sucralfate 2g by mouth twice per day for one month only Otherwise take all medications as prescribed. Please follow-up with the liver team as below. It is also important to get a MRI of your brain. Please discuss scheduling this with your primary care doctor. Followup Instructions: Department: TRANSPLANT CENTER When: THURSDAY [2110-7-3] at 1:15 PM With: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: TRANSPLANT CENTER When: THURSDAY [2110-7-3] at 2:00 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [2110-7-3] at 3:40 PM With: BONE DENSITY TESTING [Telephone/Fax (1) 4586] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5849", "2762", "4019", "3051" ]
Admission Date: [2123-10-3] Discharge Date: [2123-10-7] Date of Birth: [2042-4-22] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 81 yo male, transfer from a [Hospital 48825] hospital, s/p fall from standing. Near syncope, ? LOC. Outside imaging (CT Chest/[Last Name (un) ]) showed Grade I splenic laceration and left rib fractures [7-18], no pneumothorax. He was transported to [Hospital1 18] for further care. Past Medical History: NIDDM, Neuropathy Family History: Noncontributory Pertinent Results: [2123-10-3] 06:30PM UREA N-15 CREAT-1.0 [2123-10-3] 06:30PM CK-MB-NotDone [2123-10-3] 06:30PM cTropnT-<0.01 [2123-10-3] 06:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2123-10-3] 06:30PM WBC-11.3* RBC-4.71 HGB-13.0* HCT-38.4* MCV-81* MCH-27.7 MCHC-34.0 RDW-13.7 [2123-10-3] 06:30PM PT-13.8* PTT-26.2 INR(PT)-1.2* [2123-10-3] 06:30PM PLT COUNT-283 CT Head [2123-10-3] IMPRESSION: No evidence of acute intracranial traumatic injury seen. Evidence of inflammatory changes in the paranasal sinuses. CT C-spine [2123-10-5] IMPRESSION: 1. No evidence of acute fracture, malalignment, or paravertebral hematoma. 2. Multilevel degenerative changes, particularly at the C4-5 level and C5-6 level, with exaggerated kyphosis centered about C5. If there is concern for cord or ligamentous injury, MRI would be recommended for more sensitive evaluation. 3. Evidence of sinus disease again noted. 4. Dilated proximal intrathoracic esophagus which is filled with oral contrast, which was administered at the outside hospital. ECHO [2123-10-5] Conclusions The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild mitral regurgitation with normal valve morphology. No structural cardiac cause of syncope identified. [2123-10-5] CAROTID SERIES COMPLETE CAROTID SERIES COMPLETE. Duplex evaluation was performed of both carotid arteries. Minimal plaque was identified. On the right, peak systolic velocities are 56, 195, 79 in the ICA, CCA, ECA respectively. The ICA/CCA ratio is 0.6. This is consistent with no stenosis. On the left, peak systolic velocities are 90, 98, 81 in the ICA, CCA, ECA respectively. The ICA/CCA ratio is 0.9. This is consistent with no stenosis. There is antegrade flow in both vertebral arteries. The left vertebral artery shows an elevated velocity consistent with some intrinsic disease. IMPRESSION: No evidence of stenosis in either carotid artery. Brief Hospital Course: He was admitted to the Trauma service. He was transferred to the Trauma ICU given his injuries; especially the rib fractures and concern for respiratory complications. The Acute Pain Service was consulted for possible epidural catheter placement. Upon their evaluation it was noted that patient had previous spine surgery and would require epidural catheter placement under fluoroscopic guidance. Discussion took place with patient and team to try alternative medications for pain control. He was started on an oral narcotic regimen which included Oxycodone. This made him a bit confused and it was stopped. He was placed on around the clock Tylenol, Lidoderm patch and standing Ultram which per patient report was effective in controlling the pain. His home dose Neurontin was also restarted. He was evaluated by Physical and Occupational therapy; he made significant gains and was eventually cleared for discharge to home with services. Medications on Admission: Metformin, Zocor, ASA, Gabapentin Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to left chest region. Disp:30 Adhesive Patch, Medicated(s) Refills:0 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:120 Tablet(s) Refills:1 7. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [Last Name (LF) ], [First Name3 (LF) 487] Discharge Diagnosis: s/p Fall Rib fractures - left [7-18] Grade I splenic laceration Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: Return to the Emergency room if you develop any headaches, fevers, chills, dizziness, shortness of breath, productive cough, chest pain, rib pain not relieved with the pain medication, abdominal pain, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. AVOID any activity that may cause injury to your abdominal area because of your spleen injury for the next 6 weeks. It is important that you cough, deep breathe and use the incentive spirometer every hour as instructed while you are awake in order to minimize the likelihood of getting pneumonia. Take the pain medication as precribed. You may resume your home medications. Followup Instructions: Follow up next week with Dr. [Last Name (STitle) ], Trauma Surgery. Call [Telephone/Fax (1) 6429]. Inform the office that you will need a chest xray for this appointment. Follow up with your primary care doctor in the next 1-2 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2123-10-19]	[ "25000" ]
Admission Date: [2173-11-23] Discharge Date: [2173-12-19] Date of Birth: [2103-11-27] Sex: F Service: MEDICINE Allergies: A.C.E Inhibitors / Ativan / Ambien / Lisinopril Attending:[First Name3 (LF) 465] Chief Complaint: change in mental status Major Surgical or Invasive Procedure: L BKA History of Present Illness: 69 yo female w/ malignant HTN, DM, ESRD on HD, CAD, CHF (EF 55%), CVA, s/p R BKA 3 weeks ago, recent MSSA bacteremia s/p line change,recent colitis, who was taken to [Hospital 8] Hospital from [Hospital ] rehab after 24hrs of hypotension to SBP 80's-90's and new mental status changes s/p HD. Pt was found unresponsive this AM with SBP in 60's, FS of 163. At [Name (NI) 8] Hospital, pt was noted to have R fixed and dilated pupil. Pt was also found to be lethargic and aphasic. At [Name (NI) 8] Hospital, pt had the following vitals: T 97.9 BP 91/53 HR 97 RR 20 sat 100% 15L FM. CXR showed RLL infiltrate, sugestive of aspiration PNA. Pt was transferred to [Hospital1 18] for further workup. In the [Name (NI) ], pt was hypotensive to 80's-90's, was seen by neuro and found to have L facial droop with L sided weakness. Pt also had fever to 101 rectally. Pt was given 2L NS, vanc/levo/flagyl, and 2mg IV morphine. Past Medical History: DM >30 years with neuropathy, nephropathy, and retinopathy ESRD on HD MWF PVD s/p multiple bypasses and Right BKA [2173-11-1] CAD s/p MI in [2158], CHF, EF on TTE [2172] was normal stroke [2158], [2170] - both presented with right sided weakness, found to have parapontine stroke in [2170] and was placed on aggrenox, MRA [2171] shows left vertebral stenosis of the neck and intracranial atherosclerotic disease DVT - (?treatment) hyperhomocysteinemia anemia HTN cervical spondylosis s/p C4-7 fusion [2168] question of dementia ? h/o multiple delirium admissions due to drugs (benzos, etc) indwelling foley cath MSSA bacteremia ? aspiration pneumonia Colitis Social History: DNR/DNI, daughter is HCP [Name (NI) ] [Name (NI) 1661] [Telephone/Fax (1) 98751]. Former [Male First Name (un) ] at NE [Location (un) ], has 4 PhD's. 5 kids. Widowed. No tob/etoh/drugs. Has not lived at home since [Month (only) 205] (formerly lived with her kids). Family History: HTN CAD/MI Physical Exam: On admission: Vitals: T 98.6 BP 121/61 HR 99 RR 20 O2 97% 3L Gen: Elderly woman, lying in bed, uncomfortable. Lethargic, but arousable and responsive to commands. HEENT: PERRL. EOMI intact, but sluggish. OP dry. Neck: R tunneled cath on R side. Unable to appreciate JVD. Cardio: RRR, no m/r/g appreciated. Resp: Course BS anteriorly. Abd: soft, diffusely tender, +BS, no rebound/guarding, no masses. Ext: s/p R BKA, wound appears intact, but tender. L extremity cold, with gangrenous foot and necrotic toes. Neuro: Lethargic. Oriented to person and place only. Able to follow commands. Mild L sided weakness and L facial droop. Pertinent Results: REPORTS: MR HEAD W/O CONTRAST [2173-11-23] 7:49 PM IMPRESSION: 1. MRI of the brain demonstrates two areas of diffusion signal abnormality, which indicates recent infarction. There are new areas of susceptibility artifacts since the old study, but stable appearance of multiple chronic microvascular infarctions. 2. MRA of the circle of [Location (un) 431] is extremely limited due to motion artifact. Flow is observed in the major branches of this circulation, but vessels cannot be further assessed. CTA ABD W&W/O C & RECONS [2173-11-23] 3:05 PM IMPRESSION: 1. Right lower lobe collapse/consolidation with small bilateral pleural effusions. 2. Prominence of the intra and extrahepatic biliary duct system, which is more than expected given the patient's age and history of prior cholecystectomy. Clinical correlation with the patient's LFTs is recommended. 3. Atrophic kidneys bilaterally with multiple complex cysts demonstrated. One of these cysts within the mid pole of the right kidney demonstrates enhancement after contrast administration, which is concerning for a neoplastic process. Further evaluation of these renal cysts can be performed with MRI. 4. Patent mesenteric vessels without evidence of mesenteric ischemia. TTE: Conclusions: 1. The left atrium is normal in size. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation seen. 5.The mitral valve leaflets are mildly thickened. No mitral regurgitation seen. 6.Moderate [2+] tricuspid regurgitation is seen. 7.There is mild pulmonary artery systolic hypertension. 8.There is no pericardial effusion. EKG: Sinus rhythm Consider left atrial abnormality Prior anteroseptal myocardial infarction Modest nonspecific low amplitude T waves Since previous tracing of [2173-11-23], ventricular ectopy absent CHEST (PA & LAT) [2173-11-28] 11:00 AM IMPRESSION: Probable atelectasis and/or scarring at both bases. Slight blunting right costophrenic angle, which is equivocally more prominent than on prior exams. Otherwise, no evidence of acute pulmonary process. CT ABDOMEN W/O CONTRAST [2173-12-1] 3:45 PM 1. Hyperdense bilateral kidney cysts, stable from the previous examination and worrisome for neoplastic process in partcular in the right kidney. Further evaluation of these cysts with MRI is recommended. 2. Interval improvement of the right lower lobe consolidation with small bilateral pleural effusions. The remaining right nodular consolidation is worrisome for metastasis given the appearance of the kidneys and followup is recommended. 3. Prominence of the intra and extrahepatic biliary ductal system, stable compared to the prior examination. 4. Subcutaneous nodule in the left lateral abdominal wall of uncertain clinical significance. 5. No evidence of colitis. CTA HEAD W&W/O C & RECONS [2173-11-26] 1:49 PM IMPRESSION: 1. Bilateral exuberant calcifications at the carotid bifurcations with approximately 60% stenosis at the right internal and 30-40% stenosis at the left internal origins. 2. Moderate-to-severe stenosis of the bilateral cavernous and supraclinoid internal carotid arteries with exuberant calcifications. 3. Exuberant calcifications involving distal vertebral arteries with more than 50% stenosis involving both distal vertebral arteries, Left > Right. 4. Diffuse atherosclerotic disease involving the basilar artery. 5. Somewhat poor opacification of the vascular structures could be related to low contrast injection rate from inadequate IV access. 6. Other changes as described above. Abdominal MRI (prelim): Likely bilateral renal cell carcinoma PATH: DIAGNOSIS: Left below-the-knee amputation: Gangrenous necrosis, distal foot. Severe atherosclerosis. Resection margins free of inflammation and necrosis. LABS: [2173-12-5] 06:05AM BLOOD WBC-14.1* RBC-2.75* Hgb-8.7* Hct-28.8* MCV-105* MCH-31.7 MCHC-30.3* RDW-23.5* Plt Ct-505* [2173-12-1] 03:56AM BLOOD WBC-18.8* RBC-2.75* Hgb-8.7* Hct-29.3* MCV-106* MCH-31.5 MCHC-29.6* RDW-21.8* Plt Ct-561* [2173-11-29] 06:20AM BLOOD WBC-18.1* RBC-3.10* Hgb-10.0* Hct-32.2* MCV-104* MCH-32.3* MCHC-31.0 RDW-21.4* Plt Ct-498* [2173-11-27] 06:27AM BLOOD WBC-15.1* RBC-3.08* Hgb-10.3* Hct-31.5* MCV-103* MCH-33.4* MCHC-32.5 RDW-20.8* Plt Ct-405 [2173-11-24] 05:20AM BLOOD WBC-14.5* RBC-3.17* Hgb-10.3* Hct-34.3* MCV-108* MCH-32.5* MCHC-30.0* RDW-20.8* Plt Ct-383 [2173-11-23] 09:50AM BLOOD WBC-12.4* RBC-3.08* Hgb-10.2* Hct-32.3* MCV-105* MCH-33.0* MCHC-31.4 RDW-20.5* Plt Ct-411 [2173-11-29] 06:20AM BLOOD Neuts-84.6* Lymphs-10.6* Monos-2.8 Eos-1.5 Baso-0.4 [2173-11-25] 06:00AM BLOOD Neuts-82.2* Lymphs-11.5* Monos-3.8 Eos-2.4 Baso-0.2 [2173-11-23] 09:50AM BLOOD Neuts-83.0* Lymphs-12.7* Monos-3.8 Eos-0.4 Baso-0.2 [2173-12-5] 06:05AM BLOOD Plt Smr-VERY HIGH Plt Ct-505* [2173-12-4] 05:56AM BLOOD PT-12.9 PTT-39.2* INR(PT)-1.1 [2173-12-2] 06:11AM BLOOD Plt Smr-HIGH Plt Ct-586* [2173-11-30] 04:05AM BLOOD Plt Smr-HIGH Plt Ct-532* [2173-11-29] 05:21PM BLOOD PT-13.9* PTT-40.8* INR(PT)-1.3 [2173-11-29] 06:20AM BLOOD PT-15.1* PTT-56.5* INR(PT)-1.5 [2173-11-28] 06:32AM BLOOD PT-15.1* PTT-51.2* INR(PT)-1.6 [2173-11-27] 06:27AM BLOOD PT-14.2* PTT-49.2* INR(PT)-1.4 [2173-11-26] 05:55AM BLOOD PT-14.6* PTT-72.1* INR(PT)-1.5 [2173-11-25] 06:00AM BLOOD PT-14.7* PTT-49.8* INR(PT)-1.5 [2173-11-24] 05:20AM BLOOD Plt Smr-NORMAL Plt Ct-383 [2173-11-24] 05:20AM BLOOD PT-39.1* PTT-96.0* INR(PT)-11.9 [2173-11-23] 11:45AM BLOOD PT-14.1* PTT-52.5* INR(PT)-1.3 [2173-11-26] 05:55AM BLOOD Ret Aut-1.8 [2173-12-5] 06:05AM BLOOD Glucose-188* UreaN-32* Creat-4.8# Na-140 K-3.3 Cl-99 HCO3-27 AnGap-17 [2173-12-2] 06:11AM BLOOD Glucose-99 UreaN-22 Creat-4.2* Na-141 K-4.0 Cl-103 HCO3-25 AnGap-17 [2173-11-29] 05:21PM BLOOD Glucose-183* UreaN-13 Creat-3.2# Na-138 K-3.9 Cl-98 HCO3-27 AnGap-17 [2173-11-28] 06:32AM BLOOD Glucose-74 UreaN-16 Creat-3.9 Na-138 K-3.7 Cl-98 HCO3-26 AnGap-18 [2173-11-26] 05:55AM BLOOD Glucose-107* UreaN-19 Creat-4.8* Na-135 K-3.5 Cl-100 HCO3-25 AnGap-14 [2173-11-25] 06:00AM BLOOD Glucose-88 UreaN-24* Creat-5.6* Na-136 K-4.3 Cl-99 HCO3-23 AnGap-18 [2173-11-23] 09:50AM BLOOD Glucose-131* UreaN-15 Creat-4.0# Na-137 K-3.6 Cl-98 HCO3-26 AnGap-17 [2173-11-29] 05:21PM BLOOD CK(CPK)-111 [2173-11-26] 05:55AM BLOOD CK(CPK)-250 [2173-11-25] 06:00AM BLOOD CK(CPK)-348* [2173-11-24] 05:20AM BLOOD CK(CPK)-378* [2173-11-24] 12:12AM BLOOD CK(CPK)-330* [2173-11-23] 09:50AM BLOOD ALT-5 AST-15 CK(CPK)-159* AlkPhos-110 Amylase-34 TotBili-0.2 [2173-11-29] 05:21PM BLOOD CK-MB-5 cTropnT-0.17* [2173-11-26] 05:55AM BLOOD CK-MB-4 cTropnT-0.16* [2173-11-25] 06:00AM BLOOD CK-MB-6 cTropnT-0.17* [2173-11-24] 05:20AM BLOOD CK-MB-6 cTropnT-0.18* [2173-11-24] 12:12AM BLOOD CK-MB-7 cTropnT-0.17* [2173-11-23] 09:50AM BLOOD CK-MB-6 cTropnT-0.12* [2173-12-5] 06:05AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 [2173-12-1] 03:56AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.5 [2173-11-29] 07:40AM BLOOD Albumin-1.9* Calcium-8.7 Phos-3.7 Mg-2.2 [2173-11-27] 08:50AM BLOOD Albumin-1.9* Calcium-8.2* Phos-2.7 Mg-1.6 [2173-11-24] 05:20AM BLOOD Calcium-8.0* Phos-5.8# Mg-1.7 [2173-11-26] 05:55AM BLOOD calTIBC-46 Ferritn-GREATER TH TRF-35* [2173-11-23] 09:50AM BLOOD Folate-7.0 [2173-11-25] 06:00AM BLOOD Triglyc-102 HDL-24 CHOL/HD-2.0 LDLcalc-4 [2173-11-23] 09:50AM BLOOD Homocys-3.0* [2173-11-24] 12:45PM BLOOD TSH-2.3 [2173-11-25] 08:25AM BLOOD PTH-218* [2173-11-25] 06:00AM BLOOD Cortsol-36.4* [2173-11-25] 05:09AM BLOOD Cortsol-30.0* [2173-11-25] 04:17AM BLOOD Cortsol-13.0 [2173-12-5] 06:05AM BLOOD Vanco-14.3* [2173-12-4] 05:56AM BLOOD Vanco-15.5* [2173-12-3] 05:37AM BLOOD Vanco-20.2* [2173-12-2] 06:11AM BLOOD Vanco-8.4* [2173-12-1] 03:56AM BLOOD Vanco-9.1* [2173-11-30] 04:05AM BLOOD Vanco-8.8* [2173-11-25] 06:00AM BLOOD Vanco-22.4* [2173-11-24] 05:20AM BLOOD Vanco-12.7* [2173-11-24] 12:12AM BLOOD Vanco-15.2* [2173-11-23] 09:50AM BLOOD Valproa-<3* [2173-11-29] 05:38PM BLOOD Type-ART pO2-84* pCO2-40 pH-7.44 calHCO3-28 Base XS-2 [2173-11-29] 01:02PM BLOOD Type-ART O2 Flow-5 pO2-161* pCO2-57* pH-7.39 calHCO3-36* Base XS-8 Intubat-NOT INTUBA [2173-11-29] 05:37PM BLOOD Lactate-3.0* [2173-11-23] 10:03AM BLOOD Lactate-1.1 MICRO: Blood cx: NGTD (x 14 cultures) Stool cx: C.dif negative (x 3) Brief Hospital Course: A/P: Pt is 69 yo female with multiple medical problems, including ESRD on HD, recent MSSA bacteremia, and CAD who presented s/p multiple episodes of hypotension, fever, and acute R frontal and R cerebellar infarcts. Pt was s/p L BKA last week. . #) Neuro: Pt with R frontal and R cerebellar infarcts. Pt with hx of multiple strokes in the past. Pt had decreased responsivenes for past 3 days. - previously followed by stroke service. Stroke workup completed. - ASA was given - strict BP control instituted (goal SBP 140-180's, MAP <110) - TTE negative for source of embolus - unclear reason for pt's decreased responsiveness over past several days, possible infection vs. stroke, although likely multifactorial . #) CV: Pt with hx of MI, hx of CHF (EF 55% by last TTE). - ASA - lipitor - held all antihypertensives given hx of hypotension. - vascular followed. Pt was s/p L BKA last week. . #) ID: Pt with hx of MSSA bacteremia, with episodes of hypotension and fever. Pt afebrile over past several days. - pt afebrile overnight. Blood cx's negative to date. - pt was on vanc/levo/flagyl empirically, given hx of hypotension and fever - sacral decub possible source of pt's prior fevers - WBC count had been trending down - urine cx from [12-7] growing yeast, pt unable to take PO treatment . #) Renal: Pt with ESRD on HD. - prelim MRI read shows that BL renal masses are very suspicious for renal cell carcinoma - pt was dialyzed every MWF - Abd CT findings: 1. Hyperdense bilateral kidney cysts, stable from the previous examination and worrisome for neoplastic process. Further evaluation of these cysts can be performed with MRI. 2. Interval improvement of the right lower lobe consolidation with small bilateral pleural effusions. The remaining right nodular consolidation is worrisome for metastasis given the appearance of the kidneys and followup is recommended. 3. Prominence of the intra and extrahepatic biliary ductal system, stable compared to the prior examination. 4. Subcutaneous nodule in the left lateral abdominal wall of uncertain clinical significance. 5. No evidence of colitis. . #) GI: Pt had frequent episodes of liquid green stool. - C. dif negative x 3, O&P negative x 1. Stool negative for salmonella/shigella. . #) Endocrine: DM was stable. - TSH normal - cosyntropin stim test normal - RISS was given . #) L leg pain/cramping: Pt s/p recent BKA on R, now s/p L BKA. - PRN oxycodone was used for pain - occasional dosees of toradol (between dialysis sessions) were given as well - Pt's pain was difficult to control without oversedation or decreased BP. . #) Anemia: iron studies consistent with ACD. - pt was transfused occasionally at dialysis for goal hct>30 . #) FEN: Pt passed swallow eval on admission, but has been unable to take PO the past several days [3-3] somnolence. TPN also given since poor PO intake. Family was not in favor of PEG/Dobhoff for long-term feeding. . #) PPX: Hep SC, PPI. . #) Code: Pt was DNR/DNI. Health care proxy then made pt [Name (NI) 3225]. Pt was given morphine titrated to comfort. All additinoal meds and blood draws were d/c'd. Dialysis was stopped. The attending and pt's PCP were aware of the change to [Name (NI) 3225]. Addendum: Pt expired after several days of [Name (NI) 3225] care. Medications on Admission: (per [Hospital1 ] records) Insulin cholestyramine/sucro 4 gram [Hospital1 ] (?) PO trypsin/balsam [Location (un) 15555] to excoriations q 12 hrs TP bismuth prn neurontin 300mg ([Hospital1 ]?) PO Zinc sulfate 220 mg PO daily ascorbic acid 500mg daily valsartan 40mg daily metoprolol 100mg PO (frequency?) amlopidine 10mg PO daily topical lidocaine epo 5000 units IV q WMF diphenhydramine prn heparin [2168] units IV q MWF glycerin prn mvi latanoprost one drop to each eye (daily?) SC heparin 5000 units q 8 tylenol 975 mg PO QID isosorbide mononitrate 30mg PO daily cyanocobalomin 25 mcg daily atorvastatin 40mg daily sertraline 50mg [Hospital1 ] lansoprazole 30mg daily oxycodone 2.5mg q 6 hrs prn vancomycin 250mg PO (frequency?) nafcillin 2g q 4 hr IV, another order for q6 diphenoxylate PO QID loperamide 2mg PO Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: ESRD HTN CAD CHF ? renal cell CA s/p multiple strokes Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] Completed by:[2173-12-21]	[ "5070", "40391", "4280" ]
Admission Date: [2185-5-2] Discharge Date: [2185-5-15] Date of Birth: [2134-10-26] Sex: M Service: SURGERY Allergies: Lorazepam Attending:[First Name3 (LF) 3376] Chief Complaint: 50M w/ulcerative colitis s/p proctocolectomy and diverting ileostomy seven days prior to admission transferred from an OSH with abd pain, nausea, emesis. Major Surgical or Invasive Procedure: [5-3] percutaneous drain placement History of Present Illness: Following admission to an outside hospital, he was extensively fluid resuscitated, intubated due to respiratory distress, required vasopressor support, transfused 2 units of RBC for a Hct of 21.1, started on TPN and started on IV antibiotics Invanz and flagyl. Past Medical History: Ulcerative colitis, osteoporosis, polyps, depression Social History: non-contributory Family History: non-contributory Physical Exam: On admission T 98.5 HR 73 BP 96/59 RR 14 on CMV 0.4 500x12(5) Peep 5 sats 100% on vaso 2.4, propofol 20 Gen - intubated, sedated, ETT, OGT in place Card - RRR Pulm - Coarse bilaterally Abd - soft, mild distention, hypoactive bowel sounds, non tender Abdominal wound - healing, clean base, no surrounding erythema. Ileostomy with large amount of green stool, guiaic negative Pertinent Results: [5-3] CT-GUIDED DRAINAGE: Outside CT of the abdomen and pelvis was not available at time of the procedure. Therefore, a contrast-enhanced CT of the abdomen and pelvis was obtained prior to the procedure with administration of 130 cc of Optiray. CT demonstrates moderate amount of fluid in the abdomen and pelvis, without definite loculated components or focal abscesses. There is no evidence of bowel obstruction. This patient is status post colectomy. There is a right anterior abdominal wall ileostomy. Small amount of gas is present in the anterior abdominal wall, compatible with recent postoperative state. The liver is normal in size contour. Note is made of multiple hypoenhancing liver lesions, some of which are compatible with simple cysts, the rest are too small to be accurately characterized. The gallbladder is mildly distended and contains hyperdense material, likely reflecting vicarious excretion of contrast. The spleen is enlarged and measures 14 cm in AP dimension. A 1.6 cm splenule is seen medial to the splenic hilum. The pancreas, adrenals, and kidneys are unremarkable. The urinary bladder contains a Foley catheter and is unremarkable. The portal vein is patent. Using CT fluoroscopy for guidance, an 8 French catheter was placed into the pelvis into the largest fluid pocket utilizing Seldinger technique via the left transabdominal approach. After satisfactory position of the catheter was confirmed, approximately 70 cc of yellow minimally cloudy fluid was aspirated. A sample was sent for culture and stain. The catheter was secured to the skin by percutaneous catheter fasteners, connected to a drainage bag, and left to open drainage. Catheter care discussed with the surgical resident. The patient tolerated the procedure well. No immediate complications occurred.Radiology attending, Dr. [Last Name (STitle) 4401],was present and supervised the entire procedure. IMPRESSION: Successful CT-guided drainage catheter placement. Fluid sample sent for culture and stain. [5-8] CT Fluoroscopy was used to guide insertion of a 19-gauge guiding needle via the transabdominal approach. However, CT fluoroscopy images obtained during the procedure to confirm location of the guiding needle demonstrated significant rapid shift of fluid within the pelvis with only minimal amount of fluid remaining in the initially targeted left lower quadrant pocket. Following this, the patient was repositioned twice to achieve better accumulation of fluid in the left lower quadrant. However, despite these attempts, very minimal amount of fluid was seen most of which was interdigitating between bowel loops . Therefore, percutaneous drainage of this free flowing fluid was deemed unsafe and therefore was not performed. IMPRESSION: CT-guided drainage was not performed as fluid demonstrated continuous shifting during the procedure which rendered percutaneous catheter placement unsafe at this time. [5-9] COMPARISON: CT of the abdomen and pelvis [2185-5-8]. Limited images through the lung bases demonstrate a moderate left pleural effusion and trace amount of right pleural fluid. There is bibasilar subsegmental atelectasis. The liver is normal in size and contour. There is no intrahepatic or extrahepatic biliary dilatation. Multiple liver cysts are identified and additional smaller subcentimeter hepatic hypodensities that are too small to characterize. The gallbladder is unremarkable. The portal vein is patent. The spleen is mildly enlarged and measures approximately 14 cm in AP dimension. The adrenal glands are within normal limits. The kidneys enhance symmetrically. There is no hydronephrosis. The patient is status post total colectomy, and ileal pouch to anal anastomosis. There is a right anterior abdominal wall ileostomy. As before, note is made of a gap in the suture line of ileal pouch that measures approximately 11 mm on axial images and 3 cm on the coronal images (series 4, image 33). This gap allows direct communication of the lumen of the ileal pouch with the pelvic fluid collection. Overall, there has been no significant interval change in amount of intra-abdominal fluid and peritoneal enhancement. No definite focal loculated fluid collections are identified. There is no evidence of gas within the intra- abdominal fluid. The small bowel is normal in caliber. There is no evidence of bowel obstruction. There is no evidence of bowel pneumatosis. The urinary bladder is unremarkable. There is a Foley catheter in place. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. There is a healing fracture of the posterior tenth rib. IMPRESSION: 1. No significant interval change in the amount of intraperitoneal fluid. No definite loculated fluid collections are identified. There is no evidence of gas within the intraperitoneal fluid. 2. Gap within the right wall of the ileal pouch that directly communicates with the free pelvic fluid. 3. Moderate left pleural effusion and tiny right pleural effusion. [2185-5-3] 5:00 pm FLUID,OTHER Site: ABDOMEN ABDOMINAL FLUID. FINAL REPORT [2185-5-9] GRAM STAIN (Final [2185-5-3]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2185-5-6]): LACTOBACILLUS SPECIES. SPARSE GROWTH. [2185-5-10] 9:03 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2185-5-13] FECAL CULTURE (Final [2185-5-13]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2185-5-12]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [2185-5-11]): NO OVA AND PARASITES SEEN. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2185-5-11]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Brief Hospital Course: The patient was admitted to the ICU for continued close monitoring. He remained intubated, on pressor support, continued TPN and broad spectrum antibiotics (ampicillin, ciprofloxacin, flagyl). [5-3] pressors weaned off, a CT abdomen was performed which demonstrated moderate amount of fluid in the abdomen and pelvis, without definite loculated components or focal abscesses. A catheter was placed and drained approximately 70 cc of yellow minimally cloudy fluid. [5-4] Ventilator settings weaned and patient extubated without difficulty. [5-5] Diet advanced as tolerated from sips to clears to regular diet. Foley and central venous line discontinued. Transferred to the floor for continued monitoring. [5-6] - cont to encourage diet, ambulation, PO pain medication as needed [5-7] - ostomy/wound care nurse [First Name (Titles) ] [Last Name (Titles) 2742] of patient, started replacing ostomy output 1:1 with LR for high output. Antibiotics discontinued, abdominal drain discontinued. [5-8] - repeat CT scan abdomen demonstrating increase in the amount of intraperitoneal fluid and prominent peritoneal enhancement not not ammenable to drainage. Started on vanc/zosyn. Ensure supplements added TID for nutrtional support. [5-9] - repeat CT scan showing no significant interval change in the amount of intraperitoneal fluid. No definite loculated fluid collections are identified. There is no evidence of gas within the intraperitoneal fluid. ID was consulted, they recommended adding caspofungin to the above regimen. Physical therapy began working with the patient to aid in ambulating and strength exercises. PICC line placed for IV antibiotic and TPN. [5-10] - [5-13] continued antibiotics, encouraging PO intake, ostomy output replacement and TPN. Flomax started and foley catheter removed at midnight and the patient voided. [5-13] - caspofungin discontinued, started on fluconazole [5-15] Repeat CT scan demonstrating marked decrease in abdominal fluid collection. The patient will be discharged home with VNA set up for further home IV antibiotic treatment. Medications on Admission: Prednisone 30 qd Protonix 40 qd percocet prn fosamax zoloft 50 qhs Discharge Medications: 1. Fluconazole in Saline(Iso-osm) 400 mg/200 mL Piggyback Sig: One (1) Intravenous once a day for 2 weeks. Disp:14 Refills:0 2. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a day for 2 weeks. Disp:14 Refills:0 3. PICC Line care Picc line care per NEHT protocol. 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q 3 hours as needed for pain. Disp:75 Tablet(s) Refills:0 5. 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 6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] Discharge Diagnosis: Abdominal fluid collection Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. Incision Care: You may shower. Pat incision dry. Avoid swimming and baths until further instruction at your followup appointment. Leave the steri-strips on. They will fall off on their own, or be removed during your followup. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. JP Drain Care: Please look at the site every day for signs of infection (increased redness, swelling, tenderness, odorous or purulent discharge). Maintain the bulb deflated to provide adequate suction. Note color, consistency, and amount of fluid in drain. Call doctor if amount increases significantly or changes in character. Be sure to empty the drain frequently and record the output. Maintain the site clean, dry, and intact. Keep drain attached safely to body to prevent pulling and possible dislodgement. Monitoring Ostomy Output / Prevention of Dehydration: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. Try to maintain ostomy output between 500mL to 1000mL per day. If Ostomy output exceeds 1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg in 24 hours. Followup Instructions: Please call the office of Dr. [Last Name (STitle) 1120] to make a follow up appointment in [1-16] weeks at [Telephone/Fax (1) 29433] Please call the office of Dr. [Last Name (STitle) 7443] to make a follow up appointment at ([Telephone/Fax (1) 4170]. You should have weekly CBC, BUN/Creatinine, LFTs performed and faxed to Dr. [Last Name (STitle) 7443] at [Telephone/Fax (1) 432*]	[ "99592", "51881", "2760" ]
Admission Date: [2102-4-4] Discharge Date: [2102-4-10] Service: SURGERY Allergies: Omnipaque Attending:[First Name3 (LF) 6088] Chief Complaint: pain in left leg Major Surgical or Invasive Procedure: AngioJet thrombolysis of Left SFA with t-PA, with zenith stent Left popliteal artery stent. Left distal popliteal artery angioplasty. History of Present Illness: This patient is a [Age over 90 ] year old female who was sent to an OSH with complaints of a painful and cold LEFT leg and foot. She was found to have no distal pulses on the left and was started on a heparin gtt and transfered to [Hospital1 18]. Upon arrival to the ED she had a cold/mottled, and pulseless left foot. Heparin was infusing and she denied CP, sob, n/v/d. She was seen in the ED by Dr. [Last Name (STitle) ] and scheduled for an angiogram asap. She was then admitted to the [Last Name (STitle) 1106] service and taken to the endovascular/ angio suite. Past Medical History: PMHx: HTN, Dementia PSHx: s/p R TKR Social History: SOCIAL HISTORY: lives in a nursing home. Denies EtOH, tobacco use or illicits. Family History: FAMILY HISTORY: non-contributory for CAD Physical Exam: PHYSICAL EXAMINATION Gen: Pleasant, alert but not orientated(baseline - pt w/ dementia) Lungs: ctab Card: RRR Abd: soft/ nt/ nd no hsm Vasc: palpable fem pulses bilaterally dopplerable [Doctor Last Name ], DP, PT bilat Pertinent Results: [2102-4-8] 04:38AM BLOOD WBC-8.8 RBC-3.85* Hgb-11.0* Hct-34.9* MCV-90 MCH-28.5 MCHC-31.5 RDW-13.8 Plt Ct-186 [2102-4-10] 05:43AM BLOOD PT-31.8* PTT-36.9* INR(PT)-3.2* [2102-4-10] 05:43AM BLOOD Glucose-80 UreaN-17 Creat-1.1 Na-142 K-3.5 Cl-103 HCO3-31 AnGap-12 [2102-4-5] 07:43PM BLOOD ALT-15 AST-50* LD(LDH)-797* AlkPhos-67 Amylase-187* TotBili-0.6 [2102-4-5] 8:55 pm URINE cx - no growth [2102-4-5] 8:54 pm BLOOD CULTURE - no growth MRSA SCREEN (Final [2102-4-7]): No MRSA isolated [2102-4-5]: TTE The left atrium is moderately dilated. No thrombus/mass is seen in the body of the left atrium. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Brief Hospital Course: Ms. [Known lastname 30813] was admitted on [2102-4-4] and underwent urgent angiogram that evening. She was found to have embolus in her Left SFA and Left . She underwent AngioJet thrombectomy of the occluded SFA. There was evidence of stenosis at the level of [Doctor Last Name 26971] canal which was initially dilated with a 3-mm balloon and subsequently stented with a 5 x 80 Zilver stent. After the stent placement she began to have respiratory distress and hypotension. A dopamine gtt was started and anesthesia was called stat for endotracheal intubation. It was determined that she was having an allergic reaction to the contrast dye she received. She also was given IV solumedrol and benadryl and was stable to continue with the procedure. Subsequent arteriography revealed diminished flow in the below-knee popliteal with no filling of the previously patent popliteal and collaterals. The AngioJet was used to perform the leg thrombectomy of the distal popliteal followed by angioplasty of the distal popliteal with a 3 x 2 angioplasty balloon. She tolerated the remainder of the procedure well, had closure of her groin access with a perclose device and was transfered to the CVICU in guarded condition. She remained intubated on a heparin and dopamine gtt. On POD 1 a TTE was ordered to evaluate for a source of clot, this was negative. It was also noted that the pt had elevated troponins and some minor ekg changes and there was concern for NSTEMI prior to admission to [Hospital1 18] and a cardiology consult was obtained. Given that the pt did not have an elevated MB franction and only mildly elevated CK, it was felt that she did not suffer an MI. Later in the evening the pt had a short run of afib followed by a short run of bradycardia. She was weaned off her gtts and started on coumadin as well. On POD2 an electrophysiology consult was obtained for further evaluation. She also fever and was pan cultured. EP felt that the pt had tachybrady syndrome which had resolved. The recommended using low dose beta blockers, but stopping if the pt had junctional rhythm. She was in stable condition and transfered to the VICU late in the day on POD2. While in the VICU she remained hemodynamically stable and was continued on heparin and coumadin for anticoagulation. She worked with physical therapy, had her foley and lines removed and continued to improve daily. On pod 6 ([2102-4-10]) she was ambulating with assistance, tolerating a regular diet and voiding without difficulty. At this time it was determined by Dr. [Last Name (STitle) ] that she was stable for d/c back to her [Hospital3 ] facility with VNA and PT services. Medications on Admission: HOME MEDICATIONS: aricept 10mg daily ofloxacin gtt hctz 25mg daily verapimil 180mg daily atenolol Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:30 Tablet(s) Refills:0 3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: goal INR is [3-15] . Disp:60 Tablet(s) Refills:2 5. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 13. Outpatient [Name (NI) ] Work PT/INR to be drawn by VNA one to three times per week, as determined by PCP. [Name10 (NameIs) 357] being on weds [2102-4-12]. INR goal 2.0-3.0. Diagnosis: arterial emboli LLE Discharge Disposition: Home With Service Facility: excella home care Discharge Diagnosis: Acute on chronic left lower extremity ischemia with limb threat - arterial emboli Discharge Condition: Mental Status: Clear, intermitently confused (baseline dementia) Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You are being put on coumadin for an arterial thrombus. How will I be treated for this condition ? You will receive an oral medication called warfarin (Coumadin). This is a blood thinner and will help prevent blood clots from forming. How is warfarin (Coumadin) given? Warfarin is given orally once daily. You will be getting regular blood tests to measure how well this medication is working. The dose of warfarin may be adjusted according to the results of the blood tests. What should I do if I miss a dose of warfarin? You should contact [Name (NI) 56849],[First Name3 (LF) ] as soon as you notice that you have missed a dose. Should I be aware of other signs and symptoms? You should notify [Last Name (LF) 56849],[First Name3 (LF) ] immediately if you experience chest pain, shortness of breath, a feeling of passing out, or palpitation (heart racing). What medications do I need to avoid while on these medications? You should avoid taking medications that contain aspirin, medications such as ibuprofen (Advil, Motrin, Nuprin), naproxen (Aleve), ketoprofen (Orudis KT, Actron Caplets), or any other non-steroidal anti-inflammatory drugs (NSAIDs). You should always check with your doctor before starting any new prescription or over-the-counter medication. Moreover, alcohol and various food may also interact with warfarin. Please check with your doctor, nurse [First Name (Titles) ] [Last Name (Titles) 57] for more information. What other precautions do I need to take while on these medications? Monitor signs and symptoms of bleeding. Be careful while brushing or flossing your teeth. Avoid injuries. Keep enoxaparin syringes at room temperature. Do not refrigerate or freeze enoxaparin. Store away from heat and direct light. Keep all medications out of the reach of children Division of [Last Name (Titles) ] and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? If instructed, take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [3-15] 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 [4-13] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call [Date Range 1106] office [Telephone/Fax (1) 1237]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Visiting nurse to come out at least three times per week for wound check, medication compliance and INR draws Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3628] (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2102-4-19] 2:00 [Hospital ] [Hospital ] clinic 5b Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2102-4-19] 2:45 [Hospital ] [Hospital ] clinic 5b Your INR will be followed by your PCP. [Name10 (NameIs) ] will have a VNA come to your house and draw your blood. The results will be sent to Dr.[Last Name (STitle) 56849] and the office staff will call you and tell you how to adjust your coumadin dose if needed. It is important to follow-up on this. Name: [Last Name (LF) 56849],[First Name3 (LF) ] Address: [Street Address(2) 86037], [Location ],[Numeric Identifier 21771] Phone: [Telephone/Fax (1) 56850], Fax: [Telephone/Fax (1) 86038] Completed by:[2102-4-10]	[ "51881", "4019" ]
Admission Date: [2178-2-6] Discharge Date: [2178-4-13] Date of Birth: [2122-12-10] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 7760] Chief Complaint: enterocutaneous fistula Major Surgical or Invasive Procedure: Removal of temporary abdominal wall closure device, attempted closure of enterocutaneous fistula, and repair of ventral hernia History of Present Illness: Ms. [Known lastname ] is a 55yo woman approximately 3 weeks status [Known lastname ] a laparoscopic ventral hernia repair complicated by missed versus delayed enterotomy requiring take back to the operating room for resection of small bowel and closure of another enterotomy. She was closed with temporary abdominal wall closure device in anticipation of massive fluid shift and potential second- look. She did develop recurrent fistula, as evidenced by the drainage from her wound. After medical stabilization including IV antibiotics, aggressive diuresis, we took her to the operating room for removal of temporary abdominal wall closure device, attempted closure of enterocutaneous fistula, and repair of ventral hernia. Past Medical History: HTN Diverticulitis s/p L hemi-colectomy, cholecystectomy [9-16] s/p lap ventral hernia repair [9-17] s/p lap ventral hernia repair [2178-1-29] s/p exlap, enterotomy repair, draiange [2178-2-6] Social History: No ETOH, Tobacco Family History: Non-contributory Pertinent Results: [2178-2-6] 11:03PM TYPE-ART TEMP-37.2 RATES-18/18 PEEP-5 O2-40 PO2-94 PCO2-35 PH-7.39 TOTAL CO2-22 BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED [2178-2-6] 11:03PM O2 SAT-98 [2178-2-6] 03:35PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.017 [2178-2-6] 03:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [2178-2-6] 03:35PM URINE RBC-0-2 WBC-0 BACTERIA-OCC YEAST-NONE EPI-0-2 [2178-2-6] 03:22PM TYPE-ART TEMP-38.6 RATES-/18 TIDAL VOL-500 PEEP-5 O2-50 PO2-115* PCO2-38 PH-7.38 TOTAL CO2-23 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-AXILLARY T [2178-2-6] 03:22PM LACTATE-2.2* [2178-2-6] 03:22PM freeCa-1.25 [2178-2-6] 03:06PM GLUCOSE-119* UREA N-9 CREAT-0.6 SODIUM-137 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-19* ANION GAP-14 [2178-2-6] 03:06PM ALT(SGPT)-10 AST(SGOT)-16 LD(LDH)-159 ALK PHOS-116 AMYLASE-32 TOT BILI-1.8* DIR BILI-1.6* INDIR BIL-0.2 [2178-2-6] 03:06PM LIPASE-8 [2178-2-6] 03:06PM ALBUMIN-1.8* CALCIUM-7.9* PHOSPHATE-3.7 MAGNESIUM-1.6 [2178-2-6] 03:06PM WBC-17.3# RBC-3.10# HGB-9.1# HCT-26.7# MCV-86 MCH-29.4 MCHC-34.2 RDW-14.0 [2178-2-6] 03:06PM PLT COUNT-335 [2178-2-6] 03:06PM PT-18.2* PTT-31.6 INR(PT)-1.7* [2178-2-6] 03:06PM FIBRINOGE-591* Brief Hospital Course: Ms. [Known lastname ] was transferred from the [Hospital 620] campus under the care of Dr. [Last Name (STitle) 6633], status [Known lastname ] a laparoscopic ventral hernia repair and subsequent exploratory laparotomy and small bowel resection. She was admitted to the SICU here at the [Hospital1 18] on [2178-2-6]. She was resuscitated and monitored closely, both intubated and sedated. She was started on broad antibiotic coverage upon arrival. Her abdomen was open and covered with a sterile dressing that was changed every other day. On HD 7 she experienced a rising WBC count to 20,000 but remained afebrile. The central line was replaced and cultures were drawn which were all negative. She was extubated successfully on HD10 (POD 17/10). . On HD 12 (POD 19/12) she was reintubated for OR with Dr. [Last Name (STitle) 6633] and Dr. [Last Name (STitle) 957] for removal of the temporary abdominal wall closure device, repair of enterocutaneous fistula, and ventral hernia repair with Vicryl mesh. See operative report for details. She was extubated on POD 1 and did very well; she was subsequently transferred to the surgical floor. She continued to receive daily TPN and sterile [Hospital1 ] dressing changes. Her NG tube was discontinued on POD 22/15/3.Antibiotics were discontinued after 15 days of ceftriaxone and 10 days each of vancomycin and flagyl. She remained afebrile off the antibiotics. . She continued to do well [Known lastname ]-operatively. She was treated by physical therapy, continued to receive TPN. On POD# 27/20/8 a VAC dressing was placed. Fistula output decreased gradually. On POD# 32/25/13 the JP drain which was underneath the vicryl mesh was removed. On POD# 36/29/17 the Fentanyl patch was discontinued, a PICC was placed and CVL discontinued. On POD# 37/30/18 patient had nasuea, increased fistula ouput, tachycardia and hypotension. A CT of her abdomen was negative for fluid collection. There was stranding and a small amount of fluid beneath the mesh. These symptoms resolved and she appeared to be improving. On POD #55/50/35 Patient had dsyuria and was had UA positive for UTI. She recieved Ciprofloxaxcin x 3 days, pyridium and miconazole suppsitory with resolution of UTI symptoms. Repeat Urine Analysis showed no evidence of infection. Patient continued on TPN and VAC dressing. Electrolytes were checked once a week and TPN adjusted appropriately. Physical therapy worked with patient to get her out of bed and ambulating. On POD# 63/58/47 her Lisinopril was discontinued given improvement in BP. On POD# 71/66/55. Patient was discharged home with services including TPN and VAC care. Medications on Admission: lisinopril/HCTZ 20/12.5, Ranitidine 150", PremPro 0.625/5, Senna Discharge Medications: 1. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Paroxetine HCl 10 mg/5 mL Suspension Sig: One (1) PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation TID PRN (). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation TID PRN (). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Percocets as needed 12. TPN Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Enterocutaneous fistula with repair Ventral hernia with repair Discharge Condition: Good Discharge Instructions: Call Dr. [Last Name (STitle) 17477] office or go to the emergency room if: -You are experiencing high fevers (>101.5) or chills -You are having leakage from around your vac dressing or increasing skin irritation/redness or pus from near your wound -You are having increasing abdominal pain -You have difficulties with nausea, vomiting, or constipation -You have any other questions or concerns Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 6633] in [12-15] weeks. Please call her office at [Telephone/Fax (1) 2998] for an appointment. Please follow-up with Dr. [Last Name (STitle) 957] also in [12-15] weeks. Please call his office at [Telephone/Fax (1) 17478] for an appointment. Completed by:[2178-4-17]	[ "0389", "99592", "78552", "5990" ]
Admission Date: [2132-6-11] Discharge Date: [2132-6-17] Date of Birth: [2069-3-9] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: SOB Major Surgical or Invasive Procedure: [6-11] cardiac catherization and intra aortic balloon insertion [6-12] Coronary artery bypass graft x2 (left internal mammary artery > anterior descending, saphenous vein graft > obtuse marginal) History of Present Illness: 63 yo M s/p motorcycle MVC 10 days ago, treated for road rash and bruising as well as dehydration and dc'd home. One week later was found ashen, SOB, nauseas and weak, went to see PCP who sent him to ED. Troponin 0.25, transferred for cath which showed 90% LM. IABP inserted and patient referred for surgery. Past Medical History: Hyperlipidemia, DM, OSA (CPAP), Obesity, s/p motorcycle MVC- 10d ago, Cerebellar atrophy, GERD, s/p bil knee repl, s/p nasal septum repair after trauma Social History: cemetary/farm worker denies tobacco, etoh Family History: NC Physical Exam: HR 66 RR 18 BP 118/69 NAD multiple abrasions both arms; multiple ecchymosis groin, back lungs CTAB heart RRR, distant, IABP Abdomen Benign, obese Extrem warm, no edema, 2+ pulses t/o Pertinent Results: [2132-6-16] 05:19AM BLOOD WBC-10.4 RBC-2.77* Hgb-7.9* Hct-24.1* MCV-87 MCH-28.5 MCHC-32.7 RDW-15.4 Plt Ct-280 [2132-6-11] 03:08PM BLOOD WBC-6.8 RBC-3.77* Hgb-10.6* Hct-31.7* MCV-84 MCH-28.1 MCHC-33.4 RDW-14.0 Plt Ct-269 [2132-6-11] 03:08PM BLOOD Neuts-67.4 Lymphs-25.8 Monos-4.0 Eos-2.3 Baso-0.5 [2132-6-16] 05:19AM BLOOD Plt Ct-280 [2132-6-16] 05:19AM BLOOD PT-11.7 INR(PT)-1.0 [2132-6-12] 11:29AM BLOOD Fibrino-407* [2132-6-16] 05:19AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-136 K-4.0 Cl-101 HCO3-29 AnGap-10 [2132-6-11] 03:08PM BLOOD Glucose-118* UreaN-14 Creat-0.9 Na-140 K-4.1 Cl-105 HCO3-28 AnGap-11 [2132-6-11] 03:08PM BLOOD ALT-52* AST-31 CK(CPK)-102 AlkPhos-94 TotBili-0.8 [2132-6-11] 03:08PM BLOOD CK-MB-3 cTropnT-0.04* [2132-6-15] 02:55AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0 [2132-6-11] 04:35PM BLOOD %HbA1c-6.4* CHEST (PA & LAT) [2132-6-16] 3:53 PM CHEST (PA & LAT) Reason: evaluate effusion [Hospital 93] MEDICAL CONDITION: 63 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate effusion STUDY: PA and lateral chest radiograph. INDICATION: Status post CABG. Please evaluate size of effusion. COMPARISON: [2132-6-15]. FINDINGS: Right internal jugular central venous catheter tip terminates at the cavoatrial junction. There is mild bibasilar discoid atelectasis. Small bilateral effusions remain. There is mild cardiomegaly. Median sternotomy wires remain intact. No focal consolidation or evidence of acute pulmonary edema detected. IMPRESSION: 1. Mild bibasilar discoid atelectasis. 2. Cardiomegaly and small bilateral pleural effusions. No acute pulmonary edema detected. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name 4391] DR. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1508]Approved: MON [2132-6-16] 5:00 PM [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 78222] (Complete) Done [2132-6-12] at 11:25:38 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2069-3-9] Age (years): 63 M Hgt (in): 72 BP (mm Hg): 119/53 Wgt (lb): 300 HR (bpm): 76 BSA (m2): 2.53 m2 Indication: Intra-op TEE for CABG ICD-9 Codes: 410.91, 786.51 Test Information Date/Time: [2132-6-12] at 11:25 Interpret MD: [Name6 (MD) 928] [Name8 (MD) 929], MD, MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 929], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. 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. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5. The mitral valve appears structurally normal with trivial mitral regurgitation. Dr. [Last Name (STitle) 914] was notified in person of the results POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in Sinus rhythm 1. Biventricular function is preserved. 2. Aorta is intact post decannulation 3. IABP appears appropriately positioned 2-3 cm below take-off of left subclavian artery 3. Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 928] [Name8 (MD) 929], MD, MD, Interpreting physician [Last Name (NamePattern4) ] [2132-6-12] 16:05 Brief Hospital Course: He was admitted to the CCU after cardiac catherization that revealed coronary artery disease. He was seen by cardiac surgery and was taken to the operating room on [6-12] where he underwent a CABG x 2. He was transferred to the ICU in stable condition. IABP was dc'd post op. He was extubated on POD #1. He was seen by skin care for his multiple abrasions. He was started on amiodarone for afib. He was transferred to the floor on POD #3. He did well postoperatively and was seen by physical therapy and was cleared for discharge home. He was ready for discharge on POD #5. Medications on Admission: prilosec, crestor, prozac, motrin 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. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:30 Tablet(s) Refills:0 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: please take 400mg daily for 10 days then decrease to 200mg once daily and follow up with cardiologist. Disp:60 Tablet(s) Refills:0 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary artery disease s/p cabg Post operative atrial fibrillation Unstable angina Elevated cholesterol Diabetes mellitus Obstructive sleep apnea Gastroesophageal reflux disease Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [First Name (STitle) 1356] in 1 week ([Telephone/Fax (1) 40833]) please call for appointment Dr [Last Name (STitle) 10543] in [2-10] weeks ([Telephone/Fax (1) 4475]) please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3633]) Completed by:[2132-6-17]	[ "41071", "5180", "41401", "25000", "32723", "42731", "2859" ]
