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Admission Date: [2142-8-30] Discharge Date: [2142-9-22] Service: HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old man with a history of coronary artery disease and congestive heart failure, who was transferred from an outside hospital with complaints of shortness of breath and congestive heart failure after ruling in for a non-Q wave myocardial infarction. He also had a history of restrictive lung disease, status post coronary artery bypass grafting, multiple admissions for congestive heart failure with the last being on [2142-7-16] and [2142-8-9], chronic renal insufficiency and renal cell carcinoma status post right nephrectomy and prostate carcinoma. He was transferred at this time from [Hospital3 417] Hospital for continued management of shortness of breath, congestive heart failure and a non-Q wave myocardial infarction. The patient was admitted to [Hospital3 417] Hospital from [Hospital 27838] Rehabilitation on [2142-8-13] with shortness of breath and desaturations to the 70s. He was treated for congestive heart failure with diuresis, with minimal improvement over several days. He ruled in for a non-Q wave myocardial infarction on [2142-8-14] in the setting of continued likely demand ischemia from hypoxia. The patient underwent a pulmonary workup including a ventilation perfusion scan, which was read as low probability for pulmonary embolus, and a CT scan of the chest, which was consistent with diffuse interstitial lung disease. The patient was covered with an unknown antibiotic over an unclear duration for assumed underlying pneumonia. Despite this treatment and continued supplemental oxygen, the patient continued to have low oxygen saturation, prompting intubation on [2142-8-17]. He eventually extubated on [2142-8-23], but had since remained tenuous, requiring BiPAP and 100% nonrebreather. On [2142-8-28], a pulmonary artery catheter was placed to investigate pulmonary versus cardiac etiology of his hypoxia. By report, the initial numbers were consistent with a cardiac output of 5.1, a cardiac index of 2.5 and a pulmonary artery diastolic pressure of 25. In the two to three days preceding transfer, he had a worsening oxygen requirement, requiring continuous BiPAP. On [2142-8-29], the patient complained of chest pain and an electrocardiogram by report showed ischemic changes. He was started on intravenous nitroglycerin and received Lopressor and Lasix. His cardiac enzymes were elevated with a positive troponin and CK MB. He was transferred to the [Hospital1 69] cardiac care unit for continued management. Upon arrival, the chest x-ray was consistent with congestive heart failure, rales were audible on examination and he was requiring BiPAP to maintain his oxygen saturation. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass grafting in [2139] with a left internal mammary artery graft to the first diagonal artery, a saphenous vein graft to the distal left anterior descending artery and a saphenous vein graft to the first obtuse marginal artery, performed at [Hospital1 69]. 2. Congestive heart failure with hospitalizations in [Month (only) ] and [2142-7-22] and an ejection fraction of 20-30%. 3. Paroxysmal atrial fibrillation. 4. Renal cell carcinoma, status post right nephrectomy. 5. Prostate cancer. 6. Chronic renal insufficiency. 7. Chronic obstructive pulmonary disease secondary to smoking with an FVC of 1.79 and an FEV1 of 1.43. 8. Coronary artery bypass grafting in [2139] complicated by prolonged intubation and tracheostomy. 9. Gastroesophageal reflux disease. 10. Psoriatic arthritis, previously treated with methotrexate. 11. Gastrointestinal bleed secondary to diverticulitis. 12. Degenerative joint disease of cervical spine. 13. Restrictive lung disease, consistent with pleural fibrosis with bronchiectasis from severe postoperative pneumonia or interstitial lung disease secondary to methotrexate and/or deconditioning secondary to obesity. 14. Calcified right fibrothorax. 15. History of cerebrovascular accident. MEDICATIONS ON TRANSFER: 1. Amiodarone 200 mg q.d. 2. Lipitor 20 mg q.d. 3. Lovenox 90 mg q.d. 4. Proscar 5 mg q.d. 5. Folate one tablet q.d. 6. Lasix 60 mg intravenous b.i.d. 7. Reglan 10 mg intravenous q.i.d. 8. Lopressor. 9. Inderal. 10. Zoloft. 11. Ativan. 12. Nitroglycerin drip. 13. Proventil. ALLERGIES: The patient an allergy to morphine. SOCIAL HISTORY: Prior to his hospitalization, the patient was residing at [Hospital 27838] Rehabilitation. He had been previously living with his daughter. [Name (NI) ] was a former pharmacist. He was a former cigar smoker, but had smoked no cigarettes. PHYSICAL EXAMINATION: The patient had a blood pressure of 113/58, a heart rate of 81 in atrial fibrillation, a respiratory rate of 32, a temperature of 98.1??????F and an oxygen saturation of 95% on 65% oxygen by BiPAP. In general, the patient was an agitated, tachypneic male with BiPAP mask on. On head, eyes, ears, nose and throat examination, we were unable to assess jugular venous distention. The lungs had rales halfway up bilaterally with dry crackles audible halfway up. The patient had discreet decreased breath sounds in the right upper lobe. The heart was irregular with an S1 and S2 and no rubs, murmurs or gallops. The abdomen was soft, nontender and nondistended with good bowel sounds. The extremities had trace lower extremity edema. On neurological examination, the patient was moving all extremities had answered questions with nodes. LABORATORY DATA: The patient had a white blood cell count of 14,200, hematocrit of 26.9, platelet count of 150,000 and MCV of 91. Prothrombin time was 12.7, partial thromboplastin time was 36.9 and INR was 1.1. There was a sodium of 145, potassium of 3.6, chloride of 100, bicarbonate of 30, BUN of 81, creatinine of 2.2 and glucose of 93. ALT was 29, AST was 73, alkaline phosphatase was 110 and total bilirubin was 0.3. Troponin was greater than 50 and CK was 89. Albumin was 3.0, calcium was 8.7, phosphorus was 4.8 and magnesium was 1.8. Arterial blood gases were 7.35/69/169. RADIOLOGY DATA: A portable chest x-ray revealed bilateral vascular congestion and cephalization with congestive heart failure. ELECTROCARDIOGRAM: An electrocardiogram was normal sinus rhythm at 73 beats per minute, borderline left axis and left ventricular hypertrophy by voltage criteria, primary atrioventricular block with a P-R of 210, isolated [Street Address(2) 4793] elevations in aVF also seen previously, Q waves in leads III and aVF and ST depressions in V4 to V6. TRANSESOPHAGEAL ECHOCARDIOGRAM: A transesophageal echocardiogram from [2142-7-11] showed depressed left ventricular and right ventricular function, 1 to 2+ mitral regurgitation and no clot. HOSPITAL COURSE: Briefly, the patient is an 83-year-old gentleman with a complex past medical history, who presented with hypoxic respiratory failure in the setting of a recent non-Q wave myocardial infarction as well as underlying interstitial lung disease and chronic obstructive pulmonary disease. His hospital course is summarized by systems as follows: 1. PULMONARY: The patient was intubated for hypoxic respiratory failure on [2142-8-31]. He was diuresed for suspected congestive heart failure with a Lasix drip. On [2142-9-1], a sputum sample revealed Methicillin sensitive Staphylococcus aureus which was treated with a 14 day course of oxacillin. On [2142-9-4], a gallium scan was performed due to a question of amiodarone toxicity versus methotrexate toxicity. No evidence of an acute pulmonary process was seen on the scan. On [2142-9-8], a sputum culture revealed infection with Pseudomonas and treatment was begun with levofloxacin and ceftazidime. The ceftazidime was later discontinued, as the organism was found to be pansensitive. A repeat sputum culture from [2142-9-10] again grew out Pseudomonas and sensitivities for this were missing or pending. On [2142-9-9], a CT scan of the chest revealed bilateral lower lobe pneumonia, small pleural effusions and persistent volume loss on the right; it also revealed unchanged right fibrothorax. Throughout his intensive care unit course, the patient continued to produce thick secretions which required frequent suctioning. On [2142-9-21], a tracheostomy was performed. The patient had been switched to pressor support of 15 with 7.5 of PEEP and an FiO2 of 50% prior to the tracheostomy. Following this procedure, the patient required a switch back to assist controlled ventilation. Besides having his pneumonia treated, the patient received Lasix and occasional Diuril at increasing doses to treat his underlying congestive heart failure. He also was started on albuterol and Atrovent metered dose inhalers every four hours as well as Flovent four puffs inhaled b.i.d. 2. CARDIOVASCULAR: As far as his pump function was concerned, the patient was initially treated with intravenous nitroglycerin and Lasix drips. He was subsequently weaned off the Lasix drip and the nitroglycerin was discontinued. He continued to receive Lasix and Diuril intermittently. Late in his course, as his renal function improved, the patient was started on Captopril for afterload reduction. The patient required pressors intermittently during his hospital course, once in the setting of a tachycardia with a questionable left bundle branch block and hypotension. He also required pressors following a hypotensive episode during his tracheostomy on [2142-9-21]. As for his heart rhythm, he continued in atrial fibrillation and flutter, which was rate controlled without medication. His Lopressor was discontinued in the setting of his hypotension. His anticoagulation was discontinued in the setting of an episode of hemoptysis and a hematocrit drop with occult blood positive stool. As far as his coronary artery disease was concerned, following his initial ischemic insult this remained stable with negative CKs after the hypotensive episode. The patient was continued on aspirin and Lipitor. 3. RENAL: The patient was status post nephrectomy. His baseline creatinine was 2.2. At its height, the patient's creatinine was 2.4 and then gradually improved over the hospital course to a level of 1.5. The patient had a slight rise in his creatinine after he was started on Captopril, but this remained stable. 4. INFECTIOUS DISEASE: The patient grew Methicillin sensitive Staphylococcus aureus in his sputum on [2142-9-1] and was treated with oxacillin for 14 days. He grew pansensitive Pseudomonas from his sputum on [2142-9-8] and was treated with levofloxacin and ceftazidime. The ceftazidime was discontinued. A 21 day course of levofloxacin will be completed on [2142-10-1]. At the time of discharge, a sputum sample from [2142-9-18] had grown Pseudomonas, for which sensitivities were pending, as well as new gram-negative rod, the identification of which was also pending. In addition, the patient had several episodes of diarrhea and Clostridium difficile assays were negative. He had numerous blood cultures, which were negative for growth to date. Finally, on [2142-9-21], the patient had a slight elevation in his white blood cell count to 11,400. His right internal jugular central venous line was changed over a wire and the tip was sent for culture. This culture was pending at discharge. 5. HEMATOLOGY: The patient was placed on Epogen for anemia of chronic disease as well as for anemia of chronic renal insufficiency. He received a total of four units of packed red blood cells for a gastrointestinal bleed. He had no frank blood; however, he had guaiac positive stools. 6. FLUID, ELECTROLYTES AND NUTRITION: The patient was currently on total parenteral nutrition. He had been receiving Criticare tube feeds at a goal of 60 cc/hour, which were held prior to placement of a PEG-J tube (gastrojejunal tube) and prior to his tracheostomy. The tube feeds are to be restarted on [2142-9-22]. The total parenteral nutrition should be discontinued when tube feeds are at 50% of goal. 7. PROPHYLAXIS: The patient is receiving 6000 units of heparin and 150 mg of ranitidine in his total parenteral nutrition. Subcutaneous heparin and a proton pump inhibitor per the gastrostomy tube should be restarted when the patient's total parenteral nutrition is discontinued. 8. ACCESS: The patient has a right internal jugular central venous line, which was placed on [2142-9-21]. He also has a left radial artery line, which was placed on [2142-9-18]. His tracheostomy was performed on [2142-9-21]. His PEG-J tube was placed on [2142-9-20]. He also has a Foley catheter and a rectal tube. 9. CODE STATUS: After a lengthy discussion with the patient's daughter and son, the patient's code status was determined as no cardiopulmonary resuscitation and no defibrillation or cardioversion. They do feel that pressors and tracheostomy are appropriate. 10. COMMUNICATION: The patient's daughter, [Name (NI) ], and son, [Name (NI) ], are actively involved in the patient's care. The daughter, [Name (NI) ] [Name (NI) 98288], can be reached by cell phone ([0-0-]), at work ([Telephone/Fax (1) 108486]) or at home ([Telephone/Fax (1) 108487]). [First Name4 (NamePattern1) ] [Known lastname 98288], the son, can be reached by cell phone ([Telephone/Fax (1) 108488]), by pager ([Telephone/Fax (1) 108489]), at home ([Telephone/Fax (1) 108490]) or at work ([Telephone/Fax (1) 108491]). CONDITION ON DISCHARGE: Fair. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. Interstitial lung disease. 3. Pneumonia. 4. Chronic obstructive pulmonary disease. 5. Coronary artery disease. 6. Atrial fibrillation. DISCHARGE MEDICATIONS: 1. Levofloxacin 250 mg intravenous p.o. q.d. (to be discontinued on [2142-10-1]). 2. Albuterol and Atrovent metered dose inhalers every four hours. 3. Nystatin swish and swallow 4 to 6 ml p.o. q.i.d. 4. Nystatin cream 1% topically b.i.d. 5. Flovent four puffs inhaled b.i.d. 6. Ativan drip 1 to 10 mg intravenous, titrate to sedation. 7. Lipitor 10 mg p.o./p.g. h.s. 8. Criticare tube feeds with goal of 60 cc/hour. 9. Epogen 3000 units subcutaneous on Monday, Wednesday and Friday. 10. Aspirin 325 mg p.o./p.r. q.d. 11. Captopril 25 mg p.o./p.g. t.i.d. 12. Neo-Synephrine gtt, titrate to mean arterial pressure of greater than 65. 13. Lactulose p.r.n. 14. Dilaudid 1 to 2 mg intravenous p.r.n. [First Name11 (Name Pattern1) 4514] [Last Name (NamePattern4) 8867], M.D. [MD Number(1) 8868] Dictated By:[Last Name (NamePattern1) 11548] MEDQUIST36 D: [2142-9-21] 19:48 T: [2142-9-21] 21:47 JOB#: [Job Number ]	[ "51881", "4280", "41071", "42731", "0389" ]
Admission Date: [2161-1-10] Discharge Date: [2161-1-15] Date of Birth: [2111-6-10] Sex: M Service: MEDICINE Allergies: Lasix Attending:[First Name3 (LF) 8104] Chief Complaint: Dark emesis Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: Mr. [Known lastname 37217] is a 49 year old male with alcoholic cirrhosis and multiple admissions for upper gastrointestinal bleeding secondary to [Doctor First Name 329] [Doctor Last Name ] tears and esophagitis/gastritis who presents from home with one week of severe nausea, vomiting and coffee ground emesis. Mr. [Known lastname 37217] was recently admitted to this hospital for an upper gastrointestinal bleed in mid [Month (only) ] at which time he had an upper endoscopy which was essentially normal. At that time he was sober. He started drinking again approximately ten days ago. When he drinks he often develops severe nausea and vomiting. The nausea and vomiting began one week ago. Starting on Monday the vomit began to contain coffee grounds and he felt weak. He has a history of recurrent syncope followed by Dr. [Last Name (STitle) ] here in cardiology and reports that in this setting he fell down at least 10-20 times without prolonged episodes of loss of consciousness. Starting the day prior to presentation he reports that the vomiting worsened and he was unable to keep any liquids down. His vomiting was associated with mild bilateral lower quadrant tenderness. He has been having black bowel movements over the past week, most recently on the day of presentation. His urine output has decreased and become darker. He feels lightheaded and dizzy. He has not had any chest pain or shortness of breath. He denies sick contacts. [Name (NI) ] denies any drug use with the exception of alcohol. His last drink was one week ago. He presented to the emergency room for recurrent nausea and vomiting. . In the emergency room his initial vitals were T: 100.1 HR: 128 BP: 162/92 RR: 18 O2: 100% on 2L. He received one liter of normal saline. He received valium 5 mg IV x 1 for tremulousness. He received protonix 40 mg IV x 1, ciprofloxacin 400 mg IV x 1 and 40 meq potassium in NS @ 150 cc/hr. He had an EKG which showed sinus tachycardia at a rate of 119, normal axis, normal intervals, no acute ST segment changes, extensive T wave flattening, compared with priors, rate is faster and T wave flattening is new. He had a RUQ ultrasound which showed patent portal and splenic veins. NG lavage showed black coffee grounds which did not clear with lavage but no bright blood. He was admitted to the [Hospital Unit Name 153] for further management. . On review of systems he continues to have lightheadedness and mild dizziness. He continues to have nausea and vomiting and mild bilateral lower quadrant abdominal pain. No chest pain or shortness of breath. No dysuria or hematuria. No leg pain or swelling. No weight gain or increased abdominal girth. He does endorse tremulousness. All other review of systems negative in detail. Past Medical History: 1. Alcoholic cirrhosis, complicated by portal hypertension, with a history of grade 1 to 2 varices, status post banding. Most recent upper endoscopy [2160-12-9] was normal. 2. Portal hypertensive gastropathy. 3. Portal vein thrombosis in [2157-8-22]. 4. History of ascites, status post two large volume paracenteses in [2157]. 5. Multiple upper GI bleed, secondary to esophagitis and [Doctor First Name ]-[Doctor Last Name ] tears. 6. Recurrent syncope, currently being evaluated by Dr. [Last Name (STitle) ], of Cardiology. 7. Depression. 8. Hypertension. 9. Umbilical hernia. 10. s/p appendectomy. 11. Iron deficiency anemia 12. Gastroparesis Social History: Currently divorced and does not have any kids. He lives with his mother and is currently not working. History of heavy alcohol use. Currently drinking approximately three drinks of whiskey daily. Last drink one week ago. No hospitalizations for withdrawal. No withdrawal seizures or DTs. He denies current tobacco use. He denies drugs. Driving licensce suspended due to EtOH related driving. Denies any other ilicit drug use or smoking. Lives with his mother and currently divorced. Formerly worked as an electrician. No tobacco use. Family History: Alcoholism in mother and aunt. Mother with lung cancer. Physical Exam: Vitals: T: 100.1 BP: 147/86 P: 117 R: 16 O2: 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild tenderness to deep palpation in pelvic region, non-distended, bowel sounds hyperactive, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Rectal: Gross melena on exam in the ER Pertinent Results: [2161-1-10] 12:05PM WBC-8.8 RBC-3.66* HGB-10.3* HCT-29.9* MCV-82# MCH-28.1 MCHC-34.5# RDW-18.6* [2161-1-10] 12:05PM NEUTS-85.9* LYMPHS-10.5* MONOS-3.2 EOS-0.3 BASOS-0.2 [2161-1-10] 12:05PM PLT SMR-VERY LOW PLT COUNT-59# [2161-1-10] 12:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2161-1-10] 12:05PM ACETONE-LARGE OSMOLAL-288 [2161-1-10] 12:05PM estGFR-Using this [2161-1-10] 12:05PM UREA N-9 CREAT-0.9 SODIUM-136 POTASSIUM-2.8 CHLORIDE-87* TOTAL CO2-23 ANION GAP-29* [2161-1-10] 02:16PM LACTATE-1.0 [2161-1-10] 02:16PM TYPE-ART PO2-92 PCO2-30* PH-7.48* TOTAL CO2-23 BASE XS-0 INTUBATED-NOT INTUBA [2161-1-10] 02:24PM LACTATE-1.3 [2161-1-10] 05:56PM PT-15.9* PTT-28.5 INR(PT)-1.4* [2161-1-10] 05:56PM PLT COUNT-43* [2161-1-10] 05:56PM NEUTS-76.4* LYMPHS-17.9* MONOS-5.3 EOS-0.4 BASOS-0.1 [2161-1-10] 05:56PM WBC-6.4 RBC-2.96* HGB-8.4* HCT-23.8* MCV-80* MCH-28.4 MCHC-35.3* RDW-18.7* . Micro: none . Images: RUQ Ultrasound: 1. Cirrhosis. 2. Splenomegaly. 3. Limited Doppler ultrasound shows patency and appropriate directional flow of the main portal vein as well as the branches of the hepatic veins. . Endoscopy: Upper Endoscopy [2160-12-9]: Normal mucosa in the esophagus. Erythema in the stomach (biopsy consistent with chemical gastritis). Normal mucosa in the duodenum. Otherwise normal EGD to third part of the duodenum. . Sigmoidoscopy [2159-12-11]: Medium grade 2 external hemorrhoids were noted. Otherwise normal to splenic flexure. . EKG: sinus tachycardia at a rate of 119, normal axis, normal intervals, no acute ST segment changes, extensive T wave flattening, compared with priors, rate is faster and T wave flattening is new. Brief Hospital Course: Assessment and Plan: 49 year old male with alcoholic cirrhosis and multiple admissions for upper gastrointestinal bleeding secondary to [Doctor First Name 329] [Doctor Last Name ] tears and esophagitis/gastritis who presents from home with one week of severe nausea, vomiting and coffee ground emesis. . Upper Gastrointestinal Bleeding: Patient with a history of recurrently upper GI bleeds secondary to [Doctor First Name 329] [Doctor Last Name ] tears and esophagitis/gastritis. NG lavage in the emergency room with coffee grounds but no fresh blood. Hematocrit down to 23.9 from baseline in the low 30s. Patient was admitted to the ICU and he received PRCs and was started on PPI [Hospital1 ] and cipro for SBP prophylaxis. He underwent EGD that revealed Grade 3 esophagitis, erythema, nodularity and abnormal vascularity in the fundus compatible with gastropathy, and otherwise normal EGD to third part of the duodenum. His hematocrit and hemodynamics remained stable throughout the hospitalization and his was d/cd on [Hospital1 ] ppi. . Alcoholic liver disease: History of ascites, SBP and portal vein thrombosis and pancytopenia. RUQ ultrasound with evidence of patent flow in portal and splenic veins. The pt received ciprofloxacin for SBP prophylaxis in the setting of GI bleeding and was continued on nadolol and lactulose. His blood counts remained stable. He was also continued on iron for a previous diagnosis of fe deficiency anemia. . Alcohol withdrawal: The patient's ICU course was c/b alcohol withdrawal and hallinosos. He was treated with IV Ativan. He also received thiamine, folate and multivitamin. Following benzodiazepine therapy, he did not have evidence of ongoing withdrawal and had a clear mental status with stable vital signs at time of discharge. His acamprosate was held during this hospitalization. Following withdrawal, he was seen by our social work team. He will follow-up with his therapist and considered joinig a weekly sobriety program closer to home. Unforunately given his social circumstances (mom is an active drinker), he does not have good social support for recovery. Depression: He was continued citalopram and seroquel Medications on Admission: 1. Multivitamin 1 TAB PO DAILY. 2. Citalopram 20 mg PO DAILY. 3. Lactulose 30 ML PO TID titrate to 3 loose stools per day. 4. Nadolol 20 mg PO DAILY. 5. Metoclopramide 10 mg PO QIDACHS 6. Ferrous Sulfate 325 mg PO BID 7. Acamprosate 333 mg Two Tablets PO TID. 8. Omeprazole 40 mg PO once a day. 9. Folbalin Plus 2.5-25-2 mg PO once a day. 10. Seroquel 25 mg QHS Discharge Medications: 1. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 3. Lactulose 10 gram Packet Sig: Thirty (30) ml PO three times a day: titrate for 3 loose stools per day. Disp:qs for 1 month Refills:0 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO qid prn. Disp:60 Tablet(s) Refills:0 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:0 7. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:0 8. Folamin 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1)Upper GI bleed 2)Alcohol withdrawal 3)Alcoholic liver disease Discharge Condition: Good; stable Discharge Instructions: Please call your doctor or return to the emergency room if you develop fever, nausea, vomiting, abdominal pain, dark or bloody stool. Please resume all of your pre-admission medications. You will be on a higher dose of omeprazole. Please call Dr.[Name (NI) 37497] office tomorrow to schedule up a follow-up appointment within the next 1-2 weeks. Followup Instructions: Please call Dr.[Name (NI) 37497] office to schedule a follow-up appointment. Can not get in to see him, you should be seen by one of the other GI doctors. Please continue to see your therapist as previously scheduled. Provider: [Name Initial (NameIs) 703] (H3) GENERAL 2 RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2161-2-16] 10:00 Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2161-5-6] 1:50	[ "2875", "4019" ]
Admission Date: [2133-10-15] Discharge Date: [2133-10-20] Date of Birth: [2094-9-10] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 13159] Chief Complaint: DKA Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: 39 yo IDDM with history of DKA, diabetic gastroparesis, errosive esophagitis and chronic kidney disease (last A1c 11.1) who presented to ED after feeling unwell and not eating x multiple days and found to be in DKA with hypotension unresponsive to fluids and requiring pressors. Pt reports that he had abdominal pain and didn't eat anything for days. It is unclear whether he was taking his insulin at home. He does report that he had coffee ground emesis the night prior to admission. He complained of abdominal pain and was incontinent of stool. He was guiac positive in the ED. On arrival to the ED his VS were: afebrile, 98.8 102 77/37 20 100%. His Blood sugar was 1017 on peripheral draw with an anion gap of 24. He was given 10U bolus insulin and started on an insulin drip. He received 3L of NS and his BP did not respond so a right IJ was placed and he was started on levophed with good response. A CT abdomen was performed and he was started on vanc and zosyn emperically. He was found to be guiac positive on exam (not mention of the color of the stool). On arrival to the MICU he had no complaints. He did however develop coffee ground emesis soon after arrival but denied abdominal pain, light headedness or difficulty breathing. He denied chest pain or palpitations. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, [Last Name (NamePattern1) ], or wheezing. Denies chest pain, chest pressure, palpitations. Past Medical History: Diabetes Type 1 Orthostatic hypotension Arthritis not specified Chronic diarrhea Cellulitis GERD Severe gastritis on EGD on [12/2131] Colonoscopy in [2131-5-18] with ? diabetic enteropathy Vitamin D deficiency Iron deficiency anemia s/p amputation of #2 and #3 right toes Social History: Lives at home with both parents. He is a never smoker and does not drink. His parents report that at baseline, he does not leave the house on account of severe arthritis. He does not work. Family History: Father Alive [Name (NI) 24046] Onset Mother Alive Hypertension Sister Alive Physical Exam: Admission: Vitals: 98.0, 88/47 (off pressors), 96, 18 96%RA General: Alert, oriented, no acute distress, chronically ill appearing HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, no MRG appreciated Lungs: CTAB Abdomen: soft, nontender, nondistended, no rebound or guarding Ext: Warm, well perfused, Neuro: Moving all extremities CNII-XII grossly intact intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: Admission Labs: [2133-10-15] 10:45AM BLOOD WBC-17.4# RBC-3.25 Hgb-8.5* Hct-29.3* MCV-90# MCH-26.3* MCHC-29.2* RDW-13.6 Plt Ct-354 [2133-10-15] 10:45AM BLOOD Neuts-88.2* Lymphs-6.1* Monos-5.6 Eos-0.1 Baso-0.1 [2133-10-15] 10:45AM BLOOD PT-10.3 PTT-30.6 INR(PT)-0.9 [2133-10-15] 10:45AM BLOOD Glucose-1015* UreaN-65* Creat-3.5# Na-116 K-6.8* Cl-84* HCO3-11* AnGap-28* [2133-10-15] 10:45AM BLOOD ALT-57* AST-20 CK(CPK)-135 AlkPhos-104 TotBili-0.5 [2133-10-15] 10:45AM BLOOD CK-MB-8 cTropnT-0.46* [2133-10-15] 10:45AM BLOOD Albumin-3.3* Calcium-8.5 Phos-6.7# Mg-2.1 [2133-10-15] 12:00PM BLOOD Glucose-GREATER TH Lactate-2.3 Microbiology: -URINE CULTURE (Final [2133-10-16]): YEAST. >100,000 ORGANISMS/ML.. -Blood cultures: No growth to date -Legionella Antigen: Negative Imaging: [10-16] CXR: Heart size is top normal, though slightly larger today than on [10-15]. There is no pulmonary vascular engorgement, but new opacification at the base of the right hemithorax could be due to combination of atelectasis and right pleural effusion. When feasible, I would recommend conventional chest radiographs. Right jugular line ends centrally. No pneumothorax. [10-16] Echo: IMPRESSION: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Compared with the prior study (images reviewed) of [2133-2-12], the findings are similar. [10-15] CT Abdomen/Pelvis: 1. No acute abdominal pathology. 2. Extensive mesenteric haziness, likely secondary to third spacing. Apparent wall thickening seen in the proximal small bowel loops may relate to third spacing. 3. Trace simple right pleural effusion with compressive right lower lobe atelectasis. [10-15] CXR: IMPRESSION: Interval placement of right internal jugular central venous catheter, terminating in the mid SVC, without evidence of pneumothorax. Ill-defined focal opacity at the left mid lung of unclear clinical significance. Suggest oblique views for further evaluation to assess if it persists and if it appears pulmonary, then CT may be indicated. Brief Hospital Course: 39 M with a medical history of IDDM and hx of DKA, errosive esophagitis and chronic kidney disease presents with DKA, shock likely secondary to hypovolemia from osmotic diuresis, found to be guiac positive with coffee ground emesis likely from errosive esophagitis. . #Hypotension/Shock- Patient presented with hypovolemic shock in setting of DKA and osmotic diuresis. As he initially had SIRS criteria with elevated WBC and tachycardia with CXR showing left mid lung opacity he was treated emperically with vancomycin, azithromycin, and zosyn. Repeat CXR showed resolution of finding and antibiotics were discontinued two days after admission. He initially required levophed for blood pressure support but this was able to be discontinued within 24hours. . #DKA- He has a history of DKA ([2-/2133]) as well as episodes of hypoglycemia and is currently being closely followed by his endocrinologist. He reported that he did not take his insulin as he had not been feeling well and was not eating. It was not clear how closely he was monitoring his blood sugars while not eating and not taking insulin. In the ICU it was unclear what his home dose of lantus was as there were conflicting reports of 20U vs. 35U. Infectious evaluation was unremarkable based on CT abdomen and CXR. He was managed with an insulin drip until resolution of his anion gap and improvement in his blood sugar after which he was converted to subcutaneous lantus and insulin sliding scale. He was continued on D5 NS/LR until cleared by GI for oral diet. He was followed by [Last Name (un) ] during this admission regarding management of his insulin regimen. He will follow up with his endocrine provider following discharge. . #UGIB- He has a history of erosive esophagitis. In the ICU he had two episodes of coffee ground emesis. He was transfused three units of PRBC during his ICU admission. He underwent upper endoscopy that revealed diffuse exudate with numerous patches of necrosis with stigmata of recent bleeding were noted throughout the esophagus compatible with severe esophagitis and necrosis. There were stigmata of recent bleeding but no active bleeding. He was continued on IV PPI [Hospital1 ], started on carafate 1gram TID, started on emperic treatment for [Female First Name (un) ] esophagitis with fluconazole for two week course (day 1 = [10-17]), and his diet kept NPO. He underwent repeat EGD three days later that showed similar findings with slight interval improvement. His diet was changed to liquids and he was instructed to continue this for the next four days. After this he was instructed to change to soft regular diet. He met with nutrition for education about the soft diet. He was changed to PO PPI [Hospital1 ] at the time of discharge. He will need followup with his GI for repeat EGD in six weeks. . #Elevated troponin with ST segment elevation on EKG- patient has a history of ST elevations in the setting of DKA, with electrolyte shifts, on his previous admission. Coronary vasospasm was also considered. He was evaluated by cardiology and started on aspirin (discussed with GI), atorvastatin, and low dose metoprolol. He has a TTE that was normal without wall motion abnormality. Cardiology recommended outpatient exercise stress test for further risk stratification. . #Acute Renal failure- Patient admitted with elevated creatinine of 3.5, up from baseline of 1.0-1.2. His medications were renally dosed. His home erythropoietin and iron were initially held. With fluid resuscitation his creatinine improved back to baseline and was 1.2 at discharge. . #Hypertension: He was normotensive during the majority of his hospital stay. On discharge, his vitals were notable for a blood pressure of 180/100. He denied chest pain, vision changes, headache, or any other symptoms. He denied history of high blood pressure. There were no obvious new medications that could be causing high blood pressure. He was given the metoprolol early and monitored. Blood pressure on recheck was 170s/90s. Discussed the importance of following up with primary care physician this week for repeat blood pressure check and consideration of further medical therapy. Discussed coming to ED if symptoms of chest pain, headache, vision changes, difficulty breathing or other concerning symptoms. # Yeast UTI: growing > 100k yeast from [2133-10-16] culture. d/c'd foley. TRANSITIONAL ISSUES: 1. Follow up with GI for repeat EGD in 6 weeks 2. Follow up with cardiology for consideration of stress testing 3. Follow up with endocrine provider for further management of diabetes 4. Blood pressure management with primary care physician Medications on Admission: -Atorvastatin 80mg po qday -Lantus 20 UNITS qhs -glucagon prn hypogylcemia - Tamsulosin 0.4 mg ext release po qday -Ergocalciferol, Vitamin D2, 50,000 unit Oral Capsule, take one a week for 16 weeks -Ferrous Sulfate 325 mg po BID - Insulin Lispro (HUMALOG KWIKPEN) 100 unit/mL Subcutaneous Insulin Pen, sliding scale 100-150=2U,151-200=4U,201-250=6U,251-300=8U,301-350=10U. -Gabapentin 600 mg Oral Tablet, take 1 tablet three times a day -Omeprazole 40 mg Oral Capsule, Delayed Release(E.C.), Take 1 capsule twice daily -Sucralfate 1 gram Oral Tablet, TAKE 1 TABLET FOUR TIMES DAILY -Cholecalciferol, Vitamin D3, (VITAMIN D) 1,000 unit Oral Tablet, Take 1 tablet daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO HS 3. Fluconazole 200 mg PO Q24H RX fluconazole [Diflucan] 200 mg 1 tablet(s) by mouth daily Disp #10 Tablet Refills:0 4. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:1 5. Sucralfate 1 gm PO TID RX sucralfate [Carafate] 1 gram/10 mL 1 gram Suspension(s) by mouth three times a day Disp #90 Gram Refills:0 6. Tamsulosin 0.4 mg PO HS 7. Glargine 16 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth [Doctor Last Name ] Disp #30 Tablet Refills:0 9. Humalog insulin sliding scale Discharge Disposition: Home With Service Facility: [Hospital 86] Home Health Aides Discharge Diagnosis: DKA Esophagitis Blood loss anemia Coronary artery vasospasm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to participate in your care. You were admitted to [Hospital1 18] after having dark vomit. Your blood counts were low concerning for an upper GI bleed. You had an upper endoscopy that revealed severe erosive esophagitis. You were started on a medication to reduce the amount of acid in your stomach (pantoprazole) as well as a medication to treat fungal infection (fluconazole). You were started on liquid diet, which you should continue through Thursday. Then you can start on soft regular diet. The reason for this diet is because we are concerned about further injury to your esophagus. You will need to follow up with your GI doctor within the next several weeks and will need a repeat EGD in 6 weeks. Your blood sugar was also found to be high with labs consistent with diabetic ketoacidosis. You were started on insulin. Your blood sugar control improved. You were seen by the [Last Name (un) ] Diabetes specialists. They recommended reducing your lantus (glargine) to 16 units. You were also found to have an abnormal EKG (electrical heart tracing) that may be due to a spasm of your coronary artery. You were continued on aspirin, cholesterol medication (statin), and started on a beta blocker. The cardiology service recommended an outpatient cardiac stress test for further evaluation. Please follow up with your primary care physician and cardiologist for further evaluation. Followup Instructions: Name:[First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 85071],MD Specialty: Endocrinology Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2296] When: [Last Name (LF) 2974], [10-23] at 11:30am Name:[First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],MD Specialty: Primary Care Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 2261] When: [10-27] at 11:10am Name:[First Name8 (NamePattern2) ] [Name8 (MD) ],MD Specialty: Cardiology Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 6425] Phone: [Telephone/Fax (1) 2258] When: [11-10] at 10:50am We are working on a follow up appointment in the Gastroenterology department in the next month. You will be called at home with the appointment. If you have not heard or have questions, please call [Telephone/Fax (1) 2296]. You need to have a repeat upper endoscopy in six weeks, the GI physician will schedule this.	[ "40390", "V5867", "5849" ]
Admission Date: [2162-4-22] Discharge Date: [2162-4-25] Date of Birth: [2086-7-12] Sex: F Service: MEDICINE Allergies: Colchicine / Atorvastatin / Cinacalcet Attending:[First Name3 (LF) 99] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 75 yoF w/ ESRD on HD (T, Th, Sat) who is a nursing home resident presenting to the ER with shortness of breath. She became SOB early a.m. in addition to a cough, denies chest pain or other associated symptoms. Her SOB occured while supine, she was awake and felt acutely short of breath, she sat up and her breathing improved slightly but still felt short of breath so she let her nurse know and was sent to the hospital. She complains of 1 week of cough, no F/C, no hemoptysis, cough is non productive. No medication non compliance or dietary indescretion per patient. At baseline for the past few weeks (s/p admission/discharge for line infection) she has been working w/ physical thearpy and has dyspnea with PT, walks around room w/ assistance and walker. No angina. . She states her baseline weight is about 150 or so however, she currently weighs 124.5 lbs. She is unaware about any weight loss and feels as though she weighs the same as usual. . She has no chest pain or anginal symptoms. . In EMS she rec'd 3 sprays of NTG, and was started on BiPAP in the ambulance. . In the ER initial VS were: T 98.4 HR 96 BP 200/108 O2 sat 100% on CPAP. She was started on a nitrogtt, renal was consulted for dialysis, she was continued on BiPAP (started in EMS). VS prior to transfer to the floor were: HR 79 BP 197/77 RR 15 O2 sat: 97% on 4L. Past Medical History: Diabetes Dyslipidemia Hypertension - Complicated proximal humerus fracture ([6-/2161]): followed by orthopedics, currently advised to avoid L arm weight bearing - Stroke, per family 2, one about 4-5 years prior and one >20 yrs ago family is unsure of deficit - Post polypectomy bleed admitted on [4-24] for BRBPR - ESRD on HD: Tues, Thurs, Sat at [Location (un) ]. - CHF: ECHO [2162-3-25]: EF 30-40%. LVH (moderate, and diastolic dysfunction) - Hypertension - Type 2 DM: diagnosed >40 years ago, complicated by ESRD, controlled on insulin - Sarcoidosis with ocular involvement: seen every 3 months for eye exam - not biopsy proven - Gout: last flair [10-18]; usually occurs in R toes - Knee surgery s/p fall - Obstructive sleep apnea: [2161-8-12] sleep study shows moderate obstructive sleep apnea consisting mainly of hypopneas that produced substantial drops in oxygen saturation. Social History: No smoking history. History of rare ethanol intake. No illicit drugs. Currently resides at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] after L arm fracture, usually lives with her daughter. Ambulatory with cane at baseline. Family History: Hypertension, Diabetes mellitus type 2. Physical Exam: Vitals - T: 98.0 BP: 211/94 HR: 81 RR: 27 02 sat: 100% on 4L GENERAL: NAD, AOx3 HEENT: MMM, OP clear, JVP 10cm, distended EJ CARDIAC: RRR, 3/6 SEM at the USB, high pitched and mid-peaking, good carotid upstroke and no radiation, [3-20] HSM at the apex- soft. LUNG: poor respiratory effort, rales [2-13] way up bilaterally, no wheezes ABDOMEN: soft, NT, ND, no masses or orgnaomegaly EXT: WWP, no c/c/e NEURO: Grossly normal, AOx3 SKIN: no rashes . Pertinent Results: ================== ADMISSION LABS ================== . [2162-4-22] 08:25AM BLOOD WBC-7.0 RBC-3.25* Hgb-9.9* Hct-32.7* MCV-101* MCH-30.5 MCHC-30.3* RDW-17.2* Plt Ct-194 [2162-4-22] 08:25AM BLOOD Neuts-52 Bands-0 Lymphs-12* Monos-3 Eos-33* Baso-0 Atyps-0 Metas-0 Myelos-0 [2162-4-22] 08:25AM BLOOD PT-13.5* PTT-26.8 INR(PT)-1.2* [2162-4-22] 08:25AM BLOOD Glucose-198* UreaN-35* Creat-5.0* Na-138 K-5.1 Cl-99 HCO3-29 AnGap-15 [2162-4-22] 08:25AM BLOOD CK(CPK)-29 [2162-4-22] 08:25AM BLOOD CK-MB-NotDone cTropnT-0.12* proBNP-[Numeric Identifier 35404]* [2162-4-22] 08:25AM BLOOD Calcium-10.2 Phos-5.0# Mg-2.6 [2162-4-22] 08:31AM BLOOD Lactate-1.3 . ============== RADIOLOGY ============== . CHEST, AP: The examination is suboptimal due to underpenetration, patient motion, and low lung volumes. The lungs are clear without consolidation or edema. There is mild crowding of vascular markings. Note is made of tracheal wall calcifications. There are no pleural effusions or pneumothorax. There is unchanged moderate cardiomegaly. The aorta is slightly tortuous. A right dual-lumen central venous catheter is again seen with tip in the mid right atrium. IMPRESSION: No acute cardiopulmonary process. . EKG: IVCD, slightly worse STE in AVR and STD in II. LAE. . ECHO: 2/110/10: EF 30-40%, global hypokinesis. Mild LVH w/ wall thickness of 1.4, symmetric. RV normal. indeterminate PASP. Severe MAC, 1+MR. Mild AS. . CXR [2162-4-22]: moderate CHF, bilateral pleural effusions (small), no focal infiltrate, Tunneled Right sided HD catheter in RA. Brief Hospital Course: 75 yoF w/ a h/o HTN, DM, ESRD on HD (T,T,Sa) presents with acute onset SOB. SOB/Hypoxia: The patient had acute onset shortness of breath. EF is 30-40 and also has moderate LVH She improved with positive pressure and a nitro gtt. She is very hypertensive and the likely cause is fluid overload. Etiology of heart failure is presumed to be hypertensive heart disease however the patient has never had a cardiac cath, and her hypokinesis is global. She ruled out for an MI. SOB markedly improved with dialysis and ultrafiltration. The patient was dialyzed on Thursday, underwent UF for 2L on Friday and dialyzed again on Saturday with another 2 L removed. Her new dry weight is 53 kg. She was sating 100% while supine on room air prior to discharge. She should continue irbesartan (switched to losartan while at the [Hospital1 18] for formulary reasons) and carvedilol 12.5mg po bid upon discharge. After Eospinophilia: Has had this in the past without clear explanation. Has had negative stool O&P, in addition has had a normal cortisol in the past and there has been a thought of possible sarcoid but this has not been further evaluated. Stool O&P was negative. She should follow up with an allergist. Dr. [First Name8 (NamePattern2) 2602] [Name (STitle) 2603] ([Telephone/Fax (1) 14583] Medications on Admission: B Complex-Vitamin C-Folic Acid 1 mg po daily Allopurinol 100 mg po qod Carvedilol 12.5 mg po bid Docusate Sodium 100 mg po bid Irbesartan 150 mg Tablet po bid Lactulose 15mL [Hospital1 ] on MWF Ranitidine HCl 75mg po bid Sevelamer Carbonate 1600 mg po tid Simvastatin 80mg daily Senna 8.6 mg Tablet 2 tablets tid Aspirin 81 mg po daily NPH 12 units qam Regular insulin sliding scale Plavix 75 mg po daily Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as directed sliding scale Subcutaneous four times a day: Regular insulin sliding scale and NPH 12 units qam. 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 7 days. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Primary Diagnosis: Pulmonary Edema, acute on chronic CHF Hypertensive Emergency Discharge Condition: stable, sating 100% on room air Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. You were admitted for pulmonary edema (fluid in your lungs) which was treated with fluid removal during dialysis. Please return to the hospital if you have any further shortness of breath, chest pain, or any other symptoms that concern you. No changes were made to your medications. Followup Instructions: Please follow up with your PCP [Name9 (PRE) ],[First Name3 (LF) ] [Name Initial (PRE) ]. [Telephone/Fax (1) 608] within 2 weeks of your discharge. Please follow up with Dr. [First Name8 (NamePattern2) 2602] [Name (STitle) 2603] ([Telephone/Fax (1) 14583] upon 4 weeks of your discharge. Completed by:[2162-4-25*]	[ "4280", "32723", "2724", "V5867" ]
Admission Date: [2130-6-6] Death Date: [2130-8-18] Date of Birth: [2082-5-12] Sex: M Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: This is a 48-year-old male, with hepatitis C cirrhosis, who was initially admitted on [2130-6-6] five days after a fall with some lightheadedness and confusion. PAST MEDICAL HISTORY: Hepatitis C cirrhosis. MEDS AT HOME: 1. Paxil. 2. Tamoxifen. 3. Protonix. 4. Aldactone. 5. Lasix. ALLERGIES: No known drug allergies. EXAM ON ADMISSION: Temperature 98.7, pulse 84, blood pressure 113/60, respiratory rate 18, sat 96% on room air. GENERAL: Pleasant, jaundiced-appearing man in no apparent distress, speaking fluently but occasionally needing to correct himself. HEENT: Sclerae are jaundiced. Pupils equal, round and reactive to light. Extraocular movements intact. Oropharynx slightly dry. Small ecchymosis right temple. CHEST: Dull at left base, otherwise clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2, no murmur. ABDOMEN: Obese, mildly distended, soft with positive bowel sounds. EXTREMITIES: No edema. There is a large ecchymosis along the right lateral thigh, and a medium ecchymosis along the lateral left upper arm. NEURO: Cranial nerve exam normal. Finger-to-nose normal. He has flap when his arms are extended. LABS ON ADMISSION: White count 5.7, hematocrit 33.3, platelets 76. PT, PTT 18.9 and 45.1, INR 2.4. Sodium 129, potassium 5.2, chloride 97, bicarb 26, BUN 6, creatinine 0.7, glucose 399, ALT 24, AST 73, alk phos 131, amylase 50, T-bili 6.1. CT head on admission - very small subdural hematoma along the right cerebral hemisphere, appears subacute or chronic, minimal mass effect. Chest x-ray on admission - moderate new left-sided pleural effusions. INITIAL HOSPITAL COURSE: The patient was admitted to the medical service for follow-up of his newly diagnosed subdural hematoma. Over the course of the next few days, he developed some fevers and a Staph aureus bacteremia which were treated with broad-spectrum antibiotics. Work-up for the source of fever and bacteremia revealed only bilateral apical lung consolidations. Due to these complications, he demonstrated decompensation of his end-stage liver disease, and on [6-16] was found to have a liver donor. At that point, he was already afebrile, and there was no clear acute infection. He was still on broad-spectrum antibiotics. On [2130-6-16], he underwent an orthotopic liver transplant which he tolerated well. POSTOP COURSE SUMMARIZED AS FOLLOWS - 1) NEURO: For most of his hospital stay, since he was vent dependent, he was kept sedated, and was on a dilaudid drip. As his lung function deteriorated, he was paralyzed as well. 2) CARDIOVASCULAR: The patient had recurrent episodes of sepsis in which he was hemodynamically unstable and required significant pressor support to maintain blood pressure. 3) RESPIRATORY: Since early postop, the patient developed significant ARDS. He failed early extubation on postoperative day #5 and thereafter remained intubated, severely hypoxic, and with bilateral patchy infiltrates on chest x-ray. Over the course of his hospitalization, due to the low compliance of his lungs and the high pressures which were required on the vent, he developed multiple pneumothoraces on both sides, and multiple chest tubes were placed to a total of five drains on the right and two chest tubes on the left. 4) GI: During his hospitalization, he received nutritional support in the form of TPN, later tube feeds. 5) GU: He developed renal failure, and two points during his prolonged hospitalization attempts were made to place him on CVVH. 6) ID: During the course of his hospitalization, he grew [Female First Name (un) ] from a line, as well as yeast from the sputum, and was treated with AmBisome. He was kept on broad-spectrum antibiotics with the ID service following. CT chest/abdomen demonstrated bilateral pneumonias, and no intra-abdominal source of infection. In the days prior to his death, he demonstrated worsening renal function with increased vent pressures, in addition to hemodynamic instability which required maximal pressor support with levo, neo, vasopressin. In view of a prolonged and complicated course, and worsening multiorgan failure, his family chose to withdraw care and make him comfort measures only. This was done on [2130-8-18], and he expired shortly after. [Name6 (MD) 1344] [Name8 (MD) 1345], M.D. [MD Number(1) 1346] Dictated By:[Dictator Info 42841] MEDQUIST36 D: [2130-9-4] 10:31 T: [2130-9-4] 09:41 JOB#: [Job Number 42842]	[ "4280", "5845" ]
Admission Date: [2127-12-4] Discharge Date: [2127-12-11] Date of Birth: [2052-2-13] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Shellfish / Iodine Attending:[First Name3 (LF) 4765] Chief Complaint: Dyspnea, Chest Pain Major Surgical or Invasive Procedure: Cardiac catheterization [2127-12-4] History of Present Illness: Mrs. [Known lastname 71146] is a 75 yo F with CAD s/p CABG (SVG->LAD, SVG->OM, SVG->RCA) in [2124], hypertension, hyperlipidemia, aortic stenosis, and cirrhosis secondary to autoimmune hepatitis who presented to an OSH on [12-1] with acute onset chest pain and progressive DOE, and was transferred to [Hospital1 18] three days later for cardiac catheterization. The patient reported progressive worsening of DOE since her CABG in [2124]. Her DOE has subacutely worsened over the past 3 months-- walking up 3 stairs and around house results in dyspnea. She denied any orthopnea, PND, syncope, or lower extremity edema. Her symptoms have progressed to the point where she rarely leaves her home. She denied associated chest pain prior to the symptoms that led to her presentation to the outside hospital. Early in the morning of [12-1] she had sudden onset SSCP radiating to L arm at rest, associated with feeling 'warm'. Denied n/v. No SOB at time due to being at rest. Her anginal equivalent is atypical fleeting pain in all areas of her chest, but she states the pain that led to her presentation was more severe in nature. Chest pain lasted for 4 hours, subsided without intervention. She called her cardiologist's office in the morning and was advised by her cardiologist to go to the ED for immediate evaluation. She acknowledged being poorly compliant with blood pressure medications claiming financial hardship from medication prices. She presented to [Hospital 487] Hospital for these symptoms on [12-1]. There, cardiac enzymes showed troponin of 0.02, CK of 51, BUN/Cre was 17/0.8. She was given ASA 325 mg PO x1, metoprolol 150 mg PO, and 1 inch nitroglycerine paste, lovenox 80 mg SQ [Hospital1 ], and transferred to [Hospital1 18] for cardiac cath on [12-4]. In the cath lab, patient was noted to have severe AS (valve area of 0.7) and arterial tracing with systolic blood pressures in the 320s. Cardiac cath showed patent grafts unchanged from [1-5] cath. She was started on a nitroglycerin gtt and transferred to the CCU. In the CCU, patient denies chest pain. Her nitroglycerin gtt was weaned, and she was started on a nitroprusside gtt with good control of her SBPs in the 200s. On review of systems, she denied 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. She denied recent fevers, chills or rigors. She denied exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: [2125-1-3] Cardiac Catheterization performed for symptoms of unstable angina [2125-1-4] PTCA to mid LAD [2125-1-11] Coronary Artery Bypass Graft x 3 (Saphenous vein graft -> Left anterior descending, Saphenous vein graft -> Obtuse marginal, saphenous vein graft-> right coronary artery). A LIMA was not used due to retrograde L vertebral flow and concern of future left subclavian artery steal. [2126-1-24]: Cardiac Cath (performed in setting of chest pain, SVT): patent grafts, SVG-> OM1 occluded. No significant change in graft patency otherwise. . 3. OTHER PAST MEDICAL HISTORY: Hypertension Autoimmune Hepatitis with cirrhosis (Child's Class A) Anemia Aortic stenosis TIA [6-/2125] (significant R sided ICA stenosis) Peripheral Vascular Disease Seizure in [5-5] (oral numbness, followed by R hand/R leg numbness and weakness. has been on Keppra, but was self-discontinued by patient due to symptoms of depression). Carotid artery disease L sided subclavian steal h/o SVT in [12/2125] s/p appendectomy Social History: Retired, married lives with husband and 2 adult children. used to work at [Company 2892] for 20 years. denies tobacco or ETOH use Family History: 5 brothers and sisters all with CAD in 60's Physical Exam: VS: T= 98 BP= 259/200 HR= 85 RR= 16 O2 sat= 97% on RA GENERAL: elderly, pleasant F 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 6 cm at 45' angle. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2 (softer than S1 at the apex). +III/VI late peaking systolic crescendo-decrescendo murmur heard throughout the precordium radiating to the carotics. no gallops or rubs. Carotids: III/VI decresencdo murmer radiating to both carotids bilaerally, louder R > L. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, mild crackles at bases. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [2127-12-4] 08:37PM BLOOD WBC-7.2 RBC-3.32* Hgb-10.2* Hct-30.9* MCV-93 MCH-30.7 MCHC-33.1 RDW-15.2 Plt Ct-182 [2127-12-4] 08:37PM BLOOD PT-12.9 PTT-29.2 INR(PT)-1.1 [2127-12-4] 08:37PM BLOOD Glucose-191* UreaN-21* Creat-0.9 Na-138 K-4.0 Cl-103 HCO3-23 AnGap-16 [2127-12-4] 08:37PM BLOOD ALT-14 AST-18 LD(LDH)-212 AlkPhos-69 TotBili-0.5 [2127-12-4] 08:37PM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8 ----------------- DISCHARGE LABS: [2127-12-11] 06:45AM BLOOD WBC-5.6 RBC-3.41* Hgb-10.5* Hct-31.8* MCV-93 MCH-30.7 MCHC-33.0 RDW-14.9 Plt Ct-187 [2127-12-11] 06:45AM BLOOD PT-12.6 PTT-28.5 INR(PT)-1.1 [2127-12-11] 06:45AM BLOOD Glucose-103* UreaN-23* Creat-1.0 Na-138 K-4.7 Cl-105 HCO3-25 AnGap-13 [2127-12-10] 06:40AM BLOOD CK-MB-NotDone cTropnT-0.02* [2127-12-11] 06:45AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0 [2127-12-4] 08:37PM BLOOD %HbA1c-5.8 [2127-12-10] 04:56PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-4* pH-5.0 Leuks-TR [2127-12-10] 04:56PM URINE RBC-0-2 WBC-[5-6]* Bacteri-FEW Yeast-NONE Epi-[10-16] [2127-12-8] 04:16PM URINE Hours-RANDOM UreaN-1197 Creat-108 Na-60 ----------------- STUDIES: EKG ON ADMISSION: Rate 78, regular sinus rhythm, left axis deviation. Prolonged PR interval (254ms), consistent with 1st degree AV block (prolonged AV conduction). qrs widened in V1-V3, RSR' in V1, deep S in V6, consistent with RBBB. Given LAD, this is indicative of bifascicular block with RBBB+LAFB. R in aVL 20mm, meeting the criteria for LVH. Borderline left atrium enlargement. QTc wnl (469). T wave inversion in I, AVL, V1-V3. No significant ST changes. . CARDIAC CATH: [2127-12-4]: Hemodynamics: the aortic valve area was 0.68 cm2 with a 25mm Hg peak to peak gradient. PA pressures were: (51/34, mean 42); PCWP were: (mean 29, RA mean 16) . Coronary angiography: right dominant LMCA: non selective injection. No apparent stenosis LAD: 100% proximal occlusion LCX: Patent to tortuous OMB SVG-RCA: Patent to distal RCA. 70-80% stenosis of the origin PDA SVG-LAD: Patent to the LAD. Diffuse disease in the mid LAD<40% SVG-OMB: occluded . There was marked systemic hypertension (up to 310mmHg) and a pressure difference from the left arm to the right arm consistent with subclavian stenosis. . Assessment and Recommendation: 1. three vessel coronary artery disease 2. Patent SVG to the LAD; Patent SVG to the RCA 3. Occluded SVG to the OMB 4. Severe systemic hypertension 5. Critical aortic stenosis 6. CCU for IV nipride and BP control 7. Aortic valve replacement surgery . ECHO [2127-12-5] The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area 0.5 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. Mild to moderate ([11-29]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe calcific aortic stenosis. Symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Mild aortic regurgitation. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [2125-1-6], aortic stenosis severity and degree of LV hypertrophy have progressed. The other findings are similar. . CTA [2127-12-7] 1. Extensive atherosclerotic disease as well as ectatic dilation of the ascending aorta, similar to that seen in [2124]. 2. Left lower lobe pulmonary nodular opacity, appearing minimally enlarged from [2124]. Given the size of this lesion, followup with a PET study or dedicated CT of the chest within three months, is recommended. 3. Diverticulosis 4. Left renal hypodensity. While this is likely a cyst, it is new/enlarged from the previous study and could be correlated to U/S for further characterization. 3. Stable hepatic hypodensities too small to characterize but likely cysts. 4. Wedge compression deformity in the mid thoracic spine and degenerative changes in the remainder of the spine as cataloged above. . CAROTID US [2127-12-8] 1. 60-69% stenosis of the right internal carotid artery. 2. Less than 40% stenosis of the left internal carotid artery. 3. Reverse flow in the left vertebral artery, which may correspond to subclavian steal phenomenon. . VEIN MAP [2127-12-8] Patent right greater and lesser saphenous veins, with diameters described above. Brief Hospital Course: SUMMARY 75 yo F with CAD s/p 3V CABG and critical aortic stenosis. She arrived in chest pain that was due to hypertensive emergency (arterial line pressures in excess of 330). She was gradually brought under better control. She was discharged with sBP's of 140-180 and tolerated these pressures without syncope or neurologic deficits. She was evaluated and deemed ineligible for an open AVR. She was discharged to continue optimal medical management of her hypertension, dyslipidemia, cad and AS. She will follow up with Dr. [Last Name (STitle) ] and may receive a percutaneous AVR. BY PROBLEM # Hypertension: Patient presented with hypertensive emergency & chest pain. She was grossly hypertensive in the cath lab with arterial tracings showing systolics in the 330s. She was thought to be chronically hypertensive in setting of medication non-compliance due to financial issues. While outpatient blood pressure checks have SBPs ranging from 110s-140s, she has known left subclavian steal phenomenon and as an inpatient, her cuff pressures underestimate BPs measured via A-line. In the CCU, the patient's blood pressure was initially controlled with Nitroprusside gtt before being transitioned to PO Metoprolol 75mg TID & PO Captopril 100mg TID with resulting sbp's in the 180's-200's initially. Unfortunately, the patient continued to have intermittent SBP's >200 so metoprolol was changed to carvedilol for greater control of blood pressure. She was discharged with sBP's of 140-180 and on a regimen of Carvedilol 25 [Hospital1 ] and Lisinopril 40 [Hospital1 ]. . # Critical AS: Patient with Valve area 0.68 cm^2. Symptomatic with peak gradient of 25 mm Hg. Has [12-31] symptoms for AS triad (angina, CHF). Cardiac surgery was consulted and accepted the patient for valve replacement surgery. Given her h/o autoimmune hepatitis, she was cleared by hepatology for the procedure. However, given the degree of Aortic Calcification, she was not deemed to be a surgical candidate. Dr. [Last Name (STitle) ] will continue to follow her for percutaneous valve replacement in the spring. . # CORONARIES: Patient with known CAD s/p CABG, but patient's chest pain on admission was thought to be demand ischemia in the setting of critical AS and hypertensive emergency as pain resolved with improved bp??????s & patient with negative troponins, no new ischemic EKG changes. Her discharge medications are baby asa, pravastatin, carvedilol and lisinopril . # PUMP: Patient with evidence of acute diastolic congestive heart failure (EF 55% this admission, down from 65% in [1-/2127]), with elevated PCWP. Patient also with R sided PA and RA pressures on R heart cath, indicating evidence of pulmonary hypertension and right-sided heart failure, likely exacerbated in setting of L sided heart failure from critical AS. Her blood pressure was managed as above, avoiding agents that would decrease preload. . # RHYTHM: Patient with history of SVT in 2/[2125]. Currently in sinus rhythm with prolonged PR and RBBB/left anterior fascicular block on EKG. She was maintained on Metoprolol and observed on telemetry throughout her stay. . # Peripheral Vascular Disease: Patient with hx of PVD and TIAs. A-line [Location (un) 1131] higher than blood pressure cuff, consistent with a diagnosis of PVD. She was maintained on ASA & Pravastatin. . # Carotid artery disease: Patient with history of TIA in [6-/2125] (significant R sided ICA stenosis). Carotid US this admission, uchanged from [2125-1-9], showed 60-69% stenosis of the right internal carotid artery. Less than 40% stenosis of the left internal carotid artery. Reversed flow in the left vertebral artery, which may correspond to subclavian steal phenomenon. She was maintained on the above beta-blocker, ACE, ASA, statin regimen. . # Hyperlipidemia: Elevated LDL of 134, not at goal. HDL low at 11. Patient reportedly on Lipitor but discontinued due to patient concern about cirrhosis and possible liver damage. Patient was prescribed Zetia, but given cost, changed to Pravastatin. . # Hyperglycemia: Patient without history of diabetes. HgbA1c 5.8. She was placed on a RISS with FS qACHS during this admission. This were discontinued as her admission hyperglycemia normalized. . # Autoimmune Hepatitis with cirrhosis (Child's Class A). Followed by GI at [Hospital6 3105]. LFT's were normal during her stay and hepatology cleared patient for cardiac surgery. . # Anemia: Patient with an admission Hct of 30.9 that remained stable throughout her CCU stay. . # History of seizure: Patient was admitted for seizure in [5-5]. She has been on Keppra, but self-discontinued it because of depression. No further episodes since then or during this CCU stay. ** TO BE FOLLOWED 1) Hypertension: Patient discharged on lisinopril 40 [Hospital1 ] after 100 mg of Captopril TID in house. Patient tolerates high blood pressures but becomes weak or dizzy with sBP < 140 2) Medication Managment: Patient with poor compliance due to cost and other issues. The medications were selected with the intention of cost minimization. Her compliance is crucial to the natural history of her present cardiovascular disease. ** Medications on Admission: ASA 162 mg daily Cozaar 100 mg daily, Metoprolol XL 100 mg daily . Of note: has been intolerant of statins in the past, has been on Zetia 10 mg PO daily, but also stopped this due to non-compliance. Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for anxiety. Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Acute on Chronic Diastolic congestive Heart failure Severe Aortic Stenosis Hypertension Hyperlipidemia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had an episode of congestive heart failure and chest pain and was transferred from [Hospital 5987] [Hospital3 ] for a cardiac catherization. You did not have a heart attack. Your blood pressure has been much too high and your aortic valve is very stiff. You were seem by a cardiac surgeon here who thought that you are not a good candidate for a traditional surgical valve replacement. You may be a candidate for a valve replacement done using a cardiac catheterization technique. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] will see you at your next cardiologist visit to discuss this further. In the meantime, it is extremely important that you take your blood pressure medicine every day and check your blood pressure at home daily. You need to stay away from salt in your diet. Weigh yourself every morning, call Dr. [Last Name (STitle) ] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. . Medication changes: 1. Stop taking Cozaar and Metoprolol. 2. Start Carvedilol twice daily to keep your heart rate and blood pressure controlled. 3. Start Lisinopril twice daily to keep your blood pressure controlled. 4. continue aspirin and Pravastatin at the previous dose. Followup Instructions: Cardiology: [Last Name (LF) 5423],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 5424] [12-23] at 9:00am. Please call the office to confirm this appt. . Primary Care: [Last Name (LF) ],[First Name3 (LF) ] M. Phone: [Telephone/Fax (1) 40171] Date/time: Please keep any previously scheduled appts.	[ "4241", "4280", "4019", "2724", "2859" ]
Admission Date: [2124-2-19] Discharge Date: [2124-2-25] Date of Birth: [2048-12-1] Sex: M Service: MEDICINE Allergies: Septra / Sulfonamides Attending:[First Name3 (LF) 134] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization Ablation of ventricular tachycardia History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: 75 M h/o CAD s/p PCI x 2, EF=45%, in his USOH until 6pm while eating dinner, when he developed acute onset SSCP "15/10" non-radiating, no associated sob, diaphoresis/n/v. He describes as central chest pressure, similar to his MI in [2095]. He felt it may be [3-11] his dinner, and induced vomiting with mild releif. He took nitro spray x3 with some benefit also ([7-18] pain). . EMS was activated, and after receiving amio bolus + drip, was apparently with 2/10 chest pain though per EMS remained in stable VT. . On arrival to [Hospital1 18] ED, VS=97.6 164 90/p 22 97%. His chest pain apparently persisted, [3-19], though per pt did not worsen. BP 119/86, pt given versed 2mg and shocked @ 100J x 1 though was apparently hemodynamically stable throughout, after which he converted to NSR. He was then noted to be lethargic and sats 100%NRB, though subsequently became more arousable. He also received 1L IVF NS and amio 150mg iv x 1. He was seen by cardiology, who recommended switching to lidocaine gtt. Post-cardioversion EKG was concerning for STD V2-4, thus pt was loaded with plavix 600mg, heparin gtt, integrellin gtt, and admitted to CCU in anticipation of cath in AM. . . Of note, pt has stable central chest pressures which occurs after walking [2-11] miles, and is releived by 1 SL NTG. Has episodes 2-3x/wk, never at rest, worse after drinking coffee. . . + h/o stroke [2116] (etiology unclear, denies "embolism"), dark stools (h/o UC, none in past 5 yrs). . On review of symptoms, he denies any prior history of TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: CAD - MI '[95], PCA of RCA in '[11], in-stent re-stenosis/rotational ablation '[12], PCI Cx '[14], in-stent re-stenosis '[15]. TO LCx, with R->L collaterals. - HTN - hyperlipid - CHF (EF=40-45%) - COPD/Bronchitis - normal spirometry [11-11] (pred FEV1/FVC>100%) - multiple melanoma s/p multiple resections - ulcerative colitis s/p colectomy for uretocecal fistula - CVA - [2116] leading to slurred speach - peripheral neuropathy [3-11] "poor blood flow", numbness/tingling in feet, no claudication sx. - bowel spasm - cystitis Social History: Retired police officeer, works part-time as librarian; married with four children; 30 pack/yr smoking hx; quit 30 yrs prior; former alcoholic; quit in [2095] Family History: No family history of premature cardiac disease or sudden cardiac death Physical Exam: VS: 71 122/69 19 96%RA Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. 3/6 SEM LLSB, no radiation to carotids. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crackles bilateral bases, no wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. vertical midline well healed scar [3-11] colectomy. No abdominial bruits. Ext: No c/c/e. No femoral bruits bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP RECTAL: guaic negative. Pertinent Results: [2124-2-19] 08:45PM PT-12.9 PTT-26.6 INR(PT)-1.1 [2124-2-19] 08:45PM PLT COUNT-249 [2124-2-19] 08:45PM NEUTS-75.8* LYMPHS-18.1 MONOS-3.6 EOS-2.2 BASOS-0.3 [2124-2-19] 08:45PM WBC-11.3# RBC-4.47 HGB-14.3 HCT-40.0 MCV-90 MCH-32.1* MCHC-35.8* RDW-12.9 [2124-2-19] 08:45PM CALCIUM-9.6 PHOSPHATE-2.1* MAGNESIUM-2.0 [2124-2-19] 08:45PM cTropnT-0.01 [2124-2-19] 08:45PM CK(CPK)-76 [2124-2-19] 08:45PM UREA N-19 CREAT-1.2 SODIUM-141 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 [2124-2-19] 11:41PM MAGNESIUM-2.1 [2124-2-19] 11:41PM POTASSIUM-3.8 . ECHO [2124-2-24] The left atrium is normal in size. The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the inferior and inferolateral walls. Right ventricular chamber size and free wall motion are normal. The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 1.2cm2). The mitral valve leaflets are mildly thickened. Mild to moderate ([2-9]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. . Cardiac CATH [2124-2-21] COMMENTS: 1. Selective angiography in this right dominant system revealed one vessel CAD. The LMCA was calcified but free of angiographically apparent obstructive CAD. The LAD had proximal 20% stenosis and 50% mid vessel. The LCX had moderate calcification and was proximally occluded. The RCA had minimal luminal irregularities, diffuse disease and serial 30-50% stenoses. 2. Resting hemodynamics revealed normal right sided and elevated left sided filling pressures with RVEDP of 6 mmHg and LVEDP of 15 mmHg. There was elevated systemic blood pressure with SBP of 143 mmHg. Cardiac index was preserved at 2.75 l/min/m2. 3. There was mild aortic stenosis with mean gradient of 16.55 mmHg and calculated aortic valve area of 1.36 cm2. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Mild aortic stenosis. Brief Hospital Course: . ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS: . 75M h/o CAD, s/p PCI, EF=45%, presenting with stable VT s/p external shock x 1 with conversion to NSR, with ?STD on post-cardioversion EKG. . # CAD/Ischemia: baseline stable angina, unchanged over past [3-12] yrs, post-cardioversion EKG with STD in V2-5, and ?horizontal STE in III, aVF. CP. Taken to cath lab which showed diffuse dx and TO to LCX but no intervention was performed. Recommended medical management. Patient was continued on aspirin, statin and Betablocker and ACE inhibitor were titrated as blood pressure tolerated. Electrolytes were repleted aggressively. Not started on plavix as no intervention was performed. Patient remained chest pain free for duration of stay. . # Pump: Repeat ECHO on this admission demonstrated persistent hypokinesis of inferior walls with EF 45%, unchanged from prior. Treated with ACE inhibitor for afterload reduction. No need for diuresis as currently was not in decompensated heart failure. . # Rhythm: S/p VT ablation. 4 areas of inducible VT were noted.Pt had CP during VT underwent cardiac catheterization that showed TO of LCX but no lesion to intervene upon. The following day second EP study was performed. Several endocardial ablations were completed. 1 VT was induced and patient became hypotensive requiring external shock and pressors for short time. Not all foci could be ablated. Patient monitored on telemetry with no further episodes of VT. Did have occasional PVCs. . # Valves: Bicuspid aortic valve. Moderate AV stenosis [Location (un) 109] 1.2cm noted on ECHO, worse since prior study in [2122]. Will require serial ECHOs as outpatient . # Fever: Started augmentin. UA with 8 WBCs. As had line placements, patient treated empirically with 7 day course of augmentin. . # ulcerative colitis - s/p colectomy for uretocecal fistula, currently asx, on asacol, guaiac negative presently. Continued home dose asacol. . # CVA - [2116] leading to slurred speach. Continued on aspirin and statin. . # BPH - continued home finasteride. . # Code: FULL CODE. . # Communication: wife - [Name (NI) ] - ([Telephone/Fax (1) 93491]. Medications on Admission: aspirin 81 mg po qdaily pravachol 80 mg po qdaily prilosec 20mg po qdaily finesteride 5mg po qdaily asacol 1600mg po tid metoprolol succinate 25mg po qdaily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 5. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 6 days. Disp:12 Tablet(s) Refills:0 6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Ventricular tachycardia Secondary: Coronary artery disease Discharge Condition: Vital signs stable, normal sinus rhythm, chest pain free Discharge Instructions: You were admitted to the hospital and were found to have an abnormal heart rhythm called ventricular tachycardia. This required electric shocks to reverse. . You were started on new medications. These include: Aspirin 325mg daily Toprol xl 50mg daily Lisinopril 5mg daily . You were also given a prescription for Augmentin. You were spiking fevers prior to discharge. Since starting your antibiotics, your fevers have improved. Please complete the course of medication. . Please call Dr.[Name (NI) 9388] office to set up an appointment at [Telephone/Fax (1) 10662] in the next 2 weeks. . Please call your primary care doctor, Dr. [Last Name (STitle) 2204] to set up an appointment in the next 2-3 weeks. . Please call your doctor or return to the emergency room if you develop any worrisome symptoms such as chest pain, shortness of breath, lightheadedness, palpitations (fluttering in your chest), etc. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], MD Phone:[Telephone/Fax (1) 10662] Date/Time:[2124-4-11] 9:30	[ "41071", "5990", "41401", "4019", "2724", "V4582", "412", "496", "4280" ]
Admission Date: [2129-9-11] Discharge Date: [2129-9-26] Service: VSU CHIEF COMPLAINT: Ischemic left lower extremity. HISTORY OF PRESENT ILLNESS: This is an 85-year-old female who is transferred from [Hospital3 417] Hospital who is a resident at [Hospital1 ] Rehab with an ischemic left foot. The patient recently underwent revascularization of the left lower extremity in [Month (only) 216] of this year and was hospitalized because of the ischemic extremity on [2129-9-5]. The patient was referred here for further evaluation and treatment. PAST MEDICAL HISTORY: Illnesses - peripheral vascular disease, status post left fem-[Doctor Last Name ] in [2129-7-6] with thrombectomy, history of stroke x2 - ischemic stroke and hemorrhagic stroke with residual dysphagia and aspiration; asymptomatic abdominal aortic aneurysm 4.3 cm in size; type 2 diabetes, controlled; history of hypertension; ALLERGIES: Haldol allergy new. MEDICATIONS ON TRANSFER: Nexium 40 mg daily; Lopressor 25 mg b.i.d.; Arimidex 1 mg daily; nitro patch 0.4 mg daily; Remeron 15 mg at bedtime; ferrous sulfate 300 mg twice a day; Tylenol 650 mg q.4h. p.r.n.; aspirin 325 mg daily; bacitracin ointment to left breast b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Negative for tobacco use and negative for alcohol use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAM: Vital signs - 98.3, 88, 16, O2 sat 96% on room air, blood 133/66. General appearance - is an elderly female in no acute distress. HEENT exam is unremarkable. Lung sounds are diminished at the bases bilaterally. Heart has a regular rate and rhythm without murmur, gallop, or rub. Abdominal exam is benign except for PEG tube placement site clean without erythema. Lower extremities with coolness of temperature to the distal lower left extremity, diminished capillary refill with mild mottling. Motor and sensory are unassessable. Pulse exam shows palpable femorals bilaterally with Dopplerable popliteal, DT and PT on the right and absent DP and PT on the left. HOSPITAL COURSE: The patient was initially admitted through the emergency room and evaluated. IV heparinization was continued to maintain a PTT between 60 and 80. The patient underwent on [2129-9-12], a diagnostic angio of the abdominopelvic vessels with left leg runoff via the right femoral artery. The patient tolerated the procedure well. Nutrition was consulted on admission for recommendations for tube feeds. The patient is dependent at baseline on her tube feeds. Current regimen is Probalance at 45 cc per hour which gives the patient 1296 kilocalories and 58 gm of protein. Residuals are checked q.4h. and held for residual greater than 150 cc and the tube is flushed every 4 hours with 50 cc of fluid. Speech and swallow evaluation was requested on [2129-9-13]. In summary, the patient does not appear to aspirate nectar-thick liquid and ground p.o. However, the patient's oral phase and left buccal pocketing is a safety issue. Also due to the patient's coughing (a sign of aspiration) at the completion of the assessment a video swallow was recommended. Recommendations were the patient could have thickened liquids only for comfort. A video swallow was obtained the following day on [9-14]. Recommendations were there were no signs of aspiration but the patient's oropharyngeal phase was discoordinated and PEG feedings were to be continued and thickened liquids for pleasure only. The patient had an episode of agitation and confusion which resolved with Haldol IV. Geriatrics was consulted for management of this complicated patient. They felt the delirium was secondary to multifactorial reasons and would recommend that we take her off narcotic and give her Tylenol 1 gm t.i.d. standing and to simply her opiate treatment to oxycodone 5 mg q.4-6h. p.r.n. for break through pain. The Haldol was discontinued and Zyprexa 2.5 mg nightly was instituted and 2.5 mg of Zyprexa for agitation as required. Recommendations were to avoid any type of restraints and to re-orient the patient and avoid any unnecessary interruption of sleep/wake cycle. Recommendations were to also make sure that the patient was up in a chair and that physical therapy and OT saw the patient. On [2129-9-15], the patient's Zyprexa was converted to Seroquel 50 mg at bedtime which could be repeated x1. The patient was continued to be followed both by speech and swallow and the geriatric service during her hospitalization. Heparin was continued. The patient underwent on [2129-9-18], a left axillofemoral bypass and a left femoral-to- distal bypass. The patient tolerated the procedure. She required 2 units of packed cells intraoperatively. She was transferred to the PACU in stable condition and then to the SICU for continued monitoring and care postoperatively. Postoperative day one the patient was continued on vancomycin and ciprofloxacin. She did require a total of four 250-fluid boluses for mild postoperative hypotension which was resolved with fluid resuscitation. Her heparin was continued and coumadinization was begun on [2129-9-20]. The patient did require several units of packed red blood cells postoperatively for hematocrit that drifted from 30.2 to 24. Reticulocyte count was 2.1, ferritin was 271, TIBC was 203, B12 and folate were normal. GI was consulted for the patient's persistent anemia postoperatively and dark stool. GI felt that the source was either upper or lower GI; this could not be fully evaluated given the patient's need for continuous anticoagulation but this should be evaluated on an outpatient basis when the patient has recovered from current surgery, but the patient would be monitored on a clinical basis, and if required at some point prior to discharge, would consider endoscopies to evaluate for active bleeding. On [2129-9-22], the patient's Swan was converted to a central line and her IV fluids were Hep-Locked. PT was consulted and rehab screening was requested. The patient's heparin was discontinued on [2129-9-23], and her INR was 4.1 and anticoagulation was held and the INR was serially monitored. This will be restarted when her INR is less than 3. Physical therapy would assess the patient in anticipation for discharge planning. The patient will be discharged to rehab when medically stable. DISCHARGE MEDICATIONS: Mirtazapine 15 mg at bedtime; nitroglycerin 0.4 mg per hour patch q.24h., on 12, off 12; bacitracin ointment to the left breast area b.i.d.; ferrous sulfate 300 mg b.i.d.; aspirin 325 mg daily; acetaminophen 1000 mg t.i.d.; oxycodone 5 mg q.4h. p.r.n. for break through pain; cortisone 1% cream to the affected areas t.i.d.; quetiapine 50 mg at bedtime; __________ 30 mg b.i.d.; cyanocobalamin 100 mcg [12-7] tablet daily; ascorbic acid 500 mg b.i.d.; folic acid 1 mg daily; oxycodone 5-mg solution in 5 cc, 2.5 mg b.i.d. for pain, warfarin 5 mg daily, goal INR 2.0 to 3.0; heparin flush to PICC line (of importance - the PICC has had to have irrigation with alteplase 1 mg on 3 separate occasions; the most recently was [2129-9-23]); regular insulin q.4h., see sliding scale. DISCHARGE DIAGNOSES: 1. Left leg ischemia. 2. Peripheral vascular disease, status post left fem-[Doctor Last Name ] in [2129-7-6] with thrombectomy. 3. History of cerebrovascular accident x2, ischemic and hemorrhagic strokes with residual dysphagia and aspiration. 4. Asymptomatic abdominal aortic aneurysm of 4.3 cm. 5. History of type 2 diabetes, controlled. 6. History of hypertension, controlled. 7. Haldol allergy new. 8. Preoperative delirium, multifactorial, resolved. 9. Preoperative anemia, transfused x2. 10.PICC line thrombus x3, treated. 11.Postoperative blood loss anemia, transfused. DISCHARGE INSTRUCTIONS: Aspiration precautions - the head of the bed should be elevated upright position when the patient is taking orals. The oropharyngeal cavity should be suctioned prior to reclining the head of the bed. No bed trapeze. Please call if she develops fever greater than 101.5 or if the axillary or groin wounds or leg wound develop swelling, redness, or drainage. Skin clips remain in place until seen in followup with Dr. [Last Name (STitle) 1391]. MAJOR SURGICAL AND INVASIVE PROCEDURES: Diagnostic arteriogram with left leg runoff via the right femoral artery access on [9-12]. Left axillary-femoral bypass with a left femoral to distal bypass on [2129-9-18]. FOLLOWUP: The patient should follow up with Dr. [Last Name (STitle) 1391] in 2 weeks' time. Call for an appointment at [Telephone/Fax (1) 1393]. DISCHARGE MEDICATIONS: As previously dictated. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2129-9-23] 11:10:21 T: [2129-9-24] 00:40:59 Job#: [Job Number 74709]	[ "2851", "25000", "4019" ]
Admission Date: [2143-10-14] Discharge Date: [2143-10-18] Date of Birth: [2071-4-28] Sex: F Service: CARDIOTHORACIC Allergies: Demerol Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath, chest pain Major Surgical or Invasive Procedure: Aortic Vavle Replacement (21 mm [Company 1543] Mosaic Ultra porcine) [2143-10-14] History of Present Illness: 72 year old female who presented to her primary care physician with shortness of breath. An echocardiogram showed severe aortic stenosis. She was referred to [Hospital1 1170] for cardiac catheterization. Cath showed normal coronaries and she was admitted to the cardiac surgical service for aortic valve replacement. Past Medical History: Aortic Stenosis, Osteoporosis, recent rx for poss. PNA, s/p Hysterectomy, s/p Tonsillectomy, s/p Appendectomy, s/p Bilat. hip replacement, s/p Abdominoplasty, s/p Left ear surgery x 2 Social History: lives with husband never used tobacco no ETOH use Family History: no premature CAD Physical Exam: At discharge: VS:97temp 101/58BP 68HR 18RR Gen: NAD Chest:lungs CTA B/L Heart:RRR, no Murmurs, clicks, or rubs Abd:non-tender, non-distended, +bowel sounds, +BM today Ext:+1 edema Wound:MSI C/D/I, sternum stable Pertinent Results: [2143-10-14] Echo: The left atrium is normal in size. No spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. Right ventricular chamber size and free wall motion are normal. 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. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. [2143-10-14] 10:24AM BLOOD WBC-10.3# RBC-2.78# Hgb-8.1# Hct-24.3# MCV-87 MCH-29.0 MCHC-33.2 RDW-14.1 Plt Ct-182 [2143-10-14] 10:24AM BLOOD PT-14.9 PTT-41.2* INR(PT)-1.3* [2143-10-14] 12:09PM BLOOD UreaN-15 Creat-0.6 Cl-110* HCO3-25 [2143-10-14] 09:17PM BLOOD Mg-2.3 [2143-10-18] 06:05AM BLOOD WBC-7.8 RBC-3.11* Hgb-9.1* Hct-27.2* MCV-87 MCH-29.3 MCHC-33.6 RDW-14.5 Plt Ct-198 [2143-10-18] 06:05AM BLOOD Plt Ct-198 [2143-10-18] 06:05AM BLOOD Glucose-84 UreaN-14 Creat-0.7 Na-136 K-4.1 Cl-102 HCO3-30 AnGap-8 Brief Hospital Course: Ms. [Known lastname ] was a same day admit after undergoing pre-operative work-up prior to surgery. On [10-14] she was brought directly to the operating room where she underwent an aortic valve replacement. Please see operative report for surgical details. Following surgery she was transferred to the cardiac surgical ICU for invasive hemodynamic monitoring. She received Cefazolin IV every 8 hours for four doses. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one chest tubes were removed and she was transferred to the telemetry floor for further care. Beta blockers and diuretics were given and she was gently diuresed towards her pre-op weight. Epicardial pacing wires were removed on post-op day three. Also on post op day three she was noted to be lethargic and was found to have a hematocrit of 24.3. She was transfused 2 units packed red blood cells. Her hemarocrit came up to 27.2. The patient looked better and stated she had improved energy. She worked with physical therapy for strength and mobility and on post-op day 4 she was discharged to rehab. Medications on Admission: fosamax 22 mg q week 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 Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:40 Tablet(s) Refills:0 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:20 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:40 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) 8545] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement PMH: Osteoporosis, recent rx for poss. PNA, s/p Hysterectomy, s/p Tonsillectomy, s/p Appendectomy, s/p Bilat. hip replacement, s/p Abdominoplasty, s/p Left ear surgery x 2 Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incision dry no driving for one month and until off all narcotics no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness, drainage or weight gain greater than several pounds in less than a week Followup Instructions: see Dr. [First Name (STitle) ] in [12-12] weeks see Dr. [Last Name (STitle) 80400] in [1-13] weeks see Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] please call for appts. Completed by:[2143-10-18]	[ "4241" ]
Admission Date: [2185-9-23] Discharge Date: [2185-10-5] Date of Birth: [2145-10-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: hypotension, sepsis, CRF, obesity-hypoventilation syndrome Major Surgical or Invasive Procedure: debridement of abdominal surgical wound History of Present Illness: 39 year old man with Prader-Willi syndrome, morbid obesity, obesity hypoventillation (vent. dependent), Renal failure on HD, who was rectently admitted to ICU here with sepsis s/p abdominal abscess debridement ([Date range (1) 99960]) and discharged to rehab at the [Hospital1 ] House - was found to be hypotense at HD today (sbp 55 - came up to 100/40 after HD stopped after 30 min), also noted to have hct. 22. Sent to [Hospital1 18] ED. . Past Medical History: Prader Willi Syndrome Morbid obesity T2DM CRI with baseline creatinine 1.8-2.0 OSA Mental retardation Hypothyroidism Status post tracheostomy and PEG tube placement Social History: Resident at [Hospital 100] Rehab. No smoking, ethanol or drug use. Family History: Family history of diabetes. Physical Exam: VS:98.6 86 116/doppler 12 96% (on FiO2 .4 on CMV on vent) HEENT: EOMI, PERRL COR: RRR, [3-7] HSM PULM: CTA anteriorly ABD:obese, foley in place as G tube with tube feeds leaking around ostomy, LLQ abscess drainage site with Wet-dry dsg in place. LLQ indurated, erythematous EXT:RLE edema greater than Lt LE, bilateral heel pressure ulceration NEURO:Opens eyes to voice, tracks, nods yes/no in response to questions . Pertinent Results: [2185-9-23] 05:09PM HCT-23.3* [2185-9-23] 12:48PM WBC-15.8* RBC-2.67* HGB-7.2* HCT-23.8* MCV-89 MCH-27.0 MCHC-30.2* RDW-22.6* [2185-9-23] 12:48PM PLT COUNT-265 [2185-9-23] 02:30AM GLUCOSE-96 LACTATE-1.7 NA+-143 K+-4.6 CL--105 TCO2-31* [2185-9-23] 02:10AM GLUCOSE-95 UREA N-46* CREAT-3.8# SODIUM-141 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15 [2185-9-23] 02:10AM ALT(SGPT)-22 AST(SGOT)-24 ALK PHOS-462 AMYLASE-13 TOT BILI-0.5 [2185-9-23] 02:10AM LIPASE-11 [2185-9-23] 02:10AM CALCIUM-8.5 PHOSPHATE-2.5* MAGNESIUM-1.8 [2185-9-23] 02:10AM WBC-14.1* RBC-2.21* HGB-6.1* HCT-20.3* MCV-92 MCH-27.8 MCHC-30.2* RDW-23.2* [2185-9-23] 02:10AM NEUTS-90.1* BANDS-0 LYMPHS-7.3* MONOS-1.2* EOS-1.3 BASOS-0.1 [2185-9-23] 02:10AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ SPHEROCYT-OCCASIONAL [2185-9-23] 02:10AM PLT SMR-NORMAL PLT COUNT-261 [2185-9-23] 02:10AM PT-15.4* PTT-34.0 INR(PT)-1.4* Brief Hospital Course: 39 y/o with Prader-Willi, morbid obesity, obesity-hypoventilation syndrome (vent dependent), CKD on HD who was found to be hypotense and anemic at HD. The hospital course consisted of chronic hypotension, bacteremia, worsening abdominal abscess, and HD that could not take off fluid. His sister [Name (NI) 2431] was involved in his care and health care decision making daily (she is the HCP). After long discussions with family and consulting doctors, [Doctor First Name 2431] wished to take him home with hospice care to die at home. HD and all invasive procedures were held in hospital and antibiotics were continued until the day of discharge. [Doctor First Name 2431] came in and assisted with [Known firstname 2979] care in preparation to care for him at home. Supplies and hospice services were established and in place for the day of discharge. Dr.[Name (NI) 20819] (PCP) was called and aksed for an order for Hospice care DNR/DNI/DNH. Medications on Admission: Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO DAILY (Daily). 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H as needed. 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID as needed. 6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY 7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY 9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY 10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 60 units Subcutaneous q breakfast. 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection q ACHS: Please administer insulin according to the following sliding scale. If BG 141-200, please give 8 units. If BG 201-240, give 12 units. If BG 241-280, give 16 units. If BG 281-320, give 20 units. If BG 321-360, give 24 units. If BG 361-400, give 28 units. 12. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY Discharge Medications: 1. Hydromorphone 2 mg/mL Syringe Sig: 1-2 mg Injection Q6H (every 6 hours) as needed for pain. 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [5-5] Puffs Inhalation Q6H (every 6 hours). 3. Roxanol Concentrate 20 mg/mL Solution Sig: [1-31] PO every four (4) hours as needed for pain for 10 days. 4. Ventilator Set Misc Sig: One (1) Miscell. once a day. 5. Oxygen-Air Delivery Systems Device Sig: One (1) Miscell. continuous. 6. Oxygen Tubing Misc Sig: One (1) Miscell. continuous. Discharge Disposition: Home With Service Facility: Vista Care Hospice Discharge Diagnosis: 1. prader willi 2. Anemia 3. obesity hypoventilation syndrome ventilator dependent 4. bacteremia 5. abdominal abscess 6. chronic renal failure Discharge Condition: comfort measures only Discharge Instructions: Follow the suggestions and care of Hospice nurses and doctors. Followup Instructions: Please follow up with your physician as needed	[ "25000", "2449", "32723", "99592" ]