Admission Date: [2120-5-20] Discharge Date: [2120-5-29] Date of Birth: [2075-2-10] Sex: F Service: MED This is all per notes as I was not the primary intern during this time. HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old female discharged on [5-8] after a long hospitalization course for thrombotic thrombocytopenic purpura, hemolytic- uremic syndrome, septic shock, ____________, pulmonary embolus, deep venous thrombosis, gastrointestinal bleed from colonic ulcer, off anticoagulation from [4-30] to [5-11], with an inferior vena cava filter temporarily placed on [4-29]. The patient was discharged to an acute rehabilitation and was to start Lovenox b.i.d. 110 subcu on [5-11]. This was to be continued until the filter was removed and the patient transitioned to Coumadin. However, at the rehab she did not receive any Lovenox and thought she was on Coumadin although it is unclear from her records if she was ever on Coumadin. The patient reports increasing lower extremity edema, left much greater than right, over the last week. The rehab M.D. attributed this to patient being out of bed and from physical therapy. The patient reports that she walked the entire length of the parking lot yesterday. The edema increased, however, with mild discomfort noting dyspnea and shortness of breath. No chest pain. The patient saw Dr. [Last Name (STitle) 6160] as an outpatient today and, as he was concerned, he sent her to the Emergency Department. Her __________ were negative for multiple clots bilaterally. PAST MEDICAL HISTORY: Bipolar disease. Thrombotic thrombocytopenic purpura in [2120-3-28]. Hemolytic-uremic syndrome in [2120-3-28]. Pulmonary embolus and deep venous thrombosis per PE on [4-21]. Hypertension. Diabetes likely secondary to steroids. Recent gastrointestinal bleed with colonic ulcer. Septic shock with disseminated intravascular coagulopathy. Acute renal failure. ___________ with plasmapheresis. Hepatic abscesses. Right hand calcifications. Edema secondary to infusion of calcium. ALLERGIES: Demerol. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.0, blood pressure 130/94, heart rate 108, respiratory rate 16, 98 percent on room air. General: The patient was obese in no apparent distress, pleasant and in bed. HEENT: Moist mucus membranes. Extraocular motions intact. No icterus. No lymphadenopathy. Cardiovascular: Regular rate. No murmurs, rubs or gallops. Normal S1, S2. Pulmonary: Clear to auscultation with poor inspiration. Abdomen: Obese, soft, non-tender, non-distended. Extremities: Right hand with healing calcium ulcerations. Large edematous non-pitting lower extremity edema, left greater than right. Pulses intact. Neurological: Awake, alert and oriented times three. Strength 5/5 bilaterally. Cranial nerves II through XII intact. DISCHARGE MEDICATIONS: On [5-9]: 1. Seroquel 75 q. hs. 2. Topiramate 50 b.i.d. 3. Mirtazepine 15 q. hs. 4. Folic acid one q. day. 5. Calcium carbonate 1000 t.i.d. 6. Miconazole powder. 7. Ativan 0.5 q. 6h. p.r.n. 8. Ferrous sulfate 325 q. day. 9. Bismuth p.r.n. 10. Epo-Alpha 10,000 units three times a week. 11. Simethicone p.r.n. 12. Oxycodone 10 q. 4-6h. p.r.n. 13. Benadryl. 14. Maalox. 15. Docusate two b.i.d. 16. Atenolol 75 q. day. 17. Lisinopril 40 q. day. 18. Protonix 40 q. day. 19. Glargine 15 q. hs. 20. Prednisone 20 q. day. 21. Lovenox which patient did not receive. SOCIAL HISTORY: No tobacco, no alcohol, no intravenous drug abuse. Comes from acute rehabilitation. FAMILY HISTORY: No acute diseases. RADIOLOGY: Bilateral lower extremity ultrasound showed occlusive thrombus in the left common femoral vein, greater femoral vein, superior femoral vein and right common femoral vein and popliteal. HOSPITAL COURSE: 1. Deep venous thrombosis: The patient had a large clot present on initial examination as mentioned above. The patient subsequently had a venogram on [5-23] which showed persistent clot. In the setting of inferior vena cava filter with extensive lower extremity DVT, Hematology/Oncology was consulted in addition to Interventional Radiology being consulted. IR, Hematology/Oncology and the primary team recommended proceeding with TPA to break these clots. TPA was initiated with transfers to the Intensive Care Unit. TPA was given 1 mg per hour times two hours and then decreased to 0.5 mg per hour. The patient was also initiated on a heparin drip at this time. The patient, after given TPA, returned to IR on [5-23] for a repeat venogram which showed good results with only a small amount of residual thrombus in the left femoral vein and common femoral vein. The common femoral vein, iliac vein and inferior vena cava were all patent. The patient was subsequently started on a heparin drip and Coumadin until the INR was therapeutic with INR between 2 and 3 as goal. The patient was overlapped with heparin and Coumadin for 24 hours. Additionally, the patient was maintained on a heparin drip for at least five days in order for INR to become therapeutic. On day before discharge interventional radiology attempted to remove her er IVC filter, however it had spontaneously become lodged in a position that did not allow retrieval despite multiple attempt. Vascular surgery also reviewed the angiogram and agreed that this would be extremely difficult if at all possible to retrieve. IVIR offered the patient to try a second approach that they felt had < 50% chance of success, however she refused. The patient is to continue on Coumadin with goal INR 2 to 3 for indefinitely given her IVC filter and there prothrombic state. Hematology/Oncology. 1. Pulmonary embolus/inferior vena cava filter: No clinical evidence of PE during this admission. Again, patient had her IVC filter removed during this admission with anticoagulation as above. 1. Anemia: Patient has a history of colonic ulcers and gastrointestinal bleeds. The patient was not transfused while on the floor and maintained a stable hematocrit during this admission. 1. History of thrombotic thrombocytopenic purpura/hemolytic- uremic syndrome: Patient's platelet count remained stable during this admission. Hematology/Oncology was consulted during this admission and followed the patient throughout this whole hospitalization course. Patient was continued on a steroid taper per Hematology/Oncology recommendations. The patient's prednisone was continued at 10 mg p.o. q. day on discharge. Per Hematology/Oncology, patient can slowly taper down her prednisone by 5 mg every two weeks. Therefore, patient on [6-10] should be changed to 5 mg p.o. q. day. 1. Diabetes type 2: This is most likely steroid induced as patient's hemoglobin A1C is less than 5. The patient is to continue Lentis on sliding scale for right now. At acute rehabilitation can slowly be tapered off as patient is weaned off steroids. 1. Status post acute renal failure: The patient had acute renal failure likely secondary to hypovolemia. The patient's creatinine is back to baseline on discharge. 1. Hypertension: Patient was stable on a beta blocker and ACE inhibitor which were both increased during this admission. A third [Doctor Last Name 360], hydrochlorothiazide, was added three days before discharge to goal blood pressure less than 130/80. 1. History of bipolar disorder and anxiety: Patient was continued on her Seroquel and Remeron. DISCHARGE DIAGNOSES: Include: Deep venous thrombosis. Diabetes type 2. Hypertension. Hemolytic-uremic syndrome/thrombotic thrombocytopenic purpura. Colonic ulcer. Hypertension. Bipolar disorder. Anxiety disorder. FOLLOW-UP PLAN: The patient is to follow up with Dr. [Last Name (STitle) 12590] on [6-4] at 2:40 p.m. The patient is to follow up with primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 54611], in one to two weeks and should call to schedule an appointment. DISCHARGE MEDICATIONS: Include: 1. Seroquel 35 mg p.o. q. hs. 2. Mirtazapine 50 mg p.o. q. hs. 3. Folic acid 1 mg p.o. q. day. 4. Calcium carbonate 1000 mg p.o. q.i.d. 5. Miconazole powder one application b.i.d. 6. Lorazepam 0.5 mg p.o. q. 6h. p.r.n. 7. Bismuth subsalicylate 262 mg tablets two tablets p.o. t.i.d. 8. Epo-Alpha 10,000 units three times a week. 9. Simethicone 80 mg p.o. t.i.d. p.r.n. 10. Oxycodone 5 mg p.o. q. 4-6h. p.r.n. 11. Maalox 15-30 cc p.o. q.i.d. p.r.n. 12. Lisinopril 40 mg p.o. q. day. 13. Pantoprazole 40 mg p.o. q. day. 14. Senna one tablet p.o. b.i.d. 15. Prednisone 10 mg p.o. q. day until [6-10] where patient is to be changed to 5 mg p.o. q. day which should end on [6-24]. 16. Docusate sodium 100 mg p.o. b.i.d. 17. Bisacodyl two tablets b.i.d. p.r.n. 18. Atenolol 100 mg p.o. q. day. 19. Coumadin 5 mg p.o. q. hs.; however, INR should be checked q.o.d. for the next one week to stabilize INR between 2 and 3. After that M.D. can choose how often to check INR values. 20. Hydrochlorothiazide 25 mg p.o. q. day. 21. Lentis. 22. Glargine 15 units q. hs. DR.[Last Name (STitle) 5613],[First Name3 (LF) ] 12-AHU Dictated By:[Doctor Last Name 11001] MEDQUIST36 D: [2120-5-29] 21:19:03 T: [2120-5-30] 01:54:18 Job#: [Job Number 54612]	[ "5849", "V5861" ]
Admission Date: [2178-12-30] Discharge Date: [2179-1-1] Date of Birth: [2105-3-21] Sex: F Service: MEDICINE Allergies: Zestril Attending:[First Name3 (LF) 3705] Chief Complaint: SOB and dizziness Major Surgical or Invasive Procedure: endoscopy History of Present Illness: 73 y/o female with h/o metastatic adrenal CA (liver, kidney, thyroid), adrenal insufficiency on steroids since [2157], and s/p right hip arthroplasty [2178-7-29] secondary to AVN who presents with SOB and dizziness for two days. SHe states that two days ago she noticed the SOB with ambulation and decided to present to the hospital today because the SOB got worse and she also noticed dizziness on ambulation. She denied any abdominal pain or changes in the color of her stool. She checks her stool frequently and never noticed any blood or melena. She also denies any N,V or jaundice. She reports hitting her knee about 2 weeks ago and took Advil 2tbl [Hospital1 ] for 10 days. She reports having had a colonoscopy many years prior which was normal but does not recall the colonoscopy here at [Hospital1 18] in [2174] that showed a polyp. ROS: negative for CP, dysuria, jaundice, fever, night sweats, LE edema. positive for chills since yesterday and weight loss since her THR. . In the ED, the patient was found to have a hct of 22. She had a NG lavage that showed old blood in the stomach, that cleared quickly. She also had melena in her vault. SHe was hemodynamically stable the whole time. She received Famotidine 20mg iv, Dexamethasone 10mg iv and 2 U of PRBC. She reports that after the NG tube she developed some mild abominal pain in her lower quadrant. Past Medical History: 1. Metastatic adrenal cortical ca w/ known adrenal insufficiency, on steroids since [2157], post bilateral adrenalectomy treated with mitotane, complicated by metastases to the liver status post partial lobectomy in [4-27], more recently complicated by metastases to the left supraclavicular region and left retroperitoneum status post surgical resection in [2178] 2. Drainage of the left knee for septic arthritis in [2167] following a fracture. 3. A lower anterior resection for stage II rectal adenocarcinoma. 4. Resection of 2 parathyroid adenomas. 5. s/p ccy 6. s/p hepatic lobectomy as above for metastases 7. s/p right hip arthroplasty on [2178-7-27] secondary to AVN right femoral head 8. Osteoarthritis Social History: She denies tobacco use, denies alcohol use. She lives in [Location 2312] with her husband and one son. She has three children, two sons and one daughter and four grandchildren. She is independent in her ADLs. Family History: Father died in his 70s of an aneurysm in his abdomen. Mother died in her 90s of a stroke. She has one sister who died of a heart attack in her 50s and three brothers, one of whom has had bypass surgery and two others who are alive and well. Physical Exam: VS T 99.5 BP 116/53 HR 93 RR 24 O2Sat 100% on 2L Gen: NAD, AAOx3 HEENT: NC/AT, PERRLA, mmm, pale conjunctiva NECK: no LAD, JVD at 6cm COR: S1S2, regular rhythm, no r/g, [1-30] high pitched murmur over precordium non radiating PULM: CTA b/l, no wheezing or rhonchi ABD: + bowel sounds, soft, nd, mild tenderness over lower abdomen, no rebound or guarding Skin: warm extremities, no rash, multiple small ecchymosis over the chest and arms EXT: 2+ DP, no edema/c/c Neuro: moving all extremities, following commands, PERRLA . EKG: HR 80, SR, normal axis, LBBB, no changes to prior . CXR: Heart and mediastinum and lungs are unremarkable. No pneumothorax or sizable effusions Pertinent Results: [2178-12-30] 10:34PM HCT-24.1* [2178-12-30] 05:10PM PT-13.4* PTT-22.5 INR(PT)-1.2* [2178-12-30] 04:11PM HGB-7.6* calcHCT-23 O2 SAT-68 CARBOXYHB-2.6 MET HGB-0.1 [2178-12-30] 04:00PM GLUCOSE-138* UREA N-55* CREAT-1.0 SODIUM-138 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-17* ANION GAP-20 [2178-12-30] 04:00PM estGFR-Using this [2178-12-30] 04:00PM LD(LDH)-164 CK(CPK)-25* TOT BILI-0.1 [2178-12-30] 04:00PM cTropnT-<0.01 [2178-12-30] 04:00PM CK-MB-NotDone [2178-12-30] 04:00PM CALCIUM-8.9 PHOSPHATE-4.4 MAGNESIUM-2.1 [2178-12-30] 04:00PM HAPTOGLOB-55 [2178-12-30] 04:00PM WBC-13.4* RBC-2.61# HGB-7.3# HCT-22.2# MCV-85 MCH-28.0 MCHC-33.0 RDW-17.4 [2178-12-30] 04:00PM NEUTS-83.9* BANDS-0 LYMPHS-12.7* MONOS-2.0 EOS-0.7 BASOS-0.7 [2178-12-30] 04:00PM PLT COUNT-305. . IMAGING: [12-30] CTA: CTA OF THE CHEST: There is no evidence of pulmonary embolism. There is atherosclerotic disease of the aorta and great vessels, notably with narrowing of the left subclavian vein lumen proximally unchanged compared to the previous study. There are multiple small mediastinal lymph nodes that do not meet CT criteria for pathologic enlargement. There is no pericardial or pleural effusion. There is no pneumothorax. The airways appear patent to the level of the segmental bronchi bilaterally. Lungs show minimal dependent atelectasis. BONE WINDOWS: There is a stable mild compression fracture of T12 with minimal retropulsion of the superior endplate towards the spinal canal. Note is again made of an atrophic right kidney with a 4.6 cm nonobstructing stone at its lower pole, seen on limited images of the upper abdomen. . [2178-12-31] CXR: No acute cardiopulmonary process. Brief Hospital Course: # GIB: upper GIB, secondary to PUD in conjunction with Ibuprofen consumption over the last days. GI was consulted on this patient and did an EGD on the first day of hospitalization which revealed duodenal ulcers one of whichrequired cautery to stop slow ooze of blood. The patient remained hemodynamically stable and without hematemesis. She was transferred to the floor, where her hematocrit remained stable, she tolerated a PO diet and remained symptom free. She was started on a PPI twice daily. H pylori serologies were sent; results were pending at the time of discharge. The patient was instructed to follow up with her PCP for these results. . # Adrenal carcinoma: no evidence of recurrence, but concerning in the context of weight loss since THR. Mitotane was held throughout her hospitalization and restarted upon discharge. . # Adrenal insufficiency: absolute insufficiency in the context of bilateral resection. The patient was given stress dose steroids with hydrocortisone 100mg Q6h, which covers glucocorticoids and mineralocorticoid activity for 24 hours, then was restarted on her home regimen of dexamethasone and fludrocortisone. # Hypothyroid- the patient was continued on her outpatient regimen. FULL CODE Medications on Admission: ASPIRIN E.C. 81mg DEXAMETHASONE 5mg [Hospital1 ] FLUDROCORTISONE 100 MCG QD LEVOXYL 50MCG QD MITOTANE 500 MG QD NORVASC 10MG QD Discharge Medications: 1. Levothyroxine Sodium 25 mcg IV DAILY 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): Take 1 tablet twice daily for 1 month, then 1 tablet once daily indefinitely. . Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Dexamethasone 2 mg Tablet Sig: 2.5 Tablets PO Q12H (every 12 hours). 4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Mitotane 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI Bleed, PUD, anemia Secondary: Adrenal Insufficiency Discharge Condition: Good- Hct stable, pain free, vitals stable, tolerating PO's, ambulating well. Discharge Instructions: During this admission you have been treated for anemia due to a bleeding ulcer in your small intestine. Please continue to take all medications as prescribed. We have started a medication called Pantoprazole. You should take the Pantoprazole twice daily for 1 month, then continue taking one pill daily indefinitely. Do not take Ibuprofen (also called Advil, Motrin) or Naprosyn (Aleve). You may use Acetominophen (Tylenol) as needed for pain. Avoid fatty, spicy or acidic foods. Do not resume taking Aspirin until instructed to do so by your doctor. Call your doctor or come to the emergency room immediately if you develop dark, black or bloody stools, vomiting, shortness of breath, lightheadedness, dizzyness, chest pain, or any other concerning symptom. Followup Instructions: Follow up with your PCP next week, call to make an appointment. You had serologies for H. Pylori sent while you were in the hospital; your PCP should follow up on these results.	[ "2851" ]
Admission Date: [2129-8-1] Discharge Date: [2129-8-22] Date of Birth: [2088-5-24] Sex: F Service: EMERGENCY Allergies: Ambisome / Penicillins / Cefepime Attending:[First Name3 (LF) 2565] Chief Complaint: Hypoxemia, tachypnea Major Surgical or Invasive Procedure: L IJ Central line placed History of Present Illness: Ms. [Name14 (STitle) ] is a 41 year-old female with AML status post HIDAC and MRD allo-[Name14 (STitle) 3242] [9-/2127] with remission but subsequent relapse with CNS involvement in [1-/2129] treated with XRT and IT MEC chemo with eventual remission. She presented again in [7-/2129] with HC and elevated ICP, and VP shunt was placed. She was readmitted on [2129-8-1] from clinic with altered mental status and low-grade fever. Her work-up in the hospital included normal shunt series, normal VP tap (but protein 60) and unremarkable LP. Work-up further revealed bilateral hilar infiltrates on CXR, with preserved saturation at presentation. Subsequent imaging included CT chest which showed bilateral ground glass opacities with upper lobe predominance. Sputum culture was negative. While in hospital, she was persistently febrile to 102 on [8-3]. Pulmonary was consulted, and bronchoscopy performed on [2129-8-4] showed thin secretions, but was otherwise largely underwhelming. A BAL grew no organisms, and rapid viral screen was negative. On the floor, she developed a new oxygen requirement on [2129-8-7] of 2L via NC. Repeat imaging studies also showed progression of infiltrates, and concern was raised over possible PCP (last inhaled Pentamidine dose [2129-7-14]). She was started on empiric Rx for PCP with Bactrim and Prednisone on [2129-8-7], and Levofloxacin was added to cover for atypicals. She transiently defervesced on the floor, but developed progressive hypoxemia with increasing oxygen requirement to 6L NC, then shovel mask, and eventually NRB. ABG on floor on shovel mask 70% 7.28/31/71. Antifungal coverage was added on [2129-8-9] (Caspofungin). She was given Lasix 20 mg IV, then 10 mg IV, with U/O 700mL without much improvement in her respiratory status. An ICU consult was called. Other issues on the floor have included hyponatremia with nadir to 122, with elevated UOsm and UNa suggestive of SIADH. Renal has been following. On arrival to ICU, patient tachypneic, hypoxemic to 70s on RA, 96% on NRB. She denies chest pain, mild non-productive cough. Past Medical History: 1) AML - [9-7]: Dx with M5 AML. Presented c cholecystitis, found to have WBC 56k with 50% blasts and plts 20. Marrow biopsy at [Hospital1 18] showed AML. The cholecystitis perforated, resulting in emergent open chole complicated by fistula and bleeding and 2 month stay in MICU. Daily Hydroxyurea was used for maintenence until she recovered. She had initial cytogenetic abnormality of inversion-16 which also had resolved. (7+3) Induction was done when she was stable. - [2127-11-10] repeat marrow showed a markedly hypercellular marrow with no blast clusters and CD34+ blasts comprising less than 3% of the cellularity. - [2127-12-4] started Consolidation with four cycles of HIDAC - [2127]: bone marrow biopsy later shows relapsed acute leukemia. Salvage therapy with mitoxantrone/etoposide. Course was complicated by very-delayed count recovery. Marrow bx after day 30 did show evidence of recovering marrow without a clear increase in blasts although there were some monocyte precursors noted. They were thought to not resemble her underlying leukemia. - d0 [2128-10-1] MRD allo SCT. - [2129-1-14]: admission for relapsed leukemia in the CSF and R bell's palsy. Base of skull XRT and intrathecal chemotherapy through an ommaya reservoir ([2129-1-7]) placed during her admission - [Date range (1) 57171]: continued on q2week Depo ARA-C, also with withdrawing immunosuppression. There was noted rising LFTs, unclear whether [1-6] GVH vs the underlying Hep C. - MEC finished on [3-20] - Biweekly intrathecal depocyt started [2-7], last dose [2129-4-10] - DLI [2129-4-6] 2. Endocarditis in [2125] 3. MI [2125] 4. AVR [2125] 5. MVR [2125] 6. Stroke with left hemiparesis [2125] 7. Hepatitis C: HCV Ab positive [2-/2128], VL [4-9] 22,100,000, liver biopsy in [2-7] with stage 1-2 fibrosis and bile duct damage likely [1-6] hep C but cannot exclude GVHD 8. Asthma: only on prn albuterol MDI 9. GERD 10. h/o coag neg staph, VRE Social History: She presently is living in [Hospital6 ] home. Her sister-in-law prepares her medications for her. She is widowed and her husband died from complications related to pancreatitis. She doesn't have children. She previously worked as a computer programmer with 2 years college training. She has not worked for two years and is assisted through [Social Security Number 57174]social security disability. She has a previous history of heroin use which she stopped in [9-6]. Family History: No family history of malignancy. Her mother has hypertension, her father had type II diabetes and died from an MI and stroke at the age of 57, and her brother has HIV. Physical Exam: VITALS: Afebrile, BP 108/66, HR 100-110s, RR 24, Sat 92% on NRB. GEN: Tachypneic, unable to speak with full sentences in moderate respiratory distress. Anxious. HEENT: Slightly dry MM. JVP difficult to assess secondary to respiratory distress. RESP: Bilateral inspiratory crackles, most prominent at the upper lung zones posteriorly. CVS: RRR. GI: BS present. Abdomen soft, non-tender. EXT: [1-7]+ bilateral LE edema. Neuro: Oriented to place, year, month. Pertinent Results: Laboratory results: [2129-8-1] 11:40AM UREA N-13 CREAT-0.6 SODIUM-133 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-22 ANION GAP-14 [2129-8-1] 11:40AM WBC-6.4# RBC-3.73* HGB-12.7 HCT-38.5 MCV-103* MCH-34.0* MCHC-33.1 RDW-16.7* [2129-8-1] 11:40AM NEUTS-66.7 LYMPHS-25.9 MONOS-4.9 EOS-1.9 BASOS-0.5 [2129-8-1] 11:40AM CALCIUM-8.7 PHOSPHATE-2.1* MAGNESIUM-1.9 URIC ACID-2.6 [2129-8-1] 11:40AM ALT(SGPT)-45* AST(SGOT)-93* LD(LDH)-236 CK(CPK)-20* ALK PHOS-352* TOT BILI-3.8* DIR BILI-2.5* INDIR BIL-1.3 [2129-8-1] 03:36PM LACTATE-1.3 RELEVANT IMAGING DATA: [2129-8-3] CT CHEST W/O: Multiple focal areas of ground-glass opacity in both lungs and peribronchial infiltration are more prominent in the upper lobes, and confluent in the left apex. There is no pleural or pericardial effusion. [2129-8-7] CT CHEST W/O: Worsening diffuse bilateral patchy ground glass opacities with an upper lobe predominance. This appearance is most consistent with an atypical infection such as PCP or viral pneumonia, as noted previously. Non-infectious etiologies such as drug reaction could also be considered. [2129-8-9] CXR portable: The previously described extensive bilateral parenchymal densities are again identified. They have progressed to a moderate degree in the left mid lung field and lower lung field whereas on the right base, a certain degree of regression can be identified. On both films, there is no evidence of pleural fluid accumulation in the lateral pleural sinuses. [2129-8-10] CXR portable: Increase bilateral airspace opacities with decreased lung volumes Brief Hospital Course: A/P: 41 year-old female with AML in remission, with progressive hypoxemic respiratory failure. Family meeting was held yesterday with Heme-Onc team. Pt will be made CMO this afternoon after her brothers have spoken to her mother. Otherwise ct with current treatment. 1) Hypoxemic respiratory failure: The cause of her acute respiratory decompensation was unclear to the housestaff team. Within the first day or two of her admission to the [Hospital Unit Name 153] there was a drastic change in her cxray. She now had multilobular opacities suggestive of an ARDs like picture. She was placed on broad spectrum antibiotics-Aztreonam, Vancomycin, Flagyl, Caspofungin, Levoquin along with Bactrim and steroids for presumptive PCP [Name Initial (PRE) 31304]. No nidus of infection was found and all culture data was negative. She was also started on steroids. The pt was extremely difficult to ventilation requiring high PEEP and pressure support. Abdominal paracentesis showed blasts in her abdomen suggesting reoccurence of her cancer. This is most likely the cause of her acute failure. Pt was then made CMO and she was slowly weaned off the ventilator. 2) Hemodynamic instability: Patient was persistently hypotensive during her [Hospital Unit Name 153] stay. Thought to be secondary an underlying infection, but all culture data was negative. She initially required Levophed to maintain her urine output and blood pressure but Dopamine was added in hope to wean the Levophed down. This was unsuccessfull and she required pressors until her family decided to change her code status to CMO. 3) Abdominal distention: Patient required extremely high amounts of Fentanyl and Versed to keep her sedated and synchronous with the ventilator. Her abdomen continued to increase in size, thought to be an ileus due to failure of passing stool (secondary to pain medications). CT scan of the abdomen was done and did not suggest an obstruction. Her belly was then tapped and preliminary cytology suggested reoccurence of her Leukemia. No further intervention was indicated at this time, per discussion with [Hospital Unit Name 3242]. Family was informed of this new information and they decided to change code status to CMO. 4) Thrombocytopenia: Likely secondary to possible underlying malignancy. She required multiple platelet transfusions to keep her platelet level above 30. 5) FEN: Ct with TPN. 6) Ppx: Pneumoboots, no heparin SC given thrombocytopenia. PPI. Bowel regimen prn. Insulin SS while on high dose steroids. 7) Access: PICC line, femoral a-line, left IJ. Pt passed away on [2129-8-22] after her family decided to change her code status to CMO. No autopsy was obtained. Medications on Admission: Caspofungin Acyclovir 400 mg IV q 8 hours Ketoconazole TP [Hospital1 ] Levofloxacin 500 mg PO QD Lactulose prn Methadone 10 mg PO BID, 5 mg PO prn Albuterol neb Benzonanate 100 mg PO TID Dulcolax prn Clotrimazole troches Benadryl prn Anzemet prn Folate 1mg PO QD Guaifenesin q6 prn Atrovent neb Topical flagyl Nystatin oral suspension Dilatin 100 mg IV TID Prednisone 40 mg PO BID Bactrim 350 mg IV q8 hours Ursodiol 300 mg PO TID Senna, prochloperazine Discharge Medications: Pt passed away on [2129-8-22] Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: AML Acute respiratory failure Discharge Condition: Pt died on [2129-8-22] Discharge Instructions: Pt died on [2129-8-22] Followup Instructions: Pt died on [2129-8-22]	[ "78552", "4280", "5845", "2875", "0389", "99592" ]
Admission Date: [2196-4-11] Discharge Date: [2196-4-14] Date of Birth: [2164-11-7] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1] Chief Complaint: Presents for surgery Major Surgical or Invasive Procedure: [4-11] Laparoscopic assisted ileocecectomy History of Present Illness: This is a 31 year old male wth medically refractory Crohn disease with recurrent obstruction. He presents for elective surgery. Past Medical History: Crohn's disease involving the ileum and pancolon. s/p right hydrocele removal, s/p surgery for gynecomastia, c/b postoperative pneumothorax, s/p left ear preauricular lesion consistent with pilomatricoma, Osteopenia, Anemia, Leukopenia [12-25] Imuran. Social History: Works as a consultant epidemiologist, quit tobacco in [2188], social alcohol use Family History: Father: prostate cancer Mother: healthy Brother with [Name (NI) 4522] disease Physical Exam: Pertinent Results: Operative report: Ileocecal Crohn disease. OPERATION: Laparoscopic assisted ileocecectomy Post-operative labs: [2196-4-11] 12:06PM BLOOD Hct-41.2 [2196-4-12] 06:45AM BLOOD Hct-23.9# [2196-4-12] 03:23PM BLOOD Plt Ct-178 Discharge labs: [2196-4-14] 06:20AM BLOOD Hct-25.2 [2196-4-13] 05:29AM BLOOD PT-12.0 PTT-23.1 INR(PT)-1.0 Brief Hospital Course: This patient was admitted on [4-11] for his procedure. He was prepared and consented as per standard. He was brought to the PACU in a stable condition. In the PACU, he had low urine output, with a Hct in the 40 range. He was given a fluid bolus and his urine output improved over the course of the night of POD0. . In the morning of POD1, the patient was complaining of dizziness when sitting up and the sensation of feeling light-headed when getting up out of bed. The patient's hct was checked and found to be 23.9 (checked twice). He was also noted to have frank bleeding rectally (approx 200cc) and was tachycardic and with a low BP. He was then transferred to the SICU for closer monitoring, he received two units of PRBC's, he remained hemodynamically stable with a repeat hematocrit of 26. POD 2, he was transferred back to an in-patient nursing unit in stable condition, foley catheter was removed and he was voiding without difficulty. POD 3, his diet was advanced, his pain was controlled with oral Dilaudid, he had +flatus, and remained hemodynamically stable. He was discharged home in good condition on [4-14] tolerating a full liquid diet, he was to slowly advance to a regular diet at home. He was provided a prescription for Dilaudid and Prednisone. He was to follow-up with Dr. [Last Name (STitle) ] in 2 weeks and his gastroenterologist, Dr. [First Name (STitle) 437] in [12-27] weeks. Medications on Admission: Prednisone 15', Imuran 50', Asacol 4.8', Remicade 10 mg per kilogram dosing every 6 weeks, Prilosec 30', Fosamax 3' Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed: Take with food. Disp:40 Tablet(s) Refills:0 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Crohns disease Post-operative blood loss anemia Discharge Condition: Good Discharge Instructions: Notify MD or return to the emergency department if you experience: Increased or persistent pain not relieved by pain medication Fever > 101.5 Nausea, vomiting, diarrhea, or abdominal distention Inability to pass gas, stool, or urine If incision develops redness or drainage Shortness of breath, dizziness, palpatations, chest pain, or bright red blood from any part of the body Any other symptoms concerning to you You may shower and wash incision with soap and water, pat dry Allow white paper strips to peel away on their own No swimming or tub baths for 2 weeks Avoid lifting more than 10lbs and abdominal stretching for 4 weeks No driving or alcohol use while taking pain medication You may also take Tylenol every 4-6 hours as needed for pain, do not exceed 3,000mg/24 hours You should continue your home medications of: Imuran, Prilosec, and Fosamax Be sure to eat small frequent meals and drink fluids throughout the day You can slowly advance your diet to soft solids You should slowly start to resume daily activities including walking throughout the day Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in [11-24] weeks, call [Telephone/Fax (1) 9] for an appointment Follow-up with Dr. [First Name (STitle) 437] in [12-27] weeks, call ([Telephone/Fax (1) 8892] for an appointment Completed by:[2196-4-14*]	[ "2851" ]
Admission Date: [2197-5-9] Discharge Date: [2197-5-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 358] Chief Complaint: Mental status changes Major Surgical or Invasive Procedure: None History of Present Illness: 89F with advanced dementia who presents with dehydration, somnolence, recent Hct drop and significant diarrhea. The patient was a new admission to [Hospital 100] Rehab on [2197-5-1]. At that time she was found to be dehydrated and to have a LLL PNA. In addition, she was delirious and had an elevated WBC. She was initially treated with ceftriaxone. Vancomycin was added on [2197-5-5] for continuing fever and suspicion of MRSA. She was also started on IV normal saline but remained hypernatremic and hyperchloremic so was switched on [2197-5-5] to D5W. Her hematocrit has been decreasing since admission (36.6 initially then down to 27.2 on [2197-5-8]) and was having heme positive stools since [2197-5-5]. In the AM of [2197-5-9] her nurse found her incontinent of stool. Temperature at that time was 100.2 Also of note her nares MRSA screen was negative so vancomycin was discontinued. She received both influenza and pneumoVax on [2197-5-1]. In the ED her vitals were 98.1 103 134/32 28 94%RA. A CXR was concerning for LLL infiltrate. A lactate was 7.4. She received ~6L of normal saline. A central line was deferred per discussion with family and decision that her potential agitation would be limiting. She received flagyl, po vanco, iv vanco, iv levaquin. CT abd was declined after discussion with family. Past Medical History: - Alzheimer's disease - DM Type II - Anemia - GERD - S/p L humerus fx - Urinary incontinence - Stage II right buttock ulcer Social History: The patient recently moved from [Location (un) 583] Gardens Alzheimer's Unit to [Hospital 100] Rehab on [2197-5-1]. Born and raised in [Location (un) 14307], MA. bachelor's degree at [University/College 77666]. Married then had 6 children. Now widowed. Family History: non-contributory Physical Exam: AF, VSS, on room air General Appearance: Well nourishedEyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Respiratory / Chest: clear Abdominal: Soft, Non-tender, Distended Extremities: Right: 2+, Left: 2+ Musculoskeletal: Muscle wasting Neurologic: Responds to: Not assessed, No(t) Oriented (to): Not oriented, Movement: Not assessed, Tone: Not assessed PICC, rectal tube, [Known lastname ] urinary catheter present Pertinent Results: Admission: [2197-5-9] 03:54PM BLOOD WBC-8.0 RBC-3.67* Hgb-9.9* Hct-31.6* MCV-86 MCH-27.1 MCHC-31.4 RDW-14.4 Plt Ct-155 [2197-5-9] 03:54PM BLOOD Neuts-85.3* Lymphs-12.0* Monos-1.8* Eos-0.8 Baso-0.1 [2197-5-9] 05:10PM BLOOD PT-16.0* PTT-30.6 INR(PT)-1.4* [2197-5-9] 03:54PM BLOOD Glucose-367* UreaN-21* Creat-0.8 Na-139 K-4.1 Cl-104 HCO3-18* AnGap-21* [2197-5-9] 03:54PM BLOOD ALT-45* AST-63* AlkPhos-141* TotBili-0.3 [2197-5-10] 03:43AM BLOOD Calcium-6.9* Phos-1.8* Mg-1.4* [2197-5-10] 08:12AM BLOOD Hapto-282* [2197-5-10] 06:51PM BLOOD Glucose-124* Lactate-2.8* Na-138 K-5.5* Cl-115* calHCO3-28 [2197-5-9] 04:01PM BLOOD Glucose-326* Lactate-7.4* Na-139 K-4.0 Cl-105 [2197-5-9] 05:47PM BLOOD Lactate-5.0* [2197-5-9] 07:24PM BLOOD Lactate-3.9* =========================================================== Discharge: [2197-5-12] 03:42AM BLOOD WBC-4.8 RBC-2.90* Hgb-7.9* Hct-24.0* MCV-83 MCH-27.3 MCHC-33.0 RDW-15.2 Plt Ct-140* [2197-5-12] 03:42AM BLOOD Plt Ct-140* [2197-5-11] 10:45AM BLOOD PT-19.0* PTT-31.8 INR(PT)-1.8* [2197-5-12] 03:42AM BLOOD Glucose-121* UreaN-6 Creat-0.4 Na-141 K-3.1* Cl-111* HCO3-22 AnGap-11 [2197-5-10] 08:12AM BLOOD LD(LDH)-218 TotBili-0.3 [2197-5-12] 03:42AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.7 [2197-5-10] 05:43AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.014 [2197-5-10] 05:43AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2197-5-10] 05:43AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 DIRECT INFLUENZA A ANTIGEN TEST (Final [2197-5-10]): Negative for Influenza A viral antigen. DIRECT INFLUENZA B ANTIGEN TEST (Final [2197-5-10]): NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. Legionella Urinary Antigen (Final [2197-5-10]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. URINE CULTURE (Final [2197-5-10]): NO GROWTH. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2197-5-10]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). C. diff x 2 Pending on discharge =============================================== PORTABLE ABDOMEN [2197-5-9] 4:34 PM FINDINGS: Single rotated supine view of the abdomen was submitted for review. The right margin of the abdomen is excluded from view. The ascending and transverse colon are filled with air, measuring up to 5 cm. Abdominal aorta is calcified. The patient is post- right total hip replacement. IMPRESSION: Limited study, no evidence of megacolon. ================================================ CHEST (PORTABLE AP) [2197-5-9] 4:34 PM FINDINGS: Cardiac size is moderately enlarged, with left ventricular configuration. The aortic arch is calcified. There is a retrocardiac opacity, which may represent left lower lobe atelectasis, consolidation, or combination of both. There is a small left pleural effusion. Pulmonary vascularity is normal. There is no pneumothorax. Osseous structures are diffusely demineralized. IMPRESSION: Left lower lobe opacity, may represent atelectasis, consolidation, or combination of both. Small left pleural effusion. =============================================== Brief Hospital Course: 89 year old woman with advanced dementia, DM2, GERD presenting with altered mental status, lactic acidosis and abdominal pain while continuing a recent antibiotic course for pneumonia. # Sepsis: Hospital acquired pneumonia (LLL) with hx of negative MRSA screen. Was started on ceftriaxone on [5-3] at [Hospital 100] Rehab, and received 7 days of treatment. The patient has known risk factors for multi-drug resistent organisms including uncontrolled diabetes, nursing home habitation, and severe pressure ulcers. Also had lactic acidosis on admission, now resolved after fluid resuscitation. Blood pressure has remained stable throughout her illness. Started on Vanc/Zosyn for broad coverage (possible sources include pna, UTI, pressure ulcers). Also with significant diarrhea concerning for C. Diff in the setting of abx use. Now C. Diff negative x1, labs all stable, DIC labs negative. Clinically looks well, and is back to baseline per family. - No need for broad antibiotic coverage at this point. Will discontinue and follow clinically at [Hospital1 100] Senior Life. - Follow all cultures, no cough so unable to get sputum. All NGTD. - DFA for flu negative - Urine legionella negative - DIC and hemolysis labs negative - Follow for 3rd C. Diff to rule out, continue empiric therapy with IV flagyl until rules out - Continue to monitor respiratory status - IVF prn as low PO # Altered Mental status: Per family, appears to be at baseline. Has had significant decline over the past few weeks with regard to ability to do self-care. She developed fever and delirium during her initial admission around [5-1] with some improvement after treatment for underlying pna and dehydration. - Continue to monitor - Lights on in am, lights out in pm to avoid sundowning - Continue frequent reorientation and monitoring # Acute on chronic blood loss anemia secondary to GI bleed: After patient was started on abx for her pneumonia, she developed decreasing Hct, from 32->26.5. Also in the setting of agressive volume resuscitation. On admission was 31, now stable at 23 after significant volume resuscitation (she rec'd 6 L NS in the ED). Increased on am labs today. Guaiac negative in the ED, positive here, no gross blood. Anemia likely multifactorial, follow prn. # Diabetes mellitus type 2: By report, has been poorly controlled. Patient was on metformin prior, now has a lactic acidosis, likely in the setting of continuing metformin with poor PO and diarrhea. Also on lisinopril at home, low dose (? for renal protection vs. hypertension) - Hold oral agents metformin and glipizide - D/c metformin indefinitely - Continue insulin sliding scale - Hold lisinopril pending improvement in blood pressures # Wound care: Patient has stage II decubitus ulcer on sacrul and blood blister on her right heel. - Wound care, decubitus precautions, air bed. # Code: DNR/I confirmed with patient's daughter/HCP (hcp [First Name8 (NamePattern2) 77667] [Name (NI) ] [Telephone/Fax (1) 77668], [Telephone/Fax (1) 77669]). # PICC line: placed in ICU, can remain while finishing flagyl course. Decision to remove per HSL physician. Transferred back to [Hospital1 100] Senior Life for remainder of course on [2197-5-12]. She was seen by palliative care while admitted and although family would like to slowly move toward a comfort care goal of treatment, they wish to continue current aggressive therapies. Medications on Admission: ceftriaxone 1 g daily metronidazole 500 mg q8 D5W at 50cc/hr tylenol 650 mg q4prn celexa 10 mg daily B12 1000 mcg daily colace 100 mg daily lisinopril 2.5mg daily metformin 1g [Hospital1 ] glipizide 20 mg [Hospital1 ] insulin regular sliding scale omeprazole 20 mg [Hospital1 ] poly iron 150mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: PO/PR. 2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 4. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: 1. altered mental status 2. dementia 3. diarrhea 4. poor oral intake 5. hypertension Discharge Condition: demented, interactive, vital signs stable, on room air, requires assistance with all ADLs. Has [Known lastname ], rectal tube, PICC line. Discharge Instructions: Ms. [Known lastname 8389] was hospitalized for altered mental status, with unclear origin on workup. She is back to her baseline, and will be transferred back to [Hospital 100] Rehab for futher mananagement and care. Please call your primary physician with any questions or concerns, and return to the emergency department with alarming symptoms such as fever greater than 101, difficulty breathing, altered mental status. Followup Instructions: Please follow with in-house physicians at [Hospital1 100] Senior life per their discretion. Will need to be seen daily until stable regarding diarrhea.	[ "0389", "486", "2762", "2851", "4019", "25000", "53081" ]
Admission Date: [2164-8-9] Discharge Date: [2164-8-19] Date of Birth: [2099-1-5] Sex: M Service: CARDIOTHORACIC Allergies: Norvasc Attending:[First Name3 (LF) 1505] Chief Complaint: exertional angina Major Surgical or Invasive Procedure: [2164-8-13] AVR ( [Street Address(2) 6158]. [Male First Name (un) 923] mechanical)/CABG x2 LIMA to LAD, SVG to OM) History of Present Illness: 65M with known murmur for years. He recently had new PCP and [Name Initial (PRE) ] routine ECG was concerning (downward sloping STs inferolaterally). He denies any symptoms. An echocardiogram revealed severe AS ([Location (un) 109] 0.9), gradient 36.Nl LV/RV. A nuclear stress at [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 687] V was negative. Cath revealed 60% distal LM, 40% mid LAD, 2nd diagonal lesions andno cx or Right lesions. He was referred for surgical eval. Past Medical History: varicocele repair as teen Aortic Stenosis Coronary Artery Disease noninsulin dependent Diabetes Mellitus Hypertension Hyperlipidemia Social History: Last Dental Exam: 8 drinks/week [] Illicit drug use no quit smoking 19 yrs ago Family History: No Premature coronary artery disease Father died of MI at 78yo, had AVR at 65yo Mother died at 86yo with h/o stroke Sister died at 44 of lung cancer Physical Exam: Pulse: Resp: O2 sat: B/P Right:120/60 Left:118/60 Height: 63" Weight: 170lb Five Meter Walk Test #1_______ #2 _________ #3_________ General: WDWN in NAD 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 [x] Murmur [] grade 3/6 SEM base to neck_ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm []x, well-perfused [x] Edema [] ___n__ Varicosities: None [x] 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:xx Left:xx xx= transmitted cardiac M bilat Pertinent Results: Conclusions PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF= 75%). 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 complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST-BYPASS: The patient is atrially paced. There is normal biventricular systolic function. There is a bileaflet prosthesis located in the aortic position. It appears well seated and demonstrates normal leaflet function. There is trace to mild valvular aortic regurgitation representing the washing jets intrinsic to this valve. The maximum pressure gradient through the aortic valve was 31 mmHg with a mean of 15 mmHg at a cardiac output of 7 liters/minute. The thoracic aorta was intact after decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD, Interpreting physician [Last Name (NamePattern4) ] [2164-8-13] 17:41 [2164-8-18] 07:00AM BLOOD WBC-5.5 RBC-3.26* Hgb-10.9* Hct-30.4* MCV-93 MCH-33.5* MCHC-35.9* RDW-13.0 Plt Ct-208# [2164-8-19] 06:15AM BLOOD PT-27.2* INR(PT)-2.6* [2164-8-19] 06:15AM BLOOD UreaN-12 Creat-0.6 Na-140 K-4.4 Cl-104 CXR FINDINGS: As compared to the previous radiograph, there are newly appeared small bilateral pleural effusions. Subsequent retrocardiac atelectasis. No evidence of pneumonia. Unchanged alignment of the sternal wires, unchanged position of the right internal jugular vein catheter. Brief Hospital Course: Transferred from OSH on [8-9] and underwent pre-op workup. He underwent AVR mechanical valve and CABGx2 on [8-13]. The surgery was performed by Dr. [Last Name (STitle) ] and was transferred to the CVICU in stable condition, he was intubated on phenylephrine and propofol drips initially then required Nitro for Htn. He extubated early the next morning without difficulty, his gtts were titrated off. He awoke neurologically intact and transferred to the floor on POD #1. His chest tubes and wires were removed in timely fashion and without incident. He was started on Heparin and coumadin for Mechanical valve, INR goal 2.5-3.0. His INR became supratherapeutic and his coumadin was held, TTE was obtained which was negative for effusion. His coumadin was later resumed at a lower dose. He was hypertensive and started on lisinopril and betablockade increased as tolertated. He has had brief episodes of SVT/afib but nothing sustained. He was started on a statin for the first time which he is tolerating well. His renal function has remained stable and he is being discharged to home on one week course of lasix for continued gentle diureses. His blood sugars have been stable and he is on his pre-op dose of glucophage. He was seen by PT and cleared for discharge to home on POD# 6. His follow-up appointments were not arranged at the time of discharge and the office will need to call with dates. His coumadin will be managed by the cardiac surgery service # [Telephone/Fax (1) 170] until arrangement can be made for him to f/u with his PCP or cardiologist Medications on Admission: Toprol XL 100mg daily Lisinopril 20mg [Hospital1 ] Aspirin 81mg daily Metformin 500mg [Hospital1 ] Fish oil Multivitamin Discharge Medications: 1. atorvastatin 10 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO DAILY (Daily). Disp:60 [Hospital1 8426](s) Refills:2 2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. multivitamin [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO DAILY (Daily). Disp:60 [Hospital1 8426](s) Refills:2 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. aspirin 81 mg [Hospital1 8426], Delayed Release (E.C.) Sig: One (1) [Hospital1 8426], Delayed Release (E.C.) PO DAILY (Daily). Disp:60 [Hospital1 8426], Delayed Release (E.C.)(s) Refills:2 6. potassium chloride 10 mEq [Hospital1 8426] Extended Release Sig: Two (2) [Hospital1 8426] Extended Release PO Q12H (every 12 hours) for 1 weeks. Disp:28 [Hospital1 8426] Extended Release(s) Refills:0 7. metformin 500 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO BID (2 times a day). Disp:60 [Hospital1 8426](s) Refills:2 8. acetaminophen 325 mg [Hospital1 8426] Sig: Two (2) [Hospital1 8426] PO Q4H (every 4 hours) as needed for pain, fever. Disp:60 [Hospital1 8426](s) Refills:0 9. metoprolol tartrate 25 mg [Hospital1 8426] Sig: Three (3) [Hospital1 8426] PO TID (3 times a day). Disp:270 [Hospital1 8426](s) Refills:2 10. Lasix 40 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO once a day for 1 weeks. Disp:7 [Hospital1 8426](s) Refills:0 11. warfarin 1 mg [Hospital1 8426] Sig: [Name8 (MD) ] MD [First Name (Titles) ] [Last Name (Titles) 8426] PO DAILY (Daily) as needed for mechanical valve. Disp:60 [Last Name (Titles) 8426](s) Refills:2 12. lisinopril 5 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO once a day. Disp:30 [Last Name (Titles) 8426](s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] [Hospital6 407] Discharge Diagnosis: aortic stenosis coronary artery disease s/p AVR/CABG non insulin dependent diabetes mellitus hypertension hyperlipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema ..................... Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] date to be arranged Cardiologist:Dr. [Last Name (STitle) 4610] date to be arranged Wound Check in one week to be arranged Please call to schedule appointments with your Primary Care Dr.[Last Name (STitle) 78174] in [3-27] 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 aortic valve Goal INR 2.5-3.0 First draw day after discharge Results to phoneed to [Telephone/Fax (1) 170] until can be arranged with PCP or cardiologist Completed by:[2164-8-19]	[ "4241", "41401", "25000", "4019", "2724", "42789", "V1582" ]
Admission Date: [2156-9-24] Discharge Date: [2156-9-27] Date of Birth: [2156-9-24] Sex: M Service: NB HISTORY: Patient is a 3.088 kg product of a 36 [12-17] week gestation born to a gravida 2, para 1 woman whose pregnancy was apparently complicated only by chronic hypertension. Cesarean section done on day of delivery because of onset of labor and previous history of classical C-section and large fibroids. No sepsis risk factors. Blood type B positive, antibody negative, rubella immune, RPR nonreactive, hepatitis C surface antigen negative, GBS negative. Infant did well at delivery with Apgars of 7 at 1 minute and 8 at 5 minutes. Given blow-by oxygen and stimulation. Brought to the Neonatal Intensive Care Unit after visiting with parents for mild grunting, flaring, and retracting. PHYSICAL EXAMINATION ON ADMISSION: Birth weight 3085 grams, head circumference 35 cm, length 43 cm. General: On exam, pink, active, non-dysmorphic infant, well saturated and perfused on room air. Skin: Without lesions. Head, eyes, ears, nose, throat: Within normal limits. Lungs: Clear; crackles noted bilaterally. Mild grunting at times. Appears to be resolving. Cardiovascular: No murmur; normal S1, S2; regular rate and rhythm. Pink, well perfused. Abdomen: Benign. Genitalia: Normal male. Neuro: Nonfocal and age appropriate. Hips: Normal. Spine: Intact. Anus: Patent. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Infant did not require any oxygen supplementation this hospitalization as remained on room air with respiratory rate of 50s to 60s. Initial grunting on admission resolved by day of life 1. Oxygen saturations have been greater than 96 percent. Infant had not had any apnea or bradycardia this hospitalization. Cardiovascular: No murmur; infant has remained hemodynamically stable with heart rate 140 to 150 and mean blood pressure is 39 to 46. Fluids, electrolytes, and nutrition: Due to mild respiratory distress infant received nothing by mouth, 60 cc/kg/day of D10W. Enteral feedings were started on day of life 1. Patient is currently breast feeding ad. lib. or taking Similac 20 calories per ounce ad lib. Dextrose sticks have remained normal, and infant has been off of intravenous fluids since day of life 1. The most recent weight is 2810 grams. Gastrointestinal: Infant has not received phototherapy this hospitalization. Hematology: CBC on admission - White count 16.2, hematocrit 42 percent, platelets 249,000, 68 neutrophils, 1 band. Infant did not receive any blood transfusions this hospitalization. Infectious Disease: Blood culture was sent on admission due to mild respiratory distress. Antibiotics were not started due to no maternal risk factors. Blood culture remained negative to date. Neurology: Normal neuro exam. Sensory hearing screening is recommended prior to discharge home. DISCHARGE CONDITION: Stable on room air. DISPOSITION: Level 1 Newborn Nursery, name of primary pediatrician Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 43831]). CARE RECOMMENDATIONS: Breast feeding or Similac 20 calories p.o. ad lib. Medications: None. Car seat position screening recommended prior to discharge. State newborn screen is to be sent on day of life 3. Infant has not received any immunizations. Hepatitis B is recommended. Immunizations recommended: Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this, the age for the 24 months of the child's life immunization against influenza is recommended for household contacts and out-of-home care givers. Follow-up appointment with primary pediatrician after discharge. DISCHARGE DIAGNOSES: Status post mild transitional respiratory distress Status post rule out sepsis [First Name8 (NamePattern2) 1154] [Last Name (NamePattern1) ], MD [MD Number(2) 56585] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2156-9-27] 11:11:40 T: [2156-9-27] 11:51:49 Job#: [Job Number 57322]	[ "V290", "V053" ]
Admission Date: [2143-7-29] Discharge Date: [2143-8-3] Date of Birth: [2087-12-8] Sex: M Service: SURGERY Allergies: Garlic Oil Attending:[First Name3 (LF) 2777] Chief Complaint: Right lower leg pain Major Surgical or Invasive Procedure: 1. [2143-7-30] Lower extermity catheterization 2. [2143-7-30] Lower extermity catheterization(2nd of day) 3. [2143-7-31] evacuation fo right calf hematoma, right lower extremity fasciotomies History of Present Illness: 55 y/o M / physician, [Name10 (NameIs) 151] history of hodkins lymphoma s/p chemotheraphy now in remission for 10 years, crohn's disease who presented to his PCP with right calf claudication. He was admitted for angiogram. Past Medical History: -Hodgkin lymphoma s/p ABVD, radiation to torso -- now remission -Crohn's disease -Hypothyroidism -Exercise-induced asthma Social History: Works as rheumatologist at BU Tob: Denies all use EtOH: Occasional Illicits: Denies all use Family History: Father with MI at age 55, other uncles with [Name2 (NI) ] at later ages, no known sudden death. Physical Exam: GENERAL: Appears well in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: 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. R medial and lateral incisions c/d/i witout erythema or purulent drainage SKIN: Site of cath insertion is clear and dry. No are no hematomas or bleeding. No bruits heard. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP and PT dopplerable Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: [2143-7-30] Cardiac Cath: Right Lower Extremity: The previously described right popliteal occlusion was moderately improved with reduction in the thrombus in the proximal popliteal with a funnel shaped occlusion at the takeoff of the AT. Very little flow could be seen to the foot via the popliteal. The PFA supplied collaterals filling the peroneal vessel but the AT and PT were presumable occluded with thrombus. An 0.014" wire was directed into the distal popliteal but intraluminal position in the AT could not be obtained and only entry of an accessory vessel could be made. The wire was redirected into a high-takeoff PT/accessory popliteal artery which was occluded at the knee. The wire passed into what appeared to be a small PT vessel that filled to the distal calf. A 2.0 mm balloon was used to dilate and restore flow into the vessel. [Initials (NamePattern4) ] [Last Name (NamePattern4) 7336] wire was then directed into the true popliteal and an additional course of tPA was planned. [2143-7-30] Cardiac Cath (2nd of the day): The previously imaged popliteal artery no longer had flow in the portion of the popliteal collateralizing the PT. The popliteal was now occluded at the knee while flow was previously noted to below the knee. Profunda collaterals, however, were seen to fill the peroneal artery more proximally than previously noted. [2143-7-30] Cardiac Echo: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). 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. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is no pericardial effusion. IMPRESSION: No ASD or left ventricular thrombus seen. Normal global and regional biventricular systolic function. [2143-7-30] Vein mapping VENOUS STUDY HISTORY: Right popliteal artery occlusion, vein mapping. FINDINGS: The greater saphenous veins are patent bilaterally, see digitized image on PACS for sequential measurements. [2143-7-30] arterial duplex ARTERIAL STUDY. HISTORY: Right popliteal occlusion, now on TPA. FINDINGS: Limited portable assessment of the popliteal artery on the right was performed. There is patency of the right popliteal artery, though velocities are low. Some residual thrombus versus plaque marginating the arterial walls is appreciated. [2143-7-30] 09:20AM BLOOD WBC-5.5 RBC-4.28* Hgb-10.5* Hct-32.9* MCV-77* MCH-24.5* MCHC-31.9 RDW-18.5* Plt Ct-241 [2143-7-30] 09:20AM BLOOD PT-13.0* PTT-102.2* INR(PT)-1.2* [2143-7-30] 05:22PM BLOOD CK(CPK)-31* [2143-7-30] 05:35PM BLOOD Lactate-0.7 Brief Hospital Course: 55 y/o M with history of hodkins lymphoma s/p chemotheraphy now in remission for 10 years, crohn's disease who presented to his PCP with right calf claudication and found to have right popiteal artery occulsion that was complicated by compartment syndrome. Right Popiteal Occulsion: The patient had several weeks of right lower extermity pain of several weeks which prompted an ABI that showed 0.65 on the right with monophasic arterial wave forms from the right popliteal distally. He was taken to the cardiac cath lab on [2143-7-29] and found to have a right popiteal artery blockage. The interventional team was unable to pass the wire. A TPA drip and heparin was started and he was admitted to the CCU for observation. He was taken back the the cardiac cath lab on HD#2 and continued to have the obstruction. He was maintained on TPA and heparin throughout the day but was noted to have increasing pain and swelling of his right lower extermity. He was taken back the cath lab where it was noted the obstruction was still in place but there was no bleeding seen. Right lower extermity compartment syndrome: Pt was brought to the endovascular suite for evacuation of hematoma and fasciotomies. He tolerated this procedure well and was recovered in the ICU without signigficant difficulty. The following day he was transfered to the VICU and then to the floor. His lateral fasciotomy was closed on post op day # 2. The medial fascitomy was Closed on POD #3. His diet was advanced as appropriate and he was seen by PT. At the time of discharge his pain was well controlled and he was tollerating a regular diet. He was discharged on POD #4 with follow up scheduled for [2143-8-19] Medications on Admission: Levothyroxine 50 mcg daily theophylline 300 mg daily B12 - 1000 mcg daily Advair 100/50 mcg inh [Hospital1 ] prn exercise Albuterol 90 mcg HFA INH Q6H prn exercise Discharge Medications: 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Enoxaparin Sodium 80 mg SC BID RX enoxaparin 80 mg/0.8 mL Please inject one syringe twice a day Disp #20 Not Specified Refills:0 3. Docusate Sodium 100 mg PO BID:PRN Constipation RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Not Specified Refills:0 4. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth Qday Disp #30 Not Specified Refills:0 5. Omeprazole 40 mg PO DAILY 6. Warfarin 5 mg PO DAILY16 RX warfarin 5 mg 1 tablet(s) by mouth Qday Disp #30 Not Specified Refills:0 7. Theophylline SR 300 mg PO DAILY prior to exercise 8. Albuterol Inhaler [12-24] PUFF IH Q4H:PRN wheezing 9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [Hospital1 ] 10. Cyanocobalamin 1000 mcg PO DAILY 11. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth Qday Disp #30 Not Specified Refills:0 12. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN Pain RX Endocet 5 mg-325 mg [12-24] tablet(s) by mouth Q6hrs Disp #30 Not Specified Refills:0 Discharge Disposition: Home Discharge Diagnosis: Right popliteal occlusion Right calf hematoma Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with right lower extremity pain and were found to have an occlusion of right popliteal artery. You underwent an angiogram of the right lower extremity and were given tPA to dissolve the clot. Your postoperative course was complicated by a right lower extremity hematoma. You needed to return to the operating room for removal of the blood clot. You also needed to make incisions (fasciotomies) on your right lower extremity to relieve the pressure which we were able to close at the bedside. We started you on several new medications to treat his blood clot. 1. Aspirin 2. Plavix 3. Lovenox (only until your INR is in range on coumadin) 4. Coumadin Your INR levels and coumadin dosing will be monitored by the [Hospital3 ] here at [Hospital1 18]. They will contact you on [2143-8-5] with the details of the program. They can be reached at [Telephone/Fax (1) 2173]. Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions MEDICATION: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart with pillows every 2-3 hours throughout the day and 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 ACTIVITIES: ?????? When you go home, you may walk and use 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 ?????? 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 Followup Instructions: Department: VASCULAR SURGERY When: MONDAY [2143-8-19] at 1 PM With: VASCULAR LAB [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: VASCULAR SURGERY When: MONDAY [2143-8-19] at 1:45 PM With: VASCULAR LAB [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: VASCULAR SURGERY When: MONDAY [2143-8-19] at 2:30 PM 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 Completed by:[2143-8-3]	[ "2449", "V5861" ]
Admission Date: [2113-1-8] Discharge Date: [2113-1-10] Date of Birth: [2049-1-12] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 1711] Chief Complaint: STEMI Major Surgical or Invasive Procedure: [2113-1-8] Cardiac catheterization, [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 [2113-1-10] Cardiac catherterization History of Present Illness: HISTORY OF PRESENTING ILLNESS: Mr. [Known lastname 1557] is a 63 year-old physician with hypertension who presented to the ED today for chest pain. He is relatively active at baseline and runs on the treadmill three times weekly without difficulty. About 2 weeks ago, he had an episode of mild exertional chest pain while running in the cold which resolved with rest. There was no recurrence. However, this morning at 5:30am he developed midsternal chest pain initially [3-2] increasing to [7-30] radiating down both arms (not to neck or back), and accompanied by nausea. He initially attributed this to GERD and took antacids without improvement. His wife then called EMS. EMS gave him ASA 325mg and nitro SL x 3 with decrease in pain to [3-2]. He remained hemodynamically stable. . On ED arrival, VS were 98 155/89 61 18 99%3L. EKG reviewed STEMI anterolateral ST elevations with reciprocal changes inferiorly. Code STEMI was called. He was loaded with Plavix and started on a heparin gtt. He was then taken emergently to the cath lab, reportedly pain-free. He was found to have a long, 80% mid-LAD lesion as well as a 70% hazy OM1. TIMI 3 flow in all vessels and patient pain-free but the significant anterior ST elevations persisted on ECG so DES were placed to both his mid-LAD and OM1. Patient started on integrillin. Post-procedure EKG shows improved but persistent anterolateral ST elevations. He is transferred to the CCU for monitoring. Nitro gtt is being weaned. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for minimal sensation of chest pressure, about [1-31]. No dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: GERD Hypothyroidism BPH Elevated PSA with negative prostate bx in [2108] Right proximal fifth metatarsal fracture in [2106] Social History: -Tobacco history: Quit smoking 40 years ago (~10 pack-year history) -ETOH: ~1 bottle wine/month -Illicit drugs: None Family History: His father died at age [Age over 90 ] (cause unknown). His mother has CAD s/p 3-vessel CABG at age 75, died of colon cancer. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On CCU admission: VS: T=98 BP=112/67 HR=69 RR=11 O2 sat=98% 2L NC GENERAL: WDWN Caucasian 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 no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. R femoral site with small hematoma, minimally TTP, no bruit SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Pertinent Results: Admission: [2113-1-8] 08:40AM BLOOD WBC-8.8 RBC-4.74 Hgb-14.3 Hct-40.9 MCV-86 MCH-30.0 MCHC-34.8 RDW-14.1 Plt Ct-257 [2113-1-8] 08:40AM BLOOD Neuts-54.9 Lymphs-35.1 Monos-6.2 Eos-3.1 Baso-0.7 [2113-1-8] 08:40AM BLOOD PT-14.6* PTT-150* INR(PT)-1.3* [2113-1-8] 08:40AM BLOOD Glucose-134* UreaN-31* Creat-1.2 Na-139 K-3.8 Cl-103 HCO3-29 AnGap-11 [2113-1-8] 08:40AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.1 [2113-1-8] 01:24PM BLOOD %HbA1c-5.6 eAG-114 Enzymes: [2113-1-8] 08:40AM BLOOD CK(CPK)-150 [2113-1-8] 04:32PM BLOOD CK(CPK)-790* [2113-1-8] 09:59PM BLOOD CK(CPK)-697* [2113-1-9] 04:59AM BLOOD CK(CPK)-538* [2113-1-10] 05:52AM BLOOD CK(CPK)-675* [2113-1-8] 08:40AM BLOOD CK-MB-6 [2113-1-8] 08:40AM BLOOD cTropnT-<0.01 [2113-1-8] 04:32PM BLOOD CK-MB-84* MB Indx-10.6* cTropnT-1.89* [2113-1-8] 09:59PM BLOOD CK-MB-71* MB Indx-10.2* cTropnT-1.65* [2113-1-9] 04:59AM BLOOD CK-MB-48* MB Indx-8.9* [2113-1-10] 05:52AM BLOOD CK-MB-49* MB Indx-7.3* cTropnT-1.62* Discharge: [2113-1-10] 05:52AM BLOOD WBC-13.4* RBC-4.60 Hgb-14.1 Hct-38.8* MCV-84 MCH-30.6 MCHC-36.3* RDW-14.2 Plt Ct-216 [2113-1-10] 05:52AM BLOOD PT-13.2 PTT-23.6 INR(PT)-1.1 [2113-1-10] 05:52AM BLOOD Glucose-105* UreaN-20 Creat-1.1 Na-136 K-4.3 Cl-103 HCO3-24 AnGap-13 [2113-1-10] 05:52AM BLOOD Calcium-9.2 Phos-2.3* Mg-2.2 . Micro: MRSA SCREEN (Final [2113-1-10]): No MRSA isolated. . Imaging: PCXR: IMPRESSION: Normal cardiomediastinal silhouette. . TTE: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the distal half of the anterior and distal septal and apex. The apex is not aneurysmal and the remaining segments contract well (LVEF >50%). The estimated cardiac index is normal (>=2.5L/min/m2). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal. with borderline normal free wall function. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. 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. CONCLUSIONS: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD (mid-LAD distribution). Mild pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of [2106-7-9], there is now mild hypokinesis of the distal anterior, septal, and apical segments with LVEF 50%. There is now mild pulmonary artery hypertension. . Cardiac Cath: [1-8]: 1. Selective coronary angiography in this right dominant system revealed two vessel disease. The LMCA was normal. The LAD had an 80% mid vessel stenosis. The LCx had a hazy 70% stenosis in the first obtuse marginal branch. The RCA was without significant disease. 2. Limited resting hemodynamics showed normal left sided filling pressures with central aortic pressure of 122/74 with a mean of 95 mmHg. 3. Successful PTCA and stenting of mid LAD with 2.5x28mm Promus drug eluting stent postdilated proximally to 2.75mm. 4. Successful PTCA and stenting of OM1 with 3.0x23mm Promus drug eluting stent postdilated with 3.0mm balloon. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Anterior STEMI 3. Successful PCI of LAD with DES. 4. Successful PCI of OM1 with DES. . [1-10]: 1. Limited selective coronary angiography of this right dominant system revealed no angiographically apparent obstructive coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had a patent stent with a 30% mid-stent irregularity with a 60% lesion at the origin of the jailed diagonal with normal flow. The Lcx had a patent OM stent. The RCA was no engaged. 2. Limited hemodynamics showed normotension FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Patent stents in LAD and OM1. 3. Normotension. Brief Hospital Course: 63yo M with HTN who p/w CP at rest, found to have STE in anterior precordial leads, now s/p cath showing LAD and LCx disease, but no definitive culprit lesion and s/p placement of 2 DES, pain free but with persistent ST elevations, improved compared to prior. . # CORONARIES: Pt. with history and ECG changes concerning for STEMI with no known CAD. Now s/p [1-8] cath with placement of DES x2, though no definitive culprit lesion. Integrillin gtt was continued 18h post [1-8] cath. Nitro gtt was initially weaned but pt. developed CP again once off nitro gtt, so restarted without much improvement. Pt. had further episodes of CP and was taken back to the cath lab which showed patent stents and stable disease. Nitro gtt was off post [1-10] cath. Atorvastatin 80mg was started. ASA 325mg was started and transitioned to 81mg [Hospital1 ] at discharge. Plavix 75mg was started and should be continued for at least 1 year. Atenolol was stopped and patient was discharged on metoprolol succinate 50mg daily. Given allergy to [Name (NI) 8213], pt. also discharged on low dose valsartan. A1c <6%. ECG showed improved but persistent ST elevations at discharge, CP free. Echo as below. . # PUMP: Beta blockade as above. TTE showed LVEF of >50% with mild regional left ventricular systolic dysfunction with mild hypokinesis of the distal half of the anterior and distal septal and apex. No overload on exam throughout admission. . # Insomnia/Anxiety: Pt. understandably anxious surrounding events, reports taking triazolam prn at home. He was started on Ambien 5mg QHS Prn insomnia and Lorazepam 0.5mg PO prn anxiety, which he required throughout his admission. He was asked to follow up with his PCP for continuing prescriptions for benzodiazepines. . # GERD: stable, continued famotidine [Hospital1 ] and started GI cocktail prn for symptomatic relief. . # Hypothyroidism: stable, continued home levothyroxine. . # Transitional issues: - may need benzo prescription for anxiety - titrate beta blocker, [Last Name (un) ] - TTE to follow up post STEMI Medications on Admission: 1. Atenolol 25mg PO QHS 2. Ambien 5mg PO prn insomnia 3. Levothyroxine 125mcg PO daily 4. Pepcid 20mg [Hospital1 ] Discharge Medications: 1. aspirin 81 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:62 Tablet(s) Refills:2 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:31 Tablet(s) Refills:2 3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: [Month (only) 116] take up to 3 tabs, 5 minutes apart, then go to emergency room if still having pain. Disp:30 Tablet, Sublingual(s) Refills:0 7. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:31 Tablet(s) Refills:2 8. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:31 Tablet Sustained Release 24 hr(s) Refills:2 9. simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:11 Discharge Disposition: Home Discharge Diagnosis: ST elevation myocardial infarction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for chest pain and found to have a heart attack. You were taken to the cardiac catheterization lab where two drug-eluting stents were placed. As you had chest pain afterwards with persistent EKG abnormalities, you were taken back to the catheterization lab where you were found to have no changes from prior. You had no further chest pain. . The following changes were made to your medications: - Start aspirin 81mg twice a day - Start Plavix 75mg daily for at least a year - Stop atenolol - Start metoprolol succinate 50mg daily - Start simvastatin 80mg daily - Start valsartan 80mg daily - Start nitroglycerin sublingual tabs, 1 tab every 5 minutes when having chest pain up to 3 tabs. If you are still having chest pain after 3 tabs, go to your local emergency room. . Do not stop your Aspirin or Plavix without first discussing with your cardiologist. Followup Instructions: Department: [State ]When: TUESDAY [2113-1-17] at 11:45 AM With: [First Name8 (NamePattern2) 8741] [Doctor Last Name ], (works with Dr [Last Name (STitle) 2903] MD [Telephone/Fax (1) 2205] Building: [State ] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking . Dr. [Last Name (STitle) 696] had no open appointment slots for 8 weeks, which we felt was too long for you to wait to be seen. You can make an appointment to follow up with him after the appointment below. . Department: CARDIAC SERVICES When: THURSDAY [2113-2-9] at 10:20 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "41401", "4019", "53081", "2449", "V1582", "4168" ]
Admission Date: [2163-4-14] Discharge Date: [2163-5-11] Date of Birth: [2118-9-2] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Intubation History of Present Illness: 44y male transferred from [Hospital 1474] Hospital, where he was admitted [2163-4-12] with severe abdominal pain, likely due to alcoholic pancreatitis. He was transferred to [Hospital1 18] at 7pm [4-14] after he became unstable with increasing respiratory distress. At the time of admission, he reported his abdominal pain was improved from his initial presentation. However, he was becoming more tachycardic, and his respiratory rate was increasing. He was diaphoretic. He was admitted to the medical ICU, but a surgical consult was called upon his arrival. Past Medical History: Alcohol abuse bronchitis chronic back pain with transient left arm paresthesias Social History: Married. +EtOH. 1 pack per day tobacco. Works at night. Takes care of his 3 children during the day. Family History: Noncontributory Physical Exam: T 100.4, HR 154, BP 148/100, RR 37, 96% on face mask In general, the patient is diaphoretic and agitated HEENT: PERRLA, EOMI, no JVD CV: tachycardic, sinus rythym Resp: wheezing bilaterally Abdomen: distended, appropriately tender, no guarding or rebound Ext: no clubbing, cyanosis or edema. DP and PT 1+ bilat. Neuro: alert and oriented x3. Pertinent Results: [2163-4-14] 08:08PM WBC-24.8* RBC-4.73 HGB-14.4 HCT-42.6 MCV-90 MCH-30.5 MCHC-33.9 RDW-12.7 [2163-4-14] 08:08PM PLT COUNT-181 [2163-4-14] 08:08PM PT-14.1* PTT-27.8 INR(PT)-1.3 [2163-4-14] 08:08PM GLUCOSE-165* UREA N-32* CREAT-2.3* SODIUM-142 POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-18* ANION GAP-18 [2163-4-14] 08:08PM ALT(SGPT)-13 AST(SGOT)-33 LD(LDH)-446* ALK PHOS-56 AMYLASE-658* TOT BILI-0.8 [2163-4-14] 08:08PM LIPASE-1346* [2163-4-14] 08:08PM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-2.2* MAGNESIUM-2.2 CHOLEST-101 [2163-4-14] 08:08PM TRIGLYCER-169* HDL CHOL-18 CHOL/HDL-5.6 LDL(CALC)-49 [2163-5-11] 06:50AM BLOOD WBC-12.6* RBC-3.56* Hgb-10.4* Hct-31.6* MCV-89 MCH-29.3 MCHC-32.9 RDW-13.6 Plt Ct-504* [2163-5-11] 06:50AM BLOOD Plt Ct-504* [2163-5-11] 06:50AM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-137 K-3.7 Cl-100 HCO3-22 AnGap-19 [2163-5-11] 06:50AM BLOOD ALT-74* AST-43* AlkPhos-101 Amylase-44 TotBili-0.4 [2163-5-11] 06:50AM BLOOD Lipase-38 [2163-5-11] 06:50AM BLOOD Albumin-3.4 Calcium-9.0 Phos-4.2 Mg-1.8 [4-20]: CT abdomen/pelvis: IMPRESSION: 1) Extensive peripancreatic inflammation, with inflammatory changes in the pararenal spaces bilaterally. 2) Heterogeneous enhancement of the pancreatic body and tail, which raises the question of possible early necrosis. Close short-term followup is recommended. 3) Bibasilar atelectasis and effusions. 4) Patchy bilateral parenchymal opacities in the lungs, which are nonspecific. 5) Occlusion of the splenic vein. 6) No evidence of abscess or fluid collection. [2163-4-27]: CT abdomen/pelvis: IMPRESSION: 1) Stable appearance of extensive peripancreatic inflammation and stable extent of nonenhancing regions within the pancreas (although these regions are better seen on today's exam due to differences in phase of contrast). The splenic vein is again not seen. There is no evidence of splenic artery aneurysm. 2) Persistent but decreased bilateral pleural effusions. Slight interval increase in atelectasis at the left lung base. Brief Hospital Course: The patient was admitted to the medical ICU for pancreatitis, and a surgery consult was obtained. On hospital day one, he required intubation for respiratory decompensation. He was followed closely by the medical and surgical teams. He was aggressively fluid resuscitated. He was started on imipenem and fluconazole. An insulin drip was necessary for glucose control His respiratory decompensation was suggestive of an ARDS-like picture. Due to his pancreatitis and intubated status, he was started on TPN. On hospital day 2, the patient was transferred to the hepatobiliary surgery service. On hospital day 3, he was transferred to the SICU. He had several episodes of temperature spikes throughout his early hospital course. He was pan-cultured. The only positive suggestion of infection was yeast in his sputum. On [4-21], an esophageal balloon was placed as part of an ARDS protocol for ventilation. Lopressor was added for persistent tachycardia. He was started on trophic tube feeds. He was maintained on ativan for DT prophylaxis, given his history of alcohol abuse. On [4-23], his tube feeds were held for gastric distention. He received 2units of blood for blood loss anemia. Imipenem and fluconazole were discontinued, as all cultures had been negative. However, he continued to be febrile, and on [4-24] and [4-25], blood cultures were positive for gram positive cocci, which later speciated to coagulase negative staph. He was started on vancomycin. On [4-25], his tube feeds were restarted. He was started empirically on flagyl for diarrhea concerning for c diff. On [4-27], his tube feeds were held for increased diarrhea. He was transfused with one unit of blood for anemia. His antibiotics were changed to linezolid, and the flagyl was discontinued because cultures were negative for c diff. An infectious disease consult was obtained. His lines were all resited. On [4-30], the patient was extubated. He was very agitated, hypertensive and tachycardic, and required hydralazine, labetolol, clonidine, metoprolol, haldol, and ativan. On [5-1], zosyn was added for continued temperature spikes, with no clear site of infection. On [5-3], his trophic tube feeds were again restarted. He was very confused, and so his ativan was tapered slowly. On [5-5], he was stable enough to be transferred to the floor; his linezolid was discontinued. His tube feeds were at goal. On [5-6], he was evaluated by the speech and swallow nurse, and was cleared for sips of water only, until his mental status was improved. On [5-7], his haldol was discontinued. His mental status improved dramatically and his agitation has resolved. On [5-9], his diet was advanced to full liquids. His zosyn was stopped and he was started on levofloxacin. On [5-10], he was started on a regular diet. He had been followed by physical therapy throughout his hospital course, and they cleared him to be safe to go home, with home physical therapy. On [5-11], he was discharged to home in good condition. He was advised to refrain from alcohol. Medications on Admission: nicotine patch, Tums, tylenol, motrin Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). Disp:7 Patch Weekly(s) Refills:2 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). Disp:5 mcg Refills:2 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO q 6hr prn pain as needed. Disp:50 Tablet(s) Refills:0 6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:10 Patch 24HR(s) Refills:2 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Necrotizing pancreatitis HTN GERD Discharge Condition: Stable Discharge Instructions: Please call your surgeon or return to the emergency room if you experience fever >101.5, nausea, vomiting, increasing abdominal pain, chest pain, shortness of breath or any significant change in your medical condition. Please refrain from alcoholic bevarages of any kind as this could lead to recurrent pancreatitis. Followup Instructions: Please follow up with Dr.[Last Name (STitle) ] in 3 weeks. Upon discharge from the hospital please call Dr[Doctor Last Name ] office in order to schedule a follow up appointment. ([Telephone/Fax (1) 2363]	[ "5849", "51881", "2760", "99592", "3051", "2859" ]
Admission Date: [2197-4-20] Discharge Date: [2197-4-24] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4765] Chief Complaint: chest pain Major Surgical or Invasive Procedure: CVVH History of Present Illness: Mr. [Known lastname 85937] is an 85 [Hospital ] nursing home resident with a history of HTN, ?hypertrophic cardiomyopathy, PE s/p IVC filter, massive GI bleed who presented to [Hospital3 ] with chest pain and is transferred for further management of STEMI. . He is chronically ill at baseline and has largely spent most of the last year hospitalized. He was in his USOH at his nursing home until two days ago when he developed chest pain associatred with nausea. He presented to [Hospital3 ] [2197-3-19] for evaluation and his EKG demonstrated ST elevations in the inferior leads. He was given aspirin and atorvostatin, with no anticoagulation because of a history of massive GI bleed, and he was transferred to the [Hospital1 18] for further management. En route, his troponin-I returned elevated at 29 ng/ml. . In the ED, initial vitals were 98.5 72 108/58 18 100%. He was chest pain free on arrival but had SBPs to the 70s for which he received 1L IVF. Cards was consulted and recommended CCU admission for monitoring. He was trace guaiac positive from his ostomy but given the risks and benefits of anticoagulation, he was given plavix 300 and started on a heparin gtt with no bolus. Because of a question of a high potassium and peaked t waves on ekg, a potassium was repeated and found to be 6.7. He was given 2 amps calcium gluconate, kayexalate 30g, and transferred to the floor. . On review of systems, he denies chest pain, dyspnea, orthopnea, peripheral edema, and diaphoresis. He states that he has had nausea for the past three days that is ongoing. . Past Medical History: ?Hypertrophic cardiomyopathy PVD AAA s/p repair in [12-14] Dyslipidemia Hypertension Pulmonary embolism and DVT s/p IVC filter Massive GI bleed [1-14] secondary to AVMs requiring 19 units of PRBCs and hemicolectomy/ileostomy Osteoarthritis Social History: Lives in a nursing home per report and most recently from [First Name4 (NamePattern1) 3504] [Last Name (NamePattern1) ] Rehab in [Location (un) 538]. Past smoking but quit over 20 years ago. No alcohol or drugs. Worked in construction for about 50 years. Is a passionate football and baseball fan. Nice circle of friends. [Name (NI) ] is HCP. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: nad HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to mandible CARDIAC: RRR, normal S1, S2. No m/r/g. [2-11] HSM. LUNGS: Resp were unlabored, no accessory muscle use. Limited exam secondary to patient participation, no rales or rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: +sacral decubs and left ankle decub. venous stasis changes in lower extremities PULSES: Right: 1+ DP, unable to palpate posterior tibials Left: 1+ DP, unable to palpate posterior tibials Pertinent Results: Labs on admission: CBC [2197-4-20] 02:13AM BLOOD WBC-15.4* RBC-3.32* Hgb-7.7* Hct-24.9* MCV-75* MCH-23.2* MCHC-30.9* RDW-18.7* Plt Ct-231 [2197-4-20] 02:13AM BLOOD PT-14.6* PTT-26.4 INR(PT)-1.3* Chem 7 [2197-4-20] 02:13AM BLOOD Glucose-151* UreaN-73* Creat-4.8* Na-138 K-6.6* Cl-101 HCO3-16* AnGap-28* LFTs [2197-4-20] 08:34AM BLOOD ALT-68* AST-98* LD(LDH)-517* CK(CPK)-354* AlkPhos-203* TotBili-0.6 Cardiac enzyymes [2197-4-20] 02:13AM BLOOD CK-MB-24* MB Indx-5.7 [2197-4-20] 02:13AM BLOOD cTropnT-7.07* [2197-4-20] 08:34AM BLOOD CK-MB-23* MB Indx-6.5* cTropnT-7.56* [2197-4-20] 07:32PM BLOOD CK-MB-22* MB Indx-5.0 cTropnT-8.09* Other chemistry [2197-4-20] 08:34AM BLOOD Albumin-3.2* Calcium-10.0 Phos-6.9* Mg-2.8* [2197-4-20] 07:32PM BLOOD calTIBC-143* Ferritn-GREATER TH TRF-110* [2197-4-20] 06:03AM BLOOD %HbA1c-5.9 eAG-123 [2197-4-20] 02:13AM BLOOD Triglyc-83 HDL-45 CHOL/HD-3.1 LDLcalc-77 [2197-4-22] 04:05PM BLOOD ANCA-NEGATIVE B [2197-4-22] 07:48PM BLOOD [Doctor First Name ]-NEGATIVE [2197-4-22] 06:00PM BLOOD RheuFac-14 [2197-4-20] 08:34AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Significant labs during hospitalization: [2197-4-23] 01:35PM BLOOD Glucose-63* Lactate-16.8* Na-134* K-5.7* Cl-100 [2197-4-23] 07:02PM BLOOD Glucose-140* Lactate-18.5* Na-133* K-5.3 Cl-91* [2197-4-23] 11:12PM BLOOD Lactate-15.4* [2197-4-24] 06:38AM BLOOD Lactate-12.8* [2197-4-20] echo: The left atrium is mildly dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is very small. Although the left ventricular ejection fraction is nominally within normal limits, the stroke volume is probably markedly decreased due to the small left ventricular volumes. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: severe diastolic dysfunction of the left ventricle with associated right ventricular systolic dysfunction [2197-4-20] chest x ray: 1. Limited study due to technique and low lung volumes. Probable bilateral pleural effusions with adjacent atelectasis. 2. Opacity overlying the mid lower chest may represent a hiatal hernia or a tortuous-dilated aorta. PA and lateral view of the chest may be helpful in further evaluation. 3. Prominence of the azygos vein. IMPRESSION: The evaluation is extremely limited due to the patient's inability to breath-hold. [2197-4-22] Liver ultrasound: 1. Biphasic flow of the portal venous system and accentuated biphasic waveforms of hepatic veins are consistent with congestive hepatopathy. 2. No evidence of renal artery stenosis. Normal appearing kidneys without hydronephrosis. 3. Determination of shock liver is not typically a son[Name (NI) 493] diagnosis. [2197-4-23] CT abdomen: 1. Right colectomy changes with RLQ ileostomy bag demonstrates good output. No obstruction is noted. 2. Aortobifemoral graft with questionable questionable hyperdense area is identified posterior to the graft, as detailed above. It is unclear whether this represents an endoleak since this examination is not tailored for evaluation of this entity. The need for further imaging should be determined on a clinical basis with a dedicated study. 3. Cholelithiasis with no signs of acute cholecystitis. Severe cardiomegaly with coronary calcifications. 4. Renal cyst. 5. Limited evaluation of the lower pelvic structures due to significant streak artifact from left hip prosthetic. 6. Severe degenerative changes at the rip hip joint. It is difficult to assess if this may be secondary to severe inflammatory arthritis or joint effusion. Brief Hospital Course: # ST elevations: The patient presented from an outside hospital with ST elevations on EKG that were thought to be due to myocardial infarction. The patient did not go to catheterization because he was thought to be several days out from the start of his chest pain and he had such poor baseline functional status that revascularization would likely not be of much benefit. He was started on a heparin drip and given aspirin and plavix. He had an echocardiogram of his heart which showed small left ventricular volumes and right dilated ventricular cavity with depressed free wall contractility. The findings on echo did not support the EKG changes with diffuse ST elevations including the lateral leads. It was then thought that the ST changes were not from myocardial ischemia, but another process such as uremic pericarditis given the patient's acute renal failure. In light of this thinking his heparin and plavix were held, but his aspirin was continued. His atorvostatin was held givin his elevated liver enzymes, and his beta blocker and ACEi were held due to his hypotension. # Shock/death: As above, echo showed a dilated right ventricle and depressed contractility, which was thought to be new. According to records obtained from the VA, the patient had an echo in [2196-5-6] that had a normal right ventricle. The patient's hypotension was likely secondary to to his right heart failure and inability to provide increased filling of his hypertrophic left ventricle. His poor cardiac output was further weakened by his aortic stenosis. Causes of this new right hypokinesis were thought to be from PE versus MI. (Of note, his coumadin was recently stopped due to an ENT bleed and he had had a PE in [2190], after already having an IVC filter placed and being on coumadin for a DVT in [2183].) He was restarted on a heparin drip. The pt presented with signs of multi-organ dysfunction with worsening LFTs, INR, rising lactate, and rising creatinine. He was evenutally started on phenylepfrine to maintain MAP above 60 while on CVVH (see below). This was changed to dopamine, which caused ventricular tachycardia. He was then given an amiodarone bolus. He eventually expired due to a falling heart rate followed by asystole. # Oliguric renal failure: The patient presented with a creatinine of 4.8. His most recent creatinine from one month prior was reportedly 1.2. His acute renal failure was thought to be pre-renal secondary to hypoperfusion from poor forward flow due to his decreased LV chamber size secondary to hypertrophy, and newly failed right ventricle worsening LV preload. A renal U/S confirmed no structural damage to the kidneys. He developed worsening hypokalemia refractory to treatment with kayexalate (given his colectomy), bicarb, and calcium. The patient opted for a trial of CVVH although he was told that his condition may not be reversible. He was started on CVVH and phenylephrine to maintain MAPS > 60. # Hyperkalemia: Likely related to renal failure. The patient was given kayexalate, bicarb, calcium gluconate, and insulin without improvement. He was started on CVVH and his potassium improved. # Anion gap metabolic acidosis: The patient was found to have an anion gap acidosis. Lactate was elevated and this was thought to have been from poor perfusion due to decreased stroke volume. This trended up to 18.5 when the pressors were started. # Anemia: Chronic iron deficiency anemia with trace guaiac positive contents in ileostomy. Transfused 1 unit RBCs [2197-3-21]. Continued on PO pantoprazole. # Osteoarthritis: The patient was continued on PRN oxycodone for his chronic pain. Medications on Admission: ferrous sulfate 325 mg q day morphine sulfate ER 60 mg TID Aspirin 81 mg Q day colace 100 mg Q day omeprazole 1 tab Q day Multivitamin 1 tab q day simvastatin 80 mg QS sodium carbonate 650 mg TID metoprolol tartrate 25 mg [Hospital1 ] oxycodone 15 mg [Hospital1 ] PRN tylenol 325 -650 mg q 6 H PRN milk of magnesia 30 ml Q 8 pm . Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: cardiac arrest Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "5849", "2762", "2767", "4019", "4241", "V5861" ]
Admission Date: [2166-6-18] Discharge Date: [2166-6-25] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 1267] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Graft x 3 on [2166-6-19] History of Present Illness: 85 y/o male c/o fatigue and SOB x 3 months. Transferred from OSH for CABG following cardiac cath which revealed 60% LM and 3 vessel disease. Past Medical History: Atrial Fibrillation -recent Hypertension Diabetes Mellitus Hypercholesterolemia CHF Gastritis, Hiatal Hernia Anemia Hearing loss h/o CVA [59] s/p L nephrectomy s/p THR 98 Social History: Married, lives with wife [Name2 (NI) 63369] (40 pack yr '[24]) -ETOH Family History: +FH Physical Exam: VS: 5'[71]" 160lbs HEENT: EOMI, PERRLA Neck: Supple, -carotid bruits Heart: +S1, S2, -c/r/m/g Lungs: CTAB -w/r/r Abd: Soft NT/ND, -r/r/g Ext: +edema bilat, 1+ pulses throughout, - varicosities Neuro: Alert, weel oriented Pertinent Results: [2166-6-18] 09:45PM BLOOD WBC-7.5 RBC-3.54* Hgb-9.7* Hct-30.1* MCV-85 MCH-27.6 MCHC-32.4 RDW-14.8 Plt Ct-160 [2166-6-24] 07:20AM BLOOD WBC-9.0 RBC-3.79* Hgb-10.6* Hct-32.5* MCV-86 MCH-27.9 MCHC-32.6 RDW-14.7 Plt Ct-219 [2166-6-18] 09:45PM BLOOD PT-12.2 PTT-27.3 INR(PT)-1.0 [2166-6-24] 07:20AM BLOOD PT-13.3 PTT-26.4 INR(PT)-1.2 [2166-6-18] 09:45PM BLOOD Glucose-206* UreaN-41* Creat-2.1* Na-135 K-5.3* Cl-99 HCO3-25 AnGap-16 [2166-6-24] 07:20AM BLOOD Glucose-69* UreaN-40* Creat-1.3* Na-141 K-5.2* Cl-104 HCO3-29 AnGap-13 [2166-6-18] 09:45PM BLOOD %HbA1c-7.2* [Hgb]-DONE [A1c]-DONE Brief Hospital Course: As mentioned in the HPI, pt was transferred from [Hospital1 62664] Center and on HD #2 was brought to the operating room where he underwent a Coronary Artery Bypass Graft x 3. Please see op note for details. Pt. tolerated the procedure well and was transferred to CSRU being titrated on Neo and Propofol. Later on op day, pt was weaned from mechanical ventilation and propofol and was successfully extubated. POD #1 his swan-Ganz catheter was removed. Pt. had ongoing episodes of AFib post-operatively and was started on Amiodarone. As well as Lopressor and Coumadin (started on POD #3). By POD #2 diuretics and b-blockers were started per protocol. His Chest tubes and epicardial pacing wires were removed as well on POD #2. On POD #4 he was transferred to telemetry floor. Foley catheter was d/c'd twice, but had to be re-inserted due to inability to void/urinary retention. He will go home with a leg bag and follow up with Urologist (Dr. [Last Name (STitle) 63370]. He remained stable and recovered well and had a relatively uncomplicated post-op course. By POD #5 he was at level 5 and was discharged home with VNA services. His Coumadin dosing and INR will be followed by his cardiologist, Dr. [Last Name (STitle) 61691]. Discharge Disposition: Extended Care Facility: [Doctor Last Name 62491]Health Center Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Atrial Fibrillation Hypertension Diabetes Mellitus Hypercholesterolemia Urinary Retention Discharge Condition: Good Discharge Instructions: Can take shower. Wash incisions with water and gentle soap. Gently pat dry. Do not bath or swim. Do not apply lotions, creams, ointments or powders to incisions. INR to be drawn by VNA on thursday [6-26] with results called to Dr. [Last Name (STitle) 61691] at [Telephone/Fax (1) 63371]. Coumadin titrated by Dr. [Last Name (STitle) 61691] for goal INR of [1-1].5 Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] (at [Hospital3 35813] Center) in 4 weeks. Call [Doctor First Name 553] at [Telephone/Fax (1) 62665] to schedule appointment. Follow-up in wound clinic in 3 weeks for staple removal. Again, call [Doctor First Name 553] to set up an apppoinment at [Hospital1 ]. Follow-up with PCP (Dr. [Last Name (STitle) 63372] in 2 weeks. Follow-up with Cardiologist (Dr. [Last Name (STitle) 61691] at [Telephone/Fax (1) 63371]) in 2 weeks. Follow-up with Urologist (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 63370] [Telephone/Fax (1) 63373], [Doctor Last Name 63374], [Location (un) 37361], [8-2], but office will call you for sooner appointment). Completed by:[2166-6-24]	[ "41401", "42731", "4280", "4019", "25000", "2720" ]
Admission Date: [2101-11-10] Discharge Date: [2101-11-16] Date of Birth: [2037-3-10] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 64] Chief Complaint: left hip arthritis Major Surgical or Invasive Procedure: left tha History of Present Illness: 64 y/o with OA of right hip,presents for surgical management of pain. His hematology team was consulted for pre and post operative care. infusion, high risk bleeding, high risk thrombosis . History of Present Illness: 64 y/o male with chronic hepatitis B infection with grade [3-31] cirrhosis (presently suppressed), antithrombin III deficiency and superior mesenteric thrombosis [2095](managed by Dr. [Last Name (STitle) 2805], on coumadin), thrombocytopenia/macrocytosis, esophageal varices, and hypertension who is POD #0 s/p left total hip replacement with Dr. [Last Name (STitle) ]. . From surgical perspective, blood loss estimated to be 750 cc and procedure was uncomplicated. Patient received 3L LR, 50 mL 25% albumin, 2 mg versed, 8 mg decadron, 250 mcg fentanyl, total of 6 mg dilaudid, 4 g cefazolin. UOP was 240 cc during procedure. . From hematology perspective, patient presented with several days of abdominal pain and bloating in [2095-4-28]. He underwent a CT can at [Hospital1 18] on [2095-5-19], which demonstrated a nonocculusive endoluminal thrombus within the superior mesenteric vein with extension into more distal branches and extending into the main portal vein. Work up at the time revealed low Protein C and antithrombin III levels (Antithrombin III 48%, normal range 80 to 120%; Protein C antigen 31%, protein C functional 46%). On [2095-8-3], the antithrombin III levels were determined was 54% and the antithrombin antigen was 65%, both below the range of normal. Further testing revealed he was negative for prothrombin gene mutation, factor V Leiden, and anticardiolipin. He was placed on coumadin therapy indefinitely with goal INR of [3-2]. . In anticipation of his upcoming surgery, he was recently seen in [Hospital ] clinic on [2101-9-16]. At that time he was informed that hip replacement surgery is associated with a very high risk of developing thrombotic complications. For this reason, he was recommended to stop coumadin 5 days prior to surgery and start a Lovenox bridge (150 mg daily) until the day before his surgery. He had low antithrombin III levels on [2101-9-16] (66%), although these levels were all checked while he was still on Coumadin. For this reason, he was recommended to receive ATIII repletion therapy to correct the deficiency prior to having the procedure. IVC filter was also considered for DVT prophylaxis, but he had a relatively contraindication to its use with a prior history of SMV thrombosis, and it was felt that collateral thrombosis could further put that vascular tree at risk. . With regard to his AT3 deficiency, patient received 1 dose before surgery to keep level > 100%. Level at baseline is approximately 55%. . Prior to transfer, HR 84 and BP 144/89. Access 2 piv - 16 guage x 2. Unable to obtain A-line as catheter would not thread. Past Medical History: 1. Superior mesenteric vein thrombosis ([4-/2095]) secondary to ATIII deficiency, on coumadin 2. macrocytosis/thrombocytopenia (thrombocytopenia and macrocytosis were thought [3-1] liver disease from hepatitis B. He was ruled out for myelodysplastic because his smear lacked characteristic Pelger [Last Name (un) 11605] cells, ovalomacrocytes or microcytic anemia) 3. Splenomegaly (per U/S in [2100]) 4. hepatic cirrhosis (grade III/IV) 5. HTN on Naldolol 6. Esopageal varicies (An EGD done in [2099-7-28] showed grade 1 and 2 esophageal varicies) 7. Gall bladder polyps 8. Hepatitis B, unknown source of exposure(genotype D, with precore and BCP mutations (basal core promoter mutation) on tenofovir 9. Oral HSV on Valcyclovir 10. Hematuria-one episode as a childhood of unclear etiology 11. Colonic Adenoma [2089]--> s/p polypectomy. Repeat negative colonoscopy in [2094]. Social History: NC Family History: NC Physical Exam: well appearing, well nourished 64 year old male alert and oriented no acute distress LLE: -dressing-c/d/i -incision-c/d/i -> no erythema or drainage. DIFFUSE ecchymosis throughout entire LLE. mild edema -+AT, FHL, [Last Name (un) 938] -SILT -brisk cap refill -calf-soft, nontender -NVI distally Pertinent Results: [2101-11-10] 07:12PM BLOOD WBC-11.2# RBC-3.94 Hgb-13.7* Hct-39.7* MCV-101* MCH-34.8* MCHC-34.5 RDW-13.7 Plt Ct-118* [2101-11-11] 04:52AM BLOOD WBC-9.4 RBC-3.53* Hgb-12.6* Hct-35.6* MCV-101* MCH-35.7* MCHC-35.4* RDW-14.6 Plt Ct-127* [2101-11-11] 03:12PM BLOOD Hct-33.7* [2101-11-11] 08:40PM BLOOD WBC-12.1* RBC-3.13* Hgb-10.6* Hct-31.8* MCV-102* MCH-34.0* MCHC-33.4 RDW-13.5 Plt Ct-113* [2101-11-12] 08:10AM BLOOD WBC-8.6 RBC-2.75* Hgb-9.8* Hct-28.4* MCV-103* MCH-35.8* MCHC-34.6 RDW-14.8 Plt Ct-109* [2101-11-13] 06:15AM BLOOD WBC-7.4 RBC-2.41* Hgb-8.4* Hct-24.2* MCV-100* MCH-34.8* MCHC-34.7 RDW-13.7 Plt Ct-104* [2101-11-14] 05:55AM BLOOD WBC-5.2 RBC-2.16* Hgb-7.8* Hct-22.3* MCV-103* MCH-36.0* MCHC-34.9 RDW-14.7 Plt Ct-115* [2101-11-15] 01:56AM BLOOD WBC-6.0 RBC-2.65* Hgb-9.3* Hct-26.4* MCV-100* MCH-35.1* MCHC-35.2* RDW-16.2* Plt Ct-120* [2101-11-15] 06:10AM BLOOD WBC-5.4 RBC-2.58* Hgb-8.9* Hct-25.4* MCV-98 MCH-34.6* MCHC-35.2* RDW-15.8* Plt Ct-108* [2101-11-15] 07:33PM BLOOD Hct-28.6* [2101-11-16] 06:30AM BLOOD WBC-6.4 RBC-2.75* Hgb-9.6* Hct-27.9* MCV-101* MCH-34.9* MCHC-34.5 RDW-16.7* Plt Ct-161 [2101-11-10] 07:12PM BLOOD Neuts-86.8* Lymphs-9.6* Monos-2.3 Eos-0.9 Baso-0.3 [2101-11-11] 04:52AM BLOOD Neuts-78.1* Lymphs-14.4* Monos-7.0 Eos-0.2 Baso-0.3 [2101-11-15] 01:40PM BLOOD PT-16.7* PTT-31.7 INR(PT)-1.5* [2101-11-16] 06:30AM BLOOD PT-16.9* PTT-29.2 INR(PT)-1.5* [2101-11-14] 12:21PM BLOOD LMWH-0.28 [2101-11-10] 01:59PM BLOOD AT-118 [2101-11-11] 04:52AM BLOOD AT-91 [2101-11-12] 08:10AM BLOOD AT-72 [2101-11-13] 06:15AM BLOOD AT-73 [2101-11-14] 05:55AM BLOOD AT-95 [2101-11-10] 07:12PM BLOOD Glucose-146* UreaN-16 Creat-0.8 Na-137 K-4.8 Cl-105 HCO3-24 AnGap-13 [2101-11-11] 04:52AM BLOOD Glucose-162* UreaN-18 Creat-0.7 Na-135 K-4.2 Cl-104 HCO3-24 AnGap-11 [2101-11-12] 08:10AM BLOOD Glucose-130* UreaN-19 Creat-0.8 Na-136 K-3.5 Cl-103 HCO3-28 AnGap-9 [2101-11-14] 12:21PM BLOOD Glucose-163* UreaN-17 Creat-0.7 Na-138 K-3.9 Cl-106 HCO3-26 AnGap-10 Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: 1. please see below 2. heme consulted for antithrombin III deficiency. follows with Dr [Last Name (STitle) 2805] Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with posterior hip precautions. Mr [Known lastname 11606] is discharged to home with services in stable condition. Assessment and Plan Mr. [Known lastname 11606] is a 64-year-old male with history of liver cirrhosis, hepatitis B, SMV/PV thrombosis and antithrombin III deficiency (on coumadin), who is s/p left total hip replacement and POD day 0. Admitted to [Hospital Unit Name 153] for administration of AT-3 # s/p left total hip replacement: POD #1. Uncomplicated surgery per discussion with orthopedics, with estimated blood loss 750 cc. Pain well controlled currently. - cefazolin per orthopedics recs (total of 3 doses) - pain control with standing naproxen, tylenol and prn morphine - written for dilaudid PCA per orthopedics, which can be consolidated to morphine IV or PO regimen in next 24-48 hours - monitor [Hospital1 ] Hct for now and can transition to daily once stable - hip plain film per ortho on [11-10] and [2101-11-12] - ROM Restictions post surgical hip precautions per ortho . # AT III deficiency: hip replacement surgery is associated with a very high risk of developing thrombotic complications. Given Mr. [Known lastname 11607] ATIII deficiency, underlying liver disease, and previous history of venous thromboses, he is at high risk for perioperative thrombosis. Prior to the OR, he received Thrombate (antithrombin III) at a dose of 3864U IV x1 and his AT level rose to 118%. - appreciate hematology/oncology recommendations - per heme/onc goal is an AT level >75% (ideally 80-120). This morning??????s level was 91 so will get dose of 1656 U today - he should have levels checked daily for at least the next three days and will be dosed with additional Thrombate prn (at a dose of 1656U IV daily). - For DVT prophylaxis, has satarted Lovenox 30mg SC BID 12 hours after surgery (orthopedics team aware). Currently not on treatment dose heparin bridge per heme recs. Will touch base about when to formally bridge to coumadin - Continue coumadin # Anemia: Hct 39.7--> 35.6 with baseline of 46-47. Unlikely to be dilutional given lack of dilution of platelets. Other possibility includes surgical site bleeding. Less likely B12, folate, Fe deficiency, or anemia of chronic disease. - trend with [Hospital1 ] Hcts - B12, folate, iron studies all pending - will guaiac stool # Hepatitis B: unknown source of exposure(genotype D, with precore and BCP mutations (basal core promoter mutation) on tenofovir. - continue tenofovir per home regimen # Oral HSV - continue valacyclovir per home regimen # HTN: BP currently stable. - continue nadalol per home regimen # Thrombocytopenia: stable and at baseline, per review of OMR and per discussion with hematology. - trend daily Medications on Admission: NADOLOL - 20 mg Tablet - one Tablet(s) by mouth daily TENOFOVIR DISOPROXIL FUMARATE - 300 mg Tablet - 1 Tablet(s) by mouth daily VALACYCLOVIR - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth once a day WARFARIN - 5 mg Tablet - 1-1.5 Tablet(s) by mouth once a day Patient to take 7.5 mg daily 6 days per week and 5 mg daily 1 day per week (Sunday). Medications - OTC GLUCOSAMINE SULFATE [GLUCOSAMINE] - (Prescribed by Other Provider) - Dosage uncertain OMEGA-3 FATTY ACIDS - (OTC) - Dosage uncertain Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous twice a day: until inr 2.0 -2.5. Disp:10 Refills:0 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:80 Tablet(s) Refills:0 4. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: goal INR [3-2]. Follow by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9449]. Disp:30 Tablet(s) Refills:2 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 7. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: left hip 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five days after surgery, but no tub baths or swimming for at least four weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox twice a day and coumadin 7.5 until your INR is therapeutic to help prevent deep vein thrombosis (blood clots). After your INR is therapeutic ([3-2]) you may stop lovenox injections. Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9449] on Friday. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. posterior precautions. mobilize frequently. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: post hip precautions wbat Treatments Frequency: daily dressing changes as needed ice as tolerated staples out 2 weeks from surgery Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2101-12-9] 12:40 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 2422] Date/Time:[2101-12-1] 10:20 Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 327] Date/Time:[2101-12-1] 8:30 Completed by:[2101-11-16]	[ "2875", "V5861", "4019", "2859" ]