Admission Date: [2128-10-8] Discharge Date: [2128-10-13] Date of Birth: [2064-9-5] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2569] Chief Complaint: Right sided weakness and slurred speech Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a 64 yo man with PMH of afib, on coumadin, HTN, MI, hypercholesterolemia who presents as a transfer from [Hospital1 ] with Left BG bleed. Wife reports that he woke at 0500, was getting ready for work and came to her around 0545 saying "I think I'm having a stroke". His sppech was slurred at that time. While awaiting EMS became he more dysarthric. Wife thought both arms were moving. At [Hospital1 ] reported to be aphasic with right hemiparesis and possibly neglect. CT showed 4.4 x 2.2 cm intraparenchymal hemorrhage in left BG at 0620. Received 10mg Vit K SC and transferred. ROS: Denies HA, pain, nausea, SOB. No fall/trauama. Otherwise cannot give secondary to aphasia. Past Medical History: A-fib HTN Hypercholesterolemia MI [2108] Social History: quit tob 12 yrs ago. Occ ETOH. Skilled laborer. Lives with wife. [Name (NI) ] 2 sons. Family History: No ICH, stroke or aneurysms. Father had MI. Physical Exam: T- 95.6 BP- 123/71 HR- 70 RR- 17 O2Sat 95 RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, supple Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: slight crackles left lung base? aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Says name, but dysarthric. Cannot say month/year. Intermittently expressive aphasia, however at times says near fluent sentence. Repetition dysarthric but able to do. Naming intact. Reads well. No apparent neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Right facial droop. Hearing intact to voice. Palate elevation symmetrical. Sternocleidomastoid Shoulder shrug weak right. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone down in RUE. No observed myoclonus or tremor [Doctor First Name ] Tri [Hospital1 ] WF WE FE FF IP H Q DF PF TE TF R 4 5- 5- 0 0 0 3+ 5- 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, pinprick throughout. No extinction to DSS Reflexes: +2 and symmetric throughout. Toes up bilaterally Coordination: finger-nose-finger normal left. Cannot do RUE. Left HS intact, but right ataxic. Gait: deferred. Pertinent Results: [2128-10-8] 08:30AM BLOOD WBC-8.6 RBC-4.71 Hgb-15.0 Hct-42.0 MCV-89 MCH-31.8 MCHC-35.7* RDW-14.4 Plt Ct-227 [2128-10-12] 05:50AM BLOOD WBC-8.3 RBC-4.59* Hgb-14.5 Hct-42.5 MCV-92 MCH-31.5 MCHC-34.1 RDW-14.6 Plt Ct-228 [2128-10-8] 08:30AM BLOOD PT-22.0* PTT-60.0* INR(PT)-2.2* [2128-10-12] 05:50AM BLOOD PT-13.5* PTT-40.0* INR(PT)-1.2* [2128-10-8] 08:30AM BLOOD Glucose-155* UreaN-17 Creat-0.8 Na-140 K-4.2 Cl-107 HCO3-24 AnGap-13 [2128-10-12] 05:50AM BLOOD Glucose-115* UreaN-15 Creat-0.7 Na-142 K-3.6 Cl-105 HCO3-29 AnGap-12 [2128-10-8] 08:30AM BLOOD CK(CPK)-70 [2128-10-9] 12:13AM BLOOD CK(CPK)-141 [2128-10-11] 10:40AM BLOOD CK(CPK)-77 [2128-10-10] 05:56AM BLOOD ALT-24 AST-19 LD(LDH)-151 AlkPhos-75 TotBili-0.6 [2128-10-8] 08:30AM BLOOD CK-MB-5 cTropnT-<0.01 [2128-10-9] 12:13AM BLOOD CK-MB-5 cTropnT-<0.01 [2128-10-9] 08:37AM BLOOD CK-MB-6 cTropnT-<0.01 [2128-10-8] 08:30AM BLOOD Calcium-8.9 Phos-2.3* Mg-1.9 [2128-10-12] 05:50AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.2 [2128-10-9] 07:43PM BLOOD %HbA1c-5.7 [2128-10-9] 07:43PM BLOOD Triglyc-57 HDL-53 CHOL/HD-2.8 LDLcalc-87 [2128-10-9] 12:26AM BLOOD Type-ART pO2-118* pCO2-44 pH-7.40 calTCO2-28 Base XS-2 [2128-10-8] 10:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG CT-Head [2128-10-8] MPRESSION: Left basal ganglia hemorrhage measuring 4.4 x 2.2 cm with surrounding edema and grossly stable from prior study. MRA Head and Neck [2128-10-8] MPRESSION: 1. No significant change in approximately 3.7 x 2 cm left basal ganglia hemorrhage with surrounding vasogenic edema. 2. No other intracranial hemorrhages are identified. 3. No aneurysms or vascular malformations. 4. Mild atherosclerotic stenosis of the internal carotid artery bulbs bilaterally. Repeat Head CTs on [2128-10-9] and [2128-10-10] - unchanged. Brief Hospital Course: The patient was initially admitted to the intensive care unit for closer monitoring and for concern that the patient would develop hydrocephalus due to edema around the hemorrhage. The patients coumadin was held and his INR reversed. The nitropaste was removed. Sotalol was held in favor of lisinopril and PRN hydralizine. This decision was based on the 2nd degree heartblock noticed on telemetry and on an EKG. On the second day of admission the patient was stable. He had a headache and was mildly nauseated but the head CT was essentially unchanged from admission and did not demonstrate hydrocephalus. The patient was moved to the step-down unit. The patient's headache was treated with fioricet, tylenol and prn morphine. He was eventually transitioned to percocet only, which was able to control the headache. He had no new neurological deficits on daily exam and showed improvement. He passed a swallow evaluation and was advanced to modified diet. Physical therapy worked with him as an inpatient and he had some evidence of unstable gait; rehab was recommended. Ultimately, restarting coumadin in the future was felt to be contraindicated considering his hemorrhage and his relatively lower probability of ischemic stroke (other medical problems: HTN, MI, high cholesterol) compared to the relatively higher risk of recurrence of hemorrhage, as hemorrhage occurred despite a therapeutic INR of 2.2. Medications on Admission: Coumadin 7mg/2mg (as directed) ASA 81 daily Lisinopril 40 daily Sotalol 80 daily Protonix 40 Lipitor 80 Fexofenadine 180 daily Discharge Medications: 1. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal DAILY (Daily). 2. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-30] Sprays Nasal QID (4 times a day) as needed. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for headache. Discharge Disposition: Extended Care Facility: new [Hospital 74949] rehab [Location (un) ] Discharge Diagnosis: Intracerebral Hemorrhage. Discharge Condition: Vital signs stable. The patient has residual dysarthria, mild aphasia, and weakness of the wrist and finger extensors on the right hand. Discharge Instructions: Please follow up with your clinic appointments. Please take your medications as prescribed. Please note that you have suffered a hemorrhagic stroke. Should you develop worsening of your symptoms: more language difficulty, more significant facial droop, weakness in your limbs or difficulty with gait, you return to the emergency room. Followup Instructions: Please follow up with your primary care provider in the next two weeks. An appointment can be scheduled with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 10508]. Please make a follow up appointment to see Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ] in the neurology clinic in the next month. An appointment can be made by calling [Telephone/Fax (1) 2574]. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2128-10-13]	[ "42731", "4019", "2720", "412", "V5861" ]
Admission Date: [2179-3-30] Discharge Date: [2179-4-24] Date of Birth: [2104-3-4] Sex: M Service: CARDIOTHORACIC Allergies: lactose Attending:[First Name3 (LF) 165] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2179-4-8] 1. Off Pump Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending, and saphenous vein grafts to diagonal, obtuse marginal, and posterior descending artery. 2. Left Carotid Endarterectomy [2179-4-23] Successful ultrasound and fluoroscopic-guided placement of tunneled 15.5 French 28 cm (23 cm tip-to-cuff) tunneled hemodialysis catheter via the right internal jugular vein with tip in the right atrium. The line is ready to use. History of Present Illness: This is a 78 year old male with a history of significant peripheral vascular disease and coronary artery disease. He was recently found to have severe carotid artery stenosis and in work-up for surgery he underwent a persantine exercise tolerance test. This revealed no chest pain however a moderate sized defect which consisted of a prior infarct and a small territory of inferolateral and inferoseptal ischemia was noted. Subsequent cardiac catheterization revealed severe three vessel coronary artery disease. He denies any chest pain but admits to dyspnea on exertion when walking up stairs. He was scheduled for coronary artery bypass grafting surgery but presented to [Hospital 6451] with right sided weakness and slurred speech. Given his known coronary artery disease and critical left carotid stenosis, he ws transferred to the [Hospital1 18] for further evaluation and treatement. Past Medical History: Coronary Artery Disease Prior silent Myocardial infarction Hyperlipidemia Hypertension Chronic Renal Insufficiency Renal Artery Stenosis Abdominal aortic aneurysm 5.5cm Cerebrovascular disease, Carotid Disease History of malaria Arthritis, Degenerative joint disease Prior Dental extractions Social History: Lives with: Wife and 2 sons Occupation: Retired Tobacco: Pipe smoker for the past 60+ years ETOH: < 1 drink/week Illicit drug use: denies Family History: Father died at 64 of an MI. Mother died of MI at 77. Physical Exam: PREOP EXAM Pulse: 54 Resp: 16 O2 sat: 99% B/P Right: 151/76 Left: 157/80 Height: 5'5" Weight: 164 lbs General: Well-developed male 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 [] Murmur [] grade ______ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema trace-1+ Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: - Left: - PT [Name (NI) 167]: - Left: - Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: + Pertinent Results: [2179-3-30] WBC-9.9 RBC-4.59* Hgb-12.7* Hct-39.2* MCV-85 RDW-13.7 Plt Ct-226 [2179-3-31] PT-12.0 PTT-143.1* INR(PT)-1.1 [2179-3-30] Glucose-105* UreaN-31* Creat-2.4* Na-135 K-4.8 Cl-99 HCO3-26 [2179-4-1] Calcium-8.4 Phos-4.1 Mg-2.2 [2179-3-31] Renal Ultrasound: The right kidney measures 10.1 cm and the left kidney measures 11 cm. There is no evidence of hydronephrosis, nephrolithiasis, or renal masses bilaterally. [2179-4-1] Neck CT without contrast: Within the limits of a non-contrast study, a small amount of calcified atherosclerotic disease is present in the proximal left subclavian artery as well as in the distal portion of the brachiocephalic artery. Minimal calcified atherosclerotic disease is present at the carotid bifurcation on the right and minimal-to-moderate calcified atherosclerotic disease present at the carotid bifurcation on the left. Calcified atherosclerotic disease is also present in the cavernous portion of both internal carotid arteries as well as the intracranial portion of the vertebral artery just before their confluence in to the basilar artery. [2179-4-2] MRA of Head/Neck: 1. No definite focus of acute infarction. Nonspecific white matter changes related to small vessel ischemic disease. Moderate ventricular dilation, out of proportion to the size of the cerebral sulci may relate to central parenchymal volume loss/superimposed communicating hydrocephalus. 2. Significant atherosclerotic disease involving the carotid and vertebral arteries in the neck and the head with multilevel short segment stenosis and post-stenotic dilation at multiple levels as described above. Focal prominence of the right cavernous carotid segment and anterior communicating artery complex may relate to atherosclerotic disease or fusiform dilation. [2179-4-8] Intraop 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. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). The aortic root is mildly dilated at the sinus level. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. . Brief Hospital Course: Mr. [Known lastname ] was admitted from [Hospital3 417] Hospital with right sided weakness and slurred speech that resolved prior to transfer. He was also noted to have acute on chronic renal insufficiency. The exact etiology of his transient neurologic event was unclear, and he required further vascular and neurological evaluation prior to surgical intervention. Neurology, vascular and nephrology services were consulted and imaging studies showed no definite focus of acute infarction. He was maintained on intravenous Heparin with no further neurological events. His neurologic event and acute renal insufficiency were attributed to hypotension. Over several days, his renal function improved with fluid resuscitation. Based upon extensive evaluation, left carotid endarterectomy was recommended at time of coronary artery bypass grafting surgery. Preoperative course was otherwise uneventful and he remained stable on medical therapy. . On [4-8], patient underwent off pump coronary artery bypass grafting along with left carotid endarterectomy. For surgical details, please see operative note. Given his prolonged hospital stay, Vancomycin was utilized for perioperative antibiotic coverage. He tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical condition. Upon arrival to the CVICU, Mr.[Known lastname ] had a profound metabolic acidosis which kept him intubated overnight. He was volume resuscitated, sedation discontinued, found to be neurologically intact and he was extubated. He remained in the CVICU for several days due to heart rhythm, pulmonary status and renal dysfunction. Postoperatively his mental status was somewhat lethargic, although easily arousable. Neurology continued to follow due to Mr.[Known lastname ] transient, recurrent right hemiparesis and dysarthria seen preop in the setting of hypotension and severe [Doctor First Name 3098] stenosis. He was alert and appropriate on discharge, oriented x [1-15]. Postoperative paroxysmal atrial fibrillation with a rapid ventricular response rate was treated with beta-blocker initially to which he had minimal to no response. Amiodarone and Diltiazem was initiated and the episodes of rapid AF would convert to normal sinus rhythm. Chest tubes and pacing wires were discontinued per protocol. Anti coagulation with Coumadin was initiated. He was slowly weaned off high flow oxygen to nasal cannula. Diuresis was avoided due to his bilateral renal artery stenosis noted on a preoperative CT scan and baseline creatnine of 1.8. He became oliguric initially and with higher blood pressures, his urine output improved. Renal was consulted for worsening kidney function reflective via BUN/ creatnine results. Acute tubular necrosis was evident on urine lytes and Renal continued to follow. He received a vascath for HD on [2179-4-20]. A tunneled line was placed in IR on [2179-4-23]. Vascular surgery followed Mr.[Known lastname ] throughout his hospital course as he is status post left carotid endarterectomy. Additionally, he has a known Aortic Abdominal Aneurysm which the Vascular team will surgically address after his recovery from this hospital admission. Physical Therapy was consulted for evaluation of his strength and mobility. He was transferred to the step down unit for further monitoring and recovery. The remainder of his hospital course was essentially uneventful and he continued to slowly progress. On POD#16 he was discharged to [Hospital1 ] [Hospital 48496] in [Hospital 701] rehabilitation. All follow up appointments were advised. Medications on Admission: Aspirin 325mg daily Simvastatin 80mg daily HCTZ 12.5mg daily Atenolol 50mg daily Hydralizine 10mg TID Naprosyn Fish Oil Red yeast Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for dyspnea. 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 1 weeks. 12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 13. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: 1mg on [4-24] then as directed to maintain target INR. target INR 2-2.5. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Hospital Discharge Diagnosis: Coronary Artery Disease - s/p CABG Cerebrovascular Disease, Carotid Disease - s/p Left CEA Hypertension Dyslipidemia Abdominal Aortic Aneurysm Acute tubular necrosis requiring dialysis Discharge Condition: Alert and oriented x [1-15] nonfocal Ambulating, deconditioned Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Bilat Leg incision- healing well, slight erythema no drainage. Edema- 1+ bilat Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Cardiologist: Dr. [Last Name (STitle) 7047] [2179-4-27] at 9:15a Vascular: Dr. [Last Name (STitle) ] [2179-5-24] 3:45 Provider [First Name8 (NamePattern2) ] [Name9 (PRE) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2179-5-11] 1:45 in the [Hospital ] medical office building [Doctor First Name ], [Hospital Unit Name ] Provider VASCULAR LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2179-5-24] 3:15 Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ],NIKOLAOS [Telephone/Fax (1) 6699] in [3-18] 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 Labs: PT/INR for Coumadin ?????? indication AFib Goal INR 2-2.5 First draw [2179-4-25] and every other day until stable then as directed [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2179-4-24]	[ "5845", "5849", "2762", "40390", "41401", "2724", "5859", "42731", "412" ]
Admission Date: [2198-8-17] Discharge Date: [2198-8-24] Date of Birth: [2140-9-23] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1481] Chief Complaint: Presents for surgical resection of an esophageal tumor Major Surgical or Invasive Procedure: [8-17] Minimally invasive combined thoroscopic and laparoscopic total esophagogastrectomy. History of Present Illness: Mr. [Known lastname 67088] is a 57 year old male with a history of esophageal cancer, T3N0Mo diagnosed [4-14]. He completed five and a half weeks of radiation and two cycles of chemotherapy, he presents for surgical resection of his tumor. Past Medical History: Past Medical History: Esophageal cancer Hypertension GERD Diverticulitis Colon polyps Past Surgical History: [8-15] Removal of venous access port [4-14] Placement of feeding jejuonostomy tube and venous access port '[96] Colonoscopy Tonsillectomy Wrist operation Social History: He lives in [Location (un) 3844], is married and has one son age 13 with ADHD. He is retired from work as an exercise tax auditor for the IRS. No history of smoking, drinks alcohol occasionally Family History: Mother deceased from lung cancer Father deceased from complications of COPD Pertinent Results: Post-operatively: [2198-8-17] 04:50PM BLOOD WBC-34.0# RBC-3.56 Hgb-12.0* Hct-34.3* MCV-96 MCH-33.7* MCHC-35.1* RDW-14.7 Plt Ct-278# [2198-8-17] 04:50PM BLOOD PT-13.1 PTT-28.2 INR(PT)-1.1 [2198-8-17] 04:50PM BLOOD Plt Ct-278# [2198-8-17] 04:50PM BLOOD Glucose-147* UreaN-19 Creat-0.8 Na-141 K-4.7 Cl-108 HCO3-21* AnGap-17 [2198-8-17] 04:50PM BLOOD Calcium-8.3* Phos-4.1 Mg-1.4* [2198-8-17] 09:29AM BLOOD Type-ART Tidal V-510 FiO2-100 pO2-75* pCO2-41 pH-7.44 calTCO2-29 Base XS-3 AADO2-615 REQ O2-98 Intubat-INTUBATED Vent-CONTROLLED [2198-8-17] 09:29AM BLOOD Glucose-105 Lactate-2.3* Na-143 K-4.2 Cl-106 [2198-8-17] 09:29AM BLOOD Hgb-13.4* calcHCT-40 [2198-8-17] 09:29AM BLOOD freeCa-1.19 Discharge Labs: [2198-8-21] 03:27AM BLOOD WBC-8.8 RBC-3.29* Hgb-10.9* Hct-32.2* MCV-98 MCH-33.0* MCHC-33.7 RDW-13.6 Plt Ct-232 [2198-8-22] 05:46AM BLOOD Hct-31.2* [2198-8-21] 03:27AM BLOOD Plt Ct-232 [2198-8-22] 05:46AM BLOOD Glucose-129* UreaN-16 Creat-0.7 Na-141 K-3.7 Cl-102 HCO3-33* AnGap-10 [2198-8-22] 05:46AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.8 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Esophageal cancer, status post chemoradiation. POSTOPERATIVE DIAGNOSIS: Esophageal cancer, status post chemoradiation. PROCEDURE PERFORMED: Minimally invasive total esophagectomy via thoracoscopy and laparoscopy. ASSISTANT: [First Name11 (Name Pattern1) 951] [Last Name (NamePattern4) ], MD. ANESTHESIA: General. INDICATIONS: This gentleman has esophageal cancer and has undergone neoadjuvant treatment. He has previously undergone laparoscopy and laparoscopic jejunostomy. He presents now for definitive surgical therapy. PREPARATION: In the operating room, the patient underwent general endotracheal anesthetic via a double-lumen tube. Intravenous antibiotics were given and appropriate lines were placed. A Foley catheter was placed in the bladder. He was placed in the left lateral decubitus position with the right side up. The chest was prepared with Betadine solution and draped in the usual fashion. Trocar placement: Number 12 ports were placed anterior to the scapula in a staggered position. Two #5 trocars were placed well posteriorly. FINDINGS: There was inflammatory change consistent with radiotherapy. In the thoracic portion, there was no evidence of metastatic disease nor were there any particularly concerning enlarged lymph nodes. The same was true in the abdominal portion. The tumor itself appeared to become extremely fibrotic and there was no evidence of mucosal tumor when the specimen was removed, although there was a great deal of thickening at the esophagogastric junction which could either be a complete response of scarring or submucosal tumor. PROCEDURE IN DETAIL: With 1-line ventilation, we were able to reflect the lung over anteriorly. We began the anterior portion of the esophagus by taking down the inferior pulmonary ligament up to the level of the inferior pulmonary vein. Dissection was then carried out continuing superiorly. We were able to identify and clear the lymphatic tissue over toward the esophagus. We then up and cleared the azygos vein. We were able to see the spur of the carina and come down and dissect the esophagus and surrounding lymphatic tissue off of the left main-stem bronchus, clearing the subcarinal packet. We were unable to divide the azygos vein with the Endo [Female First Name (un) 3224] stapler. A nice envelope was created in the pleura and at the level of the azygos vein. We then started our dissection right on the esophageal muscular wall so as to avoid the recurrent laryngeal nerve and work our way up into the thoracic inlet, completely dissecting this area free. A Penrose drain was placed around the esophagus and placed up in the thoracic inlet for easy identification from the neck incision. We then worked inferiorly from this area and were able to encircle the esophagus with a Penrose drain to facilitate our dissection. We were able to take the posterior pleura off relatively close to the azygos vein. We purposely left the tissue right around the thoracic duct but then were able to dissect down right down onto the aorta. We were able to work down from this level down to the diaphragm. The crura were identified and the tissue around it was reflected away and kept with the esophagus. We were able to complete our dissection clearing off this area completely, seeing the azygos vein into the inferior pulmonary vein on the left, as well as the left pleura. The Penrose drain was then left in the thorax very close to the diaphragm in order to facilitate dissection of the hiatus from below. Hemostasis was assured. A #28 chest tube was placed. The lung was reinflated. The trocars were removed. The larger thoracic incision was closed with interrupted sutures of 0 Vicryl to the musculature. The skin was closed with running subcuticular sutures of 4-0 Monocryl. Steri-Strips and dressings were applied. The chest tube was hooked up to wall suction. We then turned our attention to the laparoscopic portion. The patient was placed in supine position. The jejunostomy tube was temporarily removed in order to maintain sterility while the abdomen was prepared in the standard sterile fashion after the patient was placed in lithotomy position. Trocar placement: Open technique was used to access the peritoneal cavity and to control the incision used for thelaparoscopic jejunostomy which was approximately 14 cm below the xiphoid. The abdomen was insufflated. A #5 trocar was placed laterally on the left, and #12 dilating ports were placed superiorly on the left and the midclavicular line on the right and laterally on the right. Later on in the case, a #5 trocar was placed in the midclavicular line on the right. At this point, we encountered no other metastatic disease or pathologically enlarged lymph nodes . We began dissecting the omentum along the greater curvature of the stomach, making sure that we had preserved very nicely the gastroepiploic arcade. Dissection was carried out with the Harmonic scissors. We then moved upwards toward the short gastrics. Because the patient was fairly large and our incision was a little bit on the low side, we were going to be forced to use a longer scope for the upper dissection, and therefore we went up as far as we could with our regular scope and then started from that area on the greater curve and worked towards the patient's right. We were able to get into the posterior plane behind the stomach and lift the stomach up, and come around and find the gastroepiploic origin which was preserved. We then took the intervening tissuebetween the duodenum and the colon. The duodenum was then identified and it was completely Kocherized to allow for maximum mobility. The gastrohepatic omentum was then opened up to the level of the diaphragm with Harmonic scissors. The right gastroepiploic artery was spared. Using a longer scope, we then completed our dissection along the greater curvature, treating the short gastric vessels with the Harmonic scissors, completely freeing the fundus from the left crus. The esophagus was then identified along with a Penrose drain to facilitate its identification after the dissection of the left gastric artery. Working from below, we were then able to identify the tissue around the left gastric artery. This was dissected to some degree and was very close to thethe pancreas. Tissue was then taken with the Endo [Female First Name (un) 3224] stapler with a vascular load. Some intervening tissue between this and the esophagus was then taken with the harmonic scissors. At this point, we were satisfied with the entire stomach had been mobilized with the exception of the uppermost portion around the hiatus, which we saved until last to prevent pressurized air entering the thoracic cavity. We then divided some of the lesser curvature mesentery using the [Female First Name (un) 3224] stapler approximately 6 to 7 cm from the pylorus. We then divided the stomach and made a long gastric tube based on the right gastroepiploic artery using the Endo [Female First Name (un) 3224] stapler with a thick load. Our true diameter was approximately 7 cm. We then moved up with serial firings and were able to effect a nice long gastric conduit. The new gastric conduit was then sutured to the specimen using 3 sutures of 2-0 silk in order to facilitate transfer through the mediastinum. We then opened the neck using a collar incision. The sternomastoid was retracted laterally and the omohyoid was divided. We were then able to get into the direct plane of the thoracic inlet. We were able to identify the Penrose drain. Of interest, is that we originally had a small amount of difficulty because the Penrose drain was actually a lot higher than we thought it would be. Our entire dissection had been completed through to the thorax. The Penrose drain was pulled up and we were very satisfied that the esophagus had been nicely dissected and that were high enough to almost the level of the cricoid. With Dr. [Last Name (STitle) 952] at the neck position and I doing laparoscopy, we were able then to pull up the specimen of the gastric conduit through the mediastinum and up into the neck avoiding twisting by doing this under laparoscopic guidance. We had a very nice amount of stomach which was quite healthy. I should mention that just prior to this, we did complete our hiatus dissection, completely freeing the fundus and esophagus from the hiatus and pulling the Penrose drain down to the mediastinum. The Penrose drains were then removed prior to pulling the stomach through the thorax. We then fashioned an anastomosis using a side-to-side technique making holes in the esophagus and a stomach graft well below where the end of it was. Two runs of the Endo [Female First Name (un) 3224] stapler were then fired. The nasogastric tube was then switched to the stomach and extra amounts of esophagus and stomach were then divided with another application of the [Female First Name (un) 3224] stapler. The patient was then re-laparoscoped and the stomach was attached to the crura using interrupted sutures of 2-0 silk. The area was checked for hemostasis which was adequate. Ports were then removed under direct vision without bleeding. Closure: The camera port was closed with interrupted sutures of 0 Vicryl to the fascia. The neck was closed with 3-0 Vicryl placed to the deeper layers and staples for the skin. The abdominal skin was also closed with staples. We then attempted to replace the jejunostomy which had only been out for several hours, and I found it difficult to do so and it did not slide in easily which was extremely surprising. I did try gentle attempts with a slightly smaller tube which way in away I was not totally satisfied. I left this tube in place. The plan is for a tube study and potentially a tube replacement under fluoroscopic guidance with contrast following the surgical procedure. Appropriate dressings were applied. The patient was then extubated and sent to the surgical intensive care unit in satisfactory condition, after tolerating the procedure well. DRAINS: One #28 chest tube to the chest, 1 [Location (un) 1661]-[Location (un) 1662] drain to the neck. COMPLICATIONS: Inability to replace jejunostomy tube. ESTIMATED BLOOD LOSS: 50 cc. I attest that surgeons of 2 separate specialties were required for this very complex operation. Both surgeons were presentat the tableand active throughout the entire procedure. Dr. [Last Name (STitle) 952] had primary responsibility in the chest and I in the abdomen, and both shared responsibility in the neck. CHEST (PORTABLE AP) [2198-8-17] 10:53 PM Reason: ccvl pulled back [Hospital 93] MEDICAL CONDITION: 57 year old man with esophageal CA s/p esophagectomy REASON FOR THIS EXAMINATION: ccvl pulled back CLINICAL INDICATION: Central line pulled back. Esophagectomy. TECHNIQUE: AP view of the chest is submitted for interpretation. Findings are compared with prior examination dated [2198-8-17]. FINDINGS: There is a right internal jugular catheter with distal tip projecting over the distal SVC. NG tube is visualized with distal tip over the proximal fundus, recommend advancement. A right-sided chest tube again seen with tip projecting over the lateral right mediastinum. Again noted small amount of subcutaneous emphysema projecting along the right thorax, decreased in amount from the prior examination. Surgical staples again seen over the left neck region. Mediastinum changes are again compatible with this patient's history of esophagectomy. Unchanged plate-like atelectasis seen at the left lung base. No effusions or consolidations seen. Surgical staples again seen over the upper abdomen. IMPRESSION: No significant interval change. Reason: please advance tube under fluoro guidance. case discussed w Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 57M s/p lap esophagogastrectomy, with dysfxnal J tube (pulled out...) REASON FOR THIS EXAMINATION: please advance tube under fluoro guidance. case discussed with dr [Last Name (STitle) ] PROCEDURE: Exchange of percutaneous jejunostomy tube. CLINICAL HISTORY: 58-year-old man status post laparoscopic esophagogastrectomy with dysfunctional jejunostomy tube. RADIOLOGISTS: Drs. [Last Name (STitle) ] and [Name5 (PTitle) 380], the Attending Radiologist, present and supervising throughout. DESCRIPTION OF PROCEDURE: Utilizing usual aseptic precautions, the patient's jejunostomy tube was accessed. Contrast was instilled by way of the jejunostomy tube outlining the distal segment of the tube within the jejunum. A 0.035-inch [Last Name (un) 7648] guide wire was then advanced through the lumen of the catheter emerging distally, and coiling within the jejunum. Subsequently, the J- tube was removed over the guide wire leaving the guide wire in situ. A new, Ultrathane Wills-[Doctor Last Name 12433] 35 cm long x 12 French jejunostomy tube was delivered over the wire. Subsequent to satisfactory positioning, the catheter was sutured to the skin using a single retention suture of 2-0 silk. The site was then dressed. Catheter was then capped in place. Patient tolerated the procedure well without immediate complication. Estimated blood loss was minimal. ANESTHESIA: 1% Xylocaine, 5 cc local infiltration at the skin entry site. IMPRESSION: Status post over the wire exchange of jejunostomy tube replacement with Wills-[Doctor Last Name 12433] 35 cm x 12 French jejunostomy tube. Catheter is ready to employ. CHEST (PORTABLE AP) [2198-8-21] 7:14 AM CHEST (PORTABLE AP) Reason: eval ptx [Hospital 93] MEDICAL CONDITION: 57 year old man with esophageal CA s/p esophagectomy now w/ CT on WS REASON FOR THIS EXAMINATION: eval ptx AP CHEST, 7:35 A.M. [8-21]. HISTORY: Esophageal carcinoma. Chest tube to waterseal. IMPRESSION: AP chest compared to [8-17] through 11: Small left pleural effusion is decreasing. Left basal atelectasis has improved. No pneumothorax. Mediastinum has a normal postoperative appearance, unchanged. Mild distention of the neoesophagus is stable. Nasogastric tube ends just below the diaphragm. Right supraclavicular central venous catheter ends in the low SVC. Heart size normal. CHEST (PA & LAT) [2198-8-23] 2:15 PM Reason: please eval for interval change, ptx s/p CT d/c [Hospital 93] MEDICAL CONDITION: 57M s/p esophagogastrectomy, chest tube now d/c REASON FOR THIS EXAMINATION: please eval for interval change, ptx s/p CT d/c CHEST, PA AND LATERAL INDICATION: Status post esophagectomy, chest tube now discontinued. Evaluate for interval changes. FINDINGS: AP and lateral views obtained with patient in sitting upright position and analyzed in direct comparison with similar preceding study of [8-22]. The patient is status post esophagectomy and pull-through. Surgical subcutaneous clips still seen overlying the left apical mediastinal area. During the latest interval, the right-sided chest tube and the right internal jugular approach central venous line have been removed. The previously described residual apical pneumothorax persists but has decreased in size and measures now approximately 2 cm. No other new abnormalities have developed. Plate atelectasis remains on left base and obliteration of lower descending aortic contour is suggestive of postoperative atelectasis in left lower lobe. No new abnormalities have developed in the pulmonary fields and no evidence of pulmonary congestion is present. IMPRESSION: Persistent slightly smaller right apical pneumothorax. No new pulmonary abnormalities after removal of tubes and line. Brief Hospital Course: There were no intra-operative complications and he was transferred to the surgical intensive care unit with a foley catheter, right sided chest tube, nasogastric tube, jejunostomy feeding tube, and [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] drainage tube. Post-operatively he was managed by the general surgical team and thoracic surgery team. He required intravenous fluid bolussing for low urine output and mild hypotension; a Levophed drip was also started which he was weaned off successfully. POD 1 he had an episode of desaturation and tachycardia after being transferred from the bed to a chair, an electrocardiogram showed no acute changes and cardiac enzymes were negative. He was started on beta-blockade at this time. His desaturation improved with aggressive pulmonary toileting. On POD 4 his jejunostomy tube was noted to be leaking when his tube feeds were started, it was found to be mal-positioned under fluoroscopy and was re-positioned in Interventional Radiology without difficulty. On POD 4 he was transferred to an in-patient nursing unit, he remained afebrile and was oxygenating well on nasal cannula. His chest x-ray demonstrated a moderate left sided pleural effusion with atelectasis, no pneumothorax; the thoracic service maintained the chest tube to wall suction. On POD 5 he had +flatus, +bowel movement and a swallow study which demonstrated no leak from the surgery; his nasogastric tube was removed and his diet was advanced which he tolerated. On POD 6 his chest tube and [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] was removed by thoracic surgery, a follow-up X-Ray demonstrated no pneumothorax. On POD 7 his abdominal incision was noted to be reddened without drainage, he was started on Kefzol which he will continue for five days. He was discharged home on [8-24] with visiting nurse services via [Hospital 5065] Healthcare. At the time of discharge his pain was well controlled with oxycodone elixir, he remained afebrile and was tolerating both a clear liquid diet and tube feeds. He received diet counseling from the nutrition department regarding his diet and will continue tube feeds at home. He will follow-up in one to two weeks with the general surgery and thoracic surgery clinics. Medications on Admission: Prevacid 30mg [Hospital1 ] Maalox prn Tylenol prn Discharge Medications: 1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 inhaler Refills:2 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:0 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:500 ML(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Prevacid 30 mg Susp,Delayed Release for Recon Sig: One (1) PO twice a day. Disp:60 Refills:2 6. Keflex 250 mg/5 mL Suspension for Reconstitution Sig: Five (5) ml PO four times a day for 5 days: Give into feeding tube. Disp:100 ml Refills:0 Discharge Disposition: Home With Service Facility: Home Health and Hospice of [Location (un) 8117] Discharge Diagnosis: Esophageal cancer Discharge Condition: Good Discharge Instructions: Notify your MD or return to the emergency department if you experience: Increased or persistent pain not relieved by pain medications Fever > 101.5 Shortness of breath or difficulty breathing Nausea or vomiting Inability to pass gas or stool If incision appears red, warm to touch, or if there is drainage If feeding tube leaks, is blocked, or if it pulls out You were started on a medication for your heart rate which was elevated after surgery, this may cause dizziness and light-headness. If you experience this hold off taking the Metoprolol. Any other symptoms concerning to you You may shower and wash incision with soap and water, pat dry. Please cover feeding tube entry site with a small plastic bag and tape. No swimming or tub baths while you have the feeding tube Avoid lifting more than 5 lbs and abdominal stretching for 4 weeks Followup Instructions: Follow-up with your PCP [Last Name (NamePattern4) ] 1 week, please bring the list of medications that you were discharged with for review. Follow-up with Dr. [Last Name (STitle) ] in [12-11] weeks, call [Telephone/Fax (1) 1483] for an appointment. Follow-up with Dr. [Last Name (STitle) 952] in [12-11] weeks, call ([Telephone/Fax (1) 1504] for an appointment Completed by:[2198-8-24*]	[ "4240", "2859" ]
Admission Date: [2123-6-1] Discharge Date: [2123-6-12] Date of Birth: [2046-6-2] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 2817] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 11946] is a 76 year-old man with ESRD (dialysis T/Th/Sat), DM2, CHF, and recent admissions for hypoglycemia who presents with 4 days of watery diarrhea. He states that the diarrhea began 4 days PTA on Saturday night. He had not eaten anything different from his family members except some fish on [Name (NI) 2974]. No one around him has been ill. The diarrhea is mainly watery, non-bloody. He states he has been having > 20 episodes/day. He denies abdominal pain, fevers, chills, n/v. Of note, he had one dose of Ancef on [5-26] before his balloon dilatation of his R AV fistula. . In the ED, vitals were 97.0 123/58 75 16 99% RA. CXR showed no e/o PNA and he was guaiac negative. Lactate was elevated to 7.3 and only decreased to 3.4 after 2 L IVF. He was admitted for further evaluation and further IVF. . Overnight, he continued to receive 125 cc NS/hr. This morning, he states that he continues to have several episodes of watery diarrhea. Denies fevers/chills, n/v, abdominal pain, HA, dizziness, lightheadedness, recent travel. Diarrhea has not slowed down. Past Medical History: 1. ESRD on HD through right AVF 2. Type 2 diabetes, oinsulin. 3. Vision loss on left eye 4. CHF, EF 35% in [12-2] 5. CAD s/p cath with stent placement in [12-2] 6. Hypertension 7. Hypercholesterolemia 8. Sickle cell trait 9. S/p bilateral cataract extraction 10. Low back pain. MRI [7-1] with DJD vs. spondylodiscitis, lumbar disk herniation and lumbar spinal stenosis. 11. H/o C.diff colitis [9-1] Social History: Originally from Montserrat, moved here in [2094]. Daughter is in charge of his home meds. Quit smoking 17 years ago, smoked 1 ppd x > 20 yrs. Quit EtOH 17 years ago and states that he drank heavily before that. No hx of illicit drugs. Family History: Son has renal disease. No family hx of MI, CVA. Father had diabetes. Physical Exam: Vitals: Tm 98.6, Tc 98.6, BP 111/56, HR 70, RR 18, O2sat 100% RA General: Elderly man sitting in bed, singing, in NAD. Difficult to understand. HEENT: NCAT, anicteric. Mucous membranes not markedly dry. OP clear. No LAD. CV: No JVD. RRR. 3/6 systolic murmur in RUSB. Resp: CTAB, no wheezes/rales/rhonchi. Abdomen: +BS. Soft, non-tender, non-distended. No masses. Ext: Cool, perfused, no edema. AV fistula in RUE with palpable thrill. Neuro: MS: A+Ox3, no asterixis. CN: II-XII intact. Motor: No pronator drift. Pertinent Results: [2123-6-1] 04:25PM BLOOD WBC-6.5 RBC-5.13 Hgb-13.6* Hct-44.3 MCV-86 MCH-26.6* MCHC-30.7* RDW-20.2* Plt Ct-137* [2123-6-1] 04:25PM BLOOD Glucose-103* UreaN-31* Creat-6.0# Na-141 K-3.5 Cl-96 HCO3-28 AnGap-21 [2123-6-1] 04:25PM BLOOD ALT-13 AST-36 AlkPhos-110 TotBili-2.3* [2123-6-3] 07:00AM BLOOD Calcium-7.8* Phos-5.5* Mg-2.2 [2123-6-1] 04:36PM BLOOD Lactate-3.7* [2123-6-1] 09:55PM BLOOD Lactate-3.4* [2123-6-2] 11:35AM BLOOD Lactate-6.8* [2123-6-2] 02:41PM BLOOD Lactate-6.3* [2123-6-3] 07:05AM BLOOD Lactate-3.1* [2123-6-3] 07:44AM BLOOD Lactate-2.8* . CT abdomen/pelvis: IMPRESSION: 1. Retroperitoneal adenopathy and trace pelvic free fluid, of uncertain etiology. 2. Gallbladder sludge and trace pericholecystic fluid, without definite evidence of acute cholecystitis. Please correlate clinically. 3. New pulmonary abnormalities and cardiomegaly could reflect interstitial lung disease such as non-specific interstitial pneumonitis. 4. Atherosclerosis, with mild-to-moderate stenosis of multiple vessels. No secondary bowel signs of mesenteric ischemia. . RUQ U/S: IMPRESSION: Moderately distended gallbladder with sludge within and mild gallbladder wall edema. These findings are most likely related to third spacing in this patient with ascites and renal failure. Acute cholecystitis can not be completely excluded, but is considered unlikely. Clinical correlation is advised. If further imaging work up is considered, a HIDA scan can be performed. Brief Hospital Course: 77 yo M with history of diabetes, ESRD on dialysis, heart failure, originally presented to the ED with diarrhea on [2123-6-1]. Unknown etiology. On transfer to the ICU, the patient was on day 9 of hospitalization and has newly noted liver failure in last 3 days. Patient s/p apnea and subsequent intubation in dialysis suite and was transferred to the ICU on [2123-6-10]. . ## Respiratory failure: Apnea in dialysis suite was reason for intubation. Once patient transferred to MICU, was noted to have a fingerstick blood sugar of 30. During assessment in the dialysis suite, primary team reported that he had been hypoglycemic immediately prior to dialysis and had received an amp of D50. Given this information and patient's blood sugar shortly after intubation, possible that apnea related to hypoglycemia. Venous blood gas at time of respiratory arrest was 7.39/34/318 on NRB, which indicates that hypercapnea an unlikely cause of his altered mental status or repiratory failure. . ## Hypotension: Underlying tenous volume status given that patient is anuric and on HD. His baseline BP tends to be 90-100s systolic. All of his periods of hypotension, including a fall to 60/palp on morning of [2123-6-8] seem to correlate with periods of profound hypoglycemia. Sepsis is another possibility; however patient has not been febrile during his hospital course and his WBC count had a maximum of 11.3 on [2123-6-8] after period of hypotension. WBC count otherwise normal and was 8.0 at time of transfer to the ICU. Patient was hypothermic to 95.3 upon transfer to the ICU, but that in setting of FSBS of 30. Patient did have a lactate elevation to 4.8 at time of respiratory arrest, though has been as high as 6.8 during this hospitalization (on [2123-6-2]). Possible cardiogenic component of shock related to worsening systolic function. Related to this, should rule out acute ischemic event. Cardiac enzymes at time of respiratory arrest were CKMB of 6 and Trop of 0.22. Baseline troponin in [2123-4-20] of 0.13. The patient was started on empiric vancomycin and zosyn, however he had progressively increasing pressor requirements. At the time of expiration, he was maxed out on neo, levo and vasopressin. . ## Liver failure: Report that patient "triggered" on the floor for SBP in the 60s on [6-8], which was coincident with sharp rise in liver enzymes. This points to shock liver as an etiology of his acute liver failure. In expanding the differential, the degree of enzyme elevation would point to acute viral hepatitis, autoimmune hepatitis, toxic ingestion, drugs. Negative for AMA, [Doctor First Name ], smooth muscle Ab, Hep C. Has immunity to Hep B (positive surface Ab) and past exposure to Hep A (Hep A Ab positive). Does have a ferritin that is greater than assay, which could indicate underlying hemachromatosis. There is a hereditary hemochromatosis mutation analysis pending. . ## Hypoglycemia: Patient with severe intermittent hypoglycemia of unknown etiology. He is a diabetic at baseline, though not receiving insulin this hospitalization gvein his hypoglycemia. Hypoglycemia likely worsened in setting of liver failure resulting in impaired gluconeogenesis. The patient was maintained on a D10W drip while in the ICU, with q1h fingersticks and subsequent normalization of his blood sugars. . ## Coagulopathy: PTT and INR to 57.2 and 5.2 today from 32.4 and 1.8 in [Month (only) 547] [2122]. He did not have coags at time of admission, so rapidity of rise unknown. Associated with elevated LDH creating a concern for hemolytic process. DIC at top of differential given concern for septic physiology. All complicated by underlying liver dysfunction with recent acute injury, though hepatology reporting that degree of coagulopathy is out of proportion to his liver failure. . #Shock: Due to the above medical problems, the patient developed a worsening lactate metabolic acidosis while in the ICU that did not respond to IV fluids or antibiotics. Ventilator support was increased to no avail. A family meeting was undertaken, and the patient was made CMO. On [2123-6-12], the patient expired at 5:52am. Medications on Admission: Aspirin 325 mg daily Nephrocaps daily Calcium acetate 667 mg TID with meals Cinacalcet 30 mg daily Clopidogrel 75 mg daily Docusate sodium 100 mg [Hospital1 ] Gabapentin 100 mg with HD Toprol XL 200 mg daily Atorvastatin 80 mg daily (has not refilled since [12-2]) Lantus 30 U qAM Sertraline 25 mg daily Polyethylene glycol daily PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO WITH HD (). 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days. Disp:9 Tablet(s) Refills:0 10. Lantus 100 unit/mL Solution Sig: Five (5) units Subcutaneous at 5 PM on days when you are eating. Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Diarrhea Secondary Diagnosis: End-stage renal disease on hemodialysis, type 2 diabetes mellitus, systolic congestive heart failure, coronary artery disease, hypertension, hyperlipidemia Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2123-6-27]	[ "51881", "40391", "2762", "4280", "2875", "41401", "2724", "4241" ]
Admission Date: [2174-4-29] Discharge Date: [2174-5-20] Date of Birth: [2114-6-9] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1943] Chief Complaint: Change in mental status, memory impairment, confusion Major Surgical or Invasive Procedure: Biopsy of right parietal lobe lesion Biopsy of right iliac lymph node Bronchoscopy/BAL History of Present Illness: 59 M with hx of CAD s/p CABG, DMII (HbA1c [3-4] 5.1), >50% bil carotid stenosis, ventral hernia repair [2-/2174], who presents with 2-3 weeks of mental status changes, including impaired memory/confusion, and one week of HA. Two weeks PTA, pt's friend/boss noticed his demeanor was slightly different and that he was losing his train of thought while speaking, and was "just not acting himself". Five days PTA pt returned to his grocery store job (he was on medical leave s/p surgery) and was noted to have difficulty performing tasks that previously were second nature. He could not remember how to operate the register or lottery machine, and had coordination problems when trying to wrap a [Location (un) 6002]. During this time he developed a waxing and [Doctor Last Name 688] frontal headache, "[11-3]" pain at times. Over the next two days, these symptoms persisted and were very noticeable to the other employees. He consistently would forget what he was doing and at one point started speaking French for ten minutes to his English-speaking boss. Pt also reports that over this two week time period he has felt unstable on his feet, although this has been occurring to some extent since abd surgery. Boss sent him to PCP on Wed [2174-4-27]; PCP noted pt was having difficulty with tandem gait and remembering what he had had for breakfast; neuro exam was otherwise unremarkable. PCP sent him for contrast MRI, which revealed 15-20 ring-enhancing lesions in cerebrum, cerebellum, brainstem. He was sent directly from MRI to [Hospital1 18] for further work-up, but on arrival could not remember why he was there. He left the ED, walked back to MRI facility; they subsequently sent him back to the ED by ambulance. Patient denies vision changes (including blurring and scotoma), lightheadedness, tinnitus, hearing changes, numbness or tingling, or changes in strength. His boss/friend reports no slurring of speech, but does report pt giggles quite often. Per pt and friend, there are lucid periods, when he behaves normally with intact memory. The pt denies having a hx of serious infections or STDs. He never uses protection during intercourse, and only had two different female partners in his life. He denies ever having hematuria. He has never been tested for HIV. Denies fevers, chills, cough, N/V/D. Notably, his BP have been well controlled for several years at 130s/70s and his last few HbA1cs have been in the 5s. He has had a 10 lb weight loss since surgery in [Month (only) 958]. Patient does not travel outside of [Location (un) 86]. Denies sick contacts. In the ED, his vitals were T99.5 HR76 RR16 SaO2 100% RA. Pt unable to state time, gave "[2113]" as year initially, but then noted to be AOx3 forty minutes later. Rest of exam unremarkable. PIV 20 in R arm. CBC, Chem-7 unrevealing. Urine and Serum Tox Screen negative. Urine sent. Blood culturesx2 drawn. Vitals prior to transfer 97.7 72 152/81 16 99%RA Past Medical History: Diabetes mellitus type II (HbA1c 5.1 [2174-3-3], 5.6 [2173-9-10], 5.4 [2173-6-17]) CAD s/p CABG old anterior MI (EF 35-40% in [2169]). Carotid Stenosis (>50% bil) Social History: As per HPI. Additionally, Haitian, came her 17 years ago, has never been back. Has no connections with family in [Country 2045], does not want like to talk about it. Lives alone in [Hospital1 8]. Works at grocery store. Strong support from boss. Smoked [12-26] ppd, quit in [2169]. Minimal alcohol, no drugs. Family History: Unknown Physical Exam: EXAM ON ADMISSION VS: Tc 99 BP 199/84 HR 75 RR 22 99% RA GENERAL: Well-appearing, thin haitian man in NAD, comfortable & pleasant. HEENT: NC/AT, sclerae anicteric, no conjunctival injection, MMM, OP clear. Adentulous. NECK: Supple, no thyromegaly, no JVD, carotid bruits bil. No cervical LAD. HEART: RRR, no MRG, nl S1-S2, 1-2/6 systolic ejection murmur. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: No rashes or lesions. Mental Status: Gen: Alert, interactive, expanded affect. Difficult to follow train of thought, +flight of ideas and at times nonsensical speech and circumstantiality. Orientation:To person, place, and time. Attention: Has difficulty naming days of the week forwards and backwards. Speech/[Doctor Last Name ]: Fluent w/o paraphasic errors; Follows simple and complex commands without L/R confusion. Repetition, naming intact. Memory: [2-24] at registration, 0/3 at 5 minutes. Normal fund of knowledge. Calculations:Intact (9 quarters = $2.25). CN: I: Not tested. II: VFFC. Right pupil oval, 5 mm to 3 mm. Left pupil round 4mm to 2 mm. No RAPD. III,IV,VI EOMI w/o nystagmus (or diplopia). Mild [Name (NI) 14245] ptosis. V: Sensation intact to LT. VII: Face symmetric without weakness. VIII: Hears finger rub equally and bilaterally. IX,X: Voice normal. Palate elevates symmetrically. [Doctor First Name 81]: SCM and trapezii full. XII: Equivocal tongue protrusion Motor: Normal bulk and tone; no tremor, rigidity, or bradykinesia. No pronator drift. 5/5 strength upper and lower extremities. Coordination: Dysmetria with finger-to-nose-finger movements. No truncal ataxia. Reflex: 1+ bicep, brachial, patellar, and ankle jerk Sensory: LT intact. Joint position intact. No evidence of extinction. Gait: Posture, stance, stride, and arm-swing normal. Mild imbalance with tandem gait. Able to walk on heels and toes. Romberg negative. ------------------- EXAM ON DISCHARGE: AVSS. Comfortable, NAD NEURO: Memory: [2-24] objects at registration, [2-24] two hours later. Able to name months forwards and backwards. CN II-XII intact, EXCEPT for: 1) impaired L-sided palate raise, 2) anisocoria: R pupil > L pupil, both responsive. 5/5 strength in UE and LE. Minimal dysmetria with finger-nose-finger. Heel to shin intact. LT intact in UE and LE. Gait stable. Pertinent Results: [2174-5-19]: WBC 8.7, HCT 27.7, MCV 96, PLT 329 [2174-5-19]: Na 137, K 4.5, Cl 103, CO2 28, BUN 30, Cr 1.2, Glu 217 [2174-5-19]: ALT 26, AST 33, ALKPHOS 122, TBILI 0.6 [2174-5-12]: PT 14.5, PTT 26.9, INR 1.3 [2174-5-4]: TIBC 208, Ferritin 255, Transferrin 160 [2174-4-30]: TSH 1.1 AFP 2.01 Urine and Serum tox [2174-4-29] negative [2174-5-4]: Lymph Node Bx, FLOW CYTOMETRY NEGATIVE MICROBIOLOGY 1. Multiple bacterial blood cultures done [4-29], [4-30], [5-2], [5-3], [5-8], [5-11], [5-12]: no growth 2. RAPID PLASMA REAGIN TEST (Final [2174-5-2]): NONREACTIVE. 3. [2174-4-30] CSF Cryptococcal Antigen: negative 4. [4-30] CSF Culture GRAM STAIN (Final [2174-4-30]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2174-5-3]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take 3-8 weeks to grow.. NO MYCOBACTERIA ISOLATED. 5. [4-30], [5-1], [5-2] Induced sputum concentrate smear for AFB: negative; AFB cultures pending 6. [4-30] HIV antibody negative 7. HIV-1 Viral Load/Ultrasensitive (Final [2174-5-4]): negative 8. TOXOPLASMA IgG ANTIBODY (Final [2174-5-3]): POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 236 IU/ML. 9. [5-3] BAL ACID FAST SMEAR (Final [2174-5-4]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. GEN-PROBE AMPLIFIED M. TUBERCULOSIS DIRECT TEST (MTD) (Preliminary): SENT TO STATE LAB FOR FURTHER IDENTIFICATION [2174-5-19]. TEST REQUESTED BY DR.[Last Name (STitle) 2324],GOWRI @ [2174-5-18] 10. [2174-5-6] 9:00 am TISSUE RIGHT ILIAC NODE. GRAM STAIN (Final [2174-5-6]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [2174-5-9]): NO GROWTH. ANAEROBIC CULTURE (Final [2174-5-12]): NO GROWTH. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [2174-5-7]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2174-5-6]): NO FUNGAL ELEMENTS SEEN. 11. HBV Viral Load (Final [2174-5-10]): 1,560 IU/mL 12. [2174-5-10] 12:30 pm SWAB Site: BRAIN RIGHT BRAIN MASS. GRAM STAIN (Final [2174-5-10]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2174-5-12]): NO GROWTH. ANAEROBIC CULTURE (Final [2174-5-16]): NO GROWTH. ACID FAST SMEAR (Final [2174-5-11]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. 13. HCV antibody [5-5]: negative 14. HTLV I and II Western Blot [5-9]: negative 15. Quantiferon Gold [5-2]: positive 16. Strongyloides antibody [5-5]: negative 17. Brucella Antibody [5-12]: negative 18. Histoplasma Antibody [5-12]: negative 19. Histoplama Urine Antigen [5-11]: negative 20. [4-30] CSF WBC RBC Polys Lymphs Monos 5 1 0 80 20 TotProt Glucose 80 38 CMV PCR negative EBV PCR negative Toxoplasma PCR negative Cysticercus Antibodies, IgG CSF: negative CSF GRAM STAIN (Final [2174-4-30]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2174-5-3]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take 3-8 weeks to grow.. NO MYCOBACTERIA ISOLATED. TISSUE CULTURE DATA: no positive culture data. 1. Universal PCR for tuberculosis pending on paraffin embedded brain tissue. 2. Brain tissue pathology showed granuloma with focal areas of necrosis. Special stains for AFB were negative. Unfortunately, brain tissue was not sent to microbiology. 3. External iliac node sent to microbiology and pathology: no growth of AFB at current time in this tissue; pathology showed lymphoid tissue with necrotizing granulomas. CSF Cytology [4-30]: NEGATIVE FOR MALIGNANT CELLS OTHER STUDIES CT Torso [2174-4-30]: Solitary right apical lung lesion, soft tissue in attenuation, with a few foci of peripheral calcification and spiculated margins. No associated hilar, mediastinal, or supraclavicular adenopathy is identified. Extensive retroperitoneal and pelvic adenopathy, with multiple nodes demonstrating central hypoattenuation suggesting necrosis, and extensive adjacent inflammatory change and edema throughout the retroperitoneum. In the setting of peripherally enhancing brain lesions seen on outside hospital MRI, both neoplastic and infectious etiologies for these findings must be considered. The right apical lung lesion could represent a primary lung neoplasm, less likely metastasis, though infectious etiologies including tuberculosis could cause a similar appearance. The retroperitoneal lymphadenopathy would be unusual secondary to a primary lung neoplasm, and the extent of inflammatory change would be atypical of lymphoma. Infectious or inflammatory processes, including possible abdominal tuberculosis or AIDS-related opportunistic infections such as [Doctor First Name ], are thus alternate considerations. Tissue sampling is recommended, and a right external iliac node measuring up to 3.3 cm would represent a reasonable site for initial biopsy. --- TTE [2174-5-2]: Regional LV systolic dysfunction c/w CAD/prior MI. No valve vegetations seen. Torn/calcified mitral chordae seen. --- BIL LENI [2174-5-9]: IMPRESSION: No evidence of deep vein thrombosis in either leg. --- MRI [5-10]: IMPRESSION: Multiple infra- and supratentorial ring-enhancing lesions, relatively unchanged since the most recent examination dated [2174-4-29]. Differential diagnosis is broad and includes but is not limited to metastatic disease and infectious processes. There is no evidence of new lesions in this short interval, fiducial markers are in place. --- [5-4] and [5-6]: biopsy of superficial nodes --- [5-10]: brain biopsy --- CT HEAD non con [5-10] NDICATION: Multiple brain lesions, now presenting for post-operative follow-up. FINDINGS: The patient is status post right parietal craniotomy. A small amount of gas is seen overlying and subjacent to the craniotomy site. A tiny hyperdense focus in the parietal lobe on the right (2:21) is consistent with a small amount of blood in the surgical bed. Otherwise, there is no intracranial hemorrhage, vascular territorial infarction. Numerous ring-enhancing lesions are better assessed on the concurrent MRI. However, note is made of areas of parenchymal hypodensity such as in the thalamus on the left and in the left cerebellar peduncle, which correspond to lesions seen on MRI. Ventricles are normal in size and in configuration. There is expected effacement of the sulci of the parietal lobe on the right and elsewhere sulcation appears normal. Extracranial soft tissue structures are normal. IMPRESSION: Expected post-surgical changes, immediately following a right parietal craniotomy. --- CT HEAD non con [5-11] INDICATION: Hypertension and altered mental status in a patient recently status post brain biopsy. FINDINGS: As before, the patient is status post right parietal craniotomy and the small amount of adjacent subcutaneous gas and pneumocephalus is unchanged. There has been no interval intracranial hemorrhage. There is no vascular territorial infarction. The extent of ring-enhancing intracranial lesions was characterized to better effect on an MR from [2174-5-10], though areas of parenchymal hypodensity are noted in the left cerebellar peduncle, and the thalamus on the left. Aside from mild expected effacement of the sulci over the right parietal lobe, ventricles and sulci are normal in size and in configuration. There is interval increase in subcutaneous soft tissue swelling subjacent to the craniotomy site, with a new 4 x 1 cm pocket of fluid (2:8), likely a developing postoperative seroma. IMPRESSION: 1. Interval increase in subcutaneous soft tissue swelling and development of a 4 x 1 cm pocket of fluid subjacent to the right craniotomy site, likely a developing seroma. 2. No interval intracranial hemorrhage or change. --- CXR AP [2083-5-11] FINDINGS: There is a status post sternotomy and aortocoronary bypass surgery. Borderline size of the cardiac silhouette. No evidence of pulmonary edema. No pneumonia. No pleural effusions. On the chest radiograph, no miliary pattern or opacities are seen. --- CXR PA/LAT [2174-5-13] IMPRESSION: No acute cardiopulmonary abnormality. --- EEG [5-13] IMPRESSION: This is an abnormal routine EEG in the awake and drowsy states, due to the presence of a disorganized [7-1] Hz theta rhythm background, and frequent bursts of generalized and bifrontal (synchronous and independent) delta frequency slowing, seen during the most awake portions of the recording. This pattern is consistent with a mild diffuse encephalopathy. There were no focal abnormalities or epileptiform features noted. Of note, the presence of lead artifact over the P4-O2 electrodes throughout the tracing may obscure any underlying abnormalities. --- [5-17] MRI Spine: a. Degenerative changes of the spine with no evidence of spinal or vertebral tuberculous involvement. b. Numerous findings are only partially visualized including the known intracranial lesions, right apical pulmonary lesion, ascites, mesenteric and paraaortic lymphadenopathy, and left vocal cord paralysis. ---- Brief Hospital Course: 59 Haitian male presents with 2-3 weeks of mental status changes found to have 15-20 ring-enchancing CNS lesions by outside MRI. He is found to additionally have RUL nodule, pelvic LAD, with LN and brain biopsy suggestive of disseminated TB. He was started on anti-TB therapy with steroids on [5-14]. His delirium/encephalopathy markedly improved since starting anti-TB therapy. Hospital course: [4-29]: Neuro deficits seen: anisocoria (R pupil>L pupil, both responsive), gait instability, memory impairment, expanded affect, and confusion. [4-30]: Torso CT revealed a 1.5x1.5x3cm^3 mass in RUL (no mediastinal or hilar LAD) and retroperitoneal LAD. HIV Ab negative. Lumbar puncture: unremarkable in terms of RBCs, WBCs, glucose; mild protein elevation. CSF NCC Ab, CMV PCR, EBV PCR, Toxoplasma PCR sent and found negative. [5-2]: Echo performed: regional LV systolic dysfunction c/w CAD/prior MI. No valve vegetations seen. Torn/calcified mitral chordae seen. [4-29] -[5-2]: Ruled out for pulmonary TB by IS AFB negativex3, patient taken out of isolation. [5-3]: BAL performed; washings negative for malignant cells and otherwise unremarkable. [5-4], [5-6]: Rt iliac LN biopsy performed, pathology positive for necrotizing granuloma, consistent with TB. No malignant cells. Stains negative for organisms; AFB, fungal, bacterial cultures pending. Immunophenotyping negative for lymphoma. [5-9]: Pt with calf pain; bilateral LENI performed and negative for DVT. [5-10]: Pre-op imaging followed by brain biopsy of right parietal lesion performed. Post-op imaging showed expected post-operative changes. Pathology notable for granulomas composed of immune cells and focal areas of necrosis. No eosinophils. Gram, AFB, and GMS stains negative for organisms. AFB, fungal, and bacterial gram stains from tissue swabs and paraffin-embedded tissue negative; cultures pending. Universal PCR for AFB pending. [5-11]: After brain biopsy, pt developed hypertensive emergency, fevers to 105.5 with rigors, acute change in mental status and with incomprehensible speech, and was uncommunicative and transferred to ICU ICU course [Date range (1) 83069] 59 year old male with history of type 2 diabetes, hypertension, hepatitis B and recent ventral hernia repair who was admitted for altered mental status, felt possibly due to miliary TB with CNS involvement who is transferred to the ICU for acute worsening of mental status, hypertensive emergency vs. urgency and fevers 104 with rigors. Patient's episode resolved with initiation of Vanc/Cefepime/flagyl and with time. It is possible he had a seizure. EEG was discussed but not initiated because techs not available overnight but symptoms had resolved by am. His BP was elevated to 160s and in setting of recent brain biopsy was goal<140. His lisinopril was increased to 40mg daily and he was given IV and PO hydral. The morning after admission the patient was AAOx3 and appropriate and back to baseline per primary team. [5-14]: Pt started on four drug anti-TB regimen with steroids: Ethambutol 1000mg PO QD, Pyrazinamide 1000 mg PO QD, Rifampin 600mg PO QD, INH 300 mg PO QD, 60mg Prednisone QD. Additionally, because of chronic HBC infection (see below), Entecavir 0.5 mg PO QD was also started to prevent viral replication in the setting of steroid treatment. Pt tolerating treatment. LFTs since starting treatment have been wnl. [5-17]: Pt underwent spinal MRI to rule out tuberculoma involvement of spine, which was negative. PROBLEM LIST: # Presumed disseminated tuberculosis with granulomas in the brain, necrotizing granulomas on right iliac lymph node biopsy, positive quantiferon gold. Extensive workup also pursued for fungal, parasites, and malignancy. Pulmonary TB ruled out with sputum AFB smears negative x3. Four drug TB regimen started on [5-14] # Encephalopathy relating to brain lesions: Pt initially noted to have anisocoria (R pupil>L pupil, both responsive), gait instability, memory impairment, expanded affect, and confusion. This began to all improve once tuberculosis treatment initiated. # HTN: Pts BPs were reasonably well-controlled on his home regimen until brain biopsy. After procedure, patient required uptitrations of his blood pressure medications, including the addition of a clonidine patch on [2174-5-18]. His blood pressure was still high on discharge, but clonidine patch typically takes 2-3 days for efficacy. He is discharged on the following regimen: Lisinopril 40 mg PO/NG DAILY Amlodipine 10 mg PO/NG DAILY HydrALAzine 50 mg PO/NG Q8H Clonidine patch 0.1mg QWED # Hepatitis B/ elevated LFTs: Patient was found to have mildly elevated LFTs on admission and chronic hepatitis B by blood tests (as above). Hepatology was consulted; they recommended Entecavir 0.5 mg PO QD when starting steroid treatment (as part of anti-TB regimen), to prevent reactivation. Entecavir was subsequently started with anti-TB treatment. LFTs have been within normal limits on subsequent testing. # Diabetes mellitus, type II- Did not require insulin until after starting steroid treatment on [5-14]. Subsquently put on Lantus 8U QAM on [2174-5-20] and continues to be on sliding scale. - Continue sliding scale, but will likely need adjustment of lantus. Goal fasting blood glucose is 120. # CAD - Stable. Patient was off aspirin in setting of procedures. This was restarted on [5-16]. # Right upper lung lesion seen on CT TORSO: Recommend follow-up CT to assess for interval change in size. TRANSITIONAL ISSUES Pending studies: - Tissue cultures for AFB/ fungus/ bacteria - Brain tissue universal PCR Other issues: - Weekly CBC, chem10, and LFTs in setting starting anti-TB treatment with steroids - Transportation to and from appointments (detailed in other sections) - Prednisone taper starting [2174-6-4] (as detailed in [Month/Day/Year ] OPAT note) - Blood pressures running high; recently started clonidine patch, will need follow-up - Will need f/u of diabetes and fixed insulin dosing - Repeat CT CHEST to assess RUL lesion for interval change Medications on Admission: Metolazone 5 mg PO QAM Ibuprofen 600 mg PO PRN pain Oxycodone 5 mg PO PRN pain (NOT TAKING) Carvedilol 12.5mg PO BID Furosemide 40mg PO QOD Simvastatin 40mg Daily Lisinopril 10mg Daily Glyburide 2.5mg PO BID ASA 81mg PO Daily Omeprazole 20 mg PO before first meal of day Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). 8. pyrazinamide 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. ethambutol 400 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 10. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO BID (2 times a day) as needed for constipation. 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fevers, pain. 16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 17. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 19. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 20. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. 21. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for diarrhea. 22. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): 1 drop to each eye. 23. insulin glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous once a day. 24. insulin lispro 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous four times a day: Please see attached sliding scale. Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Primary diagnosis: Disseminated miliary tuberculosis Secondary diagnoses: Hepatitis B Coronary artery disease Diabetes mellitus type II Carotid stenosis Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with confusion, memory impairment, and instability with walking. An MRI image of your head taken before you were admitted showed multiple masses scattered through your brain. While you were in the hospital you were extensively worked up for your symptoms and findings. While you were in the hospital, many blood and urine tests were sent. A procedure called a lumbar puncture was performed to examine fluid in your spinal cord. A different procedure called a bronchoscopy was performed to examine your lungs. Tissue from your brain and a pelvic lymph node was obtained and examined (in a procedure called a "biopsy"). You underwent multiple radiographic imaging tests including CAT scans and MRI. Based on our findings, we think you have tuberculosis in your brain and other parts of your body. We did not find anything to suggest cancer. Additionally, we found that at some point you were infected with hepatitis B. You were subsequently started on a multi-drug regimen to treat tuberculosis and hepatitis B. You have been tolerating this treatment in the hospital. This treatment is very detailed and will require frequent blood tests to make sure your body continues to tolerate the medicine. Additionally, it will make your blood sugars more difficult to control. To help with all of this we have placed you in a Tuberculosis Treatment Center at the [Hospital ] Hospital in [Location (un) 538]. The director of this infectious disease. While we are quite confident that tuberculosis is the cause of your illness, we cannot be 100% sure. If after a period of time you are not improving or getting worse, additional tests will be required to determine the best treatment. We have made many appointments for you with several different doctors (detailed below). It is extremely important that you make all these appointments; the [Hospital ] hospital will help you make these appointments and find transportation for you. We have made many changes to your medications; these are detailed in the attached documentation. Followup Instructions: We have scheduled the following appointments for you: ----------- TRANSPORTATION TO AND FROM THESE APPOINTMENTS MUST BE PROVIDED BY REHABILITATION CENTER ----------- [2174-6-2] 03:10p [Name6 (MD) 1413] [Name8 (MD) 1412], MD [Hospital1 18] Division of Infectious Disease [Hospital ] Medical Office Building [First Name9 (NamePattern2) 11102] [Location (un) 86], [Numeric Identifier 718] Phone: [Telephone/Fax (1) 457] Fax: [Telephone/Fax (1) 1419] ----------- [2174-6-30] 1:10pm Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2174-6-30] 1:10pm [2174-6-30] 1:30pm Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 11071]/DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2174-6-30] 1:30pm Division of Pulmonology, Critical Care, and Sleep Medicine Department of Medicine [Hospital1 69] [Street Address(2) 17800] [Location (un) 86] , [Telephone/Fax (1) 89366] ------------ [2174-6-30] 02:15p Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. MD Department of Neurosurgery [Hospital ] Medical Office Building, [Location (un) ] [Hospital Unit Name 18400] [Telephone/Fax (1) 1669] ------------ [2174-8-22] 11:00a PROVIDER: [Name10 (NameIs) ],[Name11 (NameIs) 1112] Department of Ophthalmology SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] HMFP- EYE [Location (un) ] [Location (un) 86], MA ([Telephone/Fax (1) 5120] ------------ Completed by:[2174-5-20]	[ "5180", "4019", "V4581", "25000", "412", "2859" ]
Admission Date: [2160-6-27] Discharge Date: [2160-7-4] Date of Birth: [2087-5-29] Sex: M Service: MED Allergies: Penicillins / Codeine / Iodine Containing Agents Classifier Attending:[First Name3 (LF) 1055] Chief Complaint: SOB Major Surgical or Invasive Procedure: Tracheostomy with biopsy [2160-6-30] History of Present Illness: 73 yo male with MMP including CHF EF 30%, DM2, AFIB (on coumadin) admitted to [Hospital1 18] on [6-27] with SOB & cough (with clear sputum). He had been treated presumptively for PNA with antibiotics/combivent IH since at rehab facility (d/ced to niece's home [6-10]) without improvement. He also c/o chest tighteness with inspiration and wheezing. +PND/orthopnea. Of note, he was intubated earlier in [2159] and by report he had a difficult intubation with trauma to the trachea at that time. ROS: Dysphagia with oral secretions- tolerating liquids/solids PO without difficulty. Hoarseness x 3 days, no wt loss, good appetitie, + wheezing. No BRBPR, melena, hematemsis, hemoptosis, heamturia, n/v/abd pain. No BM x 2 days. Past Medical History: 1. CAD 2. CHF- EF 30% on [2-24] ECHO with min AS, 1+ MR, 2+ TR. & severe pulumonary HTN 3. DM2 4. AFIB on coumadin 5. CRI - baseline cr 1.8 6. HTN 7. hyperchol 8. prostate CA s/p rad prostatectomy with artificial urethral sphincter placement (replaced [3-25] when c/b erosions) 9. h/o L ventricular thrombus 10. h/o MRSA [1-24]- blood & urine 11. gastritis 12. diverticulosis with diverticulitis [8-24] 13. AOCD 14. gout 15. depression/PTSD 16. s/p pacer + ICD [8-24] for SSS/NSVT 17. s/p lap chole [11-25] for choledocholithiasis- course c/b perihepatic abscess 18. s/p recent intubation in [2159] Social History: Lives currently with niece [Name (NI) ] ([Telephone/Fax (1) 50387]) since d/ced from Rehab 2 weeks ago. Usually lives alone in [Location (un) ]. Minimal smoking history- smoked 1 pack/3 weeks from teen to age 23. Distant ETOH- no drinks occas. O'Doul's. Used to work in nightclub and unloading planes. Korean Vet. Family History: Mother died vascular disease. Sister died valvular heart dx. Father died of PNA. Extensive fam hx of DM, htn Physical Exam: PE: T 96.8 HR 50s BP 158/80 (110-158/60-80) RR 20 O2 SAT 93-98% humidified face mask WT 68.6 kg on [6-27] gen- awake and alert male with biphasic stridor but breathing comfortably HEENT- PEERL, EOMI, anicteric NECK- supple, no LAD CHEST- CTA b/l, audible biphasic stridor evident CV- irreg irreg rhythm, [12-28] HSM at LUSB ABD- NABS, soft, NT/ND, weal healed trochar scars and midline scar EXT- no c/c/e, 2+ DP b/l, warm Pertinent Results: [2160-6-27] 05:35PM BLOOD WBC-7.5 RBC-3.80* Hgb-12.2* Hct-34.1* MCV-90 MCH-32.1* MCHC-35.8* RDW-15.6* Plt Ct-159 [2160-7-4] 06:50AM BLOOD WBC-9.4 RBC-3.18* Hgb-10.3* Hct-29.0* MCV-91 MCH-32.4* MCHC-35.5* RDW-16.2* Plt Ct-121* [2160-6-28] 05:35AM BLOOD Neuts-77.6* Lymphs-15.1* Monos-3.8 Eos-3.0 Baso-0.5 [2160-6-27] 05:35PM BLOOD PT-18.7* PTT-31.5 INR(PT)-2.3 [2160-6-30] 03:00AM BLOOD PT-14.9* PTT-25.8 INR(PT)-1.5 [2160-7-4] 06:50AM BLOOD PT-15.5* PTT-42.2* INR(PT)-1.5 [2160-6-27] 05:35PM BLOOD Glucose-114* UreaN-97* Creat-1.8* Na-141 K-5.2* Cl-103 HCO3-25 AnGap-18 [2160-7-4] 06:50AM BLOOD Glucose-130* UreaN-135* Creat-5.3* Na-130* K-4.4 Cl-93* HCO3-22 AnGap-19 [2160-7-4] 03:12PM BLOOD ANCA-NEGATIVE B [2160-7-1] 03:57AM BLOOD Digoxin-1.7 [2160-7-2] 12:47PM BLOOD Type-ART pO2-135* pCO2-44 pH-7.33* calHCO3-24 Base XS--2 Intubat-NOT INTUBA [2160-7-4] 04:57PM BLOOD Type-ART pO2-24* pCO2-91* pH-7.00* calHCO3-24 Base XS--13 CXR- [6-29] am- mild CHF- mild cephalization [6-27] am- cardiomeg with no evidence CHF/PNA, pacer in place, un changed right hemidiaphram elevation NECK CT [6-28] : FINDINGS: There is narrowing in the upper trachea approximately 1.5 cm below the level of the vocal cords. The trachea measures 7 mm in this region compared to 20 mm at the level of thoracic inlet. This narrowing is circumferential without evidence of a distinct dominant mass on the anterior or the posterior aspect of the trachea. The thyroid gland is small but demonstrates no evidence of a definite mass. No definite lymphadenopathy is seen in the neck. Degenerative changes are seen in the cervical spine. In the visualized thorax a right pleural effusion is identified with small lymph nodes in the prevascular space and in the pretracheal space. Correlation with chest films and CT is recommended. IMPRESSION: Circumferential tracheal stenosis approximately 1.5 cm below the vocal cords. No dominant mass is visualized or evidence of lymphadenopathy seen in the neck. Clinical correlation to exclude previous trauma is recommended. Findings were discussed with the ENT resident at the time of interpretation of this study on [2160-6-28]. LENIs [6-27] negative [6-30]: A. Thyroid isthmus, biopsy, (A): Thyroid tissue, no evidence of malignancy. B. Trachea, secretions, (B): Mucus, inflammatory cells and bacterial organisms. C. Trachea, stenosis, biopsy (C):Squamous metaplasia, scarring, acute and chronic inflammation, no tumor seen. [7-2] RENAL US: FINDINGS: The right kidney measures 10 cm. The left kidney measures 11.4 cm. There is no evidence for masses, stones, hydronephrosis, or perirenal fluid collections. The bladder is decompressed around the Foley catheter. Brief Hospital Course: Mr. [Known lastname 50388] was a 73 yo male who presented with stridor/SOB. 1) SOB - On the morning following admission, Mr. [Name14 (STitle) 50389] was seen by ENT to evaluate for upper airway obstruction, due to stridor on physical exam. Laryngoscopy was concerning for a subglottic mass and a CT scan revealed: circumferential tracheal stenosis about 1.5 cm below vocal cords (measures 7 mm c/t 20 mm at level of thoracic outlet). No dominant mass or LAD in neck noted. That morning, [6-28], Mr. [Name14 (STitle) 50389] was started on decadron IV, humidified O2, and continuous O2 monitoring. In the morning of [6-29], the patient had an episode of worsening stridor/SOB while eatting breakfast. He felt like he was choking on his "spit" and couldn't swallow it, getting stuck in his lower throat. O2 sats were stable, however he was transferred to the MICU for closer monitoring and tracheostomy placement with direct laryngoscopy/bronchoscopy/esophagoscopy. Biopsies were taken are revealed only fibrous tissue. He was transferred back to the floor on [7-3]. He remained intubated, with good O2 with his family at approximately 3 pm on [7-4]. Later that afternoon, at around 4:30 p.m., a pulmonary fellow entered the room to evaluate the patient for his subglottic stenosis and found the patient cyanotic without breath sounds. A code was called and run for approximately 30 minutes before Mr. [Name14 (STitle) 50389] was pronounced dead. At the initiation of the code it was found that his tracheostomy tube had somehow become dislodged from the airway. It was still sutured in place on the surface of the skin. It remains unclear how the tube became dislodged. The patient had complained of feeling uncomfortable at around 4:15 p.m. and the nurse had come in and readjusted him in bed. Otherwise he had been without complaint. 2) CAD- Troponins are chronically elevated in this patient, at 0.16 on admit. He did not have any ekg changes or CP, and there was no clinical suspicion for MI. We continued his ASA, nitro, statin, and beta blocker. 3) HTN- He was maintained on a BB, hydralazine, and nitrate. 4) AFIB- Coumadin was stopped on [6-28] for his procedure. He also got 2 units FFP prior to the OR. 5) Acute renal failure - Mr. [Name14 (STitle) 50389] had a baseline creatinine of 1.8, and went into acute renal failure shortly after administration of IV contrast for his CT scan. It was felt to be contrast induced nephropathy, and was being managed with hydration and observation. He had progressed into the polyuric phase by [7-4] and was anticipated to begin recovery, however he unexpectedly passed away, as above. Medications on Admission: Meds on transfer to MICU: lasix 80 [Hospital1 ] protonix 40 qd asa 81 qd iron 325 qd ca carb 500 tid digoxin 0.125 qd neurontin 300 qhs ntg sl prn mallox -simethicane prn epogen 10K sq MWF combivent IH guafenasin lipitor 20 qd colace 100 [Hospital1 ] prn senna 1 [Hospital1 ] prn NS nasal spray percocet prn back pain dexamethasone 10 IV q8 RISS NPH 30 qam metoprolol xl 50 qd isosorbide mononitrate 30 qd tyelnol prn metolazone 2.5 qd hydralazine 20 q6 trazadone 50 qhs prn Discharge Medications: Deceased. Discharge Disposition: Extended Care Facility: Deceased Discharge Diagnosis: Subglottic stenosis. Acute renal failure. Plus multiple medical problems. Discharge Condition: Deceased. Discharge Instructions: N/A Followup Instructions: N/A	[ "51881", "42731", "4280", "5845" ]
Admission Date: [2127-12-11] Discharge Date: [2127-12-30] Date of Birth: [2069-10-16] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: s/p [9-19] ft Fall Major Surgical or Invasive Procedure: Triple Lumen Subclavian Line Placement [2127-12-17] History of Present Illness: 58 yo male s/p ~[9-19] ft fall from ladder onto his head. Comabative at scene; bleeding from left ear; transferred to [Hospital1 18] for trauma care. Past Medical History: Sleep Apnea on BIPAP at home Hypercholestrolemia Knee Surgery Social History: Married Employed as a landscaper Family History: Noncontributory Physical Exam: VS upon arrival to truam bay: 145/61 98 20 99.6 pr O2 sat 99% GCS 12 Gen-Alert & oriented to name HEENT-right periorbital ecchymosis with swelling; blood left ear Neck-c-collar in place Chest-CTA bilat Cor-RRR no m/r/g Abd-FAST exam negative Rectum-guaiac negative Extr-MAE x4 Pertinent Results: [2127-12-11] 07:28PM GLUCOSE-122* UREA N-19 CREAT-1.1 SODIUM-141 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-23 ANION GAP-12 [2127-12-11] 07:28PM CK-MB-6 cTropnT-<0.01 [2127-12-11] 07:28PM MAGNESIUM-1.9 [2127-12-11] 07:28PM WBC-15.2* RBC-4.14* HGB-11.5* HCT-33.5* MCV-81* MCH-27.8 MCHC-34.4 RDW-13.6 [2127-12-11] 07:28PM PLT COUNT-186 [2127-12-11] 07:28PM PT-13.2 PTT-20.5* INR(PT)-1.2 [2127-12-11] 12:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CHEST (PORTABLE AP) [2127-12-24] 9:09 AM CHEST (PORTABLE AP) Reason: eval infiltrate [Hospital 93] MEDICAL CONDITION: 58 year old man s/p fall, extubated [12-18], febrile REASON FOR THIS EXAMINATION: eval infiltrate INDICATION: Status post fall. Portable AP chest. The lung fields are clear. No pneumothorax. The heart size is normal. Mediastinal contours are normal. No pleural effusions. No evidence of rib fracture. IMPRESSION: No acute cardiopulmonary process. BILAT LOWER EXT VEINS PORT [2127-12-24] 1:23 PM BILAT LOWER EXT VEINS PORT Reason: S/P TRAUMA; EVAL FOR THROMBUS INDICATION: Trauma. Evaluate for thrombus. FINDINGS: [Doctor Last Name ] scale and color Doppler son[Name (NI) 493] examination of both lower extremity venous systems was performed. Normal compressibility, color flow, waveform, and augmentation was seen in both common femoral veins, superficial femoral veins, and popliteal veins. No intraluminal thrombus was identified. IMPRESSION: No evidence of DVT in either lower extremity. CT ORBITS, SELLA & IAC W/ & W/O CONTRAST [2127-12-16] 9:05 AM CT 100CC NON IONIC CONTRAST; CT ORBITS, SELLA & IAC W/ & W/ Reason: Progression of right orbital derangement. [Hospital 93] MEDICAL CONDITION: 58 year old man with multiple orbital fractures and small SAH/SDH s/p fall REASON FOR THIS EXAMINATION: Progression of right orbital derangement. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Multiple orbital fractures and intracranial bleeds status post fall, question progression of right orbital derangement. COMPARISON: Head CT, [2127-12-15] at 16:30. TECHNIQUE: Axial CT images of the sinuses without and after the administration of contrast were reviewed. FINDINGS: The post-septal extraconal right hematoma is not significantly changed from the 17-hour interval but enlarged since [2126-12-14]. The hematoma measures approximately 2 cm in greatest diameter and is located superomedially beneath a displaced right orbital roof fracture and also exhibits displacement of the superior rectus, oblique, and medial rectus muscles. There is continued elongated deformity of the right globe from hematoma-induced mass effect. The optic nerve itself is not significantly displaced. Post- contrast imaging does not demonstrate rim enhancement of the extraconal collection to indicate organized abscess formation, but superimposed infection cannot be excluded by imaging. Otherwise, the examination is unchanged, with multiple orbital fractures and sinus fractures as previously described. Fluid is present throughout the paranasal sinuses. IMPRESSION: No significant change in post-septal extraconal right superomedial hematoma with right globe distortion from mass effect. The urgency of these findings was discussed with the ophthalmology resident caring for the patient, [12-16] at 1 p.m. CT HEAD W/O CONTRAST [2127-12-16] 9:13 AM CT HEAD W/O CONTRAST Reason: re-eval of intraparenchymal brain lesions [Hospital 93] MEDICAL CONDITION: 58 year old man s/p fall REASON FOR THIS EXAMINATION: re-eval of intraparenchymal brain lesions CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL INFORMATION: Re-evaluation of intraparenchymal brain lesions. NON-CONTRAST HEAD CT. FINDINGS: There has been no change from yesterday's examination in the appearance of the brain or the multiple intraparenchymal hemorrhages with the exception that the left parietal extra-axial collection appears to perhaps be slightly more prominent. The extraconal hematoma in the right orbit is likewise unchanged. IMPRESSION: Slight increase in left parietal extra-axial blood collection. Otherwise, stable appearance of brain and orbits compared to the previous exam. MR L SPINE SCAN [2127-12-12] 2:26 PM MR L SPINE SCAN Reason: evluate L1 burst fracture [Hospital 93] MEDICAL CONDITION: 55 year old man s/p fall with multiple skull fx, ICH, L1 burst fx, intubated REASON FOR THIS EXAMINATION: evluate L1 burst fracture MRI OF THE LUMBAR SPINE CLINICAL INFORMATION: Patient is status post fall with multiple skull fractures and L1 burst fracture, for further evaluation of the fracture. TECHNIQUE: T1, T2 and inversion recovery sagittal and T1 and T2 axial images of the lumbar spine were acquired. FINDINGS: The T12 and L1 vertebral bodies demonstrate increased signal on inversion-recovery images and low signal on T1-weighted images in the mid portion, indicative of fractures and marrow edema. There is minimal decrease in height of the L1 vertebral body seen. There is no retropulsion noted. There is no evidence of destruction of the ligamentous structures identified. There is no evidence of abnormal increased signal seen within the intraspinous ligaments. From T11-12 to L4-5, no significant disc bulge or herniation is seen. At L5- S1 level, there is mild disc bulging seen. Bilateral spondylolysis of L5 is noted without marrow edema indicating chronic spondylolysis. Note is made of fluid-fluid level within the distal thecal sac in the sacral spinal canal indicative of small amount of intrathecal blood which could be secondary to subarachnoid blood seen on the head CT. The distal spinal cord shows normal signal intensities. IMPRESSION: Signal changes indicative of fractures of T12 and L1 without significant retropulsion or high-grade thecal sac compression. No evidence of epidural or subdural hematoma in the spine. Fluid-fluid level indicating intrathecal blood within the distal thecal sac, which could be related to subarachnoid hemorrhage seen on the head CT. Bilateral spondylolysis of L5 which appear chronic due to absence of signal changes on inversion-recovery images with mild disc bulging at L5-S1 level. CT C-SPINE W/O CONTRAST [2127-12-11] 1:27 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: FALL INDICATION: Status post 12 foot fall TECHNIQUE: Non-contrast axial images of the cervical spine with coronal and sagittal reformations were reviewed. COMPARISON: None. FINDINGS: No fractures of the cervical spine are identified. There is anatomic vertebral body alignment. There is no prevertebral soft tissue swelling. The patient is intubated with the tip of the endotracheal tube in standard position. A nasogastric tube is also present within the esophagus. There is no facet joint or vertebral disc widening. C1 through T2 are well visualized. Although CT is not optimal for evaluation of the intrathecal contents, the visualized intrathecal contents are unremarkable. IMPRESSION: No evidence of fracture or dislocation. Brief Hospital Course: Patient admitted to the trauma service. Plastic Surgery, Ophthalmology, Otolaryngology, Neurosurgery and Orthopedics were all consulted because of patient's multiple injuries. His orbital fractures were non operative and he will need to follow up with Plastic surgery in 2 weeks. On [12-15] he underwent right lateral decanthotomy by Ophthalmology, he is on several eye drops and will require follow up in [Hospital 8183] Clinic in 1 week after discharge. Orthopedic consulted for his lumbar spine injuries, L1 vertebral body fracture; he was fitted for a TLSO brace which will need to be worn at all times when patient is out of bed. He will need to follow up with Orthopedic Spine in 2 weeks after discharge. Neurosurgery will follow up with patient in [3-11] weeks for his head bleed; he will be booked for a repeat head CT scan at that time. Physical therapy, Speech and Swallow were consulted as well. Patient must wear his TLSO brace while out of bed. He will require 1:1 supervision for meals as per recommendation of Speech and Swallow. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 6. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours) 7. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic TID (3 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic [Hospital1 ] (2 times a day). 10. Dexamethasone 0.1 % Drops, Suspension Sig: Four (4) Drop Ophthalmic Q12H (every 12 hours). 11. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Gentamicin 0.3 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). 14. Vancomycin 500 mg Recon Soln Sig: One (1) Drop Intravenous Q6H (every 6 hours). 15. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [Hospital6 1970] - [Hospital1 1559] Discharge Diagnosis: s/p [9-19] ft fall Right displaced orbital roof fracture Ethmoid fracture Left orbital roof fracture, non-displaced Right Subarachnoid hemorrhage Bilateral Frontal and Temporal Contusions Discharge Condition: Stable Discharge Instructions: Follow up in Trauma And Plastic Surgery Clinic in [2-7] weeks Follow up in [Hospital 8095] Clinic in 1 week. Follow up with Neurosurgery in 4 weeks Follow up with ENT in 2 weeks. Follow up with your primary doctor after your discharge from rehab Followup Instructions: 1.Call [Telephone/Fax (1) 6439] for an ppointment in Trauma Clinic in [2-7] weeks 2.Call [Telephone/Fax (1) 4652] for an appointment in Plastic Surgery Clinic 3.Call [Telephone/Fax (1) 253] for an appointment in [Hospital 8095] Clinic in 1 week you will need to be seen. 4.Call [Telephone/Fax (1) 2349] for an appointment with Dr. [First Name (STitle) ], ENT in 2 weeks 5.Call [Telephone/Fax (1) 1669] for an appointment with Dr. [Last Name (STitle) 63264] in 4 weeks. Inform the office that you will need a repeat head CT scan performed prior to this appointment. 6.Call [Telephone/Fax (1) 1228] for an appointment with Dr. [Last Name (STitle) ] in 2 weeks. 7.Call your PCP after your discharge from rehab for an appointment Completed by:[2127-12-30*]	[ "486", "2859", "2720" ]