Admission Date: [2162-4-22] Discharge Date: [2162-4-27] Date of Birth: [2089-6-9] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Coronary Artery Disease Major Surgical or Invasive Procedure: CABGx3 (LIMA->LAD, SVG->OM, distal RCA) [2162-4-22] History of Present Illness: Mr. [Name14 (STitle) 61043] is a 72 year old gentleman with dyspnea on exertion and atypical chest pain. He underwent a stress test which was positive. A cardiac catheterization was performed which revealed left main and two vessel disease. He was subsequently referred to Dr. [Last Name (STitle) ] for surgical management. Past Medical History: Hyperlipidemia Hypertension Hiatal hernia Osteoarthritis Social History: Lives in [Location ] with wife. Retired [Name2 (NI) 38980]. Quit smoking 20 years ago after 25 pack years. Denies alcohol abuse. Family History: No known history Physical Exam: GEN: No acute distress. NEURO: Alert, nonfocal LUNGS: Clear CARDIAC: RRR, Normal S1-S2 ABD: Soft, nontender, nondistended. EXT: Warm, well perfused, no edema, no varicosities PULSES: 1+ Throughout Pertinent Results: [2162-4-22] 07:24AM GLUCOSE-104 NA+-139 K+-4.1 [2162-4-22] 07:24AM HGB-12.0* calcHCT-36 [2162-4-26] 05:58AM BLOOD WBC-8.9 RBC-3.04* Hgb-9.2* Hct-27.4* MCV-90 MCH-30.5 MCHC-33.8 RDW-13.8 Plt Ct-180# [2162-4-27] 06:30AM BLOOD Glucose-103 UreaN-20 Creat-1.0 Na-137 K-3.8 Cl-100 HCO3-33* AnGap-8 [2162-4-26] CXR Disappearance of left-sided apical pneumothorax, persistent partial left lower lobe atelectasis and pleural adhesions. \ [2162-4-27] EKG Normal Sinus Rhythm Brief Hospital Course: Mr. [Name14 (STitle) 61043] was admitted to the [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1675] [Last Name (NamePattern1) ] Medical Center on [2162-4-22] for surgical management of his coronary artery disease. He was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [Name14 (STitle) 61043] awoke neurologically intact and was extubated. He was transfused with packed red blood cells for postoperative anemia. On postoperative day three, he was transferred to the cardiac surgical step down unit for further recovery. Mr. [Name14 (STitle) 61043] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His drains and epicardial pacing wires were removed without complication. He had a brief run of atrial fibrillation for which his beta blockade was advanced. Mr. [Name14 (STitle) 61043] continued to make steady progress and was discharged home on postoperative day five. He will follow-up with Dr. [Last Name (STitle) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Toprol 25mg daily Imdur 60mg twice daily Lipitor 80mg daily Diovan 40mg daily Aspirin 81mg daily Nexium PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 8. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Community health and Hospice Discharge Diagnosis: Coronary artery disease. 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. [First Name (STitle) ] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Completed by:[2162-4-27]	[ "41401", "9971", "42731", "2851", "4019", "2720" ]
Admission Date: [2118-7-8] Discharge Date: [2118-7-13] Date of Birth: [2062-2-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: acute coronary syndrome Major Surgical or Invasive Procedure: Cardiac catheterization with 3 stents placed History of Present Illness: 56 y/o male with h/o anterior MI, ischemic cardiomyopathy with an EF 15%, and schizophrenia who was transferred back from the CCU after cardioversion of VT/VF to NSR approximately 8 hours after catheterization for a NSTEMI. Patient had been in his USOH until the morning of admission, when he developed nausea, vomiting without blood, and abdominal pain while at an adult day care center, but no chest pain. He was taken to [Hospital3 ] ED where EKG showed T wave flattening when compared to EKG in [2115]. Initial troponin I was 7.95 and increased to 10.12 (no CK's drawn), and the patient was started on nitro gtt and heparin gtt and transfered to [Hospital1 18] for catheterization. In the cath lab, left heart cath demonstrated a 90% thrombosis of the proximal LAD, stented with DES, and focal 90% distal LAD stenosis beyond the large D1, stented with bare metal stent. RCA was found to have a 90% focal proximal stenosis and was stented with a DES. No LV gram performed d/t dye load and recent ECHO. Right heart cath showed mildly elevated pressures (RA 12, PCWP 22) and normal cardiac function (CO 6.44, CI 3.2). The patient was then sent to the floor for recovery and observation. Later in the evening the patient went into polymorphic VT by tele monitor and was found to be unresponsive. The VT then degenerated into VF and the patient was shocked within 40 seconds with 200 joules X 1 with return to NSR (BP 150/30, HR 90). He was bagged for ventilation and after an initial period of severe agitation, he calmed down with the presence of a Portugese speaking relative at his side and did not require intubation. No epinephrine or atropine was given, and 12 lead EKG showed NSR, nl axis and intervals with no evidence of acute ST elevations (unchanged). The patient was loaded on 150 mg of amiodarone while still on the floor and transferred to the CCU. Upon arrival to the CCU the patient denied CP, nausea, SOB, diaphoresis. Past Medical History: HTN Hyperlipidemia h/o IMI [2115] - s/p lytic therapy ECHO done at [Hospital3 ] - EF 20%, anterior and apical hypokinesis (not an official read) Schizophrenia H/O VT Cardiomyopathy with EF 15-20% Social History: lives with mother, [Name (NI) ] ETOH, former smoker Family History: unknown Physical Exam: PE: 96.7; 69; 100/59; 96% RA GEN: Patient in NAD, sitting comfortably in chair HEENT: MMM, No JVD. No carotid bruits. No pharyngeal erythema CV: S1S2 RRR. No murmurs ABD: soft, NT/ND. + BS. EXT: 2+ DPs. No C/C/E Pertinent Results: EKG: OSH EKG: NSR, normal axis, evidence of old anterior infarct, flattening of T waves when compared to EKG of [2115], [Street Address(2) 4793] elevation in V1, V2, also unchanged from [2115] EKG. Post-event EKG:NSR, normal axis, evidence of old anterior infarct (q in V1), [Street Address(2) 4793] depression in V4, V5, V6 with no T wave inversion CXR: no focal infiltrates, fullness of vasculature in hilar region [2118-7-13] 08:50AM BLOOD WBC-9.1 RBC-3.93* Hgb-11.6* Hct-34.6* MCV-88 MCH-29.4 MCHC-33.4 RDW-12.7 Plt Ct-238 [2118-7-13] 08:50AM BLOOD Plt Ct-238 [2118-7-13] 08:50AM BLOOD Glucose-149* UreaN-11 Creat-0.9 Na-139 K-4.6 Cl-103 HCO3-27 AnGap-14 [2118-7-9] 03:23AM BLOOD CK(CPK)-321* [2118-7-9] 03:23AM BLOOD CK-MB-20* MB Indx-6.2* cTropnT-1.79* [2118-7-8] 07:59PM BLOOD CK-MB-37* MB Indx-7.1* cTropnT-4.18* [2118-7-13] 08:50AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.9 Brief Hospital Course: Patient was taken to the cath lab at [Hospital1 18] upon transfer from OSH. In the cath lab, left heart cath demonstrated a 90% thrombosis of the proximal LAD, stented with DES, and focal 90% distal LAD stenosis beyond the large D1, stented with bare metal stent. RCA was found to have a 90% focal proximal stenosis and was stented with a DES. No LV gram performed d/t dye load and recent ECHO. Right heart cath showed mildly elevated pressures (RA 12, PCWP 22) and normal cardiac function (CO 6.44, CI 3.2). The patient was then sent to the floor for recovery and observation. Later in the evening the patient went into polymorphic VT by tele monitor and was found to be unresponsive. The VT then degenerated into VF and the patient was shocked within 40 seconds with 200 joules X 1 with return to NSR (BP 150/30, HR 90). He was bagged for ventilation and after an initial period of severe agitation, he calmed down with the presence of a Portugese speaking relative at his side and did not require intubation. No epinephrine or atropine was given, and 12 lead EKG showed NSR, nl axis and intervals with no evidence of acute ST elevations (unchanged). The patient was loaded on 150 mg of amiodarone while still on the floor and transferred to the CCU. Upon arrival to the CCU the patient denied CP, nausea, SOB, diaphoresis. [Hospital 2076] medical management was continued with Amiodarone, ACE, BB, and ASA. He remained hemodynamically stable and was transferred to [Hospital Unit Name 196] floor. Patient was evaluated by EP for possible ICD placement; they advised to hold off on ICD placement now because VT/VF occurred in known 8-hour post-cath setting and likely accounted for event. Patient will be seen by [Hospital ] clinic in 1 month for evaluation following cardiac MRI on [6-25]. Patient remained asymptomatic on [Hospital Unit Name 196] floor without CP, shortness of breath, or GI complaints. His outpatient medications were restored. His Coumadin was re-started and discharged home with EP follow-up, appointment for cardiac MRI, and VNA to check INR in 2 days. Patient's family was instructed to schedule appointment with PCP for early next week. Medications on Admission: Risperidol 3 mg PO QHS Zyprexa 10 mg QHS Lipitor 10 mg PO QD Plavix 75 mg PO QD Lasix 20 mg PO QD Lopressor 50 mg PO BID Prevacid 30 mg PO QD Tylenol PRN Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 6. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 7. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: Stop taking this medication if you develop bleeding. Disp:15 Tablet(s) Refills:0 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Outpatient Lab Work Please draw blood to check INR Please draw blood to check Potassium, Magnesium Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Acute Myocardial Infarction, Ischemic Cardiomyopathy (EF 15%), Schizophrenia, GERD Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed. If you develop shortness of breath, chest pain, palpitations, please contact your PCP [Name Initial (PRE) ]/or report to the Emergency Room immediately. Followup Instructions: Please schedule an appointment with your PCP to see him within the next 3-5 days. Please have your INR and electrolytes checked on Friday [2118-7-15]. *Please discuss with your PCP the concurrent use of Zyprexa and Risperidone, and Amiodarone, as these are known to prolong the QT interval. Cardiac MRI. [2123-7-25]:00 AM. An instruction packet will be mailed to your home. Please read thoroughly. On the day of the appointment, please bring someone who can translate instructions into Portuguese for you. Contact information for test: [Telephone/Fax (1) 9559] Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 2934] Date/Time:[2118-8-10] 2:00 Completed by:[2118-7-13**]	[ "9971", "41401", "4019", "412", "2724", "53081" ]
Admission Date: [2109-7-29] Discharge Date: [2109-8-2] Date of Birth: [2040-3-4] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / ketia Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2109-7-29] Coronary artery bypass graft x3: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to ramus and posterior descending arteries History of Present Illness: 69 year old man with hypercholesterolemia, family history of coronary artery disease, onset of chest heavinesss about three months ago occurring during gym workouts would last a few minutes then resume his workout. Denies any episodes at rest. He was sent to the [Hospital1 ] emergency room and then was tranferred to [Hospital1 18] for Cardiac Cath in early [Month (only) 216]. Cath showed severe coronary artery disease and was referred for surgery. Past Medical History: Hyperlipidemia Hypothyroidism Seasonal Allergies Anxiety s/p Bilateral ingunial hernia rpr. [2078] Social History: He lives alone and is retired. He never smoked and drinks less than one alcoholic beverage per week. He denies illicit drug use. Family History: His mother has angina symptoms, and passed away at age 78 after cardiac surgery. His father died at age 64 year. Physical Exam: Pulse:71 Resp:20 O2 sat:99% RA B/P Right: Left:143/76 Height: 5'9 Weight:95kg General:NAD,AAOx3, no focal deficits 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 [] grade ______ Abdomen:Soft[x]non-distended[x]non-tender[x] bowelsounds+ [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [] Neuro: Grossly intact [x] Pulses: Femoral Right:+2 Left:+2 DP Right:+2 Left:+2 PT [Name (NI) 167]:+2 Left:+2 Radial Right:cath site Left:+2 Carotid Bruit: None Pertinent Results: [2109-7-29] Echo: PRE-BYPASS: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Estimated overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results on [2109-7-29] at 0930. Post Bypass: There is preserved left ventricular function that is unchanged from prebyass. There is no obvious evidence of aortic dissection. Valvular function is unchanged from prebypass with continued mild aortic regurgitation. . [2109-7-29] 11:49AM BLOOD WBC-22.4# RBC-3.91 Hgb-12.1* Hct-34.8* MCV-89 MCH-31.0 MCHC-34.9 RDW-13.1 Plt Ct-210 [2109-8-2] 06:20AM BLOOD WBC-10.8 RBC-3.60* Hgb-11.1* Hct-33.0* MCV-92 MCH-30.8 MCHC-33.6 RDW-13.4 Plt Ct-276 [2109-7-29] 11:49AM BLOOD PT-13.9* PTT-27.6 INR(PT)-1.3* [2109-7-29] 11:49AM BLOOD UreaN-12 Creat-0.8 Na-140 K-4.2 Cl-112* HCO3-22 AnGap-10 [2109-8-2] 06:20AM BLOOD Glucose-103* UreaN-21* Creat-1.0 Na-135 K-4.4 Cl-100 HCO3-31 AnGap-8 [2109-7-30] 02:59AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1 [2109-8-1] 03:57AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8 Brief Hospital Course: The patient was brought to the Operating Room on [7-29] where the patient underwent Coronary artery bypass graft x3: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to ramus and posterior descending arteries. Endoscopic harvesting of the long saphenous vein. Please see operative note for surgical details. 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. 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 services in good condition with appropriate follow up instructions. Medications on Admission: 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Aspirin 325 mg PO DAILY 3. WelChol NF (colesevelam) 625 mg Oral daily 4. Multivitamins 1 TAB PO DAILY 5. Co Q-10 NF (coenzyme Q10;<br>coenzyme Q10-vitamin E) 100 mg Oral daily 6. garlic NF 500 mg Oral daily 7. saw [Location (un) 6485] NF 450 Oral daily 8. flaxseed oil NF 1200 Oral daily 9. Magnesium Oxide 250 mg PO DAILY 10. krill oil NF [Medical Record Number 111783]-50 mg Oral daily Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 2. Levothyroxine Sodium 125 mcg PO DAILY 3. WelChol NF* (colesevelam) 625 mg ORAL DAILY 4. Furosemide 20 mg PO BID Duration: 7 Days RX furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 5. Metoprolol Tartrate 37.5 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [Last Name (NamePattern4) 9641] metoprolol tartrate 25 mg 1 [12-3] tablet(s) by mouth three times a day Disp #150 Tablet Refills:1 6. Oxycodone-Acetaminophen (5mg-325mg) [12-3] TAB PO Q4H:PRN pain RX oxycodone-acetaminophen 5 mg-325 mg [12-3] tablet(s) by mouth every four (4) hours Disp #65 Tablet Refills:0 7. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days RX potassium chloride 20 mEq 1 mEq by mouth twice a day Disp #14 Tablet Refills:0 8. Ranitidine 150 mg PO BID Duration: 2 Weeks RX ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp #28 Capsule Refills:0 RX ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp #28 Capsule Refills:0 9. saw [Location (un) 6485] NF 450 Oral daily 10. Multivitamins 1 TAB PO DAILY 11. Magnesium Oxide 250 mg PO DAILY 12. krill oil NF [Medical Record Number 111783]-50 mg Oral daily 13. garlic NF 500 mg Oral daily 14. flaxseed oil NF 1200 Oral daily 15. Co Q-10 NF (coenzyme Q10;<br>coenzyme Q10-vitamin E) 100 mg Oral daily Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: Hyperlipidemia Hypothyroidism Seasonal Allergies Anxiety s/p Bilateral ingunial hernia repair. [2078] 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 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: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office on [2109-8-8] at 10:15 in the [Hospital ] medical office building, [Hospital Unit Name ] Surgeon Dr. [First Name (STitle) ] on [2109-8-27] at 2:30 [Telephone/Fax (1) 170] at 10:15 in the [Hospital ] medical office building, [Hospital Unit Name ] Cardiologist: Please obtain referral to cardiologist from PCP Please call to schedule the following: Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [2-3] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2109-8-2]	[ "41401", "2449", "2724", "2720" ]
Admission Date: [2188-8-27] Discharge Date: [2188-8-30] Date of Birth: [2130-6-15] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 922] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Bilateral thoracotomies, mini-MAZE with resection of left atrial appendage [8-27] History of Present Illness: Mr. [Known lastname ] is a 57 year old male with history of persistent atrial fibrillation since [2182]. He complained of intermittent shortness of breath. In addition he has intermittent palpitations, lightheadedness, dizziness and fatigue. He was on Amiodarone in [2182]-[2183] and maintained a NSR but had to stop taking this medication due to photosensitivity. During this time he had two cardioversions. He is currently taking Diltiazem and Carvedilol. In addition is currently taking Pradaxa instead of Coumadin. Due to his symptoms, and frequency of atrial fibrillation, he has been referred for MAZE procedure with left atrial appendectomy. Past Medical History: Chronic Paroxysmal Atrial Fibrillation Colon/Rectal Cancer s/p surgery Prostate cancer s/p surgery GERD Bowel dysfunction Osteoarthritis Phlebitis Claustrophobia s/p Colectomy/ostomy(later reversed) s/p Radical prostatectomy [2178] s/p Right knee surgery [2187] s/p Right shoulder surgery s/p Left hip replacement [2183] s/p Ventral hernia repair s/p vein stripping of right GSV Social History: Mr. [Known lastname ] lives with his wife and is a football coach. He is a non-smoker and drinks alcohol socially. Family History: His father had a coronary artery bypass graft in his 70s. Physical Exam: Physical Exam Pulse: 85 Resp: 16 O2 sat: 98%RA B/P Right: 117/78 Left: 114/75 Weight: 237lb General: NAD, WGWN, appears stated age, slightly anxious Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] OP benign 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] well healed mid-line and RLQ incisions Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] 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+ Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 569] [Hospital1 18] [Numeric Identifier 90407] (Complete) Done [2188-8-27] at 11:57:33 AM PRELIMINARY Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] C. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2130-6-15] Age (years): 58 M Hgt (in): 72 BP (mm Hg): / Wgt (lb): 225 HR (bpm): BSA (m2): 2.24 m2 Indication: Atrial fibrillation. ICD-9 Codes: 427.31 Test Information Date/Time: [2188-8-27] at 11:57 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW-1: Machine: us2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Left Ventricle - Lateral Peak E': 0.01 m/s > 0.08 m/s Aorta - Annulus: 2.7 cm <= 3.0 cm Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - LVOT diam: 2.5 cm Findings LEFT ATRIUM: No spontaneous echo contrast in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Mild regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic function. TASPE depressed (<1.6cm) AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: No MS. Trivial MR. TRICUSPID VALVE: Mild [1+] TR. 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. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with apical hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The right ventricular cavity is mildly dilated with borderline normal free wall function. Tricuspid annular plane systolic excursion is depressed consistent with right ventricular systolic dysfunction. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) 914] was notified in person of the results at time of surgery. Post-ligation: The left atrial appendage is not seen. Color flow Doppler exam demonstrates no evidence of flow from the previous location of the left atrial appendage into the left atrium. Brief Hospital Course: On [2188-8-27] Mr. [Known lastname ] [Last Name (Titles) 1834] Bilateral thoracotomies, mini-MAZE with resection of left atrial appendage performed by Dr. [Last Name (STitle) 914]. Please see the operative note for details. He tolerated the procedure well and extubated in the operating room. He was transferred in critical but stable condition to the surgical intensive care unit. His chest tubes and temporary pacing wires were removed per protocol. He was started back on his [Last Name (un) ], calcium channel blocker, and pradaxa. He was placed on indocin and motrin for 1 month post-operatively to reduce pericardial inflammation. He was evaluated by physical therapy for strength and conditioning and was cleared for discharge to home on POD#3. Medications on Admission: Coreg 25mg [Hospital1 ] Pradaxa 150mg [Hospital1 ] Diltiazem 120mg daily Benefiber Lactobacillus Lotrisone Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 3. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 7. diltiazem HCl 120 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). Disp:30 Capsule, Ext Release 24 hr(s) Refills:2 8. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 1 months. Disp:90 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 8300] VNA & Hospice Discharge Diagnosis: atrial fibrillation Chronic Paroxysmal Atrial Fibrillation; Colon/Rectal Cancer s/p colectomy; ventral hernia repair; Prostate cancer s/p radical prostatectomy; GERD; Bowel dysfunction; Osteoarthritis; Phlebitis; Claustrophobia; L hip replacement [2183] 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 Leg Right/Left - healing well, no erythema or drainage. Edema 1+ 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 Recommended Follow-up: Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) 914] [Telephone/Fax (1) 170] on [9-30] at 2:45pm in the [Hospital ] medical office building [Hospital Unit Name ], [Last Name (NamePattern1) ] Cardiologist: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [9-26] at 1:40pm Please call to schedule appointments with your Primary Care Dr. [First Name (STitle) ],[First Name3 (LF) ] C. [Telephone/Fax (1) 30817] in [2-26] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2188-9-2]	[ "42731", "53081" ]
Admission Date: [2188-1-16] Discharge Date: [2188-1-22] Date of Birth: [2130-9-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4282] Chief Complaint: palpitations Major Surgical or Invasive Procedure: IVC filter History of Present Illness: Mr. [Known lastname ] is a 57 year old male with a past medical history significant for cholangiocarcinoma (unresectable and s/p chemo w/ gemcitabine and cisplatin), hypertension, and recent GIB (ischemic v. infectious colitis) who presents with SVT to 180s from clinic. . The patient was in his usual state of health, with chronic abdominal pain, and was seen today in clinic by Dr. [Last Name (STitle) ] for a third round of chemotherapy. While sitting in the chair in the waiting room, he felt his heart beat "fast." There he was found to have SVT to 180s and was sent to the ED. His BP at the time was 102/60. He denies any chest pain, cough, shortness of breath, lightheadedness, nausea, or vomiting. At baseline, he ambulates independently and without dyspnea on exertion. Of note, he also denies noticing any lower extremity edema, fevers, chills, diarrhea, constipation, melena or BRBPR. He endorses ~30lb weight loss over the course of 3 months. . In the ED, initial VS were: HR in 170s. Vagal maneuver was attempted and failed. He was given adenosine 6mg and converted to sinus tachycardia. He remained persistantly tachycardic to 120s and so a CTA was done that showed bilateral subsegmental PEs. His labs were notable for negative CE, leukocytosis of 12.4, hgb/hct 9.9/29.9. On exam he was guaiac neg. Heme/onc was consulted and recommended heparin gtt without bolus. VS on transfer were: 109, 124/96, 25, 100% on 2L. . Notably, he was recently hospitalized ([Date range (1) 84012]) for BRBPR s/p colonoscopy significant for segmental colitis with biopsies suggestive of ischemic vs infectious colitis. On that admission, he developed a fever 2 days and CT scan showed likely colitis; he was treated with Cipro, Flagyl, and Asacol (which was discontinued recently by Dr. [Last Name (STitle) 9916]. He did not receive any blood products at that time, and his hct on discharge was 27. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness. Denied nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: #. Cholangiocarcinoma: - [9-/2187] presented with abdominal pain and jaundice. Percutaneous transhepatic cholangiography was performed on [10-24] w/ malignant cells on brushing. - He was taken to operating [10/2187], found to have extensive common hepatic involvement and extension into the liver duodenum as well as head of the pancreas and was unresectable. - He is s/p bilateral metallic biliary stent placement on [2187-11-22] (removed on [11-22]). - Started palliative chemotherapy with gemcitobine and cisplatin (Cycle 1 [2187-12-19], cycle ends [2188-1-8]) #. Hypertension #. GI Bleed: s/p sigmoidoscopy [1-4] w/ ulcerated friable colon biopsy c/w ischemic type colitis. Social History: He works in a restaurant. He moved to the USA 20 years ago. He is married with 5 kids, the oldest 33 years old. He speaks minimal English. Wife speaks no English. Children speak English well. He smoked 1 pack for many years but quit 20 years ago. He denies alcohol or illicit drug use. Family History: No history of GI cancer. Physical Exam: Vitals: BP 133/88 HR 104 RR 20 O2 100 2L O2 General: Alert, oriented, laying in bed, conversant and following commands, in 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, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Surgical scar appreciated along RUQ, abdomen mildly tense and tender to palpation at mid-epigastric area, no guarding/rebound tenderness and normal bowel sounds Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, neg pain on dorsiflexion Skin: No jaundice Neuro: A&Ox3, tongue midline, PERRL, EOMI, [4-16] SCM/trap, neg babinski, gait deferred Pertinent Results: CTA 1. Bilateral segmental and subsegmental pulmonary embolism without evidence of right heart strain. 2. Nodular mural atheroma in the descending thoracic aorta with configuration worrisome for future embolization. 3. Hypoenhancing infiltrative hepatic mass extending into the porta hepatis and left hepatic lobe compatible with known cholangiocarcinoma. Associated biliary obstruction again noted. 4. Increasing ascites with persistent multiple nodular peritoneal implants. 5. Persistent pancreatic ductal dilation. ECHO The left atrium is normal in size. There is a 2x2 cm echodensity posterior to the left atrium (cine loop 52), probably in the posterior mediastinum. It is outside the heart and anatomically could be associated with the esophagus or the surrounding structures. 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) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. Very small pericardial effusion. There is an anterior space which most likely represents a fat pad. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Very small pericardial effusion without signs of tamponade. Normal global and regional biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. Probable extracardiac posterior mediastinal mass. Compared with the prior study (images reviewed) of [2187-12-20], cardiac findings are similar. The extracardiac mass was not appreciated on the prior study. Findings discussed with Dr. [Last Name (STitle) ] at 1650 hours on the day of the study. Ultrasound LE: Occlusive DVT in one of the two right posterior tibial veins. R [Doctor Last Name ] V patent. No other thrombus noted. ADMISSION LABS: [2188-1-16] 02:25PM BLOOD WBC-12.4# RBC-3.25 Hgb-9.9* Hct-29.9* MCV-92 MCH-30.5 MCHC-33.1 RDW-16.5* Plt Ct-510* [2188-1-16] 02:25PM BLOOD Neuts-79.1* Lymphs-14.9* Monos-5.0 Eos-0.4 Baso-0.6 [2188-1-16] 02:25PM BLOOD PT-12.5 PTT-21.7* INR(PT)-1.1 [2188-1-16] 02:25PM BLOOD Glucose-115* UreaN-10 Creat-0.7 Na-135 K-3.5 Cl-101 HCO3-28 AnGap-10 [2188-1-16] 02:25PM BLOOD CK(CPK)-50 [2188-1-17] 05:56AM BLOOD ALT-19 AST-32 LD(LDH)-219 AlkPhos-117 TotBili-0.6 [2188-1-16] 02:25PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.3 DISCHARGE LABS: [2188-1-22] 07:15AM BLOOD WBC-9.3 RBC-2.88* Hgb-9.3* Hct-27.1* MCV-94 MCH-32.2* MCHC-34.2 RDW-16.6* Plt Ct-282 [2188-1-20] 06:45AM BLOOD Neuts-69.8 Lymphs-22.8 Monos-5.6 Eos-1.3 Baso-0.4 [2188-1-21] 06:10AM BLOOD PT-12.0 PTT-21.4* INR(PT)-1.0 [2188-1-22] 07:15AM BLOOD Glucose-92 UreaN-7 Creat-0.5 Na-136 K-3.7 Cl-106 HCO3-22 AnGap-12 [2188-1-21] 06:10AM BLOOD ALT-17 AST-23 AlkPhos-111 TotBili-0.8 [2188-1-22] 07:15AM BLOOD Albumin-3.7 Calcium-8.5 Phos-3.5 Mg-2.2 Brief Hospital Course: 57M with cholangiocarcinoma (unresectable and s/p chemo w/ gemcitabine and cisplatin), hypertension, and recent GIB (ischemic v. infectious colitis) who presents with SVT to 180s from clinic and was found to have bilateral subsegmental PEs and right LE DVT. Initially admitted to the ICU for monitoring and then transferred to the oncology service. . # Pulmonary Embolism / DVT: Patient was started on heparin gtt for bilateral subsegmental PE noted on CTA and DVT on LENI then switched to lovenox SQ. She had IVC filter placed today due to hx of GI bleed and the risk of bleeding with anticoagulation. She tolerated the procedure well and had no signs of bleeding. All stools were guaiac negative. Her Hct was stable at 27 on the day of discharge. . #. History of BRBPR / ischemic colitis: Sigmoidoscopy [12-23] sig for biopsies consistent with ischemic colitis though patient was also treated for possible infectious colitis. He was recently seen by his outpatient GI doctor, Dr. [Last Name (STitle) 9916], who stopped his Asacol and has sent off stool cx for E. coli and c diff which were negative. As noted above she was guaiac negative and HCT stayed stable. . . #. SVT: Likely AVNRT/AVRT with termination by adenosine. In the [Hospital Unit Name 153] had a brief episodes of SVT, but is currently in sinus. Has had episodes of AVNRT/AVRT in the past controlled by metoprolol/amiodarone though these have been held since last admission, given concern for bleed. Metoprolol was restarted on [2188-1-18] at higher dose at 25mg TID and was started on diltiazen 30mg QID (will change to long acting prior to discharge) for rate control. Pt had short runs, only a few seconds of sinus tachycardia, asymptomatic. She also had aggressive electrolytes control. PE management as outlined above. . #. Metastatic Cholangiocarcinoma: Preliminary read is concerning for progression of metastatic disease, increase size of hepatic mass, and worsening ascites. Prior CT scan notable for sclerotic lesion in sacrum. Prior head CT w/ multiple subcentimeter low density regions (likely small vessel disease) and no evidence of obvious mets. Followed by Dr. [Last Name (STitle) 84321] as outpatient and is currently undergoing palliative chemotherapy. Pt also has increase in abdominal girth and fluid shift on exam consistant with ascitis. She had therapeutic tap with 1 L removed. She was continued on home meds including Megace, pain management with dilaudid PRN, antiemetics with Compazine/Zofran and ativan prn. . # FEN: Regular diet tolerating well, replete electrolytes PRN. . # PPx: Pain control with dilaudid prn, bowel regimen, DVT PPx lovenox . # Comm: With patient # Code: FULL # Dispo: pending above Medications on Admission: Docusate Sodium 100 [Hospital1 ] Hydromorphone 2 mg q4hr prn MSIR 15 mg Q12 Prochlorperazine Maleate 10 mg every 4-6 hours prn Lorazepam 1 mg every 6-8 hours prn ZOFRAN ODT 8 mg Tablet, Rapid Dissolve every 6-8 hours as needed for nausea. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: [12-15] once a day. Sennosides 8.6 mg [Hospital1 ] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea, anxiety. 4. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 5. Megestrol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:0 8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:0 9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 10. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: cholangiocarcinoma bilateral subsegmental PE DVT AVNRT/AVRT Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to [Hospital1 18] for a fast heart rate and you were found to have a pulmonary embolism and blood clot in your right leg. You were initially treated with anticoagulation (blood thining medication) and medication to decrease your heart rate. You had a filter placed in your vein to hopefully prevent clots from moving to your lungs. You did well after your procedure. You were also very uncomfortable due to fluid in your abdomen. You had fluid removed from your abdomen and you are feeling better. You also had episodes of increase heart rate and you were started on medication to lower your heart rate. We added the following medications to your regimen: -Started you on metoprolol XL 75mg once daily -Diltiazem 120mg orally once daily -Omeprazole 20mg daily We have not made any changes to your other medications. You will need to follow-up tomorrow with oncology as listed belw and with cardiology for your fast heart rate. Followup Instructions: Cardiology: You have an appointment with Dr. [Last Name (STitle) 84322] on [2188-2-12] at 11:00 AM on [Hospital Ward Name 23] building [Location (un) 436], Cardiology Phone # [Telephone/Fax (1) 62] ONCOLOGY: You have an appointment with Dr. [Last Name (STitle) ] tomorrow at 1:00PM On [Hospital Ward Name 23] [Location (un) ] ([Telephone/Fax (1) 27917]	[ "42789" ]
Admission Date: [2188-9-10] Discharge Date: [2188-10-24] Date of Birth: [2120-10-31] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2641] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Intubation Central Line placement Axillary Arterial Line Placement PICC placement ([10-7]) NG tube placement TIPs dilatation Cardioversion paracentesis x 3 EGD History of Present Illness: Mr. [Known firstname ] [Known lastname 487] is a 67-year-old man with a history of CHF, cirrhosis s/p TIPS, and Afib (off coumadin) was brought in the the [Hospital6 17032] by ambulance after his daughter found him to be short of breath, confused, and incontinent. At the [Hospital3 17031] he was found to be febrile to 105, HR 137, BP 72/31 RR 28 SpO2 98%. EKG reveal afib with RVR and ST depressions in V4-6. Labs were notable for a WBC 27.6, PLT 45, INR 2.3, creatinine 4.1 digoxin 0.5. A femoral line was placed and he was given levaquin and zosyn for presumed urosepsis given a positive UA (packed WBC, 4+ bacteria). CT abd/pelvis without contrast showed no free air and no bowel wall thickening. He received 6 L IVF and was started on dopamine and levophed prior to transfer to [Hospital1 18] for further evaluation. . On arrival to [Hospital1 18] ED VS were 98.9 130 77/49 28 100% 3L Dopamine was discontinued due to tachycardia and levophed was titrated up. He was given decadron 10 mg IV and 1 L IVF. Transplant surgery was consulted to evaluate for mesenteric ischemia given elevated lactate, WBC and intermittent abdominal pain. They recommended admission to MICU. . Of note, records from OSH mention admission on [2188-8-13] for SBP and recent Klebsiella infection. . Review of systems: Unable to assess due to confusion. Past Medical History: Paroxysmal atrial fibrillation (not on coumadin due to cirrhosis) Cirrhosis s/p TIPS Dilated cardiomyopathy CAD Obesity Social History: Patient lives alone. He is retired. He reports smoking 2 cigarettes per day. He admits to a history of alcohol abuse but denies any recent alcohol use. He denies use of herbal medications or illicit drugs (including IVDU). Family History: Noncontributory. Denies family history of liver disease. Physical Exam: ADMISSION EXAM GA: AAOx3, NAD HEENT: PERRLA. dryMM. Poor dentition. No LAD. No JVD. Neck supple. Cards: Tachycardic, 2/6 systolic murmur heard at LUSB. Pulm: Moderately labored breathing. Crackles at bilateral bases. Abd: soft, NT, decreased bowel sounds. No rebound, guarding Extremities: wwp, no edema. DPs, PTs 2+. Skin: dry skin, no rashes Neuro/Psych: Awake, alert, but disoriented. Follows commands, answers questions appropriately. Pertinent Results: I. Labs A. Admission [2188-9-10] 05:30PM BLOOD WBC-15.5* RBC-4.40* Hgb-13.4# Hct-41.3 MCV-94 MCH-30.5 MCHC-32.5 RDW-15.1 Plt Ct-41# [2188-9-10] 05:30PM BLOOD Neuts-76* Bands-20* Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2188-9-10] 05:30PM BLOOD PT-22.3* PTT-47.0* INR(PT)-2.1* [2188-9-10] 05:30PM BLOOD Glucose-164* UreaN-42* Creat-3.6# Na-139 K-3.7 Cl-103 HCO3-15 AnGap-25* [2188-9-10] 05:30PM BLOOD ALT-13 AST-27 AlkPhos-116 TotBili-3.7* [2188-9-10] 05:30PM BLOOD cTropnT-0.03* [2188-9-10] 05:30PM BLOOD Albumin-2.5* [2188-10-11] 05:48AM BLOOD Ammonia-26 [2188-10-11] 05:48AM BLOOD TSH-3.5 [2188-9-11] 05:34AM BLOOD Cortsol-78.0* [2188-9-10] 05:37PM BLOOD Lactate-11.8* B. Discharge ([2188-10-25]) WBC 6.2 Hgb 10.9 Hct 32.5 Plt 156 Na 140 K 3.9 Cl 107 HCO3 29 BUN 7 Cr 0.8 Glc 85 Ca 8.8 Ph 2.5 Mg 1.9 C. Other [2188-10-11] 05:48AM BLOOD VitB12-941* [2188-10-9] 03:23AM BLOOD calTIBC-122* Hapto-14* Ferritn-384 TRF-94* [2188-10-11] 05:48AM BLOOD Digoxin-0.9 D. Urine [2188-9-10] 09:21PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.015 [2188-9-10] 09:21PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-5.5 Leuks-LG [2188-9-10] 09:21PM URINE RBC-56* WBC-94* Bacteri-FEW Yeast-NONE Epi-0 [2188-9-11] 04:10AM URINE Hours-RANDOM UreaN-156 Creat-164 Na-38 K-82 Cl-12 [2188-9-11] 03:38PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG E. Ascites [2188-10-8] 08:57AM ASCITES WBC-15* RBC-20* Polys-4* Lymphs-91* Monos-4* Mesothe-1* [2188-9-29] 06:45AM ASCITES WBC-135* RBC-245* Polys-40* Lymphs-43* Monos-7* Mesothe-6* Macroph-4* [2188-10-8] 08:57AM ASCITES Albumin-LESS THAN [2188-9-29] 06:45AM ASCITES Glucose-126 LD(LDH)-63 II. Microbiology [2188-10-20] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2188-10-20] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2188-10-19] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2188-10-18] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2188-10-18] URINE URINE CULTURE-FINAL INPATIENT [2188-10-18] 1:30 am BLOOD CULTURE FINAL REPORT [2188-10-20] Blood Culture, Routine (Final [2188-10-20]): ESCHERICHIA COLI. FINAL SENSITIVITIES. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. BACTRIM (=SEPTRA=SULFA X TRIMETH) AND TETRACYCLINE Sensitivity testing per DR.[Last Name (STitle) 10000],[First Name3 (LF) ] PAGER [Numeric Identifier 37310] [2188-10-19]. Piperacillin/Tazobactam sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. TETRACYCLINE sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [2188-10-18]): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO [First Name8 (NamePattern2) 26] [Last Name (NamePattern1) 37311] -ICU- @ 12:45 [2188-10-18]. Anaerobic Bottle Gram Stain (Final [2188-10-18]): GRAM NEGATIVE ROD(S). Time Taken Not Noted Log-In Date/Time: [2188-10-17] 4:12 pm PERITONEAL FLUID PERITONEAL FLUID. FINAL REPORT [2188-10-23] GRAM STAIN (Final [2188-10-17]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2188-10-20]): NO GROWTH. ANAEROBIC CULTURE (Final [2188-10-23]): NO GROWTH. [2188-10-17] URINE URINE CULTURE-FINAL INPATIENT [2188-10-17] FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture in Bottles-FINAL INPATIENT [2188-10-16] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2188-10-16] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2188-10-15] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2188-10-15] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2188-10-14] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2188-10-14] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2188-10-11] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT [2188-10-10] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-10-10] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-10-10] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-10-8] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram Stain-FINAL INPATIENT [2188-10-8] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-10-8] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT [2188-10-5] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2188-10-1] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-10-1] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-29] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT [2188-9-29] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2188-9-29] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-29] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-28] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2188-9-28] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [2188-9-28] BLOOD CULTURE Blood Culture, Routine-FINAL {ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL INPATIENT [2188-9-23] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2188-9-22] URINE URINE CULTURE-FINAL INPATIENT [2188-9-22] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-22] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-20] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-20] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-19] URINE URINE CULTURE-FINAL INPATIENT [2188-9-18] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2188-9-17] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2188-9-16] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-15] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-14] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-12] BLOOD CULTURE Blood Culture, Routine-FINAL {ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL INPATIENT [2188-9-12] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2188-9-11] BLOOD CULTURE Blood Culture, Routine-FINAL {ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL INPATIENT [2188-9-11] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [2188-9-11] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [2188-9-10] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI} INPATIENT [2188-9-10] BLOOD CULTURE Blood Culture, Routine-FINAL {ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL INPATIENT [2188-9-10] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2188-9-10] BLOOD CULTURE Blood Culture, Routine-FINAL {ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] [2188-9-10] BLOOD CULTURE Blood Culture, Routine-FINAL {ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] III. Radiology *** A. Redo TIPS B. Doppler LUE IMPRESSION: No evidence of deep vein thrombosis in the left arm. C. Liver US ([2188-10-10]) IMPRESSION: 1. Patent TIPS, however, the flow is not satisfactory on color Doppler imaging due to lack of wall-to-wall appearance. Additionally, flow in the left and right portal veins is noted to be away from the TIPS shunt. The appearance may represent neointimal proliferation and a consult with interventional radiology is suggested. 2. Gallstones. 3. Splenomegaly. 4. Ascites and left pleural effusion. D. Bone scan ([2188-10-10]) CONCLUSION: Normal bone scan. No evidence of focal abnormality in the bone as described above. Gallium scan to follow. E. Gallium scan IMPRESSION: Normal gallium scan. Specifically no evidence of infection in the lumbar spine. F. Tib/fib Two views of the tibia and fibula demonstrate edema within the soft tissues of the calf. No abnormal findings in the fibula. Of note, there is a faint region of lucency with indistinct cortex at the medial proximal tibial shaft. This is best seen on the frontal view. It is unclear if this area correlates to the wound. Further assessment with MRI may be helpful to ascertain for osteomyelitis. G. MRI spine HISTORY: Urosepsis with ESBL E. coli and now bacteremia with unknown source. Now with worsening lower extremity weakness concerning for cord compression. Rule out cord compression. TECHNIQUE: MRI of the cervical, thoracic and lumbar spine was performed utilizing sagittal T2, sagittal T1, sagittal STIR without intravenous contrast. Due to patient's inability to cooperate axial T1 and T2 sequences were only obtained through L3-S1. After the administration of contrast sagittal and axial T1-weighted sequences were obtained. COMPARISON: None. FINDINGS: CERVICAL SPINE: Evaluation of the cervical spine is limited as only sagittal T1- and T2-weighted sequences could be performed due to patient's inability to cooperate. The cervical alignment and vertebral body height are maintained. The T1 signal of the vertebral bodies is mildly hypointense diffusely. Small disc protrusions are present at C5-C6 and C6-C7 without significant spinal canal narrowing. No gross neural foraminal narrowing although this is limited without axial images. The cervical cord is normal in signal and caliber. No intradural or extradural fluid collections are noted. The prevertebral soft tissues are normal. THORACIC SPINE: The thoracic spine vertebral body heights and alignment are maintained. Diffuse T1 hypointensity of the vertebral body marrow signal is noted as seen in the cervical spine. Multilevel mild degenerative changes are noted with mild indentation on the adjacent end-plates. There is no spinal canal or neural foraminal narrowing. The thoracic cord is normal in signal and caliber. No epidural or soft tissue fluid collections are noted. The prevertebral soft tissues are normal. LUMBAR SPINE: The lumbar spine vertebral body heights are maintained. Mild decrease in the T1 signal of the vertebral body marrow is noted similar to that seen in the cervical and thoracic spine. Approximately 4 mm of grade 1 retrolisthesis of L4 on L5 is present. L1-L2: No gross spinal canal or neural foraminal narrowing. L2-L3: A broad-based disc bulge is present asymmetric to the right without significant spinal canal or neural foraminal narrowing. L3-L4: Minimal disc bulge is present without spinal canal narrowing. Moderate facet degenerative changes are noted with mild bilateral neural foraminal narrowing. L4-L5: 4 mm of retrolisthesis of L4 on L5 along with disc protrusion, posterior osteophytes, facet arthrosis and ligamentum flavum infolding produce moderate spinal canal narrowing. Mild-to-moderate right neural foraminal narrowing is present. L5-S1: A broad-based right paracentral disc protrusion is present superimposed upon a diffuse disc bulge resulting in mild spinal canal narrowing and moderate bilateral neural foraminal narrowing. Mild increase in the discs at L4/5, L5/S1 levels may be normal/ related to superimposed inflammation/infection. Correlate with labs. The lower cord and cauda equina are not well assessed due to suboptimal quality of the L spine study. This may be due to technical factors although clumping of nerve roots cannot be excluded in this region. No epidural or intradural fluid collection is identified. The paravertebral soft tissues are grossly normal. No obvious foci of enhancement are noted within the limitations of motion. IMPRESSION: 1. The study is significantly limited as the patient could not tolerate a complete exam and there is significant motion on multiple sequences. No gross evidence for cord compression or gross evidence of spondylodiscitis. Mild increased T2 signal in the L4/5 and L5/S1 levels may be within normal limits or superimposed mild inflammtion/infection. Correlate clinically and with labs and if necessary nuclear medicine studies. 