Admission Date: [2195-8-25] Discharge Date: [2195-9-3] Date of Birth: [2139-1-6] Sex: M Service: MEDICINE Allergies: Azithromycin / Metformin Attending:[Doctor First Name 2080] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: Briefly, Mr. [Known lastname 82748] was recently on our servce with a MICU transfer for lower GIB thought to be due to Crohn's flare in setting of anticoagulation. Pt has been maintained on mesalamine and prednisone Has a recent submassive PE last month with thrombolytics and placement of IVF filter. Was admitted with Hct stable; coumadin reversed with IV vit K on admission by ED. Restarted heparin though pt quickly rebled. . Has been in ICU ~36 hours. Recieved total of 1 unit on transfer to ICU; nothing since. Had tagged RBC initially that showed diffuse bleeding ("findings consistent with intermittent active bleeding likely within sigmoid colon"). Then had sigmoidoscopy on [2195-8-28] which showed friable colon, diffuse bleeding c/w Crohn's; biopsies were taken. Hct has stabilized around 26-28. Hemodynamically stable and transferred back to our service. Past Medical History: Type 2 Diabetes Obestiy Crohn's disease, with history of GI bleed Hypertension Diverticulitis s/p Partial Colectomy x 2 s/p Multiple Herniorraphy's Arthritis Social History: After discharge in [2195-7-25]. Pt had altercation with wife leading to restraining order. Patient is not married but lives with significant other (female) and lives in [Initials (NamePattern4) ] [Last Name (NamePattern4) 19700]. He only drinks alcohol 2x year currently, but reports heavy alcohol use that stopped approximately 20 years ago. He denies tobacco use. He reports using cocaine with cessation approximately 25 years ago. He is a former mechanic. Family History: No family history of blood clots, malignancy, or sudden cardiac death. No family history of Crohn's disease. His mother passed away from pneumonia, but also had hypertension. Physical Exam: General: obese, NAD HEENT: poor dentition, neck supple Lungs: CTA b/l, no c/q/r Cardio: RR, soft heart sounds Abd: obese, + BS, soft, non tender, multiple surgical scars Ext: trace [Location (un) ] Pertinent Results: Admission Labs: [8-25]: WBC-11.1* RBC-3.88* Hgb-10.2* Hct-32.0* MCV-82 MCH-26.4* MCHC-32.1 RDW-14.1 Plt Ct-313 [8-28]: WBC-7.0 RBC-3.22* Hgb-8.8* Hct-26.8* MCV-83 MCH-27.3 MCHC-32.9 RDW-13.7 Plt Ct-279 [8-31]: WBC-6.4 RBC-3.08* Hgb-8.4* Hct-25.6* MCV-83 MCH-27.2 MCHC-32.7 RDW-14.4 Plt Ct-284 [9-3]: WBC-8.3 RBC-3.34* Hgb-9.5* Hct-28.1* MCV-84 MCH-28.4 MCHC-33.8 RDW-14.5 Plt Ct-350 [8-26]: ESR-43* [8-25]: Glucose-80 UreaN-20 Creat-1.0 Na-140 K-3.6 Cl-106 HCO3-22 AnGap-16 [9-2]: Glucose-177* UreaN-17 Creat-1.1 Na-141 K-3.7 Cl-103 HCO3-29 AnGap-13 [8-26]: CRP-77.2* . Studies: CT Abd (9/1)1. Thickening of the transverse colon, and mild thickening of the terminalv ileum, most likely related to the patient's known Crohn's disease, although infection is an additional possibility. 2. Large right spigelian hernia, with some ascending colon outside of the field of view. Small ventral hernia containing a small bowel loop, without evidence of obstruction. 3. No evidence of abscess or abnormal fluid collection.4. Right basilar airspace opacity most likely infectious, or less likely, the sequelae of prior pulmonary embolus. . CXR ([8-26]): No focal consolidation identified. However, please note, given the size and position of the opacities noted on abdominal CT, the chest x-ray may be relatively insensitive. Continued surveillance recommended. . Bleeding Study ([8-27]): Findings consistent with intermittent active bleeding likely within sigmoid colon. . GI Biopsy: Colon, biopsy: - Chronic active colitis.No dysplasia or granulomas identified. . Colonoscopy report attached. Brief Hospital Course: Assessment and Plan: This is a 56 yo male h/o Crohn's, diverticulosis s/p hemicolectomy, with recent hospitalization for bilateral PE discharged on warfarin anticoagulation who was readmitted for lower GI bleeding. Stable HCT off all anticoagulation. . # GI Bleeding secondary to Crohn's flare/Acute Blood Loss Anemia: Pt was admitted to the hospital after he noticed a small amount of blood in his bowel movements. Pt was recently admitted with a gi bleed and during admission developed pulmonary emboli necessitating intubation in the intensive care unit. He was discharged on coumadin. During admission pts hematocrit was initially stable and bleeding controlled. Mesalamine was increased to 2grams twice daily and prednisone 40mg was continued. Pt was given another trial on anticoagulation and heparin was started with the hopes of bridging to coumadin. Overnight the patient developed multiple bloody bowel movements. Pt remained hemodynamically stable however had a significant drop in hematocrit necessitating one unit of packed red blood cells and transfer to the ICU. In the ICU the patient remained stable. Labeled red blood cell scan showed bleeding in the sigmoid colon. Colonoscopy was consistent with severe Crohn's disease. After 36 hours he returned to the general medicine floor where patient continued to be stable with guaiac negative stools. At this time it was decided patient is not a candidate for anticoagulation until his Crohn's Flare is stabilized. After patient's Crohns Disease is better managed pt may then be a candidate for anticoagulation. Pt will follow up with he DR. [Last Name (STitle) ] (GI) in [Hospital1 1562] for further therapy. . # Bilateral Pulmonary Emboli/s/p IVC filter: On admission anticoagulation was reversed given GI bleed. After stablized anticoagulation was restarted with Heparin, however as noted above pt had further bleeding. It was determined the patient has failed anticoagulation give his repeat bleeding. If his Crohn's is better managed anticoaguation should be reconsidered. During his stay patient was hemodynamically stable, sating 98% on room air. Pt had IVC filter placed during previous admission. . # Type 2 Diabetes, poorly controlled, no complications: Pt was continued on lantus with sliding scale insulin. . # Depression: Pt reports major social issues after discharge from hospital. Was evaluated on [Hospital3 4298] and started on Citalopram and Ativan PRN anxiety. During stay patient tearful in regards to restraining order against him by his girlfriend. Psychiatry and social work saw patient. No active suicidal ideation per patient. Psych recommended increasing citalopram to 30mg monitoring for mania given patients hx of aggression. Also monitor closely for seretonin syndrome given patient is on Citalopram and Tramadol. Medications on Admission: 1. Mesalamine 250 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). Disp:120 Capsule, Sustained Release(s) Refills:2 2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime: please continue to take your humalog sliding scale as prior to hospitalization. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 6. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for pain. 7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: Please follow up with your PCP as scheduled to check your INR, with goal INR of [1-27]. Disp:30 Tablet(s) Refills:2 8. Citalopram 20 mg daily 9. Lorazepam 1mg Q 8hours. Discharge Medications: 1. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day: Dr. [Last Name (STitle) ] will adjust this dose at your next appt. Do not stop medicine without tappering. . Disp:60 Tablet(s) Refills:0 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety: Do not take this medication with alcohol. Do not operate vehicles or heavy machinery when taking this medication. . Tablet(s) 7. Mesalamine 500 mg Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO twice a day. Disp:240 Capsule, Sustained Release(s) Refills:2 8. Lantus Insulin 25 Units each evening. 9. Insulin Sliding Scale Please see attached sheet or refer to sliding scale provided by Dr. [Last Name (STitle) ]. 10. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Crohn's Flair with GIB Secondary Diagnoses: Recent pulmonary embolism IVF filter Discharge Condition: stable. afebrile. On room air. Ambulating without difficulty. Discharge Instructions: You were admitted to the hospital after you developed bleeding from your gastrointestinal tract. This bleeding occurred in the setting of anticoagulation (blood thinning). You were anticoagulated after your previous hospitalization when you developed pulmonary emboli. During this hospitalization your bleeding was initially controlled and medications to treat your Crohn's disease were increased. After bleeding was controlled we attempted to thin your blood again but you developed another gastrointestinal bleed. Throughout this time your hematocrit remained relatively stable. At this time we think your Crohn's disease must be better under control before anticoagulation can be restarted. You should follow up closely with your [Last Name (STitle) ]. The following changes were made to your medicine regimen. (1) Change Mesalamine 2grams twice daily (2) Continue taking Prednisone 40mg Daily, Dr. [Last Name (STitle) 36863] will decide how long to continue you on this dose of Prednisone. (3) Stop taking Warfarin until advised by your primary care doctor [First Name (Titles) ] [Last Name (Titles) ]. Please return to the hospital or contact your physician if you notice bright red blood in your stools, you have dark black tarry stools, you develop chest pain, shortness of breath, nausea, vomiting, or fever. Followup Instructions: Please follow up with your PCP [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Telephone/Fax (1) 29822], on Wednesday [9-9], at 12:00. - Follow up in regards to your recent hospitalization and bleeding. - Follow up in regards to your diabetes management. - Follow up in regards to anticoagulation for your blood clot. FU with your [Month (only) ], Dr. [Last Name (STitle) ],([Telephone/Fax (1) 82749], on Monday [9-21] arriving 3:45. -Follow up in regards to your recent hospitalization and Crohn's Disease management.	[ "2851", "25000", "311" ]
Admission Date: [2183-11-27] Discharge Date: [2183-12-3] Date of Birth: [2114-8-2] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: DOE Major Surgical or Invasive Procedure: Aortic valve replacement (#23CE Perimount Pericardial)and Mitral Valve Replacement (#31 [First Name8 (NamePattern2) ] [First Name5 (NamePattern1) 923] [Last Name (NamePattern1) 9041])[11-27] History of Present Illness: Known AS with progressive dyspnea, no complaints of angina or syncope. Past Medical History: HTN, ^chol, Wegner's Granulomatosis, Diverticular dx s/p colectomy '[57], lung bx '[80], Tonsillectomy Social History: married, lives with wife works at [Company ] remote [Name (NI) ] quit 18 years ago(20 PYH) regular ETOH- 2 scotches/day Family History: no premature CAD Physical Exam: Admission VS T HR 68 BP 120/60 RR 12 Ht 5'[86]" Wt 173lbs Gen: NAD, pleasant. Rosacea on face CV: RRR, mixed diastolic and systolic murmurs Pulm: CTA bilat Abdm: Soft, NT,ND,NABS Ext: warm well perfused, no edema or varicosities Discharge: VS T 98.5 HR 66 BP 122/68 RR 16 O2sat 99% RA Gen: NAD Neuro: A&Ox3, MAE, nonfocal exam Pulm: CTA bilat CV: Irreg, S1-S2 with soft murmur Abdm: Soft, NT, NABS Ext: warm, no edema Pertinent Results: [2183-11-27] 12:45PM UREA N-17 CREAT-1.1 CHLORIDE-113* TOTAL CO2-21* [2183-11-27] 12:45PM WBC-14.6# RBC-3.09 HGB-10.1* HCT-28.5* MCV-92 MCH-32.6* MCHC-35.3* RDW-16.6* [2183-11-27] 12:45PM PLT COUNT-106* [2183-11-27] 12:45PM PT-16.8* PTT-46.7* INR(PT)-1.5* [2183-11-30] 06:33AM BLOOD WBC-8.1 RBC-2.30* Hgb-7.8* Hct-21.4* MCV-93 MCH-33.8* MCHC-36.3* RDW-17.1* Plt Ct-77* [2183-11-30] 03:25PM BLOOD Glucose-126* UreaN-32* Creat-1.2 Na-137 K-4.4 Cl-103 HCO3-26 AnGap-12 CHEST (PORTABLE AP) [2183-11-28] 5:34 PM CHEST (PORTABLE AP) Reason: r/o ptx [Hospital 93] MEDICAL CONDITION: 69 year old man s/p AVR/MVR and ct removal REASON FOR THIS EXAMINATION: r/o ptx INDICATION: Status post aortic valve and mitral valve replacement and chest tube removal. Portable AP chest dated [2183-11-28] is compared to the prior from yesterday. The patient has been extubated and the nasogastric tube is removed. A right internal jugular Swan-Ganz catheter has been removed. The right internal jugular catheter sheath terminates in the distal right internal jugular vein. The cardiac size and cardiomediastinal, and hilar contours are stable. The lung fields show linear subsegmental atelectasis in the left mid and right mid lung zones. There is no large pleural effusion or pneumothorax. Cardiology Report ECHO Study Date of [2183-11-27] PATIENT/TEST INFORMATION: Indication: Aortic valve disease. Hypertension. Mitral valve disease. Murmur. Shortness of breath. Height: (in) 70 Weight (lb): 172 BSA (m2): 1.96 m2 Status: Inpatient Date/Time: [2183-11-27] at 08:40 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW5-: Test Location: Anesthesia West OR cardiac Technical Quality: Suboptimal REFERRING DOCTOR: DR. [First Name (STitle) ] R. [Doctor Last Name ] MEASUREMENTS: Left Atrium - Long Axis Dimension: 5.9 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.7 cm (nl <= 5.2 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.0 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.3 cm Left Ventricle - Fractional Shortening: 0.34 (nl >= 0.29) Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Valve Level: 2.5 cm (nl <= 3.6 cm) Aorta - Ascending: 3.6 cm (nl <= 3.4 cm) Aorta - Arch: 2.8 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 2.7 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: 2.7 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 92 mm Hg Aortic Valve - Mean Gradient: 55 mm Hg Aortic Valve - Valve Area: 0.5 cm2 (nl >= 3.0 cm2) Mitral Valve - Peak Velocity: 1.6 m/sec Mitral Valve - Mean Gradient: 4 mm Hg Mitral Valve - Pressure Half Time: 163 ms Mitral Valve - MVA (P [12-16] T): 1.3 cm2 Mitral Valve - E Wave: 1.6 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A Ratio: 1.60 Mitral Valve - E Wave Deceleration Time: 507 msec INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Low normal LVEF. RIGHT VENTRICLE: Normal RV systolic function. AORTA: Moderately dilated aortic root. Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Moderate (2+) AR. MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. Moderate MS (MVA 1.0-1.5cm2) Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with 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. No TEE related complications. The patient was under general anesthesia throughout the procedure. 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: 1. The left atrium is moderately dilated at 5.7 x 6.0 cm. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. The aortic root is moderately dilated. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. 4. The mitral valve leaflets are severely thickened/deformed. The mitral valve shows characteristic rheumatic deformity. There is moderate mitral stenosis (area 1.35 cm2). Moderate to severe (3+) mitral regurgitation is seen. POST-BYPASS: Patient is being A- paced, on infusion epinephrine and phenylephrine. 1. Biventricular systolic function is preserved. 2. Well seated aortic bioprosthetic valve with no paravalvular leak and trace of AI. Peak gradient across AV 27 mmHg, mean gradient 15 mmHg. 3. Well seated mitral biopresthetic valve with no paravalvular leak. Trace of MR. The peak gradient across MV 3 mmHg and mean gradient is 1 mmHg. LVOT gradient of 10 mmHg is noted, possibly from protrusion of mitral strut into LVOT. 4. Aorta is intact, there is no dissection noted. IMPRESSION: 1. Lines and tubes as described above. 2. Subsegmental linear atelectasis at the bilateral lung bases. Brief Hospital Course: Patient was a preoperative admission to the operating [***] at which time he had a AVR/MVR, please see OR report for full details. He was transferred from the OR to the Cardiac surgery ICU, did well in the immediate post-op period and was extubated. On POD1 he continued to do well however was noted to have slow sinus vs junctional rhythm and stayed in the ICU. On POD2 his intrinsic rhythm had recovered somewhat and he was transferred to the step down floor for continued post-op care, additionally an EP consult was obtained secondary to bradycardia. The electrophysiology service felt that he would be unlikely to require a pacemaker and his bradycardia slowly resolved. He was gently diuresed and seen in consultation by physical therapy. By post-operative day 6 he was ready for diascharge in good condition to home. Medications on Admission: Prednisone 2.5', Azathioprine 75', Bactrim 3x/wk, Actonel Qwk, Calcium 1000', Lipitor 10', Lisinopril 10', Prilosec 40', Doxycycline 50" x 10 days Discharge Medications: 1. Furosemide 20 mg Tablet Sig: as directed Tablet PO once a day: 40 mg QD x 1 week then 20mg Qd x10 days. Disp:24 Tablet(s)* Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(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:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 17 days. Disp:34 Capsule, Sustained Release(s) Refills:0 10. Azathioprine 75 mg Tablet Sig: One (1) Tablet PO once a day. 11. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO 3x/wk. 12. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Home With Service Facility: [Location (un) 8300] VNA Discharge Diagnosis: s/p AVR(#23CE)MVR(#31StJudeBiocor)[11-27] PMH: HTN, ^chol, Wegners Granulomatosis, Diverticular disease(s/p colectomy '[57]), lung bx '[80], tonsillectomy Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds. Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) 55164] in 1 week ([Telephone/Fax (1) 55136]) please call for appointment Dr [Last Name (STitle) 29070] in [1-17] weeks ([Telephone/Fax (1) 37284]) please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3633]) Completed by:[2183-12-3]	[ "4019", "2720", "42731", "42789" ]
Admission Date: [2180-3-23] Discharge Date: [2180-3-29] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 23347] Chief Complaint: Fever and shortness of breath. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [Known lastname ] is an 84 y.o. F with a history of hypertension, gait instability, and memory impairment, who presented to the ED from [Hospital6 459] with fever and shortness of breath. Per the patient, her son thought she was "doing something that she shouldn't be doing" and that was why he brought her to the hospital. She is not sure why she is in the hospital. She denies any sick contacts. She denies shortness of breath, chest pain, abdominal pain, and diarrhea. However, the transfer letter from [Hospital 100] Rehab states that she was "acutely unwell, falling to one side" and vitals per rehab were the following: T 102, HR 120, BP 150/100, RR 24, and O2 sats 89% RA. Per Rehab letter, she was unresponsive for a few seconds but without any obvious neurologic deficits. Additionally, she was found to be sweating, her face was pale in color, and she became weak. She was given Augmentin 850 mg, ASA 325 mg, and Tylenol as well as oxygen and then sent to [Hospital1 18] ER. On arrival to the [Hospital1 18] ER: T 103.3 HR 110 BP 130/80 RR 32 89% on RA ---> 96% with nebulizers. In the ED, her O2 sat was then 94-95% on 4 L NC, then 91% on 5 L NC, and then she was placed on NRB for 95-100% O2 sats. BP was stable throughout the course in the ED with the lowest value of 99/63. A CXR showed no acute cardiopulmonary process. EKG did not show ischemic changes. CT head showed no acute intracranial bleed. She was given levofloxacin 750 mg x 1, flagyl 500 mg x 1, and vancomycin 1 gm x 1 as well as Combivent nebs q 20 minutes x 3. Past Medical History: Pt denies any medical history; however, upon review of [2176-2-7] [Hospital1 18] Neurology Note: Hypertension Osteoporosis Hypercholesterolemia Aortic valve stenosis Social History: The patient currently lives at [Hospital6 459]. She lives in her own apartment and gets most meals in the cafeteria. She cleans her apartment, does her own grocery shopping, and drives. She used to smoke 1 ppd x 53 years, quitting 1 year ago. Family History: Per [Hospital1 18] Neurology Note in [2176-2-7]: Cardiovascular disease in her mother. Parkinson's disease in her father. Lost one sister to emphysema, one brother to CV disease and one to suicide. Her son died of AIDS. Physical Exam: VS: Temp: 95.6 Ax (97.5 oral) BP: 92/63 HR: 74 RR: 19 O2sat: 100% on NRB --> desated to 90% with NRB off for 5 minutes, in full sentences. GEN: NAD, pleasant, elderly female with NRB, able to answer questions appropriately but appears tired HEENT: EOMI, PERLL, anicteric, OP - no exudate, no erythema, MM appears slightly dry NECK: flat JVD RESP: inspiratory and expiratory rhonchi, coarse breath sounds, no wheezes or rales heard. CV: RRR, nl S1, S2, no r/g, III/VI SEM heard best at LLSB ABD: NDNT, soft, NABS, no HSM noted EXT: no c/c/e SKIN: no rashes, petechiae, ecchymosis NEURO: CN II-XII grossly intact, FTN intact, 2+ bilateral LE patellar reflexes, could not elicit reflexes in upper extremities. Gait not assessed. Pertinent Results: [2180-3-23] 05:15PM BLOOD WBC-17.5# RBC-4.67 Hgb-13.9 Hct-41.6 MCV-89 MCH-29.7 MCHC-33.3 RDW-12.7 Plt Ct-267 [2180-3-23] 05:15PM BLOOD Neuts-85 Bands-2 Lymphs-7* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2180-3-23] 05:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2180-3-23] 05:15PM BLOOD Plt Smr-NORMAL Plt Ct-267 [2180-3-23] 05:15PM BLOOD Glucose-199* UreaN-14 Creat-1.0 Na-140 K-4.4 Cl-101 HCO3-29 AnGap-14 [2180-3-23] 05:15PM BLOOD CK(CPK)-137 [2180-3-23] 05:15PM BLOOD CK-MB-3 proBNP-2204* [2180-3-24] 02:39AM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.8 Mg-2.1 [2180-3-23] 05:40PM BLOOD Lactate-2.9* [2180-3-23] 11:53PM BLOOD Lactate-1.4 URINES STUDIES: . [2180-3-23] 08:35PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.013 [2180-3-23] 08:35PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2180-3-23] 08:35PM URINE [2180-3-23] 08:35PM URINE Gr Hold-HOLD. . CT HEAD W/O CONTRAST [2180-3-23] 7:05 PM . FINDINGS: There is no evidence of acute intracranial hemorrhage, shift of midline structures or hydrocephalus. [Doctor Last Name ]-white matter differentiation is grossly preserved. Age appropriate atrophy noted. Hypodensity in the periventricular white matter of both cerebral hemispheres is seen, consistent with severe chronic microvascular infarction. Tiny hypodensity in the right basal ganglia likely represents small lacune. Mucosal thickening seen in the maxillary sinuses bilaterally, likely mucus retention cyst in the right maxillary sinus, possible small fluid level in the right maxillary sinus. Aerosolized secretions also seen in the maxillary sinuses. Mucosal thickening also noted within the ethmoid and frontal sinuses. . IMPRESSION: 1. No evidence of acute intracranial hemorrhage. MRI with diffusion-weighted images is more sensitive in evaluation for acute ischemia/infarction and for vascular detail. 2. Severe chronic microvascular infarction. 3. Sinus disease as described. . CHEST (PA & LAT) [2180-3-27] 9:29 AM . Lateral view shows a small region of consolidation in the anterior segment of one of the upper lobes, probably the right common, which could be a focus of pneumonia. No other pulmonary abnormalities are present. The heart is top normal size. Lateral view shows heavy calcification in what could be the aortic valve as well as a small right pleural effusion. There is no pulmonary edema, though the mediastinal veins and upper lobe pulmonary vessels are mildly dilated. Thoracic aorta is generally large and tortuous, but not focally dilated. . Brief Hospital Course: 84 y/o female w/ hx of hypertension, gait instability, memory impairment, was admitted to the hospital from [Hospital ] rehab with Shortness of breath, fever, new oxygen requirement, +RSV titers, healthcare associate pneumonia. . # presumed bacterial pneumonia on top of RSV pneumonia: Patient received 4 days of IV antibiotics (vanc/clinda/cipro), then transitioned over to PO levofloxacin. She responded well to the abx, but still has new oxygen requirment. Patient is on 4L of oxygen, sating 94%. This oxygen should be titrated down at rehab. Pt is scheduled to finish her levofloxacin course on [4-7]. Patients leukocytosis has resolved. Patient needs no precautions. . #Undiagnosed COPD: Patient received IV steroids during course. She has been on prednisone for several days. Recommend a steroid taper 60mg x3 days, 40mg x 3 days, 20mg x 3 days. She has responded well to ipratroprium and albuterol nebs standing q 6hours. Pt should be transitioned to as needed inhalers. . #Hematuria: Patient had a foley while in hospital with hematuria. This cleared with flushing and foley was discontinued. . # Depression: Patient has a history of depression and was continued on venlafaxine 75mg daily. . # Agitated delirium: Patient required PRN haldol and a sitter during her stay. She has not been agitated for the past 72 hours. Pt continues to receive daily olanzapine 10mg. . # Dementia [2-26] multiple small vessel disease. Patient is at her baseline for memory impairment. . # EKG abnormalities: While in MICU patient Reported symptoms concerning for possible cardiac origin with sweating, pale, and weakness vs demand from early sepsis. ST depressions seen in lateral leads compared to EKG from [2169]. Cardiac enzymes x 3 negative. No events on telemetry thus far. Patient is continued on daily aspirin. . #Hyperlipidemia: continued simvastin 20mg . #Anemia: HCT is 31, baseline 35.6. This was stable during hospital source. Guaic negative. . #CODE STATUS: Is DNR/DNI . Medications on Admission: Olanzapine 10 mg daily Ativan 0.5 mg q6 hours prn Ativan INJ 0.5 mg TID prn Raloxifene HCl 60 mg daily Cholecalciferol 1000 units daily Calcium Carbonate 650 mg [Hospital1 ] MOM 30 mL daily prn Venlafaxine HCl 75 mg daily Acetaminophen 975 mg QID prn Miralax 17 grams daily Aspirin EC 81 mg daily Senna 8.6 mg qhs Simvastatin 20 mg qpm Simvastatin 10 mg Discharge Medications: 1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 11. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): 60mg x 3 days 40mg x 3 days 20mg x 3. 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): 10 day course. Finish on [4-7]. 14. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Primary Diagonsis 1.RSV infection 2.Pneumonia . Secondary Diagnosis 3.Hypertension 4.Aortic Valve Stenosis 5.Osteoporosis 6.Hyperlipidemia 7.Memory impairment 8.Gait instability Discharge Condition: stable, 94% on 4L Discharge Instructions: Patient was admitted to the hospital from [Hospital6 ] with Fever and shortness of breath. She was not sure why she was brought to the hospital. She has dementia and short term memory deficits. . She was admitted to the MICU on [2180-3-23]. She was found to be positive for the RSV virus. She received several days of vancomycin/clindamycin/cipro. There was a chest xray which shows a possible infiltrate. Patient is being treated for a hospital acquired pna, now on levofloxacin 500mg PO daily. . We believe patient to have undiagnosed COPD. She has responded to duonebs well. Please continue on albuterol nebs and prednisone 60mg x 3days, 40mg x 3 days, 20mg x 3 days. . She has a new oxygen requirement, which should be titrated down at rehab. This o2 requirement is thought to be secondary to pneumonia and should improve with time. . Please send patient back if develops fevers over 101.5, or increased shortness of breath. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 23430] at [Telephone/Fax (1) 23431]. [Name6 (MD) ] [Last Name (NamePattern4) 23348] MD, [MD Number(3) 23349]	[ "4019", "4241", "2724", "311" ]
Admission Date: [2186-11-3] Discharge Date: [2186-11-14] Date of Birth: [2130-12-10] Sex: F Service: O-MED CHIEF COMPLAINT: Coffee-grounds emesis. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old female with a history of metastatic breast cancer who presented to the clinic on [2186-11-3] for followup with complaints of fatigue and nausea with vomiting of coffee-grounds material. She had been on gemcitabine chemotherapy for four cycles which had recently been held due to bone marrow suppression. She also had a recently admission to [Hospital1 190] after a transient ischemic attack versus cerebrovascular accident in association with a hematocrit of 16. She had been asymptomatic from a neurologic standpoint since that event, and she was hemodynamically stable when seen in the clinic. Due to her symptoms, she was sent to the Emergency Department for evaluation. In the Emergency Department, she had laboratories which revealed a hematocrit of 20.6, and she became acutely hypotensive, at which time she was admitted to the Intensive Care Unit for management. PAST MEDICAL HISTORY: 1. Breast cancer; originally diagnosed in [2178] as a stage II-B infiltrating ductal carcinoma. She is now status post modified radical with axillary lymph node dissection which revealed 17/34 nodes positive. She is also status post cyclophosphamide, doxorubicin, fluorouracil with radiation therapy in [2178-12-17]. In [2182], she was found to have increased tumor markers and bone pain and was diagnosed with metastases to the left femur. In [2183-7-17], the patient was on Taxotere and also had an allergenic stem cell rescue. In [2184-8-17], she had increased bony metastases and was started on Navelbine. She was stable after that point until [2185-6-17] when she was found to have a large mass in her abdomen and underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. She also underwent bilateral ureteral stenting due to an obstruction. She was then treated with Xeloda in [Month (only) 216] and [2185-9-17] and gemcitabine in [2185] every other week; with her last dose falling on [2186-9-29]. As stated above, treatment was complicated by recurrent thrombocytopenia and anemia. 2. Tuberculosis as a child. MEDICATIONS ON ADMISSION: Fentanyl 200-mcg patch, Percocet for breakthrough pain, Zoloft 100 mg p.o. q.d., Procrit 60,000 units weekly, and Zometa every month. ALLERGIES: PENICILLIN. SOCIAL HISTORY: The patient use to smoke approximately one-quarter pack per day for 10 years; she quit smoking in [2174]. She drinks alcohol only socially. She has four children. FAMILY HISTORY: Family history is significant for mother who had cancer. Her father had throat cancer. She has a maternal uncle with leukemia and bladder cancer, and a maternal aunt who had lung cancer. Her maternal grandmother had breast cancer as well. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed she was afebrile, with a heart rate of 112, blood pressure was 148/92 when sitting and 138/88 when standing. She was saturating 98% on room air at the time of admission. In general, she appeared pale. Her sclerae were anicteric. Her oropharynx was clear. There were no palpable nodes on her neck. Her lungs were clear to auscultation bilaterally. Her heart examination was regular without murmurs. Her abdomen was soft with normal bowel sounds, and no hepatosplenomegaly. She had no appreciable distention or ascites at the time. Her extremities were no different than their baseline revealing left upper extremity lymphedema since her mastectomy and some left lower extremity lymphedema as well. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission were significant for a white blood cell count of 6.4, hemoglobin was 6.8, and hematocrit was 20.6. Platelets on admission were 25. Chemistry-7 was unremarkable except for some slight renal insufficiency with a blood urea nitrogen of 36 and creatinine of 1.1. Liver function tests revealed AST was 54 and alkaline phosphatase was 176, but was otherwise normal. HOSPITAL COURSE: 1. UPPER GASTROINTESTINAL BLEED: The patient was admitted to the Intensive Care Unit after becoming acutely hypotensive. She did not require intravenous pressors; rather, her hypotension was controlled with intravenous fluid boluses and a blood transfusion. In the Intensive Care Unit, in total, she received 6 units of packed red blood cells in addition to platelets and fresh frozen plasma. Gastrointestinal was consulted; however, deferred an esophagogastroduodenoscopy due to the patient's thrombocytopenia and the risk of increased bleeding. The possibility of esophageal varices was raised, and a right upper quadrant ultrasound was done; which revealed normal flow demonstrated to the portal and splenic veins, mildly dilated common bile duct, and mild hydronephrosis of the right kidney. There was normal echogenic texture without evidence of focal abnormality within the liver, and the spleen was found to mildly enlarged (measuring 15.7 cm). Gastrointestinal recommended no esophagogastroduodenoscopy unless the patient re-bled. She was started on intravenous Protonix and Octreotide. There were no further events of hematemesis. The Octreotide was discontinued on [2186-11-6], and the patient was transferred to the O-MED Service. 2. HEMATOLOGY: The patient has chronically low platelets; likely secondary to her chemotherapy. On [11-7], her platelets were 18. Her INR was noted to be 1.7. There was a question of whether or not she was in disseminated intravascular coagulation. The disseminated intravascular coagulation laboratories were sent. Her LDH was elevated. Haptoglobin was very low. D-dimer and fibrin degradation products were both evaluated. Fibrinogen was not checked. As the patient remained hemodynamically stable, there was no evidence of any clotting or any obvious bleeding at that time, no further intervention was done regarding the possibility of disseminated intravascular coagulation. There was consideration to start antibiotics empirically, but that was not done. Her platelets remained low throughout her admission. She was transfused platelets occasionally as well as packed red blood cells to maintain her hematocrit in the mid to high 20s as necessary. She was transfused a total of 3 more units of packed red blood cells after leaving the Intensive Care Unit. 3. GENITOURINARY: The patient has had bilateral ureteral stents placed due to an obstruction from her abdominal mass. These stents were overdue for replacement. Urology was consulted and replaced these stents on [2186-11-9]. Prior to stent placement, the patient had received both vitamin K, fresh frozen plasma, and platelets in order to help reduce post procedural bleeding. Status post procedure, the patient had a Foley catheter in place on continuous bladder irrigation and drained red urine for approximately 24 hours to 48 hours. She was transfused platelets again and also started on Amicar for one 24-hour period to help stop the bleeding. Following the treatment with Amicar, her hematuria did resolve, and her Foley catheter was removed once her urine was clear. Afterward, the patient voided without difficulty. She was straight catheterized once to check a postvoid residual which was only 100 cc. No further intervention was done. The patient was to have the stents replaced again in three to four months. 4. INFECTIOUS DISEASE: Prior to undergoing the ureteral stent replacement, the patient was started on ciprofloxacin for prophylaxis and continued for a complete 7-day course following the procedure. In addition, given her history of methicillin-resistant Staphylococcus aureus, at the request of the Infectious Disease Department, she had perirectal swabs as well as nares swabs which did reveal Staphylococcus aureus which was resistant to oxacillin. Because of that, the patient was placed on contact precautions for methicillin-resistant Staphylococcus aureus. CONDITION AT DISCHARGE: Condition on discharge was stable. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. b.i.d. 2. Protonix 40 mg p.o. q.d. 3. Senna two tablets p.o. q.h.s. 4. Fentanyl patch 200 mcg topically q.72h. 5. Zoloft 150 mg p.o. q.d. 6. Oxycodone 5 mg p.o. q.4h. as needed. 7. Ativan 1 mg to 2 mg p.o. q.4-6h. as needed (for nausea). 8. Compazine 10 mg p.o. q.4-6h. as needed (for nausea). DISCHARGE DIAGNOSES: 1. Metastatic breast cancer. 2. Upper gastrointestinal bleed. 3. Bilateral ureteral stent replacement. 4. Thrombocytopenia and anemia secondary to chemotherapy. DISCHARGE FOLLOWUP: The patient had an appointment to follow up with Dr. [Last Name (STitle) 26065] on Tuesday, [2186-11-28] at 4:30 p.m. [First Name11 (Name Pattern1) 20062] [Last Name (NamePattern4) 26066], M.D. [MD Number(1) 26067] Dictated By:[Name8 (MD) 3491] MEDQUIST36 D: [2186-11-14] 17:51 T: [2186-11-14] 19:11 JOB#: [Job Number 26069]	[ "2875", "2859" ]
Admission Date: [2162-5-1] Discharge Date: [2162-5-6] Date of Birth: [2126-3-4] Sex: F Service: CCU CHIEF COMPLAINT: Chest pain x3 weeks. HISTORY OF PRESENT ILLNESS: A 36-year-old female with no prior history of coronary artery disease or cardiac risk factors presents with a complaint of crushing chest pain x3 weeks. The patient first noted onset of pain while driving her car. She has never experienced this pain before. Pain has been intermittent over the past three weeks. Yesterday the patient underwent stress test. She exercised for nine minutes and five seconds to stage four at the standard [Doctor First Name ] protocol with light handrail support. Test was terminated due to fatigue. The electrocardiogram demonstrated no ischemic changes. No chest pain was noted. There was no ventricular ectopy. The patient had appropriate blood pressure and heart rate response to exercise. The patient was advised to take Advil for costochondritis. This am around 9:30 the patient recurrence of chest pain, pain radiated to jaw and both arms. She took Advil and returned to bed. Her chest pain worsened. Her husband took her to the Emergency Department at [Hospital3 4527] Hospital. The patient was admitted, nitroglycerin, Heparin, aspirin, and Lopressor, and Integrilin. Initial CK was 41, troponin less than 0.2. Electrocardiogram disclosed ST segment elevations in the anterior distribution and intermittent right bundle branch block. The patient was transferred to the [Hospital1 69] Transitional Care Unit for catheterization. PAST MEDICAL HISTORY: None. ALLERGIES: No known drug allergies. MEDICATIONS: Oral contraceptive pills. MEDICATIONS ON TRANSFER: 1. Integrilin. 2. IV nitroglycerin. 3. IV Heparin. 4. Aspirin. 5. Lopressor. SOCIAL HISTORY: The patient drinks four beers per week. Denies use of tobacco. She did quit two years ago. Denies use of drugs. She is married. She has no children. FAMILY HISTORY: No coronary artery disease. Parents are alive in good health with no cardiac problems. [Name (NI) ] sister has diabetes mellitus. REVIEW OF SYSTEMS: The patient denies previous chest pain, fever or chills. She reports occasional shortness of breath. PHYSICAL EXAMINATION: Blood pressure 102/59, heart rate 63, respiratory rate 14, and O2 saturation is 97% on room air. General: Uncomfortable appearing young woman. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Mucous membranes moist. Oropharynx clear. Neck: No jugular venous distention, no thyromegaly. Heart: Regular, rate, and rhythm, S1, S2, no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities: No clubbing, cyanosis, or edema. Neurologic is alert and oriented times three. Cranial nerves II through XII are grossly intact. Examination is otherwise nonfocal. LABORATORY DATA FROM OUTSIDE HOSPITAL: Hematocrit 39.2, platelet count 292, potassium of 5.3, glucose 148, CK was 41, troponin-I less than 0.2. LABORATORY DATA AT [Hospital1 ]: Hematocrit of 33.9, platelet count of 282, BUN and creatinine of 14 and 0.9, glucose of 124, CK of 303. Serum tox screen was negative. Serum tox screen was positive for opiates, and patient was administered Fentanyl at outside hospital. ELECTROCARDIOGRAM: Normal sinus rhythm, normal intervals, normal axis, 1 mm ST segment elevation in V2. Repeat electrocardiogram showed right bundle branch block, right ST segment elevation in II, III, aVF, V1 through V5. By 12:30, electrocardiogram changes had resolved. Electrocardiogram at 2 o'clock showed sinus rhythm at 54 beats per minute, normal intervals, normal axis, 3 mm Q wave in III, Q's in V1 through V5. CHEST X-RAY: Cardiomegaly. ECHOCARDIOGRAM: Preliminary read: hypokinesis of anterior wall, no effusion, left ventricular ejection fraction 30%. IMPRESSION: A 37-year-old woman with no prior history of coronary artery disease and no cardiac risk factors transferred to [Hospital1 69] following complaints of chest pain x3 weeks with electrocardiogram changes concerning for anterior myocardial infarction. Patient was taken to CCU for further management. HOSPITAL COURSE: Patient was taken for cardiac catheterization. Coronary angiography of this right dominant circulation revealed severe single vessel coronary artery disease, the LMCA was short and had no significant stenosis. The left anterior descending artery had a thrombotic 85% lesion in the mid vessel with TIMI-2 flow throughout the remainder of a large wrap around vessel. Two small diagonal branches were free of significant disease. The left circumflex had no significant lesions that supplied a single large OM-1 that was also free of significant disease. The right coronary artery was angiographically normal that supplied small PDA and PLV branches. Limited resting hemodynamics revealed moderately elevated left ventricular filling pressures with a LVEDP of 26 mm Hg in the setting of normal systemic arterial blood pressure. No significant gradient across the aortic valve was detected. The patient underwent successful stenting of the mid left anterior descending artery. There was 10% residual stenosis, normal flow, and no apparent dissections. Echocardiogram disclosed a left atrium normal in size, left ventricular wall thickness and cavity size were normal. There was moderate regional left ventricular systolic dysfunction with hypokinesis of the basal anterior septum and anterior wall and akinesis of the more distal septum and anterior walls and the apex. No pericardial effusion, ejection fraction is 30%. Since the patient did not have any identifiable cardiac risk factors, numerous tests were sent off to include anticardiolipin antibodies, factor-[Initials (NamePattern4) ] [Last Name (NamePattern4) 12843], homocysteine, and lipoprotein-a, and C-reactive protein. Homocystine level was within normal limits. C-reactive protein was elevated since this test represents an acute reactant should be repeated. Interpretation of this value is unclear how useful [Name (NI) 49715] protein would be in this setting. Factor [Initials (NamePattern4) ] [Last Name (NamePattern4) 12843] and lipoprotein-a test should be followed up. The patient continued on aspirin, statin, and Plavix. She was also started on an ACE inhibitor and beta blocker. Due to akinesis of the anterior wall, the patient was also started on Coumadin. Patient will have repeat echocardiogram in eight weeks for further evaluation of wall motion abnormalities. At that time, it will be decided whether patient must continue on her Coumadin. Due to the patient's ejection fraction of 30%, the patient will have signal average electrocardiogram done as an outpatient. She will be referred to Dr. [Last Name (STitle) ] so that she may undergo risk stratification. DISCHARGE CONDITION: Good. DISCHARGE STATUS: Home. DISCHARGE INSTRUCTIONS: 1. The patient will follow up with her primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6955] early next week for INR check, phone number was [Telephone/Fax (1) 49716]. 2. The patient will follow up for signal average electrocardiogram to be scheduled through the Electrophysiology Laboratory. The patient will call [Doctor First Name 553] at [Telephone/Fax (1) 5518] to schedule this appointment. 3. The patient will follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at 1 pm, phone #[Telephone/Fax (1) 285]. 4. The patient will have a repeat echocardiogram on [6-29] at 10 am on the [Location (un) ] of the Grithmish Building [Apartment Address(1) 49717]. 5. The patient will follow up with Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) 49718] on [Last Name (LF) 766], [5-31] at 9 am at [Hospital3 4527] Hospital. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Zocor 40 mg po q day. 3. Plavix 75 mg po q day. 4. Lisinopril 2.5 mg po q day. 5. Atenolol 25 mg po q day. 6. Coumadin 2 mg po q day. DISCHARGE DIAGNOSES: 1. One vessel coronary artery disease. 2. Moderate left ventricular diastolic dysfunction. 3. Acute anterior myocardial infarction managed by primary angioplasty. 4. Successful direct stenting of the mid left anterior descending artery with distal protection. [First Name11 (Name Pattern1) 420] [Last Name (NamePattern4) 421], M.D. [MD Number(1) 422] Dictated By:[Last Name (NamePattern1) 5092] MEDQUIST36 D: [2162-5-7] 10:53 T: [2162-5-11] 08:09 JOB#: [Job Number 49719]	[ "41071", "41401" ]
Admission Date: [2168-7-18] Discharge Date: [2168-8-18] Date of Birth: [2121-1-20] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1406] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: [2168-8-12] MVR(29mm tissue) [2168-8-12] return to OR for chest exploration 2nd to bleeding History of Present Illness: Ms. [Known lastname 112326] is a 47yo woman with HCV cirrhosis, emphysema, heroin IVDU, who was recently admitted from [Date range (1) 112327] for septic shock, MSSA MV endocarditis ([2168-6-16]) c/b septic emboli to the brain, spleen, kidneys, and digits (w necrosis of distal extremities). Course was complicated by Klebsiella HCAP (sp 8d Levofloxacin; BAL on [6-23] also showed 2+ budding yeast), [Last Name (un) ] (Cr 1.1 --> 3.1), E. coli UTI (Dx: [2168-6-16]; sp 7d ciprofloxacin) and [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 29361]/glabarta peritonitis (Dx [2168-6-30]; sp Micafungin and Flagyl). Pt was not CT [Doctor First Name ] candidate as per CT team (TEE on [6-21] showed MV vegetation: 2.4x1.4cm and on [6-30] showed MV vegetation, measuring 1.3 cm x 0.9 cm). Pt was treated with vanc and later discharged on nafcillin (day 1 [6-17] - [7-29]). Pt presented again on [7-18] s/p unwitnessed fall w/ neck pain. In [Name (NI) ], pt was found to be febrile (102.3), tachycardic (120-140s), SOB w O2 Sat to 90s on 3LNC. Exam was notable for being combative and agitated, and [2-23] pansystolic murmur best heard over the apex, and slight diffuse abdominal tenderness. Extremities were still notable for necrotic fingers and feet with 2+ pulses bilaterally. In ED, CT Head was negative, CT spine showed possible C5-6 diskitis (focal endplate irregularities and sclerosis), CXR showed bl hazy opacities, and CTA chest showed lingular nodule and multiple nodularities w fluid overload pattern and NO PE. Echo [2168-8-2] showed a moderate-sized vegetation on the mitral valve (posterior leaflet) and severe (4+) mitral regurgitation. Csurg was reconsulted for evaluation for mitral valve replacement. Past Medical History: Recent ICU admission for MSSA endocarditis, c/b septic shock, respiratory failure, pneumonia, ATN, hand/foot necrosis, fungal peritonitis, UTI, Hep. C not treated(being followed at [Hospital1 2177]), Asthma, Vit. D deficiency, Asthma, Emphysema Social History: Currently separated from wife prior to admission because of patient's polysubstance abuse. Pt actively using heroin, MJ, BZ, cocaine, before last admission. Approximately 35 pack year smoking hx. Two sons (24, 16). Two grandchildren Family History: Father deceased lung Ca brother deceased ALL Uncle deceased [Name2 (NI) ] Ca + COPD son bladder Ca Physical Exam: Admission Temp: 98.6 Pulse: 116 B/P: 122/85 Resp: 22 O2 sat: 100%RA Height: 65" Weight: 75kg General: NAD, A&Ox3 Skin: Dry [x] intact [], gangrenous feet bilat, necrotic fingertips bilat. HEENT: EOMI [x] Neck: Full ROM [x], +trach w/ Puissy Muir valve Chest: +rhonchorous Heart: Murmur - systolic [x] grade ______, tachy w/ reg rhythm Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Dry gangrene of b/l distal phalanges, R>L. Dry gangrene of b/l feet (mid-foot to toes). Neuro: Grossly intact [x] Discharge: VS: 99.2 97 reg 105/77 18 100% RA Wt 76.6 Gen: nAD-lying in bed Neuro: A&O x3, nonfocal exam Pulm: clear, diminished in bases bilat. trach site CDI CV: RRR, sternum stable, incision CDI Abdm: soft, NT/ND/+BS. PEG site tender to touch/CDI Ext: necrotic feet bilat-dopplerable PT pulse necrotic fingertips- bilat Pertinent Results: [7-31] MRI head 1.Evolution of multiple abnormal FLAIR foci, in keeping with infarcts, throughout the brain parenchyma with some of them demonstrating more apparent hemorrhagic components. Different degrees of decreased FLAIR intensity involving some of the multiple infarcts. No evidence of acute infarct. 2. The area of concern corresponds to expected evolution of a focal infarct within the left cerebellum. No evidence of abnormal enhancement. [2168-7-29] CT torso IMPRESSION: 1. No evidence of pulmonary embolism. 2. Worsening of the bilateral nodular pulmonary densities, most likely infectious versus inflammatory in nature. These should be followed with repeat CT when the patient's current clinical scenario improves to assure complete resolution. There is also worsening of the lower lobe atelectasis and consolidations as well as worsening of the mediastinal lymphadenopathy. Pulmonary edema is similar in extent. 3. Stable splenic and renal infarcts. 4. Thrombosed right external iliac artery, an unchanged finding. 5. Increased size of a left adnexal cyst. If patient is postmenopausal then further evaluation is recommended with pelvic ultrasound on a nonurgent basis (within 6 weeks). CT OF THE ABDOMEN WITH IV CONTRAST [2168-7-22]: Included views of the lung bases demonstrate small basilar consolidations, mild interstitial edema, moderate emphysema, and multiple scattered ground-glass nodular opacities, all improved since the [2168-7-18] chest CT examination. Small left pleural effusion. The heart size is normal. There is no pericardial effusion. Relative hypodensity of the blood pool with respect to the intraventricular septum (2:6) is compatible with chronic anemia. There has been interval resolution of previously-seen ascites. The liver contour is nodular, most compatible with cirrhosis. The spleen is mildly enlarged and contains a splenic infarct in the lateral upper pole (2:12). The pancreas, adrenal glands, stomach, and intra-abdominal loops of small bowel are normal. A gastrostomy tube is appropriately positioned (2:31). Relative hypodensity of the superior spleen (2:14) and along the right renal cortex (2:29. 27) are better appreciated on the contrast-enhanced study from [2168-6-29], reflecting infarcts. Scattered prominent para-aortic lymph nodes (2:32) are slightly enlarged since the [2168-6-29] examination. ECHO REPORT [2168-7-19] The left atrium is normal in size. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are moderately thickened. There is a moderate-sized vegetation on the mitral valve. There is an abscess cavity seen adjacent to the mitral valve (not as well seen as on the prior transesophageal echocardiogram). Moderate to severe (3+) to severe (4+) eccentric mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Compared with the prior transesophageal study (images reviewed) of [2168-6-30], the mitral vegetation now appears smaller. Mitral regurgitation appears similar to slightly worse (severity of mitral regurgitation was likely underestimated in the prior report). An abscess/phlegmon is seen along the posterolateral annulus (though not as well seen as on the prior transesophageal echocardiogram). [2168-8-12] PRE BYPASS No thrombus is seen in the left atrial appendage. Mild spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There is an echolucent area in the basal lateral and anterlateral walls, below the posterior mitral annulus, that demonstrates blood flow within. This is likely an aneurysm due to abscess. The right ventricle appears to dispaly focal hypokinesis of the apical free wall. This may be due to limited imaging. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 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. There is a large vegetation on the mitral valve. The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. There is no 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 There is normal biventricular systolic function. There is a bioprosthesis located in the mitral position. It appears well seated and displays normal leaflet motion. No mitral regurgitation is appreciated. The maximum gradient through the mitral valve was 15 mmHg with a mean gradient of 5 mmHg at a cardiac output of 6.5 liters/minute. The tricuspid regurgitation may be slightly worse but is mild in total. The rest of valvualr function is unchanged. The thoracic aorta is inatct after decannulation Radiology Report CHEST (PORTABLE AP) Study Date of [2168-8-14] 3:54 PM Final Report There is no evident pneumothorax. Moderate pulmonary edema has worsened. Right lower lobe and right perihilar opacities have increased consistent with increasing atelectasis and pleural effusion. Left lower lobe retrocardiac opacities have worsened, consistent with worsening atelectasis. Swan-Ganz catheter tip is in the main pulmonary artery. Right PICC tip is in the middle SVC. Tracheostomy tube in standard position. Cardiomediastinal contours are unchanged. Small left pleural effusion has increased. Discharge labs: [2168-8-17] 05:36AM BLOOD WBC-5.6 RBC-2.86* Hgb-9.1* Hct-27.6* MCV-96 MCH-31.6 MCHC-32.9 RDW-18.9* Plt Ct-102* [2168-8-16] 06:30AM BLOOD WBC-6.4 RBC-3.16* Hgb-9.7* Hct-29.9* MCV-95 MCH-30.8 MCHC-32.5 RDW-18.7* Plt Ct-93* [2168-8-15] 02:34AM BLOOD WBC-8.0 RBC-2.79* Hgb-8.8* Hct-26.2* MCV-94 MCH-31.5 MCHC-33.5 RDW-18.6* Plt Ct-82* [2168-8-17] 05:36AM BLOOD UreaN-12 Creat-0.6 Na-134 K-3.5 Cl-103 [2168-8-16] 06:30AM BLOOD Glucose-111* UreaN-13 Creat-0.6 Na-133 K-3.3 Cl-101 HCO3-23 AnGap-12 [2168-8-15] 02:34AM BLOOD Glucose-136* UreaN-12 Creat-0.6 Na-135 K-3.5 Cl-103 HCO3-23 AnGap-13 [2168-8-14] 04:00PM BLOOD Glucose-149* UreaN-11 Creat-0.6 Na-130* K-3.7 Cl-101 HCO3-21* AnGap-12 Brief Hospital Course: MEDICAL COURSE: 47 yo F with a history of HCV, IVDU, recently d/c from ICU to rehab on [7-12] after 1 month inpatient stay for MSSA endocarditis (was on nafcillin) c/b shock, respiratory failure s/p trach, pneumonia, [Last Name (un) ] [1-21] to ATN, hand and foot necrosis and fungal peritonitis who was admitted after fall at rehab with complaints of fevers, tachycardia 1) Respiratory distress: The patient had intermittent desaturations in the ED. Upon presentation to the ICU, was initially doing well. Was found to have passey muir valve in place, and reported leaving it in place for over a week without taking out in evenings. Valve was removed. Patient quickly desaturated to 60s-70s, RR 30s, HR 150s-160s, BPs 150s/90s-100s. Became combative, agitated. Large mucous plugs were suctioned along with albuterol nebulizer, 2 mg IV ativan, and 100% O2 to bring her up to O2 sats in the 80s. She briefly required ventilatory support with a PEEP of 5cmH2O and pressure support of [4-26] cmH2O. Her respiratory status improved with suctioning and humidified oxygen. She was instructed to remove her Passey-Muir valve overnight to improve pulmonary hygeine. Ultimately, it was felt that the single desaturation event was secondary to mucous plugging, which was itself secondary to continuous use of passey muir valve. She was sent to the floor on trach mask at 40% FiO2. On the medical floor, her respiratory status stabilized, and did well with intermittent suctioning and maintained adequate cough. On [7-29] sputum cx grew colonies of Chryseobacterium and STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. As pt was afebrile and had no leukocytosis, ID team felt that there was no need for additional antibiotic coverge as this was most likely benign colonization. 2) Fever likely secondary to HCAP and MSSA endocarditis: The patient was febrile to 102.3 in the ED on initial presentation. Contributing sources included pneumonia--likely HCAP (sputum culture grew pseudomonas), persistent MSSA mitral endocarditis, possible cervical osteomyelitis/discitis as seen on cervical spine MRI. In addition, elevated beta glucan raised potential of persistent or recurrent fungal peritonitis; CT was performed, which showed no intra-abdominal or intrapelvic fluid collections. CT, however, raised potential contribution of ?new thrombophlebitis in the right iliac; this was not immediately evaluated in ICU pending improvement in renal function (for contrast load) and lack of acuity not requiring MRA. As patient continued to spike fevers, the PICC line was also pulled after placement of 2 peripheral IVs, and the PICC line tip was cultured. Her outpatient nafcillin was held and she was initially empirically treated with vancomycin 750mg IV q12h and cefepime 2g IV q8h. The antibiotic spectrum was again changed to nafcillin and cefepime in conjunction with ID, with a plan for a total of 17 days of cefepime for the HCAP, and a complete course of nafcillin of 8 weeks duration (ending on [2168-9-28]). Given peristant fevers on [2168-7-29], a CT torso was performed, which revealed the possibility of another/new infectious lesion in the brain. For further evaluation, and MRI of the brain was performed and revealed multiple septic emboli with hemorrhagic components. Cardiac surgery was again consulted in re: the timing of any MVR. A repeat echocardiogram was requested by them to evaluate. This was performed and revealed severe (4+) mitral regurgitation was seen and MVR was done on [2168-8-12]. The explanted valve was sent to pathology and had cultures sent. 3) Right external iliac artery thrombus: This was seen on a non contrasted study in the ICU. There were also some subtle changed on prior imaging from prior hospitalization. A CT torso on [2168-7-29] demonstrated thrombosis of the rt. ext iliac artery, which radiology reported as 'an unchanged finding'. ID and Vascular surgery were asked for input as to further specific managment for this finding, if any, over concern for the possible need for anticoagulation given possible nidus of septic thrombophlebitis/ongoing endovascular infection, and recommended heparin drip and would readdress operation after MVR with cardiac surgery. Heparin drip was started after vascular initially planned on operating on groin clot before C-[Doctor First Name ]. Serial neuro checks were done while on heparin as pt had septic emboli to brain and had hemmorrhagic components. Pt required a head CT after starting drip which ruled out hemorrhage. Heparin drip was discontinued as risk of intracranial hemorrhage outweighed benefit of agressive anticoagulation for clot without interval change and not symptomatic (no wet gangrene of R LE and Doppler pulses of posterior tibialis). 4) C5-C6 chronic osteomyelitis with neck pain: The patient had a head and neck CT that suggested only discitis/osteomyelitis. There was no evidence of fracture. She had no focal neurologic findings on exam. Her pain was treated with oxycodone PRN, and antibiotic thearpy was continued as above. On [8-7] pt complained of R shoulder pain (without neurologic deficits) and this was concerning for acute osteomyelitis- imaging should no signs of osteo. 5) Dry gangrene on extremities: The patient's hands and feet show evidence of dry gangrene secondary to septic emboli. She was seen by plastic surgery who recommended waiting for the necrotic tissue to demarcate and folowup in 2 weeks. Betadine was placed on hands and feet [Hospital1 ] to prevent conversion from dry to wet gangrene. Her extremities did not develop signs of wet gangrene during her hospital stay. Vascular surgery saw pt. and recommended outpatient follow up in one month for possible amputation of the feet at a TMA site or via BKA (TBD). Pt's pain was controlled with OxyContin, oxycodone for breakthrough, and Tylenol. 6) Neuropathic pain: The patient complained of burning pain in her legs that was thought to be neuropathic in nature. She was started on gabapentin 300mg PO TID which was subsequently increased to 600 mg TID. 7) Hep C: The patient's LFTs and INR remained stable during her admission. She is not being treated for Hep C currently, and no treatments were started during her admission. 8) Trach/PEG: Per IP, was going to defer downsizing tube before surgeries as pt may need bronchoscopy and trach will be used by anesthesia for procedures. In addition, IP also planned on taking out PEG tube after procedures as well. PEG tube was not used while on medical floor as pt was able to swallow medications and food without difficulty. SURGICAL COURSE: 47F seen by Cardiac Surgery on [2168-6-17] during an admission for MSSA bacteremia and mitral valve endocarditis with multiple embolic events (brain, spleen, R kidney, [Last Name (un) 1003] lesions), presumably secondary to IV heroin use. At the time of evaluation, pt was septic; thus, the initial decision was to treat her medically (vanc/Zosyn -> nafcillin x 6 wks). She then defervesced, her blood cultures after [6-16] were sterile, and a TEE failed to show progression; thus, surgery was deferred even after she stabilized. Her hospital course was also significant for Klebsiella pneumonia/respiratory failure requiring trach (treated with levofloxacin x 8d), acute kidney injury (Cr 3.1, presumed secondary to ATN, secondary to hypotension), E.coli UTI (treated with cipro x7d), and fungal peritonitis (treated with micafungin and Flagyl). She was discharged to [Hospital 100] Rehab on [2168-7-12]. On [2168-7-18], pt was sent back to ED s/p fall out of bed with neck pain and agitation. In the ED, she was noted to be febrile (102.3), tachycardic (120-140s), and hypoxic (mid-low 90s on 3L). WBC was normal. CT and MRI C-spine demonstrated C5-6 chronic osteomyelitis. CXR and CTA chest demonstrated multifocal pneumonia. She was admitted to Medicine. Repeat echo demonstrated that the MV vegetation had decreased in size. Again, an abscess/phlegmon along the posterolateral annulus was noted. MV regurgitation was noted to be similar/slightly worse. All blood cultures since readmission have been sterile. On [2168-7-29] pt was noted to be somnolent, febrile (100.8), and tachycardic. CT head demonstrated a new R vertex ring-enhancing lesion, ?early abscess. However, CTA torso also demonstrated worsening pneumonia. Csurg was reconsulted to re-evaluate for possible surgical intervention in the setting of continued septic emboli. [2168-8-2] Echo showed moderate-sized vegetation on mitral valve. No MS. [Name13 (STitle) 650] (4+) MR. On [2168-8-12] the patient was transferred to the cardiac surgical service. The patient was brought to the operating room on [2168-8-12] where the patient underwent MVR (29mm tissue). See operative report for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Later on the night of POD#0 she was taken back to the operating room for re-exploration for bleeding. POD 1 she was weaned from the ventilator and able to maintain adequate oxygenation on trach collar. She remained alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward 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 and rehab was recommended. She is non-weight bearing due to her dry necrotic feet. By the time of discharge on POD 6 the patient was afebrile on IV nafcillin, tolerating a regular diet but remained on cycled tube feeds to maximize nutrition. She was eating well and so the tube feeds can likely be discontinued soon. Trach and G tube removal to be evaluated at rehab once procedures completed. The sternal wound was healing and the pain in her extremities and sternum was controlled with oral analgesics. She is to continue Nafcillin until [2168-9-9] via PICC and had infectious disease follow up arranged. The day before discharge she experienced pain at her PEG tube site but it was found to be clean, dry, and intact on inpection. Dr.[Name (NI) 5070] team, who placed the tube on [6-23], asked for a tube study that revealed that the tube was in in good position. They are hesitant to remove the tube in this malnourished patient until the tube has been in place for at least a total of 12 weeks due to the risk of peritonitis. The patient was discharged to [Hospital1 ] [Hospital1 8] on POD 6 in good condition with appropriate follow up instructions. Cardiac surgery and vascular follow up have been arranged. Medications on Admission: Albuterol Inhaler [1-23] PUFF IH Q4H:PRN wheeze Acetaminophen 650 mg PO Q6H pain Do not exceed 4g in one day Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes Docusate Sodium (Liquid) 100 mg PO BID Hold for loose stools. Nafcillin 2 g IV Q4H endocarditis OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain in feet Quetiapine Fumarate 25 mg PO HS:PRN agitation, insomnia Senna 1 TAB PO BID:PRN constipation Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [Hospital1 ] Discharge Medications: 1. Nafcillin 2 g IV Q4H 2. Heparin 5000 UNIT SC TID 3. Gabapentin 600 mg PO TID 4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [Hospital1 ] 5. Senna 1 TAB PO BID:PRN Constipation hold for loose stools 6. Acetaminophen 650 mg PO Q4H pain do not exceed 4g in one day 7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain in feet hold for sedation, rr < 10 8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing 9. Amitriptyline 25 mg PO HS 10. Aspirin EC 81 mg PO DAILY 11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing 12. Lorazepam 0.25 mg PO Q4H:PRN anxiety 13. Povidone Iodine 1/2 Strength 1 Appl TP ASDIR hands and feet twice daily 14. Ranitidine 150 mg PO BID 15. Oxycodone SR (OxyconTIN) 20 mg PO Q12H hold for sedation and/or RR < 10 16. Metoprolol Tartrate 12.5 mg PO BID Discharge Disposition: Extended Care Facility: [Hospital3 ] in [Hospital1 8] Discharge Diagnosis: Primary diagnoses: Mitral valve endocarditis S/p MVR with return to operating room for post-operative bleeding, PMH: Pseudomonas pneumonia, Mitral valve endocarditis-MSSA, cervical osteomyelitis, necrotic finger tips and feet, hepatitis C, endocarditis, IVDU, [Last Name (un) ], hand foot necrosis, fungal peritonitis, right iliac septic thrombus, , cirrhosis, asthma, emphysema, vit D deficiency, chronic headaches, PSH: tracheostomy, PEG Discharge Condition: Alert and oriented x3 nonfocal, anxious at times [Doctor Last Name 2598] lift to chair Incisional pain managed with oxycodone and oxycontin Incisions: Sternal - healing well, no erythema or drainage Legs with dry black necrotic feet. Edema of both lower extremities: 2+ UE with nectrotic fingers bilaterally 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 one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge 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 Infectious disease Instructions: OPAT Antimicrobial Regimen and Projected Duration: [Doctor Last Name ] & Dose: Nafcillin 2g IV Q4H Start Date: [2168-6-17] Stop Date: [2168-9-9] CBC with differential (weekly) Chem 7, BUN/Cr, AST/ALT/Alk Phos/Total bili, CPK, ESR/CRP -weekly All laboratory results should be faxed to the Infectious Disease R.N.s at ([Telephone/Fax (1) 4591]. All questions regarding outpatient parenteral antibiotics should be directed to the Infectious Disease R.N.s at ([Telephone/Fax (1) 21403] or to the on-call ID fellow when the clinic is closed Infectious Disease Fellow: [Doctor First Name ] [Doctor Last Name ] (First contact for patient-related matters, if unavailable please contact the ID fellow on-call [Numeric Identifier 112328]) Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [2168-9-8] at 1:30p in the [Hospital ] medical office building, [Doctor First Name ], [Hospital Unit Name ] Cardiologist: Needs referral Infectious disease Clinic on [2168-9-6] at 09:00am in the [Hospital ] medical office building, [Doctor First Name ] Basement Infectious Disease Fellow: [Doctor First Name ] [Doctor Last Name ] (First contact for patient-related matters, if unavailable please contact the ID fellow on-call [Numeric Identifier 112328]) Vascular surgery: VASCULAR LMOB (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time: [2168-9-28] 10:15 [Hospital Ward Name ] BLDG ([Doctor First Name ]), [Location (un) ] Please call to schedule appointments with your Primary Care Dr.[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 112329] [Telephone/Fax (1) 11463] in [3-24] 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:[2168-8-18]	[ "4240", "49390", "3051" ]
Admission Date: [2128-11-14] Discharge Date: [2128-11-30] Date of Birth: [2051-9-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: SOB Major Surgical or Invasive Procedure: thorocentesis History of Present Illness: 77 y/o male w/ h/o rheumatic heart dz s/p mechanical mvr/avr, afib (s/p VVI PPM); CAD s/p stenting; h/o CHF with preserved EF 55%; s/p recent admit to [Hospital1 18] for 7 wks (work up for valve leakage included TTE, TEE, MRI showing 2+ MR [First Name (Titles) 31820] [Last Name (Titles) 31821]e; s/p cath x 2 with stenting of RCA and LAD; s/p VVI pacemaker for chronic afib) who was discharged and then readmitted with SOB and resp failure, aggressively diuresed with natrecor and laxis and DC to rehab on [11-9]. Now readmitted with increased SOB and weight gain (148 on [11-13], 153 on [11-14], goal is 132). Unable to diurese at rehab despite increasing Bumex to 3mg [Hospital1 ] on [11-13]. Increaed edema, decreased sats. In ED: Decreased BP to 60s systolic (usually 90s) and somnolent. Recieved 250 bolus and dopamine gtt. ABP 7.19/82/94 placed on bipap. had temp to 101 in ED and recieve 1gm vanco. K was 6.2 and recieved 10 units of insulin/D50/2gm cal glu. Rt fem CVL placed. CXR showed worse right pleural effusion aas compared to previous. Pt transferred to floor, ABG 7.16/87/61 and decided to intubate after extensive discussion with family about code status. Past Medical History: 1. CAD - s/p cath [2128-7-30]:stenting of the RCA with 3 overlapping cypher [Name Prefix (Prefixes) ] -[Last Name (Prefixes) ] [2128-8-11]: rotational atherectomy, PTCA and stenting of the LAD/LCX. 2. MVR/AVR 3. CHF - EF >55% 2+MR [Month/Day/Year 31820], RV dysfunction, moderate pulmonary HTN 4. PAF s/p VVI pacemaker 5. CRI 6. MDS 7. Chronic mechanical hemolysis 8. Hx. of perirectal abscess s/p surgery Social History: no hx of etoh or tobacco, lives at home alone, widower. Children are very involved in his care. Family History: non-contributory Physical Exam: Vitals: T= 99.8, HR = 60-89, BP = 82/45 on dopa of 5, RR = 20 , SaO2 = 100% on AC 500, rate 18, Peep 8. FiO2 50%. weight 153 lbs General: uncomfortable, mild distress, intubated HEENT: Normocephalic and atraumatic head, no nuchal rigidity, anicteric sclera, moist mucous membranes. Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. Chest: chest rose and fell with equal size, shape and symmetry, lungs with decreased breath sounds, left greater than right. CV: PMI appreciated in the fifth ICS in the midclavicular line- hyperdymanic, afib, mechanical S1 and S2. III/VI systolic murmur, II/IV diastolic murmur Abd: Normoactive BS, NT and ND. No masses or organomegaly Back: No spinal or CVA tenderness. Ext: NO cyanosis, no clubbing. 2+ symetric edema with 2+ dorsalis pedis by doppler pulses bilaterally Integument: no rash Neuro: Solmnmelent but answer questions yes, no. communicates with family. CN II-XII symmetrically intact, PERRLA. Pertinent Results: CXR: FINDINGS: A single AP supine image. Comparison study taken 3 hours earlier. The ETT has been withdrawn slightly and its tip is now 3 cm above the carina in good position. The NG line is well positioned in the lower portion of the stomach. The heart shows fairly marked enlargement, predominantly left ventricular. There is evidence of prior cardiac surgery but the prosthetic valves are not clearly defined. There is also evidence of CABG procedure with some cardiovascular clips and sternal sutures noted. The aorta is slightly calcified and unfolded. The pulmonary vessels show fairly marked upper zone redistribution. There is a moderate sized right sided pleural effusion. These findings are consistent with left heart failure. The severity of the cardiac decompensation is not significantly changed since the prior study. An external electrode overlies the inferior aspect of the cardiac silhouette. A pacemaker overlies the left shoulder region with a single electrode extending into the apex of the right ventricle. IMPRESSION: 1) Evidence of prior surgery. There is now left ventricular decompensation of moderate severity associated with a right sided effusion. The ETT is now in good position. Brief Hospital Course: 1. Respiratory failure: When the aptient was admitted, he was placed on BiPap, however continued to have decreased PaO2 and was acidotic and hypercarbic. Therefore he was intubated and remained intubated until [11-18] when he was successfully extubated/ The patient's respitary failure was though to be due to a combination of CHF, a large pleural effusion and possibly a PNA. He was aggressively diuresed, and his plueral effusion was tapped and found to be transudative, and he was placed on broad spectrum antibiotics. The IV antiobiotics were switched to PO levofloxacin. Repeat CXR showed increased right pleural effusion compared to the CXR after the thoracentesis. However, pt continued to breath comfortably on room air. Pt also got Flu vaccine during his stay. 2. Decompensated CHF: The patient came in with a weight of 69.4kg and his dry weight is 60kg. The patient later admitted to drinking a large amount of water in rehab and being constantly thirsty. Historically the patient responds best to natrecor with dopamine. He was started on dopamine and natrecor for diuresis and Lasix IV bolsues were added as needed. As his urine output fell, he was started on a Lasix drip. Once he was close to his dry weight, Natrecor was stopped and he was switched to PO Zaroxyln and Lasix prn. He was eventually switched converted to standing po Bumex 2 mg po bid and achieved his ideal wt of 60 kg and remained stable. Once pt was off dopamine tolerating BP, Toprol XL was started. Lisinopril was re-started as well. These medications were administered at bedtime since his SBP drops to 80's with these meds. Standing po Bumex was started (2 mg [Hospital1 ]). Pt achieved his ideal dry weight of 60.5 kg at one point, but wt returned to 63.5 kg which was thought to be secondary to sodium retention from the prednisone he took for gout flare. His discharge weight was 62.8 kg. He was discharged with Toprol 12.5 mg po qhs, Lisinopril 1.25 mg po qhs, Bumex 2 mg po bid. Pt is very sensitive to ACEI and drops his BP in 80's, so it is given at bedtime. It is emphasized that his baseline BP is in the 80's-low 100's, and no medications should be held for SBP of high 80's or 90's. Toprol and Lisinopril should be spaced 2 hr apart. Pt will be followed at [Hospital 1902] clinic. 3. CAD: The paitent is s/p RCA stenting on [2128-7-30] for reversible inferior wall defect. His ASA and plavix were continued and carvediol and lisinopril were initially held for low SBP. As above, after diuresis and improved cardiac output, pt was started on Toprol and lisinopril. 4. Rhythm: Chronic afib s/p VVI pacer [2128-8-12]. Pt was initially started on digoxin for rate control while he was hypotensive and on dopamine gtt. But it was switched to Toprol later for rate control. Coumadin was held for thoracentesis but re-started. 5. Chronic anemia [1-26] mechanical hemolysis MDS, and anemia of chronic disease. He was initially continued on iron and folate, but the EPO was given 10,000 units qMWF which is half of what he was getting on last admission to keep his Hct stable. His Hct slowly drifted down, so the EPO was increased to 20,000 units qMWF with good response. His Hct remained stable at 29-30. Pt will be discharged with EPO 20,000 qMWF and Iron supplement. 8.CRI: The paitent's baseline is 1.2. He had a bump up to 3.0 on admission. His creatinine improved to his near baseline after aggressive diuresis to improved the cardiac output. 9.Mechanical valve: Pt was on Coumadin which was held initiallya and bridged with Heparin gtt for procedures. Coumadin was re-started with goal of INR 2.5-3.5. INR was 3.5 on discharge. 10. Gout: Pt developed a severe left foot pain localized at tarsal area. The area appeared erythematous and tender to palpation. Pt responded well to prednisone 30 mg x 3 days. Pt was given additional 15 mg x 3 days. He will be followed by outpatient [Hospital 2225] clinic and decide whether he needs to be on long term prophylaxis. Pt's uric acid was 10.6. Gout flare may have been triggered by chronic mechanical hemolysis, chronic diuresis, and CRI. 11. FEN: Pt needs to be on 2gm sodium diet, cardiac diet, and fluid restriction of 1.5 L. Pt needs to be weighed daily and be reported to MD if he has more than 1 kg of weight gain, so his medications could be adjusted. Medications on Admission: Plavix 75, folic acid 1, atrovent, lipitor 20, asa 81, remeron 15, no aldactone (was not supposed to start this in rehab given labile K), ranitidine 150, epogen [Numeric Identifier 389] qMWF, cravediolol 3.125 [Hospital1 ], lisinopril 5 (was supposed to be taking 3.75), Bumex 2 [Hospital1 ] increased to 3 [Hospital1 ] on [11-13], Coumadin 13mg. Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 13. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet Sustained Release 24HR PO HS (at bedtime): Please give 2 hrs before lisinopril Hold for SBP<90, HR<55. 16. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Please have INR checked frequently. 18. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO once a day: Please base the dosing on INR level. Goal 2.5-3.5. 19. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) for 2 days. 20. Lisinopril 2.5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime): Take 2 hrs after Toprol. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: CHF exacerbation Pneumonia Gout A-fib CAD Discharge Condition: Stable, pt near his ideal weight, breathing on room air. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L Patient was instructed to take all of the medications as instructed. Pt needs to be weighed daily and needs to report to MD (Dr. [Last Name (STitle) 73] or MD at the rehab and have his medications be adjusted accordingly. Pt needs to restrict the fluid intake to 1.5 L/day. Pt should have his INR checked until it is at a stable level between 2.5-3.5, and have the coumadin dose adjusted accordingly. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4582], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 3512] Date/Time:[2128-12-6] 3:30 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: LM [Hospital Unit Name 16933] Phone:[Telephone/Fax (1) 2226] Date/Time:[2128-12-15] 10:00 Provider: [Name10 (NameIs) 900] [Name8 (MD) 901], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 902] Date/Time:[2128-12-29] 11:30 Completed by:[2128-11-30]	[ "4280", "51881", "486", "42731", "2767", "5849" ]
Admission Date: [2120-4-20] Discharge Date: [2120-4-23] Date of Birth: [2058-12-29] Sex: F Service: CHIEF COMPLAINT: Status post myocardial infarction and RCA stent placement. HISTORY OF THE PRESENT ILLNESS: The patient is a 61-year-old female with a history of coronary artery disease, status post stenting times two in the past with hypertension, hypercholesterolemia, GERD, and family history of coronary artery disease, who has had stuttering chest pain approximately 20 minutes in duration and dyspnea on exertion over the past two weeks. She has been taking aspirin up to six times per day and sublingual nitroglycerin and dyspnea on exertion which would occur after walking a few blocks. At 7:00 p.m. the night prior to admission, she developed substernal chest pain which did not radiate along with dyspnea on exertion but no nausea, vomiting, or diaphoresis. She went to sleep after the pain resolved until 11:00 p.m. At 5:00 a.m., the chest pain recurred and she was taken to an outside hospital. At the outside hospital, she was found to have ST elevations in leads II, III, and aVF, and ST depressions in I, aVL and V1 and V2. She received heparin, aspirin, beta blocker, and Aggrastat and was transferred to [Hospital1 18] for further care. On the floor, on arrival, she had one episode of nausea and vomiting and 1/10 chest pain without EKG changes. The chest pain resolved with 3 mcg nitroglycerin drip. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post stenting of the diagonal in [2114], distal RCA also in [2114]. 2. GERD, known since [9-26]. 3. Shingles. 4. Measles. 5. [Doctor First Name 533] measles. 6. Chicken pox. 7. History of endometriosis. 8. Tonsillectomy. 9. History of a left arm fracture and right arm fracture. 10. History of bilateral patellar bursitis. 11. Hypertension times five years. 12. Hypercholesterolemia. 13. Laryngotomy. 14. Question of asthma. MEDICATIONS AT HOME: 1. Aspirin 325 q.d. 2. Senokot 1.5 q.h.s. 3. Nitroglycerin p.r.n. 4. Toprol XL 100 q.d. 5. Ativan p.r.n. ALLERGIES: The patient has an allergy to penicillin, tetracycline, Rhinocort, and iodine. FAMILY HISTORY: Significant for coronary artery disease in both parents and also diabetes. SOCIAL HISTORY: No tobacco. No drugs. Positive alcohol use, one to two drinks per day. Works as an attorney. PHYSICAL EXAMINATION ON ADMISSION: General: The patient appears fatigued, otherwise in no apparent distress. Vital signs: Heart rate 68, blood pressure 111/65, respiratory rate 17, 98% on 2 liters. HEENT: PERRL. EOMI. The oropharynx was clear and moist. Neck: No carotid bruits, JVP to 8 cm. Chest: Bilateral expiratory upper airway sounds. No rales. Heart: Regular S1, S2. Abdomen: Soft, nontender, nondistended. Bowel sounds positive. Extremities: No lower extremity edema, 2+ right dorsalis pedis pulse, 1+ left dorsalis pedis pulse. LABORATORY DATA ON ADMISSION: White blood cell count 8.1, hematocrit 35.3, platelets 240,000. INR 1.1, Na 138, K 3.4, Cl 206, C02 21, BUN 14, creatinine 0.5, glucose 148, AST 91, total bilirubin 0.6, alkaline phosphatase 67, CK 993, MB 178, calcium 7.8, magnesium 1.7, phosphorus 3.4. The patient underwent cardiac catheterization on arrival with results of a total occlusion of the OM1 which appeared chronic and collateralized and total occlusion of the distal RCA. She had successful primary angioplasty with stenting of the RCA. The OM1 treatment was deferred to a future date. HOSPITAL COURSE: 1. CARDIAC: The patient did well after cardiac catheterization with no recurrent chest pain. Cardiac enzymes trended down and she tolerated her medications well. There was no significant arrhythmias post MI. She was kept on telemetry throughout hospitalization. She did have some post catheterization nausea which was treated successfully with Zofran. She has follow-up arranged with her cardiologist, Dr. [Last Name (STitle) ] within 10-14 days. She was explained the importance of exercise and reporting any worrisome symptoms. Over the course of admission, her Lopressor was kept at 12.5 mg b.i.d. but lisinopril was increased to 5 mg q.d. as her blood pressure tolerated. These can be titrated up further as an outpatient. She will also need a repeat echocardiogram in the future to assess the residual loss of cardiac function from this inferior myocardial infarction. 2. PULMONARY: The patient had no pulmonary issues during the hospitalization and no evidence of pulmonary edema or reactive airway disease. 3. RENAL: The patient's renal function was stable post catheterization with a creatinine remaining approximately 0.06. 4. HEMATOLOGY: The patient's hematocrit was stable as were platelets on heparin. 5. GASTROINTESTINAL: The patient was continued on Protonix for GERD. DISPOSITION: The patient was discharged to home in good condition. FOLLOW-UP: She is to have follow-up with her cardiologist, Dr. [Last Name (STitle) ], and her primary care physician. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Plavix 75 mg q.d. for 30 days. 3. Lipitor 10 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Lopressor 0.5 mg b.i.d. 6. Lisinopril 5 mg p.o. q.d. DISCHARGE DIAGNOSIS: 1. Acute myocardial infarction secondary to total occlusion of the distal right coronary artery. 2. Chronic coronary artery disease. 3. Gastroesophageal reflux disease. [First Name11 (Name Pattern1) 420] [Last Name (NamePattern4) 421], M.D. [MD Number(1) 422] Dictated By:[Last Name (NamePattern1) 1737] MEDQUIST36 D: [2120-4-22] 08:16 T: [2120-4-27] 10:41 JOB#: [Job Number 19234]	[ "41401", "42789" ]
Admission Date: [2160-6-24] Discharge Date: [2160-7-6] Date of Birth: [2121-5-9] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 297] Chief Complaint: transfer from OSH with liver failure Major Surgical or Invasive Procedure: intubation placement of central venous line CVVH - placement of dialysis line placement of Dobhoff feeding tube History of Present Illness: 39yoW with h/o cirrhosis of unknown etiology, presented to [Hospital 8] Hospital with hematemsis, epistaxis, melena, and change in mental status earlier today. Etiology of liver dysfunction is unknown. Work-up has included negative viral serologies, autoimmune antibodies, anti-smooth muscle antibodies, and h/o of EtOH abuse. Cirrhosis thought to be due to chronic cholestatic hepatitis, and she underwent ERCP with stent placement in [2153]. According to the patient's family, she was in her normal state of health until 11pm on [2160-6-22]. At baseline she does not leave her home but is independent in ADLs. At 11pm on [2160-6-22] patient first complained of a headache, then developed changes in her mental status, hematemesis, epistaxis, and dark red blood per rectum. The following morning the patient's mother found her unresponsive and called 911. . She was brought to OSH ED where initial vitals were T 96.7 HR 51 BP 60/40 RR 24 98%10L O2. She was unresponsive, icteric, jaudiced, and using accessory muscles to breath. Course at OSH complicated by acidemia and hypoxemia (7.1/62/68), coagulopathy with INR >assay, and acute anuric renal failure. She was intubated and put on levophed and bicarbonate gtt. CXR showed opacification of right lung field. RUQ U/S showed patent portal vasculature and no ductal dilatation or evidence of cholecystisis. EGD was performed and varices banded. . Patient was transferred to [Hospital1 18] on levophed. On arrival she became acutely hypotensive with BP 70s/30s, HR 60s. She was treated with boluses of NS and started on levophed, vasopressin, and neosynephrine. Dopamine was subsequently added, and BP stabilized with MAP 50s. . On review of records, patient was found to have liver mass on MRI and underwent biopsy [3-/2160] showing either necrotic liver abscess or necrotic malignancy. AFP was nml in 3/[2159]. No further work-up was done. Past Medical History: Cirrhosis of unknown etiology Type II diabetes mellitus Cholestatic hepatitis Portal hypertension Choledocolithiasis, s/p ERCP and stent [2153] Gerd Iron deficiency anemia Social History: lives with her mother, independent in ADLs does not smoke tob, drink EtOH, or use illicits Family History: not known Physical Exam: T 96.4 HR 70 BP 75/41 RR 28 99% pulses <10mmHg AC 600x24, FiO2 60% PEEP 5 GEN: jaundiced, unresponsive to voice, withdraws to pain HEENT: PERRL, icteric, ETT, blood at OP NECK: JVP nondistended CV: RRR, no mrg RESP: coarse bilaterally with rhonchi ABD: Obese, soft, distended with fluid wave, large panus, +BS, RUQ mass palpable EXT: no edema, trace radial pulses B, DPs not palpable NEURO: PERRL, gag intack, spontaneously moves all extremities. Pertinent Results: [2160-6-24] 01:53AM FIBRINOGE-514* [2160-6-24] 01:53AM WBC-29.1* RBC-3.70* HGB-10.8* HCT-30.4* MCV-82 MCH-29.2 MCHC-35.5* RDW-18.4* [2160-6-24] 02:21AM freeCa-0.69* [2160-6-24] 02:21AM LACTATE-4.4* K+-4.3 [2160-6-24] 04:29AM PLT COUNT-260# [2160-6-24] 04:29AM WBC-14.4# RBC-2.96 HGB-9.0* HCT-24.2* MCV-82 MCH-30.3 MCHC-37.1* RDW-18.2* [2160-6-24] 04:29AM CORTISOL-45.6* [2160-6-24] 04:29AM ALBUMIN-2.4* CALCIUM-6.5* PHOSPHATE-10.6* MAGNESIUM-1.5* [2160-6-24] 04:29AM LIPASE-287* [2160-6-24] 04:45AM LACTATE-4.3* [2160-6-24] 04:45AM TYPE-ART TEMP-35.8 PO2-82* PCO2-23* PH-7.33* TOTAL CO2-13* BASE XS--11 [2160-6-24] 07:47AM PT-38.4* PTT-67.4* INR(PT)-4.3* [2160-6-24] 07:47AM PLT COUNT-314 [2160-6-24] 07:47AM NEUTS-93* BANDS-3 LYMPHS-2* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2160-6-24] 07:47AM WBC-20.3* RBC-2.84* HGB-8.7* HCT-23.3* MCV-82 MCH-30.5 MCHC-37.1* RDW-18.5* [2160-6-24] 07:47AM CALCIUM-7.0* PHOSPHATE-10.4* MAGNESIUM-2.6 [2160-6-24] 07:47AM ALT(SGPT)-88* AST(SGOT)-250* LD(LDH)-313* ALK PHOS-233* TOT BILI-33.7* [2160-6-24] 07:47AM GLUCOSE-210* UREA N-128* CREAT-6.0* SODIUM-141 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-11* ANION GAP-36* [2160-6-24] 09:40AM URINE RBC->50 WBC-[5-10]* BACTERIA-MOD YEAST-NONE EPI-0-2 [2160-6-24] 09:40AM URINE COLOR-[Location (un) ] APPEAR-Cloudy SP [Last Name (un) 155]-1.020 [2160-6-24] 10:24AM PT-31.8* INR(PT)-3.4* [2160-6-24] 10:24AM PLT COUNT-237 [2160-6-24] 10:24AM WBC-16.1* RBC-2.59* HGB-8.0* HCT-21.1* MCV-82 MCH-31.0 MCHC-38.0* RDW-18.3* [2160-6-24] 10:24AM CORTISOL-36.7* [2160-6-24] 10:24AM GLUCOSE-251* UREA N-128* CREAT-5.6* SODIUM-141 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-11* ANION GAP-36* [2160-6-24] 10:34AM freeCa-0.72* . CT HEAD IMPRESSION: 1. New acute left extra-axial hemorrhage involving the frontoparietal and temporal regions. 2. Questionable intraparenchymal involvement within the left temporal lobe which is difficult to assess given patient movement and involvement near the skull base. 3. Moderate shift of midline structures rightward with subfalcine herniation. These findings were discussed with the referring Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1852] at 1:45 p.m. . LE Dopplers: IMPRESSION: Pseudoaneurysm in the left groin which is relatively unchanged in relation to the left common femoral artery. Small amount of nonocclusive thrombus within the right common femoral vein. . CXR: IMPRESSION: Improvement of ARDS. Persistent right lower lobe atelectasis and right pleural effusion . RUQ U/S: IMPRESSION: 1. Cirrhotic liver with moderate ascites of right upper quadrant. 2. Distended gallbladder containing a moderate amount of sludge with a marginally thickened wall. There is pericholecystic fluid in the setting of ascites. The findings, in this patient with chronic liver disease, are concerning for but not necessarily diagnostic of acute cholecystitis. Correlation with a HIDA scan would be helpful to confirm the diagnosis, if clinically indicated. . Echo: Conclusions: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Brief Hospital Course: 39yo woman with history of cryptogenic cirrhosis, thought to be primary biliary cirrhosis, transferred from outside hospital after upper GI bleed with acute fulminant liver failure, coagulopathy, acute renal failure, obtundation, and hypotension. During her hospitalization the following issues were addressed: # Acute / Fulminant liver failure: The patient has a history of cirrhosis of unknown etiology and acutely decompensated resulting in mental status change and coagulopathy with variceal bleeding. Her coagulopathy was reversed, and she maintained synthetic function. Her bilirubin rose to as high as 50, and she remained encephalopathic. Prior to extubation she was able to answer some questions appropriately. She remained jaundiced, icteric, and with elevated liver function tests. She was followed by the hepatology service. # Septic Shock: Hypotension was thought to be due to septic shock with either pneumonia or gram positive cocci bacteremia as the source. Her blood cultures from the OSH grew coag negative Staph in [3-4] bottles, and gram negative rods in [12-5] bottles. She was treated with antibiotics to cover aspiration and community acquired pneumonia including levofloxacin and Zosyn, and vancomycin for the bacteremia. She initially required four pressors to support her blood pressure on admission. These were weaned. She remained on vasopressin and dopamine, although these too were eventuall weaned. # Acute renal failure: She developed and anuric acute renal failure due to ATN from hypotension. She was maintained on CVVH dialysis. # Coagulopathy: likely due to hepatic synthetic dysfunction. it was reversed, and synthetic function improved. # Blood loss anemia: she did not have recurrent variceal bleeding after banding at the OSH. She required PRBC and FFP transfusions on admission until counts normalized. # Right femoral DVT: She was anticoagulated at first with heparin. She became thrombocytopenic, and the heparin was held out of concern for HIT. HIT antibody was negative. She was temporarily on argatroban, but developed bleeding as discussed below. Surgery and IR were consulted for filter placment, but she was not felt to be a candidate for this procedure. # LEft femoral pseudoaneurysm: She developed a pseudoaneurysm at the site of her femoral line that was placed at [Hospital 8] Hospital. She bled into this developing a hematoma after heparin and then argatroban were started. Anticoagulation was held, and the hematoma stabilized as did her hematocrit. # Subdural and subarachnoid hemorrhage: Prior to her death she was noted ot have a right sided neglect. Head CT revealed a left fronto-temporal hemorrhage. Neurology and Neurosurgery were consulted. Anticoagulation had already been reversed. She developed CNS compromise with decreased respiratory drive. She became hypercarbic and acidotic. # ARDS: She was intubated on admission for hypoxemic respiratory failure and hypercarbic respiratory failure. She was maintained on lung protective ventilation and eventually weaned from the vent and was extubated. She subsequently developed worsening respiratory acidosis, thought to be related to her CNS dysfunction. Given her numerous medical problems and the fact that she was not a liver transplant candidate and would not likely recover, the decision was made to not reintubate or escalate the level of care. Comfort measures were initiated with morphine boluses as needed. She expired on [2160-7-6] of respiratory arrest. # Social issues: Her mother functioned as her health care proxy being her next of [Doctor First Name ] but was unavailable. She did not have a phone initially, but did get one. She was called numerous times and asked to come to the hospital for a family meeting. She did not. She was called on the night her daughter expired but did not come to the hospital. She was notified by telephone when Ms. [Known lastname 2643] died. Medications on Admission: Aldactone 100mg po daily Nadolol 20mg po daily Protonix 40mg po daily Metformin 1g po QAM, 50mg QPM Os-Cal D 500mg [Hospital1 ] MVI Ursodiol 1200mg po daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Hepatic failure Renal failure - ATN Hypoxemic/Hypercarbic respiratory failure RLE DVT LLE pseudoaneurysm Subdural/SAH hemorrhage Sepsis Pneumonia Bacteremia Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "51881", "78552", "5845", "2851", "5070", "99592", "25000" ]
Admission Date: [2120-10-30] Discharge Date: [2120-11-29] Date of Birth: [2053-11-23] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old woman who was admitted status post elective anterior communicating artery aneurysm clipping and smaller posterior communicating artery clipping on [2120-10-30]. There were no was monitored in the surgical Intensive Care Unit. Her vital signs were stable. She was on Nipride to keep her blood pressure less than 140. She had CPKs drawn that were 156, an MB of 3 and a troponin less than .3. Chest x-ray showed mild cardiac enlargement. Lungs were essentially clear. The patient was awake but sleepy, oriented to day, date and year. name of the surgeon, smile was equal, tongue midline. 5/5 strength. The patient was neurologically stable. At 2:30 a.m. on [2120-10-31] the patient developed labile fluctuating blood pressure requiring increasing Nipride with systolic blood pressures up in the 160-180 range and tachycardia up to 118. The patient was given Lopressor and shortly before 3 a.m. the patient was noted to be less responsive, less alert and did not follow commands but opened her eyes briefly with stimulation, but moved all four extremities. The patient had a head CT without contrast which showed no acute hemorrhage or bleed or shift. At 3:45 a.m. the patient was moving all extremities with bilateral graft, initially equal, but over the next 20-30 minutes the patient was noted to be not moving her right upper extremity spontaneously and essentially no withdrawal to pain of the right upper extremity. She was continued to be easily arousable, opening her eyes and appeared attentive, but had been non verbal since 2:30 a.m. The patient was taken back for CTA which showed decreased flow distal to the clipped aneurysm which was treated with a fluid bolus and blood pressure was increased the 160-180 range. On [2120-10-31] the patient was taken at 5:30 am to the endovascualr suite and underwent emergent angiography which revealed vasospasm of the distal left MCA superior division which was treated with intraluminal injection of papaverine with good result. The angiogram also showed that both aneurysms were clipped with good result. On [2120-11-1] the patient continued to have left/right upper extremity paresis. CTA demonstrated left MCA branch vasospasm and patient continued to be lethargic. The patient had Swan Ganz catheter placed and was started on triple A therapy. The patient was intubated and sedated. PAST MEDICAL HISTORY: Included type 2 diabetes, CAD with MI in [Month (only) 216] and lateral wall ischemia, hypertension, hypercholesterolemia and cervical carcinoma. On [2120-11-1] the patient also developed coffee ground emesis and EKG changes. She had T wave changes. A TTE showed diffuse left wall hypokinesis. Her troponin levels came back at 17, CK was 504 and MB was 6. HOSPITAL COURSE: In the afternoon she developed coffee ground from her NG tube, she was lavaged and cleared after 800 cc. She had no melena or bright red blood per rectum and no further coffee ground. She was seen by the GI service who recommended holding tube feeds for 24 hours, starting her on Protonix, checking hematocrit and not allowing NSAIDS. The patient, after the bleeding stopped, was allowed to start on a baby Aspirin for cardiac problems. The patient ruled in for a non Q wave MI in the inferior leads with T wave changes in 2, 3 and AVF. Chest x-ray at the time showed no CHF. On [2120-11-5] the sedation was shut off, patient did not follow commands, neuro signs were unchanged, she did move the right lower extremity spontaneously, arousable to voice, does not follow commands, moving the right leg on the bed, left leg lifts and falls occasionally, tries to bring the left arm up to head level. Right arm not moving spontaneously. Does not withdraw to noxious stimulation. Pupils were 3 mm and briskly reactive bilaterally. Left eye remains swollen. On [2120-11-7] the patient had a vent drain placed. The patient had problems with elevated blood sugars in the Intensive Care Unit. She was on an insulin drip briefly. She was also continued on sedation on [2120-11-11]. She was not following commands, head rear, spontaneous movement of the lower extremities, upper extremities were edematous. Cardiac-wise she was stable with some potassium level related ectopy, and occasional hypertension. On [2120-11-14] the patient spiked a temperature to 101.5. The patient was given Tylenol and blood cultures were sent as well as chest x-ray and CBC were sent. At this point patient was on C pap on the vent. She remained awake and restless and repeat head CT on [2120-11-11] was unchanged. On [2120-11-7] the patient had head CT which showed a left frontal infarct from basal spasm. The patient spiked a temperature to 103 on [11-7] and [2120-11-8]. The patient had MRI on [2120-11-7] which again showed evidence of small left frontal infarct. On [2120-11-8] the patient had positive blood cultures for gram positive cocci. CSF had no growth. Patient was started on Oxacillin for gram positive cocci in her blood. The patient also had CSF from the 16th that grew staph aureus. Sputum came back positive for Klebsiella pneumonia on [2120-11-7]. The patient continued on Rocephin and Oxacillin for antibiotic coverage. On [2120-11-12] the patient developed coffee drainage from the incision site on her left side of her scalp from her aneurysm clipping. The patient was taken emergently to the OR and had evacuation of the subgaleal empyema and debridement of the tissue and removal of bone flap. There were no intraoperative complications. Postoperative patient's temperature was down to 101. White count was 12, hematocrit 30.4, platelet count 437,000. Neurologically she was opening her eyes spontaneously, withdrawing to pain in the left upper extremity and both lower extremities and had minimal withdrawal to pain in the right upper extremity. The patient grew staph from her left subclavian line on [2120-11-8] that was sensitive to Oxacillin. On [2120-11-12] the patient also had an episode of atrial fibrillation, atrial flutter which required electric cardioversion which was successful in converting her to normal sinus rhythm. She was seen by the ID service who recommended Ceftriaxone. Patient also had CT of the chest on [11-12] which was consistent with an acute thrombus of the left brachiocephalic vein and possibly extending into the left subclavian and consolidation at the lung bases with bilateral pleural effusion. The patient also continued on Oxacillin 2 gm IV q 4 hours and Ceftriaxone for antibiotic coverage. On [2120-11-18] the patient had LP. Opening pressure was 18, closing pressure was 11, 12 cc of CSF was drained off and sent for culture, cell count, protein and glucose. Neurologically patient was not following commands consistently. Right upper extremity was still flaccid, moves toes to command, withdraws bilateral lower extremities to pain, toes were downgoing. Incision was clean, dry and intact and there continued to be a fluid collection under the incision but it was not tense, it was easily ballottable. Pupils were 3.5 mm and equally reactive. The patient was extubated on [2120-11-20]. On [2120-11-21] the patient was awake, alert, attentive, stating her name, smiling, showing thumb on the right hand. Attempts to show two fingers on the left, moving the right lower extremity less than the left lower extremity but still moving spontaneously. Withdraws the left lower extremity to pain. Pupils were 2.5 down to 2 bilaterally. Her wound continue to be ballottable, clean, dry and intact with no leakage. Her labs were within normal limits. Her white count was 9.5, sodium 138, potassium 4.2, CVP was [2-3]. She continued on insulin drip at 1-2 units per hour. Blood pressure was 165/71, T max was 102.2. On [11-21] the patient had a chest x-ray which showed right lower lobe consolidation. She continued on Oxacillin for MSSA extra axial fluid collection. Continued on Vancomycin for coag negative staph and Levo for pneumonia and coag negative line sepsis, pneumonia and sinusitis. The patient was seen by physical therapy an occupational therapy and found to require rehab prior to discharge to home. The patient remained in the Surgical Intensive Care Unit until [2120-11-25] when she was transferred to the regular floor. She continued to be followed by the ID service who recommended a full six week course of Oxacillin for her gram negative line sepsis and a two week course of Vancomycin for her brain abscess, line sepsis pneumonia and sinusitis. The patient had swallow study on [2120-11-27]. She failed the swallow study and they recommended that she remain npo with an NG tube in for retry of po in 5 days. Neurologically at the time of discharge the patient was moving the left upper extremity with 5/5 strength. The right upper extremity was [1-29], lower extremities were moving spontaneously. The patient was out of bed to chair with assist of two people. Continued to be afebrile with stable vital signs and will continue on antibiotics, Oxacillin for a six week course, Vancomycin for a two week course. The patient should be maintained on fall precautions secondary to the lack of bone flap in her incision. Preventing falls is one of the most important issues to be aware of. The patient will need to have swallow study done at rehab. DISCHARGE MEDICATIONS: Impact with fiber with 25 gm of ProMod at 65 cc per hour, Albuterol and Atrovent nebs q 4 hours, Dilantin 200 mg per NG tid, Lipitor 20 mg per NG q day, ASA 81 mg per NG q day, Lopressor 150 mg NG tid, Vancomycin 1 gm IV q 12 hours for complete two week course, the medication was started on [2120-11-22], Levofloxacin 500 mg IV q day, started on [2120-11-21] and should continue for a 14 day course, Captopril 150 mg NG q 8 hours, NPH 20 units subcu [Hospital1 ], Heparin 5,000 units subcu tid, Prevacid 30 mg NG [Hospital1 ], Epogen [Numeric Identifier ] units subcu q 7 days, Mag Oxide 800 mg NG tid. Patient is on a sliding scale for regular insulin 61-120 2 units, 121-200 4 units, 201-250 6 units, 251-300 8 units, 301-350 10 units, 351-400 12 units, Amiodarone 200 mg NG [Hospital1 ], Tylenol 650 mg q 6 hours prn, Oxacillin 2 gm IV q 6 hours. The patient should have weekly LFTs, CBC and BUN and creatinine checked while on antibiotics. Follow-up with Dr. [Last Name (STitle) 1132] in one week, [Telephone/Fax (1) 2992] to book follow-up appointment. CONDITION ON DISCHARGE: Stable. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D., Ph.D. 14-133 Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2120-11-29] 15:26 T: [2120-11-29] 16:01 JOB#: [Job Number 104219]	[ "9971", "41071" ]
Admission Date: [2120-11-26] Discharge Date: [2120-11-28] Service: CHIEF COMPLAINT: Difficulty breathing, tracheal stenosis. HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old female with complicated medical history within the past year, transferred from [Hospital3 33538] to have treatment for tracheal stenosis. The patient has had difficulty breathing since Friday due to increased secretions and weakness. Patient had bronchoscopy on day of admission by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3100] which showed mild tracheal stenosis. The patient is transferred to [Hospital1 346] for bronch, possible stent, possible balloon dilation of the tracheal stenosis. The patient has had a prolonged hospital course since [2120-7-17] when she was admitted to [Hospital1 3487] Hospital for a 9 cm thoracic aneurysm repair and coronary artery bypass graft of left anterior descending artery (50% lesion), complicated by bleeding requiring reop. Postop course complicated by afib managed with Lopressor and amio. The patient was slow to wean off vent and on [2120-8-8] had a trache and PEG placed. Hospital course was also complicated by congestive heart failure and a cerebrovascular accident which presented with right sided weakness with negative CT scan. Tracheostomy complicated by necrosis at site with positive Methicillin-resistant Staphylococcus aureus swab culture. Sputum and Gram stain at [Hospital1 3487] Hospital was positive for Gram-negative rods and Gram-positive cocci. The patient was transferred to [Hospital1 ] for slow vent wean. No DC sent from [Hospital1 ] was available, however, patient's family states that she was taken off the vent around [Holiday 1451] time. Her hospital course was complicated by multiple pneumonias and increased secretions. The patient complained of difficulty breathing in [Hospital1 ] and had a bronch on the morning of admission which showed mild tracheal stenosis. The patient states the breathing has improved since Friday before admission after aggressive suctioning. PAST MEDICAL HISTORY: 1. Thoracic aneurysm repair in [2120-7-18] with coronary artery bypass graft times one to left anterior descending artery complicated by bleeding requiring repeat surgery. 2. Cerebrovascular accident. 3. Atrial fibrillation with RVR treated with amiodarone. The patient is currently in sinus. 4. Methicillin-resistant Staphylococcus aureus positive. 5. Status post trach. 6. Status post PEG. 7. Status post left fem endarterectomy with patch graft and left posterolateral thoracoplasty with Hemashield graft. 8. Echocardiogram shows ejection fraction of greater than 55%, mild-to-moderate mitral regurgitation, mild tricuspid regurgitation with left ventricular hypertrophy at [Hospital1 37009] Hospital at 08/01. 9. Hypertension. 10. Arthritis. 11. Hyperthyroidism treated with PTU. 12. Claustrophobia. ALLERGIES: Penicillin. MEDICATIONS ON TRANSFER FROM [Hospital1 ]: Captopril 87.5 mg q eight hours, Atrovent q four hours prn, enoxaparin 60 mg subQ q 12 hours, Coumadin 2 mg q hs, free water boluses via G-tube 250 cc q six hours, Glyburide 2.5 mg q day, bacitracin ointment topical q 12 hours, Vancomycin 1 gram IV q 12 hours, Bactrim 20 ml q shift, propanolol 40 mg q 12 hours, venlafaxine 50 mg [Hospital1 ], amiodarone 200 mg q day, bisacodyl 10 mg pr, lactulose 30 mg q day prn, multivitamins, lactobacillus two tablets q eight hours, Flagyl 500 mg q eight hours, levofloxacin 500 mg q day, digoxin 0.125 mg qod, droperidol 0.6 q 5 mg q eight hours prn, Peratize 60 ml an hour, PTU 50 mg q eight hours, oxymetazoline two sprays q day prn, docusate sodium 100 mg q eight hours, aspirin 81 mg q day, Atrovent/Albuterol inhalers four puffs q eight hours prn, Motrin 400 mg q four hours prn, Tylenol 650 mg q four hours prn. SOCIAL HISTORY: The patient is transferred from [Hospital3 105]. Has eight children and has a living will. No history of tobacco use. PHYSICAL EXAMINATION: On physical exam, vital signs: Temperature 96.0, blood pressure 110/80, heart rate 60, respiratory rate 20, O2 saturation is 96% on 5 liters nasal cannula. In general, the patient is an elderly woman, weak appearing in no apparent distress. HEENT: Extraocular movements are intact. Neck is supple. No jugular venous distention. Heart: Systolic murmur 2-3/6 at left sternal border, hyperdynamic heart, PMI shifted 1 cm to the left. Lungs: Poor air movement, positive rhonchi bilaterally. Abdomen is soft, nontender, positive bowel sounds. G tube still slightly erythematous, no induration, no discharge. End site is nontender. Extremities: Hyperpigmentation to mid shin bilaterally. No edema noted. Neurologic: Right sided upper and lower extremity 3-4/5 strength, left upper and lower extremity 4/5 strength. Right nasolabial fold decreased excursion with smile, tongue midline. 2+ patellar reflexes. Babinski right upgoing and left downgoing. LABORATORY DATA ON ADMISSION: White blood cell count 8.9, hematocrit 28.9, platelets 219,000. PT 14.4, PTT 29.7, INR 1.5. Urinalysis: Specific gravity 1.015, red blood cells 38, white blood cells [Pager number ], occasional bacteria, many yeast, no epithelial cells. Sodium 146, potassium 4.4, chloride 112, bicarb 27, BUN 54, creatinine 0.7, glucose 55. Calcium 8.2, magnesium 2.4, phosphorus 4.6, albumin 2.6. TSH 6.7. Free T4 0.8. Urine culture currently pending. HOSPITAL COURSE: In sum this is an 81-year-old female with complicated medical history admitted for treatment of tracheal stenosis. 1. Pulmonary: Tracheal stenosis, PNA diagnosed at outside hospital, increased secretions. Anticoagulation was held in anticipation of surgery. The patient was taken to the operating room on [2120-11-27]. Patient had general anesthesia. Patient had rigid/flexible bronchoscopy rigid dilation and balloon dilation of the tracheal stenosis found at the level of passed trach. The mild tracheal stenosis was dilated. Patient did not have any complications and returned to the floor afterwards. The patient was also continued on her albuterol/Atrovent prn metered-dose inhalers and nebulizers which she did not require during this admission. 2. Cardiac: History of afib, congestive heart failure secondary to diastolic dysfunction. Anticoagulation was started after the surgery with Lovenox 60 mg subQ [Hospital1 ] and Coumadin 2 mg po q hs which she had started at the outside hospital. The patient is currently in sinus rhythm. Will continue amiodarone 200 mg po bid and propanolol 40 mg po bid. Patient was also continued on captopril 87.5 mg per G tube q eight hours and digoxin 0.125 mg per G tube qod. 3. ID: Pneumonia diagnosed at outside hospital and methicillin-resistant Staphylococcus aureus positive. A chest x-ray was done during this admission which showed a probable right upper lobe pneumonia and left apical pleural thickening versus loculated pleural effusion. [First Name11 (Name Pattern1) 2515] [Last Name (NamePattern4) 4517], M.D. [MD Number(1) 4518] Dictated By:[Last Name (NamePattern1) 218] MEDQUIST36 D: [2120-11-28] 07:53 T: [2120-11-28] 08:26 JOB#: [Job Number 37010]	[ "51881", "4280" ]
Admission Date: [2145-9-30] Discharge Date: [2145-10-14] Date of Birth: [2084-4-20] Sex: M Service: THORACIC SURGERY/MICU/[Location (un) 259] HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 51497] is a 61 year-old male with a one year history of nonsmall cell lung cancer who was transferred from an outside hospital to Cardiothoracic Surgery on [2145-9-30]. The patient originally presented to the outside hospital on [9-18] with nausea and vomiting and found to have a small bowel obstruction. A CT of the chest also revealed a right sided pleural effusion as well as an obstructing right upper lobe mass. CT scan of the abdomen showed small bowel obstruction secondary to diffuse abdominal metastases and the patient underwent exploratory laparotomy with small bowel resection on [9-23]. His postoperative course was complicated by fevers and he was initially treated with Zosyn. By report all blood and urine cultures were negative. The patient was then transferred to [Hospital1 69] on [9-30] for further management of the right upper lobe obstructing mass. On admission the patient denies any chest pain, shortness of breath or dizziness. He did complain of a cough productive of clear sputum. PAST MEDICAL HISTORY: 1. Stage four nonsmall cell lung cancer diagnosed in [2144-9-3] status post chemo/radiation with metastases to the abdomen. 2. Paroxysmal atrial fibrillation. 3. Small bowel obstruction secondary to abdominal mets status post small bowel resection. MEDICATIONS AT HOME PRIOR TO HOSPITAL ADMISSION: Prednisone 20 mg po q day started by the patient's primary care physician for shortness of breath. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient was an electrician with the [State 350] National Guard. He retired last year. He lives on [Location (un) ]. He has never been married and has no children. The patient has a 30 pack year cigarette smoking history. He quit in the [2122]. He drinks every once in a while and denies any intravenous or recreational drug use. FAMILY HISTORY: The patient denies any family history of cancer. PHYSICAL EXAMINATION ON TRANSFER TO THE MEDICINE SERVICE: Temperature max 98.9. Current temperature 98.8. Blood pressure 145/84. Heart rate 97. Respiratory rate 20. Oxygen saturation 98% on 1 liter nasal cannula. In general, the patient is awake, alert, appears his stated age and in no acute distress. He is cooperative with the examination, but very grouchy. HEENT examination pupils are round and reactive to light. Extraocular movements intact. Sclera anicteric. Oropharynx is clear. Neck is supple. Chest examination coarse breath sounds on the right greater then left, no wheezing, no dullness to percussion with decreased breath sounds at the right lung base. Cardiovascular examination regular rate and rhythm. Abdominal examination soft, nontender, nondistended with good bowel sounds. A well healing midline scar with mild erythema. Extremities no lower extremity edema. Neurological examination alert and oriented times three. Cranial nerves II through XII grossly intact. Strength 5 out of 5 in the upper and lower extremities. Sensation intact to light touch in the upper and lower extremities. LABORATORIES ON TRANSFER FROM THE CARDIOTHORACIC SURGERY SERVICE TO THE MEDICINE SERVICE: White blood cell count is 4.4, hematocrit 26.4, platelets 399, creatinine 0.7, glucose 112. Chest x-ray shows large medial right upper lobe mass with opacification at the right heart border due to collapse or consolidation of the right lower lobe. There is an irregular pleural thickening on the right apex as well as the chest wall. There is a hydropneumothorax at the right apex. The left lung is clear with gross interstitial markings. HOSPITAL COURSE: 1. Lung cancer: The patient was transferred from an outside hospital following small bowel resection for further management of the right upper lobe obstructing tumor. The patient was initially admitted to the Thoracic Surgery Service. Interventional pulmonary was consulted. On [10-1] interventional pulmonary performed a rigid bronchoscopy with placement of the right upper lobe stent. A chest tube was also placed into the right chest wall for evacuation of the right pleural effusion. Steroids, which had been started at the outside hospital were continued for the patient's wheezing and dyspnea. On [10-4] the chest tube was removed following resolution of the pleural effusion. The patient's steroids were slowly tapered over the course of a week. Zosyn had also been started at the outside hospital for postoperative fever and the patient was continued on Zosyn intravenously. He was eventually switched to Flagyl and Levofloxacin po and received a total of 18 days of antibiotics. His postoperative fever was believed to be due initially to postoperative pneumonia, however, the patient continued to have low grade fevers to 100 despite antibiotics. Multiple blood cultures and sputum cultures and urine cultures were obtained, which were all negative. It was believed that the continued fevers on antibiotics was possibly due to either tumor fever or a drug reaction to the antibiotics. Following stent placement and chest tube removal the patient continued to have intermittent shortness of breath and worsening cough and he was taken by interventional pulmonary for a repeat bronchoscopy on [10-12] for removal of mucous plug. Following this repeat bronch the patient symptomatically felt better, but continued to require oxygen by nasal cannula at 2 liters. Following discussion with the patient, interventional pulmonary decided to attempt photodynamic therapy. On [10-8] he received his infusion of Photofrin followed by light treatment on [10-12] and finally a bronchoscopy to clean out necrotic tissue on [10-13]. The patient tolerated this procedure well without any complications. Throughout the hospital course the patient was continued on aggressive chest CT, incentive spirometry, Albuterol nebulizers, Atrovent nebulizers and cough syrup. A physical therapy consult was obtained and they determined that he would require outpatient chest physical therapy as well as home oxygen therapy. At the time of discharge the patient's cough and shortness of breath had much improved and he was arranged to follow up with outpatient chest physical therapy. 2. Fever: The patient was transferred from an outside hospital on Zosyn intravenously for postoperative fever. It was believed the cause of his fevers to be due to a post obstructive pneumonia. He was continued on Zosyn intravenously initially in his hospital course and was eventually switched to po antibiotics when the patient was tolerating po well. He was started on Flagyl and Levofloxacin to complete the total 18 day antibiotic course. The patient continued to have low grade fevers to 100 despite these antibiotics. Multiple blood cultures, urine cultures and sputum cultures all returned negative. It was believed the cause of his continued fevers to be due to either tumor fever or drug reaction. 3. Atrial fibrillation: The patient has a history of paroxysmal atrial fibrillation, which was detected at the outside hospital. At [Hospital1 69] the patient had one brief 10 second episode of what appeared to be atrial fibrillation. The patient was asymptomatic during this episode. The patient had no further episodes of atrial fibrillation throughout the remainder of the hospital course. 4. Small bowel obstruction: The patient had a small bowel resection on [9-23] at the outside hospital for small bowel obstruction due to lung metastases. At the time of transfer the patient was tolerating po and having bowel movements and he continued to have [Last Name ] problem throughout the remainder of his hospital course. 5. Diarrhea: The patient complained of multiple loose bowel movements - up to four bowel movements a day. Multiple samples were tested for C-diff all of which returned negative and the patient's diarrhea eventually subsided. No cause was found for this diarrhea. 6. Anemia: On transfer to [Hospital1 69] the patient's hematocrit was 26. Anemia studies were consistent with an anemia of chronic disease, although the patient was already on iron supplements. His hematocrit remained stable at 26 throughout most of the hospital course. On the day prior to discharge his hematocrit decreased to 23.5. A repeat hematocrit confirmed this decrease and the patient received 1 unit of packed red blood cells. The morning following his transfusion his hematocrit had appropriately increased. The patient's stool was also tested for blood, but found to be guaiac negative. He was discharged on his iron supplements. 7. Methemoglobinemia: On [10-11] while receiving his light treatment the patient's O2 sats dropped to 54%. An arterial blood gas showed 16% methemoglobinemia and the patient received Methylene blue times one dose empirically. The cause for his methemoglobinemia was believed to be due to the Lidocaine with a possible contribution for Metoclopramide, which the patient had been taking for nausea and vomiting and from Benzonatate, which the patient had been taking for his cough. The patient was transferred to the Medical Intensive Care Unit for observation following the procedure. His O2 sats remained stable and he developed no signs of symptoms of cyanosis, so the following day he was able to be transferred back to the Medicine [Hospital1 ]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is discharged back to his home in [Hospital3 ]. His sister will be living with him and he will be receiving chest physical therapy as an outpatient. The patient was also discharged with home O2. DISCHARGE DIAGNOSES: 1. Malignant pleural effusion. 2. Stage four nonsmall cell lung cancer status post right bronch stent placement and photodynamic therapy. 3. Paroxysmal atrial fibrillation. 4. Anemia of chronic disease. 5. Methemoglobinemia. 6. Small bowel obstruction status post small bowel resection. DISCHARGE MEDICATIONS: 1. Iron polysaccharide complex 150 mg po b.i.d. 2. Levofloxacin 500 mg po q day for two more days. 3. Metronidazole 500 mg po t.i.d. for two more days. 4. Metoprolol 125 mg po b.i.d. 5. Lorazepam 0.5 mg po q 4 to 6 hours prn anxiety. 6. Megestrol 40 mg po t.i.d. 7. Guaifenesin/dextromethorphan syrup po q 4 hours prn cough. 8. Albuterol one puff inhaled 4 to 6 hours prn. 9. Ipratropium one puff q 6 hours prn. FOLLOW UP PLANS: The patient is asked to follow up with his oncologist Dr. [Last Name (STitle) 51498] at [Hospital 40262] Hospital for further chemotherapy. The patient prior to hospital admission had discussed with Dr. [Last Name (STitle) 51498] trying another round of chemotherapy after the patient regained his strength. He is also asked to follow up with his primary care physician in one to two weeks. The patient was also given information concerning his outpatient chest rehab. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (STitle) 51499] MEDQUIST36 D: [2145-10-14] 03:05 T: [2145-10-15] 12:47 JOB#: [Job Number 51500]	[ "42731", "5180", "2859" ]
Admission Date: [2197-3-10] Discharge Date: [2197-3-14] Date of Birth: [2163-7-18] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 17345] Chief Complaint: severe headache Major Surgical or Invasive Procedure: 1) endotracheal intubation 2) Magnesium Sulfate infusion History of Present Illness: 33 yo G2P2 PPD # 7 s/p SVD [3-3] at [Hospital3 2783] transferred from OSH with severe headache. Pt awoke at 2AM with a severe headache. She took Motrin 800mg without relief. She went to the ED at an OSH with headache and had 3 episodes of emesis with urinary incontinence. No neck stiffness, visual changes or RUQ tenderness. She did admit to photophobia. Pt with cough starting 3 days before delivery. The patient reports her daughter at home had an ear infection. A CT scan at OSH showed ?hemorrhage into the pituitary stalk. Her vital signs at OSH were: 97.6, HR 57, RR 16, BP 187/85, 99%. She was then transferred to [Hospital1 18] with possible [Doctor Last Name 1349] syndrome. Received Dilaudid 1mg at OSH, HA improved. CT here showed a possible pituitary hemorrhage. In the ER, her BP was 160s/90s and she had a witnessed tonic-clonic sz x 5 minutes. She was intubated in the ER, loaded with Dilantin, and a repeat CT showed a prominent pituitary, without a clear bleed. Pt given Magnesium 4gm IV bolus followed by 2gm/hr. Her most recent pregnancy/delivery history was essentially unremarkable. She presented to L+D at [Hospital1 2436] at 0935 on [3-2] with a temperature of 101F since the night before. She was 38 wk GA. Fetal tachycardia was noted; her initial BP on admission 104/68 temp 101.3F. Pt was diagnosed with maternal flu and she underwent an induction of labor. Prenatal labs significant for GBS+. She was treated with penicillin in labor. She had an epidural. There was a 3rd degree laceration. EBL was 400 cc. She delivered a viable female (6#15oz) on [3-3]. No uterine atony. Second stage of labor was 70 minutes. Pt was discharged [3-5] afebrile on motrin with normal blood pressure. Post-partum per husband (not reflected in medical record), pt had fever and was continued on antibiotics for 12 hrs and these were discontinued. Pt's bleeding wnl per husband. Past Medical History: pOB: [2197-3-3] IOL secondary to maternal flu 38 wk VD [Hospital3 38285] by Dr. [Last Name (STitle) 40625]. Number at [Hospital1 2436] [Telephone/Fax (1) 40626]. Wt 6# 15 oz G1: [5-/2194] female FT vd at [Hospital3 2783]: no complications. Induced for post-dates pGyn: negative PMH: Hypothyroidism dx'd [2194] No history of headache Social History: Social History: Lives in [Location ] with her husband and two girls (3 years and 6 days.) Both work as software engineers. Are originally from [Country 11150]. Arranged marriage. Tobacco: none; EtoH: rare; illicit drugs: none Family History: Family History: DM, HTN, no history of endocrine disorders sister with migraines Physical Exam: PE (in ED): VS 99.8 175/90 59 20 96% RA GEN: Intubated, sedated HEENT: Pupils constricted bilaterally LUNGS: Coarse breath sounds bilaterally COR: RR nl s1s2 no murmurs/rubs/gallops ABD: Soft, NT/ ND/ hyperactive bowel sounds Fundus firm 3cm below umbilicus. Pelvic: Mobile 14 cm uterus no adnexal enlargement appreciated EXT: no edema DTR [Name (NI) ] bilateral patellar tendons NEURO: Moving all 4 extremities, toes down going, patellar reflexes [Name (NI) 19912] bilaterally Pertinent Results: Lab info: chem 7 wnl, Hct 40.8 Plat 307 Coags wnl, Prolactin, TSH, FreeT4, CalcTBG, Cortisol all pending. ALT 177 AST 134 [Doctor First Name ] 61 UA: trace protein CT pituitary hyperdense no areas of hemorrhage or midline shift MRI: Abnormal T2 hyperintensity in multiple cortical and subcortical locations, without diffusion signal abnormality, suggesting reversible encephalopathy syndrome. discussion with Neurology service findings can be see in eclamptic seizure MRA/MRV: negative for bleed EEG: no spikes Head Sinus Films: negative for fluid, layering Brief Hospital Course: HD #1: admitted to the ICU, intubate on a Mg 2g/h infusion to maintain a serum Mg of >=5. She was extubated shortly upon arriving to the [Hospital Unit Name 153]. Her blood pressures remained 110-120/60-70. She remained sedated. The neurosurgery service deemed that surgical intervention was unnecessary. The neurology service evaluated her MRI/MRA/MRV and EEG. All were deemed most likely consistent with an eclamptic seizure. Her Decadron and Dilantin was discontinued. Her LP was negative for meningitis. She had a fever to 101F shortly after arriving in the ICU. A pelvic US showed likely blood/clot in her uterus without evidence of retained POC. She defervesced in less than 24hours. HD #2: neurologic status improved and patient was more alert. The patient was called out of the unit and went to the postpartum floor. HD #3: the patient complained of a severe headache not improved with Tylenol. Her physical examination was suggestive of a sinus headache. Sinus films were obtained; the wet read was negative for fluid/mass/layering. She was given Dilaudid SC (1mg) x 1 with complete resolution of her symptoms. Her blood pressure remained 110-130/60-80 through the hospitalization. She was started on a z-pack for her URI symptoms. HD #4: she was afebrile x >24hrs with normal blood pressures. She will be discharged to home with f/u with her primary ob in [Hospital1 2436]. She will f/u with Neurology within 2 weeks. She will obtain a repeat MRI of the head/pituitary in [1-8] weeks. Medications on Admission: Synthroid 75 Ibuprofen 800 prn PNV senna Discharge Medications: 1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 3 days. Disp:3 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: eclampsia Discharge Condition: good Discharge Instructions: 1) call with any headache, vision changes, abdominal pain 2) continue pumping & breastfeeding 3) finish all antibiotics Followup Instructions: 1) primary OB/Gyn at [Hospital3 ] within 1 week 2) Neurology @ the [Hospital1 18] within 1 week after head MRI 3) Repeat Head MRI within 1 week [Name6 (MD) 8175] [Name8 (MD) ] MD [MD Number(1) 17346]	[ "2449" ]
Admission Date: [2200-3-23] Discharge Date: [2200-3-31] Date of Birth: [2200-3-23] Sex: M Service: NEONATOLOGY HISTORY: Baby [Name (NI) ] [Known lastname ] Twin #1 is a former 32-week IUI diamniotic dichorionic male twin #1 born following premature rupture of membranes in preterm labor. Twin #2 was breech presentation, so delivery was via cesarean section to a 32-year-old G4, P2-3 mom. PRENATAL SCREENS: A+, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, GBS unknown. History of HSV. No lesions at the time of delivery. This pregnancy was uncomplicated until rupture of membranes early on the day of delivery, presented to [Hospital3 ] Mother was transported to [Hospital6 2018]. Magnesium sulfate was continued, but labor progressed, and so progressed to cesarean section delivery. This infant emerged with good cry, given blow-by O2 briefly. Apgar scores were 8 at 1 minute and 8 at 5 minutes, and was transported to the Newborn Intensive Care Unit for further treatment and care. PHYSICAL EXAM ON ADMISSION: Nondysmorphic male, bilateral breath sounds with a few inspiratory crackles and mild grunting, flaring and retracting. Regular rate and rhythm. No murmur. Pulses 2+, equal. Abdomen soft, nontender, no HSM. Three-vessel cord. Normal male genitalia with testes palpable in scrotum bilaterally. Straight spine, no dimple. Stable hips. Palate and clavicles intact. Anterior fontanel soft and open. Activity appropriate for gestational age. Birth weight 1,870 gm, 75th percentile. Length 41.5 cm, greater than 25th percentile. Head circumference 31.5 cm, greater than 75th percentile AGA. Discharge weight 1,775 gm. REVIEW OF HOSPITAL COURSE BY SYSTEMS - 1) RESPIRATORY: Baby was placed on continuous positive airway pressure of 6 for respiratory distress. His oxygen requirement weaned from 30 to room air. On day of life #1, he transitioned to nasal cannula O2 which he required for approximately 48 hours, and then transitioned to room air. He has been in room air with no further respiratory distress, with a baseline respiratory rate in the 40s-60s. Bilateral breath sounds are now clear and equal. The baby was started on caffeine on day life #2 for an occasional episode of apnea and bradycardia. He currently is receiving 11 mg of caffeine po qd which on today's weight of 1,775 equals 6.3 mg/kg/day. He has had one episode of apnea and bradycardia in the past 24 hours. Our plan was to continue observing if apnea and bradycardic spells increased or worsened; however, if clinically worsened, we would consider increasing the dose of caffeine citrate, or consider discontinuing it completely. 2) CARDIOVASCULAR: The baby initially had a soft, intermittent murmur that was no longer audible. Baseline heart rate is 140s-160s. He has had a stable blood pressure. He did not require any pressor support during this admission, and his blood pressure was currently in the systolics of the 70s, diastolics in the 40s, and means in the 50s. 3) FLUID, ELECTROLYTES AND NUTRITION: The baby initially was NPO, was started on peripheral IV fluid of 60 cc/kg/D. His dextrostix were stable at greater than 50. Enteral feedings were introduced on day of life #2, once his respiratory issues improved, and he advanced without issue to full enteral feedings. Currently he is eating 150 cc/kg of breast milk, increased to 22 cal/oz today with 2 cal/oz of HMS. He is requiring mostly gavage feedings, takes an occasional bottle. Mom does plan on breast-feeding. Our plan was to increase him to 24 cal/oz with a total of 4 cal of HMS/oz, and watch his growth, and if appropriate we would hold there. We would also recommend adding supplemental iron of 2 mg/kg/D once he achieves 24 cal/oz. 4) GASTROINTESTINAL: The baby had a peak bilirubin on day of life #3 of 13.3/0.3. He was started on phototherapy. His bilirubin on [3-31] was 8.2/.3. We discontinued his phototherapy today with a plan to check a rebound bili on [4-1]. The baby was voiding and stooling. 5) HEMATOLOGY: The baby did not require any blood products during this admission. 6) INFECTIOUS DISEASE: He initially had a sepsis evaluation because of PROM, prematurity and respiratory distress at the time of delivery. His white count was 10 with 47 polys, 1 band, 47 lymphs, platelet count 281,000, hematocrit 42.6. He was started on 48 hours of ampicillin and gentamicin. At 48 hours of age, his cultures remained negative. He was clinically improved, and the antibiotics were discontinued. He has had no further issues with infection. 7) NEUROLOGY: The baby had a head ultrasound done on [3-31] which was within normal limits with no evidence of any intraventricular hemorrhage. His exam was appropriate for gestational age. 8) SENSORY - Audiology screening has not been done at the time of this dictation. 9) OPHTHALMOLOGY: Exam not indicated, as gestational age of greater than 32 week's. 10) PSYCHOSOCIAL: Parents have been visiting daily and look forward to transition closer to home. [First Name9 (NamePattern2) 46381] [Doctor Last Name 6861], [Doctor Last Name ], is the social worker who has met with this family during their admission here at [Hospital6 256]. She can be reached at beeper# [Serial Number 36451]. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: Transfer to [Hospital6 1109] Special Care Nursery. Primary pediatrician is Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) 49489] in [Location (un) 1110], MA. CARE RECOMMENDATIONS: Continue 150 cc/kg of breast milk 22 supplemented with 2 cal/oz of HMS, with a plan to increase to 24 cal/oz on [4-1], and add supplemental iron 2 mg/kg/D. MEDICATIONS: Currently caffeine citrate 11 mg po PG qd. CAR SEAT POSITION SCREENING: Not done to date. STATE NEWBORN SCREEN: Initial one sent on [3-26]--results are pending. Next one due on [2200-4-6]. IMMUNIZATIONS RECEIVED: None at the time of discharge, as baby is less than 2 kg. 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 day care during RSV season, with a smoker in the household, or with preschool sibs, 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 care givers should be considered for immunization against influenza to protect the infant. FOLLOW-UP APPOINTMENTS: With primary care pediatrician per routine. Offer VNA services after discharge for a smooth transition. DISCHARGE DIAGNOSES: 1) Twin #1, former 32 week male. 2) Status post mild respiratory distress syndrome. 3) Status post rule out sepsis with antibiotics. 4) Status post physiologic jaundice. 5) Apnea and bradycardia of prematurity. Reviewed By: [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36250] Dictated By:[Last Name (NamePattern1) 36251] MEDQUIST36 D: [2200-3-31] 13:11 T: [2200-3-31] 12:57 JOB#: [Job Number ]	[ "7742", "V290" ]
Admission Date: [2147-4-9] Discharge Date: [2147-5-31] Date of Birth: [2079-9-8] Sex: M Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: The is a 67 year old male who presented with a three day history of abdominal pain with nausea and vomiting. The patient presented to the emergency department and had not had a bowel movement in one day but had been passing gas. PAST MEDICAL HISTORY: Significant for coronary artery disease, status post an myocardial infarction, hypertension, hypercholesterolemia, head trauma with right hemiparesis. PAST SURGICAL HISTORY: Includes a cardiac catheterization with stents to the LAD and diagonal in [2144]. MEDICATIONS: Included aspirin, Lipitor, hydrochlorothiazide, Lopressor and Nitrostat. ALLERGIES: There are no known drug allergies. PHYSICAL EXAMINATION: Vital signs: Temperature of 97.4, pulse 55, blood pressure 90/60, respirations 18, saturation 100 percent. Patient was awake and alert. His chest was clear. Heart was regular rate and rhythm. Abdomen was soft with some epigastric tenderness with normal bowel sounds. No peritoneal signs. Extremities were warm. Rectal was guaiac negative without any masses. PERTINENT LABORATORY TESTS: White count was 14, hematocrit was 53, platelets 99. Sodium 136, potassium 4.2, chloride 98, bicarb 25, BUN 31, creatinine 1.4, glucose 111. Liver function tests: AST 16, ALT 23, alkaline phosphatase 84, total bilirubin 1.0, amylase 63, lipase 25. Abdominal x-rays showed dilated loops of small bowel. Abdominal CT scan revealed small bowel obstruction with dilated proximal small bowel and decompressed distal small bowel. Patient was admitted to the surgical service and was treated for small bowel obstruction with nasogastric tube, n.p.o. and intravenous fluids. HOSPITAL COURSE: The patient was observed on the surgical service and failed to resolve the small bowel obstruction and on [2147-4-11] patient underwent a diagnostic laparoscopy, laparoscopic lysis of adhesions with exploratory laparotomy and wash out for enterotomy and repair of enterotomy. Postoperative course after the procedure on [2149-4-10] was significant for respiratory failure and sepsis. The patient required reintubation and vasopressors. Postoperative day number three the patient underwent re-exploration for abdominal compartment syndrome with abdominal wash out and closure of the abdominal wall with Aqua mesh on [2147-4-14]. On [2147-4-27] patient underwent exploratory laparotomy, removal of Vicryl mesh, lysis of adhesions and ventral hernia repair with component separation and Aqua mesh overlay. The postoperative course during the period was significant for ARDS, pneumonia and sepsis. The patient required support with mechanical ventilation and was treated with broad spectrum antibiotics. The sources of sepsis included abdominal as well as pulmonary. Abdominal sepsis was controlled with antibiotic and the serial washouts as previously described. Patient's sputum culture was positive for methicillin resistant staph aureus as well as Klebsiella which were treated with antibiotics. The patient also had a blood culture which was positive for yeast and was treated with fluconazole during the postoperative period. The Intensive Care Unit course was prolonged and was further characterized by renal failure as well as cholestasis and liver failure secondary to sepsis. The patient required hemodialysis and was followed by the renal service and the hepatology service was consulted and complete evaluation with ultrasound as well as MRCT confirmed that there was no biliary ductal obstruction and no other significant liver lesions and the liver failure was likely secondary to sepsis. Hepatitis profile also was negative for any active hepatitis. The patient continued with low grade sepsis and respiratory failure. Tracheostomy was performed on [2147-5-3]. In the weeks before discharge the patient's issues included staph aureus methicillin resistant arterial line infection as well as Klebsiella pneumonia for which the patient is completing a course of levofloxacin and Vancomycin. The following is a summary of the condition at discharge with relevance to previous history. 1. Neurologic: The patient is awake, Spanish speaking and is intermittently following commands. Patient has no significant active neurologic issues. 1. Pulmonary: The patient is on the ventilator supported by 18 depressed port and 5.0 PEEP with 40 percent FIO2 with a tracheostomy. 1. Cardiac: The patient had a history of intermittent atrial fibrillation and was briefly on amiodarone. However, has been in sinus rhythm without problems of tachyarrhythmia recently. 1. Gastrointestinal: The patient is being supported nutritionally by tube feeds Nephro at 35 cc an hour. The abdominal wound is open. It was recently debrided four days prior to discharge of all necrotic and purulent tissue and is being treated with a wet to dry dressing B.I.D The patient has elevated liver function tests with elevated AST, ALT, bilirubin and alkaline phosphatase as well as mild coagulopathy which is likely due to liver injury from sepsis. Again MRCP as well as ultrasound showed no evidence of biliary ductal obstruction and hepatology consult suggested treatment with Actigall and no further work up was necessary. 1. Renal: Patient is on hemodialysis Monday, Wednesday and Friday. 1. Hematology: The patient has had some evidence of anemia likely related to the renal failure and is on Epogen. However, there is no evidence of any active bleeding issues. Patient is also on subcutaneous heparin for prophylaxis. 1. Infectious disease: The patient is now completing a course for treatment of the methicillin resistant staph aureus arterial line infection as well as Klebsiella pneumonia. Patient on day of discharge, [2147-5-31] will be day five of 14 of Vancomycin and 11 of 14 of Levofloxacin. 1. Endocrine: Patient has not had problems with elevated blood sugar. DISPOSITION: The patient is in the Intensive Care Unit and with plans for transfer to rehabilitation. DISCHARGE STATUS: Fair. DISCHARGE DIAGNOSES: 1. Small bowel obstruction. 2. Status post laparoscopic lysis of adhesions, exploratory laparotomy and enterotomy repair on [2147-4-11]. 3. Status post re-exploration, abdominal wash out and abdominal wall closure with Aqua mesh on [2147-4-14]. 4. Patient is status post exploratory laparotomy, removal of Aqua mesh, lysis of adhesions, abdominal wash out and ventral hernia component separation on [2147-4-27]. 5. ARDS. 6. Acute renal failure. 7. Atrial fibrillation. 8. Cholestasis, hyperbilirubinemia. 9. Methicillin resistant staph aureus and Klebsiella pneumonia. 10. Methicillin resistant staph aureus line sepsis. 11. Status post tracheostomy [2147-5-3]. 12. Coronary artery disease, status post myocardial infarction. 13. Hypertension. 14. Hypercholesterolemia. 15. History of head trauma with right hemiparesis. DISCHARGE MEDICATIONS: 1. Actigall 300 per feeding tube t.i.d. 2. Calcium 667 mg per nasogastric tube t.i.d. 3. Vancomycin 1 gram intravenous p.r.n. Vancomycin level less than 15, checked q day. 4. Levofloxacin 250 mg intravenous q 48. 5. Heparin subcutaneous q 8. 6. Desitin topical p.r.n. 7. Epogen 5,000 units intravenous every hemodialysis. 8. Nystatin 5 cc P.O. p.r.n. 9. Lopressor 2.5 mg intravenous q 8 p.r.n. 10. Lansoprazole 30 mg per nasogastric q.d. 11. Versed 1 mg intravenous q 4 p.r.n. 12. Hydromorphone 0.5 to 2 mg intravenous q 2 to 3 p.r.n. 13. Insulin sliding scale. 14. Artificial tears p.r.n. 15. Albuterol 1 to 2 puffs inhaler q 6 p.r.n. 16. Lacrilube ointment p.r.n. FOLLOW UP PLANS: Patient will follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [MD Number(2) 11162] Dictated By:[Name8 (MD) 26127] MEDQUIST36 D: [2147-5-30] 16:06:55 T: [2147-5-30] 17:45:56 Job#: [Job Number 26128]	[ "0389", "99592", "51881", "9971" ]
Admission Date: [2133-3-6] Discharge Date: [2133-3-11] Date of Birth: [2072-6-13] Sex: F Service: MEDICINE Allergies: Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim Attending:[First Name3 (LF) 10842] Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: PICC placement History of Present Illness: 60F with a history of diabetes mellitus (type I vs. type II), HTN, HLD, PVD and multiple recent hospital admissions (first for pneumonia, requiring ICU admission with intubation) and then earlier this month for altered mental status felt secondary to UTI. At that time, she was initially treated with IV antibiotics (vanco/cefepime -> ceftriaxone) but then discharged on Bactrim to complete a 14-day course. No organism was ever isolated from the urine. At home, she reports continued dysuria (burning) that never resolved. For the last several days, she's been having worsening nausea and vomiting (mulitple 6-7 episodes today prior to presentation) as well as diarrhea/loose stool (no blood). She has not had a bowel movement since arrival in the ED. In the ED inital vitals were T 97.8, HR 70, BP 140/91, RR 16, O2 sat 97% RA. Initial labs returned notable for hyperkalemia in non-hemolyzed specimen to 7.2. Subsequently, the patient was noted to develop arrhythmia on telemetry with bigeminy/Wenckebach and short runs of VT (~10 beats). During runs of VT, she had palpable pulse in 40s despite rate in 110s-150s on monitor, and was symptomatic (lightheaded) with these episodes. She was given albuterol nebs, 40 mg IV furosemide, calcium gluconate, insulin/D50 and kayexelate. Prior to transfer, a U/A was checked and returned dirty, so she received a dose of ceftriaxone and also got 2g of IV magnesium. Vitals on transfer were HR 102, BP 124/84, O2 sat 100% on RA, T 98.6. On arrival to the ICU, she is vomiting x multiple times, non-bloody, non-bilious. She reports having some SOB in the ED with the arrhythmias, but no chest pain or palpitations. Breathing is now comfortable. She denies abdominal pain but still having nausea (especially with movement). Past Medical History: 1. DM2: insulin-dependent may be Type 1 -followed by [Hospital ] Clinic -c/b recurrent ulcers, urosepsis -Charcot deformity 2. s/p amputation of L 2nd & 3rd toe 3. chronic ulcer of R pretibia 4. hx of MRSA foot [3-/2125] 5. HTN 6. PVD 7. hypercholesterolemia 8. Anemia, ? ACD, baseline low 30s 9. Hematemesis in [2125] thought to be [1-15] small [Doctor First Name 329] [Doctor Last Name ], EGD ulcer in GE junction Social History: The patient lives with her husband and has a 10 year old child. She works at the Causeway VA as a secretary. She smokes 10 cigs per day x 40 years. No ETOH and drugs. Family History: Mother had DM2, died of diabetes related coma Father has DM2, still alive Several family members on paternal side with DM2 No FH of CAD, MI, or cancer. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress. Speaking in full sentences. HEENT: Sclera anicteric, MMM, oropharynx clear. Left pupil is 1-2 mm bigger than the right, slightly irregular, and poorly reactive compared with the right. Patient reports prior surgery on this eye and thinks this may be her baseline. Neck: Supple, JVP not elevated (though difficult to assess given body habitus), no LAD Lungs: Clear to auscultation bilaterally (distant given body habitus), no wheezes, rales, rhonchi CV: Regular rate and rhythm, distant S1 + S2 but no audible murmurs, rubs, gallops Abdomen: Soft/obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: Chronic venous stasis changes bilaterally on lower extremities. Multiple skin lesions/ulcerations more on the right leg which appear chronic but per patient are healing slowly. DISCHARGE EXAM: VS; TC 98.4 BP 137-159/74-75 HR 78-82 RR 18-20 96% RA GENERAL - well-appearing F in NAD, comfortable, appropriate NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - ctab, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding, ecchymosis at heparin shot sites EXTREMITIES - hyperpigementation from mid-shin down bilaterally with erythema and several draining wounds bilaterally, feet wrapped, with weeping, raw erythema (per patient, this is chronic), no edema SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [4-18] throughout, sensation grossly intact throughout Pertinent Results: ADMISSION LABS: [2133-3-6] 06:20PM BLOOD WBC-10.5 RBC-5.11 Hgb-15.1 Hct-48.9* MCV-96 MCH-29.6 MCHC-30.9* RDW-13.8 Plt Ct-248 [2133-3-6] 06:20PM BLOOD Neuts-79.7* Lymphs-15.0* Monos-2.8 Eos-1.8 Baso-0.8 [2133-3-6] 09:50PM BLOOD Glucose-484* UreaN-28* Creat-2.1* Na-138 K-5.6* Cl-100 HCO3-25 AnGap-19 [2133-3-6] 06:20PM BLOOD Glucose-359* UreaN-28* Creat-2.0* [2133-3-6] 09:50PM BLOOD CK(CPK)-84 [2133-3-6] 06:20PM BLOOD cTropnT-0.01 [2133-3-7] 02:10PM BLOOD CK-MB-4 cTropnT-0.01 [2133-3-6] 06:20PM BLOOD Calcium-9.5 Phos-3.9 Mg-1.8 [2133-3-7] 03:06AM BLOOD Osmolal-312* [2133-3-7] 03:20AM BLOOD Type-ART pO2-70* pCO2-41 pH-7.41 calTCO2-27 Base XS-0 [2133-3-7] 03:20AM BLOOD Lactate-2.3* Na-136 K-4.4 Cl-99 [2133-3-7] 03:20AM BLOOD freeCa-1.13 DISCHARGE LABS: [2133-3-11] 05:58AM BLOOD WBC-6.1 RBC-4.37 Hgb-12.9 Hct-42.1 MCV-96 MCH-29.6 MCHC-30.7* RDW-13.6 Plt Ct-189 [2133-3-11] 05:58AM BLOOD Glucose-144* UreaN-22* Creat-1.5* Na-139 K-4.2 Cl-102 HCO3-27 AnGap-14 [2133-3-11] 05:58AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9 MICROBIOLOGIC DATA: [2133-3-6] Urine culture - yeast IMAGING STUDIES: [2133-3-7] CHEST (PORTABLE AP) - Heart size and mediastinum are unremarkable. There is no evidence of interstitial pulmonary edema. There is no appreciable pleural effusion. Minimal bibasal, left more than right, atelectasis is present. STRESS [2133-3-10]: INTERPRETATION: 60 yo woman with HTN, HL, DM and morbid obesity; h/o stage III CHD and PVD was referred to evaluate an episode of nonsustained VT. The patient was administered 0.142 mg/kg/min of Persantine over 4 minutes. No chest, back, neck or arm discomforts were reported by the patient during the procedure. No significant ST segment changes were noted. The rhythm was sinus with one instance of a sinus pause vs SA Exit block noted post-infusion; there was no blocked sinus or atrial premature beat noted on the ECG. The heart rate and blood pressure response to exercise was appropriate. Post-infusion, the patient was administered 125 mg Aminophylline IV. IMPRESSION: No anginal symptoms or ischemic ST segment changes. Appropriate hemodynamic response to the Persantine infusion. Nuclear report sent separately. MIBI [2133-3-11]: The image quality is poor due to extensive soft tissue and breast attenuation. Left ventricular cavity size is normal. Resting and stress perfusion images reveal probably uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 58% with an EDV of 78 ml. IMPRESSION: 1. Probably normal myocardial perfusion in the setting of extensive attenuation. 2. Normal left ventricular cavity size and systolic function. In the setting of diabetes, normal myocardial perfusion does not necessarily imply a low risk of adverse cardiac events. Brief Hospital Course: 60 y/o F with diabetes (multiple complications), HTN, HLD, PVD and two recent hospitalizations who presented with N/V/D and found to have hyperkalemia and arrhythmia in the ED. # HYPERKALEMIA - Patient was noted to have hyperkalemia to 7.2 on admission. The etiology of her symptoms is not entirely clear, but it was possibly multifactorial with contributions from ACE inhibitor use, hyperglycemia and low insulin state, worsening renal failure in the setting of dehydration, and recent Bactrim use. However, the relationship with bactrim seems to be most striking as her elctrolyte imbalances were corrected after she stopped taking the bactrim. She received multiple treatments in the ED including calcium gluconate, furosemide, albuterol, insulin with D50 and kayexelate. Her potassium improved with these interventions. She was monitored via telemetry and her EKGs remained stable. Her ACEI was held in this setting. CK values stable without evidence of rhabdomyolysis. # ARRHYTHMIA - Patient was noted to have bigeminy and Wenckebach pattern on telemetry in the ED, with multiple self-limited runs of ? VT with rate in 100s-150s associated with palpable pulse drop to 40s and lightheadedness (patient reports symptoms were not severe, no LOC). This was attributed to electrolyte imbalance. She was maintained on telemetry and her EKGs remained reassuring. However, she continued to have brief runs of VT (upto 11 beats) even after stabilization. She was started on metoprolol XL 25. A percantine MIBI was performed which showed NO ISCHEMIA and normal myocardium. # ACUTE ON CHRONIC RENAL FAILURE - Baseline of 1.1-1.3, peaked at 2.1. Likely partially prerenal in the setting of dehydration from nausea and emesis. FeNA >2%, concerning intrinsic causes such as ATN, Bactrim-induced crystal nephropathy was felt to be msot likely. Now trending still 1.6-1.7. Patient initially received IVF boluses. Lisinopril and HCTZ were held but HTZ was restarted. # POSITIVE U/A - Patient hax > 182 WBCs in urine despite recently completing a course of Bactrim for UTI (ended day prior to admission). No organisms were isolated from her last culture at prior admission. Patient continues to report dysuria (burning) never fully resolved since last admission. A urine culture was obtained and she was treated with IV Ceftriaxone x3 days till urine culture showed yeast and no bacteria. Vaginal estrogen for UTI prevention was started. # VOMITING/DIARRHEA - Unclear etiology, though given presence of diarrhea viral gastroenteritis seems likely. Diarrhea could also be due to recent antibiotics, with N/V due to other cause such as UTI or medications (Bactrim). Cardiac etiology is unlikely, and troponin negative. Tolerated regular diet on discharge. # HYPERGLYCEMIA/DIABETES MELLITUS - Possibly type I as the patient is insulin dependent and has multiple complications. She was hyperglycemic on arrival to 359 on labs, which may be related to underlying illness (e.g. gastroenteritis vs. UTI). After receiving D50 in the ED, glucose was elevated to "critically high" on arrival to the ICU. This may represent HONK given calculated serum osm of 313. She received 10 units of regular insulin with improvement on arrival to the MICU. Subsequent glucose values improved. On the floor, patient with difficult to control blood glucose, in the 300-400s, partially because she did not know her insulin sliding scale, which was uptitrated rapidly. # SKIN CHANGES - Chronic ulcerations are improving per patient. A wound consult was obtained for guidance with dressing changes. # HYPERTENSION - Lisinopril and HCTZ were held in the setting of [Last Name (un) ] (see above). SBP 130-150s off antihypertensives. Received PO hydralazine 10mg x1 for SBP>160. Howeevr, HTZ was restarted and she was initiated on amlodipine 5mg and metoprolol XL 25. # HYPERCHOLESTEROLEMIA - Her statin medication was continued. # TRANSITION OF CARE ISSUES: Lisinopril is being held and can be restarted if Cr stable on visit to Dr [Last Name (STitle) 1147]. Vaginal estrogen for UTI prevention was started. Metoprolol XL and amlodipine were also started. Pt has followup with [Last Name (un) ] and PCP. Medications on Admission: - insulin levemir 70 units qHS - insulin lispro sliding scale- rough idea of: Bglc 150- 2-3U; Bglc 200- 15U; Bglc 250- 30U; Bglc 300- 40U - lisinopril 20 mg PO once a day - nortriptyline 75 mg PO HS - pantoprazole 40 mg PO Q24H - rosuvastatin 20 mg PO DAILY - aspirin 325 mg PO DAILY - hydrochlorothiazide 25 mg PO DAILY - docusate sodium 100 mg PO BID as needed for constipation - senna 8.6 mg PO BID as needed for constipation - sulfamethoxazole-trimethoprim 800-160 mg PO BID last dose [2133-3-5] Discharge Medications: 1. nortriptyline 75 mg Capsule Sig: One (1) Capsule PO at bedtime. 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:0 8. conjugated estrogens 0.625 mg/gram Cream Sig: One (1) gram Vaginal DAILY (Daily). Disp:3 tubes Refills:0 9. Humalog Subcutaneous 10. Levemir 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous at bedtime. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: PRIMARY: Nausea/vomiting/diarrhea Hyperkalemia Pyuria SECONDARY: Hypertension Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [Known lastname 35127], It was a pleasure participating in your care at [Hospital1 18]. You were admitted because you had nausea, vomiting and diarrhea. We thought this was likely due to Bactrim. As a result of the vomiting and diarrhea, your kidney function decreased. We stopped your lisinopril while your kidneys are recovering. You also had high potassium which we treated with medications. There was a question of recurrent UTI and we treated you with antibiotics. We stopped your antibiotics because your urine culture did not grow bacteria. You are being started on a vaginal cream that should help prevent UTIs in the future. There were also some irregular heart rhythms noted while you were admitted. We performed a stress test which ruled out any underlying heart damage that may have been contributing to the abnormal heart rhythm. The results of the test were normal. We made the following changes to your medications: - STOPPED Lisinopril: please restart after having your kidney function assessed by Dr [Last Name (STitle) 1147]. - STARTED Vaginal Estrogen Cream: this cream, applied once daily, will help prevent Urinary Tract Infections in the future. - STARTED Metoprolol XL 25mg to alleviate irregularities in heart beat - STARTED Amlodipine 5mg (Norvasc) for blood pressure control Please bring your insulin sliding scale chart with you to your [Last Name (un) ] appointment Followup Instructions: Name: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3640], NP Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3402] Appt: Tuesday, [3-17] at 1:30pm Department: ADULT MEDICINE When: THURSDAY [2133-3-26] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12175], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "5849", "2767", "2724", "40390", "5859", "2720", "V5867" ]
Admission Date: [2124-10-25] Interim Date: [2124-11-24] Date of Birth: [2124-10-25] Sex: M Service: Neonatology HISTORY: This is an interim summary covering the dates of [2124-10-25] to [2124-11-24]. [Known lastname ] was born at 25-3/7 weeks gestation to a 38-year-old G2 P1 now two mom with prenatal screens of blood type A positive, antibody negative, GBS unknown, hepatitis B surface antigen negative. Antepartum history remarkable for incompetent cervix treated with cerclage at 13 weeks. Mom admitted at 22-1/7 weeks and placed on bed rest, placed on tocolysis for preterm labor. Increased contractions developed on the day prior to delivery. Tocolysis maximized and dose of betamethasone administered eight hours prior to delivery. Vaginal bleeding developed and with breech presentation, a C section under spinal anesthesia was performed. Baby emerged with good tone and grimace. Dry, given blow-by O2, and PPV, intubated without difficulty. Apgars at 4 and 8. Exam remarkable for preterm infant with vital signs stable. Color pink. Anterior fontanel soft. Eyes fused. Mild retractions on vent. Fair air entry, no murmur. Present femoral pulses. Abdomen: Soft, nontender, nondistended without hepatosplenomegaly, normal phallus, testes not distended, hips stable. Normal tone and activity for gestational age. HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: Patient escalated on ventilatory support on day of life one and was transitioned to high frequency ventilation. Maximum MAP of 12 and amplitude of 28 always with a minimal O2 requirement. Weaned rapidly on vent settings. Was transitioned to conventional ventilation on day of life one. Patient electively extubated to CPAP on day of life two, however, required reintubation for frequent bradycardic spells about 24 hours after extubation. Patient was maintained on conventional ventilation on minimal to moderate vent settings. Self extubated on [11-17] and placed on NP CPAP of 6. Did well on CPAP for one week, then with increasing bradycardic spells. Was re-intubated on [2124-11-23]. Currently on conventional ventilation with a PIP of 20, PEEP of 6, rate of 20, FIO2 in the 20s. [Known lastname ] was started on caffeine on day of life two for apneic and bradycardic spells. He remains on caffeine. Has frequent episodes of desaturation responsive to an increase in FIO2. Has bradycardic spells about 5-7x/day. Usually response to stimulation and increase in FIO2. Occasional spells have required bagging. 2. Cardiovascular: On day of life 0, the patient developed hypotension, received 2 normal saline boluses, and was subsequently started on dopamine. Dopamine weaned off on day of life #1. Subsequent blood pressures have remained within normal limits. He developed a murmur and physical findings consistent with a PDA on day of two and echocardiogram on day of life three confirmed the moderate PDA. Was treated with one course of Indocin and PDA subsequently with resolution of murmur and other clinical finding of PDA. On [11-15], [Known lastname ] again developed a prominent murmur on his examination and bounding pulses. Echocardiogram on [11-16] revealed a small to moderate PDA and [Known lastname ] was treated with a second course of Indocin again with resolution of his murmur and no further signs of PDA. 3. FEN: Initially NPO on IV fluids. Parenteral nutrition started on day of life one, total fluids reached a maximum of 180 cc/kg/day. Enteral feedings were started on [10-31] (day of life six) with trophic feeds with breast milk. Patient tolerated this well and feeds were slowly advanced. Patient reached full enteral feedings on day of life 14. Kilocalories were then advanced and again [Known lastname ] tolerated this well. He is currently on 150 cc/kg/day of breast milk 32 with ProMod. Given PG over two hours. Birth weight was 950 grams, weight dropped as low as 735 grams on day of life five, and subsequently with good weight gain. Weight on [11-24] was 1085 grams. Glucoses monitored and remained stable throughout. Maintained good urine output throughout. Electrolytes monitored throughout. [Known lastname ] had some initial hyperkalemia and in the first couple days of life treated with alkalinization, and calcium gluconate boluses, as well as Lasix x1. Potassium subsequently normalized. Electrolytes subsequently stable. Last set of electrolytes on [11-24] was a sodium of 131, potassium of 4.9, chloride 97, bicarb 25, calcium 10.8, phosphorus 6.4. 4. GI: Bilirubin levels monitored. Started on single phototherapy on day of life two with a bilirubin that peaked at 4.8/0.4. Remained on single phototherapy through day of life 10. Phototherapy discontinued and rebound bilirubin of 3.5/0.3. Bilirubin up to 6.6/0.3 following a transfusion on day of life 16. Bilirubin was then restarted on phototherapy. Bilirubin was down the following day to 3.1/0.4 and phototherapy discontinued with a rebound bilirubin of 3.8/0.3. Maintained good stool throughout, occasional heme positive stools. The stools were primarily heme negative. 5. Hematology: Baby's blood type is O positive, Coomb's negative. Initial hematocrit of 37. Patient transfused on day of life three for blood out. Transfused again on day of life 14 for a hematocrit of 31. Was also transfused on [11-24] for a hematocrit of 33.1. Last hematocrit on [11-24] was 33.1 with a platelet count of 378. Patient was started on Fer-In-[Male First Name (un) ] and vitamin E on day of life 16 and remains on these medications. 6. ID: CBC and blood cultures sent on admission and [Known lastname ] was started with ampicillin and gentamicin. Blood cultures were no growth at 48 hours and antibiotics were discontinued. CBC and blood culture again sent on day of life 14 because of increased apneic and bradycardic spells, for which [Known lastname ] was slow to recover. White count at that time 27 with 60 polys and 1 band. Was treated with Vancomycin and gentamicin for 48 hours. Blood cultures showed no growth in 48 hours and antibiotics were discontinued. CBC and blood culture again sent on [11-23] with increased apneic and bradycardic spells requiring reintubation. White count was 25.6 with 36 polys and no bands. Antibiotics were not started. Blood cultures with no growth to date. No further infectious disease issues. 7. Neurologic: [Known lastname ] had a normal head ultrasound on day of life one and day of life seven and day of life 28. 8. Ophthalmology: Not examined. Patient has not yet had his first eye examination. 9. Social Work: [Hospital1 69] Social Work involved with the family. The contact social worker is [Name (NI) 553] and she can be reached at [Telephone/Fax (1) 8717]. 10. Access: UAC and UVC were placed at birth. UAC was discontinued on day of life five. [First Name11 (Name Pattern1) 37693] [Last Name (NamePattern4) 37927], M.D. [MD Number(1) 37928] Dictated By:[Last Name (NamePattern1) 50027] MEDQUIST36 D: [2124-11-30] 09:19 T: [2124-11-30] 09:35 JOB#: [Job Number 50788]	[ "7742", "2767" ]
Admission Date: [2179-11-18] Discharge Date: [2179-12-30] Date of Birth: [2114-8-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1674] Chief Complaint: [First Name3 (LF) ]/diarrhea Major Surgical or Invasive Procedure: IJ placement History of Present Illness: 65 year old man with hx of CHF (EF 30%), CAD (with NSTEMI on [9-10] s/p cath on [2179-9-19] showing 3VD s/p BMS to LMCA, LAD, POBA of OM), PVD, COPD, h/o mesenteric ischemia s/p bowel resection in [7-/2179], MRSA pneumonia, initially p/w [Year (4 digits) ]/diarrhea on [2179-11-18]. In the [Hospital1 ] [Name (NI) ], pt afebrile, but SBP 50s. Pt's pressure was responsive to aggressive fluids. Pt also had a leukocytosis (wbc 36) and positive U/A, and was started on vanc/levo/flagyl. Noted to have rising CEs. In the ED, the patient developed VT arrest in setting of sepsis and a Mg 0.8. Magnesium was repleted, and he received one shock with recovery of Normal Sinus rhythm. During the code the pt was intubated and sent to the MICU. He was subsequently extubated on [2179-11-19]. Of note, CT scan done in ED showed pancolitis. In the MICU the pt was noted to have loose stools. He was diagnosed as sepsis/hypovolemia. He was given aggressive fluids via CVL. Pt briefly on lidocaine drip from the ED, but never required pressors. C diff from [11-18] was positive. Pt's abx changed to po vanc/flagyl alone. Pt extubated on [11-19]. He required a lasix drip [Date range (1) 46801] for fluid overload from resuscitation. He was then transfered to medicine for further management. On the medicine floor he became dyspneic with O2 requirement. On [11-24] Lasix was held for hypotension and dyspnea worsened. Because of this worsening of dyspnea CE were drawn and showed elevated Trop-T to 3.12 and CK of 15 c/w NSTEMI. Heparin gtt was started. On [11-25] BP stablized and pt has responded with increased urine output to Lasix IV bolus with Metolazone. He was transferred to [Hospital1 1516] today for management of NSTEMI and better management of fluid status. Past Medical History: PVD- s/p aorto [Hospital1 ] fem bypass DM Bladder CA COPD s/p cholecystectomy Aorto [Hospital1 ] Fem Bypass mesenteric ischemia s/p stenting of SMA CAD with 3 vessel disease on cath [2179-8-4] duodenal angioectasia respiratory failure MRSA pneumonia Social History: Pt has 75 pack/year smoking history, quit during last hospitalization, previous ETOH use about 6-12 beers/week. He is a retired highway heavy equipment operator, currently lives at [Hospital3 ]. Family History: Family history significant for CAD, brother with MI at age younger than 50. Physical Exam: MICU Physical Exam: Vs- 100/50 98.0 95 20 100% on PS 10/5, 50% FiO2 Gen- intubated, arousable, not sedated, appears comfortable Heent- MMM, anicteric, symmetric, PERRL Neck- supple, could not assess JVP Cor- regular, tachy, distant heart sounds could not apprec. murmur Chest- expiratory wheeze with vent sounds. Decreased at bases Abd- soft, open surgical wound with minimal purulent drainage proximally. Pos BS. Tender along wound. Ext- no c/c/e. Pneumoboots on. Bounding femoral pulses with scars from prior bypass surgeries. Neuro- Appears alert , though cannot fully assess orientation due to endotracheal tube. Floor: D/C Physical Exam Vitals; 98.8 104/58 88 18 97% on 2l Gen: NAD, comfortable HEENT: MMM, no LAD, EOMi, anicteric Neck: supple Card: RRR Chest: CTAB, no wheezing/crackles Abd: soft, NT/ND. dressing in place (c/d/i) over open surgical wound Ext: no c/c/e. muscle wasting in bilateral lower extremities Neuro: alrt, oriented Skin: stage 2 sacral decubitus ulcer Pertinent Results: Lab results on Admission: [2179-11-18] 12:49AM BLOOD WBC-36.2# RBC-3.48 Hgb-10.8* Hct-32.2* MCV-93 MCH-31.2 MCHC-33.7 RDW-18.5* Plt Ct-530* [2179-11-18] 12:49AM BLOOD Neuts-83* Bands-3 Lymphs-3* Monos-11 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2179-11-18] 04:18PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Burr-1+ [2179-11-18] 12:49AM BLOOD PT-16.4* PTT-30.1 INR(PT)-1.5* [2179-11-18] 12:49AM BLOOD D-Dimer-5720* [2179-11-18] 05:10AM BLOOD Fibrino-597# [2179-11-18] 12:49AM BLOOD Glucose-43 UreaN-25* Creat-1.5* Na-138 K-4.4 Cl-103 HCO3-19* AnGap-20 [2179-11-18] 12:49AM BLOOD CK(CPK)-22* [2179-11-18] 12:49AM BLOOD CK-MB-NotDone cTropnT-0.28* [2179-11-18] 05:10AM BLOOD Phos-2.8# Mg-0.8* [2179-11-18] 01:10PM BLOOD Type-ART FiO2-100 pO2-440* pCO2-42 pH-7.10* calTCO2-14* Base XS--16 AADO2-233 REQ O2-47 Intubat-INTUBATED [2179-11-18] 03:20PM BLOOD Type-ART pO2-335* pCO2-32* pH-7.28* calTCO2-16* Base XS--10 Intubat-INTUBATED [2179-11-18] 12:38AM BLOOD Lactate-4.7* [2179-11-18] 03:45AM BLOOD Glucose-153* Lactate-3.0* [2179-11-18] 03:20PM BLOOD freeCa-1.05* Discharge labs: IMAGING: [11-18] CT ABD: IMPRESSION: 1. Findings consistent with pancolitis, significantly increased in severity and extent compared to the prior study. This could be due to an inflammatory or infectious process, including C. Difficile colitis. 2. Large bilateral pleural effusions. 3. Diffuse anasarca. [11-18] CXR: IMPRESSION: 1. Appropriate placement of ET and NG tubes. 2. Increased interstitial opacities bilaterally consistent with fluid overload. 3. More focal airspace opacities involving the right lung may represent asymmetric pulmonary edema or pneumonia. 4. Persistent opacification of the right cardiophrenic angle may represent right middle lobe collapse. [11-18] EKG: Baseline artifact. Sinus rhythm. Marked left axis deviation. Right bundle-branch block. Early R wave progression. ST-T wave abnormalities. Since the previous tracing of [2179-10-1] ST-T wave abnormalities may be improved or there is pseudonormalization [11-19] ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %) with regional variation: the inferior and posterior walls are more hypokinetic than the rest of the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [11-24] CT Chest: IMPRESSION: 1. Interval worsening in now large bilateral pleural effusions (compared to CT [2179-11-18], but similar to CT [2179-9-29]), without evidence of loculated component. Peripheral interstitial septal thickening suggests congestive failure as part of the cause for the effusions. 2. Debris dependently within the trachea. This finding was called to Dr. [Last Name (STitle) ] on [2179-11-25] [11-26] CXR: FINDINGS: In comparison with the study of [11-24], there is again moderate-to- severe pulmonary edema with substantial pleural effusions bilaterally and enlargement of the cardiac silhouette. Right IJ catheter again extends to the lower portion of the SVC. ECHO [12-23]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is inferior akinesis with moderate hypokinesis of the other LV segments, c/w multivessel coronary artery disease or systemic process. Overall left ventricular systolic function is moderately depressed (LVEF= 30%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate regional and global left ventricular systolic dysfunction. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [2179-12-3], the findings are similar. [11-29] C. Cath: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Systemic hypotension. 3. Low filling pressures. 4. Successful stening of the LM with a CYPHER DES. COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt [2179-12-30] 06:30AM 11.0 3.32* 10.7* 32.4* 98 32.0 32.9 16.5* 393 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2179-12-30] 06:30AM 126* 21* 1.1 137 4.5 104 31 7* Brief Hospital Course: 65 year-old man with 3-vessel CAD initially admitted for Cdiff colitis complicated by polymorphic VT arrest on initial presentation, NSTEMI and then STEMI s/p L main stenting, systolic CHF with acute exacerbations, hospital acquired pneumonia with sepsis and GIB. . # Cardiac arrest / Ischemia: In the ED a 'code blue' was called when he became unresponsive and was noted to have a polymorphic VT vs. torsades rhythm. He was resuscitated with defibrillation, epinephrine, and started on a lidocaine drip. The etiology of the arrest is likely due to severe electrolyte derangements, including a magnesium of 0.8 that was in the process of repletion. This was likely complicated by cardiac ischemia from sepsis/hypotension. Cardiac enzymes were trended and were markedly elevated as expected after defibrillation and troponin reached a peak of 1.95 and then trended downward. He was initially placed on aspirin , plavix and atorvastatin 80mg and later re-started on metoprolol as tolerated by his blood pressure. The patient was treated in the MICU and transferred to the Medicine team. While on the medical floor he developed hypotension and dyspnea. Cardiac Enzymes were again drawn and showed an increased troponin to 3.12, up from 1.52 five days prior. He was started on a heparin drip and transferred to the [Hospital1 1516] Cardiology service for management on his NSTEMI and for better managment of his fluid status. Troponin peaked at 3.58 and trended down. The Heparin drip was stopped after 48 hours. He was chest pain free while on the Cardiology service. On [11-29], pt had an episode of hypotension with SBP 84. An EKG was done which showed marked TWI in V2-V4 and ST elevations in II,III and AVF. Pt went to cath lab and underwent successful stening of the LM with a CYPHER DES. Pt was hypotensive peri-operatively, and recovered to the CCU for 24 hours. He was briefly on a dopamine gtt but this was quickly weaned. He was then transferred to the cardiology floor and was subsequently stable from a cardiac standpoint. Pt needs to continue on Aspirin and Plavix at all times. On the medicine floor pt had intermitted episodes of increased HR (see atrial tachy below) as well as episodes of hypotension (unrelated to tachyarrythmias), see below. . # Afib/Atach: Pt w/ VT code upon presentation. Recurrent runs of atrial tachycardia to 140s/150s, self resolving, but w/ occasional cp. cards c/s, recommended no albuterol to decrease adrenergic drive, aggressive pain control, inc metoprolol to 50 [Hospital1 ] (from 25 tid),and change captopril to lisinopril 10. the metorpolol/lisinopril were subsequently d/ced due to increasing number of episodes of asympt hypotension w/ SBP in 70s. metoprolol currently restarted at 12.5bid, lisinopril restarted [12-29]. . # Asymptomatic hypotension: pt triggered multiple times on floor for SBP 70-80. Pts bp tends to be low (85 to 110s). asymptomatic during events. lisinopril decreased and eventually d/ced. metoprolol decreased to 12.5 in an attempt to normalize BP. repeated full workups, last on [12-23] w/ cxr (improved), blood cx(NGTD), [Last Name (un) 104] stim borderline (low baseline, but response to cosyntropin). [12-24] Starting on 2d 100 hydrocortisone, then 5mg prednisone daily to continue. [Note, on admission to micu patient was on 5 mg po prednisone for unknown reason. Pt got stress dose steroids in micu, which were subsequently d/ced on floor. Restarted at 5mg qdaily given persistent borderline BPs, though asymptomatic . # Sepsis: At presentation Mr. [Known lastname ] had evidence by labs, history, and imaging of a severe c.dif colitis, which was confirmed by laboratory results. He has been treated with PO flagyl and vancomycin for a two week course, transitioned to vancomycin po taper. Other possible sources could be his UTI or his abdominal wound / recent surgery. He was resuscitated with ~6L IVF in the ED, and his lactate trended downward. Stress dose steroids were started in the icu, d/ced on the floor. He is being treated for the C.diff with PO Vancomycin to complete a 14 day course free of other abx with vanco taper, 3d at tid, 5d at [Hospital1 ], 5 d more qdaily prior upon discharge. The [Hospital 228] hospital course was also complicated by hospital acquired pna w/ + resistant acinobacter now s/p 7d course tobra, 10d course vanc/zosyn. cough/sob resolved. . # Left Ischemic Optic neuropathy-Pt reported poor vision in left eye [11-29] initially and had reported this had been ongoing for the few days prior. However this intial complaint of vision change was in the context of a STEMI and pt quickly went to cath; thus upon review of systems when patient came back from cath, pt reported poor vision in both eyes, Left>right. Patient appeared to have complete loss of vision in the left eye and there was a concern for embolic stroke. An MRI/MRA was done which did not show evidence of embolic dz or stroke. Opthamology consulted and felt pt likely has ischemic damange to optic nerve likely [2-5] hypotensive episodes. No further intervention was needed other than to maintain a stable blood pressure. The pt will need f/u with neuro-opthamology as outpt. ([Telephone/Fax (1) 5120] . # Respiratory failure: Patient was intubated during code situation, extubated [11-19]. Extubation c/b acute on chronic CHF. Subsequent intubation in the context of hospital acquired pneumonia and sepsis. Now on 2L O2. Stable. Needs continous aggressive chest PT. . # CHF: Acute on chronic CHF exacerbation. Appeared slightly fluid overloaded in the setting of sepsis. A transthoracic echo revealed an LVEF 30% He successfully underwent diuresis with improvement in pulmonary symptoms. Euvolemia maintained, autodiuresing, and gentle diuresis/hydration as necessary. home lasix d/ced as pt has not been volume overloaded. [2-5] hypotension, metoprolol decreased to 12.5 [Hospital1 ], lisinopril to 2.5mg qdaily . # COPD: He has a history of copd with long smoking history. He was on albuterol, ipratropium and systemic steroids. Albuterol d/ced [2-5] cardiac recs that it may be contributing to patients runs of atrial tachycardia. Systemic steroids not continued after icu course. Acetylcysteine added to regimen, aggressive chest PT and inspirative spirometry. . # DM2: He was on an insulin sliding scale and long-acting insulin. ISS continued in hospital (no long acting [2-5] inconsistent eating habits) with poor control of sugars. Restarted low dose lantus on discharge with ISS, which will be adjusted at rehab. . # Mesenteric ischemia: His small bowel resection was in [Month (only) 205] [2179], and his abdominal wound was closed shortly thereafter. The wound itself appears to okay, though there is some increased purulence at the proximal aspect. Dr.[Name (NI) 15146] team evaluated the wound and thought it was healing well. Patient was followed by the wound care nurse throughout his hospital stay. . # GIB: Pt w/ melanotic Stools and known UGI AVMs, considered likely source. no EGD required (unless pt rebleedsand becomes unstable) as unlikely to be of benefit. Pts HCT remained stable with a plan to transfuse PRBCs to HCT 30 given recent myocardial ischemia, stools guaiaced (no rebleed) and pt continued on pantoprazole. 1u prbcs on [12-22] and 12/23 [2-5] hct<30, with occasional guaiac positive stools. Will get CBCs at rehab with pRBCs fpr hct<30. . # Urinary Retention: [12-17] pt w/ no UOP x8hrs s/p foley removal. bladderscan >500cc. foley reinserted. flomax started. [12-20] +UA, cx positive for yeast. no tx at this time except foley d/ced [2-5] to pos UA, but reinserted overnight [12-20] [2-5] no urine. - continue foley - restarted flomax [12-27]; currently unable to transfer to urinal. should d/c foley for trial after pt. increases mobility to maximize chance for success. . . # Code: full, long discussions were held with patient. Patient is considering DNR/DNI status and discussion should be continued. . # FEN: soft diet with ensure, patient was given megace and mirtazapine for appetite stimulation with good effect Discharged to rehab for more intensive physical therapy [2-5] deconditioning after long hospital stay Medications on Admission: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed. 5. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed. 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 19. Megestrol 40 mg/mL Suspension Sig: Four Hundred (400) mg PO BID (2 times a day). 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 21. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 22. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 23. Insulin Pt receives NPH 12 units at breakfast, 9 units at bedtime, plus fingersticks qid and a sliding scale for coverage Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every eight (8) hours for as directed days: 125mg po tid for 3 days, then 125 mg po bid for 5 days, then 125mg po qday for 5 days then off. 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 6. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) [3-8] ML Miscellaneous Q6H (every 6 hours) as needed for break up secretions. 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10 ml PO BID (2 times a day) as needed for constipation. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 11. Insulin Lispro 100 unit/mL Solution Sig: as dir Subcutaneous ASDIR (AS DIRECTED): per sliding scale. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day): sub cutaneous injection. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 14. Megestrol 40 mg/mL Suspension Sig: Four Hundred (400) mg PO BID (2 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 17. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed. 18. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 19. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for diarrhea. 21. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 22. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 23. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 25. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 26. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold if SBP<90. 27. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 28. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 29. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous at bedtime: adjust per finger sticks. 30. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Country [Hospital 731] Rehabilitation & Nursing Center - [Location (un) 5028] Discharge Diagnosis: Primary diagnosis: C. diff. colitis Acute on chronic systolic CHF STEMI [Hospital 7792] [Hospital ] Hospital acquired pneumonia and sepsis Ischemic optic neuropathy s/p drug-eluting stent placement . Secondary diagnoses: PVD- s/p aorto [Hospital1 ] fem bypass DM, on insulin COPD Mesenteric ischemia s/p stenting of SMA Discharge Condition: good, tolerating pos, minimal diarrhea, satting well on RA, able to sit for 1-2 hours with assist Discharge Instructions: You have came into the hospital with a bowel infection. You have had a complicated course, developed a pneumonia and were in the ICU for several days for treatment of your infections. The pneumonia has been treated, but the bowel infection requires continued antibiotics. You are to continue the PO vancomycin on taper as directed with your medications. While in the Emergency department you suffered from a cardiac arrest and required a shock. You also have had multiple heart attacks, one of which required catheterization with balloon stenting of the blocked area. Please call your primary care doctor or return to the hospital if you have chest pain, shortness of breath, [Hospital1 ] >101.4, or any new symptoms which are concerning to you. Please continue with your medications as instructed. Please attend all follow up appointments below. Followup Instructions: Please follow up at the following appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD Phone:[Telephone/Fax (1) 920] Date/Time:[2179-2-10] 3:40 Please follow-up in Tuesday [Hospital1 18] Plastic Surgery Hand Clinic after discharge. You can make an appointment by calling: [Telephone/Fax (1) 4652] Additionally, please follow up with neuroophthamology. The number is [Telephone/Fax (1) 24169]. They have been notified and should call you to make an appointment, but please call to arrange appointment [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677]	[ "5849", "41071", "4280", "496", "25000", "41401", "42731", "412", "51881", "5990", "5070", "5180", "78552", "2851" ]