2. The cauda equina is not readily discernable from the conus medullaris and is difficult to evaluate which may be technical due to the above limitations although, abnormality of the cauda equina and conus cannot be excluded such as clumping of nerve roots and arachnoiditis. A repeat examination when the patient is able to tolerate would be helpful for further evaluation. 3. Diffuse diminished T1 signal of the vertebral body marrow signal is present suggesting such processes as myeloproliferative disorders, chronic anemia and marrow replacement. Clinical correlation recommended. 4. Multilevel, multifactorial degenerative changes in the lumbar spine from L3-S1; can be assessed better on repeat study. H. CT Abdomen INDICATION: 67-year-old male with congestive heart failure, cirrhosis, status post TIPS, presents with bacteremia with failed antibiotics, here for evaluation of source of infection. COMPARISON: [2188-9-10]. TECHNIQUE: MDCT images were acquired from the lung bases through the pubic symphysis following administration of oral contrast, without IV contrast. Multiplanar reformations were generated. G. CT ABDOMEN: Small bilateral pleural effusions are new since [2188-9-10]. There is atelectasis and/or scarring in the lung bases. A 12-mm subpleural nodularity (2, 4) is similar to [2188-9-10]. The heart is top normal in size without pericardial effusion. A large abdominal ascites is new since [2188-9-10]. Patient is status post TIPS, which is in stable position. The liver is small and nodular in contour. There is splenomegaly to 15 cm. Along the splenic hilum is an ovoid structure isoattenuating to the spleen, most likely a large splenule, although this may be confirmed by nuclear study if desired. Gallstones are redemonstrated. There is no definite evidence to suggest cholecystitis. The pancreas, adrenal glands, and bilateral kidneys appear within normal limits. A small hiatal hernia is noted. The stomach, duodenum, small and large bowel loops are normal in caliber. The appendix is normal. A duodenal diverticulum may be present. There is no free air. No mesenteric or retroperitoneal lymphadenopathy. Mild atherosclerotic disease is seen in the infrarenal aorta. CT PELVIS: The bladder is partially collapsed, containing air along the nondependent portion, likely related to recent instrumentation. A Foley catheter is in place. The rectum and sigmoid colon are unremarkable. BONE WINDOW: Multilevel degenerative disease is seen in the lumbar spine, with spondylosis, most pronounced at L2-3, L4-L5 and L5-S1. There is grade 1 anterolisthesis of L5 with respect to L4 and S1. A sclerotic focus within L3 vertebral body is redemonstrated, liekly a bone island. IMPRESSION: 1. No drainable collection. 2. Bilateral small pleural effusions with atelectasis and/or scarring. 3. Cirrhosis status post TIPS. New large abdominal ascites. 4. Probable large splenule, which could be confirmed by scintigraphy if desired. 5. Mild anasarca, new since [2188-9-10]. I. INDICATION: 67-year-old man with hypotension, cirrhosis and diffuse abdominal pain, to assess for colitis. COMPARISON: No prior study is available for comparison. TECHNIQUE: Outside hospital images done at [Hospital3 18201] have been uploaded to the [Hospital1 18] PACS for a second opinion. The visualized lung bases demonstrate linear atelectasis. Trace pleural effusions are seen bilaterally. This study is limited without intravenous contrast for assessment of mesenteric ischemia. The liver demonstrates a nodular contour. A TIPS is in place. Multiple gallstones are present in a mildly distended gallbladder, but no other evidence of acute cholecystitis is present. Both adrenal glands are normal. Both kidneys are unremarkable without evidence of nephrolithiasis or hydronephrosis. The pancreas is unremarkable. A large round lobulated soft tissue mass measuring 5.4 x 4.6 cm is seen in the left upper quadrant, and is not well characterized in this non-contrast study. The adjacent presumed spleen is slightly abnormal in morphology and a well-defined hilum is absent. No stigmata of splenectomy noted. The stomach and small bowel loops are unremarkable without evidence of bowel wall thickening or obstruction. The study is limited for assessment of mesenteric ischemia without intravenous contrast. Within this limitation no pneumatosis or portal venous gas is identified. The visualized large bowel is decompressed and unremarkable. Incidental note is made of a lipoma of the ileocecal valve. A small focus of gas in the retroperitoneum adjacent to L2-L3 intervertebral disc space, could represent extension of air from the disc degeneration. A small amount of pelvic free fluid is present, of unclear clinical significance. The bladder is empty with a Foley catheter in place. The rectum and sigmoid colon are normal. No significant pelvic lymphadenopathy is detected. Prostate is unremarkable. OSSEOUS STRUCTURES AND SOFT TISSUES: Multilevel degenerative changes of the lumbar spine are noted with mild grade 1 anterolisthesis of L5 on S1. A rounded sclerotic focus in L3 vertebral body likely represents a bone island. IMPRESSION: 1. Limited study without intravenous contrast. No portal venous gas or pneumatosis is detected to suggest bowel ischemia. 2. Cholelithiasis without evidence of acute cholecystitis. 3. Left upper quadrant soft tissue mass. Unclear etiology. [Month (only) 116] represent a splenule adjacent to large native spleen. No history given or stigmata present of prior splenectomy. Nuclear spleen scan can help confrim splenic origin of mass to exclude neoplasm. 4. A trace amount of pelvic free fluid of unclear clinical significance. 5. Small amount of gas in the retroperitoneum adjacent to the L3-L4 disc space could represent extension of the gas from the degenerating disc at that level. CT Chest with contrast CHEST CT ON [10-22] HISTORY: Pleural nodularity right apex and mediastinal adenopathy. TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of 100 cc Optiray 250 nonionic iodinated contrast [Doctor Last Name 360] reconstructed as contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal and paramedian sagittal images compared to torso CT [2188-10-18]. FINDINGS: The mediastinum is markedly widened with fat. Lymph node enlargement is greatest in the prevascular station where 10 and 13 mm wide nodes were previously 14.6 and 13.5 mm. A 10mm right paraesophageal node, 2:29, was 12 mm on [10-18] and right lower paratracheal lymph nodes, though numerous are neither pathologically enlarged nor changed. The interval involution in node size probably reflects decreased edema since previous mediastinal edema and mild anasarca in the upper chest on the prior study have also cleared. Small nonhemorrhagic bilateral pleural effusions layer posteriorly, slightly smaller today than on [10-18]. There is mild thickening of parietal pleura on both sides of the chest and the radiodensity of the effusions is higher than one would expect from serous fluid, but since the patient has a history of chronic and recurrent pleural effusion, this need not represent an active exudate such as infection. There is no pericardial effusion. All cardiac [Doctor Last Name 1754] are chronically, moderately enlarged. Atelectasis at the lung bases is probably due to chronic pleural abnormality. There is no bronchial obstruction. Previous mass-like atelectasis at the right apex has cleared. A new region of mild peribronchial infiltration in the anterior segment of the right upper lobe is probably atelectasis. Relatively symmetric areas of discrete demineralization in the tips of both scapulae are most likely due to osteoporosis. If patient has known malignancy, a bone scan would be prudent to exclude lytic metastasis. Thoracic spine is unremarkable except for a focal sclerotic nodule in T11, a benign finding. The thyroid gland is mildly enlarged diffusely, particularly the right lobe and isthmus, but there is no focal heterogeneity to suggest malignancy. This study is not designed for subdiaphragmatic diagnosis except to note chronic calcified gallstone, interval increase in moderate ascites and a portosystemic shunt in the right lobe of the liver. IMPRESSION: 1. Decreasing reactive mediastinal lymph nodes, probably a reflection of improved fluid status given concurrent resolution of previous mediastinal edema and mild anasarca and smaller chronic, bilateral pleural effusions, responsible for pleural thickening and basal atelectasis. 2. No focal pulmonary lesion of concern. 3. Chronic cardiomegaly. Chronic calcific cholelithiasis. 4. Left PIC line ends in the upper SVC. 5. Mild thyromegaly. No discrete mass. 6. Increased moderate ascites. 7. Focal lytic lesions in both scapulae, most likely focal osteoporosis. Further attention would be indicated only if patient has known malignancy or other indication of osseous malignancy. INDICATION: Assess left basilic vein PICC line placement. COMPARISON: Upright PA portable chest x-ray from [2188-10-15]. TECHNIQUE: Upright AP portable chest x-ray. FINDINGS: The tip of the left basilic PICC line is in the right atrium. PICC line nurse, [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], was called concerning this finding and we suggested that she withdraw the PICC line 5 cm to the distal superior vena cava. Interval mediastinal widening and cephalization of lung vasculature suggest of worsening heart failure. Bilateral pleural effusions are small, but there is no pulmonary edema.. Retrocardiac atelectasis appears unchanged. IMPRESSION: 1. PICC line ends in the right atrium, suggest withdrawing 5 cm. 2. Mild CHF increased since [2188-10-15]. INDICATION: Left greater than right swelling, rule out DVT. COMPARISON: None. FINDINGS: Grayscale and Doppler evaluation of bilateral common femoral, superficial femoral, popliteal veins demonstrate normal compressibility, flow, response to augmentation. The peroneal and posterior tibial veins were suboptimally visualized; however, demonstrated normal compressibility on real-time evaluation. IMPRESSION: No evidence of DVT in bilateral lower extremities. IV. Cardiology A. TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: No evidence of spontaneous echo contrast or intracardiac thrombus. Good left atrial appendage emptying velocities. B. EKG Atrial fibrillation with a ventricular rate of 122. ST-T wave changes in leads I, II, III, aVL, aVF and V4-V6. Compared to the previous tracing of [2188-9-25], when the patient was also in atrial fibrillation, there are no longer ventricular premature beats. The rate is faster. The non-specific ST-T wave changes are unchanged. The possible flutter waves seen previously in lead V1 are no longer seen on the current tracing. Otherwise, no diagnostic interval change. # Pending Above blood cultures Brief Hospital Course: 67-year-old man with a history of secondary to tachycardia-induced dilated CM, alcoholic cirrhosis s/p TIPS ([2182]), and paroxysmal atrial fibrillation (off coumadin) presented from OSH with ESBL E. coli urosepsis and recurrent bacteremia with possible TIPs infection. # Septic Shock: Initially presented with altered mental status, elevated creatinine, decreased urine output, and persistent hypotension after aggressive fluid resuscitation requiring three pressors. Lactate initially elevated to 11. Intubated for altered mental status, acidosis, and aggressive volume rescitation. Empirically started on vancomycin, cipro and zosyn. Cultures ultimately grew ESBL E. coli in both urine and blood. . # Respiratory Failure/Intubation: Pt required intubation on admission given respiratory distress. He was ultimately extubated [2188-9-18], HD#8. Respiratory status has been stable over the last few weeks. . # ESBL E.Coli Bacteremia: Presumed to be secondary to TIPS infection. Infectious work-up included TTE, MRI spine to r/o osteo, multiple paracentesis, and multiple CT scans of abdomen and pelvis. He was started on meropenem on [2188-9-11]. Given recurrent bacteremeia after an initial 14 day course of meropenem another 14 day course given which again resulted in positive blood cxs shortly after the abx was stopped. Given presumed TIPS he will likely need long term suppressive abx therapy. plan is to dc him on meropenem 1g Q8 until he follows up in [Hospital ] clinic on [2188-11-12]. His ID physicians will determine whether he can be transitioned to an oral abx. At time of discharge cxs had been negative since [2188-10-18]. . # Atrial Fibrillation/Atrial Flutter: Pt with long h/o difficult to control afib/aflutter. While septic in MICU developed SVT with rates in the 160s. He was started on an amiodarone drip with minimal decrease in his rates and without conversion to sinus rhythm. Electrophysiology was consulted and ultimately he was cardioverted and started on flecainide 75 mg [Hospital1 ] on [2188-9-25]. He was cont on digoxin as well.He had rhythm and rate control during the rest of his hospitalization with some limited episodes of atrial fibrillation with RVR to 130s. Given multiple procedures, and recurrent hematocrit drops, coumadin was deferred until outpatient colonoscopy could be performed. Risk of remaining off coumadin was discussed with pt and family. . # Volume Overload: Pt was 18L positive following fluid resucitation from sepsis. He required slow diuresis with lasix gtt. Currently, he is near euvolemia and should restart home regimen of lasix and spironolactone. . # Altered Mental Status: Delirium during much of initial hospitalization likely related to illness and encephalopathy. He was restarted home lactuose, resolution of infection, avoidance of narcotics all improved patient's mental status. . # Acute renal failure: Creatinine 4.0 on presentation. Muddy brown casts shown demonstrated ATN, either secondary to hypoperfusion given inital low blood pressures vs. direct effect of sepsis. His renal function returned to ~ 0.9 after treatment of his infection and diuresis. . # Cirrhosis (MELD 13): Patient with history of cirrhosis s/p TIPS for ascites. Per patient's hepatologist, cirrhosis is likely secondary to alcohol abuse. Denies recent alcohol use. Hepatology followed the patient while in house. Should continue lactulose, furosemide and spironolactone. . # Ascites The patient had interval development of abdominal swelling likely secondary to increased hydrostatic pressure from portal hypertension. He had multiple RUQ and two therapeutic and diagnostic paracenteses to rule out SBP. Given continuing ascites despite paracentesis, his TIPS was explored with dopplers and found to have stenosis. IR performed a TIPs venogram with successful dilitation on [10-16]. # Congestion Heart Failure, diastolic, chronic: Patient with history of dilated cardiomyopathy (presumably secondary to alcohol abuse). Cardiology note from [2186] suggests EF of 50% up from prior estimates of [10-24]%. No known coronary disease. Echo performed during admission did not show any focal wall motion abnormalities, and did show a normal EF. It is of note, his echo was performed with pressor support, so his ejection fraction may be over-estimated. Patient was total body positive in terms of fluid status given his aggressive fluid resuscitation initially. No active signs or symptoms of heart failure at discharge. # Thrombocytopenia: Unknown baseline. Likely chronic or chronic in setting of hepatic disease. He had a platelet nadir at 10 and was given one transfusion of a pack of platelets with improvement in numbers. No episodes of bleeding. DIC labs negative. He subsequent had platelets in 60s-100s. # Diabetes The patient was placed on SSI in house and Lantus 25. Due to persistent hypoglycemia in the morning, he was discharged on Lantus 12 units. He should also be on a humalog SS. . # Diarrhea The patient developed diarrhea on [10-14]. Differential includes medication side effect secondary to lactulose, excessive juice intake with sorbitol, and C. diff with the later being negative three times. No longer having diarrhea at time of discharge. . # Hemoccult positive stool with anemia The patient has no gross blood per stool. His stools were dark at times. He had a post-procedural hematocrit drop on [10-8] to 22.9 and was subsequently transfused. Hepatology was consulted and performed an EGD on [10-10] for upper tract causes with EGD showing grade I varices, portal gastropathy, and erosions in the stomach/cardia. He was started on a PPI, and his anemia gradually stabilized. He had some variable fluctuations that on repeat were near baseline. Outpatient colonoscopy is advised. # Loss of bilateral foot function, resolved On [10-7], patient reported loss of bilateral foot function with sensory lossin the lower extremities. Stat MRI showed L2 signal abnormality,No gross evidence for cord compression or gross evidence of spondylodiscitis. Following MRI he was able to move both LE again. He denied any bowel/bladder incontinence or saddle anesthesia. Rectal exam was performed with normal tone and enlarged prostate with any nodules or discrete masses. He continues to have adequate extremity movement on discharge. . # Left UE swelling Given concern for L>R UE swelling, UE dopper was performed to r/o DVT. Doppler was negative for DVT on both [10-4] and [10-14]. . # Joint pain The patient endorses joint pains throughout the hospital. There was a history of early joint pains per his daughter. [Name (NI) ] took prednisone at home, which was held secondary to issues with infection. Given that his back pain was variably controlled, bone and gallium scans as above were performed showing no osteomyelitis. He was discharged with oral pain medication. . # Insomnia The patient was continued on home trazodone. Given habitus and snoring noted during rounds, outpatient sleep study may be indicated given underlying heart disease. Would avoid ativan for insomnia given risk of confusion. . # Adjustment disorder Given multiple medical problems, the patient had a flat affected and endorses passive SI that seemed to correlate with his medical condition and progress. Social work was consulted for coping in addition to psychiatry. A family meeting was held with subsequent better spirits, expansive affected, and interval denial of SI or HI. The patient does have guns given his history as a police officer and an antique knife at home. His daughter was notified that these items should be removed from his home after he returns and stabilizes. . # Nutrition The patient had poor PO intake on the floor with excessive consumption of juice. Nutrition was consulted with suggestion for a feeding tube, but the patient refused. His appetite subsequently improved, and he was given ensure supplementation as well. Would continue to monitor. . # Left upper tooth Disease: Patient has severe dental disease with upper left tooth with severe decay. Advise outpatient dentist follow-up # Incidentals on imaging --Large splenule noted on abdominal CT scan. --CT chest with contrast revealed focal lytic lesions in both scapulae, most likely focal osteoporosis. Further attention would be indicated only if patient has known malignancy or other indication of osseous malignancy. --MRI spine showing Diffuse diminished T1 signal of the vertebral body marrow signal is present suggesting such processes as myeloproliferative disorders, chronic anemia and marrow replacement. # Code status: Full Code # Contact Information: 1. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 37312] 2. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 37313] 3. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 22633] [Telephone/Fax (1) 37314] (not preferred for contact) # Access: L PICC placed [10-22] # Pending - Blood cultures per lab section Outpatient considerations: 1. Patient will need outpatient ID visit to manage meropenem therapy and plan for suppressive therapy. 2. Consider outpatient colonoscopy given recurrent hematocrit drops. 3. Atrial fibrillation: He will need to follow-up with Dr. [Last Name (STitle) 11493] to manage rhythm control medications (flecainide and digoxin) 4. Patient will need outpatient hepatology follow-up given liver disease. Medications on Admission: Digoxin 0.125 mg po daily Metoprolol 50 mg po daily Lasix 40 mg po bid Prednisone 2.5 mg daily KCl 20 meq po daily Trazodone 50 mg daily Ativan unknown Lactulose unknown Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [1-12*] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for back/bottom. 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours): Titrate to two bowel movements per day. 4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. flecainide 50 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s)* Refills:0 12. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 13. 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. 14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. meropenem 500 mg Recon Soln Sig: 1000 (1000) mg Intravenous every eight (8) hours: Please infuse over 3 hours Stop date: [2188-11-30]. 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 18. spironolactone 25 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Do not exceed greater than 2 grams of APAP/daily. Discharge Disposition: Extended Care Facility: [Hospital1 ] Care and Rehab Woodmill in [Known lastname 487] Discharge Diagnosis: PRIMARY: ESBL E. Coli bacteremia, Septic Shock, Acute renal failure, Atrial Fibrillation with Rapid Ventricular Response, Portal Gastropathy SECONDARY: Cirrhosis, Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 487], You were treated at [Hospital1 18] for a blood infection that required you to be admitted to the ICU. Your infection has resolved, though you will continue to need IV antibiotics and to follow up closely with your infectious disease physician, [Last Name (NamePattern4) ]. [First Name (STitle) ]. . Medications ---------------- STOP Toprol STOP potassium supplement STOP prednisone STOP lorazepam STOP tylenol with codeine . START ferrous sulfate, flecainide, folic acid, lidocaine patch, meropenenm, multivitamin, oxycodone, omeprazole, thiamine, spironolactone . CHANGE Lasix 20 mg by mouth daily instead of 40 mg by mouth twice daily Followup Instructions: Name: [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital6 ] Address: [Apartment Address(1) 37315], [Location (un) ],[Numeric Identifier 28704] Phone: [Telephone/Fax (1) 37316] Appointment: Thursday [2188-10-30] 4:00pm . Department: [Hospital3 249] When: WEDNESDAY [2188-11-12] at 12:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: [Hospital3 249] When: WEDNESDAY [2188-12-3] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Please make an appointment for pt to follow up with his cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11493] ([Telephone/Fax (1) 29810] within 2 weeks of leaving rehab.	[ "51881", "78552", "5845", "2762", "5990", "2851", "99592", "42731", "41401", "2875", "25000", "4280" ]
Admission Date: [2106-8-3] Discharge Date: [2106-8-12] Date of Birth: [2041-4-4] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2597] Chief Complaint: Abdominal aortic aneurysm Major Surgical or Invasive Procedure: [2106-8-3] Resection and repair of abdominal aortic aneurysm with 18-mm Dacron tube graft. History of Present Illness: This 65-year-old gentleman with obesity and COPD has an enlarging abdominal aortic aneurysm, now about 5.5 cm in maximum transverse diameter. The aneurysm starts at the level of the renal arteries and is not a candidate for endovascular repair. Past Medical History: COPD hypertension CAD (s/p PTCA and stenting of the left circumflex) AAA nephrolithiasis chronic back pain alcohol abuse Anxiety Social History: divorced - wife still very involved in care unemployed (used to work as a painter and handyman). Smokes 0.5 pk/day. History of alcohol abuse. Family History: unknown Physical Exam: VSS, Afebrile Gen: Obese male in NAD, alert and oriented Cardiac: RRR Lungs: CTA bilaterally Abd: soft,no m/t/o; incision - clean, dry, intact, without drainage or erythema Extremities: warm, well perfused. mild edema bilat. Palpable pedal pulses bilat Pertinent Results: [2106-8-10] 07:30AM BLOOD WBC-9.2 RBC-3.70* Hgb-11.4* Hct-33.0* MCV-89 MCH-30.8 MCHC-34.6 RDW-14.9 Plt Ct-224 [2106-8-9] 04:52AM BLOOD WBC-8.2 RBC-3.59* Hgb-11.1* Hct-31.8* MCV-89 MCH-30.8 MCHC-34.7 RDW-14.8 Plt Ct-187 [2106-8-3] 01:52PM BLOOD Neuts-87.9* Lymphs-8.5* Monos-2.8 Eos-0.5 Baso-0.2 [2106-8-10] 07:30AM BLOOD Plt Ct-224 [2106-8-9] 02:49PM BLOOD Glucose-123* UreaN-12 Creat-0.4* Na-138 K-3.5 Cl-96 HCO3-35* AnGap-11 [2106-8-9] 04:52AM BLOOD Glucose-140* UreaN-11 Creat-0.4* Na-138 K-3.4 Cl-96 HCO3-35* AnGap-10 [2106-8-4] 04:10AM BLOOD ALT-10 AST-17 AlkPhos-27* Amylase-22 TotBili-0.3 [2106-8-3] 05:50PM BLOOD CK-MB-6 cTropnT-0.02* [2106-8-9] 02:49PM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9 [2106-8-7] 07:55AM BLOOD Glucose-94 K-3.3* [2106-8-7] 01:35AM BLOOD Glucose-94 Lactate-0.6 K-3.8 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 27740], [Known firstname ] [Hospital1 18] [Numeric Identifier 31495]Portable TEE (Complete) Done [2106-8-5] at 10:10:23 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) 1111], [First Name3 (LF) 1112] B. [Hospital Unit Name 19046] [Location (un) 86], [Numeric Identifier 31496] Status: Inpatient DOB: [2041-4-4] Age (years): 65 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Hypertension. Left ventricular function. ICD-9 Codes: 396.9 Test Information Date/Time: [2106-8-5] at 10:10 Interpret MD: [Name6 (MD) 19047] [Name8 (MD) 19048], MD Test Type: Portable TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 19048], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR non-cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW538-: Machine: IE33 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.0 cm Left Ventricle - Fractional Shortening: 0.18 >= 0.29 Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aortic Valve - Valve Area: 3.4 cm2 >= 3.0 cm2 Findings 65 years old male for AAA with suprarenal clamp. Hasa multiple DES in the RCA, LAD and CRX distribution. There is mild MR and E/E' ratio is 9 suggesting normal LVEDP. The patient developed anterior and inferior wall hypokinesis with suptrarenal clamp that recovered after the clamp came off. There is right coronary cusp calcification without any regugitation or stenosis. LEFT ATRIUM: Mild LA enlargement. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderately depressed LVEF. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). Doppler parameters are most consistent with Grade I (mild) LV diastolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. GENERAL COMMENTS: 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. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is moderately depressed (LVEF= 40 %). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Electronically signed by [Name6 (MD) 19047] [Name8 (MD) 19048], MD, Interpreting physician [Last Name (NamePattern4) ] [2106-8-5] 10:21 Brief Hospital Course: [2106-8-3] The patient was scheduled for an open AAA repair. He had cardiology clearance preop by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Intra-op the patient required multiple blood transfusion for blood loss of 4500cc and hypotension. He was transferred to the CVICU for immediate post op care. [2106-8-4] POD #1, Continued to be intubated and sedated. No overnight issues. Aggressive pulmonary toilet. Plavix held (patient has bare metal cardiac stents) for bleeding- this was cleared with Dr. [Last Name (STitle) ]. Neo gtt for pressure support. ICU monitoring. [Date range (1) 5287] Continued intubation and diuresis. CMV vent setting. Received 2 units of PRBC for Hct of 26. No active bleeding presently. Neo weaned off. Good pain management. CPAP trials [8-6]. [2106-8-7] Extubated, stable. Continued pulmonary toilet. OOB to chair. Transferred to VICU. [2106-8-8] Some deliruim overnight. Received 2units PRBC for Ht of 26. Continues to diuresis with IV lasix TID. Started on clear, liquid diet and bowel regimen. [2106-8-9] Stable. Physical therapy working with patient and recommending Rehab. Mentally intact. Rehab screening. Foley and central line removed. Tolerating regular diet. Plavix 75mg po QD restarted. [2106-8-10] Rehab screening. 1-2 L NC of 02 (which is patient's baseline). [2106-8-11] Pt remains stable on 1-2L of O2. Diuresing well, change to oral lasix today. Ambulating with PT. [Hospital 25403] rehab bed offer [2106-8-12] Pt has done well overnight with no acute issues. He is discharged to rehab facility today. Medications on Admission: albuterol 90mcg prn, plavix 75', diazepam 5'', fluoxetine 60mg', advair 500/50 1 puff'', vicodin 5/500 prn, motrin 800mg prn, toprol xl 25', singulair 10', penicillamine 500mg 6x/day, Kcitrate 20meq''', ranitidine 150'', simvastatin 40', spiriva 18mcg', trazodone 100mg', vit c 1000', asa 81mg', mvi', omega 3 FA 1000mg' Discharge Medications: 1. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a day. 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): may d/c when pt fully ambulatory and at low risk for dvt. 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed for itching. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for mild pain. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day. 18. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 19. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take 20 [Hospital1 ] x 2 weeks then 20 qd x 1 week, then discontinue if pcp feels appropriate . 21. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Inhalation [Hospital1 ] (). Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - Heathwood - [Location (un) 55] Discharge Diagnosis: Primary: Abdominal aortic aneurysm Secondary: COPD HTN CAD (s/p PTCA and stenting of the left circumflex) Nephrolithiasis Cystinuria Chronic back pain Alcohol abuse Anxiety Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [7-13] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [3-10] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions We have made you a follow up appointment with a new PCP who is in the [Hospital1 18] system. Please keep this apppointment - this new physician will be able to manage all of your long term medical issues and medications and write prescriptions for your medications. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 815], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2106-8-25] 3:00 Location: [Hospital Ward Name 23] Building ([Hospital1 18] [Hospital Ward Name 516]) Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2106-8-30] 10:00 Location: [Hospital Unit Name ] clinic 5b ([Hospital Ward Name 517]) Completed by:[2106-8-12]	[ "496", "V4582", "4019", "3051", "41401" ]
Admission Date: [2141-1-6] Discharge Date: [2141-1-5] Date of Birth: [2090-1-30] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 50 year old female admitted to the neurosurgery service on [2141-1-4] with intraparenchymal and subarachnoid hemorrhage. She was struck by a motor vehicle by walking. Serial CT scans at that time showed stability of the bleed in her brain and she was discharged. The patient presented on [2141-1-6] with failure to thrive, decreased activity and decreased intake. She denied headache, she denied visual changes, she had no fevers or chills, she had no diarrhea or vomiting. She developed diabetic ketoacidosis over the first 24 to 48 hours in the hospital. She was transferred to the Medical Intensive Care Unit and was started on a regular insulin drip with electrolyte repletion significant for marked hypophosphatemia. She was more alert and was transferred to the floor. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus, patient was on a stable dose of Glargine HS and lispro before meals. 2. Essential thrombocytosis, status post cerebrovascular accident, on aspirin at the time of presentation, stroke in [2136] presumably due to essential thrombocytosis. 3. Mastectomy in [2127] on right, patient did not undergo radiation or chemotherapy at that time, no recurrence; reconstruction in [2136]. 4. Motor vehicle accident, as stated above, complicated by subarachnoid hemorrhage, intraparenchymal bleed; three fractures in the lower back. ALLERGIES: Intravenous contrast. MEDICATIONS ON ADMISSION: Glargine 24 units q.p.m. on a lispro scale before meals and Neutra-Phos. HOSPITAL COURSE: As stated above, the patient was initially admitted to the neurosurgical service for monitoring. While she remained neurologically stable with detailed serial examinations being unremarkable for any acute changes, she did develop diabetic ketoacidosis over the first 24 to 48 hours. She was transferred to the Medical Intensive Care Unit, where she received intravenous insulin as well as fluid and electrolyte repletion. Of note, she required intravenous phosphorous repletion. On [2141-1-9], the patient's anion gap had closed to the point that it was safe for her to be transferred to the medical floor. Her examination at that time was as follows: Generally, she was tired, comfortable, oriented to person and place; she spoke in full sentences. Head, eyes, ears, nose and throat: She had a left occipital hematoma 6 x 8 cm, tender to palpation, she also had a left frontal hematoma approximately 3 x 2 cm, the calvaria were intact, pupils equal, round, and reactive to light from 4 mm to 2 mm, extraocular movements intact without nystagmus, fundi had sharp disks, V to A ratio less than 3:2, there were no hemorrhages, there was no exudate. Neck: Jugular veins were flat, there was no carotid bruit, thyroid was not palpable, full range of motion, left external jugular vein catheter in place, not warm or tender. Nodes: No cervical, supraclavicular or axillary adenopathy. Cardiovascular: Regular, normal S1 and S2, no S3, no S4, no murmur, rub or gallop. Lungs: Clear to auscultation bilaterally. Abdomen: Thin, soft, normal bowel sounds, tender to palpation on right flank without rebound or guarding, liver edge not palpable. Extremities: Wearing compression stockings, no cyanosis, clubbing or edema, no calf tenderness. Vascular: Radial, carotid, dorsalis pedis and posterior tibialis pulses +2 bilaterally. Neurologic: Patient had a constricted affect but was euthymic, she had slow clear speech, normal thought content and process, no suicidal or homicidal ideations, intact short and long term memory; cranial nerves I and VIII not tested formally, cranial nerves II, III, IV, VI, pupils equal, round, and reactive to light, extraocular movements intact without nystagmus, as above, cranial nerves V, VII, normal facial sensation bilaterally, symmetric face, could elevate brow and puff cheeks, cranial nerves IX, X, XII, tongue midline, normal gag reflex, could phonate, cranial nerve [Doctor First Name 81], normal sternocleidomastoid (SCM) strength bilaterally, neck with full range of motion, normal shoulder shrug; motor [6-19] upper and lower extremities bilaterally, median, radial and ulnar nerves normal bilaterally; sensation, proprioception and light touch (microfilament) intact; deep tendon reflexes, biceps +2 bilaterally, brachial radialis +2 bilaterally, patella +1 bilaterally; cerebellum, rapid hand movements normal. The patient's neurologic examination, as stated above, remained stable for the remainder of her stay. Her hospital course was marked by a slight increase in her evening Glargine dose up to 36 units as well as an increase in her insulin sliding scale lispro. She remained off of aspirin for the duration of her stay. This decision was made in consultation with the hematology service. By hospital day three, the patient was taking adequate oral intake such that intravenous fluids were stopped. The intravenous nausea medication, Zofran, was also stopped. The patient no longer required intravenous pantoprazole. DISCHARGE MEDICATIONS: 1. Glargine 36 units q.p.m. and lispro sliding scale with meals; of note, this scale will likely be adjusted by the patient's endocrinologist given that her head trauma resolved completely, the insulin demands will likely go down. 2. The patient has taken metoprolol in hospital. The decision to continue this will be made by Dr. [First Name (STitle) 452] when the patient returns to his office for follow-up. 3. Likewise, the patient is currently off of aspirin but will restart this medication after seeing Dr. [First Name (STitle) 452]. DISCHARGE STATUS: To home. FOLLOW-UP: The patient has an appointment with her neurologist, Dr. [Last Name (STitle) ], on [2141-3-2] at 1:00 p.m. DISCHARGE DIAGNOSES 1. As above. 2. Diabetic ketoacidosis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7937], M.D. [MD Number(1) 7938] Dictated By:[Name8 (MD) 7102] MEDQUIST36 D: [2141-1-13] 15:20 T: [2141-1-13] 16:34 JOB#: [Job Number ] cc:[Last Name (NamePattern1) 105163]	[ "4019" ]
Admission Date: [2155-9-18] Discharge Date: [2155-9-23] Date of Birth: [2155-9-18] Sex: M Service: NEONATOLOGY HISTORY: Baby [Name (NI) ] [First Name8 (NamePattern2) ] [Known lastname 62951] was admitted to the newborn ICU for management of respiratory distress at birth. He was born at 35-2/7 weeks to a 33-year-old, G1, now P1 mother. Prenatal screens were notable for a blood type of O+, antibody negative, group B strep negative, hepatitis B surface antigen negative, RPR nonreactive. Pregnancy was remarkable for mild growth restriction. Fetus was noted to be at the 10th percentile on prenatal ultrasound. Mother was admitted on [9-17] with premature rupture of membranes. Induction was attempted on day of delivery, and delivery ultimately was by C-section under spinal anesthesia because of a nonreassuring fetal heart tracing. Apgar's were 8 and 9 at 1 and 5 minutes. On exam, birthweight was 2.055 - 25th-50th percentile, head circumference 30.5 cm - 10-25th percentile, length 41 cm - 50th-75th percentile. Baby was [Name2 (NI) ] with oxygen, had normal appearing facies, soft and flat anterior fontanel. Nares patent. Intact palate. Chest notable for mild retractions, intermittent grunting, fair air entry. Cardiovascular - no murmur. Femoral pulses present. Abdomen flat, soft, without hepatosplenomegaly. GU - normal phallus, testes and scrotum. Musculoskeletal - hips stable. Clavicles intact. Extremities - well-perfused. Neuro - normal tone and activity. HOSPITAL COURSE BY SYSTEM: Baby was placed on CPAP 6 cm, max FIO2, 24%, with respiratory rates in the 30s-70s. He continued on CPAP of 5 cm for the next 24 hours, at which time he was weaned off and was placed in room air breathing 60s-90s, [Name2 (NI) ] and well-perfused, clear and equal breath sounds. Required nasal canal O2 at about 48 hours of age. Continues in nasal cannula, breathing 40s-70s, clear and equal breath sounds. CARDIOVASCULAR: Remained hemodynamically stable with blood pressures ranging from systolics of 50s-72 with diastolics 35- 54, means 40s-50s, no murmur on exam. He was noted to have some periodic breathing with bradycardia to the 50s requiring mild stimulation and has not been treated with xanthines at this point in time. FEN: Initial D-stick was 49 which improved to 89 with initiation of IV fluids and D10W at 80 mL/kg/D. Enteral feeds were started on day of life 2 with breast milk or Enfamil 20 at 20 mL/kg, advancing 20 b.i.d. IV fluids were discontinued on day of life 3. Electrolytes were noted to be in the normal range. Infant had low urine output in the first 24 hours, but then picked-up and has been noted to be normal. Baby has passed meconium stool, and now is passing transitional stools. Bilirubin was 5/0.2 at 24 hours and was started under phototherapy on day of life 3 for a bilirubin of 10.0/03. On [9-23], the bilirubin is 9.0/02, continues under single phototherapy. HEMATOLOGIC: Initial CBC notable for a white count of 10.8 with 26 polys and 0 bands, 51 lymphs, hematocrit 54.3%, and platelets 263,000. A blood culture was obtained, and the ampicillin and gentamicin were started and discontinued at 48 hours with negative cultures and improved clinical course. NEUROLOGIC: Infant has appropriate exam for postmenstrual age, 35 weeks. Hearing screening has not yet been done to date, but will be done prior to discharge. Ophthalmology exam is not indicated in this infant. CONDITION AT DISCHARGE: Good. Discharge is to [Location (un) 2274] service. NAME OF PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [First Name8 (NamePattern2) ] [Last Name (Titles) 8985] [Hospital1 ]. There have been no immunizations received to date. Infant is on no medications. Feeds at time of transfer of care are breast milk, Enfamil 20 at 120 kg/D. DISCHARGE DIAGNOSES: Prematurity at 35-2/7 weeks, respiratory distress, rule out sepsis with antibiotics, physiologic jaundice. [Doctor First Name ] [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 62348] Dictated By:[Last Name (Titles) 62952] MEDQUIST36 D: [2155-9-23] 11:51:13 T: [2155-9-23] 12:27:04 Job#: [Job Number 62953]	[ "7742", "V290", "V053" ]
Admission Date: [2135-7-7] Discharge Date: [2135-7-9] Date of Birth: [2053-8-8] Sex: F Service: NEUROSURGERY Allergies: Mobic / Cyclobenzaprine / Clonidine / Prednisone Attending:[First Name3 (LF) 1835] Chief Complaint: headache Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Name14 (STitle) 78849] is an 81 y/o female s/p ground level fall. She was transferred to an outside hospital where a head CT revealed a 7 mm right temporal-parietal subdural hematoma. She had no focal neurological deficits. She was transferred to [Hospital1 18] for neurosurgical care. Past Medical History: pancreatic cancer Social History: denies tobacco, EtOH, or IVDU Family History: noncontributory Physical Exam: PERRLA EOMI FC all 4 extremities sensation to LT intact all around A & O x 3 gait unsteady, uses walker to ambulate no evidence of dysmetria cranial nerves II - XII grossly intact no clonus negative babinski Pertinent Results: Click "Import Result" to add to discharge summary. Results from [2135-7-6] to Note: For Cytogenetics results see Clinical Information System Blood Urine CSF Other Fluid Microbiology Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2135-7-9] 07:40AM 10.1 4.18* 12.4 35.0* 84 29.8 35.5* 14.1 300 Import Result [2135-7-8] 06:24AM 10.2 3.76* 11.1* 31.9* 85 29.6 34.9 14.2 283 Import Result [2135-7-7] 12:52PM 15.9# 3.91 11.6* 33.0* 84 29.6 35.1* 14.1 272 Import Result DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [2135-7-7] 12:52PM 93* 0 4.0* 3 0 0 Import Result BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2135-7-9] 07:40AM 300 Import Result [2135-7-8] 06:24AM 283 Import Result [2135-7-7] 12:52PM 272 Import Result [2135-7-7] 12:52PM 11.6 21.0* 1.0 Import Result Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2135-7-9] 07:40AM 78 23* 0.7 134 4.4 102 24 12 Import Result [2135-7-8] 06:24AM 125* 31* 0.7 133 4.2 102 24 11 Import Result [2135-7-7] 12:52PM 233* 58* 1.1 134 4.2 102 25 11 Import Result ESTIMATED GFR (MDRD CALCULATION) estGFR [2135-7-7] 12:52PM Using this Import Result ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2135-7-7] 12:52PM 126 Import Result CPK ISOENZYMES CK-MB cTropnT [2135-7-7] 12:52PM 0.03* Import Result [2135-7-7] 12:52PM 7 Import Result CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2135-7-8] 06:24AM 3.4 8.6 2.3* 2.2 Import Result NEUROPSYCHIATRIC Phenyto [2135-7-8] 06:24AM 1.6* Import Result LAB USE ONLY GreenHd [2135-7-7] 12:52PM HOLD Import Result Brief Hospital Course: Ms. [Known lastname ] was transferred to [Hospital1 18] on [2135-7-7] for neurosurgical evaluation and observation. She was followed up with a repeat head CT which revealed the subdural hematoma to be stable. She did not require surgical intervention. PT was consulted to evaluate her gait. They recommended on [2135-7-9] that she is stable for discharge to home with services. Medications on Admission: ambien ASA cozaar diltiazem os-cal percocet premarin synthroid fentanyl morphine lexapro lidoderm patch motrin decadron Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 3 weeks. Disp:63 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: subdural hematoma Discharge Condition: neurologically stable Discharge Instructions: ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ]. Followup Instructions: schedule appointment with Dr. [Last Name (STitle) ]; call [Telephone/Fax (1) 1669] Completed by:[2135-7-9]	[ "4019", "25000" ]
Admission Date: [2155-5-23] Discharge Date: [2155-5-29] Date of Birth: [2105-9-26] Sex: F Service: MEDICINE Allergies: Penicillins / Tetracyclines / Plaquenil / Chloroquine / Sulfonamides / Floxin / Heparin Agents Attending:[First Name3 (LF) 134] Chief Complaint: Fever, hypotension. Major Surgical or Invasive Procedure: Removal of left subclavian line. Placement of right internal jugular line. History of Present Illness: 49 year old female with h/o Pulm HTN DM lupus on flolan via hickman presenting for possible line infection. A new Hickman line was placed 3 weeks ago after [Last Name (un) ] line became infected and she is s/p 14d vanco course for Micococcus. Micrococcus was grown out of Cultures on [2155-4-23] and [2155-4-25]. Subsequent cultures on [4-19] were all negative. Hickman line insertion (for Flolan) was on [2155-4-29] and PICC line (for Vanco) insertion was on [2155-4-28]. . She comes in with 2 days sweats, chills, as well as tenderness, warmth and drainage from line. Blood sugars 220, usually 100-200. It also has been draining a clear green fluid. She was apparently scheduled for a dental procedure tomorrow for ? infected tooth. No other ROS positive. Mult drug allergies. Exam: crusting and purulence at site. . In the ED: Her initial vitals were 98.1 103 145/82 12 94RA, she was started on Vancomycin but developed itching and rash, benadryl given, -> continued vanco at slower rate -> got worse -> stopped. This is strange since she finished off a 14 day course of Vancomycin dating from her recent visit. . On arrival to the floor she was noted be hypotensive 70s, 1L NS in ED, and received 500cc NS, and 2nd iv was placed. Past Medical History: -Diabetes mellitus type 2 -pulmonary arterial hypertension on Flolan -atrial septal defect of the secundum type (versus a stretched PFO) -obstructive sleep apnea on home oxygen -anticardiolipin antibody -type 1 heparin induced thrombocytopenia -systemic lupus erythematosus with history of pleuritis, glomerulonephritis ([2144]) -obesity -restrictive pulmonary disease -migraines -history of sinusitis -fibromyalgia. Social History: significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: On Admisison to Floor: VS: T 95.5 BP 82/38 HR 104 RR27 O2 5LNC Gen: WDWN middle aged male in mild distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, dry mm Neck: Supple, CV: S1 S2 no mrg Chest: Ant CTA b/l no w/r/r, Hickman 2cm erythema around site, no discharge Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, Pertinent Results: Labwork on admission: [2155-5-22] 11:10PM WBC-4.0 RBC-4.60 HGB-14.3 HCT-40.9 MCV-89 MCH-31.0 MCHC-34.9 RDW-16.1* [2155-5-22] 11:10PM PLT COUNT-198# [2155-5-22] 11:10PM NEUTS-64.6 LYMPHS-28.6 MONOS-5.3 EOS-0.4 BASOS-1.1 [2155-5-22] 11:10PM GLUCOSE-150* UREA N-16 CREAT-0.7 SODIUM-141 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19 [2155-5-22] 11:27PM PT-20.5* PTT-28.2 INR(PT)-2.0* [2155-5-22] 11:36PM LACTATE-2.6* [2155-5-23] 12:25AM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-[3-24] [2155-5-23] 12:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2155-5-23] 09:16AM CORTISOL-39.3* [2155-5-23] 09:16AM ALT(SGPT)-25 AST(SGOT)-51* LD(LDH)-262* ALK PHOS-40 TOT BILI-0.2 . CHEST (PA & LAT) [2155-5-22] IMPRESSION: No evidence of pneumonia. . ECHO Study Date of [2155-5-23] Conclusions: The left atrium is mildly dilated. The estimated right atrial pressure is >20 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is markedly dilated. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is moderately dilated athe sinus level. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is at least moderate to severe pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetations seen (cannot definitively exclude). Compared with the prior study (images reviewed) of [2155-4-9], the IVC is now more dilated. Brief Hospital Course: 49 F PMH pulmonary HTN on flolan, SLE, APA syndrome, underwent recent Hickman change due to line infection who returned with likely line sepsis. . #) Sepsis: Most likely due to Hickman line infection. She was in the ICU for sepsis for a few days where she received several liters of fluids, pressors which were quickly weaned, high dose antibiotics and stress dose steroids. She was subsequently transferred to the floor when off pressors x 48 hours. UA/culture remained negative. CXR negative for infection. Of note, her Hickman was removed [5-24] and a RIJ placed. She was treated with Gentamycin/Linezolid since [5-24] until [5-26] when Daptomycin replaced Linezolod (see "Headache" section below) and then on [5-27] we switched Gentamycin to Levofloxacin to prevent Gentamycin induced toxicity. All of the antibiotic regimens were per ID recs. No blood or catheter tip cultures grew out any organisms during this admission. On the floor she remained hemodynamically stable and afebrile with no further signs of sepsis. She had a midline placed [5-28] for 8 more days of home antibiotics (per ID) to end [6-6] and she had her Hickman replaced by surgery without event on [5-29]. . #) Pulmonary HTN: She had a right heart cath on [5-27] which revealed pulmonary hypertension with mean PA pressure of 47mmHG with PA systolic of 70. The PVR was 513. There was elevation of RA pressure with mean RA of 15mmHG. The PCWP was near normal at 13mmHG. The cardiac index was preserved. Based on this, and concersations with Dr. [Last Name (STitle) ] (pulmonology) we will continue Flolan at home for now via her Hickman. She has follow up scheduled with Dr. [Last Name (STitle) ] to discuss further management of her Pulmonary HTN. . #) Tooth pain: Pt with right questionable tooth infection prior to admission. She had considerable pain and headaches off Amitriptyline. based on this we got Panorex films of her jaw and a Dental consult. Per Dental recs, there was no obvious source of infection/abscess and she was recommended for outpatient dental workup. . #) SLE: Stable throughout admission. We continued steroid taper for a few days after stress dose steroids. As she has had recurrent infections in the past few months, we consulted Dr. [Last Name (STitle) ] (Rheum) re: tapering her home Prednisone which may be contributing to her susceptibility to infections. Per Dr. [Name (NI) 29165] recs, we will discharge Ms. [Known lastname ] on 9mg daily Prednisone and she will follow in the outpatient setting and consider a further taper. . #) Migraine HA: Patient was off amytriptilline for migraine prophylaxis while on Linezolid (due to increased risk of Seratonin syndrome). Her headaches were significantly worse off her home meds. We temporized with Toradol, and Dilaudid PRN and eventually switched from Linezolid to Daptomycin per ID so we could resume Amytriptilline which we did a few days prior to discharge. Her headaches subsequently improved significantly. . #) APA syndrome/history of HIT: Stable. Coumadin was held for procedures/line placements and she remained off Heparin products without event. We resumed Coumadin on day of discharge which she is on for line patentcy. She will follow INRs in the outpatient setting. . #) DM: Stable. FS QID, SSI while in house. We resumed oral agents prior to discharge. . #) OSA: Stable. On home oxygen during admission with stable O2 sats. . Medications on Admission: 1. Allopurinol 100 mg daily 2. Amitriptyline 50 mg qhs 3. Estrogens Conjugated 0.625 mg PO DAILY 4. Fexofenadine 60 mg [Hospital1 ] 5. Fluticasone 50 mcg spray daily 6. Furosemide 20 mg daily 7. Gabapentin 300 mg PO DAILY 8. Gabapentin 600 mg PO HS 9. Metformin 850 mg [Hospital1 ] 10. Prednisone 10 mg daily 11. Warfarin 1 mg daily 12. Zolpidem Tartrate 10 mg PO HS Discharge Medications: 1. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 8 days: Last dose 5/18. Disp:8 Recon Soln(s) Refills:0 2. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. PredniSONE 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:120 Tablet(s) Refills:2 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day: Take with four 1mg tablets for a total of 9mg a day. Disp:30 Tablet(s) Refills:2 5. Epoprostenol 0.5 mg Recon Soln Sig: One (1) Recon Soln Intravenous INFUSION (continuous infusion). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Nasal once a day. 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Amitriptyline 50 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 14. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days: Last dose 5/18. Disp:8 Tablet(s) Refills:0 16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO once a day. Disp:120 Capsule, Sustained Release(s) Refills:2 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 18. Flush Please flush Midline catheter with saline flushes before and after antibiotics daily 19. Saline Flush 0.9 % Syringe Sig: One (1) Injection twice a day for 8 days: Before and after antibiotics. Disp:8 Days Refills:0 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Sepsis -Diabetes mellitus type 2 -pulmonary arterial hypertension -obstructive sleep apnea -systemic lupus erythematosus -migraines Discharge Condition: Fair Discharge Instructions: You were admitted for sepsis secondary to a presumed Hickman line infection. The line was pulled and you were placed on antibiotics and did quite well. You had the Hickman replaced and are now ready for discharge on antibiotics through [2155-6-6]. . Seek medical attention immediately if you experience new symptoms including shortness of breath, chest pain, fainting, arm/jaw pain or numbness, coughing, blood in sputum, worsening diarrhea or other concerning symptoms. . Follow up as per below. Have your potassium checked by your doctor this week as well as your INR (to assess Coumadin level). . Take all medications as prescribed. Followup Instructions: [Doctor Last Name ]-[Last Name (LF) ],[First Name3 (LF) 29166] L. [Telephone/Fax (1) 27854] Call today for an appointment within 1 week. Have your INR and potassium checked this week Provider: [Name10 (NameIs) ] [Name8 (MD) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2155-7-15] 10:00	[ "0389", "25000", "V5867", "49390", "2859", "32723" ]