Admission Date: [2130-8-7] Discharge Date: [2130-8-7] Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 425] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: This was an 88 year-old woman with a history of atrial fibrillation, hypertension, and Alzheimer's disease who presented with chest pains for 1 day accompanied by nausea and diaphoresis. She first presented to [Hospital1 ] [Location (un) 620] and transferred for cardiac catheterization and evaluation for primary angioplasty. EKG showed occasional PVC, LVH with strain versus ST depressions in leads I and aVL. Past Medical History: Atrial fibrillation Hypertension Alzheimer's disease Hyperlipidemia Gastroesophageal reflux disease Moderate-severe aortic stenosis Aortic regurgitation Choledocholithiasis Social History: Unable to obtain due to severe acute illness. Family History: Unable to obtain due to severe acute illness. Pertinent Results: [2130-8-7] 10:30AM BLOOD Glucose-103 UreaN-13 Creat-1.2* Na-138 K-4.3 Cl-104 HCO3-20* AnGap-18 Brief Hospital Course: Cardiac catheterization was performed for evaluation of chest pains and an abnormal ECG. Coronary angiography of her right dominant system demonstrated left main and 3 vessel coronary artery disease. The LMCA had a 70% ostial stenosis. The LAD had a 60% stenosis at D2. The LCx had a 50% mid-segment stenosis. The RCA had a long 95% stenosis at the mid-vessel with TIMI 2 flow. A 0.014" wire was placed across the RCA stenosis. After predilation, flow became slower and ST elevation occurred. A 3.5x28mm Vision BM stent was deployed and severe flow reduction followed. A second stent was deployed just distal to the first stent, but flow did not improve. The patient became progressively hypotensive and bradycardic which was treated with temporary ventricular pacing, atropine, and IV fluids. She suffered a cardiac arrest and was rapidly intubated. CPR was performed with excellent chest compressions. Dopamine, levophed, and epinephrine were given and an IABP was placed in the LFA. She suffered multiple VF arrests that were treated with DC cardioversion, amiodarone, magnesium, and lidocaine. After multiple defibrillations, a stable rhythm could not be achieved, despite the fact that the RCA was widely patent with good flow. She was pronounced dead at 11:46 AM. These findings and events were discussed extensively with 4 family members including the patient's daughters (next of [Doctor First Name ]). The case was presented to the Medical Examiner. Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Multivessel coronary artery disease Alzheimer's disease Hypertension Hyperlipidemia Discharge Condition: Expired	[ "42731", "41401", "4019" ]
Admission Date: [2169-10-17] Discharge Date: [2169-10-29] Date of Birth: [2107-12-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5129] Chief Complaint: Back pain s/p fall Major Surgical or Invasive Procedure: T7-L1 posterior thoracic fusion History of Present Illness: Per admission note: 61M s/p mech fall down 10 stairs with back pain. CT spine at OSH showed vertical shear T10 with likely ankylosing spondylosis. Patient emergently transferred to [Hospital1 18] for surgical management. Pt denies new neuro deficits. Of note, he does c/o chronic left lower leg/ankle swelling and numbness ever since have an infected ulcer debrided by Dr. [Last Name (STitle) 25027] (podiatry). He also intermittenly has difficulty walking up stairs on his left leg. He is surprisingly a fairly poor historian. No changes in urinary/fecal incontinence. PMH: HTN, hypothyroidism, DMII, psoriasis, left foot ulcer (treated by Dr. [Last Name (STitle) 25027] last in [8-3]), right achilles rupture (nonoperative), ?ankylosing spondylitis, blind left eye Meds: allopurinol 100', glyburide 5'', levothyroxine 25', atenolol 100' All: NKDA Past Medical History: HTN, Psoriasis,?DM2 PSH: L knee sx ([2137]), Shoulder sx ([2129]), eye sx ([2129]), L arm sx ([2161]) Social History: Pt denies smoking and Etoh. He is an an attorney. On further questioning later in his hospital stay, he reports drinking 1 quart (32 oz) vodka daily. He denies smoking or other drug use. Family History: Diabetes (paternal), CAD (paternal) Physical Exam: Per admission and [Female First Name (un) ] notes: Gen: NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, no exudates or ulceration. Neck: Supple, JVP not elevated. CV: RRR, normal S1, S2. No m/r/g. Chest: Resp were unlabored, no accessory muscle use. CTAB, no rales, wheezes or rhonchi. Abd: Obese, Soft, NTND. No HSM or tenderness. Ext: No c/c/edema. Psoriatic plaques bl LE Skin: No stasis dermatitis, ulcers, scars. Neuro exam intact/stable from baseline Pertinent Results: [2169-10-17] 08:55PM TYPE-ART O2-60 PO2-195* PCO2-40 PH-7.39 TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [2169-10-17] 08:55PM GLUCOSE-153* LACTATE-1.3 NA+-133* K+-3.5 CL--100 [2169-10-17] 08:55PM HGB-10.9* calcHCT-33 [2169-10-17] 08:55PM freeCa-1.08* [2169-10-17] 06:59PM O2-60 PO2-177* PCO2-41 PH-7.36 TOTAL CO2-24 BASE XS--1 INTUBATED-INTUBATED VENT-CONTROLLED [2169-10-17] 06:59PM GLUCOSE-163* LACTATE-1.4 NA+-134* K+-3.2* [2169-10-17] 06:59PM HGB-12.2* calcHCT-37 [2169-10-17] 04:45PM PT-13.3 PTT-23.8 INR(PT)-1.1 [2169-10-17] 04:45PM PT-13.3 PTT-23.8 INR(PT)-1.1 [2169-10-17] 02:30AM GLUCOSE-103 UREA N-10 CREAT-0.7 SODIUM-135 POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-12 [2169-10-17] 02:30AM estGFR-Using this [2169-10-17] 02:30AM URINE HOURS-RANDOM [2169-10-17] 02:30AM URINE HOURS-RANDOM [2169-10-17] 02:30AM URINE GR HOLD-HOLD [2169-10-17] 02:30AM WBC-7.5 RBC-3.75* HGB-12.1* HCT-33.9* MCV-91# MCH-32.3# MCHC-35.6 RDW-15.6* [2169-10-17] 02:30AM NEUTS-79.8* LYMPHS-16.3* MONOS-2.3 EOS-1.3 BASOS-0.3 [2169-10-17] 02:30AM PLT COUNT-210 [2169-10-19] 02:29AM BLOOD WBC-8.0 RBC-2.78* Hgb-9.1* Hct-24.9* MCV-90 MCH-32.6* MCHC-36.4* RDW-15.9* Plt Ct-190 [2169-10-23] 04:55AM BLOOD WBC-6.3 RBC-2.52* Hgb-8.0* Hct-22.7* MCV-90 MCH-31.8 MCHC-35.3* RDW-15.8* Plt Ct-258 [2169-10-23] 09:10PM BLOOD Hct-29.7# [2169-10-26] 04:50AM BLOOD WBC-9.1 RBC-3.14 Hgb-9.8* Hct-27.8* MCV-88 MCH-31.3 MCHC-35.5* RDW-16.0* Plt Ct-187 [2169-10-20] 04:45AM BLOOD Glucose-144* UreaN-10 Creat-0.6 Na-132* K-3.5 Cl-98 HCO3-23 AnGap-15 [2169-10-25] 05:20AM BLOOD Glucose-114* UreaN-10 Creat-0.8 Na-133 K-4.1 Cl-101 HCO3-21* AnGap-15 [2169-10-26] 04:50AM BLOOD Glucose-120* UreaN-22* Creat-1.2 Na-130* K-4.0 Cl-98 HCO3-23 AnGap-13 [2169-10-23] 09:30AM BLOOD ALT-33 AST-34 CK(CPK)-171 AlkPhos-81 TotBili-0.8 [2169-10-23] 01:00PM BLOOD CK(CPK)-178* [2169-10-23] 09:30AM BLOOD CK-MB-5 [2169-10-23] 01:00PM BLOOD CK-MB-6 [2169-10-23] 09:30AM BLOOD Albumin-2.6* Calcium-7.9* Phos-3.3 Mg-1.6 [2169-10-23] 01:00PM BLOOD calTIBC-186* VitB12-643 Folate-11.6 Ferritn-634* TRF-143* [2169-10-23] 01:00PM BLOOD TSH-3.5 [2169-10-21] 07:45AM BLOOD TSH-6.3* [2169-10-17] 06:59PM BLOOD FiO2-60 pO2-177* pCO2-41 pH-7.36 calTCO2-24 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [2169-10-17] 08:55PM BLOOD Type-ART FiO2-60 pO2-195* pCO2-40 pH-7.39 calTCO2-25 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2169-10-18] 01:15AM BLOOD Type-ART pO2-186* pCO2-37 pH-7.40 calTCO2-24 Base XS-0 Reports: Cardiology Report ECG Study Date of [2169-10-17] 11:52:16 AM Sinus rhythm. Left atrial abnormality. Delayed precordial R wave transition. Compared to the previous tracing of [2168-8-3] no diagnostic interim change. Read by: [Last Name (LF) 578],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 579] Intervals Axes Rate PR QRS QT/QTc P QRS T 81 [Telephone/Fax (3) 63156]/438 27 0 28 CT Spine [2169-10-17]: IMPRESSION: 1. Type 3 dens fracture, non-displaced and without canal compromise. 2. Fracture of anterior osteophytes of C4, age indeterminate. 3. Some degree of prevertebral soft tissue swelling. MRI of the cervical spine is recommended for further evaluation. Plain films Orbits [2169-10-17]: IMPRESSION: No radiopaque metallic foreign body within the orbital structures. MR [Name13 (STitle) 1093] [2169-10-17] TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the C-spine and T-spine and L-spine was attempted. However, this study is significantly suboptimal, due to patient motion and lack of appropriate coverage of the area of interest. FINDINGS: The images are not interpretable, to give any useful information. IMPRESSION: Uninterpretable study due to pt. motion. Repeat study TO be considered, with appropriate precautions like sedation, for further assessment of any ligamentous injury and injury to the cord. T-Spine film: [2169-10-17]: HISTORY: Spinal fusion. Three cooperative AP and lateral views of the thoracolumbar spine. There is a comminuted distracted fracture of T10 involving the anterior and superior portions of this body. There is a spinal fusion with calcified anterior spinal ligaments both anterior and posterior to the fractured level with this fracture, presumably involving posterior elements in this patient with ankylosing spondylitis. Final films show posterior fusion of T8 through T12 with corresponding pedicle screws, laminectomies, and vertical metallic rods. CXR [2169-10-18]: IMPRESSION: AP chest compared to [2168-8-3]. ET tube tip in standard placement approximately 4 cm from carina. Lung volumes lower in volume today than previously, but lungs are clear. No pleural abnormality. Healed right rib fractures noted and spinal stabilization device in place. MRI C-Spine [2169-10-19]: IMPRESSION: 1. No abnormal signal is seen in the C2 vertebra or odontoid process to indicate marrow edema. No vertebral malalignment is seen at this level. The fracture cleft visualized on the CT is not apparent on the MRI, which could be secondary to lack of marrow edema. 2. Abnormal signal at the anterior margins of C4 and C5 vertebral bodies and increased signal in the anterior portion of the disc with prevertebral soft tissue swelling extending from this region superiorly indicative of extension injury with injury to the anterior portion of the C4-5 disc and injury to the anterior longitudinal ligament. The posterior longitudinal ligament and the ligamentum flavum are intact. 3. No evidence of spinal cord compression or intrinsic spinal cord signal abnormalities. 4. Mild multilevel degenerative changes. 5. Somewhat limited examination secondary to motion. CXR [2169-10-23]: FINDINGS: In comparison with study of [10-18], the endotracheal tube has been removed. There is little change in the appearance of the heart and lungs. Specifically, no evidence of acute pneumonia. There may be some increased prominence of interstitial markings, raising the possibility of overhydration or vascular congestion. Healed right rib fractures and spinal stabilization device remain in place. Cardiology Report ECG Study Date of [2169-10-24] 9:06:14 AM Sinus rhythm. Baseline artifact. Borderline low limb lead voltage. Compared to the previous tracing of [2169-10-23] no diagnostic interim change. TRACING #2 Read by: [Last Name (LF) 578],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 579] Intervals Axes Rate PR QRS QT/QTc P QRS T 96 186 104 382/445 74 -10 82 Brief Hospital Course: A/P: 61 yo man w/ h/o alcohol abuse, hypertension, diabetes now postop day 6 s/p T10 fracture repair with agitation, hypertension, tachycardia attributed to benzodiazepene overdose. #) Type III Odontoid fracture and vertical shear T10 s/p fall: After imaging and evaluation in the ED, the patient was admitted to the SICU and taken to the operating room and had a T7-L1 decompression/fusion on [10-17]. After being stable in the SICU, he was transferred to the floor, and he had an MRI of his cervical spine. He continued to wear the cervical collar at all times, and his wound was noted to be healing well per orthopedics. He is to wear the cervical collar at all times, and to follow up with orthopedics at 2 weeks post discharge. Her remained neurologically intact perioperatively and post-operatively. There was no clinical evidnece of myelopathy. #) Altered Mental Status/Delerium: Postoperatively, the patient was delerious, and received ativan on a CIWA scale for presumed alcohol withdrawl. He was seen by psychiatry on [10-22], and was thought to instead of exhibiting evidence of benzo overdose, and recommended a taper. He has also been hypertensive to the 160s-180s and tachy to the 100s, receivng toprol and prn hydralazine. His benzodiazepenes were tapered, from 2 mg lorazepam q6hrs on [10-23] to 1 mg lorazepam q 4 hours on [10-24], with his last dose 10/29. During this taper, he was also intially receiving 5 mg Haldol IV BID with 2 mg Haldol IV TID prn agitation, though the standing haldol was discontinued on [10-25]. EKG was checked daily for QT prolongation. His electrolytes were monitored and repleted as necessary. He was continued on telemetry. Repeat TSH was noted to be in the normal range. His mental status improved daily, so a head CT was not performed, though it was considered should his symptoms. During the taper, he was intermittently delirious and confused, and intially required a full time sitter and occasionally 2-point restraints to keep from pulling his IV and collar. These symptoms became less frequent and severe through [10-23] to [10-25], when his wife reported that he was nearing his baseline (85%). He was alert and oriented x 3, and had memory of the circumstances surrounding his fall, though he still had difficulty discussing the reasons for his prolonged stay, and his delirium. After he became more lucid, he was able to discuss his alcohol use and abuse in more detail. He related that he drank much more than he initally admitted, and when asked to quantify, reported that he drank a quart of vodka daily. He recognized this was a problem, and said at various points that he would never drink again. The risks of drinking were discussed with both the patient and his wife, and he was seen by social work during the stay to discuss resources to help with alcohol abuse. . #) Hypertension: During his stay in the ICU, his blood pressure was controlled with IV metoprolol. As noted above, he had very labile blood pressures during various portions of his stay, and occasionally required IV hydralazine. Once he was on the regular floor, he was treated with Metoprolol xl 50 mg daily. During episodes of hypertension, he also occasionally received IV hydralazine. However, as his delirium and withdrawl improved, he became less hypertensive. . #) Sinus Tachycardia: He was monitored on telemetry during his stay, and did receive IV metoprolol as above. As he became able to take PO, he was transitioned to Metoprolol xl 50 mg daily. . #) Anemia: He was consistently anemic while in the hospital. Labs, including iron studies were sent, which suggested, postoperatively, his hematocrit reached a nadir of 22.7 on [10-23], at which point he received 2 units PRBCs with an increase in hematocrit to 29.7. His hematocrit remained stable throughout the remainder of his hospital stay. . #) Diabetes Mellitus: His blood sugars were monitored closely, and he was treated with sliding scale insulin while an inpatient. His home glyburide was held, and restarted at discharge. . #) Hypothroidism: He was continued on levothyroxine daily. The initial TSH was elevated, though on recheck, it was within the normal range. . [Month/Year (2) ] on Admission: Per Medicine Consult: allopurinol 100' glyburide 5'' levothyroxine 25' atenolol 100' Discharge [Month/Year (2) ]: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:20 Tablet(s) Refills:0 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 8. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Mom[Name (NI) 6474] 0.1 % Cream Sig: One (1) application Topical once a day: to affected areas. 10. Walker One adult walker. No refills. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Primary: Type III Odontoid fracture T10 fracture Delirium Alcohol Abuse . Secondary: Diabetes Mellitus Hypertension Discharge Condition: stable, tolerating po, pain controlled on oral regimen. Ambulating. Discharge Instructions: You were admitted to the hospital after a fall down the stairs. You broke one of the bones in your neck and one in your back. The broken bone in your neck is being treated with a cervical collar that needs to stay on at all times. Your back fracture was repaired operatively. . During your hospitalization, you were started on medicines to prevent withdrawal from alcohol, as well as narcotic pain [Hospital1 4982] and anti-psychotic [Hospital1 4982]. You became agitated and delirious, and were seen by psychiatry, who recommended a prolonged taper of the lorazepam. You were transferred from the orthopedics service to the medicine service, where your medical problems were managed, and you were weaned off the lorazepam. By the time of discharge, you were only requiring pain [Hospital1 4982] for the pain in your back. . Change the dressing on the wound once daily if there is drainage, otherwise you can leave it open to the air. Activity as tolerated. You will need to follow up with Orthopedics to have your staples removed in 4 days (2 weeks after the surgery). . The following changes were made to your [Hospital1 4982]: Added oxycodone for pain control Please continue to take all other [Hospital1 4982] as prescribed. . Talk with your doctor [First Name (Titles) ] [Last Name (Titles) 4982] to help you with your goal of alcohol abstinence. . Please call your doctor or return to the ED for the following: - fever/chills - drainage, redness, or pus around the incision site - numbness, weakness, or tingling - new or uncontrolled pain - confusion or changes in mental status - any other new or concerning symptoms Followup Instructions: Follow up with Dr. [Last Name (STitle) 1007] of orthopedics in 4 days to have your staples removed. Please call [Telephone/Fax (1) 1228] to schedule an appointment. . Please follow up with your PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. Call [Telephone/Fax (1) 3183] schedule an appointment in the next 1-2 weeks. You will need to discuss your alcohol use and your other medical issues. You may benefit from a support group such as Alcoholic Anonymous.	[ "25000", "2449" ]
Admission Date: [2154-5-15] Discharge Date: [2154-6-18] Date of Birth: [2076-1-26] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: Unable to elicit from patient due to unresponsiveness. Major Surgical or Invasive Procedure: Left occipitoparietal craniotomy and evacuation of hematoma ([2154-5-20]). PEG placement ([2154-5-31]). History of Present Illness: Code stroke called at 4pm for R side weakness . History is per EMS, chart and friend/witness/caretaker([Name (NI) 95638] [Name (NI) ], [Telephone/Fax (1) 95639]) . HPI: 78-yo female with no known seizure disorder who presents here after a seizure. She has had a gradual decline over the past month, needing a caretaker to help her get to medical appointments, pay her taxes and take care of finances. She has remained able to feed and dress herself and walk independently, but slowly. She has had visual hallucinations over this time period, speaking to people she had seen on TV. Her speech has been normal but rambling and repetitive. . Per her friend/caretaker, Ms. [Last Name (Titles) ], the patient had a doctor's appointment the day of admission at 3pm and she contact[Name (NI) ] Ms. [Known lastname ] to remind her to get ready at 11am. Her friend came around 2:30pm to take the patient to the appointment (PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1726], [Hospital1 ]). The patient had difficulty opening the door but finally was able to do so. Her friend found her standing in the [Doctor Last Name ], saying that she could not see and wanting to find her glasses. But she did not walk to do so. Per the friend, she "looked like she was blind". . She told her to sit down but again the patient did not move. She brought a chair behind her and sat her down in it. She then went to call the doctor's office. While she was speaking to the RN, the patient straightened her right arm, as if she was "reaching for something" and she was leaning to her left. Her eyes then rolled back and she had bilateral convulsions and lost consciousness. 911 was called. On EMS arrival, they found her unresponsive to voice with right hemiparesis and she was brought here. En route, her right arm/leg weakness resolved, leaving only right facial asymmetry. . On our arrival, the patient was awake and alert. She would occasionally vocalize, for example, saying "wait a minute! wait a minute! what are you doing?" when moved to the CT table. She would not follow commands. At times, she uttered non-sensical speech. ROS: On review of systems, the pt's caregiver denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: PMH: Dementia HTN Hyperlipidemia Hypothyroid, following thyroidectomy for nodule (benign path) Arthritis Breast cancer ([2123]) PSH: Left Mastectomy Social History: Lives by herself in [Location (un) 2268] on [Location (un) ]. Widow for ~40years and no children of her own. Did raise a daughter. She does not eat properly or cooks. She has meals on wheels and her friends help her. At baseline, she can eat and dress herself, walks slowly. Over the last month, she's had a deterioration in caring for herself. Also visual hallucinations and short-term memory loss. Patient does not use EtOH or smoke. [Last Name (LF) ], [Name (NI) ] [Name (NI) 95640] of [Last Name (LF) 9012], [First Name3 (LF) 3908], has applied for guardianship. Family History: N/A Physical Exam: PE VS 100.0 (rectal) 180/81 72 12 100% Gen Awake, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, systolic ejection murmur Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Awake, alert. Does not respond to questions consistently. Preference towards left side of space. Speech fluent, but often non-sensical with neologisms. Normal prosody. Unable to follow commands. No apraxia. Neglects the right side of space. No dysarthria. CN CN I: not tested CN II: Visual fields were full to confrontation, no extinction. Pupils 3->2 b/l. Fundi clear CN III, IV, VI: EOMI no nystagmus CN V: intact to LT throughout CN VII: right NLF flattening CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [Doctor First Name 81]: shrug [5-27] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. Moves all limbs purposefully antigravity Sensory intact to noxious stimuli Reflexes Br [Hospital1 ] Tri Pat Ach Toes L 2 2 2 1 1 up R 2 2 2 1 1 up Coordination unable to assess Gait deferred CODE STROKE SCALE: Neurologic (NIHSS): 19 1a. LOC: alert, responsive (0) 1b. LOC questions: 2 1c. LOC commands: 2 2. Best gaze: No gaze palsy (0) 3. Visual: 2 4. Facial Palsy: 1 5a. Left arm: 2 5b. Right arm: 2 6a. Left leg: 2 6b. Right leg: 2 7. Limb ataxia: x 8. Sensory: no sensory loss bilaterally (0) 9. Language: 2 10. Dysarthria: None (0) 11. Extinction/inattention: 2 Pertinent Results: CT [2154-5-15] Left occipital intraparenchymal hemorrhage is little changed in appearance, currently measuring 4.8 x 2.5 cm in greatest axial dimension. As before, hemorrhage is in contiguity with the left subdural space, and acute left subdural hematoma is again seen, unchanged. Local edema and mass effect on the occipital [Doctor Last Name 534] of the left lateral ventricle is similar, and there is mild, 4 mm rightward subfalcine herniation, similar to previous exam. There is no intraventricular blood. Basal cisterns are not effaced. Periventricular white matter hypodensity, most prominent in the left frontal lobe most likely represents chronic small vessel ischemic disease. [Doctor First Name ] ganglia calcifications are unchanged. IMPRESSION: Unchanged appearance of left occipital intraparenchymal hemorrhage, with left subdural hematoma, and local mass effect on the occipital [Doctor Last Name 534] of the left lateral ventricle. Unchanged mild rightward subfalcine herniation. EEG [5-16] This is an abnormal portable EEG due to the slow and disorganized background admixed with bursts of generalized mixed frequency slowing consistent with a mild encephalopathy suggesting dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, and infection are among the common causes of encephalopathy but there are others. There were no areas of prominent focal slowing although encephalopathic patterns can sometimes obscure focal findings. There were no clearly epileptiform features. PATH clot [5-20]: Clinical: Intraparenchymal bleed, left. Gross: The specimen is received fresh labeled with the patient's name "[Known lastname ], [Known firstname 55617]" with the medical record number and "blood clot". It consists of multiple fragments of blood clot measuring 1.8 x 1.5 x 0.7 cm in aggregate. The specimen is entirely submitted in A-B. CT [5-22] No significant interval change compared to one day prior. The patient is status post left parietal craniotomy. Again seen is a moderate sized left parietooccipital hemorrhage with extensive surrounding edema and additional foci of blood anteriorly. There is a stable amount of pneumocephalus related to the craniotomy. Intraventricular extension of blood and blood clots within the lateral ventricles are stable. Ventricular size is stable. When accounting for head position and slice selection, there is no appreciable change in mass effect, rightward midline shift of the midline structures and unchanged asymmetry of the perimesencephalic cisterns suggesting early uncal herniation. Extra-axial blood in the left frontoparietal subdural location is unchanged and likely related to craniotomy. Subgaleal hematoma and soft tissue swelling overlying craniotomy defect are stable. IMPRESSION: No interval change in the left parietooccipital hematoma with extensive surrounding edema, interventricular extension, and mass effect. CT [5-25] Overall, exam is unchanged compared to the CT head of four days prior. The patient is status post left parietal craniotomy. A moderate-sized left parietal occipital hemorrhage with extensive surrounding vasogenic edema is unchanged. Small amount of extra-axial hematoma along the left convexity along with a small amount of pneumocephalus related to recent craniotomy is unchanged. There has been interval evolution of blood clots within the lateral ventricles, which is now layering within the posterior horns. There is mass effect upon the left lateral ventricle and 7-mm shift of normally midline structures towards the right, which is unchanged. Asymmetry of the perimesencephalic cisterns is unchanged, suggesting early uncal herniation. No new focus of hemorrhage is seen. Subgaleal hematoma and soft tissue swelling overlying craniotomy site are stable. The visualized paranasal sinuses and the mastoid air cells remain well aerated. IMPRESSION: Unchanged exam compared to four days prior with left parietooccipital intraparenchymal hematoma with extensive surrounding vasogenic edema, intraventricular hemorrhage, and rightward shift of normally midline structures. LIVER/GALLBLADDER ULTRASOUND [5-31]: The liver is normal in echotexture with no focal lesions identified. There is appropriate forward portal venous flow. The gallbladder wall is thickened to 5 mm, however, nondistended. There is no pericholecystic fluid or evidence of gallstones. The common duct measures 6 mm, within normal limits given patient's age. The limited views of the pancreatic head are unremarkable. The body and tail are obscured by bowel gas. CT neck [6-6] Study is very limited due to patient motion and patient rotation. No definite prevertebral soft tissue abnormality is identified. There is no obvious evidence of fracture or malalignment. Multilevel degenerative changes are seen, with most severe at C3-4, C4-5, C5-6, with anterior and posterior osteophytes and Schmorl's nodes. However, no significant canal narrowing or neural foraminal stenosis is identified. There is straightening of the normal cervical lordosis. Visualized lung apices reveal left apical scarring or atelectasis. IMPRESSION: Limited study as noted above. 1. No evidence of acute injury. 2. Multilevel degenerative changes, most severe at C3-4. However, there is no significant central canal stenosis or neural foraminal stenosis. Of note, CT is not as sensitive as MR for evaluation of the thecal contents. CXR [6-10]: In the interim, the left lower lobe opacity has resolved. The lungs are clear. A right PICC is again visualized but tip is obscured by cardiomediastinal structures. There is no pleural effusion. The heart size is normal. IMPRESSION: Complete resolution of lower lobe atelectasis. Clear lungs. Brief Hospital Course: 78 F h/o mild dementia, HTN, admitted with two GTC seizures, R sided visual fieldcut and R sided hemiparesis on [5-16]. CT brain showed a large left parietal occipital hemorrhage with a subdural hematoma. She was admitted to the floor but neurologically deteriorated slowly (hemiparesis, level of arousal, communication) - and she had an urgent craniotomy with partial evacuation of the hematoma (by then 6 x 3 x 4.5 cm, increased edema, midline shift, breakhrough in ventricles) on [5-20]/8. She was transferred to the ICU for further care. PMH Dementia (lives at home with help, ...) HTN Hyperlipidemia Hypothyroid Arthritis Breast cancer [2123] s/p L mastectomy MEDS ON ADMISSION HCTZ, zocor MEDS ON ICU TRANSFER Metoprolol Tartrate 75 mg PO/NG [Hospital1 ] Metoprolol Tartrate 10 mg IV Q4H:PRN Amlodipine 5 mg PO DAILY Captopril 25 mg PO TID Hydrochlorothiazide 25 mg PO DAILY HydrALAzine 10 mg IV Q6H:PRN SBP>160 Insulin SC Sliding Scale & Fixed Dose Heparin 5000 UNIT SC BID Famotidine 20 mg PO Q12H Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN LeVETiracetam 500 mg PO BID Levothyroxine Sodium 88 mcg NG DAILY Bisacodyl 10 mg PR [Hospital1 ]:PRN Docusate Sodium (Liquid) 100 mg NG [Hospital1 ] Senna 1 TAB NG [Hospital1 ]:PRN Acetaminophen 325-650 mg PO/NG Q6H:PRN Lorazepam 0.5-2 mg IV PRN SEIZURE>5MIN OR >2/HR ICU COURSE: Neuro - Gradual and limited recovery of consicousness, remained only minimally interactive with grimacing to noxious stimulation, verbalizing only "auw" or "no" (non-appropriate). * Developed significant L sided weakness with residual tone, serial CTs did not reveal a solid explanation, although a new subcortical [Male First Name (un) 4746] stroke was found on [5-25]/8. Critical illness neuro-/myopathy was considered but rejected. * Dilantin was tapered off and replaced by Keppra. Cardiovasc - No ECHO done. EKG on admission SR, [Name Prefix (Prefixes) ] [Last Name (Prefixes) 6192] NOS, LVH. Was on Nicardipine drip on and off, started on multiple oral antihypertensives. CVPs 6-11. Resp - Extubated on [5-22] in PM, slow wean of oxygen - frequent suctioning, had prolonged stridor. Level of arousal and hypotonic orofacial musculature raised possibility for tracheostomy, but rejected after 3 more days of observation. Last bloodgas prior to extubation(!) 152* 40 7.52* 34* 9. last CXR on [5-26]/8: Streaky density in the right upper lobe consistent with subsegmental atelectasis, but consolidation cannot be excluded. FEN - Went through SIADH, lowest NA 126 on [5-20], on fluid restriction and salt tabs, d/c'd by 5/3/8. Tubefed throughout, now replete w/fiber 3/4 strength at 70 cc/hr. ID - Received Cefazolin 2 grams IV q8 up to 2 days post-surgery. White-count persistently high up to 26.4 on [5-23], at that time also getting low dose of dexamethasone (for edema). Multiple cultures blood, urine all negative other than [5-20] UCx GPR ~4000/mL (Corynebacterium). One day on Cipro for this, then off. White count came down, now back up (see below). C Diff negative on [5-24]. SpCx [5-26] 3+ GNR 2+GPC, sparse oropharyngeal flora but mixed culture (>3 species) with amongst others Citrobacter. Recommended repeat. [5-27] SpCx poor sample. VRE and MRSA pending. ENDO - Has been on RISS with fixed dose of 10 NPH qAM and qPM. Levothyroxine suppletion 75 ug/d, last TSH level [5-21] was 12 (ULN 4). FSBG in range of 140's to max 240's, mean <180. HEME - Hct trending down slowly ([5-20] 40.9), now hovering around 25 - 26. 1 unit transfused on [5-27]/8. DDx anemia of chronic illness, multiple blooddraws, GI leakage (guiac(+)). Elevate white count, infectious? See below. PPx/CODE/DISPO - DNR on [5-25]/8. Boots, Heparin 5000 SC TID, HOB > 30 degree, PT/OT for passive movement. Dispo acute rehab eventually. EXAM on Tx to FLOOR Vitals 100.2 (ax), HR 87, RR 21, BP 146/42 Torticollis to L. Cardiac S1S2 Pulm CTA all fields anteriorly. Wet respirations with non-cleared secretions Abdomen supple, NT/ND, BS+ Skin warm and well perfused, onychomycosis. Left arm edemateus. NEUROLOGICAL EXAM on Tx to FLOOR Alert and says name, dysarthric, wet speech. Palalalia and echolalia, but able to greet examiner with long-whined and melodious voice. Does not follow commands. Gaze deviation to L, does not attend to R. Head to L as well (torticollis). Limited atttention span, does not fix or follow. PERRL, gaze pref as above, facial droop R. Flaccid R hemiparesis, does not withdraw to noxious, L hyptonic hemiparesis, no withdraw to pain but per report brings arm out to fence off while sunctioned. Legs very weak withdraw bilaterally. Brief FLOOR COURSE: Neuro - her exam continued to improve. She would continuously alert to voice, but did not blink to threat bilaterally. She answers questions semi-appropirately, with perseveration and at times not at all. Her L arm would at times be moving purposefully but she never withdrew to noxious stimulation. When held up, it would fall back to the bed. Her R hemibody remained plegic. A movement disorder consult was done to assess for botox for the torticollis, but given the hypertrophy of the SCM muscle it was thought to be chronic, and no intervention was made. A neck CT was done to rule out luxation and cricital cervical canal stenosis but it was negative (see results). Note that she is still on a small dose of Keppra 500 mg [Hospital1 ] and this can probably be discontinued. GI - She had a refractory diarrhea on the floor, and C diff was repeatedly negative. Her whitecount was elevated as well, persistently. When she started complaining about R upper quadrant pain (by exam) an U/S was done, revealing a thickened wall of the gallbladder, suggesting acalculous cholecystitis. She was started on a two-week course of ceftriaxone and metronidazole, with good effect. The diarrhea also resolved when the bulk of her G-tube flushes was given per G-tube, not through the J-lumen. Cardiovasc - Her bloodpressure medications were reduced and some eventually slowly tapered off (metoprolol, amlodipine). On the day of discharge, her lisinopril was held but she had no signs of illness, sepsis, pain. Endocrine - Small adjustment was made in her levothyroxine (upward by 12.5 mcg). Access - She has a PICC line for easier access but this remains a potential source of infection. Please D/C it ASAP, i.e. when she no longer needs any blooddraws. At the nurses advice, for now it has been left in place. Medications on Admission: Hydrochlorothiazide Zocor Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed. 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 unit Injection [Hospital1 ] (2 times a day). 8. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous once a day: 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. . Discharge Disposition: Extended Care Facility: [Location (un) 582] of [Location (un) 583] Discharge Diagnosis: 1 Left parietal-occpital intracranial hemorrhage, likely due to amyloid angiopathy. 2 Dementia, Alzheimer type Discharge Condition: Stable - exam as outlined elsewhere in detail under [Hospital ] hospital course' Discharge Instructions: You have had a left parieto-occipital stroke, and this bloodclot was surgically removed - you have a residual left hemiparesis though. Please take all your medications excactly as directed and please attend all your follow-up appointments. Please report to the nearest ER or call 911 or your PCP immediately when you experience recurrence of weakness, numbness, tingling, problems with speech, vision, language, walking, thinking, headache, or difficulties arousing, or any other signs or symptoms of concern Followup Instructions: The Stroke Service of the [Hospital1 18] can be contact[Name (NI) ] at time of discharge to rehab for a follow up appointment [Telephone/Fax (1) 7667]. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2154-6-18]	[ "486", "4019", "2449", "2859" ]
Admission Date: [2113-10-11] Discharge Date: [2113-10-19] Date of Birth: [2030-4-11] Sex: F Service: CARDIOTHORACIC Allergies: Bactrim Attending:[First Name3 (LF) 5790] Chief Complaint: asymptomatic RLL mass Major Surgical or Invasive Procedure: [2113-10-11] Redo right thoracotomy, lysis of adhesions, right lower lobectomy, mediastinal lymph node dissection, bronchoscopy with bronchoalveolar lavage, and pericardial fat pad buttress to the bronchial stump. [2113-10-13] Bronchoscopy [2113-10-16] Flexible bronchoscopy with therapeutic aspiration. History of Present Illness: Ms [Known lastname 37080] is an 83F with FDG avid RLL mass with positive bronchial washings for NSCLC. Although the biopsies were negative, the positive PET scan and positive washings make this lesion highly suspicious for lung cancer. She currently denies cough, SOB, DOE, sweats, chest pain, wt loss, HA or bony pain. Past Medical History: PMH: syncope/TIA/left facial droop [2113-5-28] hypothyroidism cavernous angioma dx'd [2094] osteopenia thyroid cancer, s/p thyroidectomy [2094] RUL lung cancer, s/p RUL lobectomy [2094] BCC hyperlipidemia HTN PSH: RUL lobectomy [2094] Thyroidectomy [2094] Social History: Cigarettes: [x ] never [ ] ex-smoker [ ] current Pack-yrs:____ quit: ______ ETOH: [x] No [ ] Yes drinks/day: _____ Drugs: Exposure: [x] No [ ] Yes [ ] Radiation [ ] Asbestos [ ] Other: Occupation: Marital Status: [ ] Married [x] Single Lives: [x] Alone [ ] w/ family [ ] Other: Other pertinent social history: Travel history: NONE Family History: Mother - [Year (4 digits) 499] Ca Father Siblings - Sister with [Name2 (NI) 499] Ca, brother with lung Ca Offspring Other Physical Exam: BP: 168/81. Heart Rate: 74. Weight: 139.6. Height: 60.5. BMI: 26.8. Temperature: 96.8. Resp. Rate: 16. Pain Score: 0. O2 Saturation%: 97. Gen: NAD Neck: no [Doctor First Name ] Chest: clear ausc Cor: RRR no murmur Ext: no CCE Pertinent Results: [2113-10-13] 4:24 pm Mini-BAL R MAINSTEM. GRAM STAIN (Final [2113-10-13]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Preliminary): >100,000 ORGANISMS/ML. Commensal Respiratory Flora. GRAM NEGATIVE ROD(S). ~1000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. WORK-UP PER DR. [Last Name (STitle) 39463],[First Name3 (LF) 39464] PAGER [Numeric Identifier 39465] [2113-10-16]. Piperacillin/tazobactam sensitivity testing available on request. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ GRAM NEGATIVE ROD(S) \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2113-10-16] 7:25 pm BRONCHOALVEOLAR LAVAGE FINAL REPORT [2113-10-18] GRAM STAIN (Final [2113-10-16]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2113-10-18]): >100,000 ORGANISMS/ML. Commensal Respiratory Flora. [2113-10-16] 4:55 am URINE Source: Catheter. FINAL REPORT [2113-10-18] URINE CULTURE (Final [2113-10-18]): CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2113-10-11] 08:02PM WBC-21.1# RBC-3.88# HGB-11.4# HCT-33.8# MCV-87 MCH-29.4 MCHC-33.8 RDW-13.4 [2113-10-11] 08:02PM PLT COUNT-303 [2113-10-11] 03:33PM GLUCOSE-149* LACTATE-1.6 NA+-139 K+-3.5 CL--108 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2113-10-19] 06:45 20.1* 3.17* 9.2* 29.0* 91 28.9 31.6 14.2 481* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [2113-10-19] 06:45 77* 0 11* 9 2 1 0 0 0 [2113-10-18] CXR : In comparison with the study of [10-17], this upright view shows at least two air-fluid levels in the right hemithorax. Presumably, these are related to the recent surgery and at least one of these represents a loculated collection in or adjacent to the mediastinum. Extensive post-surgical changes are again seen in the right hemithorax. The left lung is clear and hyperexpanded with blunting of the costophrenic angle. Brief Hospital Course: Mrs. [Known lastname 37080] was admitted to the hospital and taken to the Operating Room where she underwent a redo right thoracotomy with right lower lobectomy. She tolerated the procedure well and returned to the PACU in stable condition. She had some sinus bradycardia intraop therefore had cardiac enzymes cycled post op. Her troponin were normal x 3 and she had no EKG changes. Following transfer to the Surgical floor her chest tubes remained in place until the drainage decreased and she was attempting to use her incentive spirometer. She desaturated on post op day #2 and was transferred to the ICU for more pulmonary toilet as her remaining right lung was collapsed. A bronchoscopy was done on [2113-10-13] to evaluate her airway and thick tenacious secretions were found in the bronchus intermedius and removed. She improved from a respiratory standpoint thereafter. She was seen by the Geriatric service as she had some confusion and dizziness prior to transfer. They felt that her neuro exam was that of MCI (mild cognitive impairment) as opposed to Alzheimer's as she had no functional impairment and was not dependent. The Aricept can cause orthostasis and would not be effective with MCI therefore was stopped. She gradually improved and had no more confusion or dizziness. Her chest xrays were followed daily and she underwent another bronchoscopy on [2113-10-16] and had secretions in both the right and left main stem which were aspirated. Her nebulizer treatments were increased and she remained afebrile. From an ID standpoint she had some dysuria after the Foley catheter was removed and was started on Cipro. Her culture grew >100K Citrobacter. She also had BAL's sent with each bronchoscopy and the antibiotic was changed to Levaquin for more gram positive coverage. Her WBC has been as high as 27K and as low as 15K post op, currently 20K without any bands in her differential. Her lungs are clearer and her wound is healing well. She has no evidence of phlebitis or any skin problems and the elevated WBC is unclear as she clinically looks well. She will complete a 7 day course of antibiotics which will end on [2113-10-23]. She's tolerating a regular diet and working with physical therapy so that she may return home. She was discharged to rehab on [2113-10-19] and will follow up in the Thoracic Clinic in 2 weeks or sooner if needed. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Alendronate Sodium 70 mg PO QFRI 2. Donepezil 5 mg PO HS 3. Enalapril Maleate 20 mg PO BID 4. Levothyroxine Sodium 175 mcg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY 6. NiCARdipine 20 mg PO DAILY Start: noon give at noon 7. NiCARdipine 40 mg PO BID 8. Pravastatin 80 mg PO DAILY 9. Calcium Carbonate 1000 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Alendronate Sodium 70 mg PO QFRI 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Pravastatin 80 mg PO DAILY 6. Acetaminophen 650 mg PO Q6H:PRN pain 7. Albuterol 0.083% Neb Soln [1-30] NEB IH Q6H:PRN wheeze 8. Docusate Sodium 100 mg PO BID 9. Guaifenesin ER 600 mg PO Q12H mucus plug 10. Heparin 5000 UNIT SC TID 11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze 12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 13. Levofloxacin 750 mg PO DAILY thru [2113-10-23] 14. Milk of Magnesia 30 mL PO HS:PRN constipation 15. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain 16. Senna 1 TAB PO BID 17. TraMADOL (Ultram) 25-50 mg PO Q6H:PRN pain 18. Calcium Carbonate 1000 mg PO DAILY 19. NiCARdipine 20 mg PO DAILY give at noon 20. NiCARdipine 40 mg PO BID Hold for SBP < 100 Discharge Disposition: Extended Care Facility: [Hospital 4470] HealthCare Center at [Location (un) 38] Discharge Diagnosis: Lung cancer Collapse of the right lung with mucus plugging Right lung atelectesis Urinary tract infection (Citrobacter) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital for lung surgery and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol 650 mg every 6 hours in between your narcotic. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk 4-5 times a day and gradually increase your activity as you can tolerate. Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2113-10-31] at 2:30 PM With: [Name6 (MD) 1532] [Name8 (MD) 1533], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please report 30 minutes prior to your appointment to the Radiology Department on the [Location (un) ] of the [Hospital Ward Name 23] Clinical Center for a chest xray Completed by:[2113-10-19]	[ "5990", "5180", "9971", "42789", "2724", "4019" ]
Admission Date: [2129-5-18] Discharge Date: [2129-5-23] Date of Birth: [2080-6-18] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2129-5-18] - Off Pump CABGx2 (Left internal mammary->Left anterior descending artery, Saphenous vein graft->Posterior descending artery) History of Present Illness: 48 year old man with known CAD s/p PTCA of LAD in [2119]. Recently he has developed chest pain and underwent a stress test which was abnormal. A Cardiac catheterization was performed which revealed three vessel disease. Given the severity of his disease, he is now admitted for surgical management. Past Medical History: CAD s/p PTCA [2119] HTN Hyperlipidemia ADHD GERD Bipolar disorder Hiatal hernia Social History: Museum worker at [Location (un) 3320] Plantation. Never smoked. 1 drink of alcohol weekly. Lives with wife. Family History: Strong for CAD. Mother with MI in her 50's. 2 brothers with [Name (NI) 5290] in 40's with one having CABG in early 50's. Other brother died of MI in his 50's. Physical Exam: 55 sb 164/87 (R) 156/83 (L) 70" 217lbs GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM. LUNGS: CTA bilaterally. HEART: RRR, No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, no varicosities, no peripheral edema NEURO: No focal deficits. Pertinent Results: [2129-5-18] ECHO Pre-CABG: No spontaneous echo contrast is seen in the left atrial appendage. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CABG: The procedure was done off-pump. The patient is in NSR, on low dose Phenylephrine. Preserved biventricular systolic fxn. 1+ MR remains. No AI. Aorta intact. Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2129-5-19] for surgical management of his coronary artery disease. He was taken to the operating room where he underwent off pump coronary artery bypass grafting to two vessels. Please see operative note for further details. Postoperatively he was taken to the cardiac surgical intensive care unit. Within 24 hours, he awoke neurologically intact and was extubated. Plavix, beta blockade, aspirin and a statin were resumed. Later on postoperative day one, he was transferred to the step down unit for further recovery. Mr. [Known lastname ] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Chest tubes remained in for several days due to small pneumothorax, which was then stable post pull. He was ready for discharge home on POD #5. Medications on Admission: Aspirin 81mg daily Lamictal 150mg twice daily Concerta mg daily Vytorin 10/40mg daily Discharge Medications: 1. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 2. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. CONCERTA 27 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for off pump for 3 months. Disp:30 Tablet(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [2-20] hours as needed. Disp:50 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:30 Tablet(s) Refills:0 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 6136] Home Care Services Discharge Diagnosis: CAD s/p Off pump CABGx2 Hyperlipidemia HTN ADHD GERD Bipolar disorder Hiatal hernia Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Plavix to be taken for 3 months. 8) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [First Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Follow-up with Dr. [Last Name (STitle) 26191] in [11-17] weeks. Follow-up with Dr. [First Name (STitle) 27598] in 2 weeks. [Telephone/Fax (1) 27599] Please cal all providers to schedule your appointment. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2129-5-23]	[ "41401", "4019", "2724", "53081" ]
Admission Date: [2138-10-6] Discharge Date: [2138-10-20] Date of Birth: [2074-5-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5552] Chief Complaint: Unable to tolerate PO Major Surgical or Invasive Procedure: None History of Present Illness: 64 M metastatic esophageal CA, AF. Initially presented to [Hospital6 12112] with 20 lb weight loss over 3 weeks, emesis, inability to tolerate POs. In ED, noted to be in AF with RVR in 170-180s, SBP 90s. Received dig bolus, and started on dilt gtt. Approx 30-45 min later, spontaneously converted to SR in 80s. Transferred to [Hospital1 18] ED for further management. . In [Hospital1 18] ED, ECG confirmed SR. However, BPs noted to be mid-upper 80s systolic. Received 2L NS bolus with improvement in BP to low 90s. Started on Levophed gtt. Given vancomycin, cefepime, solumedrol 125 IV. Past Medical History: 1. Esophageal cancer: presented wtih severe indigestion which progressed to difficulty swallowing. Barium swallow [5-21] demonstrated esophageal lesion--8 cm infiltrating carcionma of distal esophagus. Biopsy demonstrated atpyical glandular proliferation. He started neoadjuvant 5FU and cisplatin and XRT from [2137-5-23]. [8-21] demonstrated total esophagogastretcomy. PET [7-22] showed multi-focal FDG avid left pleural nodular thickening and right medial upper pleural nodular thickening worrisome for metastatic disease. Left lung base nodule and right upper lobe nodule both FDG avid. Started Cisplatin, Irinotecan [2138-8-14]. Currently on day 22 Cis/irinotecan cycle. 2. History of diabetes but currently off insulin given significant weight loss. 3. Hypercholesterolemia which has resolved at this time. 4. Herniated disk. 5. DJD. . Past Surgical History 1. Operation for cholesteatoma at [Hospital 31406] 2. Multiple orthopaedics operations 3. Laparoscopy, laparoscopic jejunostomy and port placement under fluorscopic guidance Social History: He lives at a nursing home. He does not smoke or drink. He used to smoke a couple of packs a day for 40 years. He is currently on disability. He used to work for the City of [Hospital1 8] in their Sanitation Department. Family History: Father died of lung cancer Mother is [Age over 90 ] [Name2 (NI) ] and living in nursing home No other family history of malignancy Physical Exam: PE on admission: VS - T 95.4, BP 109/62, HR 88, RR 22, O2 sat 98% 2L NC General - cachectic male, in NAD, speaking full sentences HEENT - OP clr, MM sl dry CV - RRR, no mur Chest - CTAB Abdomen - mild diffuse tenderness to palp, soft, no g/r Extremities - no edema Neuro - A&Ox1 Pertinent Results: CT HEAD w/o [2138-10-6] No acute intracranial process. Please note that contrast- enhanced CT or MRI is more sensitive for evaluating intracranial metastatic lesions. . CT ABDOMEN/PELVIS w/o [2138-10-6]: 1. No intra-abdominal source of fever identified on this limited non-contrast examination. 2. Increased peribronchovascular opacities, centrilobular nodules and interstitial prominence within the visualized lower lobes. Differential diagnosis includes infectious/inflammatory, interstitial edema or lymphangitic carcinomatosis. Size of right pleural-based lesions may be slightly progressed since most recent examination. 3. Fluid fecal material within the majority of the large bowel, which displays air-fluid levels. Please correlate clinically for any signs of enteritis. . SWALLOW STUDY [2138-10-10] Pt is safe to take a PO diet of thin liquids and regular solids without oral or pharyngeal dysphagia . EGD [2138-10-13] Cervical esophagus/gastric anastomosis was patent. Suture line with metal clips was seen. Erythema and congestion in the stomach compatible with gastritis . GASTRIC EMPTYING STUDY [2138-10-14] Nearly no emptying within first hour and markedly delayed emptying at 4 hours involving the intrathoracic portion of the stomach. Normal tracer movement once it passes through the diaphragm . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2138-10-20] 12:00AM 6.0 3.14* 9.0* 28.1* 90 28.8 32.2 16.7* 319 [2138-10-18] 12:00AM 7.0 3.23* 9.3* 28.6* 89 28.7 32.4 17.0* 307 [2138-10-16] 12:00AM 4.8 2.42* 7.1* 21.3* 88 29.2 33.2 16.5* 250 [2138-10-15] 07:45AM 5.5 3.03* 8.7* 26.2* 86 28.9 33.4 16.6* 203 [2138-10-10] 08:35AM 5.8 3.40* 9.8* 28.6* 84 28.6 34.2 16.1* 194 [2138-10-9] 10:05AM 6.3# 3.39* 9.8* 29.7* 88 29.0 33.0 15.7* 200 [2138-10-8] 05:49AM 3.6* 2.82* 8.1* 24.4* 87 28.8 33.2 17.2* 195 [2138-10-6] 09:00AM 2.3* 2.69* 7.7* 23.4* 87 28.8 33.1 16.8* 237 [2138-10-6] 01:45AM 2.5* 3.16* 9.1* 26.9* 85 28.9 33.9 16.7* 217 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2138-10-20] 12:00AM 116* 22* 0.6 135 4.8 106 22 12 [2138-10-19] 12:00AM 11211 19 0.8 1302 7.03 1064 234 8 [2138-10-11] 03:00PM 100 3 0.8 134 4.1 102 26 10 [2138-10-11] 08:15AM 107* 4* 0.8 132* 3.6 100 27 9 [2138-10-10] 07:29PM 119* 6 0.8 132* 4.0 101 28 7* [2138-10-6] 08:06PM 144* 32* 1.1 143 2.81 120 111 15 [2138-10-6] 09:00AM 107 45* 1.9* 137 3.6 111* 15* 15 [2138-10-6] 01:45AM 130* 58* 2.6* 134 3.8 103 15* 20 Brief Hospital Course: ASSESSMENT/PLAN: 64 yo M with esophageal CA, admitted with AF w/ RVR, hypotension, and bandemia, initial MICU stay, also with intractable emesis of unknown etiology at this point ?r/t progression of esophageal CA. . # Emesis: Pt admitted with progressively worsening heaving and inability to tolerate po's, regardless of if solid, liquids or softs. Most recent barium study [8-/2138] prior to admission without evidence of obstruction. Swallowing study as well as EGD were negative for cause of intractable emesis with associated nausea. Pt improved gradually during admission as oral food and medications were held. TPN was initiated for nutrition. Gastric emptying study showed slow emptying of stomach as possible etiology of emesis. At discharge, pt tolerating clear and full liquids, however would be unable to support pt nutritionally. Pt was discharged home with hospice. TPN was at goal prior to discharge. . # Aspiration pneumonia: In the setting of frequent vomiting, increased risk for aspiration, evidence of possible pneumonia on chest imaging. Pt completed 10d course of levofloxacin. . # Hypotension: Appeared to be related to dehydration in the setting of volume depletion due to poor po tolerated r/t severe emesis. Also r/t atrial fibrillation with RVR. There was a possibility of sepsis, thus pt was started on vancomycin and levofloxacin, but rapid improvement with fluid resusitation hence vancomycin was discontinued. Hypotension resolved prior to transfer to OMED service, no further episodes during admission. . # Paroxysmal atrial fibrillation: Initially admitted with symptomatic afib with RVR, resolved after initial treatment at outside hospital with diltiazem and fluid resusitation. pt remained in sinus rhythm during admission. No anticoagulation as pt with chronic disease and poor prognosis. . # Dirrhea: Initially worrisome for c.diff due to ?diarrhea, however pt unable to tolerate po's and since esophagectomy with pull through, has had loose stools. c.diff negative and pt denied diarrhea. . # Anemia: Chronic, consistent with anemia of chronic disease. Pt with some blood transfusions due to low HCT which he tolerated well. No other acute issues. . # Esophageal cancer: After further discussion, no further treatment and pt was discharged with hospice. Adequate pain control was provided with fentanyl patch as well as oral morphine. . # Electrolyte imbalance: Due to intractable emesis on admission with any oral intake, multiple electrolyte imbalances. Aggressive lyte repletion was employted as well as some correction per TPN. . Pt reached maximal hospital benefit, discharged home with hospice Medications on Admission: Protonix 40 daily Marinol 2.5 [Hospital1 ] Ativan 0.5 Q6h prn KCl 20 meq PO BID Compazine 10 PO TID Oxycodone 10mg PO Q4h prn Nystatin sol'n 5cc PO QID Megace 400mg PO BID Heparin 500 SQ TID Fentanyl patch 125 mcg/hr Q72h Discharge Medications: 1. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:5 5 Refills:0 2. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q 2 h as needed for pain/shortness of breath. Disp:40 40ml Refills:0 3. HOSPICE Other Medications provided per hospice Discharge Disposition: Home With Service Facility: Hospice Care Discharge Diagnosis: Atrial fibrillation with RVR Intractable emesis Recurrent esophageal CA Discharge Condition: Fair Discharge Instructions: You were admitted with a fast, irregular heart rate, low blood pressure and inability to tolerate PO's due to vomiting. These have all resolved. . You may follow up with your PCP or oncologist within 1-2 weeks of discharge. Please discuss any concerns or questions you may have Followup Instructions: You may follow up with your PCP or oncologist within 1-2 weeks of discharge. Please discuss any concerns or questions you may have.	[ "5849", "5070", "42731", "25000" ]
Admission Date: [2102-10-27] Discharge Date: [2102-10-31] Date of Birth: [2053-8-29] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Left main coronary artery disease Major Surgical or Invasive Procedure: emergency coronary artery bypass grafts xLIMA-LAD,SVG-OM1-OM2-PDA) [2102-10-27] History of Present Illness: Progressive chest pain over three weeks requiring frequent nitro spray. A stress test was positive and the day of transfer catheterization revealed subtotal left main and an occluded right coronary artery. He was pain free and on no anticoagulants nor Nitroglycerin. Past Medical History: ? COPD ETOH abuse paroxysmal atrial fibrillation s/p CV x3 ( refused coumadin in past) hypertension dyslipidemia tobacco abuse remote mycardial infarction Social History: smokes 2ppd 10 beers /day works as driver Family History: Mother CABG in her 40s younger Sister s/p CABG Physical Exam: admission: Pulse:60 Resp: O2 sat:12 100% RA B/P Right:146/70 Left: Height:5'8" Weight: 65kg General: AAo x 3in 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 Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [], well-perfused [] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:+ Pertinent Results: [2102-10-27] 06:49PM BLOOD WBC-8.3 RBC-4.28* Hgb-14.0 Hct-40.9 MCV-96 MCH-32.6* MCHC-34.1 RDW-13.0 Plt Ct-209 [2102-10-27] 06:49PM BLOOD Glucose-83 UreaN-8 Creat-0.8 Na-135 K-6.3* Cl-102 HCO3-26 AnGap-13 [2102-10-27] 06:49PM BLOOD ALT-17 AST-42* LD(LDH)-647* AlkPhos-40 TotBili-0.6 Prebypass: Left ventricular wall thicknesses and cavity size are normal. Aside from the inferior wall which is akinetic, regional wall motion is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40%). Right ventricular chamber size and free wall motion are normal. 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. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Due to the emergent nature of surgery and fluctuating hemodynamics interatrial septum was not examined for defects by 2D or color flow. Postbypass: The patient is on infusions of phenylephrine and is not paced. Normal Right ventricular systolic function. LVEF 40%. No valvular issues. Intact thoracic aorta. 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) ] [2102-10-27] 23:53 Brief Hospital Course: Following admission, he was started on a Heparin infusion. He was taken to the Operating Room that night, where quadruple grafts were performed. He weaned from bypass on Neo Synephrine, weaned and was extubated the following morning. The pressor was weaned off and he remained stable. He was diuresed gently and his digoxin and sotalol were resumed. Physical Therapy was consulted and he transferred to the floor on POD #2. Continued to make good progress and was cleared for discharge to home with VNA on POD #4. All f/u appts were advised. Medications on Admission: Lisinopril 10mg daily Sotalol 120mg [Hospital1 ] Digoxin 0.125mg daily ASA 325mg daily Klonipin 1mg QID 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:1 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:1 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:0 7. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: paramentor VNA and Community Care Discharge Diagnosis: left main coronary artery disease s/p cabg myocardial infarction (several years ago) ? COPD ETOH abuse paroxysmal atrial fibrillation s/p CV x3 ( refused coumadin in past) hypertension dyslipidemia tobacco abuse 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 Left - healing well, no erythema or drainage. Edema -trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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) ] (for Dr. [First Name (STitle) ] at [Hospital1 ] on Thursday [11-23] @ 9:15 AM Cardiologist:Dr. [Last Name (STitle) 8051] ([Telephone/Fax (1) 8058]) on [11-30] @ 10:30 AM 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:[2102-10-31]	[ "41401", "412", "496", "4019", "42731", "2724", "3051", "V4582" ]
Admission Date: [2122-1-16] Discharge Date: [2122-1-19] Date of Birth: [2093-2-24] Sex: M Service: MEDICINE Allergies: Morphine / Darvocet-N 100 / Ketorolac / Cephalexin / Metronidazole Attending:[First Name3 (LF) 759] Chief Complaint: DKA, ICU admission as on insulin drip Major Surgical or Invasive Procedure: right IJ placement History of Present Illness: He is a 28 yo male with polyglandular autoimmune syndrome type 2 with DM1 and Addison??????s syndrome. He presented to our ED after recent hospitalization at [Location (un) 8973] Hospital where he underwent a cardiac cath on [1-13] for a report of a positive stress test. The catheterization report (that we obtained on [1-19]) was without any blockage(s) or valvular abnormalities. He was discharged to home from [Location (un) 8973]. He was then admitted to the [Hospital1 18] on [3-31] and per the discharge summary at that time had significant gastroparesis and abdominal discomfort. Per the discharge summary he became upset when he was not allowed off the floor to smoke and signed out AMA; there was no mention of LE weakness or numbness, no report of trauma. The patient gave a very different account of these events. He returned less than 24 hours later with a complaint of bilateral lower extremity numbness and weakness. In the ED patient was given IVF and insulin gtt. for glucose of 332 and A-gap of 13. Central line was placed. His CK was 2429 with flat Trop. He had CT spine done w/o signs of acute fracture or cord compression. He was seen by neurology. His vital signs remained stable with T 97.1 BP 136/90 HR 100 O2Sat100%RA . . Review of systems: Reports recent low grade temp and chills, 100.2. No cough, n/v/d or abdominal pain, no SOB. Recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. Polyglandular Autoimmune Disease - type 2 with Addison's disease, DM type I, and Hypothyroidism 2. CAD 3. Asthma 4. PUD 5. Mild mental retardation 6. hx of pancreatitis 7. s/p ccy/appy Social History: smokes, does not drink or take illicit drugs, married has 4 children, can't read or write Family History: + early CAD and Ca Physical Exam: Vitals: T: 97.6 BP: 125/77 P: 94 R: 10 18 O2:100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: upper extremities strength 5/5 in all muscle groups with preserved sensation. Lower extremities [12-1] in all major muscle groups, no babinskie, no sensation to prick and reflexes 1+ in upper and lower extremities, and symmetrical Pertinent Results: [2122-1-19] 05:22AM BLOOD WBC-9.5 RBC-3.34* Hgb-10.6* Hct-28.5* MCV-85 MCH-31.9 MCHC-37.4* RDW-13.3 Plt Ct-294 [2122-1-16] 03:30AM BLOOD WBC-11.5* RBC-3.64* Hgb-11.8* Hct-31.6* MCV-87 MCH-32.4* MCHC-37.3* RDW-12.9 Plt Ct-253 [2122-1-16] 03:30AM BLOOD Neuts-86.9* Lymphs-10.9* Monos-1.9* Eos-0.2 Baso-0.2 [2122-1-17] 03:00AM BLOOD PT-12.5 PTT-28.7 INR(PT)-1.1 [2122-1-16] 03:30AM BLOOD Glucose-332* UreaN-18 Creat-1.0 Na-133 K-5.0 Cl-98 HCO3-22 AnGap-18 [2122-1-19] 05:22AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-144 K-3.3 Cl-109* HCO3-29 AnGap-9 [2122-1-16] 03:30AM BLOOD CK(CPK)-2429* [2122-1-18] 05:58AM BLOOD ALT-36 AST-30 LD(LDH)-129 CK(CPK)-353* AlkPhos-72 TotBili-0.1 [2122-1-19] 05:22AM BLOOD CK(CPK)-267* [2122-1-16] 03:30AM BLOOD cTropnT-0.02* [2122-1-16] 10:16AM BLOOD CK-MB-10 MB Indx-0.5 cTropnT-0.02* [2122-1-16] 04:43PM BLOOD CK-MB-8 cTropnT-0.03* [2122-1-18] 10:51PM BLOOD CK-MB-3 cTropnT-<0.01 [2122-1-18] 05:58AM BLOOD Albumin-2.3* Calcium-6.8* Phos-3.0 Mg-1.6 [2122-1-16] 10:16AM BLOOD TSH-1.1 [2122-1-16] 10:16AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2122-1-16] 03:39AM BLOOD Lactate-1.0 [2122-1-16] 02:17PM BLOOD [Doctor First Name ]-PND . CT ABDOMEN W&W/O C & RECONS: Unremarkable abdominal CT. . CT CHEST: 1. No evidence of aortic dissection. 2. Prominent thymus may be related to known polyglandular autoimmune syndrome; however, neoplastic etiologies such as thymoma are possible. MRI can be obtained for further evaluation if clinically indicated. . MR C, T, L-SPINE W& W/O CONTRAST: No findings to account for the patient's symptoms. Specifically, there is no imaging evidence for cord infarct, cord contusion or epidural hematoma. . CT T, L-SPINE: 1. No evidence of acute fracture or malalignment. 2. No change in appearance of mild anterior wedge-shaped abnormality at T12 vertebral body. Brief Hospital Course: 28 yo male with polyglandular autoimmune syndrome type 2 with DM1 and addison??????s syndrome s/p cath p/w called out from MICU after DKA and lower extremity pain/numbness. . # MICU COURSE: Patient was started on insulin drip and given IV hydration. He was given volume resuscitation until gap closed then insulin ggt and D5W. Blood sugar was difficult to control initially taken off insulin drip on [1-16] once gap closed and resumed for high sugars. Patient was started on glargine with good control of blood sugars. He was seen neurology and neurosurgery. Surgery was consultd for possible removal of broken insulin needle in abdominal wall. On further evaluation, there was no needle. He had an MRI with no evidence of cord compression. . # Diabetes/ketoacidosis. Patient with DM1 [12-29] PGA type 2. His DNA has resolved. Patient takes home regimen of NPH 35 QAM and 15u at lunch and 10 QHS. He was hyperglycemic on glargine 15U. He was seen and evaluated by [Last Name (un) ] consult. He had been seen there as an outpatient sveral years ago, but is no longer followed since he is no longer a pediatric patient. He was started on glarging 26 U nightly. He should follow up with his PCP or [Name9 (PRE) ] for further management. . # Lower extremity pain/numbness/urinary retention: His symptoms resolved without intervention. Patient ambulated with PT with minimal pain. No evidence of cord compression on MRI. History of symptoms following cath is concerning for embolic phenomenon, however no evidence of infarction on MRI. Urinary retention resolved following restarting home anti bladder spasm medication. As his symptoms improved markedly during his hospitalization, neurology did not feel further imaging was necessary. He was able to ambulate without dificulty and was cleared by PT. He was given a cane for comfort. - He will follow up with neurology reagarding his symptoms and given high protein in CSF . # Chest pain: Patient had atypical chest pain on [1-19] that came on at rest and resolved spontaneously. An EKG was unchanged and cardiac enzymes were normal. He has had a cardiac catheterization in the past week with normal coronary arteries. Most likely cause is atelectasis or esophagitis. He was given reassurance and continued on his PPI. . # CK Elevation: Patient had a CK elevation on admission with normal CK-MB. This elevation improved with hydration and was likley related to recent trauma. Also could be related to autoimmune or viral myositis. If this problem returned and he was symptomatic, could consider muscle biopsy. . # PGA type 2- Addisons: continue outpatient hydrocortisone and florinef. Hemodynamically stable and no signs of crisis. He was given additional dose of hydrocort in stress setting. He was discharged on his home dose. . # Thymus abnormality on CT scan: Per report, "Prominent thymus may be related to known polyglandular autoimmune syndrome; however, neoplastic etiologies such as thymoma are possible. MRI can be obtained for further evaluation..." Findings were discussed with patient. - He should follow up with his PCP to consider an outpatient MRI. . # Communication: Patient wife hope [Telephone/Fax (1) 40748], and mother [Name (NI) ] [Telephone/Fax (1) 40749] Medications on Admission: 1. Hydrocortisone 2. Florinef 3. Reglan 4. Protonix 5. Thyroid replacement 6. Seroquel 7. Insulin (30/18/18) plus sliding scale of Humalog Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: Twenty Six (26) Units Subcutaneous at bedtime. Disp:QS one month Refills:2 2. Insulin Lispro 100 unit/mL Solution Sig: 1-12 units Subcutaneous four times a day: Per sliding scale. 3. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Hydrocortisone 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 5. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 6. Seroquel 200 mg Tablet Sig: Three (3) Tablet PO at bedtime. 7. Carafate 100 mg/mL Suspension Sig: Two (2) PO twice a day. 8. Levoxyl 25 mcg Tablet Sig: One (1) Tablet PO once 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. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cane Device Sig: One (1) Miscellaneous once. Disp:1 Refills:0 Discharge Disposition: Home Discharge Diagnosis: Diabetes Ketoacidosis Lower extremity pain and weakness Urinary retention Chest pain Addison's Secondary: Polyglandular autoimmune syndrome type 2 Discharge Condition: Ambulating, stable Discharge Instructions: You were admitted with diabetic ketoacidosis and pain in your legs and back. The ketoacidosis results from not taking your insulin. You were changed to a more simple insulin regimen, that you may be more able to take. You should continue to follow up with the [Last Name (un) ] diabetes center. You were seen by Neurology and had imaging to evaluate your spine. There were no immediately concerning findings, but you may need to follow up with them if your symptoms persist. You had a small abnormality on your thymus that was seen on CT scan. You should discuss with your PCP about getting [Name Initial (PRE) ] MRI to evaluate this. If you have new or worsening symptoms, or any other concerning findings, please seek medical attention. Followup Instructions: Please follow up with your PCP. [Name10 (NameIs) ] have an appointment scheduled for [2125-2-2]:45 PM. Please arrange a follow up appointment with a diabetes specialist. You can call [Telephone/Fax (1) 2384] to arrange an appointment with Dr. [Last Name (STitle) 40750] at [Hospital ] clinic. If your insurance does not cover this clinic, please contact you PCP. You have a follow up appointment scheduled with Neurology. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6855], M.D. Phone:[Telephone/Fax (1) 6856] Date/Time:[2122-2-3] 11:00 Completed by:[2122-1-20]	[ "41401", "49390", "2449", "V5867", "412" ]
Admission Date: [2194-9-18] Discharge Date: [2194-9-22] Date of Birth: [2143-8-12] Sex: M Service: MEDICINE Allergies: Erythromycin Base Attending:[First Name3 (LF) 1580] Chief Complaint: GIB / TIPS eval s/p banding from [Hospital 5871] Hospital Major Surgical or Invasive Procedure: 1. Endoscopic Gastroduodenoscopy (EGD) was perfomed at [Hospital 5871] Hospital. 2. Central Line Placement - confirmed by chest x-ray. History of Present Illness: Mr. [Known lastname 2253] is a 51 year old man with a history of alcoholic cirrhosis, hepatic encephalopathy, UGIB secondary to esophageal varices [4-21], and bilateral AVN of the hips who presented to [Hospital 5871] Hospital with hematemesis since 4am [9-16]. . His last endoscopy was about 1 week prior to admission, it was noted there were only grade I varices. He began experiencing nausea and bloody vomiting for about one day PTA. He also noted maroon colored stool, but was unsure of the duration (per the MICU team, 1 week). He denies any recent retching or coughing, although he has been having pain from his hips and may have been using NSAIDS. At [Location (un) 5871], his hct was noted to drop from 31 to 21. An EGD was performed in the ED with banding of two varices near the E-G junction. Levaquin/Flagyl were started "prophylactically". Nadolol was started for hypertension. Octreotide was started, as was nexium IV and 2u FFP and 2u PRBC. . Mr. [Known lastname 2253] has a history of alcoholic cirrhosis and is followed by Dr. [Last Name (STitle) 497]. He had ascites and encephalopathy in the past, but has improved such that he is off of aldactone and lactulose. His first varceal bleed was in [4-/2191] when he was diagnosed with cirrhosis. He has been abstinent from alcohol for 3.5 years now. . The patient currently feels well and is without complaints. He denies shortness of breath, chest pain, abdominal pain, numbness or tingling, weakness, dysuria, hematuria, cough, sputum production, fever, chills, night sweats, dizzyness, or lightheadedness. Past Medical History: 1. Alcoholic cirrhosis. 2. Hepatic encephalopathy. 3. Massive upper GI bleed secondary to esophageal varices. 4. Avascular necrosis of bilateral hips by MRI, now s/p THR, 2nd planned for [10-24]. (Dr. [Last Name (STitle) 49469] 5. History of acute pancreatitis - patient was unaware of this diagnosis but was informed of it in the past by Dr. [Last Name (STitle) 497]. 6. History of alcohol withdrawal seizure. 7. Hepatitis panel: Hepatitis C negative, hepatitis surface antigen negative, hepatitis B surface antibody positive, hepatitis B core antibody negative, hepatitis A antibody negative. Social History: Past significant use of alcohol and alcoholic cirrhosis. He has been clean and sober for 3.5 years. He participates in an alcoholics anonymous program. He denied any other significant drug abuse or any IV drug use. He has about 30 pack years smoking history and is a current active smoker, about 1ppd. He works as an assistant manager at [Company 4916]. He previously was in a monogamous relationship with his male partner for 20 years. He reports that they used protection. He is currently in a monogamous relationship with a genleman named [Name (NI) ], who was present and verified that the patient was off of his baseline mental status. Family History: His father died at 75 from stroke. He also had CHF. His mother died at 77 from ARDS (acute respiratory distress syndrome). Physical Exam: VS: T:97.4 (96.9-97.0) BP:130/67(130-168/67-95) HR: 88 (88-116)R:16 Sa02:100% on RA Gen:Awake alert, anxious. HEENT: NCAT, MMM, PERRL, EOMI, no oropharyngeal lesions. CV: RRR, nl s1,s2 no M/R/G Pul: CTAB no W/R/R Abd: Soft, NT, ND, nl bowel sounds. Ext: 2+ DP pulses = bilaterally. No C/C/E Neuro: MS: Patient oriented to Person, [Hospital1 18], but not to month. Was aware of President [Last Name (un) 2450]. Responded that he could hear the finger rub when there was none. Mildly positive asterixis. CNII-XII intact. Pertinent Results: [2194-9-19] Liver ultrasound. IMPRESSION: 1. Cirrhosis of the liver. The liver is not adequately examined for focal lesions on this study. 2. Gallstones and sludge within the gallbladder. 3. Splenomegaly, suggesting some element of portal hypertension. 4. Patent hepatic vasculature. [2194-9-18] 06:52PM BLOOD WBC-8.4 RBC-3.04# Hgb-9.9# Hct-28.1# MCV-92 MCH-32.6 MCHC-35.4* RDW-17.5* Plt Ct-71* [2194-9-18] 06:52PM BLOOD Hct-24.5# [2194-9-19] 03:01AM BLOOD Hct-24.1 [2194-9-22] 05:13AM BLOOD WBC-9.8 RBC-3.57* Hgb-11.4* Hct-32.7* MCV-92 MCH-32.0 MCHC-34.9 RDW-18.1* Plt Ct-101* [2194-9-19] 11:24AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2194-9-20] 06:40PM BLOOD HCV Ab-NEGATIVE [2194-9-20] 06:40PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE [2194-9-18] 06:52PM BLOOD Glucose-122* UreaN-26* Creat-1.0 Na-145 K-3.3 Cl-111* HCO3-23 AnGap-14 [2194-9-22] 05:13AM BLOOD Glucose-87 UreaN-12 Creat-0.8 Na-143 K-4.3 Cl-110* HCO3-23 AnGap-14 Brief Hospital Course: The patient received 3 units of blood during this admission and was watched on the floor until his hematocrit stabilized. An adominal ultrasound showed patent hepatic and portal vasculature. There was evidence of portal hypertension on the ultrasound in the form of splenomegaly. Ultimately the patient was restarted on lactulose to control his encephalopathy. He remained on the floor until his HCT was stable. Given his recent sclerotherapy at the outside hospital and the stabilization of the patient's hematocrit it was determined that the patient could be discharged with repeat EGD to be performed in two weeks by the patient's gastroenterologist, Dr. [Last Name (STitle) ]. J. [Doctor Last Name ]. Medications on Admission: 1. Isosorbide dinitrate 5 mg t.i.d. 2. Nadolol 40 mg b.i.d. 3. Protonix 40 mg b.i.d. 4. Benadryl 50 mg h.s. for sleep. 5. Motrin 800 mg daily. 6. Albuterol PRN Discharge Medications: 1. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:120 Tablet(s) Refills:2 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO twice a day. Disp:1800 ML(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:10 Tablet(s) Refills:0 5. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 6. Benadryl 50 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. 7. Discontinue Medication Please discontinue taking the isosorbide dinitrate (also called Isordil) Discharge Disposition: Home Discharge Diagnosis: 1. Portal hypertension 2. Bleeding Esophageal Varices 3. Alcoholic Cirrhosis. 4. Hepatic Encephalopathy 5. Bilateral Avascular necrosis of the hip. Discharge Condition: Vital signs stable. Hematocrit stable in the 30s. Discharge Instructions: Please return to the hospital if you vomit, if you vomit blood especially or if you pass bright red blood in your stool or if your stools are black or tarry. Please take your new medications along with your prior medications as prescribed. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2195-1-7] 11:00 Please also follow up with your GI doctor - Dr. [Last Name (STitle) ] [Last Name (NamePattern5) ]. We recommend that you have a repeat endoscopy (EGD) in the next week. Please notify your primary care doctor ([Doctor Last Name ],[Last Name (un) ] [Doctor Last Name ] [Telephone/Fax (1) 49470]) of your recent stay in the hospital. Please also follow up with your orthopedist regarding the pain you have in your hips. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1583] MD, MSC, MPH[MD Number(3) 1584] Completed by:[2194-9-24]	[ "2875", "2851" ]
Admission Date: [2189-1-29] Discharge Date: [2189-2-3] Date of Birth: [2121-1-30] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Positive ETT Major Surgical or Invasive Procedure: [2189-1-30] - CABGx5 (lima->lad, svg->posterior descending artery, svg->obtuse marginal artery, svg-y-graft to diagonal 1 and 2. History of Present Illness: Mr. [Known lastname ] is known to have abdominal aortic aneurysm and right iliac aneurysm and peripheral vascular disease. In the course of his workup, he was found to have a tight right coronary stenosis and ostial circumflex stenosis and moderate disease of his LAD and tight disease of a bifurcating large diagonal branch. He is referred for coronary artery bypass surgery given that his coronary disease is not thought to be amenable to percutaneous interventions. Past Medical History: HTN Hyperlipidemia AAA Right illiac aneurysm Skull fracture Social History: Married and manages a warehouse. Drinks 1 drink of alcohol per week. Smoked [12-8] pack per day for 50 years. Stopped 1 month ago. Family History: Noncontributory Physical Exam: Vitals: BP 117/82, HR 91, RR 14, SAT 99% on room air General: well developed male in no acute distress HEENT: oropharynx benign, poor dental health Neck: supple, no JVD Heart: regular rate, normal s1s2 Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2189-1-29] 07:13PM PT-12.4 INR(PT)-1.1 [2189-1-29] 07:13PM WBC-11.5* RBC-4.64 HGB-14.9 HCT-42.0 MCV-91 MCH-32.2* MCHC-35.6* RDW-13.9 [2189-1-29] 07:13PM %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE [2189-1-29] 07:13PM ALT(SGPT)-20 AST(SGOT)-24 ALK PHOS-100 AMYLASE-84 TOT BILI-0.3 [2189-1-29] 07:13PM GLUCOSE-79 UREA N-17 CREAT-1.3* SODIUM-140 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16 [2189-1-29] 08:51PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [2189-1-29] 08:51PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.015 [2189-1-29] 08:51PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2189-1-30] ECHO Pre Bypass: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post Bypass: No change in biventricular function. LVEF >55%. Aortic contours intact. Remaining exam unchanged. Results discussed with surgeons at time of the exam. [2189-2-1] CXR The endotracheal tube, nasogastric tube, chest tube, and mediastinal drains have been removed. There remains a right IJ Cordis with the distal tip in the proximal SVC. Mediastinal wires are seen. The cardiac silhouette and mediastinum are within normal limits. Previously seen densities at the left base have resolved. There is a small right-sided pleural effusion. There is no evidence for focal consolidation or overt pulmonary edema. [2189-1-30] EKG Sinus rhythm. Marked left axis deviation. Old inferior myocardial infarction. Low QRS voltage in the limb leads. Since the previous tracing of [2189-1-29] there is more suggestion of inferior myocardial infarction. Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2189-1-29] for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner and found to be suitable for surgery. On [2189-1-30], Mr. [Known lastname ] was taken to the operating room where he underwent coronary artery bypass grafting to five vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. He was tranfused with packed red blood cells for postoperative anemia. On postoperative day one, mr. [Known lastname ] [Last Name (Titles) 5058] neurologically intact and was extubated. His drains were removed withouot complication. Beta blockade, aspirin and a statin were resumed. Diuretics were initiated and he was gently diureses towards his pre-op weight. On postoperative day three, he was transferred to the cardiac step down unit for further recovery. Mr. [Known lastname ] was gently diuresed towards his preoperative weight. The Physical therapy service was consulted for assistance with his postoperative strength and mobility. Mr. [Known lastname ] continued to make steady progress and was discharged home with VNA services on postoperative day four. He will follow-up with Dr. [Last Name (STitle) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Norvasc 10mg QD Lipitor 15mg QD Lisinopril 5mg QD Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 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:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. Atorvastatin 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:45 Tablet(s) Refills:2 6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary ARtery Disease s/p Coronary ARtery Bypass Graft x 5 Hyperlipidemia Hypertension Abdominal Aortic Aneurysm Right illiac aneurysm Discharge Condition: Good Discharge Instructions: 1) Monitor wound for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lifting greater then 10 pounds for 10 weeks. 5) No driving for 1 month. 6) No lotions, creams or powders to wounds until they have healed. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in 1 month. Follow-up with cardiologist Dr. [Last Name (STitle) 2912] in [12-8] weeks. Follow-up with Dr. [Last Name (STitle) 8446] in 2 weeks. Please call all providers for appointments. Completed by:[2189-3-6]	[ "41401", "9971", "42789", "4019", "2724" ]
Admission Date: [2182-7-30] Discharge Date: [2182-8-5] Date of Birth: [2125-1-15] Sex: F Service: MEDICINE Allergies: Compazine / Darvocet-N 100 / Sulfa (Sulfonamide Antibiotics) / Penicillins / Methadone / Levaquin Attending:[First Name3 (LF) 15397] Chief Complaint: Overdose Major Surgical or Invasive Procedure: None History of Present Illness: 57 yo female with history of substance abuse and chronic pain on narcotics found down on the floor. She reports vomiting into her toilet and changing the trash before she fell asleep on the floor in her bedroom. She denies any CP, SOB, palps, LH, or dizziness prior to falling asleep. Denies LOC or head strike. Per EMS, her nephew noticed that she was acting different last night, and then found her on the floor at 0830 this morning. When he called EMS at 1430, she was moaning with sluggish pupils, but responded to painful stimuli. At [Hospital1 ], she was noted to be confused and combative. She was reportedly unable to follow commands. Initial rectal temp was 92.3. She was given 3L of IVF with 1600cc of UOP. Head and neck CT were unremarkable. Tox screen was positive for barbs, benzos, opiates, TCA, and cannibanoids. CK 1300, trop flat. Prior to transfer, nursing notes report that she was awake, yelling out of her room, and demanding to change her head position. In the ED here at [Hospital1 18], initial VS were afeb, 77, 146/73, [1-4], 99% on RA. She is reportedly confused and intermittently drowsy with no memory of events except being at [Location (un) 620]. On arrival to the MICU, she is awake and alert complaining of back pain, bilateral knee pain, and bilateral leg and requesting pain medication. Past Medical History: Spinal stenosis L4/L5 Disc herniation Chronic pain - seen at [Doctor Last Name 1193] pain, lumbar spine injections at [Hospital1 336] GERD Migraines Hyperlipidemia H/o Bells palsy Hysterectomy Cholecystectomy Social History: The patient occasionally drinks alcohol, has smoked for the past 40 years, is single and does not have children. The patient is unemployed. Formerly worked for a transportation company and in advertising. Stopped working and driving [2-21] back pain. Currently on SSI since [2161]. Family History: No history of stroke, hemorrhage or aneurysm. Father-CAD and DM. Brother-DM. Mother-Parkinsons. Physical Exam: Admission: Vitals: afeb 86 141/100 14 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, non-distended, no organomegaly Back: no CVA tenderness, tenderness over lumbar spine GU: +foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Discharge: Vitals: 98.7 130/76 p77 R18 98%RA General: Awake, oriented, no acute distress, lying comfortably in bed HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes Abdomen: +BS, soft, non-tender, non-distended, Back: no CVA tenderness, tenderness over lumbar spine and lower back Ext: warm, well perfused, no clubbing, cyanosis or edema Neuro: Alert and fully oriented. Speech clear, appropriate CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Pertinent Results: Admission: [2182-7-30] 10:35PM BLOOD WBC-6.5 RBC-3.45* Hgb-11.4* Hct-33.2* MCV-96 MCH-32.9* MCHC-34.3 RDW-12.9 Plt Ct-235 [2182-7-30] 10:35PM BLOOD Neuts-68.8 Lymphs-25.5 Monos-3.2 Eos-1.6 Baso-0.8 [2182-7-30] 10:35PM BLOOD PT-10.4 PTT-28.5 INR(PT)-1.0 [2182-7-30] 10:35PM BLOOD Glucose-79 UreaN-11 Creat-0.5 Na-147* K-3.4 Cl-109* HCO3-28 AnGap-13 [2182-7-31] 02:06AM BLOOD CK(CPK)-2605* [2182-7-31] 05:40PM BLOOD CK(CPK)-2243* [2182-8-1] 05:55AM BLOOD CK(CPK)-1654* [2182-7-31] 02:06AM BLOOD CK-MB-38* MB Indx-1.5 cTropnT-<0.01 [2182-7-30] 10:35PM BLOOD Calcium-8.8 Phos-2.5* Mg-1.8 [2182-7-30] 10:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2182-7-30] 10:43PM BLOOD Lactate-1.1 [2182-7-30] 10:35PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 [2182-7-30] 10:35PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [2182-7-30] 10:35PM URINE RBC-3* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 [2182-7-30] 10:35PM URINE UCG-NEGATIVE [2182-7-30] 10:35PM URINE bnzodzp-POS barbitr-POS opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG [2182-8-5] 06:00AM BLOOD UreaN-10 Creat-0.7 Na-142 K-3.8 Cl-104 HCO3-31 AnGap-11 [2182-8-5] 06:00AM BLOOD CK(CPK)-436* URINE CULTURE (Final [2182-8-1]): NO GROWTH. Blood Culture, Routine (Final [2182-8-5]): NO GROWTH Sinus rhythm. Same [Location (un) 1131] as tracing #2 with no interval change Brief Hospital Course: 57 yo female with history of substance abuse and chronic pain on narcotics found down with a tox screen positive for benzos, barbs, opiates. Taken to [Location (un) 620] and transfered to ICU at [Hospital1 18] because she was unable to follow commands, confused and combative, cardiac enzymes flat. On arrival to ED, drowsy with no memory of events, in the MICU more alert and requesting pain medication. Eventually transferred to floor stable for further monitoring of mental status and social work/psych eval. # Overdose: Tox screen with multiple substances not prescribed to her. Tylenol and aspirin were negative, serum tox screen negative for all substances, unclear if positive barbituates in urine is cross-reaction or if patient has access to barbituates and not disclosing this to team. She has a history of substance abuse in the past. She denied taking any additional medications than those prescribed to her initially, but later admitted that she took about two extra doses because she felt her pain was excruciating and she thought she hadn't taken her medication yet because the pain was so bad. Social work and psychiatry saw patient and spoke with nephew [Name (NI) ]. [Name2 (NI) ] nephew reports that she is found passed out 3-4 times per week, but feels he cannot intervene because she is his landlord. Psychiatry saw patient and offered inpatient detox, which patient refused. She is depressed but not found to be a threat to herself or others, and psych recommended close follow up with outpatient providers for monitoring. Per social work, patient would like help at home with homemaking but is not concerned for her safety. Patient counseled at length by primary team and social work about the importance of taking medications as directed, dangers of taking opiates, and other options for treatment. Patient verbalized understanding. Team and social work also expressed concern for patient's safety at home, patient states she is fine, denies there is a safety problem or an addiction problem and wants to go home. Communicated with primary care provider [Last Name (NamePattern4) ]. [Last Name (STitle) 13075] the events of hospitalization and arranged follow up with her, psychiatrist, and pain clinic. To prevent overdoses in the future the patient is going to keep a log when she takes her medications. # Elevated CK: No evidence of [Last Name (un) ], but reported muscle weakness initially. Differential included rhabdo secondary to fall v. statin effect. Statin and naproxen held while giving fluids and trending CK, on day of discharge CK 436, much improved from >2600 on arrival. Restarting naproxen and statin at discharge. # Hypernatremia: Likely related to poor PO intake plus administration of 3L of IVF as evidenced by elevated chloride. Free water deficit of 1.18L. She was given 1/2NS and Na normalized on hospital day 1. No further issues during the hospitalization. Inactive issues: # HTN: continued atenolol. # Normocytic Anemia: Hct 33 at admission, near recent baseline in OMR. Needs outpt anemia workup. # Migraines: continued amitripyline. # Chronic pain: continued home pain medications including oxycontin, baclofen, diazepam, promethazine, wellbutrin, gabapentin # Communication: [Name (NI) 1022] niece [Telephone/Fax (1) 105696], friend [Name (NI) 53228] [Telephone/Fax (1) 105697] Transitional Issues: -follow up CK, BUN/Cr to confirm resolution after restarting naproxen and statin with PCP [Name9 (PRE) ] up with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 13075] [Name (STitle) ] up with therapist, psychiatrist Dr. [First Name (STitle) 20246] [Name (STitle) ] up with pain clinic Dr. [Last Name (STitle) 62095] Medications on Admission: 1. Baclofen 20 mg PO TID 2. Lortab NF (HYDROcodone-acetaminophen) 10-500 mg Oral qid: prn pain 3. Oxycodone SR (OxyconTIN) 60 mg PO Q12H 9am, 6pm 4. Oxycodone SR (OxyconTIN) 40 mg PO HS 5. Promethazine 25 mg PO Q6H:PRN with pain meds 6. Diazepam 10 mg PO Q12H:PRN anxiety 7. BuPROPion 150 mg PO BID 8. Amitriptyline 50 mg PO HS 9. Atenolol 75 mg PO DAILY 10. Naproxen 500 mg PO Q8H:PRN pain 11. Fluticasone Propionate NASAL 2 SPRY NU DAILY 12. Atorvastatin 80 mg PO DAILY 13. Klor-Con M20 NF (potassium chloride) 20 mEq Oral daily 14. Gabapentin 300 mg PO TID Discharge Medications: 1. Amitriptyline 50 mg PO HS 2. Atenolol 75 mg PO DAILY 3. Baclofen 20 mg PO TID 4. BuPROPion 150 mg PO BID 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Gabapentin 300 mg PO TID 7. Oxycodone SR (OxyconTIN) 60 mg PO Q12H 9am, 6pm 8. Oxycodone SR (OxyconTIN) 40 mg PO HS 9. Promethazine 25 mg PO Q6H:PRN with pain meds 10. HydrOXYzine 25-50 mg PO Q6H:PRN anxiety RX hydroxyzine HCl 25 mg 1-2 tablets by mouth every 6 hours Disp #30 Tablet Refills:0 11. Atorvastatin 80 mg PO DAILY 12. Klor-Con M20 NF* (potassium chloride) 20 mEq Oral daily 13. Lortab NF (HYDROcodone-acetaminophen) 10-500 mg Oral qid: prn pain 14. Naproxen 500 mg PO Q8H:PRN pain 15. Docusate Sodium 100 mg PO BID RX Colace 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 16. Senna 1 TAB PO BID:PRN Constipation RX senna 8.6 mg 1 tablet by mouth twice a day Disp #30 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Health Systems Discharge Diagnosis: Altered mental status secondary to drug overdose Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 105698], You were admitted to the hospital because you took too much of your pain medication and became altered and were not responding appropriately. In the ICU, your mental status improved with time and you became more alert, and you were found to have a high level of muscle breakdown products, which happens when you fall and are unconscious or sleepy for long periods of time. There was concern that you were taking too much pain medication at home, and we discussed this with you. It is very important that you take you medications exactly as prescribed and no more to make sure that this does not happen again. You were evaluated by psychiatry because you mentioned you were feeling depressed and they recommended close follow up with your outpatient psychiatrist and therapist, primary care provider and your pain clinic. They also recommended that you consider joining a pain support group since it is very difficult to deal with pain on your own. Pleas make sure you follow up with your outpatient providers, it is very important for your health. Please take your medications exactly as prescribed. We made the following changes to your medications: Please STOP taking valium Please STOP taking ambien Please START taking hydroxyzine 25-50mg every 6 hours by motuh for anxiety instead of valium Please START taking senna 1 tab twice a day as needed for constipation Please START taking colace 100mg twice a day as needed for constipation Followup Instructions: Please make sure to follow up with all of your doctors [First Name (Titles) ] [Name5 (PTitle) 105699]. Completed by:[2182-8-6]	[ "2760", "3051", "4019", "2859", "2724" ]
Admission Date: [2143-10-30] Discharge Date: [2143-11-27] Date of Birth: [2079-11-22] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2777] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [2143-10-30]: Bilateral lower extremity fasciotomies, Right axillobifemoral bypass with PTFE graft [2143-10-30]: Right above knee amputation [2143-11-9]: Revision R above knee amputation History of Present Illness: The patient is a 63-year-old male with unknown past medical history who presented to the emergency room, a transfer from an outside hospital, with pulseless lower extremities which were also cold and mottled for the preceding 12 hours. The patient had been also found to have motor and sensory loss in both lower extremities. CT scan performed at the outside hospital revealed infrarenal aortic occlusion with a 4.7 cm infrarenal AAA. There is reconstitution of the distal external iliac arteries and patent common femoral arteries. Past Medical History: HTN, asthma, ? opioid abuse, ? EtOH abuse, bipolar disorder Social History: Pt. lives at [Location (un) 74671], a transitional housing program for homeless individuals in [Location (un) 12017], NH. Mr. [Known lastname 28331] has lived there for almost a year. SW has spoken to various staff members involved with the pt. (see below) and they all agree that he has no family members or other contacts Family History: Noncontributory Physical Exam: VS on admission: T 96.2, HR 87, BP 139/99, RR 11, PO2 98% on RA GEN: NAD, AAOx3 Chest CTA B/L Heart RRR no M/G/R Abd: NT/ND, + BS Ext: Dopplerable DP bilaterally, sensory level at nipples. Paralyzed below waist. Rectal: Guiaic negative Pertinent Results: [2143-10-30] 01:24AM WBC-16.6* RBC-4.20* HGB-14.5 HCT-40.3 MCV-96 MCH-34.6* MCHC-36.0* RDW-14.3 [2143-10-30] 01:24AM CK-MB-84* MB INDX-0.3 cTropnT-0.34* [2143-10-30] 01:24AM ALT(SGPT)-80* AST(SGOT)-331* CK(CPK)-[Numeric Identifier 74672]* ALK PHOS-55 AMYLASE-58 TOT BILI-0.4 [2143-10-30] 01:24AM GLUCOSE-140* UREA N-31* CREAT-1.4* SODIUM-133 POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-26 ANION GAP-17 [2143-10-30] 02:44AM TYPE-ART PO2-156* PCO2-42 PH-7.34* TOTAL CO2-24 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED Brief Hospital Course: On [2143-10-30] Mr. [Known lastname 28331] was taken emergently to the operating room, where he underwent bilateral lower extremity fasciotomies and axillo-bifemoral bypass. He was observed for a short while to see how he would do with revascularization; however, the appearance of the right leg did not improve, so he was taken back to the operating room and an above-knee amputation of the right lower extremity was performed to remove all infarcted tissue. See operative reports dictated [2143-10-30] for further details of the procedures. Postoperatively Mr. [Known lastname 28331] was kept intubated and transferred to the ICU. He was started on Vancomycin, Ciprofloxacin, and Flagyl. He had several repeated episodes of vtach accompanied by hypotension requiring electrical cardioversion and lidocaine drip. An echocardiogram was done and showed an EF of only 10% with significant LV dysfunction. The lidocaine drip was gradually weaned off, and he was transitioned to PO amiodarone. Tube feeds were started on POD 4. On [2143-11-5] Mr. [Known lastname 28331] was taken back to the OR for closure of his above knee amputation. He went back to the ICU, and was successfully extubated on POD [7-14]. Psychiatry consult was called to evaluate the patient for his history of anxiety and depression. On POD [10-17] he was transferred to the VICU. Upon arriving there he experienced some episodes of hematuria. Urology consult was called and instituted constant bladder irrigation, after which his urine cleared. Antibiotics were D/C'd and physical therapy was initiated. His left lower extremity faciotomy wounds required several interrupted horizontal mattress sutures to reclose them, but otherwise his wounds continued to heal well. By [2143-11-27], he was strong enough to transfer independently from bed to chair, so was discharged back to his halfway house in New [Location (un) ]. Medications on Admission: corgard, depakote, proventil, seroquel, trazadone Discharge Medications: 1. Wheel Chair Disp: Wheel Chair Quantity: 1 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Lorazepam 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:90 Tablet(s) Refills:2 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q3HP as needed. Disp:40 Tablet(s) Refills:1 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 14. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: seacoeast Discharge Diagnosis: Thrombosed infrarenal abdominal aortic aneurysm Discharge Condition: good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [10-28] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: He will need to follow-up in [Hospital 159] clinic as an outpatient for a cystoscopy 3-4 weeks after discharge. Please call [Telephone/Fax (1) 164] to arrange an appt. He should followup with Dr. [Last Name (STitle) ] in 4 weeks. Please call [Telephone/Fax (1) 2625] to schedule an appointment. He has a followup appointment with his outpatient psychiatrist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 23128], on Wednesday [12-11] at 1:30 PM. Phone: ([Telephone/Fax (1) 74673]. Completed by:[2143-12-2]	[ "4280", "25000", "4019", "412" ]
Admission Date: [2177-11-25] Discharge Date: [2177-11-26] Date of Birth: [2107-11-9] Sex: F Service: MICU-GREEN REASON FOR ADMISSION: The patient was transferred from outside hospital (Vent-Core), because of acute renal failure as well as a new serious rash. HISTORY OF PRESENT ILLNESS: This is a 70 year old woman with a history of breast cancer, chronic obstructive pulmonary disease, severe refractory hypertension, type 2 diabetes mellitus, and chronic renal insufficiency who presents from [Hospital 103101] Rehabilitation, followed there by the Pulmonary Interventional Fellow, [Name (NI) ] [Name8 (MD) ], M.D., with a desquamating rash, serum eosinophilia as well as recent acute renal failure. The patient was discharged to this rehabilitation from [Hospital1 69] in [2177-7-10]. Prior to the admission to [Hospital1 346] Medical Intensive Care Unit from [7-3] until [2177-8-1], she was also here in early [Month (only) ] as well. In the first admission, she was admitted for a chronic obstructive pulmonary disease flare and was noted to have bilateral pleural effusions and pericardial effusions with tamponade physiology. This was tapped under ultrasound guidance and found to be exudative with negative cytology and [First Name8 (NamePattern2) ] [Doctor First Name ] of 1.160. She was then readmitted nine days later with shortness of breath again, thought to be a chronic obstructive pulmonary disease flare and was treated with nebulizers, Lasix and Solu-Medrol. She was found to have tamponade physiology on a transthoracic echocardiogram, underwent balloon pericardiotomy and intubated for airway protection. An ultrasound guided thoracentesis on [7-4] for a left pleural effusion which was found to be transudative was performed and the patient was extubated successfully. Five days later, both the pleural effusion and the pericardial effusions reaccumulated requiring re-intubation on [7-9]. The patient went to the Operating Room for a pericardial window, a left chest tube and a left pleurodesis. After this, she was unable to extubate and was then returned to the Medical Intensive Care Unit. Failure to wean in the Medical Intensive Care Unit was secondary to diaphragmatic weakness and she was noted to have critical care polyneuropathy/myopathy per EMG on [2177-7-24]. She underwent tracheotomy on [2177-7-17]. The cause of the pleural and pericardial effusions are unknown. The work-up was basically negative; there were no malignant cells found in either of the fluids and the pericardial window biopsy was negative. Also, Rheumatology evaluated her and thought it was not secondary to a rheumatological cause because her admission [Doctor First Name ] on [7-6] was negative (however, she had positive [Doctor First Name ] on [2177-7-25] times two). Her Pulmonary status improved and the effusions remained stable so she was discharged to Vent-Core on [2177-8-1]. She did well at the rehabilitation and her course there was actually unknown to us at this point, however, we do know that she was unable to be weaned off of her ventilator. She was currently on CMV with a total volume of 500, respiratory rate of 12 and an FIO2 of 40% and had recently failed a PS trial secondary to tachypnea and low volume. Recent events at the rehabilitation are summarized below: We know that she recently finished a course of Vancomycin and cefepime on [11-17], which was begun empirically secondary to a fever. At this time, we do not know the length of time she was on either of these antibiotics. She was recently restarted on Lisinopril on approximately [11-16]. She does have a history of her creatinine going up on ACE inhibitors in the past, however, she was having blood pressures up to the 240s and an attempt was made to restart her on Lisinopril which she had not been on since [Month (only) 216]. Her creatinine upon discharge from [Hospital1 190] ranged from 1.0 to 1.5. She briefly had some elevations of the creatinine into the 2.4 range secondary to acute renal failure from intravenous contrast. They restarted the Lisinopril at 10, went up to 20, and discontinued her Lisinopril on [11-20], as her creatinine had started to rise. It was 3.2 on [11-21] and then increased to 3.6 at the outside hospital on [11-24]. Renal did evaluate her while she was at the rehabilitation and they suggested dialysis as well as an increase in her Lasix. She did not undergo dialysis at that time. Then, on [11-21], a rash was noted to have started that was initially limited and mild but then she underwent desquamation of her skin associated with diffuse erythema and edema. She was also noted to have an eosinophilia since [2177-10-17]. We know that her serum eosinophils were 16% on [11-19] and had decreased to 12% on [11-24]. Of note, she had also been on Prednisone for an unknown reason. At the rehabilitation it was decided to start weaning this down from 10 mg to 5 mg one week ago. According to the physicians that took care of her at the rehabilitation, her only new medications were Lisinopril from approximately [11-16] until [11-20]. She had been previously on that but not since [Month (only) 216]. She was also recently started on Amlodipine however, it was related that this was started on [11-22], after the rash had appeared. All her other hypertensive medications she had been on for quite some time, and the only other recent medications were her antibiotics, Vancomycin and Cefepime, that were discontinued on [11-17], when the course was finished. REVIEW OF SYSTEMS: The patient can nod her head with responses and denied pain and shortness of breath at time of admission. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease: Restrictive lung disease with reactive airway disease. 2. Status post tracheostomy on [7-17] and PEG placement on [2177-7-28]. Her tube feeds are at a goal of 35 cc per hour. She has been unable to be weaned off her ventilator at Vent-Core. 3. Pericardial effusion / tamponade that was found to be exudative with negative cytologies. Status post window placement on [2177-7-9]. 4. Bilateral pleural effusions, transudative, status post left pleurodesis on [2177-7-9]. 5. Breast cancer (DCIF), status post total mastectomy, ER-pos, Stage 2, no radiation, N0 M0, and currently off tamoxifen. 6. Severe hypertension, on five medications. 7. Type 2 diabetes mellitus, previously on oral hypoglycemics and now requiring insulin. 8. Chronic renal insufficiency secondary to diabetes mellitus with nephrotic range proteinuria. 9. Acute renal failure secondary to intravenous dye in [2177-7-10]. Also had a history of elevated creatinine secondary to ACE inhibitors. 10. Thalassemia trait. 11. Questionable history of osteogenesis imperfecta. 12. Legal blindness; she has a left eye prosthesis as well. 13. Urinary incontinence. 14. Echocardiogram results from [2177-6-9] revealed a right ventricular wall clot/tumor with an ejection fraction of 58%. Her latest echocardiogram at [Hospital1 188] on [2177-7-22], revealed an ejection fraction of greater than 65%, mild LAE, mild symmetrical left ventricular hypertrophy with normal cavity size and regular wall motion; mild thickened atrial valve and mitral valve leaflets; moderate pulmonary hypertension; small to moderate pericardial effusion predominantly over the right ventricle. No change when compared to the prior study of [2177-7-17]. 15. Noted to have Vancomycin resistant enterococcus in her urine on [7-23]. 16. Left ocular paresthesia. 17. Anemia; it appears that her baseline hematocrit is usually in the high 20s. 18. SPAP with 2% gamma band, likely consistent with MGUS. UPAP revealed multiple protein bands without even predominating. 19. Urine positive for Pseudomonas according to the RN at Vent-Core. 20. History of Methicillin resistant Staphylococcus aureus - question in her sputum. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER TO [Hospital1 ]: 1. Amlodipine 10 mg q. day p.o., recently began on [11-22], after the rash had appeared. 2. Hydralazine 100 mg four times a day; she has been on this medication for a while. Please note that the Vent-Core sheets report that she began this medicine on [11-21], however, this was only a renewal according to Dr. [Last Name (STitle) ]. 3. Lasix 40 mg twice a day. 4. NPH 20 units twice a day. 5. H2O 125 cc three times a day. 6. Benadryl 25 mg q. eight hours. 7. Subcutaneous heparin 5000 twice a day. 8. Prednisone 5 mg q. day. 9. Protein soy supplement, two scoops in the feeding tube q. eight hours. 10. Nepro 3/4 strength tube feeds 35 cc per hour. 11. Clonidine 0.3 three times a day. 12. Bisacodyl 10 mg q. day p.r.n. 13. Regular insulin sliding scale with Humulin. 14. Lopressor 100 mg four times a day. 15. Labetalol 200 mg four times a day. 16. Isosorbide dinitrate 40 mg q. eight hours. 17. Sublingual Nitroglycerin p.r.n. 18. Protonix 40 q. day. 19. Epogen 40,000 units subcutaneously weekly. 20. Brimonidine 0.2% solution, one drop bilaterally q. eight hours. 21. Ditolamide one drop solution to each eye three times a day. 22. Ativan 1 mg q. eight hours. 23. Calcium carbonate 500 mg q. eight hours. 24. Ipratropium and Albuterol MDI four puffs q. four hours p.r.n. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Remote history of tobacco use. No current alcohol use. She has a sister who is demented. She previously had lived with her son and her son whose name is [Name (NI) ] [Name (NI) 16093] is her primary contact, [Telephone/Fax (1) 103102]. He also has a brother, [Name (NI) ] [Name (NI) ], who is a second contact, whose phone number is [Telephone/Fax (1) 103103]. PHYSICAL EXAMINATION: Temperature 98.4 F.; heart rate 62; blood pressure 163/43, respiratory rate 12 to 18, 100% O2 saturation; vent settings are assist control, total volume 500, respiratory rate 12, O2 saturation 40% with 5 of PEEP. In general, the patient opens eyes, nods yes and no to questions. She is an elderly African American female. HEENT: She has a left eye paresthesia, right eye with questionably sclerae clouded over. Sclerae anicteric. Oropharynx is clear; there are no mucosal lesions. Mucous membranes were moist. Neck: Tracheostomy is in place. Neck is supple. Cardiovascular: Regular rate and rhythm, normal S1 and S2. Respirations: Decreased breath sounds at bases. Occasional wheeze heard in the left anterior aspect of the well healed abdomen. Normoactive bowel sounds. PEG is in place. Soft, nontender, nondistended. Extremities with plus two pitting edema diffusely with no cyanosis or clubbing. Extremities are warm; plus two dorsalis pedis is felt on the left, however, could not detect distal pulses on the right extremity. Skin: As described by the dermatologic consultation later in the evening; generalized moderate non-colorous erythema with marked desquamation and areas that show evidence of good re-epithelialization. Multiple eroded areas in the intertrigous areas of the neck, axillae, breasts and groin. Approximately 30% of her back showed superficial erosions and skin sloughing. Positive perianal punched out ulcers. Also of note, the conjunctivae appears slightly erythematous but on gross examination there were no conjunctival or corneal erosions. Neurologic: Moves all four extremities. PERTINENT LABORATORY: From Vent-Core on [11-19], white blood cell count 24, hematocrit 29.2, platelets 329, MCV of 65 with a differential of 72% polys, 5% lymphocytes, 6% monocytes, 16% eosinophils and 1% basophil. From Vent-Core on [11-24], revealed a sodium of 134, potassium of 4.4, chloride of 103, bicarbonate of 22, BUN of 130, a creatinine of 3.6 (was 2.4 on [11-21] and 3.2 on [11-19]). Glucose of 111, calcium of 8.6. Reportedly had a serum eosinophil percentage of 12. Upon admission to [Hospital1 69], white blood cell count 13.2, hematocrit of 30.1 with an MCV of 66, platelets of 315, PT of 14.4, INR of 1.4, PTT of 28.3. Sodium of 135, potassium of 4.9, chloride of 102, bicarbonate of 20, BUN of 135, creatinine of 3.6, glucose of 201, calcium of 9.0 corrected to 10.1, phosphorus of 3.4, magnesium of 2.5. ALT of 14, AST 22, LD of 233, alkaline phosphatase of 166 which is mildly elevated. Total bilirubin of 0.5, albumin of 2,6, lipase of 14, amylase of 20. Studies were: 1) Portable chest x-ray revealed fairly marked enlargement of the cardiac silhouette. Predominantly left ventricle. Pulmonary [Hospital1 56207] are predominant in the upper zones and some left ventricular failure cannot be excluded. Loss of translucency at both lung bases; left diaphragm is elevated. Tracheostomy is in satisfactory position. Probably bilateral pleural effusions with the question of a left lower lobe infiltrate/atelectasis. 2) Renal artery ultrasound from [2177-6-9] at [Hospital1 346] was notable to have a right kidney size of 9.4 and a left kidney size of 9.3. The Doppler's were unable to be done. 3) Renal artery ultrasound done on [2177-11-26], revealed no hydronephrosis, patency of the [Last Name (LF) 56207], [First Name3 (LF) ] the Doppler's were not done. The right kidney size was 9.6. The left kidney was unable to be estimated for size due to positional factors, however, it looks grossly normal. HOSPITAL COURSE: Mrs. [Known lastname 5261] was admitted to the Medical Intensive Care Unit. A Dermatology consultation was obtained on the evening of the 17th. Their assessment that this was represented likely resolving [Doctor Last Name ]-[Location (un) ] Syndrome versus TEN and it seems that it is most consistent with TEN. She does show significant re-epithelialization. There is no calor, no tenderness, no bullae evident on examination. Her eosinophils have dropped from 16% to 12 in the last few days which suggests improvement in her drug hypersensitivity. These and the fact that her prior antibiotics have now been discontinued, suggests that she is resolving from a prior TEN. The most likely culprit for this adverse reaction includes Lisinopril which was discontinued on [11-20], secondary to the development of acute renal failure. Other culprits include Vancomycin and the Cefepime that had been on board since [8-1] and were discontinued on [11-17]. Cefepime was more likely than Vancomycin to cause this adverse drug reaction. These antibiotics should be avoided as well as all ACE inhibitors. The Amlodipine was also recently added after her rash had begun and at this point until we get the actual medical sheets from the rehabilitation facility, we are holding this Amlodipine as well. I have spoken to [Hospital3 105] Vent-Core Unit, [Location (un) 1773], where the phone number is [Telephone/Fax (1) 26091], and a nurse there was going to fax the start and stop dates of all the medications she was on during her admission there. We have yet to receive that fax. They also recommended checking urine eosinophils which are currently pending, serum eosinophils which did return on her admission as only 3%, however, the morning of transfer have increased to 7%. Liver function tests which were normal except for a slightly elevated alkaline phosphatase as well as ggt of 68 and a BUN and creatinine that were at 136 and 3.6 on the morning of [11-26]. It was also recommended to follow her electrolytes twice a day. Her full electrolytes panel the day of transfer was a sodium of 137, potassium 4.7, chloride 103, bicarbonate of 20, BUN of 136, creatinine of 3.6, glucose of 208, calcium of 8.6, phosphorus of 3.2, magnesium of 2.4. Of note, she also had a white blood cell count of 13.1, hematocrit of 31.3, platelets of 324, with a differential of 78% neutrophils, 1% bands, 7% lymphocytes, 6% monocytes, 7% eosinophils and 1% metas. For her skin we were placing Xeroderm patches as well as using Bactroban instead of Bacitracin to her wounds. The next morning, Dermatology obtained two 5 mm skin punch biopsies at the left parasternal line under sterile conditions and were sent to Pathology for a diagnosis. An epidermal jelly-roll from epidermis adjacent to fresh erosion also sent in, however, on Dermatology fellow's examination, there were no bullae, only erosions. The biopsy sites were sutured with #5 Ethilon, two sutures were used at each site. These sutures will need to be removed in approximately two weeks. The above procedure was done by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 103104], pager number [Serial Number 103105] [Hospital1 756]. They also recommended swabbing the neck erosions for cultures which look slightly purulent. Other entities on differential diagnoses include Staphylococcus skin syndrome, which is possible but probably not likely in this case. We did sent pan-cultures for urine, sputum and blood. We also started her on normal saline fluids at a rate of only 60 cc per hour for now. We were concerned that she might have had some congestive heart failure on her chest x-ray. Also, she had a very small intravenous line that was in her finger and we were worried about losing access overnight. Her intakes and outputs over an eight hour period overnight was 925 cc in with a urine output of 305 cc per hour. Her other work-up for the rash revealed an ESR of 20 which is high normal, A TSH and [Doctor First Name ] which are pending, and a rheumatoid factor which returned as negative. 2. Infectious Disease: She was placed on precautions upon admission here for a history of VRE in the urine, which was treated with Linezolid in [2177-6-9]. Also with a history of Methicillin resistant Staphylococcus aureus. All antibiotics were held at this point and her white blood cell count, though, was slightly elevated (she is on Prednisone), which was basically normal and she was afebrile. Dermatology also suggested getting viral cultures of the punched out lesions of the peri-rectal area that they saw. Other Infectious Disease issues were that the sputum culture Gram stain had returned with greater than 25 polys, less than 10 epithelials, however, four plus Gram negative rods. Her secretions were slightly yellow and thick but as she was afebrile and was in the setting of an acute rash, SESSION: did not start antibiotics. Her blood cultures from [11-25] were no growth to date so far. 3. Renal: The patient is in acute renal failure; likely multi-factorial including recent ACE inhibitor, pre-renal causes secondary to a recent increased dose of her Lasix, like maybe congestive heart failure, poor oncotic pressure secondary to low albumin and nephrotic range proteinuria. Likely AIN, especially given increased peripheral eosinophils as well as rash. We decided to send her urine for electrolytes as well as urine for urine urea to check an FE urea. These are pending at the time of this dictation. Urine EOs were sent. We obtained a renal ultrasound and the results are listed above. She was put in for a cardiac echocardiogram and we decided to rule out myocardial infarction in case myocardial infarction with congestive heart failure had occurred in this case. 4. Hypertension: The patient was continued on Hydralazine 100 four times a day; Clonidine 0.3 three times a day; Metoprolol 100 four times a day, Labetalol 200 q. six hours; Isosorbide 40 three times a day, but the Amlodipine was held. Her blood pressure had ranged from 143 to 174 systolic overnight. It was decided to initiate a work-up for the secondary causes of her hypertension. It appears that since her kidneys are both of normal size, even though Dopplers were unable to be done, that the likelihood of renal artery stenosis was maybe low, however, the test is not definitive. At this time, we are avoiding all ACE inhibitors. 5. Chronic obstructive pulmonary disease: We are continuing Albuterol and Atrovent MDI. 6. For diabetes mellitus type 2, we initiated four times a day fingersticks with a regular insulin sliding scale as well as continue her NPH insulin at 20 units q. a.m. and 20 units q. p.m. 7. For her anemia with her a very low MCV which is likely secondary to her history of thalassemia trait. A type and screen was sent and her Epogen was continued. 8. Gastrointestinal: She was continued on Colace and p.r.n. Bisacodyl. Her tube feeds were started. Stools were guaiac, however, she had not had a stool. A GGT was checked because of her elevated alkaline phosphatase and this was also found to be elevated at a level of 68. 9. History of pericardial effusion status post window. This is another reason that we wanted to check a transthoracic echocardiogram. She had cardiomegaly on chest x-ray, however, there is no evidence of tamponade on her EKG. 10. Fluids, Electrolytes and Nutrition: Most of this was already discussed in the renal section. She was gently hydrated with normal saline 60 cc per hour overnight. The BUN and creatinine appear to have maybe remained stable now. She had hypoalbuminemia and Nutrition was consulted. We are continuing her calcium carbonate. We are also continuing free water boluses 125 cc per hour q. eight hours per the G-tube. However, if her sodium continues to decrease, then these can be stopped. Her electrolytes probably need to be followed twice a day. 11. Ventilator: She is currently on assist control 500 x 12, 5 of PEEP/40% saturation and is saturating well. There is no current reason to change her ventilation settings at this time. 12. Prophylaxis: She is on subcutaneous heparin and Protonix. 13. Tubes, lines and drains: She arrived to the floor with one very small peripheral intravenous in her left finger. A consultation in the a.m. was put in for a STAT PICC line. The Interventional Team had assessed her at the bedside and at the time of this dictation, it appears that she will not be undergoing PICC placement, but rather will attempt to place some sort of central line. It is unknown exactly how we are going to obtain this access at the point of this dictation. A Foley catheter is in place. 14. FULL CODE. CONDITION AT DISCHARGE: Fair. DISCHARGE STATUS: It was recommended by Dermatology that she would benefit from transfer to a Burn Unit. At this time, she has been accepted to go to the [Hospital6 ] Burn Unit. Of note, it was decided not to start her on intravenous IgG at this point. DISCHARGE MEDICATIONS: 1. Amlodipine 10 mg q. day p.o., recently began on [11-22], after the rash had appeared, but has been held today. 2. Hydralazine 100 mg four times a day; she has been on this medication for a while. Please note that the Vent-Core sheets report that she began this medicine on [11-21], however, this was only a renewal according to Dr. [Last Name (STitle) ]. 3. Lasix 40 mg twice a day. 4. NPH 20 units twice a day. 5. H2O 125 cc three times a day. 6. Benadryl 25 mg q. eight hours. 7. Subcutaneous heparin 5000 twice a day. 8. Prednisone 5 mg q. day. 9. Protein soy supplement, two scoops in the feeding tube q. eight hours. 10. Nepro 3/4 strength tube feeds 35 cc per hour. 11. Clonidine 0.3 three times a day. 12. Bisacodyl 10 mg q. day p.r.n. 13. Regular insulin sliding scale with Humulin. 14. Lopressor 100 mg four times a day. 15. Labetalol 200 mg four times a day. 16. Isosorbide dinitrate 40 mg q. eight hours. 17. Sublingual Nitroglycerin p.r.n. 18. Protonix 40 q. day. 19. Epogen 40,000 units subcutaneously weekly. 20. Brimonidine 0.2% solution, one drop bilaterally q. eight hours. 21. Eiazdolamide one drop solution to each eye three times a day. 22. Ativan 1 mg q. eight hours. 23. Calcium carbonate 500 mg q. eight hours. 24. Ipratropium and Albuterol MDI four puffs q. four hours p.r.n. DISCHARGE DIAGNOSES: 1. Acute renal failure. 2. Rash most consistent with toxic epidermal necrolysis (TEN). 3. Severe hypertension on several anti-hypertensive. 4. Chronic obstructive pulmonary disease. 5. Status post tracheostomy [7-17] and PEG [7-28]. 6. Status post pericardial effusion with window placement on [7-9]. 7. History of bilateral pleural effusion. 8. History of breast cancer as above. 9. Type 2 diabetes mellitus. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 210] MEDQUIST36 D: [2177-11-26] 13:53 T: [2177-11-26] 15:00 JOB#: [Job Number 103106]	[ "5849", "5119", "496", "4019" ]
Admission Date: [2168-7-29] Discharge Date: [2168-8-12] Date of Birth: [2094-1-2] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath and chest heaviness Major Surgical or Invasive Procedure: Aortic Valve Replacement utilizing a 21 millimeter [Last Name (un) 3843] [Doctor Last Name ] bioprosthesis History of Present Illness: Mrs. [Known lastname 36589] is a 74 year old female with ESRD, diabetes mellitus, hypertension and elevated cholesterol. She also has known aortic stenosis and coronary disease, undergoing a percutaneous intervention to the LAD back in [2160]. She was in her usual state of health until the night prior to admission, where she developed acute shortness of breath. EMS was notified and she was taken to OSH where she was diuresed with intravenous Lasix. She was subsequently transferred to [Hospital1 18]. While in the EW, she became hypotensive and started on Dopamine. She went on to develop wide complex tachycardia requiring DCCV back to a normal sinus rhythm. Dopamine was discontinued. Post DCCV, EKG was remarkable for ST depressions v2-v6. She remained hypotensive and subsequently started on Levophed. Repeat EKG was notable for resolution of subendocardial ischemia. Her hemodynamics stablized and she was admitted for further medical/surgical management. Past Medical History: HTN, ESRD - on HD, CAD - s/p LAD stent, Diabetes mellitus, Hypercholesterolemia, Hypothyroidism, Osteoarthritis, s/p Left Hip fracture, Ovarian Cancer - s/p TAH/BSO with ELAP Social History: Lives alone in senior living. Able to perform daily activities without help. Denies alcohol or tobacco use. Family History: Denies premature coronary disease. Sister underwent CABG in her 70's. Physical Exam: Temp: 97.0 BP: 92/42 Pulse: 87 Resp: 18 O2 SAT: 94% on 4L General: Elderly female with moderate dyspnea HEENT: Oropharynx benign Neck: supple, JVP approximately 10-15 cm Lungs: bibasilar crackles Heart: Regular rate, s1s2, 3/6 systolic ejection murmur radiating to carotid regions Abdomen: obese, soft, nontender, nondistended, no pulsatile masses or organomegaly Ext: 1+ edema bilaterally Neuro: Grossly intact, no focal deficits noted Distal Pulses: 1+ bilaterally Pertinent Results: [2168-8-10] 04:32AM BLOOD WBC-5.7 RBC-3.65* Hgb-10.3* Hct-33.6* MCV-92 MCH-28.1 MCHC-30.6* RDW-15.3 Plt Ct-169 [2168-8-11] 10:45AM BLOOD PT-21.0* PTT-41.3* INR(PT)-2.9 [2168-8-11] 05:08AM BLOOD Glucose-121* UreaN-26* Creat-3.7# Na-139 K-4.0 Cl-100 HCO3-27 AnGap-16 BILAT UP EXT VEINS US [2168-8-9] 12:08 PM CLINICAL DETAILS: Query right upper limb DVT. FINDINGS: There is acute noncompressible thrombus within the inferior portion of the right internal jugular vein and also the right axillary vein. On Doppler, there is also absent venous flow in the right subclavian vein. The right brachial and basilic veins are patent and compressible. CONCLUSION: Acute right upper limb deep venous thrombosis. Doppler ultrasound of the left upper limb shows patent and compressible vessels. Brief Hospital Course: Due to her complicated ED course, Mrs. [Known lastname 36589] was admitted to the CCU. She remained on Levophed. She was followed closely by the renal service and continued on her routine dialysis schedule. She was well known to the cardiac surgical service and was previously being followed for her aortic valve stenosis. Further surgical evaluation included a dental consult and bedside examination which found no evidence of infection. While in the CCU, she remained symptom free and was slowly weaned from pressor support. Amiodarone was eventually started for atrial fibrillation prophylaxis. She remained in a normal sinus rhythm - no atrial or ventricular arrhythmias were noted. Further surgical workup was unremarkable and she was eventually cleared for surgery. On [8-2], Dr. [Last Name (STitle) ] performed an aortic valve replacement utilizing a 21 millimeter [Last Name (un) 3843] [Doctor Last Name ] bioprosthesis. Surgery was uneventful and she was transferred to the CSRU. Within 24 hours, she was extubated. She remained pressor dependent and continued on Amiodarone for atrial fibrillation prophylaxis. Hemodialysis was continued per renal recommendations. She was transfused with packed red blood cells to maintain hematocrit near 30%. She remained mostly in a normal sinus rhythm - brief runs of paroxysmal atrial fibrillation were noted on telemetry. Over several days, her hemodynamics improved. Due to anuria, her foley catheter was removed. On postoperative day four, she transferred to the SDU. She remained on Amiodarone. She remained in a normal sinus rhythm - no further dysrhythmia were noted. Dialysis was continued. An ultrasound was obtained on [8-9] for right upper extremity swelling which showed thrombus in the RI, R subclavian and R axillary vein. She was started on heparin and Coumadin and by POD#9 her INR had quickly risen to 3.0. Her heparin was discontinued. She is to remain on Coumadin for 6 months for this DVT per the vascular surgery service. Also on POD#7 she developed diarrhea which was positive for C.Diff and she was started on Flagyl with resolution of the diarrhea. Medications on Admission: Aspirin, Lipitor 20 qd, Lopressor 25 [Hospital1 ], Avandia, Glipizide 2.5 qd, Renagel 800 tid, Synthroid 175 mcg qd Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day. 7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 12 days. 10. Warfarin Sodium 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 6 months: 2mg today and tomorrow, check INR Sunday, and dose for target INR 2.5-3.0. Disp:60 Tablet(s)* Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Aortic stenosis - status post Aortic Valve Replacement utilizing a 21 millimeter [Last Name (un) 3843] [Doctor Last Name ] bioprosthesis. End stage renal disease - on hemodialysis. Diabetes Mellitus. Hypertension. Hypercholesterolemia. Coronary Artery Disease. Hypothyroidism. Discharge Condition: Stable Discharge Instructions: Patient may shower. Pat dry only. No baths, creams or lotions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks. Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks Dr. [Last Name (STitle) 31187] in 2 weeks Completed by:[2168-8-12]	[ "40391", "2449", "2720", "412" ]
Admission Date: [2103-10-14] Discharge Date: [2103-10-23] Date of Birth: [2042-6-26] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain, Transfer from [Hospital3 3583] Major Surgical or Invasive Procedure: Coronary artery bypass graft ( LIMA-LAD, SVG -diagonal, Obtuse marginal, diagnonal RCA) History of Present Illness: 61M with PMH of CAD s/p AMI in [2094], multiple PCI, HLP, HTN, [Hospital ] transferred from [Hospital3 3583] where he presented with chest pain. Patient states he had approximately 30 minutes of substernal chest pressure this afternoon at 3:45pm while watching football. It felt like an elephant was sitting on his chest, non-radiating. Stated it felt the same as when he had his heart attack in [2094]. Not associated with SOB, diaphoresis or nausea. He and his wife left to go to the hospital, but the pain continued so they stopped at a local fire station where he received 2 SLNG and an ASA and was brought to [Hospital3 3583]. There his EKG showed slight STD in 1 and AVL. He was chest pain free by the time he arrived at [Hospital1 46]. In the ED here, VSS, was chest pain free. EKG unchanged from prior. Trop here was 0.03 with CK of 46. CXR clear by my read. Admitted from ROMI. Upon transfer to the floor, patient is still chest pain free. He feels back to his baseline. Denies any current CP, SOB, N/V/D, HA or vision changes. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)HTN 2. CARDIAC HISTORY: AMI in [2094] with RCP thrombectomy -CABG: None -PCI: Has had 5 caths here at [Hospital1 18], last one in [2100]: [2100]: COMMENTS: 1. Selective coronary angiography showed a right dominant system with patent but mildly disease LMCA. The LAD had moderate diffused disesae proximally and was totally occluded within the old [Doctor First Name 10788] stent. the distal vessel was diffusely diseased and filled via R->L collaterals. LCX had mild diffuse disease and the RCA stent had only mild ISR but were otherwise patent. 2. Left ventriculography was deferred. 3. Limited hemodynamics showed normal aortic systemic pressures. 4. Successful placement of two overlapping Cypher drug-eluting stents (2.5 x 28 mm distally and 3.0 x 18 mm proximally) in the proximal to mid-LAD to treat in-stent restenosis and a total occlusion. A high pressure inflation was performed with a 3.0 mm balloon. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). FINAL DIAGNOSIS: 1. One vessel coronary disease. 2. Successful placement of drug-eluting stents in the LAD. -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: HTN Hyperlipidemia DM - on po meds Obesity Social History: He is married with three children, currently not working (worked previously as a [Doctor Last Name 9808] operator) - supposed to start again on Tuesday. Moderate amount of stress because he hasn't worked in 6 months. No current or prior tobacco use. Has rare alcohol use. Family History: Mother died at 59 of an myocardial infarction. Father alive and in good health. Brother, question of an myocardial infarction at age 45. Physical Exam: VS: T=98 BP=150/82 HR= 80 RR=15 O2 sat=RA GENERAL: Well appearing middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with 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: NABS, obese. Soft, NTND. . EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: radial and DP 2+ bilaterally Pertinent Results: CCath: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed three vessel CAD. The LMCA was angiographically normal. The LAD had a 90% stenosis proximal to the prior series of stents, and was occluded in the mid portion of the stent. The distal LAD fills by faint left to left collaterals with an apparently good caliber vessel. The LCX had progression of disease up to 70% in the proximal vessel. The RCA had a tight 90% in stent restenosis within the proximal vessel. The remaining RCA was of large caliber. 2. Limited resting hemodynamics demonstrated mild systemic arterial hypertension with BP of 142/80mmHg. LVEDP was modestly elevated at 25mmHg. There was no gradient on pullback of catheter from LV to aorta. 3. Left ventriculography demonstrated anterolateral and apical hypokinesis with preserved wall motion of the basal segments. Overall EF was estimated to be 50%. There was no mitral regurgitation. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Anterolateral LV hypokinesis with low normal ejection fraction. 3. LV diastolic dysfunction. 4. Systemic arterial hypertension. Echo: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the anterior septum and anterior walls. The apex is mildly aneurysmal and hypokinetic. The remaining segments contract normally (LVEF = 45 %). No masses or thrombi are seen in the left ventricle. 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 appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD (mid-LAD distribution). Carotid U/S: Impression: Right ICA stenosis <40% . Left ICA with stenosis <40% . Vein Mapping: FINDINGS: The greater saphenous veins are patent bilaterally from the level of the ankle through to the saphenofemoral junction. Please see digitized images on PACS for formal sequential measurements. There is an element of varicose dilatation involving the right greater saphenous vein. ECG: Sinus rhythm. Q waves in the inferior leads consistent with prior infarction. Late transition with tiny R waves in the anterior leads consistent with possible prior anterior wall myocardial infarction. Non-specific ST-T wave changes. Compared to the previous tracing possible anterior wall myocardial infarction is new. COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2103-10-22] 05:40AM 12.0* 3.50* 10.2* 30.8* 88 29.3 33.2 14.4 242 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2103-10-22] 05:40AM 176* 11 0.9 137 4.4 101 28 12 Brief Hospital Course: Mr [Known lastname 30222] is a 61 year old male with known coronary artery disease s/p stenting in the past who presented to an OSH with chest pain. Was transffered to [Hospital1 ] for evaluation for revasularization. On [2103-10-15] Mr. [Known lastname 30222] had a cardiac catheterization, which showed three vessel disease. He was taken to the OR on [2103-10-19] for for coronary artery by grafting(LIMA-LAD, SVG- [Last Name (LF) ], [First Name3 (LF) ], dRCA)- see operative note for details. Post operatively, Mr. [Known lastname 30222] was transferred to the intensive care unit for ongoing hemodyanmic monitoring and mechanical ventilation in stable condition. On the evening of his surgery he was weaned and extubated. His statin and beta blocker were resumed and diuresis was begun. The following day he was transferred from the ICU to the step down floor for ongoing postoperative care. His chest tubes and temporary pacing wires were removed per protocol. He was evaluated by physical therapy for strength and conditioning and was cleared for discharge to home on POD#4 in stable condition. Medications on Admission: Metformi n500mg [Hospital1 ] Januvia Toprol 200 mg qd Fish Oil Aspirin 325 mg qd Hydrochlorothiazide 12.5 mg qd Enalapril 2.5 mg qd Isosorbide Mononitrate (Extended Release) 30 mgqd Atorvastatin 20 mg Clopidogrel 75 mg PO qd 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO qhs (). Disp:30 Tablet(s) Refills:2 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 8. Janumet 50-500 mg Tablet Sig: One (1) Tablet PO bid (). Disp:60 Tablet(s) Refills:2 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:60 Tablet(s) Refills:0 10. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:20 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] [Location (un) 5087] Discharge Diagnosis: s/p Coronary artery bypass graft x4 Hypertension hyperlipdemia Diabetes Neuropathy coronary artery disease with multiple stents S/P RCA thrombectomy and stenting IMI [2094] Gout head injury s/p traumatic fall [2102] right hand surgery tonsillectomy Discharge Condition: good Discharge Instructions: no lotions, creams, powders or ointments on any incision shower daily and pat incisions dry no lifting greater than 10 pounds for 10 weeks no driving for one month AND off all narcotics call for fever greater than 100, redness, drainage, or weight gain of 2 pounds in 2 days or 5 pounds in one weeks Followup Instructions: Please schedule the folllowing appointments: Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 30223] [Name (STitle) 30224] [Doctor Last Name ] (primary care) in 2 weeks [Telephone/Fax (1) 13687] Dr. [Last Name (STitle) 3321] in [2-13] weeks. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2103-10-23]	[ "41401", "2724", "4019", "412", "V4582", "V5867" ]
Admission Date: [2130-12-5] Discharge Date: [2130-12-25] Date of Birth: [2081-9-29] Sex: F Service: NEUROSURGERY Allergies: Amoxicillin Attending:[First Name3 (LF) 78] Chief Complaint: Headache Major Surgical or Invasive Procedure: Cerbral angiogram w/coiling of the R MCA aneurysm [2130-12-5] Cerebral angiogram [2130-12-8] Cerebral angiogram [2130-12-12] Cerebral angiogram [2130-12-18] Cerebral angiogram [2130-12-25] History of Present Illness: HPI: 49 yo F with no significant PMHx c/o the worst HA of her life at 2 am on [2130-12-4]. The headache subsided somewhat but then became worse and she was eventually brought to an outside hospital where she was found to have a SAH and R sylvian SAH. She complains of headache, notes she is tired. No nausea/vomiting, no weakness/numbness. Past Medical History: PMHx: h/o pilonidal cyst removal Social History: Social Hx: +1 ppd smoker Family History: Family Hx: mother - "stroke" Physical Exam: On admission: PHYSICAL EXAM: O: T: 98.1 BP: 103/50 HR: 63 R 20 O2Sats 97% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 2mm min react bilat EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Asleep, awakens to voice, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [4-12] objects at 5 minutes. 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, 2mm reactive 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 [6-14] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: CTA Head [2130-12-5]: IMPRESSION: 1. Unchanged extensive subarachnoid hemorrhage centered within the right sylvian fissure and extending into the basal cisterns. 2. An 8 x 14 x 6 mm multilobulated aneurysm at the bifurcation of the right middle cerebral artery. CT Head [2130-12-6]: IMPRESSION: Status post recent right MCA bifurcation aneurysm with unchanged subarachnoid hemorrhage, but no evidence of large vascular territorial infarction. Brief Hospital Course: Pt was admitted through the emergency department after OSH imaging revealed SAH and possible aneurysm. She was admitted to the ICU for close observation. She was started on Dilantin and Nimodipine. On the morning of admission she was taken to the angio suite and while under general anesthesia had coiling of the right MCA aneurysm. She tolerated the procedure well and was extubated immediately after. A cat scan was performed the following am to assess for hydrocephalus and / or infarct. This showed unchaged SAH with no evidence of infarct. On [12-8], patient remained intact. On [12-8] she returned for a cerebral angiogram which showed patency of On [12-12] patient underwent a follow up angiogram which showed moderate vasospasm in the right MCA. Patient will continue to be watched in the hospital and be monitored for stroke symptoms in the setting of vasospasm. On [12-14],The patient had a hand surgery consult for a superficial pustule on the dorsum of the left hand. A procedure ws performed to decompress pustule.1cc 1% lidocaine injected subcuteously. Overlying skin resected off sharply. No expressible pus. Cx swabs taken from wound bed. Irrigated w/ normal saline. Dry dressing applied.It was determined that dry sterile dressing changes daily until completely dry. No antibiotics were required as no cellulitic component was noted and the pustule was thoroughly debrided. On [12-15] the patient was transferred to the floor from the step down unit. On [12-16] and [12-17] the patient was seen. The patient experienced a headache behind her right eye with stabbing sensation in the back of the head. On [12-18], The patient underwent cerebral angiogram which showed severe spasm of the supraclinoid area. She was returned back to the step down for close neurochecks and started back on IV fluids. On [12-19] she complained of some right eye wavy vision. Opthamology saw the patient and felt it might related to BP drops with Nimodipine adminstration. Her Nimodipine was changed from 60mg Q4 to 30mg Q2 which she tolerated well. She remained stable and remained in the Step Down Unit until [12-25] when she was transferred to the floor. She had a repeat Cerebral Angiogram on [12-25] which was stable, she was monitored for a couple of hours and then discharged home on [12-25]. Medications on Admission: none Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [2-11] Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Brain Aneurysm: R MCA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Coiling Medications: ?????? Take Aspirin 325mg (enteric coated) 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 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 What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or [Known lastname ], 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 our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: You will need to be seen by Dr. [First Name (STitle) ] in the clinic on 4 weeks with a MRI/MRA of the brain. Takeisha ([Telephone/Fax (1) 4296]) will call you to make these appointments. Completed by:[2130-12-25*]	[ "5990", "3051" ]
Admission Date: [2137-4-29] Discharge Date: [2137-5-5] Date of Birth: [2061-10-28] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Codeine / Diazepam / Benzodiazepines / Iodine Attending:[First Name3 (LF) 443] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Pericardiocentesis, Right heart catheterization History of Present Illness: This is a 75 yof with hx of CAD s/p cardiac cath with RCA stent in [2-/2136], HTN, Hyperlipidemia, GERD, Afib, diastolic dysfunction, pericardial effusion, pulmonary HTN who presented to [Hospital3 ] after 7 days of increasing SOB, 3lb weight gain. Upon review of [Hospital1 ] records it appears pt was treated for CHF exacerbation, an Echo was performed which showed significant pulmonary HTN in the 90s, preserved EF and moderate sized effusion in the posterior aspect, small anterior pericardial effusion. During her admission she was also noted to be anemic with a Hct of 25 from a previously established Hct of 32 and was transfused 2u PRBCs. Following her Echo findings of an effusion as well as pulmonary HTN pt was transferred to [Hospital1 18] for right cardiac catheterization and evaluation for possible pericardial effusion. Pt denies any current chest palpitations, pain, pre-syncope symptoms. She does endorse some shortness of breath which is worse than when she was at home but the same as it was in [Hospital1 2519]. She endorses a cough with productive white/grey sputum. She endorses diarrhea which she has had for months, usually watery. She denies any n/v/f/c, abdominal pain, focal numbness and tingling. Past Medical History: Hypertension Hyperlipidemia Atrial fibrillation S/P TIA Depression Bilateral cataract surgery Angina Pneumonia/ Bronchitis GERD Anemia Arthritis Irritable bowel syndrome Chronically elevated WBC for past 8 years s/p TAH/BSO - also reports history of R "ovary explosion" as a young adult Hx cholecystectomy and appendectomy Cardiac Risk Factors: Hyperlipidemia, Hypertension Percutaneous coronary intervention - reports previous cath, unsure of date and location Social History: Social history is significant for the absence of current tobacco use. Hx of tobacco last use [2103] - 2-3 packs/day X 15yrs. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Pt is a widow, lives in [Location 5110]. Has 6 children and 17 grandchildren Physical Exam: VS: T=97.8, BP=141/64, HR=90, RR=22, O2 sat=93-96% on 3l GENERAL: Obses Caucasian Elderly Female in tripod position tachypneic on 3 l NC saturating well. HEENT: EOMI, MMM NECK: JVP significantly elevated CARDIAC: S1, S2, ?pericardial rub, tachycardic to 110 irregularly, irregular. Pulsus Paradoxus 8. LUNGS: Crackles noted b/l mid thorax down. ABDOMEN: Soft, obese, NT, ND. No HSM or tenderness. EXTREMITIES: 2+ mixed edema to the knees b/l. Pertinent Results: IMAGING of RELEVANCE: [2137-4-29] ECHO The left atrium is markedly dilated. The right atrium is markedly dilated. Left ventricular cavity size is normal. Left ventricular wall thicknesses are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a large pericardial effusion. The effusion appears circumferential, but is largest (> 3cm) posterior to the left ventricle. There is approximately 1 cm of fluid anterior to the right ventricle. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2136-3-2], the pericardial effusion is larger. The severity of tricuspid regurgitation is increased. Estimated pulmonary artery pressures are higher. The right ventricular cavity size appears enlarged with global hypokinesis. The ventricular rate is faster. . [5-1]/ECHO Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is a moderate sized, echo dense inferior and inferolateraly pericardial effusion without evidence for hemodynamic compromise. Compared with the prior study (images reviewed) of [2137-4-30], the pericardial effusion is now larger and echo dense suggestive of thrombus/clot. In retrospect, a smaller echo dense pericardial effusion may have been present on the prior study, but if so, the effusion is larger and much more apparent on the current study. Clinical correlation and serial evaluation is suggested. ------------------ LABS of RELEVANCE: . [2137-5-5] 04:55AM BLOOD WBC-21.8* RBC-3.19* Hgb-9.2* Hct-28.2* MCV-88 MCH-28.8 MCHC-32.6 RDW-18.3* Plt Ct-389 [2137-5-4] 05:08AM BLOOD WBC-22.5* RBC-3.24* Hgb-9.1* Hct-28.2* MCV-87 MCH-28.2 MCHC-32.3 RDW-18.2* Plt Ct-421 [2137-5-3] 05:40AM BLOOD WBC-22.5* RBC-3.09* Hgb-8.7* Hct-26.9* MCV-87 MCH-28.2 MCHC-32.5 RDW-18.9* Plt Ct-397 [2137-5-2] 05:15AM BLOOD WBC-28.4* RBC-3.36* Hgb-9.4* Hct-29.5* MCV-88 MCH-28.1 MCHC-32.0 RDW-18.3* Plt Ct-457* [2137-5-1] 05:00AM BLOOD WBC-23.1* RBC-3.18* Hgb-9.1* Hct-27.3* MCV-86 MCH-28.6 MCHC-33.3 RDW-18.8* Plt Ct-462* [2137-4-30] 06:40AM BLOOD WBC-24.7* RBC-3.15* Hgb-9.0* Hct-26.9* MCV-85 MCH-28.5 MCHC-33.4 RDW-18.7* Plt Ct-472* [2137-4-29] 07:17PM BLOOD WBC-21.8* RBC-3.20# Hgb-9.0# Hct-27.3# MCV-85 MCH-28.1 MCHC-33.0 RDW-18.6 Plt Ct-503* [2137-5-2] 05:15AM BLOOD Neuts-94* Bands-3 Lymphs-2* Monos-0 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2137-5-1] 05:00AM BLOOD Neuts-94* Bands-0 Lymphs-3* Monos-1* Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [2137-5-5] 04:55AM BLOOD PT-19.4* PTT-33.4 INR(PT)-1.8* [2137-5-4] 01:30PM BLOOD PT-19.9* PTT-32.8 INR(PT)-1.9* [2137-5-2] 05:15AM BLOOD PT-17.3* PTT-32.0 INR(PT)-1.6* [2137-5-1] 05:00AM BLOOD PT-16.1* PTT-31.9 INR(PT)-1.4* [2137-5-5] 04:55AM BLOOD Glucose-132* UreaN-53* Creat-1.1 Na-142 K-4.9 Cl-98 HCO3-33* AnGap-16 [2137-5-4] 05:08AM BLOOD Glucose-107* UreaN-55* Creat-1.2* Na-142 K-4.7 Cl-101 HCO3-32 AnGap-14 [2137-5-3] 05:40AM BLOOD Glucose-104 UreaN-57* Creat-1.1 Na-141 K-3.6 Cl-97 HCO3-31 AnGap-17 [2137-5-2] 05:15AM BLOOD Glucose-132* UreaN-60* Creat-1.3* Na-140 K-4.1 Cl-97 HCO3-30 AnGap-17 [2137-5-1] 03:44PM BLOOD UreaN-62* Creat-1.4* Na-138 K-4.1 Cl-96 HCO3-30 AnGap-16 [2137-5-1] 05:00AM BLOOD Glucose-247* UreaN-62* Creat-1.3* Na-131* K-4.1 Cl-92* HCO3-27 AnGap-16 [2137-4-30] 06:40AM BLOOD Glucose-123* UreaN-67* Creat-1.4* Na-132* K-5.1 Cl-94* HCO3-25 AnGap-18 [2137-4-30] 06:40AM BLOOD LD(LDH)-703* CK(CPK)-28 [2137-4-29] 07:17PM BLOOD CK(CPK)-27 [2137-4-30] 06:40AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2137-4-29] 07:17PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2137-5-5] 04:55AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 [2137-5-4] 05:08AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9 [2137-5-1] 03:44PM BLOOD calTIBC-194* Ferritn-717* TRF-149* [2137-5-2] 02:38PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.017 [2137-4-29] 08:26PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 [2137-5-2] 02:38PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2137-4-29] 08:26PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2137-5-2] 02:38PM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-NONE Epi-0-2 PERICARDIAL EFFUSION: [2137-4-30] 04:30PM OTHER BODY FLUID WBC-1000* Hct,Fl-<2.0 Polys-84* Lymphs-5* Monos-10* Eos-1* [2137-4-30] 04:30PM OTHER BODY FLUID TotProt-6.0 Glucose-100 LD(LDH)-642 Amylase-21 Albumin-2.8 Brief Hospital Course: # CORONARIES: Pt noted to have mild Troponin leak of 0.02-0.04 in the setting of poor renal perfusion. Pt has CAD with h.o. stent to the RCA. Do not suspect current ichemia given lack of ST changes during hospitalization. Pt was continued on home regimen of Metoprolol, Atorvastatin, ASA # PUMP: During admission pt was noted to be hypervolemic on examination with diffuse crackles on pulmonary auscultation, mixed 2+ edema in b/l lower extremities. Pt was started on a Furosemide gtt for diuresis and then transitioned to a PO regimen of Furosemide 80mg [Hospital1 ]. Pt was instructed to weigh herself every morning and call her Cardiologist if she noted any difference of more than 2 lbs. # RHYTHM: During hospitalization pt was noted to be in A. fibrillation initially with rapid ventricular response of 120-130. On day of transfer pt was noted to have SOB with a rate in the 140s after which she received IV Metoprolol 5mg Tartrate with response of heart rate within 100-120. Pt was changed to Metoprolol 100mg Taretrate TID, a heart rate of 100-120 was tolerated given the presence of hypoxia, pulmonary HTN, pericardial effusion. Pt was restarted on her Coumadin prior to discharge. # Pericardial Effusion: Pt was noted to have 2 pericardial effusions, moderate size in the posterior aspect, small effusion in the anterior portion. Pt underwent pericardiocentesis that was noted to show 800cc serosanguinous fluid. Analysis of fluid showed WBC 1000 but negative on fluid culture, anaerobic culture, AFB smear. Gram stain also nowed no microorganisms and 2+ Polymorphonuclear leukocytes. Cytology was also negative, an autoimmune panel of [Doctor First Name ], double stranded DNA were still pending at time of discharge but unlikely to be positive given her lack of symptoms in the past. Following pericardiocentesis pt was noted to have an echodensity collection thought to be clot formation. Re-examination with repeat Echos showed no changes thus indicating no unstable bleed into the pericardium. Suspect that the collection has always been present but hidden from prior Echos because of the pericardial fluid superimposed around it. - Recommend pt undergo repeat Echo in 1 week to again reassess pericardium, specifically possibility of constrictive pericarditis. # Psych: During hospitalization pt was noted to be intermittently confused primarily with delusions of being tied up or mistreated. Psychiatry were consulted and determined pt may have been having delirium super imposed on mild dementia. Per Psych recommendations pt was started on Seroquel at bedtime. Alprazolam was discontinued due it's increased risk of Delirium. Prior to discharge pt agreed to Psychiatry follow up as an outpatient, Psychiatry touched base with pt's PCP regarding this issue. # Pulmonary HTN: Pt has a history of Pulmonary HTN per transfer summary, it appears she was started on oxygen last [Month (only) 359] for it but has never been worked up. She last saw a Pulmonologist several years ago for her asthma. Her reason for transfer was due to her noted pulmonary pressures in the 90s-100s on Echo, right heart cath was performed to determine whether etiology is cardiac versus Pulmonary. Her right heart cath pressures are notable for a high mean pressure, higher PA diastolic pressure when compared to the wedge (which is elevated by itself). From her right heart cath results it is likely that there is a cardiac component superimposed on a pulmonary one given the elevated Wedge with an even greater PA diastolic pressure. I clinically suspect that there are two processes going on - acute and chronic. Her diastolic dysfunction and fluid overload state are likely the acute causes of her pulmonary HTN. I do believe though that she does have a chronic underlying pulmonary HTN that is due to a pulmonary process. Pt has OSA and is intermittently non-adherent to it which is likely a component, pt also has a smoking history and may have a COPD component too (no PFTs available). Pt also has a history notable for numerous pneumonias as a child and adult, it is possible that with recurrent infection that may be some pulmonary fibrosis which may be working in addition to the aforementioned OSA and COPD. Autoimmune conditions such as Rh. Arthritis, Lupus may also cause pulmonary HTN particularly given her pericardial effusion, pleural effusion. She does not though have any prior history of autoimmune symptoms and it would be atypical for her first presentation to be at this age. Chronic PEs is another diagnosis to consider however prior to this transfer she had been on Coumadin for her A. fib. Unfortunately further studies such as PFTs, high-res Chest CT are not helpful given her current hypervolemic status. Discussed this with family who preferred a pulmonary physician in [Hospital3 ]. - Recommend pt set up Pulmonary appointment for Pulmonary HTN work up - pt discharged onb home regimen of 2l NS to be worn at all times - encouraged pt to continue her CPAP at home # Leukocytosis: Pt has history of leukocytosis from her myelodysplastic syndrome. On review of her records from [Hospital1 2519] it appears her WBC trended up and then down from 16.1->25.3 over several days and then trended down to 23.3 prior to transfer. Her WBC has been trending up during this hospitalization from 21.8->24.7->23.1->28.4->22.5->22.5->21.8. Likely due to her MDS as she did not show any signs of infection during admission. # OSA: Continued pt in hospital on CPAP. Recommended she continue it as an outpatient. # Myeloproliferative d/o: Pt has JAK-2 mutation with a history of leukocytosis. Pt was previously on hydroxyurea when she was noted to be in polycythemia [Doctor First Name ]. Following a decrease in her Hct she was then transitioned briefly to Procrit. No [First Name9 (NamePattern2) ] [Doctor First Name ] or anemia noted during hospitalization. # HTN: Pt was continued on Amlodipine and Metoprolol. # GERD: Pt was continued on Omeprazole and Maalox PRN. # Depression: Pt was conrinued on her home regimen of Fluoxetine daily. Medications on Admission: Calcium/Vit D [Hospital1 ] Folic Acid 1 Toprol 100 [Hospital1 ] Norvasc 5 Mag Oxide 400 [Hospital1 ] Iron 325 [Hospital1 ] Imdur 120 qam Lisinopril 40 daily ASA 81 Omeprazole 20 [Hospital1 ] Oxcarbazepine 150 [Hospital1 ] Prozac 40 Bumex 3 Colchicine 0.6 Calcitonin INH Coumadin 5 qhs Lipitor 80 Flonase nasal Lidoderm prn Vicodin prn tylenol prn Nitro prn xanax prn Discharge Medications: 1. Oxygen Prescription Pt will need Oxygen at all times on 2lpm 2. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. 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 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal QHS (once a day (at bedtime)). Disp:1 bottle Refills:2 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day: Please take at 8am. Disp:30 Tablet(s) Refills:2 11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). Disp:30 Tablet(s) Refills:2 12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation four times a day. Disp:1 inhaler Refills:2 14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day: Please take at 1600. Disp:30 Tablet(s) Refills:2 15. Outpatient Lab Work Please have your blood drawn on [2137-5-7]. Please have your blood collected to check your PTT, PT, INR. Please have the results faxed ATTN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10543] Fax number: ([Telephone/Fax (1) 41630]. 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary: Pericardial Effusion, Pulmonary Hypertension, Delirium, CHF exacerbation, A. Fib, delirium Secondary: Mild dementia, Hypertensionm Hyperlipidemia, Myelodysplastic syndrome Discharge Condition: Stable, afebrile on 2l oxygen Discharge Instructions: You were transferred to this hospital for evaluation of your difficulty breathing, heart failure as well as a fluid collection around your heart. Whilst in the hospital you underwent a pericardiocentesis to drain the fluid around your heart, we also started you on a medication to get rid of the excess fluid from your heart failure. Prior to your discharge you were back down to your baseline oxygen requirement of 2 litres, you also were able to walk with physical therapy who recommended you go home with physical therapy. We made several changes to your medications. We started you on 8 new medications: 1. Please take Furosemide 80mg in the morning at 8am 2. Please take Furosemide 80mg in the afternoon at 4pm 3. Please take Questiapine 12.5mg at bedtime 4. Please take Aspirin 325mg once a day 5. Please take Fluticasone 1 nasal spray in each nostril at bedtime 6. Please take 325mg Ferrous Sulfate once a day 7. Please take Ipratropium Inhaler 2 puffs four times a day 8. Please take Coumadin 2mg at bedtime. We changed 2 of your medications: 1. Please take Prilosec 40mg once a day instead of 20mg twice a day. 2. Please take Metoprolol Tartrate 100mg three times a day instead of twice a day. We stopped 5 of your old medications: 1. Please stop taking Bumex 3mg daily 2. Please stop taking Norvasc 5mg daily 3. Please stop taking Digoxin 0.25mg daily 4. Please stop taking Imdur 180mg daily 5. Please stop taking Lisinopril 40mg daily We made no changes to the following medications: 1. Nitroglycerin spray 2. Fluoxetine 40mg daily 3. Atorvastatin 80mg at bedtime 4. Trileptal 150mg twice a day 5. Folic Acid 1mg daily 6. Colchicine 0.6mg daily Please weigh yourself every day at the same time of day in the same outfit. If you gain >2lbs please call your Cardiologist. If you experience any further chest pain, difficulty breathing please return to the ED. Followup Instructions: You have an appointment with your Cardiologist Dr. [Last Name (STitle) 10543] on [2137-5-7] at 2:45pm. You will need a Transthoracic echo in a weeks time to evaluate the collection in the lining of the heart, this should be set up through Dr.[Name (NI) 41631] office. You will also need your blood checked as you were restarted on Coumadin. Please have your blood drawn on [2137-5-7] and have the results faxed over to Dr.[Name (NI) 41631] office. His fax number is ([Telephone/Fax (1) 41630]. Please make an appointment to see a Pulmonary doctor [First Name (Titles) ] [Last Name (Titles) 2519] in the next two weeks for your pulmonary hypertension. Please make an appointment to see Dr. [First Name (STitle) ] within the next week. Please make an appointment to see a psychiatrist within the next two weeks. Please call [Telephone/Fax (1) 1387] for an appointment. Please make an appointment to see your neurologist Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 40860] to see if you still need to be on Oxcarbazepine.	[ "5849", "4280", "2859", "496", "32723", "42731", "4019", "2724", "53081", "41401", "V4582" ]
Admission Date: [2194-10-23] Discharge Date: [2194-10-27] Date of Birth: [2161-11-4] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 17813] Chief Complaint: Seizures - status epilepticus Major Surgical or Invasive Procedure: Intubation [2194-10-23] Lumbar puncture [2194-10-23] Extubation [2194-10-24] History of Present Illness: 32yo man with a PMHx significant for epilepsy (started five years ago according to OSH documentation) who presents today with breakthrough seizures. He had been in his USOH until sometime before 1600 when he had a 30 second GTC seizures. No further details are known as he was in prison at the time. Concerned about further seizures, he was given 400mg PO PHT there and EMS was called and he was transported to an OSH for further evaluation. In transit, he apparently had a two minute GTC seizure and was given 2mg of LZP, but unclear if it was in transit or not. Documentation from OSH ([Hospital1 ] [Location (un) 620]) is not clear, but apparently he had a total of four seizures and actively seizing upon arrival. Concerned about his airway, he was intubated and sedated with succinylcholine and etomidate then rocuronium and finally started on propofol gtt. A NCHCT was obtained and thought to be negative. However, given his presentation, he was urgently transported to [Hospital1 18] for neurological evaluation and further management. Past Medical History: 1. Epilepsy -- apparently diagnosed five seizures. Last seizure two years ago per report. Unknown where he is followed by neurology. Social History: Smokes 10/day Denies illicits Incarcerated - first time Family History: Unknown Physical Exam: Admission Physical Examination: done twenty mins off propofol Genl: sedated and intubated HEENT: Sclerae anicteric, no conjunctival injection CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally, no wheezes, rhonchi, rales Ext: No lower extremity edema bilaterally Neurologic examination: Mental status: Sedated, but opens left eye spontaneously. Able to fix and can track. Follows commands intermittently. Non-verbal. Cranial Nerves: Pupils equally round and sluggishly reactive to light, 3 to 2 mm bilaterally. No RAPD. Does not seem to blink to threat. Does not open right eye spontaneously. +oculocephalic reflex. No nystagmus apparent on examination. No facial asymmetry noted. Motor: Normal bulk with decreased tone bilaterally and symmetrically. Moves both sides spontaneously and antigravity, but moves L >> R. Sensation: withdraws to noxious stim, but much more briskly and robustly on the left. Reflexes: UTO on b/l UE, but 3+ at b/l patellar, 2+ at b/l achilles. Toe mute on right and downgoing on left. Coordination: unable to assess Gait: deferred . . Dischareg exam: Normal. Normal eye movements and no nystagmus. Pertinent Results: Laboratory: Admission labs: [2194-10-24] 01:40AM BLOOD WBC-10.4 RBC-3.84* Hgb-11.4* Hct-33.2* MCV-87 MCH-29.8 MCHC-34.4 RDW-13.0 Plt Ct-137* [2194-10-24] 01:40AM BLOOD Neuts-82.6* Lymphs-13.0* Monos-3.9 Eos-0.4 Baso-0.2 [2194-10-24] 01:40AM BLOOD Glucose-126* UreaN-15 Creat-0.8 Na-142 K-3.6 Cl-112* HCO3-23 AnGap-11 [2194-10-24] 01:40AM BLOOD Calcium-7.2* Phos-3.2 Mg-1.8 . Other pertinent labs: [2194-10-24] 01:40AM BLOOD Phenyto-17.3 [2194-10-24] 11:26PM BLOOD Phenyto-20.8* [2194-10-25] 06:30AM BLOOD Phenyto-23.8* [2194-10-26] 05:35AM BLOOD Phenyto-24.1* [2194-10-24] 09:32AM BLOOD Osmolal-291 [2194-10-25] 06:30AM BLOOD Albumin-3.8 Calcium-8.2* Phos-1.1# Mg-1.8 [2194-10-26] 05:35AM BLOOD PT-13.5 PTT-27.0 INR(PT)-1.2* . Discharge labs: [2194-10-26] 05:35AM BLOOD WBC-7.5 RBC-4.39* Hgb-13.2* Hct-37.3* MCV-85 MCH-30.1 MCHC-35.3* RDW-13.3 Plt Ct-151 [2194-10-26] 05:35AM BLOOD Glucose-99 UreaN-9 Creat-0.8 Na-145 K-3.7 Cl-112* HCO3-24 AnGap-13 [2194-10-26] 05:35AM BLOOD Calcium-9.0 Phos-3.1# Mg-1.8 . . Urine: [2194-10-24] 09:32AM URINE Hours-RANDOM Creat-18 Na-57 K-19 Cl-61 Uric Ac-9.5 [2194-10-24] 09:32AM URINE Osmolal-214 . . CSF: [2194-10-23] 10:52PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1* Polys-42 Lymphs-28 Monos-30 [2194-10-23] 10:52PM CEREBROSPINAL FLUID (CSF) TotProt-24 Glucose-85 . . Microbiology: [10-23] [Location (un) 620] BCs no growth to date [2194-10-23] 10:52 pm CSF;SPINAL FLUID TUBE 3. FINAL REPORT [2194-10-27] GRAM STAIN (Final [2194-10-24]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2194-10-27]): NO GROWTH. [2194-10-24] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2194-10-24] BLOOD CULTURE Blood Culture, Routine-PENDING . . Cardiology: ECG Study Date of [2194-10-23] 8:59:38 PM Sinus rhythm. Normal tracing. No previous tracing available for comparison. Read by: [Last Name (LF) 2194],[First Name3 (LF) ] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 77 130 102 362/391 70 73 53 . . Radiology: CHEST (PORTABLE AP) Study Date of [2194-10-23] 9:07 PM FINDINGS: Consistent with the given history, an endotracheal tube is present approximately 5.6 cm from the carina. A presumed nasogastric tube has also been placed with its usual course through the mediastinum, coiling in the gastric fundus with the distal tip not visualized. Post-pyloric placement cannot be excluded. The lungs are clear without consolidation or edema. Lung volumes are slightly diminished with elevation of the hemidiaphragms. No consolidation or edema is noted. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted on the supine radiograph. No displaced fractures are evident. IMPRESSION: Endotracheal tube in satisfactory position. Please note details of presumed nasogastric tube placement. No acute pulmonary process. . CT HEAD W/O CONTRAST Study Date of [2194-10-23] 10:12 PM FINDINGS: There is no intracranial hemorrhage, mass effect, or vascular territorial infarct. Diffuse blurring of the [Doctor Last Name 352]-white matter junction is noted, suggestive of postictal cerebral edema or artifact. However, there is no evidence of cerebral herniation or shift of the normally midline structures. Orotracheal tube courses in expected position. Scattered fluid is present throughout the ethmoid air cells. There is mild mucosal thickening in both maxillary sinuses, with air-fluid level on the right. Aerosolized secretions are also noted filling the nasopharynx. There is under-pneumatization of the right frontal sinus and left mastoid. However, mastoid air cells and middle ear cavities are clear. Orbits and intraconal structures are symmetric. IMPRESSION: 1. Possible mild postictal edema. No intracranial hemorrhage. 2. Sinus and nasopharyngeal secretions, secondary to intubation. . . Neurophysiology: EEG [10-24] report pending . Pending labs: [2194-10-25] 06:07AM BLOOD TOPAMAX (TOPIRAMATE)-PND [2194-10-25] 06:07AM BLOOD LAMOTRIGINE-PND Brief Hospital Course: 32yo incarcerated man with a PMHx significant only for epilepsy who presented [10-23] with breakthrough seizures and status epilepticus from an OSH where he was intubated. His neurological examination on transfer revealed following commands and moving all 4 limbs with right sided weakness. He was loaded with IV phenytpoin and continued on 110mg IV Q8H. He had a negative CT head and [Hospital1 18] and [Hospital1 ] [Location (un) 620]. After discusison with the prison nurse he had been taking his anti-epileptics as prescribed. CT-head revealed possible mild postictal edema and no intracranial hemorrhage with no focal lesion. His initial weakness was felt to be possibly due to [Initials (NamePattern4) ] [Last Name (NamePattern4) 555] paralysis. LP was unremarkable with WCC 2 RBC 1 and normal Pr and Glc. He had an initial leukocytosis at the OSH up to 17.9 with a high lactate which reslved on transfer to [Hospital1 18] felt likely secondary to his seizures. He was following commands and moving all 4 limbs and extubated [10-24]. Following extubation, he had no apparent weakness and was A+Ox3. The etiology of his presentation is unclear and toxicology screening was unremarkable and electrolytes were stable. There was no current focus for infection (UA and CXR were unremarkable and he was afebrile). On further questioning of patient, it was discovered that he had been receiving half of his Lamictal dose at the jail and in addition may have been changed from brand name to generic preparation which may have precipitated his seizures. He remained stable and was transferred to the floor on [10-25]. He was continued on his home dose of medications in addition to IV phenytoin which was latterly stopped prior to discharge. He was transferred back to jail on [10-27]. Medications on Admission: 1. Topamax 200 mg Tab Oral 1 Tablet(s) Twice Daily 2. Lamictal 100 mg Tab Oral 1 Tablet(s) [Hospital1 ] Discharge Medications: 1. Lamictal 100 mg Tablet Sig: One (1) Tablet PO twice a day: BRAND NAME ONLY NO SUBSTITUTION. 2. Topamax 200 mg Tablet Sig: One (1) Tablet PO twice a day. 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Prison facility Discharge Diagnosis: Seizures likely due to insufficient medication dose and change from Brand name to generic Lamictal 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 during your stay at the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ]. You presented following several seizures and you required a breathing tube placed (intubation) as you were too drowsy to maintain your airway. A CT scan of your head showed post-seizure changes and a spinal tap (lumbar puncture) showed no evidence of meningitis or infection. The breathing tube was removed and after having another anti-seizure medication, you had no further seizures. We stopped this other medication called phenytoin and continued you on your home medications. It appeared that you had a change in teh brand of one of your medications (Lamictal) and this does was reduced to only once per day while you were in jail which was the likely cause of your seizures. You must be kept on your home doses of Lamictal and Topamax. . . Medication changes: Continue your home seizure medcations Topamax 200mg TWICE DAILY and Lamictal (BRAND NAME ONLY - NO SUBSTITUTION) 100mg TWICE DAILY We started vitamin and mineral tablets Followup Instructions: Please follow-up as previously scheduled with the local neurologist	[ "3051" ]
Admission Date: [2147-10-13] Discharge Date: [2147-10-14] Date of Birth: [2077-8-10] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 1145] Chief Complaint: CP, abd discomfort. Major Surgical or Invasive Procedure: Cardiac catheterization with placement of multple stents and intraortic balloon pumpt, intubation History of Present Illness: Mr. [Known lastname 14223] is a 70 yo man w pmh of a HTN, right carotid stent, angina, GERD, severe OSA who presented to an OSH with c/o CP, heartburn, diaphoresis, nausea, belching that awoke him from sleep. At the OSH, he was hypertensive to the 250's/110's, he was given ASA 81mg x 4, lopressor IV, dilaudid, NTG drip. His EKG showed ST elevation in aVR, diffuse T wave invasion, ST depression in v1-v6. He was started on heparin GTT, integrilin and medflighted to [Hospital1 18]. Upon transfer, his vital were BP 111/88 hr 113 02 sat of 73% on non-rebreather. Pt. was intubated for resp. distress. He has a h/o difficult intubation, however, he was not wearing his bracelet and did not have any other documentation relaying this and was intubated with an adult tube (6.5 F). In the ED he was given amiodarone 300 IV for a WCT with rate in the 120's (EKG also showed new LBBB), His HR dropped to 20-30's and per ED nursing report progressed to asystole, he was given EPI, Atropine and CPR was initiated (for 5 minutes). His HR improved to 100's. He was hypokalemic (2.1) which was repleted. He was started on a dopamine drip and transferred to the Cath lab. In the cath lab a temporary wire was placed as well as an IABP, he was started on levo GTT, neo GTT, lasix GTT. The cath showed LMCA with mild disease, 99% proximal LAD stenosis, w/ TIMI 1 flow, 90% OM1 stenosis, total occlusion of the RCA w/ left and right collaterals. Right heart cath showed: RV 46/13, PCW mean of 25, PA 45/24 mean 33. A BM stent (3.0x18mm) was placed in the LAD, A BM (3x18mm) to the OM and 3 2.5mm stents ot the RCA. He was then transferred to the CCU. . His initial ABG was 7.24/54/37. His initial lactate was was 7.2. Initial CK was 138, TnI 0.48. In the CCU his ABG was 7.08/51/58 lactate of 6.4 . Review of systems could not be obtained due to pt. being intubated. Past Medical History: PAST MEDICAL HISTORY: angina, GERD, OSA s/p surgical correction, HTN, right carotid stent . Cardiac Risk Factors: Hypertension . Cardiac History: CABG, in anatomy as follows: NA . Percutaneous coronary intervention: no prior interventions . Social History: married, 3 children, currently a accountent. Tobacco: quit 30years ago, prior smoked 1ppd x 20years. no ETOH, no drug use. Physical Exam: VS: T 97.3, BP 107/75 on IABP as. systole: 106, [Month (only) ]. diastole 126, HR 126, intubated AC TV 500 PEEP 18 RR 30 Fi02 100% Drips: levo, neo, dopamine, lasix, insulin Gen: intubated, sedated on HEENT: intubated Neck: cannot assess JVP CV:tachycardic, regular, no MRG chest: CTA anteriorly, posterior exam deferred. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. hypoactive BS Ext: [Last Name (un) ]. No femoral bruits. Pulses: radial pulses dopplerable, pedal pulses not palpable or dopplerable. MEDICAL DECISION MAKING Pertinent Results: 1. Coronary angiography of this right dominant system revealed mild diffuse disease in the LMCA. The LAD had a 99% proximal stenosis with TIMI 1 flow. The LCX had a 99% proximal stenosis at the level of OM1. The RCA had a 100% total occlusion distally with left to right collaterals. 2. Resting hemodynamics revealed an initial systolic blood pressure of 60 mm Hg on a dopamine drip. The patient was placed on levophed and neosynephrine and the SBP rose to 133 mm Hg. Right-sided filling pressures were elevated with an RA mean of 20 mm Hg. The RVESP was 46 mm Hg. The PCWP was elevated at 25 mm Hg. The PASP was 45 mm Hg. The cardiac output was 5.5 with an index of 2.76 lmin/m2 on multiple pressors which was suggestive of cardiogenic shock. 3. Left ventriculography was deferred. 4. Successful stenting of the mid LAD with a 3.0 X 15 mm Minivision baremetal stent without residual stenosis. Successful stenting of the proximal LCX 90% lesion with a 2.5 X 18 mm MiniVision baremetal stent without residual stenosis. Successful stenting of the long 80% RCA lesion with a 2.5 X 28 mm MiniVision baremetal stent witout residual stenosis. 5. Acute anterior myocardial infarction treated with placement of IABP and primary angioplasty and stenting of the culprit LAD and well as LCX and RCA vessels, given profound cardiogenic shock. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe systolic and diastolic ventricular dysfunction. 3. Acute anterior myocardial infarction, managed by acute ptca and intraaortic balloon placement. 4. PTCA and stenting of the LAD vessel. 5. PTCA and stenting of the LCX. 6. PTCA and stenting of the RCA. Technically very limited study due to mechanical ventilation and suboptimal positioning. The left atrium is normal in size. There is symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. LV systolic function appears depressed. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. Brief Hospital Course: #STEMI: ST elevation in AVR with depressions laterally, also with [Last Name (un) ] TW. Found to have 3VD (99%LAD, 90%OM1, totally occluded RCA) s/p stents to all three vessels. Patient was continued on ASA, plavix 75, heparin drip, integrilin. Bedside echo showed was suboptimal, but showed depressed LV function and small LV. Patient was continued on pressure support on levophed, dopaine, and vasopressin in addition to the intraortic balloon pump. . #Cardiogenic shock: [3-10] to massive MI and 3VD. CI (1.23) severely depressed. S/P PCI. IABP placed. Over the night of hospitalization, the patients exited sinus tachycardia, and had a HR of 50 and sbp fell to 30s. Was paced with transveous pacing wire. Despite maximum doses of pressure support, patient has sbp of 75. pH continued to fall as patient developed a worsened lactic acidosis, with pH of 6.96 and LA of 16. Patients family was called to see if wished to start CVVH to reduce systemic acid burden. After lengthy discussion, patients family declined CVVH, and additionally wished to withraw current level of care, opting for CMO. The patient had pressures stopped, IABP turned off, and pacing d/c'd. Within five minutes, patient became asystolic, and expired with family present. . #Respiratory distress: Pt. was intubated in the ED for hypoxia. He has a hx. of difficult intubation and was apparently told he needed to be intubated with a pediatric tube. However, he did not have his bracelet nor any information relaying this. He was intubated with a small adult tube. His CXR shows pulmonary edema/ ?ARDS (awaiting official read). Despite intubation, his Pa02 remained in the 50's with ph in range of 7.08 to 7.19. Cisatracurium for paralysis was intiated to allow for better oxygenation as pt. agitated on the vent. Pulm was consulted, who began ventillating with ARDS net protocol. . # leukocytosis: elevated probably in the setting of stress. However, in setting of severe illness, we cannot r/o infection as a co-contributor to leukocytosis. Pt received 1 dose of vanc and cefepine in cath lab. - pan-cx. - cover broadly with vanc and zosyn. . Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary collapse Discharge Condition: deceased	[ "9971", "51881", "5849", "2762", "41401", "4019", "53081" ]
Admission Date: [2153-10-27] Discharge Date: [2153-11-14] Date of Birth: [2115-5-8] Sex: M Service: SURGERY Allergies: Demerol / Phenergan Attending:[First Name3 (LF) 974] Chief Complaint: Splenic artery aneurysm. Major Surgical or Invasive Procedure: [10-27] - Exploratory laparotomy, splenectomy with distal pancreatectomy, retroperitoneal exploration and control of arterial and venous bleeding and abdominal packing for damage control surgery [10-29] - Exploratory laparotomy, removal of 20 laparotomy packs, control of superficial bleeding and partial abdominal closure [10-31] - Abdominal washout and closure of open abdomen History of Present Illness: This middle-aged Asian male presents unresponsive and intubated with having been found down in his garage. He was brought to [Hospital3 ] ED where they did a CT scan finding blood in his abdomen. He was brought up to [Hospital1 1170] and in shock, arriving with a blood pressure 60. With aggressive resuscitation, we were able to get his blood pressure up in the 110-120 region. He had the CT scan with him. There was no contrast in that scan as far as IV contrast and also the issue of his being found down was not clear. His abdomen at that time was not terribly distended and he had a small amount of blood in his abdomen. Based on that, we felt it is probably necessary that we make sure that he had not suffered intracranial hemorrhage since his INR, which had been reported back, was nearly 2 and so he was quickly taken to CT scan for a head scan and a C-spine scan when he again became hypotensive. He was, therefore, taken to the OR as a STAT transfer Past Medical History: PMH: diabetes, hepatitis B PSH: liver transplant for hepB ([Hospital3 ] ~ 5 yrs ago) Social History: Married (wife [Location (un) ]. Lives in [Location 5110] w/ wife and 2 children (5&2). Is a stay-at-home dad; wife is manicurist. Came from [Country 3992] 8 yrs ago. Has 2 siblings (brother & sister) here. Buddhist Family History: NC Pertinent Results: [2153-10-27] 11:58PM GLUCOSE-422* UREA N-18 CREAT-1.3* SODIUM-144 POTASSIUM-6.0* CHLORIDE-109* TOTAL CO2-13* ANION GAP-28* [2153-10-27] 11:58PM CALCIUM-13.9* PHOSPHATE-6.8* MAGNESIUM-1.4* [2153-10-27] 11:58PM WBC-1.8* RBC-2.21* HGB-6.9* HCT-20.2* MCV-91 MCH-31.4 MCHC-34.4 RDW-14.2 [2153-10-27] 11:58PM PLT COUNT-99* [2153-10-27] 11:58PM PT-18.1* PTT-133.8* INR(PT)-1.7* [2153-10-27] 10:31PM TYPE-ART TEMP-34.4 O2-100 PO2-451* PCO2-32* PH-7.05* TOTAL CO2-9* BASE XS--21 AADO2-251 REQ O2-48 INTUBATED-INTUBATED VENT-CONTROLLED [2153-10-27] 08:46PM ALT(SGPT)-19 AST(SGOT)-28 ALK PHOS-10* TOT BILI-0.3 [2153-10-29] LIVER OR GALLBLADDER US IMPRESSION: 1. Dilation of the common duct, measuring 9 mm. 2. Patent vessels within the right lobe of the liver. The left lobe could not be well evaluated due to patient positioning and overlying bandages. 3. Right pleural effusion. Brief Hospital Course: [10-27] Transferred to [Hospital1 18] from [Hospital3 ] w/ imaging c/w hemoperitoneum. The day prior to arrival, was complaining of stomach pain & later collapsed while helping friend work on his car. At [Hospital1 18], found to be unresponsive, intubated, and hypotensive. Volume resuscitation was temporarily successful. Taken to OR as STAT transfer for ex-lap, splenectomy with distal pancreatectomy & packing. Received 24 units PRBCs, 8 units FFP, 1 unit cryoprecipitate intraopa and peri-op. Post-op, necessitated pressor support including levophed and epinephrine. Patient was started on IV vancomycin, levofloxacin and flagyl. [10-28] Patient was kept intubated/sedated with IV resuscitation, ventilator and vasopressor support. A plastic surgery consultation was obtained for epidermolysis of the left hand dorsum. His arm was splinted below the elbow in extension with xeroform and dry gauze dressing to the wound. [10-29] Taken back to OR for exploratory laparotomy, removal of 20 laparotomy packs, control of superficial bleeding and partial abdominal closure. The patient began to develop acute renal failure with a creatinine of 3.6 up from 1.6. His LFTs were also found to be rising. A transplant hepatology consult was obtained. This rise was felt to be secondary to shock liver from hypoperfusion. [10-30] Continued to stabilize and resuscitate with IV fluids. Patient was weaned off pressors. His creatinine and LFTs were followed carefully. Adequate urine output. [10-31] Takeback to OR for abdominal washout and closure of open abdomen. Antibiotic regimen changed to vancomycin and zosyn. [11-1] Tube feeding started, sedation weaned [11-2] Vent weaned from CMV to CPAP. Antibiotics stopped. [11-3] Vent wean continued. Self-extubated with immediate re-intubation. [11-5] Tube feeds advanced to goal. [11-6] Extubated [11-7] Off all drips/O2/sedation. Drinking/eating ground diet without issue. [Last Name (un) ] Biabetes center consulted for elevated sugars. He was started on an insulin regimen which required adjustment throughout his stay. [11-8] Transferred from TSICU to floor. On [11-10] he developed fevers and was pan cultured and empirically started on Vanco and Zosyn. His blood and urine cultures grew E.coli resistant to Ampicillin, Cipro and Bactrim so Augmentin was started; the Vanco and Zosyn were stopped. [11-11] He underwent abdominal imaging which revealed a perihepatic abscess which was subsequently drained by Interventional Radiology. Culture of the fluid was sent which had no growth, the catheter continued to drain bile and was eventually removed on day of discharge. [11-12] Fevers defervesced and patient doing well. He was discharged to home on [11-14] with services. Specific instructions for follow up were provided. Medications on Admission: FK [1-6], hepsera 10', lamivudine 100', RISS Discharge Medications: 1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 2. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:qs Patch 72 hr(s) Refills:0 3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:60 Tablet(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:2 5. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Adefovir 10 mg Tablet Sig: One (1) Tablet PO qday (). Disp:30 Tablet(s) Refills:2 7. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Glargine insulin Sig: Twenty Five (25) Units at bedtime. Disp:2 vials Refills:2 9. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily): Apply to left antecubital fossa daily as directed. Disp:1 Jar Refills:2 10. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 13 days. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Splenic artery hemorrhage Acute blood loss anemia Secondary diagnosis: Diabetes Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, headache, dizziness, very hih or low blood sugars, shortness of breath, abdominal pain, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Take all of your medications as prescribed and be sure to complete your entire antibiotic course as instructed. Followup Instructions: Follow up next week with Dr. [Last Name (STitle) ], call [Telephone/Fax (1) 2359] for an appointment. You will also need to be scheduled for an outpatient CTA (CT scan to look at your arteries). Please inform the office when you call to make your appointment to schedule this test. Follow up with [Last Name (un) ] Diabetes Asian American Clinic in the next week, call [Telephone/Fax (1) 58905] for an appointment. Follow up in [Hospital 3595] clinic for your left hand/arm in 1 week, call [Telephone/Fax (1) 5343]. Follow up with your primary care doctor in [12-6] weeks, you will need to call for an appointment. Completed by:[2153-11-21]	[ "5845", "2851", "5990", "2762", "25000" ]