Admission Date: [2181-3-11] Discharge Date: [2181-3-28] Date of Birth: [2099-10-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1936] Chief Complaint: fever, confusion Major Surgical or Invasive Procedure: Central line placement Arterial line placement History of Present Illness: Mr. [Known firstname ] [Known lastname 86198] is a 81 year old man with a history of CHF, Afib, COPD and DM2 presented to an OSH after several days of nausea, vomiting, and diarrhea with new onset altered mental status. His family reports several family members with similar recent GI symptoms. At the OSH he was found to be febrile 102.8, hypotensive (77/44), confused, and hypoglycemic (fsbs 45). He underwent chest x-ray and was started on vancomycin and zosyn for presumed hospital acquired pneumonia. He was also given 2 L IVF and started on stress dose steroids for history of COPD with frequent steroid use. His INR was found to be 11 and he was given Vitamin K 10 mg IV. His blood pressure was documented as 77/44 and he was started on peripheral levophed. Due to bed availablity patient was transferred to [Hospital1 18] ED. . In the ED, initial VS: T 100.1 HR 110 BP 94/55 RR 26 SpO2 100% 4L NC. WBC was elevated at 12 with 22% bands. He underwent CXR which did not show clear evidence of pneumonia. Urinalysis was negative for infection. RUQ U/S was suggestive of possible acute cholecystitis. Surgery was consulted. They did not recommend urgent surgery given his hemodynamic instability and supratherapeutic INR. They recommended perc cholecystectomy in the morning pending correction of his INR and stable blood pressures. CVL was placed and levophed was titrated to MAP > 65. He received 4 g IV prior to transfer to the ICU. . On arrival to the ICU, patient is alert and oriented. He admits to poor appetite and RUQ pain with deep inspiration or palpation. He reports several days of increased fevers and chills. He admits to increased loose stools and nausea. He denies any hematuria, dysuria, productive cough, chest pain, black or tarry stools, BRBPR, history of blood clots. . Of note, patient had multiple recent hospital admission in [State 108] for CHF exacerbations and pneumonia. Past Medical History: Coronary Artery Disease: s/p c.cath [2174] that showed 3vd (per outpt cardiologist Dr. [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ]) DM2 Gout Hyperlipidemia HTN Severe aortic stenosis Systolic CHF EF 20-25% BPH Anemia COPD/Asthma s/p appendectomy s/p hernia repair s/p carpal tunnel release s/p tonsillectomy Social History: Retired. Was in boat sales for 50 yrs. Lives with wife of 59 years. Denies any tobacco or etoh use in over 30 years. Independent of ADLs at baseline Family History: Non-contributory Physical Exam: Vitals - T: BP: 104/61 HR:104 RR: 25 02 sat: 96% on 4 L GENERAL: NAD, pleasant HEENT: watery eyes, anicteric sclera, dry mm CARDIAC: distant heart sounds, tachycardic, no MRG LUNG: CTA bilaterally, decreased bs at bases, loud rhonchorus upper airway sounds that improved with cough. Mildly labored breathing with talking, able to finish full sentences. ABDOMEN: + bs, soft, RUQ tenderness, no rebound, no guarding EXT: warm, dry NEURO: a+o x 3, no focal deficits. DERM: No rashes, small scattered ecchymoses, warm, dry Pertinent Results: Admission Labs: [2181-3-11] 10:50PM BLOOD WBC-12.0* RBC-3.91* Hgb-10.8* Hct-34.0* MCV-87 MCH-27.5 MCHC-31.7 RDW-17.0* Plt Ct-148* [2181-3-11] 10:50PM BLOOD Neuts-70 Bands-22* Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2181-3-11] 10:50PM BLOOD PT-57.4* PTT-42.4* INR(PT)-6.5* [2181-3-11] 10:50PM BLOOD Glucose-103* UreaN-36* Creat-1.3* Na-138 K-4.0 Cl-107 HCO3-18* AnGap-17 [2181-3-11] 10:50PM BLOOD ALT-16 AST-28 LD(LDH)-231 CK(CPK)-75 AlkPhos-58 TotBili-0.5 [2181-3-11] 10:50PM BLOOD cTropnT-0.10* [2181-3-12] 12:17AM BLOOD Lactate-1.9 ======== . ECHO [3-12]: moderately dilated left ventricle with severe global LV hypokinesis. Dilated and hypokinetic RV. The mid lateral wall has relatively preserved function. Calcific aortic stenosis that is probably severe/critical - low flow state makes calculation of valve area difficult. Mild mitral regurgitation. . CT Torso [3-12]: 1. Bibasilar consolidations and smaller bilateral pulmonary opacities compatible with multifocal infection. Small right and trace left pleural effusions. 2. Similar appearance of moderately dilated and edematous gallbladder with a small calculus. 3. Findings compatible with pulmonary arterial hypertension. 4. Cardiomegaly, coronary artery calcifications and significant atherosclerotic involvement of the thoracic and abdominal aorta and branches. 5. Multilevel severe degenerative changes in the thoracolumbar spine. Brief Hospital Course: . MRSA/Pseudomonas Pneumonia: Mr. [Known lastname 86198] was empirically started Vancomycin and Zosyn on presentation due to sepsis and suspicion for hospital acquired pneumonia. Sputum cultures grew MRSA and Pseudomonas aeruginosa. Chest CT was consistent with multilobar pneumonia. . MRSA Bacteremia: Blood cultures from OSH yielded two out of four bottles positive for MRSA. He was started on Vancomycin empirically on arrival to the ED. With positive cultures, ID team was consulted who recommended completing a three week course of Vancomycin. This will be complete on [4-8]. . Acute on Chronic Systolic Heart Failure: Medical records from OSH suggested systolic heart failure and aortic stenosis. Transthoracic echo was performed during this admission which showed no evidence of vegetations. Aortic valve area was measured at 0.8 cm2 and EF was 10%. After resuscitation for sepsis, he was significantly volume overloaded but with borderline low BP (low 90s systolic). The cardiac consulting team was involved. Standing IV lasix 80 mg TID was started but intermittently held for hypotension. On this regimen he improved significantly, although significant lower extremity edema persisted. He was changed to oral lasix 80 mg [Hospital1 ]. On discharge, he was changed to 100 mg [Hospital1 ] lasix and metolazone was added. Clinical status was notable for [1-17]+ lower extremity edema with clear lungs, mild orthopnea, and O2 Sats in the mid daily and consider increasing lasix or continuing metolazone beyond the 1 week in order to achieve euvolemia. . Coronary artery disease: Patient with elevated troponin on presentation. Concurrent chest heaviness, shortness of breath and elevated cardiac enzymes was concerning for ACS. Patient was continued on daily aspirin, home dose statin was increased. He was placed on a heparin gtt for 48 hours as empiric medical management of ACS. His enzymes trended down. Beta blocker was initially held due to significant hypotension. Patient's outpatient cardiologist (Dr. [Last Name (STitle) 86199] was contact[Name (NI) ] who revealed that the patient has known three vessel disease diagnosed on cardiac catheterization in [2174]. He was uncertain as to why patient did not undergo any interventions at that time. The cardiac consulting team was involved and thought that this was likely demand ischemia and did not think any intervention was appropriate. Troponin trended down. Chest heaviness recurred intermittently in the absence of EKG changes or troponin elevation. It is possible that this represents angina. He had previously been on a long-acting nitrate. This was restarted at a lower dose on discharge and should be titrated to comfort as BP tolerates. Follow up was arranged with his cardiologist, and discharge summary will be faxed. . Atrial fibrillation: Beta blocker was initially held given hypotension. This was restarted at a lower dose when he was hemodynamically stable. Rate control was adequate. He was anticoagulated with a supratherapeutic INR on admission, having received Vitamin K 10 mg IV at OSH prior to arrival. Coumadin was held initially. INR was closely monitored while on antibiotics. Coumadin was restarted when INR fell in order to maintain therapeutic anticoagulation. This was restarted at a lower dose and titrated up. In the days prior to discharge, he received 2.5 mg daily through [3-25], on [3-26] INR supratherapeutic so dose held and restarted at 2 mg daily on [3-27]. INR was 3.5 on [3-27]. Coumadin was changed to 1 mg. INR should be rechecked [3-29] and coumadin titrated appropriately. . Left wrist inflammation: Patient with known history of gout. With painful swelling of left wrist on [2181-3-16] colchicine and allopurinol were restarted and rheumatology consulted. Joint swelling was also concerning for possible septic joint given recent bacteremia. Because of patient's elevated INR arthrocentesis was not performed. His symptoms improved with allopurinol and a prednisone taper. He completed the taper in house. . GOALS OF CARE: The patient and his family expressed that he was to be DNR/DNI. Prior to discharge, the patient and his family expressed that they wanted to continue all medical measures but not pursue any further invasive measures. Medications on Admission: MEDICATIONS: .Coreg 6.25 mg Tab Oral Twice Daily .Allopurinol 100 mg Tab Oral Daily .Aspirin 81 mg Tab Oral Daily .Lipitor 10 mg Tab Oral Daily .Colchicine 0.6 mg Tab Daily .Digoxin 125 mcg Daily .Advair Diskus 250 mcg-50 mcg Twice Daily .Lasix 20 mg Daily .Glyburide 2.5 mg Twice Daily .Isosorbide Dinitrate 30 mg Daily .Mobic 7.5 mg Twice Daily .Metformin 500 mg Daily .Niaspan 500 mg Once Daily .Protonix 40 mg Daily .Aldactone 25 mg Daily .Flomax 0.4 mg Daily .Diovan 80 mg Daily .Coumadin 5 mg Daily (Odd days) .Coumadin 2.5 mg Daily (Even days) .Albuterol Sulfate Neb Solution Every 4-6 hrs, as needed .Atrovent HFA 17 mcg/Actuation Aerosol Every 4-6 hrs, as needed Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital - [Location (un) 5503] Discharge Diagnosis: primary: sepsis secondary to pneumonia, acute on chronic systolic congestive heart failure, gout secondary: type 2 diabetes mellitus, hypertension 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 came to the hospital because of a bad pneumonia. You were in the intensive care unit on antibiotics. You improved on this regimen. However, because of your congestive heart failure you had a lot of extra fluid in your body. You were on a general medicine service where you were given IV lasix to improve this. You also had a flair of your gout which improved with a course of prednisone. The following medications were changed: Coreg was decreased to 3.125 mg twice daily Lipitor was increased to 80 mg daily Lasix was increased to 100 mg twice daily Glyburide was changed to glipizide Isosorbide Dinitrate was changed to isosorbide mononitrate daily Mobic was stopped Niaspan was stopped Aldactone was stopped Diovan was decreased to 40 mg daily Coumadin was changed to 2 mg daily, but the doctors at the rehab will be adjusting this as needed Vancomycin was added, to continue until [4-8] Cefepime was added, to continue until [4-8] Tylenol was added as needed for pain Docusate was added Senna was added as needed for constipation Metolazone was added Followup Instructions: We arranged the following appointments for you: Name: EMMET [Last Name (NamePattern4) 86200] MD SPECIALTY: PRIMARY CARE Address: [Apartment Address(1) 86201], [Location (un) 10068],[Numeric Identifier 39453] Phone: [Telephone/Fax (1) 86202] WHEN: WEDNESDAY [4-4] 2pm Name: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD SPECIALTY: CARDIOLOGY ADDRESS: [Street Address(2) 86203], [Location (un) 10068], MA PHONE: [Telephone/Fax (1) 9674] WHEN: THURSDAY [4-5] 3:15pm Completed by:[2181-3-29]	[ "486", "5849", "25000", "4280", "42731", "2724", "99592", "4241", "40390", "41401" ]
Admission Date: [2159-5-7] Discharge Date: [2159-5-9] Date of Birth: [2117-5-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2763] Chief Complaint: found down Major Surgical or Invasive Procedure: Left internal Jugular central line placed Right femoral dialysis catheter placed History of Present Illness: 40 yo male known to be HIV positive with unknown other medical problems, was found down 30 minutes PTA with altered mental status. It is unclear when he was last seen at baseline. EMS was called by patient's GF, who was also reportedly altered. BS in the field was 29, and EMS was unable to obtain access so patient was brought to [Hospital1 18]. . In the ED, patient received an amp of D50 and repeat FS was 250. Patient was started on D5 drip and mental status started to improved, and FS was 296 on first check in the ED. Initial exam was notable for dense left hemiparesis, right sided cojugate gaze, left facial droop and jaundice. Labs were notable for lactate 15.8, ph 7.03 on venous gas, AGMA 37, Cr of 5.7, BUN 43, tranaminases in the 100s, Tbili 10.8, INR 4.6, WBC 17.8, Hct 35.1, plts 232, positive UA and positive u tox for methadone and opiates. Code stroke was called for left sided weakness, and CT noncontrast showed right sided subacute infarct. Neuro advised CTA head and neck, but this was deferred given Cr of 5.7. Patient received 5L NS, vancomycin and ceftriaxone. 2 PIVs were obtained. Mental status and left sided weakness improved, and patient per nursing report was oriented and interactive. Patient was being prepared to come to the ICU when he seized GTC movements. FS during seizure was 88. Patient received ativan 5 mg and was loaded with dilantin. Patient was intubauted, and OG tube put out 650cc coffee ground emesis. Peri-intubation patient received etomidate 20 mg and Rocuronium 80 mg. He was started on a PPI drip and octreotide drip. First ABG was 6.94/40/345, for which patient recieved 1 amp of bicarb. Prior to transfer, VS were 118, 97/51, 24, 100% on TV 450 RR 24 PEEP 5 FiO2 0.1. . In the ICU, patient was intubated and sedated. Past Medical History: - HIV - Hep C - polysubstance abuse Social History: Lives at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] house. IVDU, h/o homeless. Family History: unknown Physical Exam: Vitals: T: 95.2 BP: 88/39 P: 110 R: 24 O2: 99% 450 x 24 x 5 x 50% General: Intubated, sedated HEENT: + Sclera icterus, dry MM, otherwise oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with icteric urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: multiple excoriations along upper and lower extremities, Pertinent Results: [2159-5-6] 11:08PM URINE GRANULAR-50* HYALINE-50* [2159-5-6] 11:08PM URINE RBC-75* WBC-124* BACTERIA-NONE YEAST-FEW EPI-0 TRANS EPI-1 RENAL EPI-1 [2159-5-6] 11:08PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL BURR-1+ [2159-5-6] 11:08PM NEUTS-80* BANDS-10* LYMPHS-4* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-4* [2159-5-6] 11:08PM WBC-17.8* RBC-3.10* HGB-11.1* HCT-35.1* MCV-113* MCH-35.9* MCHC-31.7 RDW-15.8* [2159-5-6] 11:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-POS [2159-5-6] 11:08PM URINE OSMOLAL-327 [2159-5-6] 11:08PM OSMOLAL-330* Brief Hospital Course: 40 yo M with a past history presents after being found down for unknown duration, now with [Last Name (un) ], Acute liver failure, AGMA and altered mental status . # AMS/Seizure: Appears to have initially mostly related to hypoglycemia, as AMS has improved with dextrose administration. Patient then had seizure in the ED, when fingerstick was within normal limits. There was initial concern for stroke given assymetric weakness, but CT head shows subacute changes, and per report weakness improved when patient was awake in the ED. This may imply that patient had recrudescence of old CVA in the setting of infection and hypoglycemia. [Month (only) 116] be related to cerebral edema, infection, worsening renal function, or ingestion. Received dilantin and ativan in the ED. Pt never regained baseline mental status and was unreactive at presentation. . # AGMA: Appears mostly to be secondary to lactic acidosis in the setting of renal failure and liver failure. Predicted serum osmolality 301.3, and actual serum osm 330 indicated there is a large osmolar gap of 28, indicating a high likelihood of ingestion possible with methanol or ethylente glycol. Part of Osm gap may be due to elevated lactate. Empiric fomepizole started for toxic etoh suspected ingestion given osmolar gap. Ethylene glycol and methanol levels were negative. [2159-5-8] continue hemodialysis started. # Acute liver failure: [Last Name (un) ] prior liver disease, but at this time has jaundice, possible HE and coaglopathy. Concern that AGMA, hypoglycemia and ARF may be related to liver injury. U/s without evidence of PVT or CBD dilitation. Serum tylenol negative. Concern for other toxic ingestion. [5-8] pt started to show signs of shock liver likely secondary to hypotension. [5-8] Gave 3 units FFP for INR 8.2-->2.8 # [Last Name (un) ]: Unknown baseline, but now presents with Cr above 5 with reasonably normal electrolytes. Bun:Cr ration less than 20, indicating less likely pre-renal azotemia. However, fena of 0.7 more consistent with volume depletion. Rising CKs could indicate a component of rhabdo. Given degree of hepatic dysfunction, there is some concern for HRS. Profound acidosis and stared [5-8] CVVH . # UGIB: Post intubation patient developed 650 cc of coffee ground emesis. Patient does not have known liver disease, and platelet count is normal making portal hypertension and varices less likely. [Month (only) 116] have developed spontaneous ulcer bleed in the setting of coagulopathy. He was Transfused 2 U PRBC [5-7] and started on PPI drip . # Shock: Patient was hemodynamically stable prior to intubation. [Month (only) 116] have hypotension related to UGIB as above, or could have early sepsis. No obvious sources, except for possible CNS sources as above, and maybe aspiration during seizure. Meets SIRS criteria by hypothermia, tachycardia and leukocytosis. DIC supported by elevated INR and LDH. Hemolysis appears to be limited given bilirubin is mostly direct. [5-8] pt required increasing pressors to maintain MAP>65,MAPs to the mid 50s, placed NICOM, stroke volume indices running low, gave fluids with improvement of MAPS in AM, gave additional fluids (6L during day) with MAPs in mid 50s-low 60s by evening of [5-8] pt was maxed out on dopamin, levophed, neo and vasopressin. [5-9] pt with lacate trending up despite maximal therapy and hypotensive. Since [5-7] he was broadly covered with ampicillin, acyclovir,vancomycin and ceftriaxone. stress doese steriods and insulin slidding scale started . # Respiratory failure: Intubated in the setting of seizure. ABG with good oxygenation and ventilation , but desaturates with FIO2 less than 99% 4/6pt with cardiac arrest and death pronounced. Medical examiner notified and will have autopsy performed. [2-4] brother [Name (NI) ] and Social worker notified. Medications on Admission: unknown Discharge Disposition: Expired Discharge Diagnosis: septic shock, ARDS, cardiopulmonary arrest Discharge Condition: expired. Discharge Instructions: expired. Followup Instructions: expired. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] Completed by:[2159-5-9]	[ "0389", "78552", "5845", "2762", "5849", "2761", "99592" ]
Admission Date: [2103-7-23] Discharge Date: [2103-7-27] Date of Birth: [2069-10-13] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[First Name3 (LF) 1283] Chief Complaint: Elective PFO closure with history of cerebrovascular accident Major Surgical or Invasive Procedure: [2103-7-25] Minimally invasive patent foramen ovale closure with sutures History of Present Illness: This is a 33 year old male who suffered left arm numbness/tingling with uncontrolled movements in [2103-1-30]. Hypercoaguable workup was negative at that time while neck arteriograms and MRA's were normal. Subsequent transesophageal echocardiogram revealed a patent foramen ovale with normal aorta and normal valvular and ventricular function. He currently has no neurological deficits. Past Medical History: patent foramen ovale, status post right temporal stroke, status post left knee arthroscopy, active smoker Social History: Tobacco - [3-2] pack per day for 16 years. He denies excessive ETOH. He denies IVDA. He is an UPS supervisor. He is engaged and lives with fiance. Family History: No premature coronary disease. No congenital valvular heart disease. Physical Exam: Temp 99.1, BP 130-140/80-90, Pulse 71, Resp 18 with 98% room air saturations. General: well appearing male in no acute distress Skin: good turgor, no lesions HEENT: oropharynx benign Neck: supple, no JVD, no carotid bruits Lungs: clear bilaterally Heart: regular rate, normal s1s2, no murmur or rub Abdomen: benign Ext: warm, no edema or cyanosis Pulses: 2+ distal pulses Neuro: alert and oriented, cranial nerves grossly intact, no focal deficits noted, 5/5 strength in all extremities with FROM Pertinent Results: [2103-7-27] 06:20AM BLOOD WBC-7.5 RBC-4.00* Hgb-12.0* Hct-34.6* MCV-87 MCH-30.1 MCHC-34.8 RDW-12.6 Plt Ct-136* [2103-7-27] 06:20AM BLOOD Glucose-114* UreaN-7 Creat-0.9 Na-142 K-3.7 Cl-103 HCO3-30 AnGap-13 [2103-7-27] 06:20AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.8 Brief Hospital Course: Mr. [Known lastname 16490] was admitted and started on intravenous Heparin. He stopped his Warfarin several days prior to admission. His Heparin was maintained for a PTT between 50 - 70. His preoperative course was otherwise uneventful and he was cleared for surgery. On [7-25], Dr. [Last Name (STitle) 1290] performed a minimally invasive PFO closure. His operative course was uncomplicated and he was brought to the CSRU intubated and sedated. He was quickly weaned from sedation and extubated without incident. He remained in the CSRU for overnight observation and then transferred to the SDU on postoperative day one. He remained in a normal sinus rhythm. Low dose beta blockade was initiated. He required pain control with Motrin and Dilaudid. His chest tube was removed on postoperative day 1 without complication. His postoperative course was uncomplicated and he was cleared for discharge on postoperative day 2. Medications on Admission: Warfarin 5mg qd, Nicotine patch Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:20 Patch 24HR(s) Refills:0 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 1 months: take qid for 3 days then prn. Disp:120 Tablet(s) Refills:2 4. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap PO BID (2 times a day). Disp:60 Refills:2 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:60 Tablet(s) Refills:0 6. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 5 days. Disp:10 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Patent foramen ovale s/p minimally invasive PFO repair h/o right temporal cerebrovascular accident Discharge Condition: Stable, good Discharge Instructions: 1) Patient may shower. No creams, lotions or ointments to incision. 2) No driving for at least 4 weeks 3) No lifting more than 10 lbs for at least 10 weeks Followup Instructions: Dr. [Last Name (STitle) 1290] in 4 weeks Dr. [Last Name (STitle) 25786](PCP)in 2 weeks Provider: [Name10 (NameIs) 4267] [Last Name (NamePattern4) 4268], MD, PHD[MD Number(3) ]: [Hospital6 29] NEUROLOGY Phone:[Telephone/Fax (1) 657] Date/Time:[2103-8-15] 4:30 Completed by:[2103-7-27]	[ "3051", "V5861" ]
Admission Date: [2181-12-8] Discharge Date: [2181-12-21] Date of Birth: [2156-3-22] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [2180-12-8]: GENERAL SURGERY: 1. Exploratory laparotomy, repair of L diaphragmatic rupture 2. IVC Filter placement VASCULAR SURGERY: 1. LE angiograms ORTHOPEDIC SURGERY: 1.Closed treatment left femoral shaft fracture with manipulation. 2. Application uniplanar external fixator left femur. 3. Washout and debridement open fracture down to and inclusive of bone left femur. 4. Repair dehiscence extensive/complicated left knee. 5. Repair intermediate trunk extremities left anterior tibia approximately 3 cm in length. 6. Washout and debridement open fracture right talus. 7. Operative treatment of right tarsal dislocation with external fixator. 8. Operative treatment tarsometatarsal dislocation right foot with external fixator. 9. Application negative pressure wound therapy 10. Open debridement irrigation down to and inclusive of bone of left femur fracture via 14 x 8 cm incision. 11. Removal of external fixator left femur. 12. Retrograde nailing of left femur with 12 x 360 mm retrograde Synthes nail. 13. Open reduction internal fixation comminuted left olecranon fracture with dorsal and medial plate. 14. Operative treatment, right humeral shaft fracture, with intramedullary nail. 15. Adjustment/revision, external fixator, right ankle. PLASTIC SURGERY: 1.Irrigation debridement of skin, subcutaneous tissue of left dorsal hand wound. 2.Repair of EIP, and EDC to index, middle, and ring fingers. UROLOGY: 1. Scrotal exploration, repair of testicular capsular disruption and primary closure, washout of scrotal hematoma. History of Present Illness: 27M was brought to [Hospital1 18] ED by [Location (un) ] s/p motor vehicle crash. Patient underwent 15 min extrication and was intubated at the scene for a GCS of 8. +LOC. Past Medical History: None Social History: History of alcohol and cocaine abuse. Family History: Noncontributory Physical Exam: Upon presentation to [Hospital1 18]: HR: 149 BP: 190/89 Resp: 25 O(2)Sat: 100 Normal Constitutional: Intubated HEENT: Pupils 2 bilaterally, minimally reactive, frontal midline hematoma, small abrasion to midline chin And c-collar, tympanic membranes clear Chest: Equal breath sounds bilaterally, sternum stable, no crepitance Cardiovascular: tachycardia Abdominal: Soft, Nondistended Pelvic: Pelvis stable Rectal: Minimal rectal tone, no gross blood Extr/Back: RUE: swollen, abrasion, deformity to anterior shoulder. LUE: laceration to elbow and proximal forearm, open fracture to wrist with exposed bone and likely a foreign body. LLE: Open femur fracture, tibia laceration with foreign body, patella laceration with glass, ecchymosis and swelling over the dorsal aspect of the foot, decreased pedal pulse. RLE: laceration over the patella, open ankle fracture dislocation. 2+ pulse in the dorsal pedal artery on the right. Back: no spinal step-offs, no gross deformities Skin: As above Neuro: Intubated and paralyzed At discharge: Vitals: 97.8 110 152/60 18 97% RA GEN: A&Ox3, NAD, calm and cooperative CARD: Normal S1,S2, no MRG PULM: CTA bilaterally GI: Abd soft, nontender, nondistended. +flatus. Abd incision with steristrips intact, no errythema EXTR: All for extremities with +PP/CSM. RLE with exfix in place. Pertinent Results: Lactate trend: On admission: 2.8 Peak: 4.7 (POD#1) Resolution: 1.7 (POD#2) Troponin trend: 0.38 ([12-8]) -> 0.19 ([12-10]) CPK Trend: 3737 --> 2847 Hct trend: On admission: 33.5 POD#2: 22 (received 2U) --> [2181-12-8] ASA-NEG Ethanol-298* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CXR ([2181-12-8]): - Findings concerning for left diaphragmatic rupture. - Right basilar patchy opacity may reflect atelectasis or contusion. Cspine: No evidence of acute fracture or malalignment. CT Head: - Small foci of subarachnoid hemorrhage involving right frontal and parietal regions. - 2-mm hyperattenuating foci and subcutaneous tissues overlying left frontal sinus may represent foreign bodies, correlate clinically. - Soft tissue edema of the frontal region, without underlying fracture. - Minimally displaced fracture of the right lateral nasal wall. CT Chest/Abd/Pelvis: 1. Left diaphragmatic rupture with associated herniation of nearly the entire stomach and small segment of the colon within the left hemithorax. There is minimal right-sided shift of midline structures. Left lower lobe opacification likely represents atelectasis. 2. Small amount of hemorrhagic fluid is noted posterior to the spleen, near the site of diaphragmatic rupture. The spleen itself appears intact without a distinct laceration. 3. Small area of right lower lobe opacification is non-specific and may represent aspiration. An additional ill-defined ground-glass opacity in the right lower lobe may represent a small contusion. 3. Fractures involving left transverse processes of L1 and L2 vertebral bodies. Right ninth rib fracture. R arm xray: A comminuted displaced fracture involving the mid to proximal diaphysis of the right humerus Bilateral ankle xray: Severe talocalcaneal joint dislocation and medial displacement of the talus along with the tibia and fibula. Extensive overlying soft tissue edema and subcutaneous gas, likely post-traumatic. Left femur xray: An open comminuted displaced fracture of the mid-to-distal diaphysis of the left femur, as described above. Bilateral eblow xrays: LEFT: Comminuted fracture of the left elbow with avulsion of the olecranon and potential avulsion fracture of the coronoid process are noted. Substantial soft tissue swelling is seen. RIGHT: No definitive evidence of fracture is seen on the right, although note is made that the patient was imaged with the casting material on. Bilateral wrist xrays: RIGHT: Fracture of the radial styloid process is noted, otherwise no abnormality seen on the right. LEFT: Fracture of the hamate is present. On the lateral view, there is an 8-mm radiopaque object projecting at the dorsal aspect of the palm at the level of hamate and might represent either bone chip or foreign body, exploration of this area is required. Scrotal US: 1. Findings are concerning for rupture of the left testicular lower pole with adjacent hematoma. 2. Hypoechoic lesion with septations in the upper pole of the left testicle laterally. A followup ultrasound of this finding in six months is recommended should the testicle be spared. CT Head [2180-12-9]: 1. Interval resolution of previously seen subarachnoid hemorrhage. No evidence of new hemorrhage. Brief Hospital Course: Mr. [Known lastname ] was evaluated in the trauma bay for severe polytrauma with the following injuries identified based on primary & secondary surveys and radiographic imaging: - Left diaphragmatic rupture - Right frontal/parietal subarachnoid hemorrhage - Minimally displaced nasal bone fracture - L1/L2 transverse process fractures - Right 9th rib fracture - Right comminuted displaced humerus fracture - Right fracture of the radial styloid process - Left elbow fracture - Left wrist open fracture of the hamate, Tendon injury - Left open comminuted displaced femur fx - Right subtalar dislocation racture - Left Testicle rupture - Splenic laceration Operarations: [2181-12-8] DIAGNOSTIC LAPAROSCOPY,EXPLORATORY LAPAROTOMY;REDUCTION OF THORACIC CONTENTS;LEFT CHEST TUBE PLACEMENT;REPAIR OF DIAPHRAGMATIC RUPTURE.SPLENORRAPHY,LEFT FEMUR I & D AND EXTERNAL FIXATOR, RIGHT FOOT OPEN REDUCTION AND EXTERNAL FIXATOR AND I&D ,LEFT FEMUR THIGH WOUND VAC PLACEMENT,LEFT LOWER EXTREMITY ANGIOGRAM. PLACEMENT OF FEMORAL IVC FILTER [Doctor Last Name ] [2181-12-10] 1. ORIF LEFT FEMUR WITH SYNTHES FEMORAL NAIL. 2. ORIF LEFT OLECRANON. 3. WASHOUT LEFT FEMUR AND LEFT OLECRANON.4. EXAMINATION UNDER ANAESTHESIS LEFT LOWER LEG. 5 Removal ext fix [Doctor Last Name 1022] [2181-12-11] 1. ORIF RIGHT HUMERUS WITH SYNTHES HUMERAL NAIL. 2. ADJUSTMENT OF RIGHT LOWER LEF EX-FIXATOR. 3. SCROTAL EXPLORATION, PARTIAL ORCHIECTOMY, REPAIR OF TESTICULAR FRACTURE He was admitted to the Acute Care Surgery team and taken to the OR emergently for repair of his diaphragmatic injury and multiple orthopedic procedures as previously listed. Intraoperatively he was noted to have a cool left foot with diminished pulses. Despite orthopedic reduction of injuries, the left foot remained cool and a vascular surgery consultation was obtained emergently. Angiogram was performed with no evidence of vascular compromise. Patient was transferred to the trauma ICU intubated. His hospital course is described by system: Neuro: Small SAH was noted on initial imaging but found to resolve on repeat CT of the head. Neurosurgical consultation was obtained with recommendations for no seizure prophylaxis and no log-roll precautions for lumbar transverse process fractures. Patient was following commands and neurologically intact throughout. Pain was well controlled with IV and then po narcotics and tylenol. He currently still remains alert and oriented x3, moving all extremties only limited by pain and his non weight bearing status in 3 of his 4 extremities. CV: Patient was hemodynamically stable throughout. A troponin of 0.38 was noted at the time of injury which trended down thereafter. No EKG abnormalities were present. Lactate also trended down. On HD# 11 because of high fevers, tachycardia and elevated white cell count he underwwent CT torso shwoing a pericardail effusion; a surface ECHO was performed the following day which showed minimal effusion and no other gross abnormalities. He is still experiencing intermittent tachycardia which is not uncommon in young trauma patients bu no other associated symptoms. His Na+ was also noted to be low in the high 120's range, he was fluid restricted and his Na+ level has normalized to 134 on [2181-12-20]. Resp: Patient was extubated on POD#4. Intraoperatively a chest tube was placed had minimal output and was put to water seal on POD#2. Chest tube was left in for 12 days due to high output initially but as the output decreased and he remained stable on water seal for several days the chest tube was removed on [2181-12-19]. Post pull chest xray showed only a tiny left apical pneumothorax persisting. He currently has no oxygen requirements and has stable saturations. GI/FEN: He was initially kept NPO with NGT decompression. Once extubated, he was tolerating a regular diet. There are no active issues with his GI system. GU: Patient's creatinine remained normal throughout. A scrotal hematoma was noted to be stable, though US showed evidence of left testicular rupture. Urologic consultation was obtained and he was taken to the operating room by Urology for repair of his injury. He is voiding without any issues and has had no further issues from a GU standpoint. Heme: IVC filter was placed at time of laparotomy in anticipation of limited mobility and high risk for bleeding with anticoagulation. HCT trended down from 33 to 22 over first two postoperative days and he was given 2U PRBCs. Postoperatively, patient's pulses were intact in bilateral LE. HCT remained stable thereafter. His hematocrit at time of discharge was 27. ID: Treated with Ancef and Cipro for complex open wounds and fractures. Antibiotics were stopped on [2180-12-14]. His WBC intermittently has trended along with fevers upward for which he was cultured and to date there has been no growth on his fluids with exception of some yeast from BAL that was done while he was in the ICU. His fevers have defervesced and white count coming down each day. MSK: Multiple orthopedic injuries were managed by the orthopedic and plastic surgical teams. After multiple trips to the OR (as detailed above), patient's injuries were gradually repaired. He is non weight bearing in all extremities with exception of his right arm. He has been actively participating with PT and OT and is being recommended for acute rehab after his hospital stay. Medications on Admission: None Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain; temp > 101.0 . 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. 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. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: s/p Motor vehicle crash Injuries: - Left diaphragmatic rupture - Right frontal/parietal subarachnoid hemorrhage - Minimally displaced nasal bone fracture - L1/L2 transverse process fractures - Right 9th rib fracture - Right comminuted displaced humerus fracture - Right fracture of the radial styloid process - Left elbow fracture - Left wrist open fracture of the hamate, Tendon injury - Left open comminuted displaced femur fx - Right subtalar dislocation racture - Left Testicle rupture - Splenic laceration - Hyponatremia - Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital following a motor vehicle crash where you sustained mulitple injuries requiring many operations to repair some of these injuries. Due to the extent of your trauma it is being recommended that you go to a rehabilitation facility after your hospital discharge to strengthen you. Followup Instructions: Department: SURGICAL SPECIALTIES When: THURSDAY [2181-12-27] at 3:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4653], MD [Telephone/Fax (1) 164] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SURGICAL SPECIALTIES When: MONDAY [2181-12-31] at 1:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], MD [Telephone/Fax (1) 31444] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2182-1-3] at 3:15 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage We are working on a follow up appointment in the Orthopedics department. The rehab will be called with the appointment. If you have not heard in the next two business days, please call [Telephone/Fax (1) 1228] option 6 for the status [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2181-12-21]	[ "2761", "2851" ]
Admission Date: [2120-12-6] Discharge Date: [2120-12-13] Date of Birth: [2067-9-13] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1283] Chief Complaint: syncopal episode and stuttering chest pain Major Surgical or Invasive Procedure: MVR (30 mm Band)/CABGx3 (LIMA->LAD, SVG->OM, SVG->PDA) [12-9] History of Present Illness: 53 yo M who presented to OSH following a syncopal episode and 24 hours of stuttering chest pain. At some point during this episode he fell and suffered a superficial laceration to his face which was sutured at the OSH. He was found to have EKG changes, ruled in for NSTEMI and was started on integrillin, heparin, aspirin and plavix after a negative head CT. He had a hct of 28 and was transfused one unit. Cardiac cath showed severe 3VD, and he was transferred for CABG. Past Medical History: Hypertension Diabetes type 2 Coronary Artery Diseasse Mitral Regurgitation Hypothyroidism Obesity Social History: Lives with Spouse [Name (NI) 1403] as manager of store ETOH infrequently a beer Tobacco denies Family History: NC Physical Exam: 99 116/72 69 20 98% on 3L ill appearing male in NAD A&O x 3 RRR CTAB obese NT ND 2+ DP no edema Pertinent Results: [2120-12-13] 09:30AM BLOOD WBC-13.6* RBC-2.98* Hgb-8.8* Hct-26.4* MCV-89 MCH-29.5 MCHC-33.3 RDW-15.5 Plt Ct-255 [2120-12-13] 09:30AM BLOOD Plt Ct-255 [2120-12-13] 07:20AM BLOOD Glucose-76 UreaN-32* Creat-1.0 Na-135 K-3.8 Cl-97 HCO3-29 AnGap-13 Brief Hospital Course: Transferred in from outside hospital on integrillin and heparin. He was taken to the operating room for coronary artery bypass graft and mitral valve repair. Please see operative report for further details. He was transferred to the ICU in critical but stable condition. He had a low SVO2 despite epinephrine and neo and underwent TEE. He was given volume and PRBCs, that he responded with and then weaned from drips. He was extubated and continued to improve. He was transferred to the floor POD 2. Physical followed him during entire post-op course for strength and mobility. His tubes and wires were removed and he continued to make steady process. By post-operative day 4 he was ready for transfer to rehab. Medications on Admission: [Last Name (un) 1724]: Metformin 1gm", prednisone , lisinopril 10', levothyroxine 50', lipitor, glyburide, fluoxetine 40", seroquel, simvastatin 10' . MEDS ON ADMISSION: Heparin gtt, integrellin gtt, Plavix 75 (p 600 load), ASA 325', lisinopril 10', simvastatin 40', fluoxetine 40'', lopressor 25 Q6h, levothyroxine 50', insulin SS 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. 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 3. 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 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Paxil 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:20 Tablet(s) Refills:0 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 10 days. Disp:20 Tab Sust.Rel. Particle/Crystal(s) Refills:0 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 15644] Long Term Health - [Location (un) 47] Discharge Diagnosis: Mitral regurgitation s/p MV repair Coronary Artery Disease s/p CABG Hypertension Hyperlipidemia Diabetes Mellitus Discharge Condition: Good. Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] [Last Name (NamePattern4) 2138]p Instructions: Please call to schedule all appointments Dr. [Last Name (Prefixes) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) ] after discharge from rehab [Telephone/Fax (1) 20261] Dr. [Last Name (STitle) 2603] after discharge from rehab Completed by:[2120-12-13]	[ "41401", "4240", "2724", "4019", "25000" ]
Admission Date: [2145-1-17] Discharge Date: [2145-1-25] Date of Birth: [2070-3-24] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 30] Chief Complaint: abdominal pain, acute renal failure, hypotension Major Surgical or Invasive Procedure: left subclavian central line Upper endoscopy Transfusion of packed red blood cells History of Present Illness: Ms. [Known lastname 4886] is a 74 year old woman with a history of CHF, chronic renal insufficiency, peptic ulcer disease, CAD, HTN, who is admitted to the MICU for management of acute renal failure, abdominal pain, and hypotension. She was brought in to the [Hospital6 10353] ED yesterday after reportedly having several days of poor PO intake and abdominal pain at her [Hospital3 ] facility, per her daughter. The patient gives a vague history of recent URI symptoms, and she reports a mechanical fall yesterday, without any head trauma or loss of consciousness. . At the [Hospital3 ] ED, she was noted to be in acute-on-chronic renal failure with a creatinine of 4.9 and a serum HCO3 of 6. She had a SBP in the mid-80s and was reportedly hypothermic to 95.8, with a leukocytosis to [Numeric Identifier 2686]. An ABG showed a metabolic acidosis (7.22/22/175 on 2L n.c.). She was noted to vomit 200cc of "blood-tinged mucous". She underwent an abdominal CT with PO (no IV) contrastwhich showed no acute process. She was given a dose of metronidazole and moxifloxacin for empiric antibiotics. She was also given a dose of IV ondansetron, a 1000cc NS bolus, and 150 mEq of NaHCO3. A left-sided subclavian central line was placed and she was transferred to [Hospital1 18]. . Upon arrival to the [Hospital1 18] ED, she was afebrile with a temperature of 98.2, BP 91/59, HR 84. She was given 1000cc NS bolus and 1000cc D5W with 150 mEq HCO3. She reportedly had a decrease in her BP to 56/44 which improved to 102/58 with a 250cc NS bolus and low dose of norepinephrine. She was also given 10 mg of IV dexamethasone for unclear reasons. She had a CT which showed no acute process and an abdominal ultrasound which showed a mildly dilated (1.1cm) CBD; no gallbladder was identified. Per the [Hospital1 18] ED resident, she was noted on two separate rectal examinations to have black tarry stool which was Guaiac negative. . Upon arrival to the MICU, she had a dry black stool which was Guaiac positive. Her norepinephrine was weaned off upon arrival to the MICU. . Of note, she had a similar presentation to [Hospital 882] Hospital in [9-/2144] when she presented with acute-on-chronic renal failure, decreased PO intake, and left-sided abdominal pain. An EGD on that admission showed a nonbleeding gastric ulcer, and her ppi was changed from pantoprazole to omeprazole and increased [Hospital1 ]. She also had a question of antral thickening on a CT scan, and antral biopsies were taken, the results of which are unavailable to us at the time of this note. Past Medical History: Past Medical History: - congestive heart failure (by report, LVEF 50% om [4-/2144]) - CAD with ?MI - peptic ulcer disease with ? bleeding ulcer in distant past; EGD in [11/2143] showed nonbleeding gsatritis; EGD in [9-/2144] showed nonbleeding erythematous gastritis and nonbleeding gastric ulcer - short-term memory loss - ?CVA vs TIA - chronic renal insufficiency (baseline creatinine 1.6) with multiple recent episodes of acute exacerbations - HTN - hx C2 fracture with hardware in place - "moderate" right-sided RAS - s/p appendectomy - s/p cholecystectomy - s/p partial colectomy for diverticulitis - osteoporosis - hyperlipidemia - COPD . Social History: Social History: Quit smoking >15 yrs ago. No alcohol or drugs. Lives in River Bay Club [Hospital3 ] facility. Family History: Family History: Per daughter, the patient's father died at an early age from an MI. Physical Exam: T 97.8 BP 121/58 HR 93 RR 23 Sat 100% on 2L n.c. CVP 4cm General: uncomfortable, but in no acute distress HEENT: no scleral icterus, MM moderately dry Neck: JVP 6cm, no thyromegaly Chest: clear to auscultation throughout, no w/r/r CV: regular rate/rhythm, normal S1S2, no m/r/g Abdomen: soft, mild voluntary guarding esp. in LLQ; tenderness to moderate palpation mostly in LLQ; no rebound Extremities: no edema, 2+ PT pulses Skin: no rashes Neuro: alert, oriented to self, "[2142-1-3]" and "River Bay Club". Pertinent Results: From [Hospital3 ] Ctr: ABG (9:45pm) 7.22/22/175 on 2L n.c. . Labs on admission: [2145-1-17] 12:30AM BLOOD WBC-16.2* RBC-3.56* Hgb-11.1* Hct-32.5* MCV-91 MCH-31.3 MCHC-34.3 RDW-14.1 Plt Ct-253 [2145-1-17] 12:30AM BLOOD Neuts-95.9* Bands-0 Lymphs-2.8* Monos-1.2* Eos-0.1 Baso-0 [2145-1-17] 12:30AM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1 [2145-1-18] 06:09AM BLOOD Ret Aut-0.7* [2145-1-17] 12:30AM BLOOD Glucose-196* UreaN-119* Creat-4.0* Na-137 K-4.7 Cl-110* HCO3-13* AnGap-19 [2145-1-17] 12:30AM BLOOD ALT-14 AST-25 CK(CPK)-164* AlkPhos-143* Amylase-68 TotBili-0.2 [2145-1-17] 12:30AM BLOOD Lipase-80* [2145-1-17] 12:30AM BLOOD CK-MB-8 cTropnT-0.01 [2145-1-17] 12:30AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.3 [2145-1-18] 06:09AM BLOOD calTIBC-148* Ferritn-397* TRF-114* [2145-1-19] 06:05AM BLOOD Osmolal-307 [2145-1-21] 06:15AM BLOOD PEP-NO SPECIFI [2145-1-17] 06:02AM BLOOD Type-ART pO2-123* pCO2-22* pH-7.36 calTCO2-13* Base XS--10 [2145-1-17] 12:31AM BLOOD Lactate-1.3 [2145-1-17] 06:02AM BLOOD freeCa-1.28 . Labs on discharge: [2145-1-24] 11:00AM BLOOD WBC-9.5 RBC-2.75* Hgb-9.1* Hct-26.0* MCV-95 MCH-33.2* MCHC-35.1* RDW-14.5 Plt Ct-266 [2145-1-25] 06:04AM BLOOD Glucose-83 UreaN-8 Creat-1.2* Na-140 K-4.0 Cl-108 HCO3-22 AnGap-14 [2145-1-25] 06:04AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.5* . Microbiology: [2145-1-17] blood culture - negative [2145-1-17] Urine culture - negative [2145-1-17] c diff - negative [2145-1-18] blood culture - negative [2145-1-19] h pyloi - negative . Other Studies: Abd CT ([2145-1-16]- from [First Name4 (NamePattern1) 392] [Last Name (NamePattern1) ]): Appendix is not identified. Atrophic kidneys. Gallbladder is not visualized. Atherosclerotic aorta. Old healed deformity of left anterior and superior pubic rami. . Head CT ([2145-1-17]): Examination is mildly limited by motion artifact. There is no hemorrhage, mass effect, shift of the normally midline structures, or vascular territorial infarct. Mild periventricular white matter hypodensity is consistent with chronic microvascular ischemia. There is no hydrocephalus. The [Doctor Last Name 352]-white matter differentiation is preserved. Orthopedic hardware is seen within the dens. The visualized paranasal sinuses and mastoid air cells are well aerated. . Abd US ([2145-1-17]): The liver is unremarkable without focal or textural abnormality. The portal vein is patent with appropriate hepatopedal flow. There is no intrahepatic biliary dilatation. The common bile duct is dilated measuring 1.1 cm. The gallbladder is not definitively identified. The structure interrogated on multiple views located near the gallbladder fossa most likely represents bowel/stomach with gallstone-filled gallbladder. . ECG ([2145-1-17]): NSR at 93 bpm. Normal axis, normal intervals. Poor baseline. Biphasic T waves noted in I, aVL, II, aVF, and V5-V6. . CT Abd/Pelvis ([2145-1-17]): IMPRESSION: 1. Mild colonic wall thickening extending from the splenic flexure to the distal sigmoid, suggestive of infectious or less likely, ischemic etiology. No perforation or fluid collection. No abscess. Following recuperation of renal function, a CT angiogram of the mesenteric vessels could be performed if clinically indicated. 2. Likely subacute fracture of the left symphysis pubis and rami. Correlation with prior outside imaging studies may be of assistance. 3. LLL 6 mm pulmonary nodule. 6 month fllow-up exam advised. . CT Abd/Pelvis, repeat ([2145-1-24]): IMPRESSION: 1. Resolution of mild colonic wall thickening seen on prior study. 2. No additional evidence to explain patient's symptoms. Brief Hospital Course: 74 year old woman with abdominal pain, Guaiac-positive black stool, and acute-on-chronic renal failure. . 1) Guaiac-positive black stool: Patient was initially admitted to the ICU for management. GI consulted and recommended endoscopy, [Hospital1 ] PPI, and C. Diff studies. Endoscopy was performed demonstrating a non-bleeding duodenal ulcer w/o exposed vessels, and gastritis. Continued on [Hospital1 ] PPI with stable Hct thereafter. H. Pylori negative. . 2) Abdominal Pain: Certainly could be due to PUD, though the location of her pain is not classic for PUD. Abdominal CT scan report from OSH unrevealing (status post cholecystectomy and appendectomy). Pancreatic/hepatic labs within normal limits. Abdominal CT without contrast here with mild distal colonic thickening - unclear if infectious vs. inflammatory vs. ischemic (less likely). GI consulted for guiac + stool. Recommended C. Diff studies (negative x1). On transfer to the floor abdominal pain remained mild, but persisted over several days. Patient had unimpressive abdominal exam, but with definite tenderness to palpation in the LLQ and RLQ. Repeat CT of the abdomen was performed demonstrating clearance of the colonic thickening. Her abdominal pain was ultimately attributed to constipation, as she had not had a bowel movement in 7 days. Bowel regimen was uptitrated resulting in multiple bowel movements (and some diarrhea) with some resolution of abdominal discomfot. . 3) Acute renal failure: Likely due to hypovolemia/prerenal azotemia given CVP of 4 on initial presentation to ICU, poor PO intake, known renal artery stenosis. Creatinine improved with IV hydration and reached nadir of 1.1 - 1.2, patient's baseline. . 4) Metabolic Acidosis/hypophosphatemia: Patient was noted to have metabolic acidosis in setting of renal failure. Renal consulted. They felt this was likely due to the patients renal failure, and did not recomend chronic bicarbonate repletion. Unable to clearly diagnose type I or type II RTA in setting of acute renal failure. Upon resolution of renal failure, acidemia resolved. . 5) Hyphophatemia: Floor course complicated by severe hypophosphatemia requiring aggressive repletion and thought due to chronic poor PO intake and refeeding syndrome. Resolved by time of discharge. . 6) Tachypnea: Patient notably tachypneic throughout most of her ICU course, but without SOB, cough or other pulmonary complaints. All pulmonary work up was negative and this was felt due to her metabolic acidosis with respiratory compensation. Resolved with resolution of metabolic acidosis. . 7) Hypotension: Patients SBP improved with IV hydration. Cultures were negative. Was orthostatic on transfer to the floor, but resolved with further hydration. Felt all to be due to dehydration/GI bleed. Completely resolved at time of discharge. . 8) Leukocytosis: Patient with prominent leukocytosis on admission. C. Diff negative, cultures NGTD. Steadily improved over hospitalization and thought to be due to low level GI bleed and UTI. Urine culture was negative, but treated for UTI as below. . 9) Urinay tract infection: During work up for leukocytosis above, urinalysis was sent, which was borderline positive. She was treated with 7 day course of levofloxacin, as this was felt to be a foley catheter related UTI. Urine culture returned negative. . 10) Pulmonary Nodule: Patient had right lower lobe lung nodule noted incidentally on abdominal CT scan. This will require follow up with repeat chest CT in 6 months Medications on Admission: Home Medications: ferrous sulfate 325 mg daily lisinopril 10 mg daily aspirin 81 mg daily multivitamin 1 tab daily calcium carbonate/vitamin D 1 tab daily docusate 100 mg [Hospital1 ] ipratropium/albuterol MDI 2 puffs [Hospital1 ] mirtazapine 7.5 mg qhs atorvastatin 80 mg daily acetaminophen 500 mg tid omeprazole 20 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): [Month (only) 116] take an extra 2 tablets per day as needed for constipation. Disp:60 Tablet(s) Refills:2 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 12. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 13. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 14. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Elder Services Plan Discharge Diagnosis: Primary: Acute renal failure Hypotension-Dehydration Mixed metabolic acidosis Left sided colitis NOS Hypophosphatemia Duodenal ulcer Left lower lobe 6 mm pulmonary nodule Constipation Secondary: Osteoporosis Subacute fracture - left symphysis pubis and rami CKD Stage III COPD C2 fracture s/p instrumentation Hyperlipidemia CAD NOS Diastolic heart failure NOS Depression s/p appendectomy s/p cholecystectomy s/p partial colectomy for diverticulitis Discharge Condition: Good. Patient ambulating, symptoms improved. Discharge Instructions: You were admitted to the hospital for evaluation of a mechanical fall, and treatment of low blood pressure, acute renal failure and abdominal pain. During your hospital course, your low blood pressure and acute renal failure resolved with fluid hydration. You were also evaluated for a low blood level with an endoscopy that demonstrated an ulcer, and inflammation of your stomach. You were started on pantoprazole 40mg twice daily. Your abdominal pain was evaluated with a CT scan, repeat was normal. However it did incidentally note a small left sided pulmonary nodule which will need to be followed up in 6 months time. Otherwise your abdominal pain was treated with giving you medications to help you have a bowel movement. . Please take all medications as directed. . Please follow up with all appointments as directed. . Please contact physician if develop worsening abdominal pain, diarrhea, blood in stool, weakness/dizziness, black colored stools, any other questions or concerns. Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] ([Telephone/Fax (1) 76456] in [2-4] weeks time. . Of note, you had a left lower lobe lung nodule that was 6mm in size that was noted on a CT scan during your hospital course. You will need a 6 month follow-up CT scan that should be scheduled by your primary care physician. . Please have your primary care physician set you up with follow up with gastroenterology, for follow up of your duodenal ulcer.	[ "5849", "5990", "2760", "2762", "4280", "496", "40390", "41401", "2724" ]