Admission Date: [2115-1-21] Discharge Date: [2115-2-14] Date of Birth: [2063-7-30] Sex: M Service: SURGERY Allergies: Codeine / Demerol / Oxycodone Attending:[First Name3 (LF) 4691] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: [2115-1-25] - IVC filter placement [2115-1-28] - tracheostomy, PEG tube placement [2115-2-1] - non-instrumented fusion C5-T6 History of Present Illness: 50M unrestrained driver s/p rollover MVC with ejection. Pt was found 10 ft from his car with +LOC. On arrival to the [Name (NI) ], pt was hypotensive to SBP 50s but mentating appropriately with GCS 15. Exam revealed loss of motor and sensory function below the xiphoid process. Despite fluid resuscitation he remained hypotensive and was started on pressors with suspicion of neurogenic shock. Imaging revealed T3-T5 vertebral body fractures with severe spinal cord injury concerning for transection, along with multiple bony thoracic fractures and a small left hemopneumothorax. He was admitted to the TSICU for close monitoring. Following admission to the TSICU he underwent closure of extensive scalp lacertaions. His respiratory mechanics worsened; found to have progressed to flail chest in the setting of multiple bilateral rib fractures. Given his increasing fatigue, he was intubated, and a left subclavian line was placed. A post-intubation/line film revealed a significantly increased left pneumothorax with increasing pressor requirement. A chest tube was placed which drained approximately 500cc blood upon placement, with hemodynamic improvement thereafter. Past Medical History: PMH: bipolar disorder PSH: appy Social History: 1ppd x 30 yrs heavy EtOH in the past, trying to cut down Family History: N/C Physical Exam: Vitals: T 99.4, HR 59, BP 133/52, RR 20, O2 50% trach collar Gen: a&o x3, nad CV: rrr, no murmur Resp: cta bilat Abd: soft, NT, ND, +BS Extr: warm, 2+ pulses Pertinent Results: CT Head [2115-1-21]: 1. No acute hemorrhage or intracranial process. 2. Left occipital condyle fracture better assessed on cervical spine CT. 3. Bilateral extensive deep scalp lacerations (degloving injury) with debris and gas within the wounds. CT C-Spine [2115-1-21]: 1. Multiple fractures in the cervicothoracic junction including: C7 spinous process, T1 vertebral body, both T1 pedicles and transverse processes, T2 body, T2 left inferior facet and right transverse process. Extensive fracture of T3 which is detailed with the CT torso report. 2. Bilateral small pneumothoraces, upper lung contusions, large paravertebral hematoma surrounding the upper thoracic spine with extensive bilateral upper (posterior displaced and comminuted) rib fractures. 3. Acute fracture of the left occipital condyle. CT Torso [2115-1-21]: 1. Severe injury to the thoracic spine with a flexion teardrop injury at T3 likely causing severe spinal cord injury. Additional fractures of vertebrae: C7 - T9, described in detail above. Extensive paravertebral hematoma without active bleeding. 2. Extensive ribcage injury involving every rib, many displaced and segmental. 3. Bilateral scapula fractures, sternal fracture with retrosternal hematoma. 4. Bilateral small hemothorax, small bilateral pneumothores and pulmonary contusion in the upper lungs. MRI Spine [2115-1-21]: 1. Multiple fractures of the upper thoracic spine, most notably with instable 3 column burst fracture of T3. The latter demonstrates significant retropulsion with cord compression and cord signal abnormality, representing either contusion, edema, ischemic change or a combination of those. Burst fracture of T4 with mild retropulsion and no cord abnormality. Injury to the anterior and posterior longitudinal ligaments; assessment of other ligaments is limited. Small amount of epidural hematoma is posisbly noted and distinction from osseous component is limited. Osseous details are better seen on prior CT. (Pl. note that the injury is at T3 and T4 levels and not T10 as mentioned on the wet read.) 2. Mild Compression fracture of T1. 3. Multilevel spinous, transverse process and rib fractures, better characterized on previous CT torso. 4. Extensive signal abnormality along the posterior paraspinal soft tissues and interspinous ligaments from C2 through T8, suggesting soft tissue edema, multilevel disruption of the posterior ligamentous complex or, most likely, a combination of both. 5. Stable extent of pre/paravertebral hematoma and hemothorax. 6. Degenerative changes in the cervical spine. 7. A 2.0cm lesion in the right kidney-? cyst- see prior CT Torso study Brief Hospital Course: Mr. [Known lastname 51284] was evaluated in the ED as a trauma activation, and the following injuries were identified: -Scalp degloving/lacerations -C7 spinous process fracture -T1 body fracture -T3 flexion teardrop comminuted fx w/ retrolisthesis -Severe spinal cord injury at T3 w/ concern for transection -T4, T5 burst fx -Paraspinal hematoma, upper T spine -Sternal fx w/ retrosternal hematoma -Rib fx (R [1-28], L [11-23], [6-30]) -Small L hemo-PTX -Bilateral apical pulmonary contusions -Bilateral scapular fx -Occipital condyle fx He was admitted to the TICU for evaluation and monitoring. His extensive scalp lacerations were thoroughly irrigated and debrided, then closed. His hospital course is detailed below, and he was discharged to vent rehab. Neuro: He had pain control issues throughout his admission to the ICU, for which the chronic pain service was consulted. He suffered a severe spinal cord injury at the level of his thoracic spine injuries, with complete bilateral lower extremity paralysis. He went to the operating room for fusion of his spinal fractures, but was unable to tolerate the prone position. Instead of having an instrumented fusion, as planned, he had a non-instrumented fusion with bone matrix, and was placed in a [Location (un) 36323] brace post-operatively. This was changed to a Halo on [2115-2-8]. CV: He was initially hypotensive and bradycardic, consistent with spinal shock, and required pressors at the beginning of his hospital stay. The pressors were slowly weaned, and he remained hemodynamically stable. Resp: He was breathing well on arrival to the hospital, though he had extensive bilateral rib fractures. Overnight on HD 1, he developed respiratory distress, and imaging was consistent with flail chest, so was intubated. He was kept intubated for the OR with spine, and was unable to wean from the vent post-operatively. He also developed a pneumonia, which was treated with appropriate antibiotics. He underwent tracheostomy on HD 8. He has been able to wean to CPAP/PSV, and has been tolerating trach collar the past 24 hours. His rib fractures were evaluated by thoracic surgery, who did not think he would benefit from rib plating. He will be discharged to vent rehab. GI/GU: He was kept NPO with IVF while intubated. He was initially started on tube feeds through an OG tube, then transitioned to feeds through his PEG after placement on HD 8. He was cleared to start an oral diet on [2-13], and was given sips, which he tolerated well. His PEG tube was inadvertently removed by the patient on [2-13], and was replaced with a foley catheter. Catheter position in the stomach was confirmed with contrast x-ray. He will have this exchanged under fluoroscopy next week for a formal G-tube, but may have feeds through the foley until that time. He developed a transaminitis on HD 14, which continued to increase, and a HIDA scan was obtained, which was normal. He was started on ursodiol for presumed cholestasis, with improvement in his LFT's. His foley catheter was removed on [2115-2-13] and he began having intermittent straight caths performed, which will be continued at rehab. He developed a UTI on [2115-2-13], which is being treated with cipro x7 days. Heme: An IVC filter was placed for protection from embolism, and heparin subcutaneously was given for DVT prophylaxis. His hematocrit intermittently drifted to the low 20's, though he never manifested signs or symptoms of acute bleeding, and always responded appropriately to transfusion. A CT scan obtained to evaluate his abdomen on [2115-2-8] showed migration of his IVC filter above the renal veins. IR attempted to retrieve and replace the filter on [2115-2-12], but were unable to do so, as there was clot in the filter. He will be given a 2-week course of lovenox, and then will have a repeat CT scan. If the clot burden has resolved, he will then have the filter retrieved and replaced by IR. ID: He developed a moraxella pneumonia while intubated, and was appropriately treated with antibiotics. He continued to spike fevers despite antibiotics, so ID was consulted. After completing his antibiotic course, he remained afebrile without leukocytosis. He was started on cipro for a UTI on [2115-2-13], and will complete a 7-day course of antibiotics at his rehab facility. Medications on Admission: -Simvastatin 40mg daily -Potassium citrate 20mEq TID -Nexium 40mg daily -Abilify 20mg daily -Carbamazepine 200mg [Hospital1 ] -Fluoxetine 40mg daily -Hydroxyzine 50mg Q6H PRN -Topamax 200mg [Hospital1 ] -Gabapentin 300mg TID Discharge Medications: 1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing, dyspnea. 4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for Pain. 5. fluoxetine 20 mg/5 mL Solution Sig: Ten (10) ml PO DAILY (Daily). 6. insulin regular human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED). 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. acetaminophen 650 mg/20.3 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours). 9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 10. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 11. senna 8.8 mg/5 mL Syrup Sig: Five (5) mL PO BID (2 times a day). 12. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 13. lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q4H (every 4 hours) as needed for Anxiety. 14. hydromorphone (PF) 1 mg/mL Syringe Sig: 1-2 mg Injection Q3H (every 3 hours) as needed for breakthrough pain. 15. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. lorazepam 2 mg/mL Syringe Sig: [11-19] ml Injection Q4H (every 4 hours) as needed for Anxiety. 17. enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous Q12H (every 12 hours). 18. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 19. Cipro 500 mg/5 mL Suspension, Microcapsule Recon Sig: Five Hundred (500) mg PO twice a day for 5 days. 20. Outpatient Lab Work Please check creatinine weekly. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital for Continuing Medical Care - [Location (un) 1121] ([Hospital3 1122] Center) Discharge Diagnosis: s/p polytrauma bilateral rib fractures thoracic spinal cord injury bilateral scapula fractures 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 Acute Care Surgery Service after your traumatic injuries. You were kept in the ICU during your stay, and required multiple surgical procedures. You are now being discharged to rehab to continue your recovery. Please follow these instructions to aid in your recovery. Please take all medications as prescribed. Please contact our office if you develop fever, chills, increased pain, or drainage from your wounds. Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2115-2-26] 3:15 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2115-2-26] 3:30 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2115-2-26] 3:45 [2115-2-28] - Acute Care Surgery Clinic, 3:45pm LM [Hospital Ward Name ] BLDG ([Doctor First Name ]), [Location (un) ] SURGICAL ASSOCIATES Clinic starts at 1pm. [Month (only) 116] come directly from spine appointment and will try to work-in for earlier visit. [2115-2-28] - [Doctor Last Name ],SPINE, 11am SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] SPINE CENTER (SB) Completed by:[2115-2-14]	[ "2760", "2851", "5990", "3051", "2767" ]
Admission Date: [2190-12-29] Discharge Date: [2191-1-3] Date of Birth: [2114-6-28] Sex: M Service: MEDICINE Allergies: Naprosyn Attending:[Doctor First Name 1402] Chief Complaint: Transfer for urgent cardiac catheterization Major Surgical or Invasive Procedure: Cardiac catheterization Central venous line placement (subclavian) History of Present Illness: Mr. [Known lastname ] is a 76 year-old man with a history of DM, HTN, HL but no known CAD, who initially presented to an OSH with shortness of breath on [12-27] who is now being transferred with a STEMI. Per the OSH records (no history could be obtained from the patient as he is intubated): Presented on [12-27] with two weeks of cough and dyspnea. Seen by his PCP and was given tylenol with codeine. On the day of admission, had worsened SOB and cough with white sputum. No fevers. Also with chest pain, reportedly from coughing. Noted to have ARF (SCr of 1.5 on admit) with a lactate of 1.6. CK and troponin were negative. BNP was 386. CXR showed RLL PNA and he was treated with levaquin. On HD#2, at 7pm, noted by to be SOB and wheezing. O2 sat <80% and placed on NRB after which time he became unresponsive with reported right eye gaze and questionable weakness of the RUE. An ABG was done and showed 7.03/106/297 (on NRB) and he was intubated. Soon after, BP 220/113 with a HR of 114. Labs later returned with a CK of 186, MB 10.2, trop T 0.495. ECG showed sinus tach. Aspirin then increased to 325 and atorvastatin 80 given. A head CT was ordered before heparin was administered. At 4:30am on day of transfer patient was hypotensive with ECG showing ?STEMI. Neosynephrine was started. He is transferred to [Hospital1 18] for urgent cardiac catheterization, on Neo, insulin, and heparin gtts. Cardiac catheterization at [Hospital1 18] showed: Two vessel coronary artery disease. Diastolic dysfunction with severely elevated filling pressures. Stenting of mid LAD with two overlapping BMS. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Diabetes (+) Dyslipidemia (+) Hypertension 2. CARDIAC HISTORY: -CABG: None. -PCI: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: - Diverticulosis - History of colon polyps - Osteoarthritis Social History: Lives at home alone. Quit smoking 15 years ago, prior to that smoked [1-13] ppd x18 years. Denied EtOH and illicit drug use. Family History: Non contributory Physical Exam: GENERAL: Intubated and sedated. HEENT: NCAT. Sclera anicteric. Pupils constricted. NECK: Difficult to assess JVP with central line in place. CARDIAC: RRR, nl S1-S2, no MRG LUNGS: Vented resp were unlabored. Diffuse wheezes anteriorly. ABDOMEN: +BS, soft/NT/ND. EXTREMITIES: WWP, No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ DPs bilaterally. Pertinent Results: Laboraotyr studies: [2190-12-29] 07:51AM BLOOD WBC-10.5 RBC-3.43* Hgb-11.0* Hct-31.6* MCV-92 MCH-32.0 MCHC-34.9 RDW-13.2 Plt Ct-217 [2190-12-30] 04:21AM BLOOD WBC-14.5* RBC-3.31* Hgb-10.5* Hct-30.0* MCV-91 MCH-31.9 MCHC-35.1* RDW-13.3 Plt Ct-194 [2191-1-2] 06:21AM BLOOD WBC-9.4 RBC-3.33* Hgb-10.3* Hct-29.8* MCV-90 MCH-31.1 MCHC-34.7 RDW-13.3 Plt Ct-186 [2190-12-29] 07:51AM BLOOD Neuts-87.8* Lymphs-10.4* Monos-1.2* Eos-0.6 Baso-0 [2190-12-29] 07:51AM BLOOD PT-15.1* PTT-68.6* INR(PT)-1.3* [2191-1-2] 06:21AM BLOOD PT-21.7* PTT-150* INR(PT)-2.1* [2190-12-29] 07:51AM BLOOD Glucose-174* UreaN-29* Creat-1.4* Na-139 K-4.5 Cl-106 HCO3-23 AnGap-15 [2191-1-2] 06:21AM BLOOD Glucose-112* UreaN-27* Creat-1.1 Na-142 K-3.6 Cl-102 HCO3-30 AnGap-14 [2190-12-29] 11:10AM BLOOD CK(CPK)-262* [2190-12-29] 03:00PM BLOOD CK(CPK)-511* [2190-12-29] 10:01PM BLOOD CK(CPK)-714* [2190-12-30] 04:21AM BLOOD CK(CPK)-644* [2190-12-29] 11:10AM BLOOD CK-MB-19* MB Indx-7.3 cTropnT-0.36* [2190-12-29] 03:00PM BLOOD CK-MB-50* MB Indx-9.8* cTropnT-0.64* [2190-12-29] 10:01PM BLOOD CK-MB-80* MB Indx-11.2* cTropnT-1.24* [2190-12-30] 04:21AM BLOOD CK-MB-71* MB Indx-11.0* cTropnT-2.02* [2190-12-29] 11:10AM BLOOD Calcium-7.8* Phos-2.8 Mg-2.2 Cholest-246* [2190-12-29] 07:51AM BLOOD Albumin-3.6 [2191-1-2] 06:21AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1 [2190-12-29] 07:51AM BLOOD VitB12-352 [2190-12-29] 07:51AM BLOOD %HbA1c-6.2* [2190-12-29] 11:10AM BLOOD Triglyc-113 HDL-45 CHOL/HD-5.5 LDLcalc-178* [2190-12-29] 09:55AM BLOOD Type-ART pO2-113* pCO2-56* pH-7.28* calTCO2-27 Base XS--1 [2190-12-31] 02:10PM BLOOD Type-ART pO2-100 pCO2-46* pH-7.43 calTCO2-32* Base XS-4 [2190-12-30] 03:12PM BLOOD Type-ART Temp-37.3 Rates-/15 PEEP-5 FiO2-40 pO2-105 pCO2-53* pH-7.31* calTCO2-28 Base XS-0 Intubat-INTUBATED [2190-12-30] 05:52AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.022 [2190-12-30] 05:52AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2190-12-30] 05:52AM URINE RBC-10* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [2190-12-30] 05:52AM URINE CastGr-4* CastHy-28* Microbiology: [2191-1-1] SWAB RESPIRATORY CULTURE-Pending; GRAM STAIN-No organisms; FUNGAL CULTURE-Pending [2191-1-1] BLOOD CULTURE Blood Culture, Routine-PENDING [2191-1-1] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-Pending [2191-1-1] BLOOD CULTURE Blood Culture - Pending [2191-1-1] CATHETER TIP-IV Pending [2191-1-1] ASPIRATE Nasal Sinus GRAM STAIN- GRAM STAIN (Final [2191-1-1]): 2+ (1-5 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS. 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. Respiratory culture and fungal cultures - Pending. [2190-12-30] CATHETER TIP-IV WOUND CULTURE-negative [2190-12-30] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY {ASPERGILLUS SPECIES}, sparse growth; oropharyngeal flora [2190-12-30] BLOOD CULTURE Blood Culture, Routine-PENDING [2190-12-30] BLOOD CULTURE Blood Culture, Routine-PENDING [2190-12-30] URINE URINE CULTURE-Negative [2190-12-29] MRSA SCREEN MRSA SCREEN-negative [2190-12-29] CATHETER TIP-IV Negative Imaging/Studies: ECG 12.17: Artifact is present. Sinus rhythm. There are tiny R waves in the anterior leads consistent with possible prior anterior infarction. There is ST segment elevation in the lateral and anterolateral leads with ST segment depression in the inferior leads consistent with acute myocardial infarction. Clinical correlation is suggested. C. Catheterization [12-29]: FINAL DIAGNOSIS: 1. STEMI. 2. Two vessel coronary artery disease. 3. Diastolic dysfunction with severely elevated filling pressures. 4. Successful stenting of the mid LAD with two overlapping BMS. CXR 12.17: IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Heterogeneous peribronchial infiltration in the lower lungs, right greater than left could be due to asymmetric edema, but alternatively, given the presence of partially calcified pleural thickening along the right lower costal margin could be due to overlying pleural abnormality. Upper lungs are clear, and free of either vascular congestion or edema. There is no layering pleural effusion. Heart size is normal. ET tube in standard placement, an ascending pulmonary floatation catheter tip projects over the left pulmonary artery at the origin of the descending portion, nasogastric tube passes into the stomach and out of view and a right subclavian line can be traced as far as the low right atrium. No pneumothorax. ECG [12-30]: Sinus rhythm. ST segment elevation in the anterior and anterolateral leads with terminal T wave inversion and more modest ST-T wave changes in the remaining leads consistent with evolving myocardial infarction. Compared to the previous tracing evidence of evolution is now present. Clinical correlation is suggested. ECHO [12-31]: The left atrium is elongated. A small secundum atrial septal defect is present. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Small secundum ASD. CXR [12-31]: FRONTAL CHEST RADIOGRAPH: The endotracheal tube and Swan-Ganz catheter have been removed. A left subclavian central venous line tip terminates in distal SVC. There is no pneumothorax. The cardiomediastinal silhouette is stable. Bibasilar opacities likely represent atelectasis and are unchanged. CTA head/neck: 1. No evidence of acute infarct, vessel cutoff or intracranial hemorrhage. Final read pending reformats. 2. Left maxillary opacification and mass effect mass causes dehiscence of the medial wall. Consideration includes inverting papilloma but squamous cell cancer or infectious process cannot be excluded. Appearance is unchanged from [Location (un) 620] study performed [2190-12-29]. Chest CT: Preliminary - No focal consolidation to suggest aspergillus pneumonia. Brief Hospital Course: 76M with HTN, DM, HL, but no known CAD, presented to OSH w/ PNA and ARF, now transferred to [Hospital1 18] CCU w/ STEMI. S/p BMS x2 to mid-LAD 90% stenosis. 1. CAD. Pt w/ STEMI, admitted to CCU on [12-29] s/p BMS x2 to mid-LAD for 90% stenosis. On cath, Fick CO 6.73, CI 3.20. Anatomy also w/ proximally occluded RCA w/ robust collaterals. ECG pos cath showing STe in V2-V6 w/ biphasi Tw in same leads. His CKs peaked at 714, MB 11.2 on [12-29] and troponin at 2.02 on [12-30]. On [12-29] patient was started on ASA 325, Plavix 75 and high dose statin. Patient was also started on lopressor 12.5 TID. Patient was continued on this regimen until [12-30] when he was extubated. He was started on captopril 12.5mg TID for elevated BPs and MI on [12-31]. After extubation, patient denied CP or shortness of breath. Throughout this time he was continued on heparin gtt for anterior wall MI and was transitioned to coumadin. He was trasferred to the floor on [1-1]. He remained symptom free through hospital stay to discharge. At time of discharge his medications included Metoprolol XL 50 mg QD and Lisinopril 10. The patient was started on coumadin for prophylaxis of possible thrombus formation after MI. His INR was therapeutic at 2.6 on discharge. 2. Pneumonia. Noted on CXR from OSH w/ RLL infiltrate, and started on Levofloxacin at OSH, [12-27] for CAP. He was continued on this regimen while intubated. Patient remained afebrile throughout CCU stay. As respiratory status and oxygenation improved and pt was extubated, repeat CXR showed bibasilar opacities consistent w/ atelectasis. Sputum Cx did not grow organisms w/ exception of Aspergillus species. Patient will complete a 7day course of levofloxacin the day after discharge. 3. Aspergillus positive sputum Cx & Left maxillary sinus opacification with dehiscence of medial sinus wall. Significance of Aspergillus on sputum culture was unclear. Pt. is diabetic and received solumedrol at OSH and one dose of prednisone for COPD exacerbation while at [Hospital1 18], but is not frankly immunocompromised. CT chest was obtained that did not show changes consistent w/ infiltrative aspergillus. Sinus cultures were negative/pending at time of discharge. ID was consulted who did not feel that the findings were consistent w/ invasive aspergillosis. CT at OSH and CTA at [Hospital1 18] showed opacification found in L maxillary sinus with mass effect mass and dehiscence of the medial sinus wall. This was felt to be unlikely an infectious process, but was felt to be more likely a neoplastic one by ID. ENT was consulted and felt the process was not related to the respiratory failure/COPD exacerbation. A Cx sample was obtained. Patient was recommended to follow up w/ ENT as an outpatient for further workup. 4. Hypercarbic respiratory failure. Pt. was intubated at OSH for CO2 >100 on ABG, treated w/ duonebs, levofloxacin and solumedrol IV for COPD exacerbation. PCO2 was 56 on admission and pt was found to have diffuse wheezes on exam. He was started on Ipratropium and Xopenex nebs stadning and prn. Levofloxacin was continued. He received one dose of 20 mg IV lasix. Respiratory status improved w/ ABG of 105/53/7.31/28 and patient was successfully extubated on [12-30]. He remained somewhat somnolent post extubation, ABG PCO2 was 46, however this improved significantly by [12-31] w/ pt being A&O x3, communicating clearly. By day of discharge he was sating well in the mid 90's on RA. He contineud to be treated with xopenex tid and atroven q6h for COPD flare. 5. Left facial droop and hemiparesis. On day of extubation patient was noted to have a left facial droop, LE hyperreflexia, upgoing left toe and LLE LUE weakness, however patient was somnolent and could not cooperate w/ a full motor exam. Given OSH report of R gaze deviation and these findings, CVA or ICH was suspected. Heparin gtt was temporarily held. CTA of heach and neck did not show flow limiting lesions, ICH or lesions consistent w/ CVA. Carotid U/S showed 60-69% R ICA stenosis, 40-59% L ICA stensosis. Pt's symptoms and exam improved on [1-1], w/ slight L nasolabial fold flattening remaining on exam. It was felt that this may have been a TIA or possible localized symptoms that may occur in patient's w/ encephalopathy. Anticoagulation was restarted and patient was arranged for OP Neurology follow up. 6. Congestive heart failure, diastolic, acute. Pt. w/o symptoms of HF on exam or hx, however w/ slight suggestion of HF on initial XR. He received one dose of lasix 20mg prior to extubation. Echo showed LVEF > 55% and mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Pt was continued on metoprolol and started on ACEI for HTN. At time of discharge his medications included Metoprolol XL 50 mg QD and Lisinopril 10. 7. Acute renal failure. Creatinine on arrival to OSH elevated to 1.5, no baseline was available. This improved to 1.1 by [1-2]. U/A was consistent w/ pre-renal etiology, however possible CKD given hx of HTN and DM. No proteinuria on UA. Patient was started on ACEI during admission (see above) for HTN and renal protection. On discharge his ARF had resolved and his Cr had decreased to 1.0. 8. Diabetes. On PO Metformin at home, was on insulin gtt at OSH ICU. While hospitalized, his home Metformin was held. Patient was started on Lantus and RISS for tight blood sugar control. Fasting BG ranged between 124 - 188, but [1-2] improved to 112 on Lantus 15u and RISS. He was discharged back on his home metformin. 9. Depression. Pt was continued on home Celexa. Medications on Admission: Aspirin 81mg daily Lisinopril 10mg daily Simvastatin 80mg daily Metformin 500mg daily Citalopram 40mg daily Tylenol PRN Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation TID (3 times a day). 12. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for cough. 13. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 620] Discharge Diagnosis: Primary- ST elevation myocardial infarction Respiratory failure Pneumonia Transient ischemic attack Secondary- Hypertension Diabetes Hyperlipidemia Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted to [Hospital1 18] as a transfer from [Hospital3 ] for a heart attack and respiratory failure (You were intubated). While at [Hospital1 18] you underwent a cardiac catheterization with placments of stents to open flow in the blood vessels of your heart. You were also treated with medications for your heart attack. You were also treated for pneumonia and Chronic Obstructive Pulmonary Disease exacerbation with antibiotics and medications to help you breathe better. With this regimen, you heart condition and your breathing improved significantly. You were started on multiple new medications and you should continue to take these as you leave the hospital. Please see below for detailed list of new medications. After you were extubation, it was noticed that you had weakness which quickly resolved. Neurology evaluated you and did not feel that you had a stroke, however this may have been a transient ischemic attack (a mini-stroke). You will need to follow up with neurology. In addition, you were also found to have changes in your left sinus that may be concerning for a mass. You were evaluated by infectious disease and head and neck specialists who felt that you should follow up for this mass as an outpatient with your ENT doctor. Changes to your medications: 1. You were started on plavix 75 mg daily. It is very important that you take this medication every day and do not miss a dose. 2. You were started on coumadin 5 mg daily. You will need to have blood work checked to ensure that you anticoagulation is at an appropriate level. 3. You were started on pantoprazole 40 mg daily to decrease the risk of stomach bleeding on anticoagulation. 4. You were started on Toprol XL 50 mg daily. 5. You were started on xopenex nebs three times daily and atrovent nebs every 6 hours to treat your COPD exacerbation. 6. You will need to take one more day of levofloxacin to finish treatment for the pneumonia. Otherwise continue your outpatient medications as prescribed. Should you experience any fevers, chills, weight loss, nightsweats, chest pain, shortness of breath, cough, swelling in your legs, dizziness, visual changes, weakness, difficulty walking or any other symptoms concerning to you, please call your primary care physician or go to the nearest emergency room. Followup Instructions: Please follow up with your Primary care doctor, Dr. [First Name4 (NamePattern1) 3075] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 19980]). An appointment was made for you on [1-10] at 11:40 am. Please follow up with ENT within the next 1-2 months for workup for the sinus mass which was found on CT. It is very important that you see your ENT doctor for this. An appointment was made for you to follow up with neurology ([Telephone/Fax (1) 2574]) on [2-7] at 1 pm. His office is located in the [Hospital Ward Name 23] Building on the [Location (un) ]. If you cannot keep any of the above appointments, please call to reschedule.	[ "486", "5849", "51881", "41401", "4280", "25000", "4019", "2724", "V1582", "311" ]
Admission Date: [2175-11-26] Discharge Date: [2176-1-30] Date of Birth: [2096-9-20] Sex: F Service: MEDICINE Allergies: Ibuprofen / Penicillins Attending:[First Name3 (LF) 8487] Chief Complaint: abdominal pain, fever Major Surgical or Invasive Procedure: Insertion of left subclavian line on [2175-11-27]. S/p electrical cardioversion on [2175-11-27] for rapid Afib right knee arthrocentesis PICC line placement [Last Name (un) ]-intestinal feeding tube insertion Endo-tracheal intubation and mechanical ventilation History of Present Illness: 79 yo F with history of hypertrophic cardiomyopathy (s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ], pacemaker placement, EF 65%), CRI (baseline Cr 1.4), COPD (on prednisone taper currently), status-post recent right total knee replacement ([2175-11-9], with pre-operative antibiotics), s/p TAH-BSO, appendectomy, distant SBO, presenting with RLQ abdominal pain x several hours, fever. Patient recently status-post right TKR at [Hospital6 2910], with post-operative course complicated by persistent oxygen requirement (94-2L => 70s-80s on RA), delirium (described below). Was discharged from NEBH on [2175-11-14] to [Hospital 100] rehab, where remained until [2175-11-16], when was transferred back to [Hospital1 18] for presumed CHF, at which time myocardial infarction was excluded by serial cardiac enzymes, CTA negative for PE. She was diuresed for elevtaed BNP, but persistently desaturated with minimal exertion to 80s. Patient was on coumadin post-operatively for DVT prophyalxis, and developed some hemoptysis (while on bridge with IV UFH). Her hospital course was complicated by leukocytosis with CTA evidence of ground glass opacities that were read as consistent with CHF or pneumonia, for which she was empirically treated with levofloxacin (completed in-house?). She was discharged back to [Hospital 100] rehab on prednisone taper, pain control, and lasix for CHF on [2175-11-23]. Patient was doing well until the morning of [2175-11-25], when she awoke with achy, non-radiating RLQ abdominal pain, subjective fever, anorexia. Her symptoms improved and appetite returned after a BM x 1 (unclear whether bloody, pus, or black), and she remained stable until the morning of admission ([2175-11-26]), when pain returned in a similar location, and with a similar quality. In both instances, the pain was constant, and, in the second case, did not ease with oxycodone or BM. On [11-25], fever was noted to 101.4, and patient was referred to [Hospital1 18] for further evaluation. No nausea, vomiting, hematemesis, diarrhea, BRBPR, melena, hematuria, dysuria, back pain, rash, cough, HA, vision changes, chest pain, increased shortness of breath, increased joint pain. Of note, her family has noted some "intermittent confusion" since her R TKR, consisting of right arm tremor, weakness, dysarthria/speech difficulty, and dysphagia for liquids/solids. She has had attacks of difficulty "opening my mouth," though she claims to comprehend speech, and denies other focal weakness or numbness, urinary incontinence. These attacks have been ascribed to medications (opiates), but are not related temporally to medication administration. Past Medical History: CHF CAD HOCM EF 65%, s/p EtOH septal ablation [9-22] complicatedby complete heart block s/p pacer knee arthritis s/p [10-24] R TKR HTN carotic stenosis CRI baseline 1.4 COPD/emphysema Restrictive lung disease GERD PVD s/p appy diverticulitis VRE s/p TAH/BSO Social History: Lives alone. One son locally. One daughter in [Name2 (NI) ]. Approx. 100 pack-yr smoking history. Rare EtOH. Family History: Non-contributory, no history of IBD Physical Exam: VS 97.4/96.9 100-120/30 CVP 14-19 96-99-2L I/O in MICU: +3.4L, UOP = 1300 ml since MN (~ 50-60 cc/hr) Gen: NAD Neck: No JVD appreciated. Cor: RRR S1, S2, II/VI SEM at base, variably increased with Valsalva. -r/g Chest: CTA B with scattered wheeze Abd: Soft, distended, hypoactive BS, RLQ > LLQ tenderness with light palpation; + mild shake tenderness Extr: R knee TKR c/d/i without ooze, non-tender. No c/c/e, 2+ DP in both pulses. Neuro: AAOx3, appropriately interactive. Pertinent Results: Echo (TEE) [2175-12-18]: ____________ . Echo (TTE) [2175-12-15]: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 3. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. 6. No obvious evidence of endocarditis seen. 7. Compared with the findings of the prior report (tape unavailable for review) of [2175-12-4], there has been no significant change. . Echo [2175-12-6]: EF>60%. The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR [2175-12-15]: A permanent pacemaker remains in place. There has been placement of a right PICC line, terminating in the superior vena cava, and a feeding tube, coursing below the diaphragm. Removal of a left subclavian vascular catheter is noted. The heart is mildly enlarged. There is vascular engorgement and worsening perihilar haziness as well as an increasing bilateral interstitial pattern. Small pleural effusions are noted bilaterally. IMPRESSION: Worsening congestive heart failure with increasing interstitial edema. . LENI [2175-12-12]: No DVT. . CXR [2175-12-8]: Mild interstitial pulmonary edema and greater caliber to the mediastinal veins suggest cardiac decompensation is progressed since [12-4]. Moderate cardiomegaly is longstanding. Tip of the left subclavian central venous line projects over the lateral margin of the SVC and should be withdrawn 1-2 cm to avoid mural trauma. Transvenous right atrial and right ventricular pacer leads follow their expected courses from the right pectoral pacemaker. No pneumothorax. . AXR [2175-12-8]: Limited study secondary to body habitus. No evidence of free air. Contrast is seen in the colon, likely secondary to the patient's video oropharyngeal swallow study. Gas is seen in the stomach. Note is made of degenerative changes of the lumber spine. IMPRESSION: No evidence of free air. . Brief Hospital Course: 79-year-old female, who recently underwent a right total knee replacement at the [Hospital1 ], who was admitted from Rehab for fever, abdominal pain, and diarrhea with leukocytosis and CT scan evidence of colitis. Initial hospital course outlined by problem. . ## ID: --C. Diff Colitis: She was initially treated broadly with levofloxacin and metronidazole since she had been on prednisone at the Rehab for a COPD exacerbation. However, once her C. diff toxin assay returned positive, her antibiotics were weaned to only metronidazole. Abdominal pain and diarrhea reduced dramatically after continued flagyl. Repeat c. diff studies were negative x4 days. Her end date for flagyl will be 7 days after stopping her levoquin. Ideally we would continue the flagyl for 7 days until stopping all antibiotics, however to avoid polypharmacy, ID favors the former plan. . --Coag negative staph line infection: Developed central line catheter infection with 2/4 bottles postive and postive line culture. The line was removed and she was started on vancomycin. Surveillance cultures were initially negative, however a single bottle grew out coag neg staph 3 days after starting treatement. Given the presence of her pacer and knee replacement, it was decided in consultation with infectious disease to extend her vancomycin course to 4 weeks. TTE was negative for obvious endocarditis and a right knee tap by her orthopedic surgeon grew no organisms. All surveillance cultures were subsequently sterile. A TEE was not performed given the lack of further positive cultures and the great degree of anxiety that the procedure generated in this patient. . --Rash/cellulitis: The Pt. developed a weeping, erythematous rash on her flanks bilaterally that was painful. This was thought to be a mild cellulitis, however worsened despite being on vanco for her line sepsis. Under the direction of ID, levoquin was added for gram negative coverage and her cellulitis appeared to improve. Toward the end of her hospital stay she continued to have persistent erythema with some tenderness on palpation, however was afebrile with a normal WBC. This was felt to be related to her anasarca and should improve with mobilization of her fluid. She will have to have this area watched for skin breakdown related to the edema. . ## CHF / AFib with RVR: Experienced 3 episodes of atrial fibrillation with rapid ventricular rates symptomatic for chest pain and hypotension. On each occasion she failed rate conrol with IV CCB's and BB's and needed resusitation with fluids and cardioversion. First episode was treated with amio and cardioversion. Second episode was treated with cardioversion only. third episode was attempted with ibutilide, then cardioversion which was transiently successful. She was then taken to the EP lab for an AV nodal ablation. She already had had a pacemaker placed in [2173] for her EtOH septal ablation. Amiodarone was stopped. Anticoagulation was continued. She continued to be in heart failure which was slow to diurese in the setting of her anasarca, hypoalbuminemia, and HOCM. She responded slowly with IV lasix without any worsening of her renal function. She will need continued, but careful, diuresis given the low oncotic state of her plasma. * ACEI and BB held for low blood pressures surrounding afib with rapid vent rate with hypotension. ACEI will need to be restarted. . ##. Fluids and Nutrition: Unfortunately, due to malnutrition (hypoalbuminemia) and deconditioning she was difficult to diurese. IV lasix did result in an increase in urine output, but it was a challenge to achieve net negative fluid balance (in's included IV Abx and tube feed volume). She had a speech and swallow evaluation done on HOD#16 which revealed moderate remaining aspiration risk. As such, she has been tube fed with the goal of transitioning her back to PO as tolerated. This will likely need to be performed in consultation with nutrition. . ## Ortho: Her right knee was also noted to be stiff and painful. This was thought to be due to her recent surgery, but with her recent bactermia a septic arthritis could not be ruled out so orthopedics was consulted to tap the knee. The fluid revealed a hemarthrosis, but no evidence for infection on the gram stain. Prior to discharge her orthopedic attending okay'd her for full weight bearing status on her right knee. . ## Heme: maintained on coumadin for Afib with goal INR 2.0-2.5. (held for intervention) and restarted on [12-19] . ## Pulm: h/o COPD, s/p recent 3 week prednisone taper for COPD. O2 via NC, albuterol and atrovent nebs. [Month/Year (2) 4010] was increased. At the end of her stay albuterol was stopped for worsening benign essential tremor. . MICU Update: Brief summary of prior hospital course: 79F with HOCM s/p septal ablation with hospitalized [2175-11-26] for c diff colitis after total knee replacement in [10-24] and rehab at [Hospital ] Rehab. This hospitalization c/b AF RVR requiring ablation and pacer placement [12-17], diastolic CHF exacerbation, pulmonary edema and anasarca, poor nutrition, coag neg staph line infection, recurrent candiduria, delerium, and right abdominal wall cellulitis. . She was sent to CCU [1-3] with hypotension and intubated for resp distress during a code. For 3 days previous to event, she had episodes of hypothermia and hypoxia on floor presumably interpreted as worsening pulmonary edema requiring additional diuresis. CTA at that time with no PE, but bilat ground glass with some pockets of consolidation and small bilat effusions. Diuresis continued with effect but on AM of [1-3] pt dropped SBP to 70's, minimally responsive to 1.5L NS IVF. Dopamine gtt started at 19.1 prior to CCU transfer with effect BP 79/31. . In the CCU, hypotension presumed to be septic shock, WBC up to 20, creat up to 1.2 from 0.9. Loose bowels noted. BP was very responsive to low dose levophed and vasopressin. Cosyntropin stim performed after random cortisol < 15 without appropriate rise. Stress dose steroids were started. Ventilation complicated by poor compliance and high PIPS, was placed on PCV then changed to AC for unclear reasons. Antibiotic treatment broadened to include caspofungin for candiduria not improving on fluconazole, aztreonam for hospital acquired pneumonia in pt allergic to PCN, and continued vancomycin for h/o coag neg staph bacteremia. Weaned off levophed and vasopressin overnight with MAPS > 60. In CCU, multiple attempts made at central line placement, s/b left subclavian hematoma despite FFP reversal of anticoagulation. Hct drop presumed due to volume shifts 29->25% s/p 4 units prbcs [Date range (1) 97594]. . MICU Course as of [2176-1-17]: Pt was transferred to the MICU for further management of septic shock. . # Pseudomonas Pneumonia - Responded to combination of aztreonam and gentamicin. Further fever work up showed no endocarditis, no pacer abscess, no other growth from cultures. . # Hypoxic Respiratory Failure: Initial resp failure was due to the combination of pneumonia and fluid overload and weaning was complicated by difficulty with diuresis and baseline interstitial/restrictive lung disease of unclear etiology. Patient was transitioned to pressure support ventilation, and continued a slow wean with plans for possible tracheostomy if the pt was unable to extubate by [2176-1-23] . # Anemia: Hct has stabilized at 25-26, adequate retics . # CRI: Initially had elevated Cr on transfer which improved with diuresis and hemodynamic stability. . # Diastolic CHF, h/o HOCM s/p septal ablation: Pt was restarted on ACE and BB for BP control and afterload reduction with IV lasix and chlorthalidone for diuresis. . # CAD: Pt was ruled out for MI and then continued on asa, lipitor, BB and ACE-I as BP tolerates. . # AF s/p ablation and pacer: Pacer dependent, will need rate turned down by EP (currently at 80) after either extubation or tracheostomy and stabilization of respiratory status. . Code: DNR/DNI, no electricity of chest compressions Communication: Daughter (HCP) and son Addendum: As per legnthy and frequent family meetings, including a meeting between the family, Dr. [Last Name (STitle) 4427], and Dr. [Last Name (STitle) 58318] on [2176-1-23], the decision was made to extubate the pt. when she was thought to have the most promising picture for respiratory success, with no further plans for future intubation despite the post-extubation outcome. Therefore, on [2176-1-29], the pt was felt to be doing well with a high RISB, decreased bicarb from diamox treatment, and HOB upright. At this point, the medical team felt that the pt. is at a point where she has the best chance to succeed with an extubation. The pt. was subsequently extubated. The pt. was succeeding for a number of hours with moderate respiratory effort and family encouragement, but then progressively became more tired with increased WOB and slowly decreasing oxygen saturations. As per the decided plan of action, and as per the patients wishes to be DNR/DNI, the pt was made as comfortable as possible through this time of increased air hunger without any further intubation attmepts. The pt. subsequently expired on [2176-1-30] and was not attempted to be resussitated due to her DNR order. Medications on Admission: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H:PRN. 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day) as needed. 14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q2H (every 2 hours) as needed. 16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 17. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): 40mg total on [11-23], then taper to 20mg total each day for [11-24] - [11-26], then taper to 10mg total each day for [11-27] - [11-29]. 19. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 20. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezing, SOB. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for wheezing, SOB. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 9 days: For C. difficile colitis. 12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Dose may need to be adjusted. Goal INR = [2-23]. 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 16. Furosemide 10 mg/mL Solution Sig: Forty (40) mg IV Injection [Hospital1 ] (2 times a day) for 1 days: Adjust as needed for goal diuresis of approximately 4 liters of fluid at a rate of 500-1000cc daily. 17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: Respiratory failure Psudomonas Pneumonia C. difficile colitis Myocardial infarction - due to demand related ischemia (peak TropT = 0.18) Hypertrophic Obstructive cardiomyopathy Atrial Fibrillation with rapid ventricular response Sepsis Total knee replacement - right leg Chronic renal insufficiency Chronic obstructive pulmonary disease congestive heart failure coronary artery disease Central line infection coagulase negative staph bacteremia malnutrition Discharge Condition: Expired Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2175-12-18] 2:00 Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 2207] Date/Time:[2175-12-18] 2:30 Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2176-5-1] 12:40 Please follow-up with your PCP [Last Name (NamePattern4) ] [2-23**] weeks.	[ "78552", "42731", "41071", "5990", "0389", "99592" ]
Admission Date: [2128-1-30] Discharge Date: [2128-2-7] Date of Birth: [2128-1-30] Sex: F Service: NB HISTORY: Baby girl [Known lastname 60788] is a 3530 gram product of a 38 [1-26] week gestation age (expected date of confinement [2128-1-31]) gestation born to a 37 year old G3 P2 mother with prenatal screen showing blood type A positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B negative and GBS unknown. This pregnancy was complicated by gestational diabetes which was diet controlled. The mother had a previous pregnancy that was complicated by a loss at 29 weeks due to hydrops. That infant was chromosomally normal. Mother was taking prenatal vitamins and Zantac. Baby girl [Known lastname 60788] was born by a repeat scheduled cesarean section with an Apgar score of 4 at one minute, 5 at five minutes, and 7 at ten minutes. She require positive pressure ventilation in the delivery room, and was noted to be limp and lethargic in the delivery room. She was then taken to the neonatal intensive care unit for further evaluation. EXAMINATION: The infant was found to be profoundly pale, and had obvious decreased tone and poor respiratory effort. The initial vital signs included a temperature of 97.3, heart rate of 156. Oxygen saturation on room air was seventy four percent, blood pressure 81/52, with mean of 62. Her head was normocephalic, atraumatic, with anterior fontanel open and flat. Her palate was intact, with no obvious clefts of the lip or palate. Neck was supple. Lungs were clear on auscultation and equal bilaterally. Cardiovascular system - Her heart sounds were regular in rate and rhythm, with S1 and S2 normal and no audible murmur. Femoral pulses were 2 plus bilaterally. Abdomen was soft, nondistended, with active bowel sounds. There was no obvious mass or hepatosplenomegaly. The extremities were warm, well perfused, brisk. Skin appeared mottled and pale. Neurologically, unable to elicit deep tendon reflexes at the knees. The tone was decreased and was symmetrical bilaterally. The spine appeared in the midline, and there was an obvious sacral dimple. The hips were stable. The genitourinary appeared as a normal premature female. The birth weight was 3530 grams, 70th percentile, length 53 cm, greater than 90th percentile, head circumference 35.5, 90th percentile. SUMMARY OF HOSPITAL COURSE BY SYSTEM: A. RESPIRATORY. Due to the poor respiratory effort and low saturations on room air, the patient was intubated in the neonatal intensive care unit to secure the airway. She was intubated with a size 3.5 endotracheal tube. The infant tolerated the procedure well, without complications. The patient was put on low mechanical ventilator settings. The settings on the conventional mechanical ventilator were pressures of 20/5, rate of 20, and FIO2 requirement of 22-30 percent. The blood gases were within normal limits. The patient self extubated the next day to room air. The patient remained on room air during her remaining course in the neonatal intensive care unit. her initial chest x-ray had shown evidence of mild respiratory distress syndrome, along with bibasilar hazy atelectasis. The heart and the mediastinal contours were normal. There was no other evidence for pneumonia or pleural effusion. B. CARDIOVASCULAR. On arrival to the neonatal intensive care unit, the patient's blood pressures were low, with amounts ranging from 37 to 40. He required two normal saline boluses. After her initial hypotensive episode, he remained hemodynamically stable. The patient did not require any vascular support medication during her stay in the neonatal intensive care unit. After initial examination, a low pitched audible murmur was heard on day one of life. This murmur was localized to the lower left sternal border, grade I/VI systolic, and radiated to the axilla. The murmur persisted to the day of discharge. A cardiac evaluation was performed which included an EKG, a four extremity blood pressure, and hyperoxia test. She passed her hyperoxia test with paO2 greater than or equal to 300 on 100 percent FIO2. An EKG obtained was within normal limits. Her four limb blood pressure did not show any variation. The murmur was felt to be PPS and would be followed clinically. C. FLUID, ELECTROLYTES, NUTRITION. The patient remained NPO until day two of life. During this time, she was on intravenous fluid at 60 cc/kg/day with electrolytes. Her total fluid was gradually advanced. The electrolytes obtained during her neonatal intensive care unit stay remained within normal limits. She maintained a brisk urine output during her stay in the NICU. Her most recent weight is 3505 grams. Her initial dextrose check was 115 mg/dL, and she maintained her dextrose level during this period in the NICU. D. GASTROINTESTINAL. The patient was NPO for the initial two days of life. She was gradually started on feeds and advanced to full feeds on day four of life. She has been tolerating all p.o. feeds since day five of life. She had initial set of liver function tests which showed elevated ALT at 64, AST 176, alkaline phosphatase 107. Her bilirubins at this time were total 2.6, direct 0.2. Her repeat liver function tests were performed on day two of life, which showed a trend towards an increase, with ALT levels at 150 and AST at 343 and alkaline phosphatase at 100. Her final LFT's were done on [2128-2-6]. At that time her AST 31 ALT 48 Alk Phos 133. Her peak bilirubin was 11.6, and a direct of 0.3, on day three of life. She did not require any phototherapy during her stay in the neonatal intensive care unit. E. HEMATOLOGY. Her initial CBC had shown an hematocrit of 15.8 and a platelet count of 345. An exchange transfusion was done for hematocrit of 15.8, with a post exchange hematocrit of 35, then 31.9, for which she was given 20 cc/kg of packed red blood cells. Kleihauer-Betke test was performed on the mother, which was positive for 16 mL of fetal blood in the maternal circulation. She had an umbilical venous catheter placed, and she was exchange transfused with reconstituted RBC's rather than packed RBC's. Hematocrit on banked blood equaled 52 percent, and was used in the calculation to correct hematocrit. Total 200 cc was removed, and a total of 245 cc infused in 5 cc aliquots, and later on 10 cc aliquots. This was done over fifty minutes. Ionized calcium and glucose remained stable before, halfway, and at the end of the exchange. The infant tolerated the procedures very well, with no complications. The catheter was removed at the end of the procedure without incident. Her last blood transfusion was on [1-28], with a resultant hematocrit of 44.5 on [2128-2-2]. Her final hematocrit on [2128-2-5] was 55.9. F. INFECTIOUS DISEASE. Her initial CBC had shown a white count of 21.2 with 44 polymorphs and two bands. She was started on ampicillin and gentamicin, which was discontinued at 48 hours of life. The blood cultures remained negative to date. She became cold while in an open crib [2127-2-5] a CBC and blood culture were drawn at that time with wbc 6.7 (28P 0B 56L) she had a blood culture drawn at that time which showed no growth. She was not started on antibiotics. G. NEUROLOGY. Baby girl [Known lastname 60788] was noticed to have a seizure on day of life zero. She was loaded with phenobarbital at 20 mg/kg/dose and started on a maintenance dose. Neurology from [Hospital3 1810], [Location (un) 86], was consulted. The infant was initially lethargic, with minimal activity. This improved after the exchange transfusion. A CT scan was done on [2128-1-30]. CT scan showed no evidence of infarction or hemorrhage. An EEG was obtained on [2128-1-30] which was within normal limits. An MRI was obtained on [2128-2-4] which showed structurally normal infant brain with no signs of intracranial mass effect or recent infarction. An ultrasound of the spine was obtained because of the sacral dimple. This showed normal examination of the spinal cord, with no evidence of tethering. Phenobarbital was discontinued on [2128-2-3]. There was no notable seizure after the two episodes of seizures on day zero of life. The patient has a neurology followup at one month of life. H. AUDIOLOGY. The hearing screen was normal in both ears F. OPHTHALMOLOGY. The patient did not have any eye exam because of her gestational age. G. PSYCHOSOCIAL. [Hospital1 69] social worker involved with family. Contact social worker is [Name (NI) 60789] [Name (NI) 6861] who can be reached at [Telephone/Fax (1) ]. CONDITION ON DISCHARGE: Stable. DISPOSITION: Home. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 8071], [Hospital1 3597], [State 350] ([Telephone/Fax (1) 43314]). CARE RECOMMENDATIONS: A. The patient is on breast feeding or Similac 20 ad lib as tolerated. B. Medications - none. C. Car seat passed. D. State newborn screening was sent on [2128-1-30] and [2128-2-4]. E. The patient received hepatitis B vaccine on [2128-2-1]. F. Immunizations recommended: 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. G. Follow up appointment in neonatal neurology is being scheduled at the time of this dictation at one month of age. DISCHARGE DIAGNOSES: 1. Anemia. Fetal-maternal exchange. 2. Perinatal depression. 3. Seizures. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Doctor Last Name 60445] MEDQUIST36 D: [2128-2-4] 15:33:22 T: [2128-2-4] 16:44:39 Job#: [Job Number 60790]	[ "V053", "V290" ]
Admission Date: [2102-6-15] Discharge Date: [2102-6-18] Date of Birth: [2020-4-21] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1167] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 82yoM w/ PMH HTN, dyslipidemia presents to the CCU after having had an inferior STEMI. Pt reports that 1 day PTA he was doing water aerobics and after workout had generalized weakness, but no CP/SOB. Afterwards he was feeling well and went about the rest of his day. Today, he was washing his windows at 1:30pm when he began having substernal chest pressure. He went to the [Hospital 191] Clinic where EKG revealed ST elevations in II, III, AVF and depressions in AVL. Given 2 NTG, 5 minutes apart and became acutely diaphoretic and hypotensive (BP60/P). ST elevations worsened. BP came up to 102/60 after 1L NS. Patient administered 4 ASA and instructed to chew. Taken to ED by ambulance, where initially he was chest pain free. . In the ER, initial VS 97.2 54 120/62 18 99% 4L. At 6:15pm he had recurrence of the chest pain and ST elevations in II,III, AVF with depressions in AVL. A code STEMI was called at this time. He received heparin gtt, plavix load, and was emergently taken to the cath lab. In the cath lab, he was found to have a 70% proximal and 80% mid LAD lesion, as well as a 100% proximal right lesion. DES was placed to the RCA lesion. The only complication of the catheterization was transient bradycardia to the 40's. . In the CCU, patient is chest pain free. He has absolutely no complaints. . 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. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of current chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Benign Prostatic Hypertrophy GERD Erectile dysfunction Low Back pain/Sciatica Seborrheic Dermatitis Retinal Detachment ?Paget's Disease Colon Polyps Anemia Actinic Keratosis Hemangiomas Social History: Patient is married and lives with his wife and his mother in [Name (NI) 5110]. He is a native of [Country 10363] and moved to this country in [2072]. -Tobacco history: None -ETOH: Social (0-3 drinks/week) -Illicit drugs: None Family History: NC Physical Exam: GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP 8cm. 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: CTAB in anterior fields, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. R groin w/ no hematoma. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Femoral 2+ DP 2+ PT 2+ Left: Femoral 2+ DP 2+ PT 2+ Pertinent Results: Labs on admission: [2102-6-15] 06:18PM GLUCOSE-125* NA+-140 K+-3.5 CL--100 TCO2-27 [2102-6-15] 06:18PM HGB-12.4* calcHCT-37 [2102-6-15] 06:00PM PT-13.6* PTT-25.3 INR(PT)-1.2* [2102-6-15] 06:00PM WBC-9.8 RBC-4.14* HGB-12.7* HCT-36.9* MCV-89 MCH-30.6 MCHC-34.3 RDW-13.1 [2102-6-15] 06:00PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.3 Cardiac enzymes: [2102-6-15] 06:00PM BLOOD cTropnT-0.07* [2102-6-16] 03:43AM BLOOD CK-MB-63* MB Indx-10.2* cTropnT-2.57* [2102-6-16] 01:49PM BLOOD CK-MB-33* MB Indx-6.9* cTropnT-1.22* [2102-6-17] 06:35AM BLOOD CK-MB-13* MB Indx-5.1 cTropnT-0.83* EKG: [6-15] Sinus bradycardia. ST segment elevation in leads II, III and aVF with reciprocal ST segment depression in lead aVL suggestive of acute ST segment inferior wall myocardial infarction. C Cath [6-15] 1. Selective coronary angiography of this right dominant system revealed two vessel coronary artery disease. The LMCA was normal in appearence. The LAD had a long 70% proximal and 80% mid vessel stenosis. The LCx had mild luminal irregularities. The RCA had a 100% proximal total occlusion with left to right collaterals. 2. Limited resting hemodyanmics revealed mild systemic hypertension, with a central aortic pressure of 142/69 mmHg. 3. Successful PTCA/stenting of Proximal RCA occlusion with 3.5 X 23 mm PROMUS DES, post dilated with 3.5 mm NC balloon at high pressure (details under PTCA Comments). Final angiogran showed 0% residual stenosis, no dissection and normalf flow. 1. Two vessel coroanry artyer disease with total occlusion of the RCA. 2. Successful primary PCI of proximal RCA with DES. 3. Consider PCI of LAD if recurrent ischemia or positive ETT. CXR [6-15] IMPRESSION: No acute cardiopulmonary process. Echo [6-16] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild focal basal inferior/infero-lateral hypokinesis suggested on long axis views. The remaining segmetns are dynamic and therefore the overall LVEF is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2098-4-9], subtle regional LV systolic dysfunction is new Brief Hospital Course: 82yoM with HTN, dyslipidemia presents after inferior STEMI. He is now status post [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] to RCA. . # CORONARIES: Patient is s/p inferior STEMI with [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] to RCA. Started on atorvastatin 80mg daily, plavix 150mg x 1 week then 75mg daily, ASA 325mg daily, lisinopril 5mg daily, metoprolol succinate 25mg daily. Cardiac enzymes peaked at trop 2.57 as above. Follow-up echo showed mild LV dysfunction as above. The LAD also had a long 70% proximal and 80% mid vessel stenosis. PCI to the LAD should be considered if there is recurrent ischemia or positive ETT. He will follow-up with Dr. [Last Name (STitle) ], but ETT still needs to be obtained. He was cleared by physical therapy on the day of discharge. . # PUMP: Echo showed mild LV dysfunction. Started on metoprolol succinate and lisinopril. Euvolemic on exam at time of discharge. . # RHYTHM: Patient initially bradycardic in the setting of inferior wall STEMI, but this eventually improved and he was able to tolerate beta blocker. . # HTN: Stopped HCTZ and nifedipine as no cardiac benefit. Started BB and ACEi as above. . # Dyslipidemia: Goal LDL is less 70 (last was 106 while on lipitor 10mg daily). Started atorvastatin 80mg daily as above. Medications on Admission: HCTZ 25mg daily Lipitor 10mg daily Potassium (Micro-K 10) 20meQ daily Nifedipine XL 90mg daily Omeprazole 20mg daily Colace 100mg [Hospital1 ] MVI Fish Oil Vitamin A,C,E-zinc-copper Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. clopidogrel 75 mg Tablet Sig: ASDIR Tablet PO DAILY (Daily): 2 tablets through [2102-6-23], then one tablet daily. Separate from omeprazole by 4 hours. Disp:36 Tablet(s) Refills:2 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary: Inferior ST elevation MI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [Known lastname 105703] it was a pleasure taking care of you. . You were admitted to [Hospital1 18] and were found to have a heart attack and a stent was place in your occluded right coronary artery. You were started on medications to protect your heart as well as stabilize plaques and ensure patency of new stent. . CHANGES TO YOUR MEDICATIONS: To ensure stent patency: -Start taking Plavix two 75mg tablets daily through Friday [2102-6-23], then take one tablet daily. Please separate from omeprazole by 4 hours. -Start taking Aspirin 325mg tablets. Take one tablet daily Do not stop taking these medications unless advised by your cardiologist or PCP . To aid your heart in remodeling after your heart attack: Start taking Lisinopril 5mg tablets. Take one tablet daily. Start taking Metoprolol Succinate 25mg daily . To stabilize plaques: Start taking Atorvostatin 80mg tablets. Take one tablet daily . Stop taking hydrochlorothiazide and nifedipine. . Again it was a pleasure taking care of you. Please contact with any questions or concerns. Followup Instructions: Please call Dr. [Last Name (STitle) ] in cardiology at ([Telephone/Fax (1) 2037] to make an appointment in the next 2 weeks. Since you were discharged on a Sunday we couldn't make this appointment for you. Please call Dr. [Last Name (STitle) ], your PCP, [Last Name (NamePattern4) ] [Telephone/Fax (1) 250] for an appointment in the next 1-2 weeks. Department: [Hospital3 249] When: WEDNESDAY [2102-8-2] at 11:10 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2967], RNC [Telephone/Fax (1) 250] Building: [Hospital6 29] None Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 1935] CENTER When: WEDNESDAY [2102-9-13] at 1:10 PM With: EYE IMAGING [Telephone/Fax (1) 253] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 1935] CENTER When: WEDNESDAY [2102-9-13] at 1:30 PM With: [First Name11 (Name Pattern1) 354] [Last Name (NamePattern4) 3013], M.D. [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "41401", "4019", "2724", "53081" ]
Admission Date: [2159-11-6] Discharge Date: [2159-11-13] Date of Birth: [2102-10-12] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: chest pain, SOB Major Surgical or Invasive Procedure: CABG X 3 (LIMA > LAD, SVG>Diag, SVG>Ramus) on [11-8] IABP placement (pre-op) History of Present Illness: 57 y/o female with chest pain X 1 year, worse just prior to admission. Presented to [Hospital6 3105], and transferred to [Hospital1 18] for cath. This revealed LM & 3vCAD. She was referred for urgent CABG Past Medical History: ITP (baseline plt. ct. 25-30K) DM-1 neuropathy retinopathy s/p MI in [2152] HTN hyperlipiddemia Social History: married non-smoker Family History: non-contributory Physical Exam: unremarkable pre-op Pertinent Results: [2159-11-13] 06:00AM BLOOD WBC-10.5 RBC-3.88* Hgb-11.4* Hct-33.1* MCV-85 MCH-29.3 MCHC-34.4 RDW-15.0 Plt Ct-309 [2159-11-13] 06:00AM BLOOD Glucose-87 UreaN-24* Creat-1.0 Na-138 K-4.6 Cl-101 HCO3-29 AnGap-13 [2159-11-8] 02:44PM BLOOD ALT-12 AST-64* LD(LDH)-415* AlkPhos-26* Amylase-26 TotBili-0.5 Brief Hospital Course: 57 y/o female transferred to [Hospital1 18] from [Hospital3 19345]. She underwent cardiac catheterization on [2159-11-6] which revealed 50% LM & 3vCAD. She had hemodynamic compromise in the cath lab requiring emergent IABP placement and intubation. She was transferred to the CCU, and extubated. Hematology service was consulted re:ITP. She was also given Plavix at the time of her cath. She was optimized from the medical standpoint, and taken to the OR on [2159-11-8]. She underwent CABG X 3 (LIMA>LAD, SVG>diag, SVG>Ramus) by Dr. [Last Name (STitle) ]. PLease see operative report for details of surgery. Post-op she was taken to the CSRU on epinephrine, phenylephrine and propofol gtts. She remained intubated while her vasoactive gtts, and IABP were weaned. Her IABP was discontinued on POD # 1, and was extubated on the morning of POD # 2. She remained in the CSRU for 2 more days due to her high insulin requirement necessitation an insulin gtt. The was ultimately transitioned to her insulin pump (which she was on pre-operatively), and she was transfered to the telemetry floor on POD # 4. She has remained hemodynamically stable, has progressed with ambulation, and is ready to be discharged home today. Medications on Admission: Imdur 30' Diltiazem CD 120' Hyzaar Toprol XL Vytorin Xanax Insulin pump 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Vytorin [11-23] 10-20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Insulin Regular Human 100 unit/mL Solution Sig: pump as pre-op Injection ASDIR (AS DIRECTED). Disp:QS Refills:2 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 7. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: then 1 tab (5mg) daily for 1 week, then discontinue. Disp:21 Tablet(s) Refills:0 8. 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 10. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: greater [Location (un) ] vna Discharge Diagnosis: CAD DM ITP Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no driving for 1 month no lifting > 10# for 10 weeks Followup Instructions: with Dr. [Last Name (STitle) ] in 4 weeks with Dr. [Last Name (STitle) 5686] in [3-9] weeks with Dr. [Last Name (STitle) 67537] in [3-9] weeks Completed by:[2159-11-13]	[ "4019", "2720", "412", "41071", "41401", "4280", "4240" ]
Admission Date: [2173-7-13] Discharge Date: [2173-7-17] Date of Birth: [2127-8-16] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 668] Chief Complaint: end stage renal disease Major Surgical or Invasive Procedure: [2173-7-13] Living unrelated kidney transplant History of Present Illness: 45-year-old gentleman with end-stage renal disease secondary to multiple etiologies. He underwent nephrectomy at age 15 for recurrent infections and underwent a renal biopsy of his remaining kidney, which demonstrated a secondary FSGS. He has over the last several years progressed to end-stage renal disease and presented on [2173-7-13] for living unrelated kidney transplant from his fiancee. Past Medical History: PMH: HTN, diabetes (formerly treated with insulin, currently on oral agents) PSH: left nephrectomy in [2142] and an AV fistula constructed in [2171] Social History: ETOH is one to two times per week. No smoking, no IV drug use or marijuana use. Family History: His mother died at age 54. His father is currently alive with heart disease. He has three siblings, two of the three with diabetes and two children that are aged 12 and 15 are currently healthy. Physical Exam: Day of discharge: AVSS Gen NAD CV RRR Chest CTAB Abd soft, nontender, nondistended; incision clean/dry/intact; JP drain site with suture in place Ext no edema; WWP Pertinent Results: [2173-7-17] 04:35AM BLOOD WBC-2.8* RBC-2.94* Hgb-8.4* Hct-26.4* MCV-90 MCH-28.7 MCHC-31.9 RDW-17.9* Plt Ct-114* [2173-7-17] 04:35AM BLOOD Glucose-202* UreaN-58* Creat-2.8* Na-139 K-4.8 Cl-108 HCO3-21* AnGap-15 [2173-7-17] 04:35AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0 [2173-7-17] 04:35AM BLOOD tacroFK-4.9* [2173-7-16] 05:10AM BLOOD tacroFK-4.0* [2173-7-15] 05:30AM BLOOD tacroFK-2.1* [2173-7-14] 05:00AM BLOOD tacroFK-4.4* [2173-7-13] Renal transplant ultrasound: 1. Patent renal transplant vasculature with appropriate waveforms. 2. No hydronephrosis. Brief Hospital Course: The patient presented for a living unrelated kidney trasnplant on [2173-7-13]. In the perioperative period he was kept intubated due to moderate intraoperative hypotension requiring pressors. He was noted to have a metabolic acidosis at the time of surgery and started on a bicarbonate drip and sent to the SICU, intubated. Overnight his acidosis improved and his blood pressure stabilized off pressors. Urine output was 300-500mL/hr in the first 24 hours postop. He was extubated in the morning of postop day #1 and transferred to the floor later that day. On the floor his diet was advanced from clear liquids to regular diet. His pain was well controlled with oral pain medications. He was initialy given cc per cc repletion of his urine output with IVF, then transitioned to 1/2 cc per cc repletion. The repletion was then discontinued and his urine output remained appropriate. He ambulated and moved his bowels without difficulty. The foley catheter was removed. His creatinine decreased from >10 preop to 2.8 on the day of discharge. He tolerated his immunosuppresion regimen and antibiotic prophylaxis. His blood sugars were elevated to the 200-400s initially and he was treated with first an insulin drip, then transitioned to SC insulin lantus and sliding scale. He received med teaching and demonstrated understanding of his home meds and self care. His JP drain output decreased and the JP drain was removed on the day of discharge. At the time of discharge he was ambulating, voiding and eating without difficulty. He is discharged to home on [2173-7-17] in good condition. Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day EPOETIN ALFA [PROCRIT] 20,000 unit/mL Solution - 40,000 units every 2 weeks SIMVASTATIN 20 mg Tablet - 1 Tablet(s) by mouth once a day SITAGLIPTIN [JANUVIA] 25 mg Tablet - 1 Tablet(s) by mouth once [Last Name (un) 5490] VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] - (Prescribed by Other Provider) - 320 mg-12.5 mg Tablet - 1 Tablet(s) by mouth once a day CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] 315 mg-200 unit Tablet - 1 Tablet(s) by mouth once a day OMEGA 3-VITAMIN E-FISH OIL - 1,100 mg-700 mg-15 unit Capsule - 2 Capsule(s) by mouth once a day Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 2. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 10. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 2 doses: DOSE AS DIRECTED BY TRANSPLANT CENTER; YOU WILL BE CONTACT[Name (NI) ] BY PHONE WITH YOUR DOSE STARTING TONIGHT [2173-7-17]. 11. hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 12. insulin glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. Disp:qS 30 days Refills:2 13. Humulin N 100 unit/mL Suspension Sig: One (1) Unit Subcutaneous with meals and at bedtime: Per insulin sliding scale. Disp:qS 30 days Refills:2 14. prednisone 10 mg Tablet Sig: 2.5 Tablets PO once for 1 days: Take ONCE on [Last Name (LF) 1017], [2173-7-18] for your last dose of prednisone. 15. test strips Sig: One (1) strip every four (4) hours: For use with glucometer. Disp:qS 30 days Refills:2 16. Alcohol Wipes Pads, Medicated Sig: One (1) wipe Topical every four (4) hours. Disp:qS 30 days Refills:2 17. syringe (disposable) Syringe Sig: One (1) syringe Miscellaneous every four (4) hours: Insulin syringe and needle. Disp:qS 30 days Refills:2 18. Pepcid (pt taking own home dexlansoprazole in lieu of this medication) Discharge Disposition: Home Discharge Diagnosis: End stage renal disease Living unrelated renal transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if you have any of the following: fever (101 or greater), chills, nausea, vomiting, increased abdominal pain or distension, constipation, pain/burning/urgency with urination or incision redness/bleeding/drainage You may shower; Do not apply powder/lotion/ointment to incisions No driving while taking pain medication No heavy lifting (nothing heavier than 10 pounds) or straining You need to have your blood drawn on [Last Name (LF) 766], [7-19] for the following: Chemistry, liver function tests, and tacrolimus level. The blood should be drawn JUST BEFORE your morning dose of tacrolimus is due. If you have this done at an outside hospital, please ensure that the results are called or faxed to Dr.[Name (NI) 670] office ASAP. You will need to take insulin at home. Please call Dr.[Name (NI) 670] office if you have any questions about your insulin dose. When your are finished with the prednisone, your blood sugars are expected to decrease and you may need less insulin. Followup Instructions: Department: TRANSPLANT CENTER When: THURSDAY [2173-7-22] at 1:10 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: TRANSPLANT CENTER When: THURSDAY [2173-7-29] at 8:20 AM With: [Name6 (MD) 2105] [Name8 (MD) 2106], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: TRANSPLANT CENTER When: [Hospital Ward Name ] [2173-8-2] at 10:10 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "40391", "2762", "2724" ]
Admission Date: [2136-4-12] Discharge Date: [2136-4-24] Date of Birth: [2090-9-11] Sex: M Service: Plastic Surgery ADMISSION DIAGNOSIS: Right hand crushing injury. SECONDARY DIAGNOSES: Tobacco abuse. CHIEF COMPLAINT: Right hand injury. HISTORY OF PRESENT ILLNESS: Forty-five-year-old left-hand dominant male without significant past medical history suffered a crush injury to right hand at approximately 16:15 on the day of admission. Patient was at a construction site, where he was working and a hydraulic press crushed his hand. No other injuries and no significant bleeding seen at an outside hospital, where the wound was dressed, and the patient was given Ancef and tetanus. No history of heart disease or diabetes. Positive two pack per day smoking history for many years, last p.o. approximately 1 p.m. on day of admission. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS ON ADMISSION: None. SOCIAL HISTORY: Two-packs per day of cigarettes for many years. Social alcohol. PHYSICAL EXAM: Patient was afebrile with stable vital signs, alert and oriented in no apparent distress. Clear to auscultation bilaterally. Soft abdomen. Regular rate and rhythm. Right upper extremity: Hand is dressed in sterile gauze. He has an oblique dorsal laceration from mid palm to the second metacarpophalangeal. There is exposed tendon. On the dorsal aspect, there is a significant degloving injury involving much of the dorsal aspect of his hand. There is a positive volar laceration with exposed tendon and nerves and vessels at the thenar crease, exposed second metacarpophalangeal joint, exposed fracture at the head and the neck of the second metacarpal. The digital nerves and vessels to the ulnar aspect of the thumb were visualized, no damage seen grossly. On the radial aspect of the thumb, the digital nerves and not visualized. Positive nerve and vessel damage to the ulnar and volar aspect of the second finger or index finger. The ulnar digital arteries and nerves were interrupted and the radial nerves and arteries appeared to have undergone shear forces. Fingers: The middle, ring, and little fingers exhibit normal motor and sensory function. The thumb shows positive EPL function held in slight flexion, weak opponent function. Capillary refill of the thumb was less than two seconds. Positive light touch on radial and ulnar aspects. The index finger inconsistent sensory examination. No capillary refill, no movement, dusky in appearance. X-RAYS: A-P, lateral, and oblique of the right hand shows a comminuted base of the first metacarpal fracture and a comminuted head of the second metacarpal fracture. No other fractures visualized. Chest x-ray was within normal limits. LABORATORIES: White count 14.6, hematocrit 44.2, platelets 241. Chemistry was 137/4.7/103/26/18/0.8/109. Coags were 12.1/22.1/1.0. EKG was within normal limits. BRIEF HOSPITAL COURSE: In the Emergency Room, the patient was given 15 cc of 1% lidocaine and 0.25% Sensorcaine without Epinephrine at the radial, median, and ulnar nerve sites in order to provide wrist block. Prior to physical exam, wounds are irrigated with 1 liter of sterile normal saline and above examination was performed. In the Emergency Room, the patient's second digit, index finger of the right hand was amputated. The wound was dressed in a sterile fashion with one stitch placed. That evening called late at night regarding the thumb being somewhat dusky and cold without capillary refill and patient was seen and examined. The splint was loosened. Capillary refill improved. Color improved. Temperature improved and patient was seen and examined with Dr. [Last Name (STitle) 55134] Poled, and it was determined that the thumb at that point was viable. On [2136-4-13], patient underwent debridement of the right hand and open reduction, internal fixation of the right first metacarpal and also underwent vein graft to that thumb and during the operation, the thumb appeared to be somewhat dusky. Postoperatively, the patient was stable. He was continued on Ancef and levo, which was started in the Emergency Room. The patient was sent to the ICU in stable condition. This is done in order to monitor the thumb q.1h. The thumb remained with good capillary refill. He then went back to the operating room for irrigation and debridement of the wound and completion of amputation. Patient remained afebrile and stable. Postoperatively, he was kept on levo and Ancef. Remained in the SICU. Postoperatively, patient's pain was well controlled with a PCA. He had a VAC dressing placed on the open wound on the dorsum of his right hand. Patient was found smoking on multiple occasions in the bathroom against the hospital policy and against the advice of the team. This is discussed significantly with him that this endangers his thumb, the revascularization procedure performed to his thumb. The patient then gave his cigarettes to the nursing staff and did not smoke to our knowledge for the rest of the admission. After the VAC was placed, the patient was sent to the floor and remained on antibiotics for the next few days. He was then taken back to the operating room for skin graft placement on [2136-4-19], and VAC placements again along with I&D of the wound. Patient postoperatively was sent to the floor. He did well. He remained on antibiotics, Ancef and levo. Pain was well controlled postoperatively. Patient's VAC was then removed on day of discharge. The skin appeared to have 100% take. Capillary refill of his thumb remained intact. It was determined that the patient will be discharged to home with sterile dressing changes, Xeroform dressing changes to the skin graft site q.d. by home on nursing, and he will remain on antibiotics. DISCHARGE INSTRUCTIONS: Patient should follow up with Plastic Surgery in one week. He will remain on antibiotics for the next week, Ancef and levo, and he will go home on Percocet for pain control. He will call if he develops any fevers or any changes in his wound. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 7738] Dictated By:[Last Name (NamePattern1) 43342] MEDQUIST36 D: [2136-4-24] 15:54 T: [2136-4-25] 08:47 JOB#: [Job Number 55135]	[ "3051" ]
Name: [Known lastname ], [Known firstname ] Unit No: [Numeric Identifier 8799] Admission Date: [2105-10-24] Discharge Date: [2105-11-2] Date of Birth: [2017-4-9] Sex: M Service: [Doctor Last Name 633] Medicine Please see discharge summary record in OMR note for the rest of details. [Name6 (MD) 1658] [Name8 (MD) ], M.D. [MD Number(1) 7153] Dictated By:[Last Name (NamePattern1) 8800] MEDQUIST36 D: [2105-12-10] 19:12 T: [2105-12-11] 12:08 JOB#: [Job Number 8801]	[ "42731", "496", "5849", "4280" ]
Admission Date: [2166-10-30] Discharge Date: [2166-11-6] Date of Birth: [2095-6-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Cardiac Cath with IABP placement Carotid angiography History of Present Illness: 71 year old male with DM2, HTN, h/o L carotid artery stenosis, hx L rib trauma 2 weeks ago presented to the ED on [10-30] via EMS with acute dyspnea. . On [10-30] experienced sudden dyspnea, diaphoresis, and nausea. Denies any increase in chest pain. Has very low functional status, DOE after 50 feet per report. Denies orthopnea, no clear triggers for this episode (change in diet or medications.) ROS otherwise negative. . In the ED, had mild chest pressure, recieved levofloxacin 500mg, 1L NS, lopressor 5mg iv, 10 units regular insulin for FS 300s, and was started on heparin gtt for ST depression V3-V6 in the setting of elevated troponin. Past Medical History: HTN well controlled on outpatient meds DM2 R cataract surgery R wrist tendon injury Social History: Used to work for school busing contract and also was a gang leader when younger. Lives alone but has a girlfriend. Quit smoking 20 years ago. Prior to that held cig in hand 5 packs/day for 20 years. Social drinker. Past mariujna use but quit 45 years ago. Family History: Mother DM, HTN. Never knew father. Brother ?cancer Physical Exam: PE: VS: 98.3, 102/60, 93, 22, 95% on RA. FS 218. GEN: Lying in bed, pleasant, talkative, NAD HEENT: PERRL, EOMI, MM dry, OP clear NECK: Thick neck, unable to assess JVD. No carotid bruit. Heart: Distant heart sound [1-29] to habitus but RRR without m/r/g. Chest: decreased bs throughout and bibasilar crackles. No wheezes or rhonchi. Abd: Obese, soft, NT, ND, +bs. Ext: No edema/cyanosis. Distal pulses intact. Neuro: AOx3. CN II to XII grossly intact. Pertinent Results: Labs: 142 \| 4.2 \| 110 \| 22 \| 23 \| 0.9 < 179 14.9 > 12.2 / 35.1 < 182 7.33 \| 42 \| 115 \| 23 (98% sat) during catheterization ALT 32, AST 116, [Doctor First Name ] 37, AlkP 70, TBili 0.7, Alb 3.4 . ECG: NSR with 2-[Street Address(2) 2051] depression V3-V6. . CXR: RLL opacity, no effusion CATH: 1. RV pressure 66/18, Wedge 31, Cardiac OP/Index 3.9/2.1, SVR 1169. PA %sat64. 2. left-dominant circulation. The LMCA was short and patent. The LAD had diffuse disease with a long high-grade stenosis at the bifurcation of a large and diseased D1. The LCX had a long 70% stenosis of the proximal vessel with a focal 80% stenosis in the midvessel. 3. abdominal aorta- diffuse mild disease. 50-60% right common iliac disease, 80% RCFA stenosis and a 50% LCFA stenosis. 4. A 7 French 30 cc IABP was placed via LCFA. . Echo: Elongated LA, mild sym. lvh, LVEF mod depressed (35-40%), anterior, lateral, and inferior hypokinesis. Mild to moderate ([12-29]+) MR. . Carotid studies- right 60-69% and a left 70-79% carotid stenosis. . MRA/MRA head - High-grade stenosis of the left internal carotid artery at the bifurcation with moderate-to-severe stenosis of the right internal carotid artery at the bifurcation. Complete loss of signal beginning at the petrous portion of the left internal carotid artery. A Gadolinium enhance MRA could be performed to differentiate a high grade stenosis from an occlusion. Brief Hospital Course: A/P: 73 year old male with HTN, CAD, who is admitted with acute dyspnea and on catheterization was noted to have 3 vessel disease. . # Cardiac: Ischemia/+troponin: Peak CK 539. On catheterization pt was noted to have multivessel disease. Immediately post cath pt was placed on IABP given his multivessel disease and likely bypass surgery soon after. However on consultation with CT surgery it was thought that the episode of ischemia was not likely due to an acute ischemic event. He was diuresed and IABP was removed on post cath day2. Pt was also started on ASA,Plavix,statin/ACEI/BB. CT surgery recommended work up of bilateral carotid stenosis, PFTs and COPD workup prior to elective scheduling for bypass surgery as outpt. . PUMP: Pt had elevated filling pressures on cath and Depressed EF 35%on echo. Pt was diuresed while the IABP and swan were inplace. Pulmonary pressures decreased with diuresis. His shortness of breath improved and did not have any further episodes of acute dyspnea. . Rhythm: Sinus. . # PVD(CAROTID and femorals) - carotid ultrasound. R 60-69% stenosis, L 80% stenosis. Pt underwent MRI/MRA which revealed bilateral stenosis. [Doctor First Name 3098] with significant stenosis which could not be intervened by interventional cardiolgoy. Pt did have collaterals from likely Ant. Communicating artery to the LMCA and LACA. On catheterization pt was also noted to have significant stenosis of femoral arteries bilaterally, R>L. ABI were done inhouse however the final report is pending at time of discharge. He will followup with Dr. [First Name (STitle) ] in 2 month time for ?peripheral intervention. . # PULMONARY/ID - ?RLL infiltrate on presentation cxr. Pt with also WBC of 20K on admission. he was started on treatement for CAP with levofloxacin. Mild productive cough persisted during the hospitilization. Treated with Levofloxacin 250 mg po qd x 7 days. - given significant smoking history pt will likely need PFTs prior to CABG per CT surgery recs. . # DM2 - Pt was maintained on RISS while in house started on his usual outpt regimen on discharge. . # Glaucoma - Continue predforte and ketorolac (outpatient meds) . # Dispo - Short term rehab. Pt will follow up with CT [Doctor First Name ], Cardiology and PCP. * DNR / DNI * per patient request Medications on Admission: plavix 75mg qday glyburide 10 [Hospital1 ] atenolol 25 qday glaucoma medications Discharge Medications: 1. Aspirin 325 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 4. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed): Take one tablet if you have severe chest pain. If the pain is not resolved in 5 mins you can repeat the nitro again and return to Emergency room. Disp:20 Tablet, Sublingual(s) Refills:2 5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). Disp:qs Refills:2 6. Ketorolac Tromethamine 0.5 % Drops Sig: One (1) Ophthalmic qid (). Disp:qs Refills:2 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:PRN as needed. 15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: [12-29] Inhalation twice a day. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 533] [Last Name (NamePattern1) ] for Extended Care - [Location 1268] Discharge Diagnosis: NSTEMI COPD Discharge Condition: Stable, no dyspnea at rest. Discharge Instructions: You were started on several new medications while you were in the hospital. It is important that you take all your medications exactly as directed. Please make and follow up with all your appointments. . If you experience severe shortness of breath and chest pain that is not relieved with rest or nitroglycerin please contact your cardiologist or return to the emergency room. Followup Instructions: 1. You have an appointment with Dr. [Last Name (STitle) ], Cardiothoracic Surgery, on [11-11] at 1:00 PM at the [Hospital ] Medical Building ([Hospital Unit Name 66290]. To reschedule, please call ([Telephone/Fax (1) 12124]. 2. Pulmonary Function Testing: Thursday, [11-13], at 9 AM, on the [Location (un) ] of the [Hospital Ward Name 23] Building ([Hospital Ward Name 516]). This testing is required prior to getting cardiac surgery. To reschedule, please call ([Telephone/Fax (1) 1504]. 3. You also have an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], your cardiologist, on [2167-1-9] at 12:30 PM at [Hospital1 2292]. Please call ([Telephone/Fax (1) 66291] to reschedule. 4. Please call your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 28549] at ([Telephone/Fax (1) 66292] to make a follow up appointment in the next 2-4 weeks. 5. Please call Dr. [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) ] in 2 months to setup an appointment for Interventional Cardiology at [Telephone/Fax (1) 4022]. Completed by:[2166-11-9]	[ "41071", "486", "496", "4280", "2762", "41401", "4019", "25000", "4240" ]