Admission Date: [2154-11-26] Discharge Date: [2154-11-28] Date of Birth: [2115-4-30] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1711] Chief Complaint: Bilateral shoulder pain Major Surgical or Invasive Procedure: Cardiac [First Name3 (LF) 29817] History of Present Illness: The patient reports that for the last two weeks she has been experiencing shoulder pain. The pain started in her left shoulder and then migrated to her right shoulder. Within a week, both shoulder and her neck were in pain. She reported to her PCP, [Name10 (NameIs) ] an EKG was evidently normal. She was diagnosed with arthritis. The patient, however, continued to have increasing pain in her shoulders that radiated down to her fingers. Soon it was accompanied by a feeling of tightness in her throat. Over the last weekend, the patient further experienced some diaphoresis. She also had some difficulty in breathing. The pain finally moved the patient to go to the ED. . On Monday in the emergency room, the patient had a CPK of 334, CK-MB of 10.9, troponin 2.61. The patient was started on ASA, SL nitroglycerin, and heparin. Her EKG showed significant ST depression in her inferior and lateral leads. The patient was then placed on Plavix, nitro drip, statin, and heparin drip before transfer to [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) 29817] tomorrow. . On review of systems, the patient denies any change of vision, sinus congestion, dysphagia, cough, palpitations, chest pain, nausea, vomiting, constipation, diarrhea, dysuria. She says she regularly has headaches (migraines) and has always bruised easily. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, and palpitations. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: None 3. OTHER PAST MEDICAL HISTORY: - Hypertension - Pre-eclampsia during both pregnancies - Anxiety - Depression - Migraines Social History: -Tobacco history: 20 years' smoking history; [1-26] pack a day -ETOH: No -Illicit drugs: No The patient is currently unemployed, caring for 6yo and 4yo children Family History: Father had CABG x 6 in his 50s; alive in his 60s. Mother has history of strokes and hypertension. Physical Exam: PHYSICAL EXAMINATION: GENERAL: Obese woman in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple, no cervical LAD. CARDIAC: Normal S1, S2. No m/r/g. LUNGS: No accessory muscle use. CTA bilaterally ABDOMEN: Soft, NTND, bowel sounds positive. EXTREMITIES: No cyanosis, clubbing, edema. PULSES: Radial/pedal pulses 2+ Pertinent Results: Cardiac biomarkers: [2154-11-27] 12:00AM BLOOD CK-MB-19* MB Indx-9.1* cTropnT-0.91* [2154-11-27] 05:23AM BLOOD CK-MB-15* MB Indx-8.9* cTropnT-1.25* [2154-11-27] 03:48PM BLOOD CK-MB-11* MB Indx-7.4* [2154-11-28] 05:19AM BLOOD CK-MB-11* MB Indx-7.2* Admission labs: [2154-11-27] 12:00AM BLOOD Calcium-9.2 Phos-2.0* Mg-1.6 [2154-11-27] 05:23AM BLOOD ALT-20 AST-39 LD(LDH)-271* CK(CPK)-168 AlkPhos-69 TotBili-0.3 [2154-11-27] 12:00AM BLOOD Glucose-169* UreaN-12 Creat-0.7 Na-138 K-3.6 Cl-106 HCO3-25 AnGap-11 [2154-11-27] 12:00AM BLOOD WBC-10.0 RBC-3.97* Hgb-12.6 Hct-35.3* MCV-89 MCH-31.9 MCHC-35.8* RDW-13.5 Plt Ct-223 Discharge labs: [2154-11-27] 05:23AM BLOOD WBC-9.8 RBC-3.98* Hgb-12.6 Hct-35.5* MCV-89 MCH-31.7 MCHC-35.5* RDW-13.3 Plt Ct-201 [2154-11-28] 05:19AM BLOOD UreaN-14 Creat-0.8 Na-137 K-4.0 Cl-106 [2154-11-28] 05:19AM BLOOD CK(CPK)-152 Cardiac [Month/Day/Year 29817] 1. Coronary angiography in this left-dominant system demonstrated two-vessel disease. The LMCA had no angiographically apparent disease. The LAD had a 60% ostial stenosis. The LCx had a distal hazy 80% stenosis. The RCA was non-dominant and had mild diffuse disease. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. Brief Hospital Course: # CORONARIES: NSTEMI, showing in inferior and lateral leads. The patient underwent cardiac catherization. Her catherization showed LAD 60% obstruction at origin, LCX distal 80% onstruction, RCA non-dominant w/ diffuse disease. A drug-eluting stent was placed in LCX. Recommendations included that the patient undergo an exercise stress test to assess LAD in about a month. If the stress test should show anterior ischemia, the patient will likely need LIMA to LAD. She tolerated the procedure well and had no signs of hematoma at her radial site of entry. The patient should continue aspirin, plavix, statin, lisinopril and metoprolol. She should follow up with Cardiology in one month. The patient was counseled on smoking cessation and reports that she is not experiencing any withdrawal symptoms. She did not require nicotine replacement during her hospitalization. The patient was also informed about the importance of follow up and of continuing on her medications. . # PUMP: Echo from [11-26] shows inferior wall hypokinesis, LVEF 50%. . # RHYTHM: Patient was in normal sinus rhythm for the duration of her stay in the unit. . # HYPERTENSION: The patient's blood pressure was well controlled on metoprolol and lisinopril, which she should continue. . # DEPRESSION/ANXIETY: Continued the patient's home doses of Wellbutrin and Remeron. Medications on Admission: - HCTZ 25mg PO QD - Mirtazapine 45mg QHS - Trazodone 100mg QHS - Wellbutrin 150mg [Hospital1 ] - Cyclobenzaprine 5 mg TID Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:14 Patch 24 hr(s) Refills:2 6. mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 9. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Non ST elevation myocardial infarction Secondary Diagnoses: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for shoulder and arm pain. An electrocradiogram (EKG) and blood tests revealed that you had a heart attack, a blockage of one of the arteries in your heart. You had a coronary [Hospital1 29817] and a stent was placed in your heart. You were also treated with medications. It is extremely important that you take the medications that you started in the hospital. Please start taking: PLAVIX (clopidogrel) 75mg tablet, take one daily LIPITOR (atorvastatin) 80mg tablet, take one daily Metoprolol 25mg tablet, take one twice daily Lisinopril 10mg, take one tablet daily Aspirin 325mg, take one tablet daily Please continue all other medications as you were before. It is very important that you take plavix (clopidogrel) after having a stent. DO NOT STOP taking plavix without talking to your cardiologist. Please stop smoking. We have provided your with a prescription for a nicotine patch. Followup Instructions: Please follow up with the following appointments: PCP: [Last Name (NamePattern4) ]. [Last Name (STitle) 12593] Date/Time: [2154-12-5], 10:00 am Telephone: [Telephone/Fax (1) 82482] Cardiology: [Name6 (MD) ] [Name8 (MD) 10828], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2154-12-31] 11:20	[ "41071", "41401", "4019", "3051" ]
Admission Date: [2126-9-28] Discharge Date: [2126-9-28] Service: CCU HISTORY OF PRESENT ILLNESS: This is an 81 year old male with diabetes mellitus, hypertension, and severe aortic stenosis, presenting with increasing shortness of breath times thirty days. He tried sublingual Nitroglycerin times one which helped but he kept having shortness of breath after a recent discharge from C-Medicine for congestive heart failure exacerbation. No chest pain, positive orthopnea, positive paroxysmal nocturnal dyspnea, positive lower extremity edema, positive constipation, no fever, chills, nausea, vomiting, diarrhea or abdominal pain. He was brought in by EMS. He had a urology appointment the day of admission so was more active than usual. In the Emergency Department, he had some relief with 40 mg of intravenous Lasix with 500cc of urine output and given 162 mg of Aspirin after the patient had an episode of chest pain which resolved. The patient was seen by Cardiology who recommended gentle diuresis with addition of low dose Dopamine as he did have severe aortic stenosis and was preload dependent and was admitted to C-Medicine. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Hypertension. 3. Gout. 4. Severe aortic stenosis, valve area 1.1 with a gradient of 42 mmHg. 5. Coronary artery disease, status post myocardial infarction in [2110], status post coronary artery bypass graft with ejection fraction of 15 to 20%, 2+ mitral regurgitation. 6. Peripheral vascular disease. 7. Chronic Foley, status post transurethral resection of prostate. MEDICATIONS ON ADMISSION: 1. Captopril 50 mg three times a day. 2. Lopressor 50 mg p.o. twice a day. 3. Norvasc 5 mg once daily. 4. Lasix 20 mg twice a day. 5. Urecholine 25 mg three times a day. 6. Allopurinol 100 mg three times a day. 7. Colchicine 0.8 mg twice a day. 8. Aspirin 325 mg p.o. once daily. 9. Amaryl 1 mg p.o. twice a day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No tobacco, ethanol or drug use. Chest x-ray revealed cardiomegaly, positive pulmonary edema, bilateral effusions. PHYSICAL EXAMINATION: In general, the patient is in mild respiratory distress. Vital signs revealed a temperature of 97, blood pressure 113/58, pulse 101, respiratory rate 20, 93% on four liters nasal cannula. Head - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The oropharynx is clear. Pulmonary - Rales one half way up bilaterally. Cardiac - regular rate and rhythm, III/VI systolic ejection murmur radiating to the carotids. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities - 2+ bilateral pitting edema. Neurologically, cranial nerves II through XII are intact. Strength is [3-24] bilaterally. LABORATORY DATA: White blood cell count is 5.8, hematocrit 30.4 which is baseline, platelet count 143,000, neutrophils 26%, bands 1%, 72% lymphocytes, Sodium 125, potassium 4.9, chloride 94, bicarbonate 20, blood urea nitrogen 71, creatinine 2.4, baseline is 2.4 to 2.6. CK 91, troponin less than 0.3. Electrocardiogram revealed left bundle branch block, but has had left bundle branch block on most previous electrocardiograms. Sinus tachycardia at 100 beats per minute. INITIAL ASSESSMENT: An 81 year old male with severe aortic stenosis, coronary artery disease, status post coronary artery bypass graft with ejection fraction of 15 to 20%, presenting with shortness of breath and chest x-ray consistent with congestive heart failure exacerbation. Because of aortic stenosis, must be careful with diuresis as he is preload dependent. HOSPITAL COURSE: The patient was on the floor briefly when he started to desaturate. The patient was paced on a 100% nonrebreathing mask secondary to decreased oxygen saturation and was hypotensive on Dopamine upon arrival. The patient was assessed by the CCU team, was found to be tachycardic with decreased blood pressure and was moved to CCU to attempt noninvasive ventilation. Given that the patient had previously made it clear that he was DNI, however, he was not "Do Not Resuscitate". Upon arrival to the CCU, noninvasive ventilation was initiated. The patient went into PEA arrest and a cardiac code was called. ACLS protocol was begun. The patient was DNI, however. Documentation of cardiopulmonary arrest was provided. PEA continued. The patient's pulse briefly returned. Upon further discussion with the patient's family, the patient was made "Do Not Resuscitate". The patient soon after lost his pulse and unsuccessful resuscitation was started and shortly discontinued. The code duration lasted from 07:40 to 07:57 a.m. Time of death was 7:57 a.m. on [2127-9-28]. DISCHARGE STATUS: Expired. [Name6 (MD) 475] [Last Name (NamePattern4) ], M.D. [MD Number(1) 9632] Dictated By:[Name8 (MD) 8279] MEDQUIST36 D: [2127-3-17] 15:57 T: [2127-3-22] 10:12 JOB#: [Job Number 32345]	[ "4280", "4241", "25000", "41401", "4019", "V4581" ]
Admission Date: [2115-12-30] Discharge Date: [2116-1-10] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: HYPOXIA Major Surgical or Invasive Procedure: Endotracheal intubation and ventilation Arterial Line History of Present Illness: [Age over 90 ]F h/o HTN, PVD, spinal stenosis, who was transferred from [Hospital1 ] after presenting with calf pain and numbness x 1 day. Pt reports having left leg pain "off and on" for months. Was diagnosed with bursitis and has been receiving steroid injections. Yesterday pt reports pain was so severe that she fell to the ground. EMS was called, and pt was taken to OSH where O2sat was 82% on RA/100%on NRB. Pt denied SOB, cough, CP. Also denied N/V/D/F/C/dysuria, or abdominal pain W/U at OSH notable for EKG changes without ishemic changes, CXR showing honeycombing insterstitial patterns. CTA was negative for PE but showed patchy ground glass opacities, bibasilar fibrosis, peripheral bullous disease and increased interstitial markings. Pt started on empiric CTX and zithro, given supp O2, and transferred to the [Hospital1 ] per pt's request. Past Medical History: HTN, PVD, Hypercholesterolemia, spinal stenosis, h/o pleural empyema as child s/p surgery, bilateral cataracts, fibrocystic breast disease; echo [2114]: EF 65% with mild pulmonary HTN Social History: Lives alone in [Hospital3 ]. Quit tobacco 30 years ago, 40-50 pack year history prior. EtOH: 2 glasses of wine a day. Former real estate [Doctor Last Name 360]. Family History: Non contributory Physical Exam: At the time of death: Pulseless, apneic No response to sternal rub, corneal reflex, or nailbed pressure. No heart sounds or lung sounds. Pertinent Results: [2115-12-30] 10:52PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.037* [2115-12-30] 10:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2115-12-30] 10:20PM GLUCOSE-127* UREA N-25* CREAT-0.9 SODIUM-137 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19 [2115-12-30] 10:20PM CK(CPK)-100 [2115-12-30] 10:20PM CK-MB-5 cTropnT-<0.01 [2115-12-30] 10:20PM CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-2.0 [2115-12-30] 10:20PM WBC-12.5* RBC-4.05* HGB-13.5 HCT-38.0 MCV-94 MCH-33.3* MCHC-35.5* RDW-13.4 [2115-12-30] 10:20PM PLT COUNT-284 [2115-12-30] 09:07PM TYPE-ART PO2-60* PCO2-28* PH-7.48* TOTAL CO2-21 BASE XS-0 [2115-12-30] 09:07PM LACTATE-1.4 [2115-12-30] 09:07PM freeCa-1.12 UNILAT LOWER EXT VEINS LEFT PORT [2115-12-31] 9:17 AM Left common femoral, superficial femoral, and popliteal veins demonstrate normal compressibility, color flow, Doppler waveforms, and response to augmentation. No intraluminal thrombus is identified. CHEST (PORTABLE AP) [2115-12-30] 9:20 PM A mild degree of bilateral pulmonary vascular congestion and cardiomegaly. ECHO Study Date of [2116-1-2] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60-70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis. Mild to moderate ([11-24]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([11-24]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. CT Chest - Findings consistent with possible nonspecific interstitial pneumonitis. Brief Hospital Course: Upon admission to [Hospital1 18] MICU, patient was placed on NRB w/ nasal cannula for additional oxygen delivery, and it was noted that patient would desaturate with any attempt to remove mask. CT suggested a diffuse process w/ ground-glass opacities and differential diagnoses included LIP,IPF/UIP,AIP/ARDS,BOOP,PAP. Nonetheless, patient appeared subjectively without distress. However, on subsequent days, despite empiric antibiotic treatment and diuresis for presumptive pneumonia and pulmonary edema, patient's hypoxia continued to progress and patient ultimately became subjectively dyspneic. In addition, patient was also treated empirically for Pneumocystis carinii pneumonia w/ high dose sulfamethoxazole/trimethoprim. Echocardiogram revealed no significant only 2+TR, normal LV function, and no findings that would explain patient's persistent progressive hypoxia. Lower extremity doppler ultrasound revealed no evidence of deep venous thromboses. Hypoxia was considered to be less likely due to infectious and/or cardiogenic causes and thought more to be secondary to a primary pulmonary process. Radiological consultants suggested that CT findings were consistent with nonspecific interstitial pneumonitis. Therefore, in addition to empiric antibiotics, patient was given high dose steroids in an attempt to reverse any acute changes - as it was felt that patient's hypoxia was most likely an acute exacerbation of chronic pulmonary process. On hospital day six, given patient's continued progressive symptomatic hypoxia (found confused whenever patient had accidentally removed NRB mask), patient was electively intubated by anesthesia. At that point, open lung biopsy was considered to determine cause of patient's pulmonary disease, however, in discussion with family and thoracic surgery consultants, it was felt that patient would not have been interested in such an invasive procedure, and that yield in terms of diagnosis of a reversible cause would be extremely low. As patient continued to exhibit no improvedment over the next five days, a decision was made by the patient's family and healthcare proxy to withdraw care and extubate patient. Patient was given comfort measures only and expired at 2:30 PM [2116-1-10]. Medications on Admission: On Transfer: Ceftriaxone 1g QD Azithromycin 250mg QD Lisinopril 5mg QD Atenolol 25mg QD Heparin 5000 SC TID ASA 325mg QD Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Nonspecific interstitial pneumonitis Respiratory failure Myocardial infarction (post-mortem diagnosis) Discharge Condition: Deceased Discharge Instructions: n/a Followup Instructions: n/a	[ "4280", "5849", "V5867", "4019", "2720" ]
Admission Date: [2185-8-14] Discharge Date: [2185-8-19] Date of Birth: [2142-2-20] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1390] Chief Complaint: Trauma: fall Injuries: L [10-18] post rib fx R [5-16] post rib fx R lung contusions L medial orbital wall fx T11 chance fx with post disloc on T10 C2-5,C7,T8-10 spinous process fx C2-C3 intraspin lig tear C1-C4 edema Major Surgical or Invasive Procedure: [2185-8-14] T7-L1 laminectomy, fusion (ortho spine) History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 43 year old male who presents after being found under bridge, half submerged in water. Initially unresponsive, but now improved. ? seizure. ? [2185]5-20 feet. ? ETOH. Thought that patient lying in water at least half hour. Pt has h/o seizures, and now states that he thinks he might have seized. Past Medical History: PSYCHIATRIC HISTORY: Inpatient detox 3 times (2 at [Doctor First Name 1191] in [2182], 1 at [Hospital1 ] in [2182] or [2183]). Never taken meds, never seen a psychiatrist. AA did not help him much, did not attend. PAST MEDICAL HISTORY: Denies Social History: From [Location (un) 3786], 1 sister, 2 brothers (1 in [State 2690], 1 he does not keep in touch with 2/2 abuse). States was in the USMC from 87-89, d/c'ed for crystal meth in urine. Has 1 son, 20, was not involved but tried contacting recently via facebook, upsetting son. Lives under the [Last Name (un) 88305] bridge, [Street Address(1) ] Inn helps with blankets and food. Works as a bike courier fulltime. No close friends, few acquaintances, never a long term relationship (dates but women are not intereseted [2-9] alcoholism Family History: Father - ETOH Physical Exam: PHYSICAL EXAMINATION upon admission: [8-14] HR: 84 BP: 120/P Resp: 18 O(2)Sat: 92 Low Constitutional: GCS 14 HEENT: 2 cm lac L eyebrow, small lac within L eyebrow, L cheek swelling with ecchymosis, midface stable, Extraocular muscles intact, Pupils equal, round and reactive to light Oropharynx within normal limits, no blood in mouth; blood in L nares, No hemotympanum; no c spine tenderness Chest: no crepitus Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, FAST negative for free fluid, Nondistended Pelvic: pelvis stable GU/Flank: obvious deformity L midback with ecchymosis and swelling Extr/Back: 2+ pulses in LE; abrasion LLat calf Neuro: Speech fluent, moving all extremities Pertinent Results: [2185-8-18] 07:15AM BLOOD WBC-10.0 RBC-2.82* Hgb-8.9* Hct-26.0* MCV-92 MCH-31.7 MCHC-34.3 RDW-14.3 Plt Ct-270 [2185-8-17] 09:55AM BLOOD WBC-11.9* RBC-2.89* Hgb-9.2* Hct-26.6* MCV-92 MCH-31.8 MCHC-34.6 RDW-14.4 Plt Ct-235 [2185-8-16] 06:10PM BLOOD WBC-13.4* RBC-3.31* Hgb-10.8* Hct-29.2* MCV-88 MCH-32.5* MCHC-36.9* RDW-14.3 Plt Ct-201 [2185-8-18] 07:15AM BLOOD Plt Ct-270 [2185-8-17] 09:55AM BLOOD Plt Ct-235 [2185-8-15] 01:51AM BLOOD PT-14.8* PTT-27.5 INR(PT)-1.3* [2185-8-14] 03:00PM BLOOD Plt Ct-244 [2185-8-18] 07:15AM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-139 K-3.8 Cl-105 HCO3-27 AnGap-11 [2185-8-17] 09:55AM BLOOD Glucose-130* UreaN-11 Creat-0.5 Na-140 K-3.8 Cl-107 HCO3-26 AnGap-11 [2185-8-16] 06:55AM BLOOD Glucose-135* UreaN-7 Creat-0.7 Na-140 K-3.8 Cl-105 HCO3-27 AnGap-12 [2185-8-15] 01:51AM BLOOD ALT-24 AST-67* LD(LDH)-282* AlkPhos-36* TotBili-0.4 [2185-8-18] 07:15AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.0 [2185-8-17] 09:55AM BLOOD Calcium-7.4* Phos-2.4* Mg-1.9 [2185-8-15] 02:04AM BLOOD Type-ART pO2-118* pCO2-44 pH-7.39 calTCO2-28 Base XS-1 [2185-8-14] 10:10PM BLOOD Type-ART pO2-127* pCO2-41 pH-7.37 calTCO2-25 Base XS--1 [2185-8-14] 01:28PM BLOOD Hgb-11.8* calcHCT-35 [2185-8-14] 10:10PM BLOOD freeCa-1.08* [2185-8-14] 03:10PM BLOOD freeCa-1.25 [2185-8-14] chest x-ray: IMPRESSION: 1. Volume loss and diffuse opacities of the right lung. 2. Rigth sided posterior rib fractures. 3. Chronic left clavicle fracture. [2185-8-14]: head cat scan : IMPRESSION: 1. Volume loss and diffuse opacities of the right lung. 2. Rigth sided posterior rib fractures. 3. Chronic left clavicle fracture. [2185-8-14]: cat scan of abdomen and chest: IMPRESSION: 1. Chance fracture at T11 with posterior translation of T11 on T10 and locked facets at this level. High concern for spinal cord transection. Multiple additional fractures as described. 2. Right lung contusions. 3. High attenuation in the lumen of a RLQ small bowel loop is of higher attenuation than the aorta and may related to ingested material. Intraluminal hemorrhage secondary to small bowel injury would be less likely, but please clinically [Last Name (un) 41269] [2185-8-14]: cat scan of sinus and mandible: IMPRESSION: 1. Fracture of the medial left orbital wall with herniation of intraorbital fat into the ethmoid, but no evidence of medial rectus herniation. Entrapment cannot be excluded by imaging. 2. Extensive left facial hematoma and laceration. Limited evaluation of other left facial bones due to positioning; no definite additional fractures seen. 3. Fluid in the right mastoid tip air cells. [2185-8-14]: cat scan of the c-spine: IMPRESSION: 1. Spinous process fractures of C2, C3, C4, C5 and C7. Likely disruption of the C2-3 interspinous ligament. 2. Prevertebral edema from C1 through C4, which may be better assessed by MRI, if clinically indicated. While this not mentioned in the wet [Location (un) 1131], the consult note in the online medical record by orthopedic surgeon Dr. [First Name (STitle) ] indicates that Dr. [First Name (STitle) ] is aware of this finding. [2185-8-14]: cat scan of the lumbar spine: Multiple lateral views show screws at the T12 and L1 body levels. A single image shows a posterior rod in place extending superiorly from the L1 body level with the superior margin not included. [2185-8-14]: MR of lumbar spine: IMPRESSION: 1. Following laminectomy and instrumented fusion from T7 to L1, there is good dorsal alignment of the vertebral column. 2. Evidence of epidural collection/hematoma/post op seroma extending from T5 to T12 with moderate mass effect on the spinal cord. 3. Extensive ligamentous injury at the cervical spine with prevertebral hematoma and diffuse hemorrhage in the posterior paravertebral soft tissues. Small anterior epidural hematoma at levels C3 through C7 without relevant mass effect on the spinal cord. 4. No MR evidence of osseous fractures in addition to those identified by initial post trauma CT studies. [2185-8-14]: MR of thoracic spine: IMPRESSION: 1. Following laminectomy and instrumented fusion from T7 to L1, there is good dorsal alignment of the vertebral column. 2. Evidence of epidural collection/hematoma/post op seroma extending from T5 to T12 with moderate mass effect on the spinal cord. 3. Extensive ligamentous injury at the cervical spine with prevertebral hematoma and diffuse hemorrhage in the posterior paravertebral soft tissues. Small anterior epidural hematoma at levels C3 through C7 without relevant mass effect on the spinal cord. 4. No MR evidence of osseous fractures in addition to those identified by initial post trauma CT studies. [2185-8-14]: MR of cervical spine: IMPRESSION: 1. Following laminectomy and instrumented fusion from T7 to L1, there is good dorsal alignment of the vertebral column. 2. Evidence of epidural collection/hematoma/post op seroma extending from T5 to T12 with moderate mass effect on the spinal cord. 3. Extensive ligamentous injury at the cervical spine with prevertebral hematoma and diffuse hemorrhage in the posterior paravertebral soft tissues. Small anterior epidural hematoma at levels C3 through C7 without relevant mass effect on the spinal cord. 4. No MR evidence of osseous fractures in addition to those identified by initial post trauma CT studies. Scoliosis series ( rad. [Location (un) 1131]) good alignment ,hardware appropriate, mild degenerative changes L5, L5-S1 Brief Hospital Course: 43 year old gentleman admitted to the acute care service after being found under a bridge partially submerged in water. Upon admission, he was made NPO, given intravenous fluids, and underwent radiographic imaging. He sustained multiple facial lacerations which were sutured. He was also found to have bilateral rib fractures, as well as cervical and thoracic spine injuries. He was admitted to the trauma sicu for monitoring. Because of the extent of his cervical and thoracic injuries, he was evaluated by ortho-spine. He was taken to the operating room on HOD #1 where he underwent a T7-L1 laminectomy and fusion. His operative course was notable for a siginficant blood loss of 1 liter. In addition to this, he required packed red blood cells to correct his blood loss. He was transported to the intensive care unit after the surgery still intubated and sedated on propofol. He was evaluated by Plastic surgery and was found on imaging to have a left orbital wall fracture. For this injury, he was placed on sinus precautions and no further intervention. The Neurology service was consulted regarding resuming his anti-seizure medication. His depakote was re-started per their recommendations. He has not had any seizure activity during his hospitalization. His post-operative course has been stable. He was fitted for a cervical-TLSO brace and has used this when out of bed. He is tolerating a regular diet and voiding without difficulty. His vital signs are stable and he is afebrile. He has been evaluated by physical and occupational therapy and recommendations made for discharge to a rehabilition facility. He has been evaulated by psychiatry because of the nature of his injury and his history of poly-substance abuse to ascertain if this injury is self-inflicted. It was thought that this injury did not represent a suicide attempt. He is preparing for discharge with recommended follow-up with Dr. [First Name (STitle) ], seizure specialist, opthamology, and ortho-spine. Medications on Admission: [Last Name (un) 1724]: celexa, depakote, neurontin Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [1-9] Drops Ophthalmic PRN (as needed) as needed for dryness. 4. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day): to facial lacerations. 5. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day): start [8-19]...give [Hospital1 ] dosing only [8-19]. 9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day): start on [8-20] . 10. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO Q3H (every 3 hours) as needed for pain: hold for increased sedation, resp. rate <12. 11. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 12. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day: pt has not resumed related to causing him increased sedation. Discharge Disposition: Extended Care Facility: [Hospital 671] [Hospital 4094] Hospital - [Location (un) 86] Discharge Diagnosis: Injuries: L [10-18] post rib fx R [5-16] post rib fx R lung contusions L medial orbital wall fx T11 chance fx with post disloc on T10 C2-5,C7,T8-10 spinous process fx C2-C3 intraspin lig tear C1-C4 edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane ( requires brace when out of bed) Discharge Instructions: You were admitted to the hospital after your were found in the water after falling off a bridge. It was thougth that you may have had a seizure. You sustained injuries to your ribs and back. You underwent a spinal fusion to stalize your back. You have a received a brace for getting out of bed. You are now preparing for discharge to a rehabilitation facility where you can regain further strenth and mobility. You must wear your cervical collar at all times and the TLSO brace with the collar when you are out of bed. Because of your orbital wall fracture, you will need to maintain sinus precautions. Followup Instructions: Please follow up with acute care service in 2 weeks. You can schedule your appointment upon discharge. The telephone number is # [Telephone/Fax (1) 600] Please follow up with Dr. [Last Name (STitle) 4033] in 2 weeks. You can schedule your appointment when you are discharged. The telephone number is # [Telephone/Fax (1) 3573]. You should also follow up with the epilepsy specialist. The telephone number to schedule your appointment is #[Telephone/Fax (1) 2574]. Please follow up with the cognitive neurologist, Dr. [First Name (STitle) ] in [1-9] weeks. The telephone number is # [Telephone/Fax (1) 6335] You will also need to follow up with the Opthalmologist in [2-10] weeks. The telephone number is #[Telephone/Fax (1) 253] Completed by:[2185-8-19]	[ "2851" ]
Admission Date: [2195-8-15] Discharge Date: [2195-9-4] Date of Birth: [2120-12-18] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2777] Chief Complaint: Cold, painful right foot Major Surgical or Invasive Procedure: [2195-8-17] Abdominal aortogram, right lower extremity arteriogram, percutaneous balloon angioplasty of the distal posterior tibial, infusion for thrombolysis, AngioJet mechanical thrombectomy. Ultrasound imaging for access. [2195-8-21] 1. Right superficial femoral artery to dorsalis pedis bypass graft with non reversed saphenous vein, venous angioscopy with valve lysis, venovenostomy. 2. Re-exploration, graft thrombectomy and patch angioplasty of the distal anastomosis with completion arteriogram. [2195-8-22] Thrombectomy of right superficial femoral artery/dorsalis pedis bypass with intraoperative right lower extremity arteriogram. [2195-9-1] Right below-the-knee amputation. History of Present Illness: 74 y/o gentleman p/w cold, numb, painful right foot. He has difficulty walking due to pain. He was recently admitted to [Hospital1 18], [2195-8-6] with CVA and was sent home on Coumadin. He has a baseline left sided weakness after the stroke. He experienced increased left sided weakness in the last week and was seen in ED 1 day prior to admission. Exam was unchanged from discharge at that time, and CT head was negative for acute stroke. Cath team saw him in ED for questionable ST changes, but felt that no intervention was necessary. His cardiac markers were negative. Patient denies chest pain, shortness of breath, abdominal pain, nausea, vomiting, fever, chills, cough, or cold. No change in bowel movements. He denies any recent headache or dizziness. No recent change in vision, hearing. Foley was placed during last admission after patient experienced urinary detention. It was a difficult placement which required Urology assistance. Past Medical History: PMH: - Patient had CVA on [2195-8-6] and was on heparin drip until coumadin became therapeutic. He was discharged on coumadin. ?seizure - Mediastinal lymphadenopathy confirmed to be metastatic adenocarcinoma by biopsy, unclear primary. Planning to see Dr. [Last Name (STitle) ], [Hospital1 18] Thoracics. - Prostate cancer status post XRT in the [2178] - Hypertension - Cholecystitis s/p cholecystectomy - Colon polyps - Varicose veins - Gallstones - h/o kidney stones - chronic back pain PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 21136] [Telephone/Fax (1) 25441] Social History: Fifty-pack-year smoker, now quit. Police officer for 31 years. Transferred to nursing home after the CVA. Denies alcohol or exposure history. Family History: Mother had lymphoma problems. Father had prostate cancer. Brother had cancer of some kind and diabetes, and a sister had end-stage renal disease and diabetes. Sister [Name (NI) 1022] involved in recent care. Physical Exam: T 98.4 BP 162/80 P 58 100% O2sat in 2-5L/min NC Gen: Alert and oriented x 3, NAD HEENT: PEERL, left facial droop Lungs: CTAB Heart: S1S2 RRR Abd: BS present, soft NTND Ext: LLE - warm to touch, no tenderness, DP barely palpable, PT 2+, Capillary refill 2 sec RLE - cold and tender to touch from toes upto ankle, DP nonpalpable, PT nonpalpable, capillary refill 7 sec Neuro exam: Stregth [5-16] RUE, 4+/5 in LUE, relexes [2-15] bilat Pertinent Results: On Admission: [2195-8-14] 02:40PM BLOOD WBC-10.9 RBC-3.88* Hgb-10.9* Hct-34.0* MCV-88 MCH-28.0 MCHC-31.9 RDW-15.3 Plt Ct-219 [2195-8-14] 02:40PM BLOOD Neuts-76.6* Lymphs-15.8* Monos-5.4 Eos-1.8 Baso-0.5 [2195-8-14] 02:40PM BLOOD PT-26.8* PTT-35.9* INR(PT)-2.7* [2195-8-14] 02:40PM BLOOD Glucose-97 UreaN-22* Creat-1.5* Na-136 K-6.1* Cl-101 HCO3-23 AnGap-18 [2195-8-14] 02:40PM BLOOD CK(CPK)-88 [2195-8-14] 02:40PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2195-8-14] 02:40PM BLOOD Calcium-9.3 Phos-4.7* Mg-2.6 [2195-8-14] 03:35PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.005 [2195-8-14] 03:35PM URINE Blood-LG Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [2195-8-14] 03:35PM URINE RBC-[3-16]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 [2195-8-14] URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA} On Discharge: [2195-9-2] 05:40AM BLOOD WBC-15.5* RBC-3.40* Hgb-9.6* Hct-28.6* MCV-84 MCH-28.3 MCHC-33.7 RDW-19.4* Plt Ct-559* [2195-9-4] 06:05AM BLOOD PT-14.6* PTT-32.0 INR(PT)-1.3* [2195-9-2] 05:40AM BLOOD Glucose-112* UreaN-9 Creat-0.6 Na-136 K-4.5 Cl-99 HCO3-27 AnGap-15 [2195-9-2] 05:40AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1 Brief Hospital Course: 74M with recent CVA ([2195-8-6]), metastatic adenocarcinoma with unknown primary, and HTN admitted to Medicine on [2195-8-14] with cold, numb, painful right foot. . VASCULAR: Vascular Surgery was consulted on [2195-8-15]. It was felt to be chronic in nature, so Coumadin was held and a heparin drip started. On [2195-8-17], he underwent abdominal aortogram, right lower extremity arteriogram, percutaneous balloon angioplasty of the distal posterior tibial, infusion for thrombolysis, AngioJet mechanical thrombectomy, R SFA stent. Please see angiographic findings on operative report. The angioplasty failed, and he underwent fight superficial femoral artery to dorsalis pedis bypass graft with non reversed saphenous vein, venous angioscopy with valve lysis, venovenostomy on [2195-8-21]. He lost his graft pulse and pedal signal during transfer to the stretcher post-operatively; he then underwent immediate re-exploration, graft thrombectomy and patch angioplasty of the distal anastomosis with completion arteriogram. Five hours after the procedure, he lost his DP pulse and Doppler signals. He was taken back to the OR on [2195-8-22] for thrombectomy of right superficial femoral artery/dorsalis pedis bypass with intraoperative right lower extremity arteriogram. This also ultimately occluded despite heparin gtt. The patient was to be sent to rehab while his leg demarcated, but began to experience severe pain, so the decision was made to keep him in house while he demarcated. The heparin gtt was continued due to concerns about CVA. On [2195-9-1], patient underwent right below-the-knee amputation. His post-operative course was uncomplicated. Vanco, Cipro, and Flagyl was started. Anticoagulation was d/c'd to avoid hematoma formation on the stump. It was restarted on [2195-9-3] for CVA prophylaxis. On [2195-9-4], he was deemed stable for discharge to rehab on PO Augmentin. He was tolerating regular diet, his pain was well-controlled on PO Percocet, and he was able to get out of bed to chair. He is to follow up with Dr. [Last Name (STitle) ] in 1 month. . UROLOGICAL: Cipro was started for a urine culture positive for Pseudomonas on admission. Patient had a history of prostate cancer s/p XRT in the 90s. In his previous admission, he had developed urine retention, requiring Foley placement on [2195-8-10] by Urology. He failed a voiding trial on [2195-8-19]. A Foley was placed with some bleeding noticed. Urology was consulted, and placed a Coudee on [2195-8-26]. It was left in for the remainder of his hospital stay. He is to follow up with Dr. [Last Name (STitle) 25443] at [Hospital1 112] after discharge. . CARDIAC: Patient had an abnormal EKG on admission, but was asymptomatic. Cardiac enzymes were negative. Cath team signed off in the ED. . NEUROLOGIC: Neurology was consulted and followed the patient throughout his hospital course for his anticoagulation/CVA prophylaxis. He will follow-up with Neuro as an outpatient. Medications on Admission: Protonix 40 mg daily Zetia 10 mg daily Coumadin 5 mg daily Lisinopril 10 mg daily HCTZ 12.5 mg daily Avodart 0.5 mg daily Flomax 0.4 mg qHS Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily (). 16. insulin sliding scale Insulin SC Sliding Scale Fingersticks qAC & qHS Glucose Regular Insulin Dose 0-50 mg/dL 4 oz. Juice 51-150 mg/dL 0 Units 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. 17. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Peripheral vascular disease, ischemic R lower extremity s/p R below-the-knee amputation Discharge Condition: good Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL / ABOVE KNEE OR BELOW KNEE AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your amputation you are non weight bearing for 4-6 weeks. You should keep this amputation site elevated when ever possible. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. Do not drive a car unless cleared by your Surgeon No heavy lifting greater than 20 pounds for the next 14 days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. WOUND CARE: Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid pressure to your amputation site. No strenuous activity for 6 weeks after surgery. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with 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: Primary Care: Provider: [First Name8 (NamePattern2) 569] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) ] Date/Time:[2195-10-6] 11:00 Neurology: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2195-9-17] 1:30 Thoracic Oncology: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[0-0-] Date/Time:[2195-9-17] 10:30 Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 3150] Phone:[Telephone/Fax (1) 22] Date/Time:[2195-9-17] 10:30 Urology: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) 25444] Date/Time: [2195-10-6] 02:00 Vascular Surgery: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) 2625] Date/Time: [2195-10-8] 09:15 Completed by:[2195-9-4]	[ "5990", "4019", "V5861" ]
Admission Date: [2152-4-13] Discharge Date: [2152-4-17] Date of Birth: [2105-9-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2160] Chief Complaint: Chest pain, dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 46 M with history of ETOH abuse, asthma, reports chest pain and dyspnea, brought into ED by EMS, intoxicated with ETOH level of 162. Complains of chest pain for several days, sometimes it's hard to breathe, no nausea, no diaphoresis. Denies other substance abuse, drinks a pint of vodka a day. He is homeless and lives in shelters. He states he had chest pains three years ago worked up in hospital. He denies ETOH withdrawal and had his last pint of vodka yesterday. In the ED, his vitals were 140/70, 130s, mildly tremulous, no hallucinations, was suspected to be due to ETOH withdrawal. He was given valium 5, valium 5, then ativan 2, with little change in his vitals. Spiked a fever 100.1. CXR showed pna with retrocardiac opacity, so ceftriaxone and azithromycin were started. AST and ALT were elevated and consistent with alcoholism. CT abd was done, but CT torso had been anticipated. Was going to do LP in ED but had not sent coags. EKG shows STD in V4-V6, RBBB, narrow QRS, no baseline. Past Medical History: ETOH abuse Asthma Social History: Drinks 1 pint of vodka per day. Denies other substance abuse. Divorced with 3 children who work in Ethiopian restaurants in [Location (un) 86]. Family History: Noncontributory. Physical Exam: VS: 100.0 / 124/82 / 109 / 22 / 100% RA GEN: Alert and oriented, difficult historian, Ethiopian accent HEENT: Soft, yellowing dentition but intact, OP clear LUNGS: Diffuse rhonchi, prolonged expiratory wheezing CHEST: Mild tenderness to costochondral palpation HEART: RRR, no m/r/g ABD: Soft, thin, +BS, ND NT EXTR: NO c/c/e NEURO: Gait not tested, [4-15] motor SKIN: No rashes Pertinent Results: 140 97 12 -------------< 68 3.4 20 0.6 Trop-T: <0.01 CK: 132 MB: 4 Serum EtOH 162 Serum ASA, Acetmnphn, [Last Name (LF) 2238], [First Name3 (LF) ], Tricyc Negative 87 5.6 > 11.3 < 100 35.2 N:91.6 L:5.6 M:2.8 E:0.1 Bas:0 Hypochr: 2+ Anisocy: 2+ Microcy: 1+ EKG: NSR 115, Q waves in I, L, V4-V5, STE 1mm in L, RBBB morphology Head CT: Unremarkable head CT with no evidence of intracranial hemorrhage. CXR: Mild pulmonary vasculature congestion without overt edema, and no evidence for pneumonia. Brief Hospital Course: 46 M with history of ETOH abuse, here with ETOH withdrawal, possible pneumonia, and chest pain. . # ETOH withdrawal: He reports drinking 1 pint of vodka daily and his last drink was the day prior to admission. He was put on a CIWA scale for alcohol withdrawal and was monitored in the ICU for a day before he was called out to the regular Medicine service. His LFTs and pancreatic enzymes were elevated on admission and consisted with alcohol hepatitis. This normalized over this hospital course and patiet was not requiring any benzodiazepenes on day of discharge. This was likely the source of his chest pain. . # ETOH abuse: He was given multivitamin, thiamine and folate. Social work was consulted to discuss his homeless situation and his alcoholism. . # Chest pain: He was ruled out by three sets of cardiac enzymes. His EKG showed RBBB but there was no old EKG for comparison. He chest pain could be from costochondritis since he was tender to the chest wall. He was given NSAIDs and this resolved over his hospital course. He was monitored on telemetry without events. . # Possible retrocardiac opacity on CXR: Given his low grade fever and cough, he was treated with levoquin x 7 days. He defervesced and remained stable. . # h/o asthma: Albuterol and atrovent inhalers . # Pancytopenia: Likely from alcohol. . # Question of diabetes: Normal blood glucose, but urine glucose 1000 and ketones 150. He was put on QID fingersticks and regular insulin sliding scale. . . After discussion with the patient and the medical staff, all were in agreement that Mr. [Name14 (STitle) 111538] was a suitable candidate for discharge. Medications on Admission: Inhalers Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 3. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 1 Refills:0 7. Atrovent 0.02 % Solution Sig: One (1) Inhalation every [3-17] hours as needed for shortness of breath or wheezing. Disp:1 1 Refills:0 8. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:30 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Alcohol withdrawal . Secondary Diagnoses: Asthma Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You were admitted for alcohol withdrawal. . 1. Please take all medications as prescribed. 2. Please attempt to make all medical appointments. 3. Please return to the Emergency room if you have any concerning symptoms. Followup Instructions: Please make an appointment with your PCP: [Name10 (NameIs) ] HEALTH GROUP [Telephone/Fax (1) 22331] for follow up. Completed by:[2152-5-6]	[ "486", "49390" ]
Admission Date: [2136-12-19] Discharge Date: [2136-12-23] Date of Birth: [2058-12-17] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1185] Chief Complaint: Confusion, lethargy and hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 78F h/o Atrial fibrillation (not on coumadin), dementia, and DM2 sent in from rehab for altered MS today. She is demented at baseline, AAOx person and place and able to report immediate medical complaints. She is a poor historian and oriented only to self. She is stating only that she does not feel well. Denies specific complaints when asked, including chest pain, SOB, cough, abdominal pain, N/V, diarrhea, and dysuria. Did not answer question about sick contacts. Daughter thinks she may not have been eating quite as well as usual, but otherwise has been in her usual state of health without any complaints. . In the ED, initial vitals 97.8, 91, 100/60, 16, 98% RA. Labs significant for glucose 1053, Hct 54, AG 25, Creatinine 1.7, lactate 8.1, K 4.0, Na 141, trop <0.01. U/A positive for 9 WBC, few bacteria, 1000 glucose, neg nitrite, 3 epi. CXR obtained which showed "Subtle streaky opacity at the right lung base." Pt given levofloxacin 750mg x 1. Got 10 units IV insulin in ED, then started on drip at 7 units per hour. Fingerstick still elevated; got another 10 units insulin and drip increased to 10 units per hour. Got 2 liters of fluid and 40 mEq potassium chloride. Lactate 7.4 on recheck. VS at time of transfer 97.7, 90, 16, 140/61, 99% RA. . On arrival to the MICU, VS 96.7, 108/57, 97, 19, 97% RA. She states she doesn't feel well but unable to specify how or why. AAO x person only. . Review of systems: Per HPI Past Medical History: Atrial fibrillation, not on coumadin Diabetes Mellitus type 2 History of noncompliance with medical therapy dementia Social History: Lives at rehab ([Hospital3 1186]). Denies smoking, ETOH, or illicit drugs Family History: NC Physical Exam: Upon Admission Vitals: T:96.7 BP:108/57 P:97 R:19 O2:96% RA General: AAOx person, not place or time. appears uncomfortable, but in NAD HEENT: Sclera anicteric, MM dry, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, obese, bowel sounds present, appears uncomfortable to palpation but denies pain Ext: warm, well perfused, 2+ pulses, blue-tinged feet with dilated superficial veins/spider veins Discharge: No change Pertinent Results: On Admission: [2136-12-19] 02:00PM BLOOD WBC-8.6# RBC-5.38# Hgb-15.5# Hct-54.0# MCV-100# MCH-28.8 MCHC-28.7* RDW-14.0 Plt Ct-223 [2136-12-19] 02:00PM BLOOD Neuts-79.6* Lymphs-14.4* Monos-5.5 Eos-0.2 Baso-0.2 [2136-12-19] 02:00PM BLOOD Plt Ct-223 [2136-12-19] 07:03PM BLOOD PT-11.0 PTT-32.5 INR(PT)-1.0 [2136-12-19] 02:00PM BLOOD Glucose-1053* UreaN-51* Creat-1.7* Na-137 K-4.1 Cl-94* HCO3-18* AnGap-29* [2136-12-19] 02:00PM BLOOD cTropnT-<0.01 [2136-12-19] 02:00PM BLOOD Calcium-9.9 Phos-5.3# Mg-2.3 [2136-12-19] 07:22PM BLOOD Type-[Last Name (un) ] Temp-36.0 pO2-48 pCO2-55* pH-7.27* calTCO2-26 Base XS--2 Intubat-NOT INTUBA [2136-12-19] 02:06PM BLOOD Glucose-GREATER TH Lactate-8.1* Na-141 K-4.0 Cl-97 [2136-12-19] 07:22PM BLOOD freeCa-1.18 Pertinent Results: [2136-12-19] 02:20PM URINE RBC-2 WBC-9* Bacteri-FEW Yeast-NONE Epi-3 [2136-12-19] 02:20PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2136-12-23] 07:00AM BLOOD WBC-7.0# RBC-4.07* Hgb-12.2 Hct-37.5 MCV-92 MCH-29.9 MCHC-32.5 RDW-13.8 Plt Ct-140* [2136-12-23] 07:00AM BLOOD Plt Ct-140* [2136-12-19] 02:00PM BLOOD Neuts-79.6* Lymphs-14.4* Monos-5.5 Eos-0.2 Baso-0.2 [2136-12-23] 07:00AM BLOOD Glucose-63* UreaN-19 Creat-0.8 Na-140 K-4.3 Cl-112* HCO3-25 AnGap-7* [2136-12-20] 08:57AM BLOOD CK(CPK)-250* [2136-12-20] 08:57AM BLOOD CK-MB-10 MB Indx-4.0 cTropnT-<0.01 [2136-12-23] 07:00AM BLOOD Calcium-8.5 Phos-2.2* Mg-1.8 [2136-12-20] 09:07AM BLOOD %HbA1c-12.9* eAG-324* Brief Hospital Course: Ms. [Known lastname 1187] is a 78 year old woman with a PMHx of afib (not on coumadin), DM2, and dementia admitted for HHS with glucose to 1053. # HHS: Glucose elevated to 1053 on admission with anion gap 25, hemoconcentrated to Hct 54. Glucose on u/a but no ketones. Although this picture could also be consistent with b-hydroxybutyrate ketoacidosis, the high glucose and type II diabetes history makes HHS more likely. AG could also be secondary lactate elevation from poor perfusion in the setting of volume depletion. AG resolved within 12 hours of IVF. The underlying trigger of her HHS is uncertain. Urinalysis demonstrates 9 WBC and few bacteria (along with 3 epidermal cells). Streaky RLL ifiltrate on CXR was thought unlikely to be pneumonia. Ischemic cardiac event was ruled out with troponins x 4. Considering that she was reported as poorly complaint at her ECF with medications, and refused several medications each day while in the MICU, she likely had an aspect of medical noncompliance either contributing or even causing her HHS. Her non-compliance and/or inadequacy of home diabetes therapy is further bolstered by her A1C of 12. She was started on insulin drip, received 7 L of IV fluids, and then was transitioned to a SQ insulin regimen [First Name8 (NamePattern2) ] [Last Name (un) ] recommendations which included a QACHS insulin sliding scale with humolog and QHS lantus. We held her oral diabetes medication while inpatient. On transfer to the floor from the MICU the patient was stable and her blood sugar was being controlled with SQ insulin regimen. . # UTI: Admission urinalysis concerning for possible UTI, but culture more likely contamination. Pt asyptomatic. Received 3-day course of levofloxacin. Urinalysis demonstrated 9 WBC and few bacteria (along with 3 epidermal cells). Urine culture with 10-100K gram positive cocci concerning for lactobacillus vs. group a strep. [12-24] sets of blood cultures were positive for coag negative staph which was thought to be a contaminant. Ms. [Known lastname 1187] was treated for her UTI with 3 days of levofloxacin. . # HLD: Simvastatin was continued while Ms. [Known lastname 1187] was in house. . # HTN: Atenolol was continued while Ms. [Known lastname 1187] was in house. Lisinopril and furosemide were held as patient initially demonstrated pre-renal azotemia with initial creatinine to 1.3 which responded to 0.9 with IVF. . # afib: Ms. [Known lastname 1187] was rate controlled while in house with atenolol. Aspirin was started. . Transitional issues: 1. Diabetes. Reportedly poor medication compliance at ECF (patient sometimes hides pills). [Last Name (un) ] consulted and started on insulin per med list. Please have sugars followed closely. Thus her Metformin and glypizide were stopped. 2. Her lisinopril and furosemide were stopped in the setting of her acute illness. Please start these as you see fit if her blood pressures become elevated as her systolic blood pressure have been in the 110's prior to discharge here and thus we didn't start them. 3. A second round of blood cultures are pending on discharge given coag pos staph in blood culture on admission. Medications on Admission: multivitamin daily omeprazole 20mg [Hospital1 ] metformin 1000mg [Hospital1 ] ferrous sulfate 325mg [Hospital1 ] lisinopril 10mg TID simvastatin 10mg qHS glipizide 2.5mg daily atenolol 100mg qAM citalopram HBr 20mg daily furosemide 80mg po daily acetaminophen 650mg q4h prn pain bisacodyl 10mg supp daily prn constipation milk of magnesia 30mL po daily prn constip fleet enema daily prn constip Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28) units Subcutaneous at bedtime. 12. Humalog 100 unit/mL Solution Sig: as per sliding scale Subcutaneous qAC qHS. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] - [Location (un) 538] Discharge Diagnosis: PRIMARY DIAGNOSES: - Hyperosmolar Hyperglycemic State - Diabetes Mellitus 2 SECONDARY DIAGNOSES: - Dementia - Poor adherence to medical therapy 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: Ms.[Known lastname 1187], It was a pleasure to participate in your care at [Hospital1 18]. You came to the hospital because your blood sugar was extremely high, which caused you to be confused. You were admitted to the Intensive Care Unit where you were started on intravenous insulin to control your blood sugar. While you were here, the diabetes experts evaluated you and it was decided to start you on insulin which is felt to be critical for your health that you take it. MEDICATION CHANGES: - Medications ADDED: Insulin Sliding scale w/ humalog and Long-acting insulin Lantus, Aspirin - Medications STOPPED: metformin 1000mg [Hospital1 ], glipizide 2.5mg daily, furosemide 80mg po daily, lisinopril - Medications CHANGED: None Followup Instructions: You should follow up with your primary care doctor in [12-24] weeks. [Name6 (MD) ] [Name8 (MD) ] MD [Doctor Last Name 1189]	[ "486", "5849", "42731", "2720" ]
Admission Date: [2138-10-31] Discharge Date: [2138-11-7] Date of Birth: [2078-11-12] Sex: M Service: [Last Name (un) ] The patient is a 59-year-old male with end-stage renal disease, atrophic right kidney, left nephrectomy for malignancy, status post cadaveric renal transplant [2138-3-14]. Received a kidney from extended donor 80 year-old kidney. DGF initially on hemodialysis presented on admission with mental status changes with poor compliance with medication. While at home the patient was ambulating and defecating in the refrigerator. The patient attempted assault on emergency room staff while the patient was in the emergency room on [2138-10-31]. The patient has been taking medications for the past 10 days according to girlfriend but prior to that was not compliant for one week. No reported fevers. PAST MEDICAL HISTORY: Atrophic right kidney, left nephrectomy for malignancy, cadaveric renal transplant [2138-2-15]. Deafness secondary to auto toxicity. Noncompliant, difficult patient. ALLERGIES: Heparin, beef. MEDICATIONS: 1. Rapamune 7 mg once daily 2. CellCept [Pager number ] mg once daily 3. Iron 4. Multivitamin 5. Protonix SOCIAL HISTORY: Lives with girlfriend, positive marijuana use, positive tobacco, history of intravenous drug abuse. PHYSICAL EXAMINATION: Temperature 96.9, 87, 122/56, respirations 16, 100% on room air. The patient was asleep when resident from transplant saw patient. Lungs clear to auscultation bilaterally. CV: Regular rate and rhythm. Abdomen: Soft, nontender, nondistended. The patient does have a left AV thrill, no extremity edema. The extremities are well perfused, range of motion appears to be intact. Pulses are palpable at the dorsalis pedis and to a lesser extent PT level on both sides. There is no popliteal aneurysm. Femoral's are fully palpable and bounding. LABORATORY FINDINGS: White blood cell of 2.8, crit of 19.2, platelets 151, sodium 142, 4.3, 112, 10, BUN and creatinine 126 and 8.4. Glucose 144. Tox screen demonstrated ethanol was unremarkable. Tox screen was negative. The patient had a gas arterial blood gas which demonstrated a pH of 7.20, pO2 182, pCO2 25, bicarbonate 10. The patient was not intubated at that time. Rabomycin level on [2138-10-31] was 18.8. The patient was admitted to the SICU under transplant service. The patient had hemodialysis on [2138-10-31] later that afternoon renal service was consulted. Social work followed the patient while the patient was in the hospital. The patient remained afebrile, vital signs stable. The patient was on a bicarbonate drip, continued on Rabomycin MMF. The patient was transferred from intensive care unit to regular floor, continue with hemodialysis while patient was in in-house. The patient had intermittent acute anger episode while in house and on [2138-11-4] the patient was very upset and abusive to nursing staff when he realized that clothes and shoes were missing. Social Work continued to meet with patient. Psychiatry met with patient on [2138-11-4] who made threats towards his present girlfriend saying "I am going to kill her." The patient did get an ultrasound while he was an inpatient demonstrating interval increased amount of hydronephrosis of the left kidney with interval increase of resistive index within this kidney, mild increase in the index in the right kidney without hydronephrosis. No perinephric fluid collection. On [2138-11-5] the patient had an acute episode of right visual field loss which was episodic now and then on [2138-11-6] had completely resolved. The patient was unclear to exact duration of visual disturbance, he noted blurry vision and "double vision" on [2138-11-5]. The patient had a workup of his acute visual episodic visual loss which included ophthalmology who met with the patient and felt that it was possible to have retinitis pigmentosus of both eyes, had recommended getting an ultrasound of the carotids, MRI of the head and CT of the head. On [2138-11-6] carotids were performed demonstrating a right non- occlusive thrombus and IJ carotids demonstrated no stenosis otherwise within normal limits. CT of head demonstrated no bleed, no midline shift and the MRI that was performed demonstrated it was a very limited study but there was no evidence of acute infarction. Neurology specifically the stroke team was consulted as well and felt that they definitely would like to have an MRI of the head performed and MRA of the head and carotids, to start aspirin and check a sed rate. Since the patient had moved on [2138-11-6] the patient was scheduled for repeat MRI of the head and neck on [2138-11-7]. On [2138-11-6] the patient had syncopal episode at 10 PM, no head trauma. On [2138-11-7] the patient afebrile, vital signs stable. Normal visual fields, normal finger-to-nose coordination, strengths were [6-19] bilaterally. The patient was awaiting an MRI of the head on [2138-11-7] and then on [2138-11-7] the patient was scheduled for hemodialysis and had refused to go to hemodialysis today, that he was leaving against medical advice. He felt that the hemodialysis personnel did not care about and that they would not dialyze him even though they had stated that they would dialyze him. Dr. [First Name (STitle) ] [Name (STitle) ] discussed early the risks of leaving without having dialysis and he stated that he did understand and did not care. The patient appeared to understand and be competent to make his own decision. Dr. [Last Name (STitle) 49187] notified social services. The patient did sign the against medical advice form. Girlfriend notified transplant team of the patient's decision to leave. The patient's girlfriend did call to let staff know that he arrived safely to his home. Throughout the patient's hospitalization the patient had acute episodes of outbursts of anger and being noncompliant with staff so the patient abruptly left and actually has returned since then onto renal transplant team and is a patient on Far 10. It is uncertain whether or not the patient was discharged on his medications that he was on during his hospitalization but he was supposed to leave on an aspirin EC 81 mg once daily, ferrous sulfate 325 mg once daily, insulin sliding scale, MMF 500 mg twice a day, Protonix 40 mg q 24 hours, ______5 mg q day and Bactrim SS one tablet once daily but again since his abrupt leave against medical advice he is currently on nephrology service receiving hemodialysis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 3432] Dictated By:[Last Name (NamePattern1) 4835] MEDQUIST36 D: [2138-11-7] 20:41:47 T: [2138-11-7] 22:24:04 Job#: [Job Number 49188]	[ "5849", "2762" ]
Admission Date: [2102-12-30] Discharge Date: [2103-1-3] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: s/p Fall Left arm pain Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] yo female who sustained a mechanical fall at home. She was reportedly climbing up a flight of stairs when she fell backwards striking the back of her head. No reported LOC. She was taken to an area hospital where it was noted on CT imaging that there was a parafalcine subdural hematoma with tracking to the right temtorium. She was subsequently transferred to [Hospital1 18] for continued care. Past Medical History: HTN Diabetes Osteoarthritis Social History: Resides with her sister. Daughter is HCP [First Name5 (NamePattern1) 2048] [Name (NI) 70429]) DNR/DNI Family History: Noncontributory Pertinent Results: [2102-12-30] 04:00PM PHENYTOIN-14.8 [2102-12-30] 02:45PM HCT-32.1* [2102-12-30] 05:53AM GLUCOSE-211* UREA N-12 CREAT-0.7 SODIUM-135 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13 [2102-12-30] 05:53AM WBC-9.0 RBC-3.82* HGB-12.2 HCT-36.0 MCV-94 MCH-31.9 MCHC-33.9 RDW-13.1 [2102-12-30] 05:53AM PLT COUNT-179 [2102-12-30] 05:53AM PT-11.7 PTT-25.3 INR(PT)-1.0 [2102-12-30] 12:59AM FIBRINOGE-341 Phenyto [2103-1-2] 06:40AM 19.7 CT HEAD W/O CONTRAST Reason: F/U SDH. [Hospital 93] MEDICAL CONDITION: [Age over 90 ] year old woman s/p fall down stairs REASON FOR THIS EXAMINATION: follow SDH - please do approximately midnight tonight CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Subdural hematoma. COMPARISON: [2102-12-30]. FINDINGS: Again seen is a parafalcine subdural hematoma slightly decreased in extent compared to the prior examination. High density blood overlying the right tentorium is less evident on the current examination. No new areas of hemorrhage are identified. There is no mass effect, shift of the normally midline structures, or hydrocephalus. Please see the earlier reports for further description of the right maxillary findings. IMPRESSION: 1. Slight interval decrease in size of parafalcine subdural hematoma. CHEST (PORTABLE AP) Reason: eval for traumatic injury [Hospital 93] MEDICAL CONDITION: [Age over 90 ] year old woman with pulmonary contusion & rib fx's s/p 12ft fall down stairs REASON FOR THIS EXAMINATION: eval for traumatic injury INDICATION: [Age over 90 ]-year-old female status post fall. COMPARISONS: None. TECHNIQUE: AP SUPINE CHEST: The heart size is normal. The aorta is calcified and tortuous. Lungs are clear. There are no pleural effusions or pneumothoraces. The pulmonary vasculature is not congested. Acute fractures are seen to the right posterior third and fourth ribs. IMPRESSION: 1. No acute cardiopulmonary process. 2. Acute fractures of the posterior third and fourth right ribs. ECG [2102-12-30] Sinus rhythm. Intraventricular conduction delay. Probable atypical left bundle-branch block. Delayed R wave progression could be due in part, to intraventricular conduction delay but consider also prior anterior myocardial infarction. Diffuse non-specific ST-T wave changes. Clinical correlation is suggested. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 170 122 378/416.42 3 -49 -20 Brief Hospital Course: She was admitted to the Trauma service. Neurosurgery and Orthopedic Surgery were consulted because of her injuries. Her injuries were non operative. She was loaded with Dilantin and maintained on 300 mg tid; her levels were followed, last level on [1-2] was 19.7. There have been no observed or reported seizure activity. Repeat head imaging revealed stable head bleed. She will follow up with Dr. [Last Name (STitle) ], Neurosurgery, in 4 weeks for repeat head CT imaging and will continue with the Dilantin until follow up. Orthopedic surgery recommended non operative intervention; she will need to wear a sling and remain non weight bearing on her left arm. Follow up in 1 week with Dr. [Last Name (STitle) ] for repeat films. She was started on Calcium and Vitamin D for bone prophylaxis. Physical and Occupational therapy were consulted and have recommended short term rehab. Medications on Admission: Lisinopril Atenolol Glipizide Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 4 weeks. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR <60; SBP <110. 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for constipation. 8. Oxycodone 5 mg Tablet Sig: [1-2] - 1 Tablet PO every 4-6 hours as needed for pain. 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three times a day. 11. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a day. 12. Glipizide 5 mg Tablet Sig: [1-2] Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57850] Healthcare Center - [Location (un) ] Discharge Diagnosis: s/p Fall Subdural hematoma Small left pulmonary contusion 2nd left rib fracture Left humerus fracture Discharge Condition: Stable Discharge Instructions: DO NOT bear any weight on your left arm because of your fractures humerus. Continue to wear the sling for comfort. Followup Instructions: Follow up in 1 week with Dr. [Last Name (STitle) ], Orthopedics. Call [Telephone/Fax (1) 1228] for an appointment. Follow up in 4 weeks with Dr. [Last Name (STitle) ], Neurosurgery. Call [Telephone/Fax (1) 1669] for an appointment; inform the office that you will need a repeat head CT scan for this appointment. You may follow up in Trauma Clinic as needed in 4 weeks. Call [Telephone/Fax (1) 6429] for any concerns related to your fall and recent hospitalization. Completed by:[2103-1-3]	[ "4019", "25000" ]
Admission Date: [2105-7-9] Discharge Date: [2105-7-15] Date of Birth: [2046-4-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1491] Chief Complaint: Transfer from OSH for SVT Major Surgical or Invasive Procedure: Diagnostic peritoneal fluid tap ~10cc History of Present Illness: 59 yo M with MMP including cirrhosis of unclear etiology, Hep C, CRF on HD, anemia, hypothyroidism transferred from OSH for SVT. Patient was admitted to OSH on [7-4] with tachycardia admitted to CCU with HR 160, narrow complex, CP [6-22], a/w SOB, O2 sats 88%-->97-98% on 2L NC. Patient converted with Adenosine 6 mg IV x 1, HR decreased to 98-103. Patient then had a second episode of SVT on [7-8], recieved Adenosine 6 mg then 12 mg and converted again. Patient's BP remained 90-100s which is his baseline. Patient then transferred for further management. Upon transfer BP 98/47 HR 95 RR 15 O2 sat 96% 2L. Today patient also spiked a temp to 102.3 treated with gent 80 mg iv x 1, vanco 1 gm x 1 then Ancef x 1. . He reports [2-14] lifetime episodes, each time a/w chest pressure and shortness of breath, which started a few months ago while at a rehab facility. His second episode was at dialysis. Patient denies CP or pressure otherwise. He has shortness of breath a/w COPD and abdominal distension and noticed increased LE edema over the past few months requiring increasing doses of lasix and prompting recent admission on [6-10] to same OSH. . Upon arrival to the CCU, patient was stable with HR in 80-90s. Denies any CP, cough, sob, sputum production, N/V, abdominal pain or other complaints at this time. Past Medical History: - etoh cirrhosis (per OSH) with h/o hepatic encephalopathy - portal hypertension +/- esophageal varices - HCV - CRF - AOCD - +TOB - LE edema - COPD - T3 hypothyroidism - h/o thrombocytopenia - DJD - h/o PNA, bronchitis . Past Surgical Hx: Periumbilical hernia s/p repair [2101]; lumbar laminectomy, shoulder sx, ventral hernia repair Social History: Married, lives with wife and mother-in-law. Used to work as an auto mechanic. Patient strongly denies every drinking heavily, used to have a "couple of beers" and stopped drinking anything after he was dx with liver dz. Unclear how he contracted Hep C. Smokes few cigarettes per day, ppd x 45 yrs, no IVDA. Family History: Etoh abuse, hyperlipidemia, thyroid disease, anemia Physical Exam: VS: 99.7 98/46 89 18 99% RA Ht 6'0" Wt 180 lbs Gen: ill appearing male, NAD HEENT: OP clear and moist, edentulous, slightly icteric, EOMI Neck: supple, no LAD, no JVD Chest: diffusely poor air entry, no BS at bases ~1/3 up CVS: nl S1 S2, RRR, no m/r/g Abd: distended, soft, NT x 4, diffuse echymoses and prominent veins, +ventral hernia ~5x5 cm, ?fluid wave, NABS, unable to appreciate any hepatosplenomegaly Ext: warm bilaterally, symmetric calves, 2+ pulses, decreased sensations b/l in feet, 1+ edema b/l to mid calf. Neuro: CN II-XII grossly intact, no flap, strength full throughout, sensations decreased in b/l LE Pertinent Results: ---OSH labs: [7-8] Na 138 K 3.6 Cl 103 CO2 29 Bun 7 Cr 3.3 Glu 129 ---CBC [7-7] WBC 5.8 Hct 26.6 Plts 36 ---Bl cx x 2 pending . LABS: AT ADMISSION: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2105-7-9] 10:30PM 7.6 3.26* 10.6* 31.1* 96 32.5* 34.1 17.8* 33 Glucose UreaN Creat Na K Cl HCO3 AnGap [2105-7-9] 10:30PM 153* 13 3.4* 136 3.3 99 25 15 . AT DISCHARGE: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2105-7-15] 05:47AM 6.0 2.99* 10.1* 30.1* 101* 33.7* 33.4 20.0* 50 Glucose UreaN Creat Na K Cl HCO3 AnGap [2105-7-15] 05:47AM 106* 15 3.7* 135 4.1 103 26 10 . LFTs: ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2105-7-13] 05:35AM 18 49* 233 158* 0.7 . ASCITES FLUID: WBC RBC Polys Lymphs Monos Mesothe Macroph [2105-7-13] 04:42PM 160* 200* 3* 16* 58* 8* 15* ASCITES CHEMISTRY TotPro Glucose LD(LDH) Albumin [2105-7-13] 04:42PM 1.0 165 61 <1.0 . . CARDIAC: cTropnT [2105-7-12] 08:00AM 0.02 [2105-7-10] 04:56AM 0.02 [2105-7-9] 10:30PM <0.01 . CK(CPK) [2105-7-12] 08:00AM 19 [2105-7-10] 04:56AM 12 [2105-7-9] 10:30PM 12 . HEME: calTIBC Ferritn TRF [2105-7-10] 04:56AM 60* 927* 46* . TSH [2105-7-10] 04:56AM 3.2 . PEP IgG IgA IgM IFE [2105-7-14] 05:25AM MULTIPLE T1 1570 451* 301* NO MONOCLO2 . HBsAg HBsAb HBcAb [2105-7-14] 05:25AM NEGATIVE - - [2105-7-10] 04:56AM - NEGATIVE NEGATIVE . . AUTOANTIBODIESAMA Smooth [2105-7-10] 07:38PM NEGATIVE POSITIVE . [Doctor First Name ] AFP [2105-7-10] 07:38PM NEGATIVE [2105-7-10] 04:56AM 3.71 . MICRO: HEPATITIS C VIRUS RNA BY PCR, QUALITATIVE Test Result HCV RNA, QUAL, PCR NOT DETECTED . IMAGING: [2105-7-10] ABDOMINAL U/S: IMPRESSION: Cirrhotic liver with moderate ascites and patent forward portal venous flow. No hepatic masses on this limited exam. Cholelithiasis with no evidence of cholecystitis. . [2105-7-10] ECHO: Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure (<12mmHg). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . [2105-7-10] ECG: Sinus rhythm. Borderline left axis deviation. Possible left anterior fascicular block. No previous tracing available for comparison . [2105-7-13] CXR PA&LAT: Dialysis catheter remains in place with the distal lower tip within the right atrium, unchanged. There is slight worsening of opacity in the right lower lobe, particularly in the right retrocardiac region, which has an adjacent linear component. This may be due to either atelectasis or pneumonia. Small right pleural effusion is also noted on the lateral view. Brief Hospital Course: A/P: 59 yo M with cirrhosis of unclear etiology (?HepC), CRF on HD, anemia, HepC, hypothyroidism, and SVT controlled with rate control admitted for continued management of renal failure and liver transplant evaluation. . # SVT: Patient was admitted to [Hospital1 18] initially for continued management of SVT. Patient had two episodes of SVT at OSH which both converted with adenosine. Patient was stable with rate control since conversion. He was maintained on Propanolol with good HR control and no further episodes of SVT. His CE did not indicate active ischemia. His ECHO also showed a normal EF, without any wall motion abnormalities. . # CIRRHOSIS: Unclear etiology of patient's liver cirrhosis. Patient transferred here for further evaluation of cirrhosis and management. Formal transplant evaluation was started while patient was admitted. Hepatitis serologies were negative. Patent portal flow noted on abdominal U/S. Pt had diagnositc tap which did not show SBP. Pt was to complete liver transplant w/u as outpatient. His diuretics were not resumed at time of discharge. Pt had several episodes of hypotension requiring several boluses of 250cc NS. His BP remained 90s without any symptoms. He was to follow up with Dr. [Last Name (STitle) 497] in 2 weeks and possibly resume diuretics then. . # FEVER: Patient had a Tmax of 102.3 at the OSH and had one episode of a mild fever with chills and SOB. CXR demonstrated question of right lower lobe infiltrate and patient was started on cefepime and vancomycin to cover hospital-acquired pneumonia. Repeat PA and Lat done which also noted RLL infiltrate. He was switched to levofloxacin and was sent home on Levo to complete 7day course for PNA. He remained on RA with stable O2 sats. . # CRF on HD. Patient's renal failure was though to be secondary to hepatorenal syndrome, although urine Na was 20 on admission. Pt was continued on HD without incident 3x/week. His Cr at time of discharge was 3.7. . # Anemia. Patient was noted to be anemic at OSH with Hct of 26.6. Patient's anemia likely multifactorial in etiology - anemia of chronic disease and question of slow GI bleed given likely portal gastropathy. No hematemesis/melena per patient. Patient was continued on Procrit. He did not require blood transfusions, his iron studies were c/w ACD. . # COPD. Patient was maintained on albuterol and atrovent nebs. His O2 sats were stable on RA. . # Hypothyroidism. Patient was maintained on thyroid replacement per home regimen. . #. CODE: FULL Medications on Admission: - Lasix 80 mg daily - Prilosec 20 mg daily - Cytomel 25 mcg [Hospital1 ] - Dilaudid 4 mg TID - Iron TID - Lactinex 2 tabs po TID - Lactulose 30 cc [Hospital1 ] - Lopressor 25 daily - Magnesium 400 daily - MVI - Procrit 40,000 qwk - KCl 20 daily - Selenium - Soma - Thiamine - Folate . 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. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 5. Liothyronine 25 mcg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Liver Cirrhosis Chronic renal failure on HD Presumed Pneumonia DM SVT Discharge Condition: Stable Discharge Instructions: Please take all your medications as directed and keep all your follow up appointments. . If you have increasing abdominal girth, with incresed weight, shortness of breath, vomiting blood or have bright red blood from below or any other concerning symptoms please call your physician or go to the emergency room. . Followup Instructions: 1. Please follow up with your Primary care physician [Name Initial (PRE) 176] [1-16] weeks. Please call his office for an appointment. . 2. Transplant Hepatolgy: [Name6 (MD) ] [Name8 (MD) ], MD, Phone:[Telephone/Fax (1) 673], [2105-8-10] at 11:00am . 3. Transplant Social Work: [Last Name (LF) ],[First Name3 (LF) 156], [2105-8-10] at 2:00pm. . Completed by:[2105-7-19]	[ "5859", "486", "496", "5990", "42789", "2449", "2859" ]
Admission Date: [2104-7-10] Discharge Date: [2104-7-19] Date of Birth: [2047-12-5] Sex: M Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: Patient is a 36-year-old male with a history of hepatitis C x30 years, hypertension, cardiomyopathy, who presents with two days of bloody painless diarrhea. Patient has a history of diverticuli on recent colonoscopy three weeks ago. He ate at a restaurant yesterday for lunch, had chicken, rice, and beans. He was the only one who ate the meal. One hour later started having abdominal cramping with bloody diarrhea, about two cups of melena, and then bright red blood per rectum. Patient currently denies abdominal pain, fevers, chills, sick contacts, recent travel, antibiotic use. He has never had a history of GI bleeding before. His hepatitis C has been evaluated with liver biopsy recently, which showed no evidence of cirrhosis. He has had no nausea, no vomiting, no chest pain, no shortness of breath. He has a baseline orthopnea. He uses three pillows at night. Patient has no pedal edema. Patient is not lactose intolerant. Has no food allergies. The patient states blood has now decreased and the diarrhea has decreased. PAST MEDICAL HISTORY: Cardiomyopathy. Hypertension. Hepatitis C diagnosed last year not treated. Diverticuli. MEDICATIONS AT HOME: 1. Aspirin 325 mg a day. 2. Hydrochlorothiazide 25 mg a day. 3. Simvastatin 20 mg a day. 4. Lisinopril 20 mg a day. 5. Carvedilol 30 mg twice a day. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is retired. Lives at home with his wife and grandson. [Name (NI) ] does not use IV drug. He has a history of tobacco use one pack per day x20 years. He quit 20 years ago. PHYSICAL EXAMINATION: On physical examination the patient had a temperature of 97.3, pulse of 75, blood pressure 122/78, respiratory rate of 20, and 99 percent on room air. General: The patient is in no acute distress. Alert and oriented times three. HEENT: Dry mucous membranes. No scleral icterus and no jaundice. Heart: Regular, rate, and rhythm, no murmurs, rubs, or gallops. Normal S1, S2, no JVD. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended, positive bowel sounds, and no hepatosplenomegaly. Extremities: No clubbing, cyanosis, or edema. Two plus dorsalis pedis pulses. LABORATORIES ON ADMISSION: Significant for a hematocrit of 37.9. Normal coagulation profile. Normal electrolytes. Patient's LFTs, amylase, and lipase were normal. HOSPITAL COURSE: The patient was initially admitted to the medical service on [2104-7-10]. The patient got large bore IV's. Received serial hematocrit checks. Was placed in the ICU for close monitoring and telemetry, and received a GI consult. Patient received a colonoscopy, which showed blood in the colon, but no definite source of bleeding. After two days of persistent bleeding, the patient underwent angiogram, which located the bleed to the right colon and the patient underwent vasopressin therapy. Initially, this appeared to work well. However, on the following day, the patient early in the morning started to bleed again. After multiple transfusions from blood loss anemia with swing in hematocrit from 45 to 22, it was decided to take the patient to the operating room on [2104-7-13]. Patient tolerated the procedure well, and was transferred back to the ICU for observation afterwards. After an overnight stay and confirmed stable hematocrit, the patient was transferred to the floor. Interventional Radiology sheath was pulled without complication at that time. Patient's nasogastric tube was pulled at that time. Patient was making good urine output, and hematocrits remained stable. Early in the patient's postoperative course, the patient experienced postoperative fevers. He had a urine culture performed, which was negative. The patient also was told to increase his incentive spirometry and ambulation. Patient quickly started to pass flatus, and the patient's diet was advanced without complication and is now [2104-7-19], and the patient was on postoperative day six in good condition tolerating a p.o. diet without rectal bleeding and with stable hematocrit. DISCHARGE INSTRUCTIONS: Patient is discharged in good condition and may observe a regular diet. He may observe regular activity except he may not lift anything greater than 10 pounds for six weeks and may not drive while on narcotic pain medication. He is being sent home with Colace with a stool softener and Percocet for pain. FOLLOW-UP INSTRUCTIONS: He is to followup with Dr. [Last Name (STitle) 468] in approximately 1-2 weeks. His staples were removed before discharge. [Name6 (MD) ] [Last Name (NamePattern4) 7542], [MD Number(1) 7543] Dictated By:[Last Name (NamePattern1) 3956] MEDQUIST36 D: [2104-7-19] 22:03:15 T: [2104-7-20] 06:08:58 Job#: [Job Number 7544]	[ "2851", "4019" ]
Admission Date: [2173-7-1] Discharge Date: [2173-7-12] Date of Birth: [2125-6-25] Sex: F Service: CHIEF COMPLAINT ON ADMISSION: Shortness of breath, fever, and groin pain. HISTORY OF PRESENT ILLNESS: This is a 48 year old female status post right total knee replacement in [2172-6-18] for osteoarthritis who was discharged to rehabilitation with an uncomplicated postoperative course. In [2173-2-16] she developed a right septic knee and arthrostomy was performed at [Hospital 1774] Hospital. On [2173-5-10], a revision to the right total knee replacement was performed and the second stage removal of antibiotic cement. In [2173-5-18], incision and drainage of the right knee hematoma was performed. Over this period (from [2173-2-16] to [2173-6-18]) the patient had been on Oxacillin through a PICC line. A temperature spike two to three weeks ago lead to removal of the PICC line and a new PICC line was placed in the right arm and the patient was started on Vancomycin on [2173-6-26]. He was also on low dose Coumadin since surgery in [2172-6-18]. The Coumadin was recently stopped two weeks prior to this current admission. The patient also completed a course of Levaquin for left lower lobe pneumonia approximately one month prior to admission. Five days prior to admission the patient had reported acute onset of shortness of breath while sitting in a chair. The shortness of breath has been episodic since then with oxygen saturation dropping to the high 80s at [Hospital3 2558]. He reports occasional right calf pain but no calf or sputum currently. The patient feels currently short of breath and exhibits dyspnea on exertion. She had an episode of chest pain the day of admission with pressure lasting hours with intermittent sharp, stabbing pains, also episodic diaphoresis and regurgitation with temperature up to 102.8 one week prior to admission. PAST MEDICAL HISTORY: 1. Morbid obesity; 2. Severe degenerative joint disease, status post total knee replacement; 3. Depression; 4. Anxiety; 5. Substance; 6. Hepatitis C; 7. Anemia; 8. Nephrolithiasis; 9. Hypertension; 10. Hernia repair; 11. Status post cholecystectomy; 12. Questionable history of Methicillin-resistant Staphylococcus aureus. ADMISSION AS AN OUTPATIENT: Diltiazem, Lisinopril, Wellbutrin, Protonix, Effexor, Iron Sulfate, Oxy-Contin, Oxycodone, Trazodone, Compazine, Vancomycin ALLERGIES: Iodine SOCIAL HISTORY: Tobacco use for 35 years, [11-19] pack per day. There is a history of ethanol use and intravenous drug use including heroin, cocaine and other illicit drugs. The patient currently lives at [Hospital3 2558]. PHYSICAL EXAMINATION: Temperature 98.4, blood pressure 108/52, heartrate 103, respiratory rate 14, oxygen saturation 98% on room air. General: This is a very obese female. Head, eyes, ears, nose and throat; Moist mucous membranes, oropharynx clear. Neck: Jugulovenous distension not present, supple. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. Abdomen: Marked surgical scars and large ventral hernia. Extremities: There is a right PICC line, no erythema, negative for Hommas sign. No tenderness on palpation and no asymmetric edema. LABORATORY DATA: Laboratory data on examination revealed sodium 152, potassium 4.5, chloride 98, bicarbonate 23, BUN 16, creatinine 1.0, glucose 109, white blood cell count 15.7 with a differential of 74% neutrophils, 0 bands, 14 lymphocytes, hematocrit 31.5, compared to a prior 38 and platelets 187. Chest x-ray was negative for pneumonia or congestive heart failure. Lower extremity noninvasives were performed and were negative. V/Q scan was negative. Electrocardiogram was non-contributory. HOSPITAL COURSE: The patient was admitted to Medicine. There was a strong suspicion for a pulmonary embolus given the recent history of surgical procedures and the morbidity status of the patient. A computerized tomographic angiography was performed and revealed a right segmental defect which was attributed as a possibility. The patient was started on heparin and was evaluated by cardiac enzymes for myocardial infarction. The patient ruled out for myocardial infarction and echocardiogram showed an ejection fraction of 35%, mildly dilated left atrium, moderately dilated right atrium, mildly dilated left ventricle and moderate global left ventricle hypokinesis. On [7-2], three out of four blood cultures came back positive for gram negative rods and the patient was started on Zosyn. A computerized tomography scan of the pelvis demonstrated a right iliacus, iliopsoas abscess or myositis. On [7-3], the patient experienced worsening right groin and abdominal pain with now the pain radiating to the right flank. He became hypotensive with a systolic blood pressure in the 70s and a hematocrit of 25. A computerized tomography scan of the pelvis with contrast revealed a large retroperitoneal hematoma and the patient was transferred to the Medicine Intensive Care Unit Service. The hematocrit further dropped to 20 and surgical consult was asked for. Also Interventional Radiology consulted. PTT was 100 that morning and the patient was administered packed red blood cells and 4 units of fresh frozen plasma. A left subclavian line and a right arterial line were placed. The patient was treated with Vancomycin and Imipenem. Because of the falling hematocrit the patient received additional packed red blood cell transfusions. Eventually on [7-6], the hematocrit stabilized and the patient was transferred again back to the floor. At that time, the vital signs revealed temperature 98.7, blood pressure 140/80, heartrate 88, respiratory rate 20 and oxygen saturation 99% with 4 liters of oxygen. Subsequently, the patient's hematocrit was followed every 12 hours and remained stable. Antibiotics were continued with Vancomycin discontinued on [7-10]. Repeat abdominal computerized tomography scan demonstrated stable retroperitoneal hematoma. On [2173-7-10], the patient complained of increased abdominal pain. At this point the pain medications were Oxy-Contin, Oxycodone, Morphine prn, Tylenol and these were increased. Pain consult was called but was unable to see the patient because the patient was repeatedly outside of her room in the building, in order to smoke. At the point of dictation of this summary, the plan is for the patient to have PICC line installed on the morning of [2173-7-12] and to be discharged to a rehabilitation facility on the same day. The plan is for the patient to continue the antibiotics, in particular Meropenem for a total of four to six weeks pending repeat of the abdominal computerized tomography scan and repeat of the blood cultures. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Furosemide 40 mg p.o. q.d. 2. Oxycodone 15 mg p.o. q. 4 hours prn 3. Oxy-Contin sustained release 110 mg p.o. q. 12 hours 4. Morphine Sulfate 2 mg intravenously q. 4 hours prn 5. Bisacodyl 10 mg p.r. b.i.d. 6. Meclizine 25 mg p.o. t.i.d. prn 7. Pantoprazole 40 mg p.o. q. 24 hours 8. Senna 1 tablet p.o. b.i.d. 9. Captopril 12.5 mg p.o. t.i.d. 10. Hydralazine 10 mg intravenously q. 6 hours prn 11. Metoprolol 12.5 mg p.o. b.i.d. 12. Docusate sodium 100 mg p.o. b.i.d. 13. Meropenem 1000 mg intravenously q. 8 hours, to continue for the next four to six weeks 14. Ondansetron (Zofran) 4 mg intravenously q. 6 hours prn 15. Miconazole powder 2% one application b.i.d. prn 16. Albuterol 1 to 2 puffs inhaler q. 6 hours prn 17. Acetaminophen 325-650 mg p.o. q. 6 hours prn 18. Prochlorperazine 10 mg p.o. q. 6 hours prn 19. Trazodone 50 mg p.o. h.s. prn 20. Ferrous Sulfate 325 mg p.o. t.i.d. 21. Venlafaxine 150 mg p.o. b.i.d. 22. Bupropion sustained release 150 mg p.o. b.i.d. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8829], M.D. [MD Number(1) 8830] Dictated By:[Last Name (NamePattern1) 10203] MEDQUIST36 D: [2173-7-11] 16:14 T: [2173-7-11] 16:38 JOB#: [Job Number 101534]	[ "2851", "4019" ]
Admission Date: [2121-2-20] Discharge Date: [2121-3-13] Date of Birth: [2050-1-9] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 18252] is a 71-year-old male patient with known 3-vessel disease diagnosed in [2120-2-4] by cardiac catheterization. At that time, he was referred to Dr. [First Name (STitle) ] [Name (STitle) ] for evaluation for CABG. Surgery was deferred secondary to a climbing creatinine with a maximum of 5.0 and need for temporary dialysis. Mr. [Known lastname 18252] has since been seen in our office with hopes for a decreased creatinine and optimized hemodynamics prior to coronary artery bypass grafting and mitral valve replacement/repair. He presented to an outside hospital with anemia. He was transfused with 1 unit of packed red blood cells with flash pulmonary edema and intubation. He was thus transferred to the [Hospital1 69] for ongoing management. His creatinine was below baseline on admission at 1.6, and we were asked to consider surgery at that time. Mr. [Known lastname 18252] reports dyspnea on exertion, orthopnea, shortness of breath, and weakness. PAST MEDICAL HISTORY: Type 1 diabetes (diagnosed at the age of 24), chronic renal insufficiency (baseline creatinine of 1.9), glaucoma (legally blind), coronary artery disease (myocardial infarction in [2119]), congestive heart failure, peripheral vascular disease, anemia, hypertension, benign prostatic hypertrophy, hard of hearing, and degenerative joint disease. ALLERGIES: Question allergy to ACE INHIBITOR'S. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. once daily, multivitamin, Lipitor 80 mg p.o. once daily, Protonix 40 mg p.o. once daily, Lopressor 50 mg p.o. three times per day, Imdur 40 mg p.o. three times per day, amlodipine 5 mg once daily, trazodone 50 mg p.o. once daily, hydralazine 50 mg p.o. three times per day, Timolol 0.5 percent 1 drop at bedtime, Bimatoprost 0.03 percent 1 drop both eyes at bedtime, and insulin. PHYSICAL EXAMINATION ON PRESENTATION: Height of 5 feet 0 inches, weight of 69.9 kilograms. Vital signs revealed temperature was 96.0, the heart rate was 63 (in sinus rhythm), the blood pressure was 94/31, the respiratory rate was 16, and 100 percent intubated. In general, flat in bed. Intubated, sedated, and in no acute distress. Neurologically, responded to painful stimuli. He moved all extremities. Respiratory examination revealed fine rales at bilateral bases. Cardiovascular examination revealed a regular rate and rhythm. S1 and S2. A positive 2/6 systolic ejection murmur. Gastrointestinal examination revealed soft, round, nontender, and nondistended. Positive bowel sounds. The extremities were warm and dry. Positive red scaly shins without any open areas. LABORATORY DATA ON PRESENTATION: White blood cell count was 8.9, the hematocrit was 30.9, and platelets were 230. PT was 13.9, PTT was 28.8, and INR was 1.2. Sodium was 142, potassium was 3.8, chloride was 109, bicarbonate was 25, BUN was 38, creatinine was 1.6, and glucose was 245. Urinalysis was negative. Typed and crossed - O positive. RADIOLOGIC STUDIES: A chest x-ray revealed congestive heart failure with bilateral effusions. SUMMARY OF HOSPITAL COURSE: As stated in the History of Present Illness, Mr. [Known lastname 18252] was admitted on [2121-2-20] from an outside facility with flash pulmonary edema, status post red blood cell transfusion. On [2-21] - on hospital day two - he was successfully weaned and extubated. He continued in the Intensive Care Unit that day. His cardiac surgery workup was continued. The patient suspected of having a right lower lobe pneumonia, for which he was on azithromycin with sputum culture pending. His anemia was worked up showing low iron stores and low TIBC which supported anemia of chronic disease diagnosis, and was transfused as needed for that with a Hematology consult deferred. He remained in the Intensive Care Unit for hemodynamic management. On hospital day four, he was transferred to the inpatient floor for continued management. A preoperative echocardiogram documented no mitral regurgitation; whereas a past echocardiogram in [2120-12-4] had shown 2 plus mitral regurgitation and transesophageal echocardiogram was performed in the Operating Room to thoroughly evaluate this. Mr. [Known lastname 18252] [Last Name (Titles) 20354] to the Operating Room on [2121-2-26] with Dr. [First Name (STitle) ] [Name (STitle) ] and underwent coronary artery bypass grafting times three with a LIMA to the LAD, a saphenous vein graft to the OM, and a saphenous vein graft to the RCA. He also had a mitral valve repair with a 28-mm ring. Please see the Operative Report for further details. He was unable to wean on his operative evening, and on postoperative day one was successfully weaned and extubated. His IV drip medications were also discontinued as tolerated, and he was started on Natrecor as well as Lasix for diuresis. On postoperative day three, his milrinone was restarted. As well, he was transfused with 1 unit of packed red blood cells for a hematocrit of 27. On postoperative day three, he remained hemodynamically stable on milrinone and Natrecor; increased to maintain his blood pressure for renal perfusion. The Lasix drip was also continued to maintain urine output. On postoperative day four, the same medications were continued. As well, he was transfused with 1 more unit of packed red blood cells. On postoperative day four, a Renal consultation was also obtained for a rise in creatinine of up to 2.3 with recommendations for diuretics as needed, but no aggressive diuresis. On postoperative day four, he also had sustained bursts of rapid atrial fibrillation which was treated with intravenous amiodarone. On postoperative day six, he was started on Coumadin for anticoagulation secondary to the atrial fibrillation with a subsequent jump in his INR to 2.2 the following day. His creatinine also dropped down to 2.0 with ongoing evaluation by the Renal staff. Over the next several days his intravenous drip medications were discontinued. As well, his Coumadin was held for an elevated INR, and his creatinine remained stable at 2.0. He was transferred to the inpatient floor on postoperative day 10 for ongoing recovery and rehabilitation. He was also restarted on his Coumadin on postoperative day 11 at only 1 mg with close monitoring of his INR. A pericardial friction rub was noted on postoperative day 12; for which he was started on ibuprofen 800 mg p.o. q.8h. On postoperative day 13, a recheck of his creatinine showed a creatinine of 1.6; which was significantly improved. He was reevaluated by Physical Therapy, and it was decided that he needed some additional physical therapy prior to being safe for discharge home, with dropping of his oxygen saturation to 74 on room air with ambulation. On postoperative days 14 and 15, he continued on his oral Coumadin and was seen by Physical Therapy with some improvement in ambulation, but still requiring oxygen with ambulation with a decrease oxygen saturation on room air to 84 percent. On postoperative day 15, it was decided that he would be better served to be discharged home than to rehabilitation with agreement by the patient and his wife. [Name (NI) ] was thus discharged home with followup by visiting nurses. CONDITION ON DISCHARGE: Stable. Vital signs revealed temperature was 98.0, the pulse was 68 (in sinus rhythm), the blood pressure was 112/50, the respiratory rate was 18, weight was 76.7 kilograms (with a preoperative weight of 72.7), and his oxygen saturation was 97 percent on room air. PT was 14.8 with an INR of 1.4. On physical examination, neurologically he was alert and oriented; nonfocal. Pulmonary examination revealed the lungs were clear bilaterally. Cardiac examination revealed a regular rate and rhythm. The sternal incision without drainage or erythema. The sternum was stable. The abdomen was soft, nontender, and nondistended with positive bowel sounds. The extremities were warm with 2 plus edema. Right and left leg incisions were clean and dry. DISCHARGE STATUS: To home with visiting nurses to follow. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass grafting. 3. Mitral regurgitation. 4. Status post mitral valve repair. 5. Type 1 diabetes. 6. Chronic renal insufficiency. 7. Peripheral vascular disease. 8. Anemia. 9. Hypertension. 10. Benign prostatic hypertrophy. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 mg p.o. once daily. 2. Lipitor 40 mg p.o. once daily. 3. Colace 100 mg p.o. twice daily. 4. Percocet 5/325 one to two tablets by mouth q.6h. as needed (for pain). 5. Trazodone 50 mg p.o. at bedtime. 6. Methazolamide 50 mg p.o. twice daily. 7. Coumadin 2 mg tonight ([2121-3-13]); to be dosed daily per INR by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1726]. 8. Norvasc 5 mg p.o. once daily. 9. Lasix 20 mg p.o. twice daily. 10. Potassium chloride 20 mEq p.o. twice daily. 11. Brimonidine tartrate 0.15 percent drops 1 drop ophthalmic twice daily. 12. Timolol 0.5 percent drops 1 drop bilateral eyes at bedtime. 13. Bimatoprost 0.03 percent drops 1 drop both eyes daily. DISCHARGE FOLLOWUP: 1. Call to schedule an appointment with Dr. [First Name (STitle) ] [Name (STitle) ] within four weeks. 2. Call to schedule an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1726] within two to four weeks. 3. Call to schedule an appointment with Dr. [Last Name (STitle) 284] within four weeks. 4. Visiting nurses daily to draw INR and call results to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1726] (telephone number [Telephone/Fax (1) 36012]). [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2121-3-13] 16:27:49 T: [2121-3-13] 17:37:17 Job#: [Job Number 60055]	[ "41401", "4240", "4280", "42731", "5845", "486", "496", "4019" ]

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