[ ] Date: [2115-1-7] Discharge Date: [2115-1-23] Date of Birth: [2058-4-23] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2195] Chief Complaint: Abdominal pain, diarrhea, found to have C.diff colitis. Major Surgical or Invasive Procedure: Hemodialysis x 3 sessions. Tunneled line removal. PICC line removal. History of Present Illness: Reason for MICU transfer: As per family request transfer from [Hospital6 ] MICU to [Hospital1 18]. . History of Present Illness: 56 yo male with pmh significant for HTN, HLD, alcohol abuse who was transferred from [Hospital3 ] MICU for c-diff colitis. . Most of the information was obtained from family and records, pt is drowsy. As per patient's family, he developed cough, nausea/vomiting then diarrhea ~ 1week ago. He did not have fever, chills or any other symptom. No blood or dark tarry stools were noted. He had no recent travel, no unsual meals, no sick contacts; although there is a day care at his work and he plays with the children at times. He has been drinking 0.5 pint of vodka or rum daily. He went to his PCP on [Name9 (PRE) ], [1-1] and he was treated with cipro. As per his family he continued to have diarrhea up to 30 episodes per day and he felt very ill. He went to work, while he was at work he was found to be very pale, and to be loosing his balance. His co-workers insisted that he went to the ED. He called his PCP and went to [Hospital3 ] ED. . He was admitted to South on [1-3]. His [Month/Year (2) ] vitals were BP 90/54, HR 94, RR 16, sat 99% on RA. His labs were notable for: Na 127, K 3.8, Cl 86, CO2 20, BUN of 47, Creat of 8.4, bili of 1.7, AST 181, ALT 57, alk phos 70, albumin of 3.2, and lipase of 160, WBC of 14.3, Hct 37.7, plat 131, CK 1548. His ABG at [Month/Year (2) ] 7.3/27/86/15.8. He was also noted to be oliguric. As per [Hospital3 ] note, pt was given several liters of fluid (uncertain on amount) and started on Norepi. Despite fluid resuscitation, his creatine remained high and UO was low. So, he had temporary HD line placed and was started on HD. He had 3 L of fluid removal today. His stool was + for Cdiff toxin and he was started on Flagyl 500mg IV, vancomycin 250mg PO Q6hours. He had ID, GI and surgery following him. As per notes he was not a surgical candidate. His abdomen has become more distended and his WBC increased from 14->13.2->18.6->21 then to 22K today. He was also noted to be withdrawing from ETOH with tremors, anxiety, confusion. As per [Hospital3 ] notes, his last drink was the day prior to [Hospital3 ] on [2114-12-31]. He was started on Ativan with CIWA scale. Prior to his transfer he was getting 2 mg of Ativan for CIWA of 12. . On arrival to the MICU, pt is drowsy but easily arousable to verbal stimuli. As per nursing staff, he received 2 mg of Ativan prior to transfer. He appears comfortable. Does not increase WOB. His abd is [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] and non-tender. He was accompanied by his sister, who is a RN, and his 2 daughters . Review of systems: As per HPI, pt lethargic and unable to answer questions. Past Medical History: HTN was on lisinopril, HCTZ HLD Obesity Depression ETOH abuse Social History: Pt lives by himself, currently in a relationship. His wife died 15 years prior. He works as a facility manager in [Hospital3 ]. He has 2 daughters. [Name (NI) ] drinks 0.5 pints of vodka/rum per day (as per family, he told the ED doctor [First Name (Titles) ] [Last Name (Titles) ]). Last drink was prior to [Last Name (Titles) ]. He does not smoke and as per family he does not use any drugs. Family History: NC as per family. Physical Exam: [Last Name (Titles) ] PE: General: Drowsy, but easily arousable by verbal stimuli. He is mumbling words, in NAD HEENT: Sclera icteric, MM dry, oropharynx clear, PERRL Neck: supple, JVP not elevated, no LAD CV: RR tachy, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, diminished at bases, no wheezes, rales, ronchi Abdomen: very distended, tympanic, soft, non-tender, + hyper active BS, GU: foley- small amount of dark brown urine Ext: warm, 2+ pulses, no clubbing, cyanosis, + trace edema Neuro: Drowsy, easily arousable to verbal stimuli, no following commands, moving all ext in bed. Mild tremor, no asterix. DISCHARGE PE: General: alert and oriented in NAD HEENT: Sclera icteric, PERRL, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, ronchi Abdomen: +BS, soft, NT, ND Ext: warm, 2+ pulses, no clubbing, cyanosis, + trace edema Pertinent Results: [Hospital ] HOSPITAL LABS: Na 127, K 3.8, Cl 86, CO2 20, BUN of 47, Creat of 8.4, bili of 1.7, AST 181, ALT 57, alk phos 70, albumin of 3.2, and lipase of 160, WBC of 14.3, Hct 37.7, plat 131, CK 1548. His ABG at [Hospital ] 7.3/27/86/15.8. PT 15.5/INR 1.2/PTT 47.4 [Hospital ] LABS: [2115-1-7] 06:04PM BLOOD WBC-21.8* RBC-3.54* Hgb-11.8* Hct-36.2* MCV-102* MCH-33.3* MCHC-32.7 RDW-15.4 Plt Ct-231 [2115-1-7] 06:04PM BLOOD Neuts-87.1* Lymphs-8.6* Monos-2.7 Eos-1.4 Baso-0.3 [2115-1-10] 04:42AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Tear Dr[Last Name (STitle) ]1+ [2115-1-7] 06:04PM BLOOD PT-13.4* PTT-71.0* INR(PT)-1.2* [2115-1-7] 06:04PM BLOOD Glucose-126* UreaN-30* Creat-5.3* Na-143 K-3.6 Cl-106 HCO3-26 AnGap-15 [2115-1-7] 06:04PM BLOOD ALT-88* AST-238* CK(CPK)-97 AlkPhos-177* TotBili-1.6* [2115-1-7] 06:04PM BLOOD Lipase-295* [2115-1-7] 06:04PM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.7 Mg-2.0 [2115-1-8] 03:09PM BLOOD Triglyc-65 [2115-1-8] 12:00AM BLOOD Type-ART pO2-103 pCO2-47* pH-7.32* calTCO2-25 Base XS--2 [2115-1-7] 06:17PM BLOOD Lactate-1.5 LABS PRIOR TO DISCHARGE: [2115-1-23] 04:56AM BLOOD WBC-10.5 RBC-2.52* Hgb-8.4* Hct-25.5* MCV-101* MCH-33.4* MCHC-33.0 RDW-14.9 Plt Ct-314 [2115-1-15] 10:20AM BLOOD Neuts-83.2* Lymphs-9.9* Monos-4.9 Eos-1.2 Baso-0.8 [2115-1-10] 04:42AM BLOOD Neuts-86* Bands-11* Lymphs-2* Monos-0 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2115-1-23] 04:56AM BLOOD PT-13.5* PTT-39.6* INR(PT)-1.3* [2115-1-23] 04:56AM BLOOD Glucose-87 UreaN-8 Creat-0.7 Na-138 K-4.0 Cl-109* HCO3-23 AnGap-10 [2115-1-23] 04:56AM BLOOD ALT-92* AST-155* AlkPhos-115 TotBili-1.3 [2115-1-21] 06:02AM BLOOD ALT-114* AST-168* AlkPhos-140* TotBili-1.2 [2115-1-18] 05:36AM BLOOD ALT-145* AST-223* AlkPhos-193* TotBili-2.5* [2115-1-13] 04:33AM BLOOD ALT-43* AST-103* LD(LDH)-361* AlkPhos-142* TotBili-1.6* DirBili-0.9* IndBili-0.7 [2115-1-23] 04:56AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.6 [2115-1-8] 09:36AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2115-1-8] 09:36AM BLOOD HCV Ab-NEGATIVE [2115-1-14] 06:30AM BLOOD HEPARIN DEPENDENT ANTIBODIES- MICRO: [2115-1-10] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [2115-1-10] BLOOD CULTURE Blood Culture, Routine-FINAL [2115-1-10] BLOOD CULTURE Blood Culture, Routine-FINAL [2115-1-8] BLOOD CULTURE Blood Culture, Routine-FINAL [2115-1-7] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [2115-1-7] MRSA SCREEN MRSA SCREEN-FINAL [2115-1-7] BLOOD CULTURE Blood Culture, Routine-FINAL IMAGING: [2115-1-7] CXR: In comparison with the earlier study of this date, there are continued low lung volumes. Increased opacification at the left base is consistent with atelectasis and effusion. In the appropriate clinical setting, the possibility of supervening pneumonia would have to be considered. Right IJ catheter tip is in the region of the cavoatrial junction. Nasogastric tube extends well into the stomach. [2115-1-7] KUB: A nasogastric tube terminates in the distal stomach or proximal duodenum. There is no free gas or pneumatosis. There are multiple prominent air-filled loops of small bowel throughout the central abdomen, findings which suggest ileus. There is no non-surgical radiopaque foreign body or soft tissue calcifications. Remnant barium is present within the ascending colon. [2115-1-7] RUQ U/S: Evaluation is limited due to body habitus. The liver is echogenic due to which may be due to fatty infiltration. There are no focal hepatic lesions. There is no intra- or extra-hepatic biliary dilatation with the common bile duct measuring 3 mm. Small amount of perihepatic free fluid. The gallbladder is normal without evidence of stones. The partially visualized right kidney is normal. There is small amount of free fluid in the right lower quadrant. The portal vein is patent. IMPRESSION: 1. Echogenic liver may relate to fatty infiltration; other forms of more advanced liver disease such as cirrhosis/fibrosis not excluded on this study 2. No evidence of gallstones or acute cholecystitis. 3. Small amount of free fluid. [2115-1-8] TTE: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild pulmonary Hypertension. [2115-1-8] CT ABD/PELVIS: 1. Diffuse thickening and edema of the large colon which would be in keeping with Clostridium difficile colitis. 2. Moderate amount of intra-abdominal ascites. 3. Hepatosteatosis with focal areas of increased fat deposition. 4. Small bilateral pleural effusions with overlying left-sided compressive atelectasis. 5. Gastric varices. [2115-1-12] CT ABD/PELVIS: 1. Pancolitis with associated moderate intra-abdominal and intrapelvic ascites. The overall appearance is unchanged since the [2115-1-8] CT examination. No focal collections or abscesses are detected. 2. Hypoenhancing right hepatic lesion, which may reflect focal hepatic steatosis, but a primary mass such as HCC cannot be excluded on this single-phase study. Non-urgent evaluation with contrast-enhanced MRI or multiphasic CT is recommended. 3. Small bilateral pleural effusions, with adjacent compressive atelectasis. 4. Perigastric and perisplenic varices. [2115-1-16] CXR: In comparison with the study of [1-10], the hemodialysis catheter has been removed and replaced by a right subclavian PICC line that extends to the mid portion of the SVC. The opacification at the left base has essentially cleared with minimal residual atelectasis and blunting of the costophrenic angle. The right base is essentially clear and there is no evidence of vascular congestion. Brief Hospital Course: 56 yo male with hx of HTN, HL, obesity, and ETOH abuse who presented to OHS 4 days ago on [1-3] for nausea, vomiting, and diarrhea and was found to be have [Last Name (un) ] with anuria, and severe c.diff colitis, transferred to [Hospital1 18] for further management. . # C.Diff Colitis: Risk factor was two days of cipro prior for a GI bug prior to [Hospital1 ]. Stool studies were not sent during his GI bug. He presented to the OSH with septic shock requiring fluid and pressors, which were weaned off in 2 days. His abdomen was very distended at presentation, however it was soft and non-tender. His KUB showed dilated loops of bowel with air fluid levels, but no free air. Upon arrival to [Hospital1 18], his vancomycin PO was increased from 250mg to 500mg, IV flagyl was continued, and vancomycin enemas were started given concern for decreased gut motility. His white count continued to trend up so flagyl was stopped and he was switched to tigecycline. General surgery was also consulted but they did not recommend surgery. He had an NG tube placed which was draining bilous drainage. He had negative stool cultures here. He had 1 + cdiff PCR at the OHS. He was improving clinically, but his WBC continued to trend up peaking at 29K. ID recommended stopping the Tigecycline since it could be affecting his gut flora. Po and PR vancomycin were continued with recs to hold NG tube suction for 1.5hours after. Fecal transplant was discussed, but this was not pursued given patient's clinical improvement. He had a repeat CT abd/pelvis that continued to show pancolitis with associated moderate intraabdominal and intrapelvic ascites. His lactate was never elevated. He required three HD sessions at the OSH and three here at [Hospital1 18], then his Cr remained at or below 1.0 since [2115-1-19]. IR removed his tunneled line. He was continued on vancomycin 500mg po q6hr until [2115-1-22] when the dose was decreased to 125mg po q6hr, given literature showing its equivalence. His loose stools became more formed prior to discharge, with fiber supplementation and BRAT diet. Hygiene and safety precautions to prevent cdiff infection were reviewed with him prior to discharge. He was also strongly encouraged to take Florastor with any future course of antibiotics. . # Lower Extremity Swelling: Mr. [Known lastname ] developed 3+ lower extremity edema secondary to fluid resuscitation while in the MICU. He was started on Lasix 40mg po daily when his Cr fell below 1.0. His weight was 110.4kg on discharge with only trace lower extremity edema. His weight prior to [Known lastname ] was 104kg. . # [Last Name (un) ]: Presented with acute renal failure compliated by anuria. This was likely secondary to poor renal perfusion from hypovolemia secondary to diarrhea and hypotension secondary to septic shock. As per [Hospital6 33] notes, he received HD 3 times, most recently done on the day of transfer with 3L fluid removal. he had three sessions of HD at [Hospital1 18]. He was started on CVVH and his renal fucntion started to improve. He was given lasix as above. Cr remained below 1.0 since [2115-1-19]. . # Elevated LFT's, hypoalbuminemia, elevated INR: Patient has been a heavy drinker for many years. His elevated LFT's were initally thought to be secondary to alcoholic hepatitis with a discriminant function of 6. US of liver/gallbladder showed echogenic liver potentially related to fatty infiltration; but could not exclude more advanced liver disease with cirrhosis or fibrosis. His LFTs have been trending down but still not WNL, and his synthetic function was also abnormal with elevated INR and low albumin. Hepatitis serologies were negative. More likely to explain his LFT's were his cdiff pancolitis infection. His elevated bili during this infection and findings of gastric and splenic varices raise concern for cirrhosis. He needs outpatient follow up with liver for a liver biopsy. He should also be vaccinated against hepatitis A and B as an outpatient. . #Hypoenhancing right hepatic lesion: Found on CT abd/pelvis which showed a hypoenhanncing hepatic lesion which may reflect focal hepatic steatosis, but a primary mass such as HCC cannot be excluded on this single-phase study. Non-urgent evaluation with contrast-enhanced MRI or multiphasic CT is recommended, particularly in the setting of alcohol abuse and potential cirrhosis. . #Hypertension: Typically hypertensive, but was hypotensive during [Month/Day/Year ] with improvement to systolic 110s while on lasix during last day of hospitalization. His home hydrochlorothiazide and lisinopril have been held. These medications will be restarted pending his outpatient pcp [Name Initial (PRE) 2742]. . #Thrombocytopenia: Likely related to sepsis, but with concern for cirrhosis this etiology must be ruled out. Thrombocytopenia resolved prior to discharge. . # ETOH abuse: Patient's last drink was on [12-31], the day prior to hospitalization. [Doctor Last Name 4866] on 12 on CIWA at [Doctor Last Name ] on lorazepan 1-2mg IV. He did not withdraw. Social work was consulted. He has no desire to join AA but is amenable to outpatient social work services for alcohol abuse. These resources were provided to him, as well as a list of AA meetings in his area. . #Transitional Issues: -Outpatient follow up with PCP [Name10 (NameIs) ] biopsy to rule out cirrhosis -Contrast-enhanced MRI or multiphasic CT to rule out HCC -Florastor for any future course of abx -Code Status: Full Code (Confirmed) -Contact: Daughter, [First Name8 (NamePattern2) ] [Name (NI) ], is his health care proxy: [Telephone/Fax (1) 91841]/cell: [Telephone/Fax (1) 91842]. Sister, [Name (NI) ] [Name (NI) 438]: [Telephone/Fax (1) 91843]. Medications on [Telephone/Fax (1) ]: HCTZ 25mg once daily Simvastatin 40mg Qday Lisinopril 20mg ASA 81mg daily Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. psyllium 1.7 g Wafer Sig: One (1) wafer PO DAILY (Daily) as needed for diarrhea. Disp:15 wafers Refills:0 4. Outpatient Lab Work Please have CBC, Chem 7, and LFT's checked on Friday, [1-25], [2114]. Please have these faxed to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 17664]. 5. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 22 doses. Disp:22 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary Diagnosis: Clostridium Difficile Colitis Septic shock Anuric renal failure requiring hemodialysis Secondary Diagnosis: Hypertension Hyperlipidemia Alcohol Abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Weight at discharge: 110.4 kg Discharge Instructions: It was a pleasure to take care of you here at the [Hospital3 ] [Hospital 1225] Medical Center. You presented to an outside hospital after having had multiple episodes of watery diarrhea, fevers, chills, and dehydration. You were diagnosed with an infection called clostridium difficile (C.diff) infection that caused low blood pressures. Your kidneys also failed and you required several sessions of dialysis - thankfully they recovered by themselves. You will complete a 21 day course of vancomycin to treat your infection. You may get this infection again. Antibiotics make you at higher risk for Cdiff infection. Next time you take antibiotics, you should also take the probiotic Florastor with your antibiotic to help prevent repeat infection. In addition, warning signs of reinfection include fever, chills, abdominal pain, diarrhea. Please seek medical attention as soon as you recognize any of these symptoms. In order to prevent reinfection or spread of infection, wash your hands after every bathroom trip and before every meal. Bathrooms that are shared should be cleaned with diluted bleach. While you were here you were seen by social to address your alcoholism. We encourage you to stop drinking alcohol completely. It was recommended that you seek out patient treatment at one of the following out patient programs. Please call to make an intake appointment when you are ready to do so. North River Counseling Inc [Street Address(2) 91844]. [Location (un) 17927] [Numeric Identifier 91845] [Telephone/Fax (1) 91846] [Hospital1 ] [Location (un) 91847] [Apartment Address(1) ] [Hospital1 392] MA [Telephone/Fax (1) 91848] We have also provided you with a list of AA meetings if you would like to participate. If you have any questions or need further help please contact the social worker you saw while you were here: [Name (NI) 636] [Last Name (NamePattern1) 12471], LICSW [Telephone/Fax (1) 57081]. The following changes were made to your medication list: START Vancomycin 125mg four times a day until [2115-1-28] HOLD Hydrochlorothiazide and Lisinopril. Your PCP may [Name9 (PRE) ] these medications at your next visit. START psyllium wafers or fiber supplement at home to bulk up your stools Followup Instructions: Please attend the following appointments: Name: NP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557] Location: [Hospital3 ] MEDICAL CENTER Address: [State ]., [Location (un) ],[Numeric Identifier 85712] Phone: [Telephone/Fax (1) 17663] Appointment: Friday [2115-1-25] 10:45am *This is a follow up appointment for your hospitalization. You will be reconnected with primary care physician after this visit.	[ "0389", "78552", "5845", "99592", "4019", "2875", "2724" ]
Admission Date: [2122-2-18] Discharge Date: [2122-2-25] Date of Birth: [2060-1-29] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4891] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: History of Present Illness: 62M with PMHx of CAD s/p MI x 5, CHF w/EF 20-25% w/AICD, uncontrolled DM2, and afib & h/o DVT on coumadin who presented to [Hospital3 ] with crushing substernal chest pain and acute dyspnea associated with feeling clammy. He reports that he has been having chest pain (somewhat relieved by SL NTG) and black stools since 2 days prior to admission. On the night prior to admission, he was having ongoing chest pain, not relieved by 5 SL NTG and decided to go to [Hospital3 ]. Patient states that prior to leaving for the hospital, he has 2 episodes of acute dyspnea during which he was gasping for breath. His family took him to [Hospital3 ] where he was found to have deep ST depressions in V3-V6 on EKG, a hemoglobin/hematocrit of 5.4/16.3, INR 5.9 and blood glucose in the 500s with anion gap 19 on initial labs. He was started on an insulin drip and heparin drip for presumed ACS. He was given 3 SL NTG with BP drop to 80/60; got 500cc NS bolus The results of the troponin T (0.02) did not come back until the patient had already been transferred. He received a total of 2L IVF and 1u PRBC. In the [Hospital1 18] ED, initial VS were T 97.6, HR 101, RR 30, BP 142/72, SpO2 100% NRB. Labs were significant for Hgb/Hct 5.8/19.6, lactate 4.5, INR 7.7, K 4.2, WBC 17.2, trop 0.04 (2nd set, 1st negative at OSH). EKG sinus @ 99, NA, QTc 456, ST depressions V3-6, similar to OSH. Guaiac positive brown stool. UA negative except glucose 1000, ketones 10. He became tachypenic to 30s after receiving more IVF, likely related to pulmonary edema in the setting of CHF. O2 sat 100% on non-rebreather, 88-90% 4L NC. CXR revealed mild pulmonary edema and cardiomegaly. He was placed on BiPAP and lasix 40mg IV and appeared more comfortable. He also received doses of vanc/zosyn to cover for infection. He was ordered for 1u PRBC and cardiology was consulted. Heparin was stopped and they recommeded rule-out MI, TTE to evaluate EF, and stress test when clinically improved. In the context of coagulopathy, CT abdomen and pelvis was ordered to rule out retroperitoneal bleed; there was no evidence of hemorrhage to explain anemia. Of note, the patient has a history of a GI bleed with similar presentation in [2119]. On arrival to the ICU, the patient appears comfortable and states that his pain has improved to [12-19] out of 10. Past Medical History: - CAD s/p MI x 5, most recent [7-/2121], got 2 stents [2103] - AICD placed [2119] for EF 20-25% (per patient) - PVD s/p iliac reconstruction & 3 right leg stent [12/2121] (total 5 stents in right leg, 2 in left) - DM2 (does not check his blood sugar or take his insulin) - HTN - Atrial fibrillation - H/o DVT (on coumadin) - Restless leg syndrome - Depression - Anxiety Social History: Married, lives with wife in [Name (NI) ], MA. Previously worked as a house painter and army scout. Walks with a cane - Tobacco: ~100 pack-year history. Previously 3ppd, now down to <1 ppd. - Alcohol: Denies. - Illicits: Denies. Family History: Mother & father with DM2. Physical Exam: Admission Physical Exam: Vitals: 99.5, 129/65, 110, 18, 99%2L NC, FSBG 363 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [2122-2-18] 05:45AM BLOOD WBC-17.2* RBC-2.32* Hgb-5.8* Hct-19.6* MCV-84 MCH-25.0* MCHC-29.7* RDW-19.5* Plt Ct-300 [2122-2-18] 11:29AM BLOOD Neuts-90.3* Bands-0 Lymphs-3.9* Monos-4.9 Eos-0.3 Baso-0.5 [2122-2-18] 11:29AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL [2122-2-18] 05:45AM BLOOD PT-76.5* PTT-150* INR(PT)-7.7* [2122-2-18] 05:45AM BLOOD Fibrino-198 [2122-2-18] 11:29AM BLOOD Ret Aut-6.3* [2122-2-18] 11:29AM BLOOD Glucose-289* UreaN-27* Creat-0.8 Na-136 K-3.4 Cl-99 HCO3-27 AnGap-13 [2122-2-18] 11:29AM BLOOD ALT-18 AST-25 LD(LDH)-204 CK(CPK)-175 AlkPhos-61 TotBili-0.3 DirBili-0.1 IndBili-0.2 [2122-2-18] 05:45AM BLOOD Lipase-30 [2122-2-18] 05:45AM BLOOD cTropnT-0.04* [2122-2-18] 11:29AM BLOOD CK-MB-10 MB Indx-5.7 cTropnT-0.09* [2122-2-19] 01:10AM BLOOD CK-MB-8 cTropnT-0.37* [2122-2-19] 08:45AM BLOOD CK-MB-6 cTropnT-0.27* [2122-2-18] 05:45AM BLOOD CK-MB-6 proBNP-1297* [2122-2-18] 05:45AM BLOOD Calcium-8.2* Phos-5.3* Mg-1.9 [2122-2-18] 11:29AM BLOOD calTIBC-420 Hapto-157 Ferritn-18* TRF-323 [2122-2-18] 11:29AM BLOOD Triglyc-402* HDL-16 CHOL/HD-6.4 LDLmeas-<50 [2122-2-18] 05:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2122-2-18] 05:55AM BLOOD Type-[Last Name (un) ] pO2-40* pCO2-43 pH-7.39 calTCO2-27 Base XS-0 [2122-2-18] 05:55AM BLOOD Glucose-337* Lactate-4.5* Na-132* K-4.2 Cl-97 [2122-2-18] 05:55AM BLOOD freeCa-1.03* [2122-2-18] 05:55AM BLOOD Hgb-5.7* calcHCT-17 O2 Sat-63 COHgb-5 MetHgb-0 RADIOLOGY: CXR [2122-2-18] There is mild cardiomegaly and mild pulmonary edema. There is no pleural effusion or pneumothorax. There is no focal lung consolidation. ICD lead ends in the right ventricle. IMPRESSION: Mild cardiomegaly and mild pulmonary edema. CT TORSO [2122-2-18] CT OF THE TORSO WITHOUT IV CONTRAST TECHNIQUE: Multidetector scanning is performed from the thoracic inlet through the symphysis without intravenous contrast. CT OF THE CHEST WITHOUT IV CONTRAST: There is no axillary lymphadenopathy. Small lymph nodes are seen in the mediastinum measuring up to 0.8 cm in short axis. These are not pathologically enlarged. There is no hilar lymphadenopathy. There is a 4.1 x 4.3 cm rounded mass in the azygoesophageal recess. This measures fluid density and is consistent with a pericardial cyst. A single-lead pacemaker is identified. There are no pleural effusions. There is a 6-mm non-calcified nodule in the right middle lobe (series 2, [Female First Name (un) 899] 42). There is atelectasis in the dependent portions of both lungs. There is a somewhat oblong opacity is identified in the right upper lobe (series 2, [Female First Name (un) 899] 32). There is subpleural emphysema in the upper lobes. There is a 3-mm nodule in the right middle lobe (series 2, [Female First Name (un) 899] 14). CT OF THE ABDOMEN WITHOUT IV CONTRAST: The liver is without focal lesions. The spleen is normal in size. The patient is status post cholecystectomy. The pancreas is unremarkable. There is no dilatation of the pancreatic duct. The adrenal glands are normal. There are extensive vascular calcifications of the kidneys bilaterally. There is a 2-mm calcification in the left lower pole that potentially could represent a small non-obstructing stone. There is no retroperitoneal lymphadenopathy. There is mild dilatation of the infrarenal aorta to 2.9 cm compared to a normal caliber of the remainder of the aorta of 2.4 cm. CT OF THE PELVIS WITHOUT IV CONTRAST: The right common iliac artery is dilated to 2.3 cm immediately below the bifurcation. Immediately above the bifurcation in the external and internal iliac artery, the vessel is dilated to 3.0 cm. Both external iliac arteries are extensively calcified. There is a surgical clip in the right groin and a rim calcified tubular structure lateral to the common femoral artery which may represent a bypass graft. There is no free fluid in the pelvis. No pelvic lymphadenopathy is identified. The small and large bowel are normal. On bone windows, there are no consistent osteolytic or osteosclerotic lesions. IMPRESSION: 1. No evidence for hemorrhage to explain acute blood loss. 2. Pulmonary nodules measuring up to 9 mm in size. Followup chest CT at 3, 6 and 24 months is recommended to ensure stability. If prior chest CTs are available for comparison, this would be helpful to determine stability. 3. 3 cm and 2.3 cm aneurysms of the right common iliac artery. Aneurysmal dilatation of the infrarenal aorta to 2.9 cm. 4. Extensive arteriosclerosis involving the renal arteries bilaterally. A 2-mm punctate calcifications in the lower pole of the left kidney may represent a non-obstructing renal stone. 5. 4.3 cm pericardial cyst. Brief Hospital Course: 62 y.o. man with severe CAD, ischemic cardiomyopathy with EF 20-25%, and PVD presenting with chest pain and shortness of breath in the context of Hct of 16. GI Bleed / Acute Blood loss anemia: Patient presented with chest pain and a history of 2 days of black, pasty stool and was found to have a supratherapeutic INR at 7.7 and a hemoglobin of 5.4. INR was reversed with vitamin K. A CT torso was performed to look for other sources of bleeding as GI losses were not brisk, but was negative for any evidence of hemorrhage. The patient received received a total of 8 units of blood until hemoglobin stabilized around 8.5. EGD on [2122-2-19] showed patchy friability and erythema of the mucosa were noted in the antrum consistent with gastritis. The patient was placed on 20 mg [Hospital1 ] omeprazole. Given gastritis was felt probably inadequate to cause that degree of bleeding patient went on to have a colonoscopy that showed an ischemic ulcer and cecal AVMs, which was felt to explain his bleeding. We felt that he had likely bled slowly from his AVMs, and then developed the ulcer after his Hct was low. CAD / Chest Pain: The patient presented with substernal chest pressure, dyspnea, and diaphoresis to the outside hospital with EKG changes. Likely etiology of this was demand ischemia in the context of severe anemia. Patient originally was put on heparin drip at OSH but given his troponins returned not significantly elevated with flat MBs, INR was therapeutic, and he his pain improved with transfusion this was stopped and this was treated as demand ischemia. Troponin peaked at 0.37 and CK at 175 suggesting any degree of mycoardial injury likely extremely small and echo showed EF of 30% which sounds compatible with previous echocardiogram. On presentation the patient's aspirin and clopidogrel was held but Aspirin restarted when hematocrit stabilized. Clopidogrel was restarted. The patient's cardiologist agreed with plans to perform an outpatient stress test as needed. We decided to defer repeat echo as well, given stable echo at time of anemia, and lack of CP or HF active symptoms. Patient also with angiogram in [2120] without eivdence of occlussive disease, per d/w Dr [Last Name (STitle) 174]. Discussed with prior consulting cardiology team as well as Dr [Last Name (STitle) 174] on [2-24], who felt that outpatient work-up as needed would be reasonable. Stressed importance of close follow-up and glycemic control with the patient, to reduce risk of recurrent MI. Acute on Chronic Systolic CHF: Patient had known systolic CHF with previous EF of around 20% per his report. On presentation to [Hospital1 18] he did have acute exacerbation of CHF with volume overload in the context of likely transient ischemia due to anemia and multiple transfusions leading to massive expansion of volume. He received BiPAP and furosemide on presentation and improved rapidly. Furosemide was then held in the context bleeding but home maintenance dose restarted on [2122-2-22] as was digoxin (beta blocker had already been restarted). TTE showed EF 25-30% with dilated left ventricle (likely consistent with prior) so etiology of acute decompensation at presentation likely reversed ischemia and volume from transfusions. The patient was not started on an ACE I given his limited follow-up and the need for close monitoring which would not be available at this time. History of Atrial Fibirllation and DVT's with Elevated INR: Patient presented with INR 7.7. Reversed with FFP and vitamin K now and returned to subtherapeutic and coumadin continued to be held due to occult GI bleed pending work up. Unclear why INR was supratherapeutic as patient reports long term stability on regimen. Denies any recent changes in diet or any alcohol intake. No new medications. Patient does report that he buys his medications, including coumadin, off the "black market", so it is possible that he took incorrectly labeled pills. We suggested that the patient restart his warfarin after consulting his cardiologist within several days from discharge. DM2: Patient has uncontrolled DM2, and reports he does not take insulin as directed. He was put on glargine and sliding scale in house (which is his intended home regimen) with reasonable control of blood glucose. We provided diabetic teaching prior to discharge. 6) Insomnia, chronic: Pt has received trazodone over home zolpidem, will restart zolpidem as this is likely contributing to insomnia FEN: heart healthy/low sodium today, clears for dinner, NPO afer MN PPx: heparin SC Code: FULL, confirmed Dispo: Patient appropriate for discharge to home. Discussed with the patient and his wife at the bedside for over 35 minutes regarding discharge plans. Patient is aware of follow-up needs and the importance of working with a new internist despite his insurance status, for his ongoing medical needs. TRANSITONAL ISSUES: -Restart anticoagulation once he sees his cardiologist. -Incident pulmonary nodules per above -Should be on ACEi at some point, but not until he has clear and regular follow-up. -The patient should establish care with an internist, and plans to do this once home. Medications on Admission: Aspirin 81 mg daily Lovastatin 40 mg daily Metoprolol Digoxin 0.125 mcg Diltiazem 240 mg daily Warfarin 6-7 mg daily Lantus 50 units qhs Humalog sliding scale Zolpidem 10 mg qhs prn Aldactone 25 mg daily Isosorbide mononitrite 30 mg daily Lasix 40 mg day Plavix 75 mg daily Oxycodone Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. digoxin 125 mcg Tablet Sig: [11-17] Tablet PO DAILY (Daily): We lowered this dose from your admission dosing. 4. ropinirole 1 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: Please HOLD this medication until Dr [Last Name (STitle) 174] tells you to restart it. . 9. insulin glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous once a day: Please speak with your new PCP about adjusting this medication. 10. amiodarone 200 mg Tablet Sig: [11-17] Tablet PO once a day: Please discuss with your cardiologist about potential changes to this medication. 11. insulin aspart 100 unit/mL Solution Sig: One (1) vial Subcutaneous three times a day: Please take your insulin sliding scale as you were doing before your admission. 12. metoprolol tartrate 25 mg Tablet Sig: [11-17] Tablet PO twice a day: Please start this medication [2-26], and increase as you see Dr [Last Name (STitle) 174] back to your home dose gradually. Disp:60 Tablet(s) Refills:0 13. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: Please continue for one month, then decrease to once daily. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Gastrointestinal bleed Acute blood loss anemia Coronary artery disease Chronic systolic CHF Secondary Diagnoses: Diabetes Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [Known lastname 2987], It was a pleasure to care for you during your admission. As you know, you were admitted with chest pain that was likely due to poor blood flow to your heart in the setting of a very low red blood cell count. We believe that you had bleeding from your GI tract that caused the low blood count, but has since improved. You received blood and your symptoms resolved. Thankfully, it appears that very little heart muscle was damaged, and your pump function is the same as Dr [Last Name (STitle) 174] has measured in the past. We did investigations to determine the source of your bleeding (the colonoscopy) that showed the blood vessel changes (AVMs) in the cecum at the point between the small bowel and the colon, as well as the ulcer that resembled an area of ischemia or temporarily decreased blood flow. Neither of those areas were actively bleeding, but likely both contributed to your anemia. We held your warfarin while you were here, as a result of your blood loss, and would like for you to see Dr [Last Name (STitle) 174] within several days as noted below, to discuss restarting this medication. We wanted to give your bowel a chance to heal before you restart this medication. Your medications have been changed temporarily, as your blood pressure here has been 110-130. -You should take twice daily pantoprazole for one month, then decrease back to once daily. -Warfarin is being held for a few more days, until [3-3] (2 weeks total). -Decrease amiodarone to 100mg ([11-17] tablet) -Decrease metoprolol to 12.5mg twice daily (from 50-100mg) -Decrease digoxin to 0.0625mcg ([11-17] tablet) -HOLD diltiazem until you see Dr [Last Name (STitle) 174] [Name (STitle) 66360] aldactone until you see Dr [Last Name (STitle) 174] [Name (STitle) 66360] isosorbide until you see Dr [Last Name (STitle) 174] [Name (STitle) ] insulin (glargine) to 10 units at bedtime and continue your usual sliding scale. You will need the help of Dr [Last Name (STitle) ] to make further adjustments. Note: Please do not exceed 3 grams of tylenol daily, as we discussed. This medication can interact with your warfarin, amiodarone and other medications. Followup Instructions: We discussed that either speaking with Dr [Last Name (STitle) ] or a new PCP is very important. We feel that you would benefit from close monitoring of your blood sugars, and adjustment of several of your medications. We hope that you will find a doctor either through the VA system or locally that can help you with your long-term health issues. Please schedule an appointment to see Dr [Last Name (STitle) 174] within 2-5 days, where he should check your INR and CBC (blood counts), as well as your heart rate and blood pressure. We suggest that he restarts your warfarin if your counts are stable, and also will need to help you get back on your heart medications gradually. You should also discuss with Dr [Last Name (STitle) 174] about further monitoring of your heart conditions, including adjustments that might be needed of your digoxin and amiodarone. Your biopsies are still pending. The GI office can be reached at [Telephone/Fax (1) 463] if you do not hear back within one week. You can also call [Telephone/Fax (1) 2756] and ask for the GI office. Dr [First Name8 (NamePattern2) 3095] [Last Name (NamePattern1) ] and [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 452] were the doctors who completed the procedure.	[ "2851", "3051", "V5861", "41401", "412", "4280", "42731" ]
Admission Date: [2166-3-26] Discharge Date: [2166-4-1] Service: Medicine, [Hospital1 139] Firm HISTORY OF PRESENT ILLNESS: The patient is a [Age over 90 ]-year-old male with a past medical history of hypertension, atrial fibrillation (status post pacemaker placement for symptomatic bradycardia), obstructive sleep apnea, cor pulmonale, chronic renal failure, and peripheral vascular disease who was transferred from the Medical Intensive Care Unit to the floor status post management of a hypercarbic respectively decompensation. The patient originally presented with knee pain on [2166-3-26]. He called Emergency Medical Service who found the patient to be dyspneic and hypoxic with an oxygen saturation of 70% on room air. Of note, the patient had been complaining of increased lower extremity edema and dysphagia for which he was seen in the [Hospital6 733] Clinic on [3-21]. For his edema, the patient was told to double his Lasix dose. His dysphagia was for solid foods, and the patient described it as if "something was caught in my throat." The patient was referred for Ear/Nose/Throat and had a swallowing study done on [3-25] (one day prior to admission) with a barium esophagogram showing a nonspecific motor disorder of the esophagus with one episode of aspiration. In the Emergency Department, the patient's oxygen saturation was 70% on room air and improved to 90% to 95% on a nonrebreather. His blood pressure was 96/50. An arterial blood gas revealed a pH of 7.41, a PCO2 of 46, and a PO2 of 98. The patient did give a history of gradually increasing dyspnea without chest pain. His mental status deteriorated, and he was only nodding to questions. He received 40 mg of intravenous Lasix, 120 mg of intravenously methylprednisolone, albuterol and ipratropium nebulizers, and aspirin 325 mg. An electrocardiogram was done revealing ST elevations in leads III and aVF and ST depressions in leads I and aVL. He was taken to the Cardiac Catheterization Laboratory and catheterization showed clean coronary arteries. In the Catheterization Laboratory, the patient developed further deterioration of his mental status as well as hypoxemia and respectively acidosis with an arterial blood gas of 7.25/61/67. He was placed on [Hospital1 ]-level positive airway pressure and transferred to the Medical Intensive Care Unit for further management. In the Medical Intensive Care Unit, the team felt that his presentation was likely secondary to an aspiration event in the setting of his lying flat in the Catheterization Laboratory. He was placed on levofloxacin and metronidazole as well as [Hospital1 ]-level positive airway pressure. He was given stress-dose steroids with intravenous hydrocortisone 50 mg q.8h. As of [3-27], the patient was off of [Hospital1 ]-level positive airway pressure since 4 a.m. and stable with an arterial blood gas of 7.38/46/82. PAST MEDICAL HISTORY: 1. Status post pituitary adenoma resection; panhypopituitarism. 2. Paroxysmal atrial fibrillation. 3. Cor pulmonale. 4. Obstructive sleep apnea. 5. Asthma. 6. Chronic renal failure (with a baseline creatinine of 1.2 to 1.5). 7. Hypertension. 8. Status post pacemaker placement for symptomatic bradycardia. 9. Benign prostatic hypertrophy. 10. Peripheral vascular disease. 11. Gastroesophageal reflux disease. 12. Venous insufficiency. MEDICATIONS ON TRANSFER: 1. Hydrocortisone 60 mg p.o. once per day. 2. Levofloxacin 250 mg p.o. every day. 3. Terazosin 5 mg p.o. q.h.s. 4. Levothyroxine 50 mcg p.o. once per day. 5. Albuterol as needed. 6. Amiodarone 200 mg p.o. once per day. 7. Protonix 40 mg p.o. once per day. 8. Regular insulin sliding-scale. 9. Flagyl 500 mg intravenously three times per day. 10. Heparin 5000 units subcutaneously q.12h. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone independently and is capable of taking care of his activities of daily living. He denies alcohol and tobacco use. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination at the time of transfer revealed temperature was 96.1, blood pressure was 114/49, heart rate was 60, respiratory rate was 25, and oxygen saturation was 95% on 5 liters nasal cannula. In general, the patient was sitting upright in bed, in no acute distress. Head, eyes, ears, nose, and throat examination revealed surgical pupils, 2 mm bilaterally. Sclerae were anicteric. The oral mucosa was moist. The neck was without lymphadenopathy and with normal jugular venous pulsation. Heart examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. Distant heart sounds. The lungs with occasional coarse expiratory wheezes. Fair air movement. No rales. The abdomen was obese, soft, nontender, and nondistended. Bowel sounds were present in all four quadrants. Extremity examination revealed 1+ pitting lower extremity edema to the knees bilaterally with venous stasis skin changes. Neurologic examination revealed alert and oriented times three. Cranial nerves were grossly intact. Extremities with full range of motion. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on transfer revealed white blood cell count was 13.9, hematocrit was 36.7, and platelet count was 204. Sodium was 145, potassium was 3.4, chloride was 107, bicarbonate was 25, blood urea nitrogen was 17, creatinine was 2.1, and blood glucose was 170. Calcium was 8.1, magnesium was 2, and phosphate was 3.7. Total bilirubin was 1.4 and direct bilirubin was 0.4. Creatine kinase was 104. Troponin I was 0.5. INR was 1.1 and partial thromboplastin time was 26. Urinalysis revealed yellow/clear and small blood. Negative nitrites, ketones, bilirubin, leukocyte esterase, 30 mg/dL of protein, 3 to 5 red blood cells, 0 to 2 white blood cells, and a few bacteria. Toxicology screen was negative for aspirin, ethanol, acetaminophen, benzodiazepines, barbiturates, and tricyclics. PERTINENT RADIOLOGY/IMAGING: A chest radiograph on [3-26] revealed an increased density at the left base, right hemidiaphragm less distinct, perihilar edema consistent with heart failure. A chest radiograph on [3-27] showed decreased heart failure, no infiltrates, and decreased bibasilar atelectasis. An echocardiogram on [3-26] was a suboptimal study with normal left ventricular wall thickness and cavity size. No distinct wall motion abnormalities in the left ventricle. The right ventricle was within normal limits. Trace aortic regurgitation. Catheterization on [3-26] revealed no significant obstructive disease. No wall motion abnormalities. Ejection fraction was 60%. Increased left ventricular end-diastolic pressure at 17 mmHg. Moderate pulmonary hypertension of 38 mmHg. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. PULMONARY ISSUES: Initially, after transfer from the Medical Intensive Care Unit the patient continued to have a 4-liter to 5-liter of oxygen requirement to maintain his oxygen saturation. His episode of hypoxemia was felt to be most likely secondary to an aspiration event followed by flash pulmonary edema in the setting of diastolic cardiac dysfunction. With further diuresis, the patient's oxygen saturations were improved and by [4-1] he was saturating greater than 92% on room air. His furosemide was held starting on the evening of [3-29] because he started to appear hypovolemic on examination with dry mucous membranes and poor skin turgor. He received a video oropharyngeal swallowing study which demonstrated an intact swallowing mechanism with no evidence of aspiration. A recommendation was made to avoid the use of straws, however. The patient continued to receive albuterol nebulizer treatments while on the floor, and these were effective in treating his episodic wheezing. To rule out further heart failure, a chest radiograph was obtained on [3-31] which demonstrated some bibasilar atelectasis, but no evidence of heart failure. The patient was completing a 10-day course of levofloxacin and metronidazole for aspiration pneumonia. 2. LEG PAIN ISSUES: The patient notably had persistent pain in both his lower extremities below the knees throughout his admission. The legs were symmetrically slightly edematous and tenderness to palpation anteriorly and posteriorly. Lower extremity venous ultrasounds with Doppler studies were obtained and revealed no deep venous thrombosis in either lower extremity. Given the patient's recent history of twisting his left ankle, a plain film was obtained which revealed no evidence of fracture or dislocation. The patient described his pain as "tingling" as well as "burning." This was felt to be perhaps secondary to a neuropathy; although the patient did not have known conditions that would predispose to a neuropathy such as diabetes. Prior to discharge, the patient was empirically started on low-dose gabapentin for treatment of presumed neuropathy. 3. RENAL ISSUES: As aforementioned, at the time of transfer from the Medical Intensive Care Unit, the patient had a creatinine of 2.1. His fractional excretion of sodium was 0.19%. His acute-on-chronic renal failure was felt to be secondary to prerenal azotemia in the setting of the furosemide he was given as well as the dye load he received in the Catheterization Laboratory. Another condition of the differential diagnosis was acute tubular necrosis secondary to the dye load he received. The patient maintained good urine output throughout his time on the floor, and his creatinine improved to a level of 1.4 at the time of discharge. 4. ENDOCRINE ISSUES: The patient was continued on hydrocortisone 60 mg once per day as well as levothyroxine for his panhypopituitarism. He had persistent mild elevations in his fasting blood sugars which ranged between 150 and 200. He received a regular insulin sliding-scale for this. DISCHARGE DIAGNOSES: 1. Status post aspiration event and heart failure exacerbation in the setting of diastolic cardiac dysfunction. 2. Chronic renal failure; status post acute-on-chronic renal failure. 3. Bilateral peripheral sensory neuropathy. 4. Hypoproliferative normocytic anemia of undetermined etiology. 6. Panhypopituitarism. 7. Diffuse deconditioning. 8. Paroxysmal atrial fibrillation. 9. Hypertension. 10. Chronic obstructive pulmonary disease. 11. Cor pulmonale. 12. History of pacemaker placement for symptomatic bradycardia. 13. Obstructive sleep apnea (requiring [Hospital1 ]-level positive airway pressure). 14. Peripheral vascular disease. CONDITION AT DISCHARGE: Condition on discharge was fair. DISCHARGE STATUS: Discharge status was to [Hospital3 94515]. PRIMARY CARE PHYSICIAN: [Name10 (NameIs) ] patient's primary care physician is [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] (telephone number [Telephone/Fax (1) 250]). MEDICATIONS ON DISCHARGE: 1. Furosemide 40 mg p.o. q.a.m. 2. Gabapentin 100 mg p.o. q.h.s. 3. Albuterol nebulizer inhaled q.4-6h. as needed. 4. Atrovent nebulizer inhaled q.4-6h. as needed. 5. Vitamin D 400 units p.o. once per day. 6. Calcium carbonate 500 mg p.o. three times per day. 7. Flagyl 500 mg p.o. three times per day (through [2166-4-4]). 8. Levofloxacin 250 mg p.o. once per day (through [2166-4-4]). 9. Hydrocortisone 60 mg p.o. once per day. 10. Terazosin 5 mg p.o. q.h.s. 11. Levothyroxine 50 mcg p.o. once per day. 12. Amiodarone 200 mg p.o. once per day. 13. Protonix 40 mg p.o. once per day. 14. Regular insulin sliding-scale. 15. Heparin 5000 units subcutaneously q.12h. [First Name11 (Name Pattern1) 198] [Last Name (NamePattern4) 199], M.D. [MD Number(1) 200] Dictated By:[Last Name (NamePattern1) 5596] MEDQUIST36 D: [2166-4-1] 15:13 T: [2166-4-1] 15:37 JOB#: [Job Number 94516]	[ "4280", "2762", "5070", "42731", "5849" ]
Admission Date: [2110-12-25] Discharge Date: [2110-12-30] Date of Birth: [2045-7-16] Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Hydromorphone Attending:[First Name3 (LF) 64] Chief Complaint: Left Hip Pain. Major Surgical or Invasive Procedure: Complex conversion of failed left dynamic hip compression screw to a cemented left hip hemiarthroplasty with strut allograft, cerclage, trephine, removal of failed deep hardware. History of Present Illness: HPI: 65 yo F who underwent left TKA with Dr. [Last Name (STitle) ] [9-/2109] and then suffered a left hip fx in 5/[2109]. She then underwent ORIF with a dynamic compression hip screw at an outside hospital. Unfortunately the implant failed and the patient suffered from a nonunion, subsequent collapse, and repeat fracture of the hip. She presented for removal of hardware and left hip arthroplasty. Past Medical History: PMH: NIDDM, HL, GERD, Liver disease (cryptogenic cirrhosis with portal hypertension), Daily narcotic use, OA, Bipolar disease, Esophageal varices, Essential tremor, Anemia PSH: Left TKA, partial hysterectomy, appendectomy, Left hip DHS Social History: SH: Former smoker, no EtOH. Married with very supportive husband. Family History: Noncontributory. Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Left Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength TA/GS/[Last Name (un) 938]/FHL * SILT DP/SP/T/S/S * Toes warm Pertinent Results: [2110-12-25] 06:55PM BLOOD WBC-8.6# RBC-3.01* Hgb-8.8* Hct-26.4* MCV-88 MCH-29.1 MCHC-33.3 RDW-14.5 Plt Ct-189# [2110-12-25] 10:20PM BLOOD WBC-12.6* RBC-3.47* Hgb-10.4* Hct-29.9* MCV-86 MCH-29.9 MCHC-34.6 RDW-14.3 Plt Ct-158 [2110-12-25] 06:55PM BLOOD PT-15.0* PTT-29.7 INR(PT)-1.3* [2110-12-25] 10:20PM BLOOD PT-14.7* PTT-26.5 INR(PT)-1.3* [2110-12-25] 10:20PM BLOOD Glucose-228* UreaN-13 Creat-0.5 Na-138 K-4.5 Cl-108 HCO3-24 AnGap-11 [2110-12-26] 08:04AM BLOOD WBC-10.9 RBC-3.18* Hgb-9.3* Hct-27.3* MCV-86 MCH-29.2 MCHC-34.0 RDW-14.7 Plt Ct-153 [2110-12-26] 04:39PM BLOOD Hct-23.1* [2110-12-26] 04:53AM BLOOD PT-15.3* PTT-26.9 INR(PT)-1.3* [2110-12-26] 04:53AM BLOOD Glucose-164* UreaN-13 Creat-0.6 Na-138 K-4.4 Cl-110* HCO3-22 AnGap-10 Calcium-8.6 Phos-3.0# Mg-1.2* [2110-12-27] 05:31AM BLOOD WBC-7.6 RBC-3.02* Hgb-8.9* Hct-26.7* MCV-88 MCH-29.3 MCHC-33.1 RDW-14.7 Plt Ct-88* [2110-12-27] 12:50PM BLOOD WBC-7.1 RBC-2.76* Hgb-8.1* Hct-23.9* MCV-87 MCH-29.5 MCHC-34.1 RDW-15.0 Plt Ct-99* [2110-12-27] 07:10PM BLOOD Hct-26.7* [2110-12-27] 05:31AM BLOOD PT-14.6* PTT-26.9 INR(PT)-1.3* [2110-12-27] 05:31AM BLOOD Glucose-177* UreaN-13 Creat-0.6 Na-133 K-3.6 Cl-105 HCO3-21* AnGap-11 Calcium-8.4 Phos-2.6* Mg-1.9 [2110-12-28] 02:20AM BLOOD Hct-28.1* [2110-12-28] 05:00AM BLOOD WBC-7.3 RBC-3.18* Hgb-9.4* Hct-27.9* MCV-88 MCH-29.6 MCHC-33.7 RDW-14.9 Plt Ct-109* [2110-12-28] 10:30AM BLOOD Hct-26.5* [2110-12-28] 03:00PM BLOOD PT-14.3* INR(PT)-1.2* [2110-12-28] 05:00AM BLOOD Glucose-166* UreaN-20 Creat-0.8 Na-133 K-3.6 Cl-101 HCO3-23 AnGap-13 Calcium-8.6 Phos-2.6* Mg-1.8 [2110-12-29] 05:20AM BLOOD WBC-6.4 RBC-2.79* Hgb-8.4* Hct-24.3* MCV-87 MCH-29.9 MCHC-34.4 RDW-15.3 Plt Ct-124* [2110-12-29] 05:20AM BLOOD PT-16.1* INR(PT)-1.4* [2110-12-29] 05:20AM BLOOD Glucose-128* UreaN-21* Creat-0.8 Na-132* K-3.4 Cl-100 HCO3-25 AnGap-10 Albumin-2.5* Calcium-8.8 Phos-2.0* Mg-1.6 [2110-12-30] 08:40AM BLOOD WBC-5.0 RBC-3.17* Hgb-9.7* Hct-26.9* MCV-85 MCH-30.5 MCHC-36.0* RDW-15.6* Plt Ct-139* [2110-12-30] 08:40AM BLOOD PT-27.1* PTT-35.7* INR(PT)-2.6* [2110-12-30] 08:40AM BLOOD Glucose-127* UreaN-13 Creat-0.5 Na-136 K-2.6* Cl-99 HCO3-29 AnGap-11 Albumin-2.8* Calcium-8.8 Phos-1.5* Mg-1.6 Brief Hospital Course: The patient was taken to the operating room on [2110-12-25] by Dr. [Last Name (STitle) ] for a complex hip procedure involving hardware removal and cemented hemiarthroplasty. The procedure consisted of complex conversion of failed left dynamic hip compression screw to a cemented left hip hemiarthroplasty with strut allograft, cerclage, trephine, removal of failed deep hardware. The EBL was 2000cc and UOP was 300cc. Products infused included Cellsaver 300cc, IVF 2000cc, 4u PRBC, and 3u FFP. Please see operative report for details. The patient tolerated the procedure well but was transferred intubated to the ICU secondary to blood loss and concern for coagulopathy. After testing she was found not to have a coagulopathy and her blood volume began to normalize, but she required several transfusions to accomplish this. She was extubated on POD#1 and transferred out of the ICU on POD#2. A Medicine Consult was requested and their recommendations were followed. Peri-operative antibiotics (both ancef and vancomycin) were given due to her history of staph aureus colonization (no MRSA documented). Lovenox for DVT prophylaxis was used as a bridge to coumadin anticoagulation. Coumadin was started on POD#3 in anticipation of at least 6 weeks of anticoagulation. Pain was controlled initially with a PCA and then transitioned to oral pain meds on POD#2. The foley was removed on POD#4 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and an incisional vac was placed. The vac was removed on POD#4 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. Postoperatively the patient was given a total of 6 units PRBC with the goal of keeping her Hct >26. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a diabetic diet and feeling well. She was afebrile with stable vital signs. On the day of discharge the patient's hematocrit was stable and her pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient progressed well with physical therapy. Post-operative Xrays demonstrated hardware in good position. The patient was discharged to rehab in stable condition. Daily Report: [12-25] (POD#0): Patient transferred to ICU intubated [1-20] concern for blood loss and possible coagulopathy. POC done by moonlighter. Left hip and femur Xrays [12-25]: hardware in good position, no evidence of complication. Hct 26.4, INR 1.3, Fibrinogen 299. [12-26] (POD#1): Extubated. Drain removed. Hct 23.1 so stayed in ICU. Transfused 2 units PRBC. Mg 1.2 repleted. INR 1.3. [12-27] (POD#2): Hct 26.7. Dressing changed and incisional vac placed to 75mm Hg continuous suction. Repeat Hct 23.9, ordered additional 2units PRBC. [12-28] (POD#3): Hct 27.9 and INR 1.2. [12-29]: Hct 23.4. Asymptomatic. Transfused an additional 2 units PRBC and gave 10mg IV lasix in between units. INR 1.4, ordered 2mg coumadin. Repleted lytes. Left hip and femur Xrays [12-29]: hardware in good position, no evidence of complication. [12-30]: Hct 26.9 and INR 2.6. Lovenox bridge discontinued. Labs notable for low potassium and phosphate: daily supplements started per Medicine Consult recommendations. Discharge to rehab. Medications on Admission: MEDS: Effexor, Zyprexa, Lamictal, Actonel, Ursodiol, Primidone, Simvastatin, Metformin, Potassium, Lasix, HCTZ, Lactulose, Dilaudid, Extra-strength Tylenol, Protonix, Colace, Iron, MVI ALL: Dilaudid IV, Codeine Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain: Do not drive, operate machinery, or drink alcohol while taking this medication. As your pain decreases, take fewer tablets and increase the time between doses. Take a stool softener to prevent constipation. 2. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Primidone 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for Constipation. 16. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily): 25mg PO daily. 17. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily): 150mg PO daily. 18. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 19. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Insulin Lispro 100 unit/mL Solution Sig: 1 - 3 units Subcutaneous ASDIR (AS DIRECTED): for blood glucose control. 21. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): 10mg PO QHS. 22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours): do not exceed 4000mg Tylenol per 24hr period. 23. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP<100. 24. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): 400mg PO TID. 25. Warfarin 2 mg Tablet Sig: Variable Tablet PO Once Daily at 4 PM: Goal INR 2.0 - 2.5, Last dose 2mg on [2110-12-29]. 26. Dextrose 50% in Water (D50W) Syringe Sig: One (1) Syringe Intravenous PRN (as needed) as needed for hypoglycemia protocol. 27. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): 10mg [Hospital1 ]. Please give [Hospital1 ] potassium supplement at the same time. . 28. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 29. Potassium Chloride 20 mEq Packet Sig: Two (2) 20mEq packets PO BID (2 times a day): 40mg [Hospital1 ]. Please give [Hospital1 ] lasix at the same time. . Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) 5165] Discharge Diagnosis: Failed left dynamic hip compression screw with four part intertrochanteric femur fracture and avascular necrosis of the femoral head. Discharge Condition: AVSS, hemodynamically stable, pain well-controlled, tolerating a regular diet, voiding independently, ambulating with crutches, neurovascularly intact distally. 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. While you were in the hospital you were found to have consistently low potassium and phosphate levels. this is dangerous in patients with liver disease because it can cause encephalopathy. We have started potassium and phosphate supplements. Your electrolytes should be checked every other day and the doses of potassium and phosphate supplements revised accordingly. Goal potassium is [3-23] and goal phosphate is > 2.5. In addition, your creatinine should be monitored while taking lasix. 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 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 Coumadin with a goal INR of 2.0 - 2.5. Coumadin therapy will continue for at least 6 weeks: total duration of therapy to be determined at your follow-up appointment with Dr. [Last Name (STitle) ]. INR should be checked daily at rehab and Coumadin dosed accordingly. Due to your liver disease, INR may be hypersensitive to Coumadin dosage adjustments and should be checked daily. When you leave rehab your INR and Coumadin dosing will be followed by your PCP or by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in Dr. [Last Name (STitle) 67] office. INR can then be checked every other day by the VNA. Please call [Telephone/Fax (1) 1228] if there is any confusion about who will follow your INR and adjust your Coumadin doses. 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. INR checks and Coumadin dosing as above. Monitoring of electrolytes (particularly potassium and phosphate) as above. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior hip precautions and trochanteric osteotomy precautions. No active abduction and no excessive hip flexion, adduction, or internal rotation. Abduction pillow while in bed. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: ACTIVITY: Weight bearing as tolerated on the operative extremity. Posterior hip precautions and trochanteric osteotomy precautions. No active abduction and no excessive hip flexion, adduction, or internal rotation. Abduction pillow while in bed. No strenuous exercise or heavy lifting until follow up appointment. Treatments Frequency: 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. Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2111-1-23] 1:40 Completed by:[2110-12-30]	[ "2851", "25000", "2724", "53081" ]
Admission Date: [2137-12-12] Discharge Date: [2137-12-15] Date of Birth: [2068-7-3] Sex: M Service: TRA HISTORY OF PRESENT ILLNESS: This 69 year old male fell off a ten foot high roof and had head trauma and loss of consciousness. He was transferred from an outside hospital with the diagnosis of multiple left rib fractures of ribs three through eight and a questionable subarachnoid hemorrhage on CT. Upon arrival to [Hospital1 190], the patient had [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] Coma Scale of 15, but was unable to recall the events of the fall. He did not complain of chest pain, shortness of breath or lightheadedness. He did have a mild headache at presentation. PAST MEDICAL HISTORY: Hypertension. Anxiety. Arrhythmia (specific type unknown). PAST SURGICAL HISTORY: Status post hernia repair times three. Status post knee surgery times one. Status post appendectomy. Status post discectomy times four. MEDICATIONS ON ADMISSION: 1. Paroxetine 20 mg p.o. daily. 2. Diovan 80 mg p.o. daily. 3. Hydrochlorothiazide 25 mg p.o. daily. 4. Norvasc 10 mg p.o. daily. 5. Alprazolam 0.5 mg p.o. q.h.s. p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Past history of heavy alcohol use, currently drinks one beer per day. Past history of tobacco use but quit thirty years ago. PHYSICAL EXAMINATION: Vital signs on admission revealed temperature 98.6, blood pressure 124/82, heart rate 79, respiratory rate 18, oxygen saturation 93 percent on two liters. The patient was in no acute distress. The pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Tympanic membranes clear. Cervical collar in place. Lungs are clear to auscultation, bilateral breath sounds. Tender to palpation over the left chest with no crepitus. Cardiac regular rate and rhythm, no murmurs, rubs or gallops. Abdomen - normal bowel sounds, soft, nontender, nondistended. Normal rectal tone and guaiac negative. Extremities well perfused. Tender to palpation over the left shoulder, no focal tenderness, and had full range of motion. Neurologically, alert and oriented times three. Cranial nerves II through XII are intact. Moving all extremities with 5/5 strength throughout. LABORATORY DATA: On admission, white blood cell count 11.8, hemoglobin 14.7, hematocrit 41.8, platelet count 217,000. Glucose 135, blood urea nitrogen 26, creatinine 1.0, sodium 141, potassium 3.3, chloride 102, bicarbonate 28 with an anion gap of 14. Initial CK was 1,270 which trended down over the course of his admission. CK MB 4.0. Calcium 9.0, phosphorus 2.8, magnesium 1.9. Pertinent radiology studies on admission included a head CT which showed a subarachnoid hemorrhage in the left temporal sulci with a scalp hematoma. Cervical spine CT showed a grade I anterolisthesis of C4 on C5. Chest x-ray showed left rib fractures of ribs number three, four and five with no pneumothorax. Thoracolumbosacral films were negative. Left shoulder film was negative. Magnetic resonance imaging of the cervical spine was negative. Subsequent head CT done on hospital day number one showed a stable subarachnoid hemorrhage with no increase in size. HOSPITAL COURSE: Subsequently, the patient was followed by the trauma surgery team and the neurosurgery team and was monitored in an Intensive Care Unit setting on the day of admission and on hospital day number two. He was transferred to the surgical [Hospital1 ] on hospital day number three, [2137-12-14]. He continued to do well with no change in his neurologic examination and was discharged on hospital day number four, [2137-12-15], with follow-up arranged to have a repeat head CT done in two weeks in the [Hospital 4695] Clinic and to follow-up in the Trauma Surgery Clinic in two weeks as well. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: Subarachnoid hemorrhage. Left rib fractures of ribs three, four and five. Hypertension. Anxiety. History of arrhythmia. MEDICATIONS ON DISCHARGE: 1. Alprazolam 0.5 mg p.o. q.h.s. p.r.n. 2. Percocet one to two tablets p.o. q4-6hours p.r.n. pain. 3. Paroxetine 20 mg p.o. daily. 4. Diovan 80 mg p.o. daily. 5. Hydrochlorothiazide 25 mg p.o. daily. 6. Norvasc 10 mg p.o. daily. FOLLOW UP: The patient will follow-up in the [Hospital 4695] Clinic in two weeks for a repeat head CT and the patient will follow-up in the Trauma Surgery Clinic in two weeks. [First Name11 (Name Pattern1) 518] [Last Name (NamePattern4) ], [MD Number(1) 17554] Dictated By:[Last Name (NamePattern4) 6394] MEDQUIST36 D: [2137-12-25] 15:40:52 T: [2137-12-25] 18:00:14 Job#: [Job Number 60049]	[ "4019" ]
Admission Date: [2119-9-21] Discharge Date: [2119-9-26] Date of Birth: [2052-2-14] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old woman who presented with shortness of breath and heart failure. The patient stated that she had been having worsening lower extremity edema, increasing abdominal girth, weight gain, and increasing shortness of breath over the last ten days. Also the patient has been seen in the clinic recently with labs that showed severe prerenal azotemia, in addition to her fluid retention. The patient has a known history of coronary artery disease, diabetes, and hypertension. She has had multiple admissions for severe fluid retention with renal insufficiency. Both catheterization and echocardiogram in [2118] showed mild left ventricular hypertrophy and mitral regurgitation. Since her admission on [2119-7-7], she has gained at least 20 lbs, recurrent massive lower extremity edema and exertional shortness of breath. She did not complain of any angina; however, she is now only able to walk ten steps, and at baseline, she is can walk one block. The patient was referred today from the clinic to the CCU for an elective Swan-Ganz to help assess her intracardiac pressures and adjust her medications accordingly to see if we can prevent her recurrent admissions for congestive heart failure. The patient on admission was also noted to have a hematocrit of 19, but she denied melena and hematemesis. She did note that she has had some blood streaked stools. She had a negative colonoscopy several weeks ago. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Coronary artery disease. She has had multiple catheterizations. She had a PTCA of the right coronary artery in [2109]. She had PTCA of the left circumflex in [2110], and also PTCA of the right coronary artery in [2113]. 3. History of congestive heart failure. Last echocardiogram was [2119-9-21], which showed an ejection fraction of 60-65%, left atrial enlargement, right atrial enlargement, trace aortic insufficiency, and mild to moderate mitral regurgitation, with severe pulmonary hypertension. 4. She has a history of paroxysmal atrial fibrillation on Amiodarone and Coumadin. 5. History of pulmonary embolism in [2117]. 6. History of thyroidectomy on Synthroid. 7. History of chronic renal insufficiency with a baseline of 1.1. 8. History of osteoporosis. 9. Depression and anxiety. Borderline personality disorder. 10. Sleep apnea. 11. Peripheral vascular disease. ALLERGIES: PENICILLIN CAUSES A RASH. PERCOCET ALSO CAUSES RASH. TEGRETOL CAUSES LIVER ABNORMALITIES. SHE IS ALLERGIC TO BEES, ................... WHICH CAUSE ANAPHYLAXIS. MEDICATIONS AT HOME: Lasix 120 p.o. b.i.d., 75/25 Humalog 21 U q.a.m., 18 U q.p.m., regular Insulin sliding scale, Coumadin, Actigall, Lipitor 10 q.d., Buspar 10 mg t.i.d., Celexa 60 mg q.d., Folate 1 mg q.d., Calcium Citrate, Neurontin 1200 mg q.a.m. and q.p.m., 800 mg at noon, Amiodarone 300 mg q.d., Hydrochlorothiazide 25 mg q.d., Lisinopril 20 q.d., Mirapex 0.25 b.i.d., Lopressor 25 mg b.i.d. SOCIAL HISTORY: She lives alone. She has occasional alcohol use. She denied tobacco use. FAMILY HISTORY: She had a father who died of myocardial infarction at 47 and mother with [Name2 (NI) 499] cancer. PHYSICAL EXAMINATION: Vital signs: Temperature 97.9??????, pulse 51, blood pressure 84/25, respirations 10, oxygen saturation 100% on room air. General: She was a pleasant, pale, female in no acute distress. HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular movements full. Oropharynx clear. Neck: Supple. There was an 11 cm JVP. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular, rate and rhythm. There was a 3 out of 6 systolic murmur at the left sternal border and at the right upper sternal border. Abdomen: Soft, slightly distended, obese, nontender. Normoactive bowel sounds. She also had guaiac positive brown stool. No evidence of blood. Extremities: No clubbing or cyanosis, but she had 3+ pitting edema in both lower extremities. Neurological: She was alert and oriented times three. LABORATORY DATA: On admission white count was 6.4, hematocrit 19.8, platelet count 221,000; INR 4.0, PT 24.6, PTT 45.0; sodium 128, potassium 4.8, bicarb 88, chloride 26, BUN 149, creatinine 2.7, glucose 154. ASSESSMENT AND PLAN: She was a 67-year-old female with a history of coronary artery disease, and congestive heart failure, with multiple admissions, atrial fibrillation on Coumadin and Amiodarone, diabetes type 2, peripheral vascular disease, and hyperthyroidism, presenting with worsening congestive heart failure symptoms and anemia, as well as elevated BUN and creatinine ratio, and anemia with a hematocrit of 19.8. 1. Cardiovascular: The patient had an exam consistent with congestive heart failure. We will place a Swan-Ganz to assess .............. possibility once her elevated INR has been decreased. We will give her Vitamin K. 2. Hematocrit: The patient has had over a ten-point hematocrit drop with negative guaiac positive stool. We were planning to transfuse her. After discussion with Dr. [Last Name (STitle) ], we decided not to place an NG tube because of elevated INR and the fear of aspiration. 3. Endocrine: She has a history of hyperthyroidism on Synthroid. 4. Renal: She has had worsening renal function with an increase in creatinine. We will continue to diurese anyway and hope that with improved cardiac output, the patient's renal function will improve. 5. GI: We will reverse her INR with Vitamin K and start Protonix at 40 mg IV q.d. We will also consult GI. HOSPITAL COURSE: Cardiovascular: The patient's INR was reversed with Vitamin K, and a Swan was placed. Swan numbers revealed pulmonary artery hypertension but also an elevated wedge felt to be due to left heart failure due to diastolic dysfunction. Echocardiogram was done which showed an ejection fraction of 55%. The patient was diuresed with Lasix, and throughout the hospital course, lost 10 kg with complete resolution of her 3+ lower extremity pitting edema. She remained in normal sinus rhythm throughout the hospital course. Her pulse was in the 50s and 60s throughout but stable. Once her heart failure resolved, she was restarted on her home medications, Lopressor 25 b.i.d. Lisinopril was decreased to 10 mg q.d., and she was restarted on Lasix 120 mg q.d. She was also restarted on Aspirin and placed on Lipitor per her home regimen. She was continued on Amiodarone and restarted on Coumadin after a negative GI work-up. Pulmonary: The patient has severe pulmonary hypertension on echocardiogram but has a history of PE. She had negative lower extremity Dopplers recently, so this was not repeated. At the time of discharge, the patient had good oxygen saturations on room air. Renal: Her renal function improved throughout the hospital stay with diuresis. Creatinine returned to baseline of 1.1. GI: EGD found erosions in the antrum that were small and localized. There was no active bleeding or coffee-grounds and no evidence of recent GI bleed. The patient later had a barium study with small bowel follow through which was a unremarkable small bowel study; barium passed freely through the small bowel reaching the cecum within 45 min. The small bowel was of normal caliber in the mucosal pattern, no mass lesions. Terminal ileum and cecum appeared normal. Heme: The patient was transfused multiple units of packed red blood cells. Hematocrit eventually stabilized around 31 with no evidence of further bleeding. The patient was restarted on her Coumadin, as well as Aspirin without incident. DISPOSITION: The patient saw Physical Therapy who recommended a short rehabilitation stay of several days with a plan to follow-up with Heart Failure Service on [10-5]. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: Lasix 120 mg q.d., Lopressor 25 mg b.i.d., Lisinopril 10 mg q.d., Coumadin 5 mg q.h.s. q.o.d., 2.5 mg q.o.d. q.h.s., Zantac 150 mg b.i.d., Lipitor 10 mg q.h.s., Amiodarone 300 mg q.d., Actigall 300 mg b.i.d., Buspar 10 mg b.i.d., Celexa 60 mg q.d., Folate 1 mg q.d., Aspirin 81 mg q.d., Neurontin 1200 mg q.a.m., 800 mg q.noon, 1200 mg q.h.s., Mirapex 0.25 mg b.i.d., 75/25 Humalog 21 U q.a.m., 18 U q.p.m., Levothyroxine 250 mcg p.o. q.d. FOLLOW-UP: The patient will follow-up on [10-5] with the Heart Failure Clinic with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] M.D. [MD Number(1) 7169] Dictated By:[Last Name (NamePattern1) 1203] MEDQUIST36 D: [2119-9-26] 11:23 T: [2119-9-26] 13:06 JOB#: [Job Number 105301]	[ "4280", "5849", "42731", "25000", "41401" ]
[ ] Date: [2128-5-26] Discharge Date: [2128-6-3] Date of Birth: [2056-3-12] Sex: F Service: MEDICINE Allergies: Sotalol / lisinopril Attending:[Last Name (NamePattern1) 1167] Chief Complaint: hyponatremia and lethargy Major Surgical or Invasive Procedure: [2128-5-27] right heart catheterization History of Present Illness: Ms. [Known lastname 100868] is a 72F with history of end-stage non-ischemic dilated CMP w/ EF 20%, complete heart block s/p PPM/ICD, and primary effusion lymphoma s/p chemotherapy ([2128-4-29]) who now presents with hyponatremia to 120 and [Last Name (un) ] with creatinine to 3.0 from baseline 1.6-1.9. She has been abiding by her fluid restriction and has been seeing Dr. [First Name (STitle) 437] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at all of her scheduled appointments. She has not gained very much weight, (weight was 83.9 lbs on [5-11] and today 89 lbs on bed scale). Her breathing is stable, but her appetite has decreased. She has been lethargic for about 5-7 days. Exam in the ED was notable for no JVD, mildly decreased lung sounds to bases likely representative of bilateral pleural effusions, [1-9]+ LE edema. III/VI systolic murmur with blunted S2. Quite lethargic, arouses to voice. Spoke with Dr. [First Name (STitle) 437] about her. She has end-stage heart failure and the family (mainly her son [Name (NI) ], primary caretaker) has been somewhat resistant to the idea of how sick she is. She is not English-speaking and a continuing goals of care discussion with her and her son will be very important before she gets sicker. We agreed to try hypertonic saline VERY slowly to try to avoid volume overload but make her feel better (raise her sodium). Dr. [First Name (STitle) 437] also wants to start tolvaptan to see if this will work. Patient is confirmed DNR/DNI (per son and HPC [Name (NI) ]). . In the ED, initial vitals were 98.0, 69, 110/72, 16, 100% RA. Labs and imaging significant for Na 120, Cr 3.1. Urine lytes had a Na of less than 10 with an osmolality 320 in the face of serum osmoles 300 (inappropriate concentration in the face of hyponatremia and volume overload). Patient given 3% hypertonic saline in the ED with slight improvement in mental status and Na increase to 122 over several hours. . On arrival to the floor, patient is awake and interactive. She does not have chest pain, orthopnea, shortness of breath, or palpitations. She understands what is happening with her heart, sodium, and kidneys. . REVIEW OF SYSTEMS On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain although she does not walk much at home. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, orthopnea, palpitations, syncope or presyncope. She does have ankle edema and PND x1 the day PTA. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - PERCUTANEOUS CORONARY INTERVENTIONS: Cath in [2108] @ [Hospital1 2025] with clean coronaries per report - PACING/ICD: Dual Chamber [Company 1543] Virtuoso DR [Last Name (STitle) ] in [5-/2124] as replacement of [Company ] gem for imminent pocket erosion. PPM placed originally in [2112], then repaired in [2114] and [2115]. - Nonischemic Dilated Cardiomyopathy, sCHF (LVEF 20% [2-/2128]) - Complete heart block s/p ICD - Severe tricuspid regurgitation - Pulmonary artery systolic hypertension (TTE [2-/2128]) - Atrial fibrillation on warfarin and amiodarone. - Pericardial effusion [10/2127], drained 650cc, atypical cells on cytology 3. OTHER PAST MEDICAL HISTORY: - Primary effusion Lymphoma including in the pericardial space with h/o tamponade s/p rx with velcade x 3 cycles and doxil x 2 cycles - hypercalcemia - Osteoporosis - GERD - E. Coli cystitis [11/2127] treated with 7 days of cipro - C. diff with PO metronidazole ([11/2127]) x14 days - Chronic kidney disease baseline Cr 1.4-1.6 Social History: She is originally from Sicily, [Country 2559], and immigrated in [2084], Italian speaking, can speak some English. She lives with her son, [Name (NI) 100875]. She previously worked as a factory worker. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Her mother and 1 sibling were killed during World War II in a bombing. She denies any family history of leukemia or lymphoma. She reports that her father had heart disease. Overall, she had 4 brothers and 4 sisters, none of which had any malignancy. Physical Exam: [Name (NI) ] PHYSICAL EXAM: VS: T 97.6, BP 100s/50s, HR 70s, RR 14, O2 sat 94% 2L NC GENERAL: fraily, ill-appearing F 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 5 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Prominent RV heave. RR, normal S1, S2. 4/6 systolic murmur. 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 but generally decreased breath sounds bilaterally ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: 1+ pitting edema bilaterally to mid-shin. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: radial 2+ DP dopplerable Left: radial 2+ DP dopplerable DISCHARGE PHYSICAL EXAM Pertinent Results: [Name (NI) ] LABS [2128-5-25] 11:50AM BLOOD WBC-6.3 RBC-4.12* Hgb-12.5 Hct-39.3 MCV-95 MCH-30.4 MCHC-32.0 RDW-16.3* Plt Ct-157# [2128-5-26] 12:33PM BLOOD Neuts-87.7* Lymphs-7.1* Monos-4.5 Eos-0.5 Baso-0.2 [2128-5-25] 11:50AM BLOOD PT-15.0* INR(PT)-1.4* [2128-5-25] 11:50AM BLOOD UreaN-115* Creat-3.1* Na-121* K-3.2* Cl-78* HCO3-29 AnGap-17 [2128-5-26] 12:33PM BLOOD ALT-25 AST-47* AlkPhos-257* TotBili-2.2* [2128-5-26] 12:33PM BLOOD Lipase-42 [2128-5-26] 12:33PM BLOOD Albumin-3.3* [2128-5-27] 04:03AM BLOOD Calcium-8.8 Phos-4.7# Mg-2.5 [2128-5-26] 12:33PM BLOOD Osmolal-299 [2128-5-26] 02:15PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.008 [2128-5-26] 02:15PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2128-5-26] 02:15PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 [2128-5-26] 02:15PM URINE Hours-RANDOM Creat-38 Na-LESS THAN K-42 Cl-19 [2128-5-26] 02:15PM URINE Osmolal-328 SODIUM TREND [2128-5-25] 11:50AM Na-121 [2128-5-26] 10:00AM Na-121* [2128-5-26] 12:33PM Na-120* [2128-5-26] 05:20PM Na-122* [2128-5-26] 08:22PM Na-126* [2128-5-26] 11:53PM Na-124* [2128-5-27] 04:03AM Na-127* [2128-5-27] 08:53AM Na-132* PERTINENT IMAGING [2128-5-27] TTE: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %). The right ventricular cavity is moderately dilated with borderline normal free wall function. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([12-8]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of at least moderate (2+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mildly dilated left ventricle with normal wall thickness and severely depressed global left ventricular systolic function. Moderately dilated right ventricle with borderline normal systolic function. Mild to moderate aortic regurgitation. At least moderate mitral regurgitation. Severe tricuspid regurgitation. Indeterminate pulmonary artery systolic pressure. DISCHARGE LABS: Brief Hospital Course: Ms. [Known lastname 100868] is a 72 year old female with history of primary effusion lymphoma (PEL) and non-ischemic dilated cardiomyopathy, EF 20%, who presented with hyponatremia and acute renal failure in the setting of volume overload. She was started on milrinone continuous infusion; CO increased to 3.1 from 2.9, f/u ECHO did not show significant change but her symptoms improved. . # Hyponatremia: Urine osmoles showed inappropriately concentrated urine in the face of hyponatremia and volume overload. Likely the inapproriate ADH release was related to heart failure. This was supported by low urine Na, suggesting the kidneys were seeing poor forward flow and trying to augment volume and Na. Got hypertonic saline with good results: Na increased to 122 --> 126 --> 132 and patient's lethargy resolved. When hypertonic saline was stopped, Na drifted back down. Since we felt her hyponatremia was due to heart failure and poor renal perfusion, she was managed with milrinone as below as well as salt tabs. . # Chronic systolic heart failure (sCHF): Non-ischemic etiology and symptoms are predominantly right-sided, likely due to wide open tricuspid regurgitation. Had continued with hypervolemia symptoms and weight gain despite spironolactone 25 mg daily and torsemide 80 mg daily at home. She was sent for a right heart cath which showed improvement in cardiac output with milrinone. Thus, she was started on milrinone continuous infusion at 0.5 mcg/kg/min. Her echo on this showed "Borderline dilated, globally hypokinetic left ventricle. Dilated right ventricle with borderline normal systolic function. Mild to moderate aortic regurgitation. At least mild to moderate mitral regurgitation. Severe tricuspid regurgitation. At least moderate pulmonary artery systolic hypertension. Pulmonary diastolic hypertension appreciated. Compared with the prior study (images reviewed) of [2128-5-27], at least moderate pulmonary artery systolic hypertension is now present; it was previously indeterminate. A slight decrease in left ventricular cavity size from 5.8 centimeters to 5.6 centimeters is appreciated, but may be due to a positional/angular change of the transducer used in obtaining the images, rather than a true decrease in dimension." As above, her cardiac output improved to 3.1. She was also continued on torsemide 80mg then 60mg, spironolactone was held for hyperkalemia. Metoprolol was also held, but then it was restarted at her home dose before she was discharged. She is no longer on ACE inhibitors because of her renal function and because her heart remodeling is considered complete. We discussed with her and her family that she had end-stage heart failure and likely around 6 months to live. # Acute kidney injury ([Last Name (un) ]): Her [Last Name (un) ] was likely related to poor renal perfusion from worsening heart failure as well. With addition of milrinone, her Cr improved from 3.1 on [Last Name (un) ] to 2.0 # atrial fibrillation (Afib): Chronic afib status post ICD and now constantly v-paced. TSH has been normal, most recently in [4-17]. She was continued on metoprolol for rate control and amiodarone for rhythm control. However, her warfarin was discontinued because her annual stroke risk is low compared to life expectancy with a CHADS2 score of 1. # Somnolence: Initially was lethargic for 1 week prior to [Month/Year (2) ] and taking decreased POs. Likely multifactorial with contributions from hyponatremia as well as uremia. Resolved with normalization of serum Na. . FEN: HH PO, 2 gm Na restriction, 1000 ml fluid restriction CODE: DNR/DNI confirmed EMERGENCY CONTACT: [Name (NI) ] [Telephone/Fax (1) 100871] son/HCP TRANSITIONAL ISSUES: - Continue discussions with patient and family about her prognosis from heart failure and PEL. Discussion with palliative care for hospice care is ongoing. - VNA for milrinone Medications on [Telephone/Fax (1) ]: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Amiodarone 100 mg PO DAILY 2. Spironolactone 25 mg PO DAILY 3. Torsemide 80 mg PO DAILY 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Warfarin 2 mg PO DAILY16 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. traZODONE 25 mg PO HS:PRN sleep 8. Ferrous Sulfate 325 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Milrinone 0.5 mcg/kg/min IV INFUSION RX milrinone 1 mg/mL 0.5mcg/kg/min continuous Disp #30 Bag Refills:2 2. Outpatient Lab Work Please check chem-7 on [First Name9 (NamePattern2) 100885] [6-4] with results to Dr. [First Name (STitle) 437] at Phone: [Telephone/Fax (1) 62] Fax: [Telephone/Fax (1) 9825] 3. Amiodarone 100 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Torsemide 60 mg PO DAILY Please hold for SBP < 90 8. traZODONE 25 mg PO HS:PRN sleep 9. 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. RX Heparin Lock 10 unit/mL flush with 2 ml after NS as needed Disp #30 Syringe Refills:2 10. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: PRIMARY DIAGNOSIS chronic systolic heart failure--EF 20%, non ischemic . Secondary diagnosis: Complete heart block Primary effusion lymphoma Atrial fibrillation Discharge Condition: Improved Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 100868], You were admitted to the hospital because your sodium was very low and your kidneys were not working well. We think that both of these problems were because your heart failure was worsening and the blood was not circulating well to the kidneys. You underwent a cardiac catheterization which showed that your heart pump was weak and improved with a new medication, called milrinone. You were started on continuous infusion of milrinone and your kidneys and sodium improved. An ultrasound of your heart showed that it beat more effectively with milrinone. However, this medication does not change the overall poor prognosis of your heart failure. The following changes were made to your medications: - START milrinone at 0.5mcg/kg/min, the home infusion company will help you and your son manage the pump. - STOP taking warfarin and spironolactone You should also keep all the follow-up appointments listed below. It is important to bring your medications to each appointment so your doctors [Name5 (PTitle) ] adjust the doses as needed. Also, weigh yourself every morning, call Dr. [First Name (STitle) 437] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. It was a pleasure taking care of you in the hospital! Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [2128-6-7] at 1 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ADULT SPECIALTIES When: THURSDAY [2128-6-17] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 21927], MD [Telephone/Fax (1) 721] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: THURSDAY [2128-6-24] at 11:00 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital1 18] [Location (un) 2352] - ADULT MED When: FRIDAY [2128-6-25] at 12:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6887], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: [Hospital1 18] [Location (un) 2352] - ADULT MED When: WEDNESDAY [2128-7-14] at 10:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6887], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "2761", "5849", "2724", "42731", "4168", "40390", "5859", "4280", "2767" ]
Admission Date: [2119-1-27] Discharge Date: [2119-2-2] Date of Birth: [2054-5-28] Sex: M Service: CARDIOTHORACIC SURGERY CHIEF COMPLAINT: Coronary disease. HISTORY OF THE PRESENT ILLNESS: This is a 64-year-old man with a history of prostate cancer, status post radiation seed, who underwent a stress test at the request of his primary care physician when he wanted to increase his exercise program. His stress test was notable for significant ST depressions in V5 and V6 and the patient needed to stop secondary to fatigue and chest pain. He does recall having some anginal symptoms, having chest pain while walking up [Doctor Last Name ]. He was subsequently referred for a cardiac catheterization on [2119-1-11] which showed the following: Normal left ventricular function and severe coronary artery disease. The left main coronary artery had 70% stenosis. The left anterior descending artery after the first diagonal was completely occluded. The diagonal number one had a 70% stenosis. The left circumflex had a 90% stenosis and the right circumflex had a 50% stenosis. After visiting Dr. [Last Name (STitle) 70] in the office, he was scheduled for an elective coronary artery bypass graft on [2119-1-27]. On [2119-1-27], he presented to the OR consented and his history was reviewed. He was admitted for elective procedure. PAST MEDICAL HISTORY: 1. Prostate cancer diagnosed in [2117-3-12]. 2. Status post benign positional vertigo. 3. Status post appendectomy. SOCIAL HISTORY: He is a Methodist minister. He lives with his wife. [Name (NI) ] does not smoke. He drinks one glass of wine per day. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Detrol XL 4 mg q.d. 2. Atenolol 50 mg q.d. 3. Aspirin 325 mg q.d. 4. Imdur 30 mg q.d. 5. Nitroglycerin sublingually as needed for chest pain. 6. Viagra. REVIEW OF SYSTEMS: No visual changes. No dysphagia. No shortness of breath. No palpitations. No gastroesophageal reflux. No melena. No hematochezia. He does have positive urinary frequency but no recent changes in his urinary symptoms. No weakness. No strokes. No vein stripping. No varicosities. PHYSICAL EXAMINATION ON ADMISSION: General: This is a pleasant man in no apparent distress. Vital signs: Heart rate 68, blood pressure 139/75, respirations 16, pulse oximetry 98% on room air. Head and neck: The oropharynx was clear. The extraocular movements were intact. Neck: Supple. No JVD. No bruits. No lymphadenopathy. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm with no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. Extremities: There was no clubbing, cyanosis or edema. The pulses were 2+ and equal in all four extremities. HOSPITAL COURSE: The patient was taken to the Operating Room by Dr. [Last Name (STitle) 70] on [2119-1-27]. Please refer to the previously dictated operative noted by Dr. [Last Name (STitle) 70] from [2119-1-27]. Briefly, four grafts were made; the left internal mammary artery was connected to diagonal 1 and then saphenous vein grafts were connected to the LAD, OM, and PDA. He was on cardiopulmonary bypass for 95 minutes. The aorta was cross-clamped for 52 minutes. He tolerated the procedure well and was transferred to the CRSU in good condition on a propofol and neo-synephrine drips. Postoperatively, the patient did very well and was extubated on the night of procedure and all of his drips were also weaned off on the night of the procedure. On postoperative day number two, the patient was transferred to the floor where his issues were mainly diuresis, heart rate control, and physical therapy. The patient was actively diuresed with Lasix twice a day. His Lopressor was gradually increased for tachycardia. Of note, the patient did have several episodes of postoperative atrial fibrillation which spontaneously converted back to normal sinus rhythm on postoperative day number five. After increasing his dose of Lopressor, the discharge dose of 75 mg twice a day, his heart rate was well controlled and he had no more episodes of atrial fibrillation. Physical Therapy on postoperative day number four cleared the patient to go home after he completed the stairs. Therefore, on [2119-2-2], the patient was afebrile with a pulse of 80. His heart rate was a regular rate and rhythm. His lungs were clear to auscultation bilaterally. His abdomen was soft, tender, nondistended. His wounds were clean, dry, and intact. He had trace pedal edema. His laboratory values were all within normal limits and his chest x-ray showed small bilateral pleural effusions. He had not had any episodes of tachyarrhythmia for more than 24 hours and it was decided that he could be discharged to home in good condition. DISCHARGE DIAGNOSIS: 1. Prostate cancer. 2. Positional vertigo. 3. Three vessel coronary artery disease. 4. Status post coronary artery bypass graft times four. FOLLOW-UP: The patient is to follow-up in the wound care clinic on [2118-2-10]. He should also follow-up with his primary care physician, [Name10 (NameIs) ] cardiologist, and Dr. [Last Name (STitle) 70], his surgeon. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Metoprolol 75 mg p.o. b.i.d. 3. Lasix 20 mg p.o. b.i.d. 4. Potassium 30 mEq p.o. b.i.d. 5. Detrol 2 mg p.o. b.i.d. or an extended version of 4 mg p.o. q.d. 6. Percocet one to two tablets every four hours as needed for pain. 7. Colace 100 mg p.o. b.i.d. as needed for constipation. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 41125] MEDQUIST36 D: [2119-2-2] 01:19 T: [2119-2-2] 14:14 JOB#: [Job Number 41126]	[ "41401", "9971", "42731" ]
Admission Date: [2152-4-30] Discharge Date: [2152-5-6] Date of Birth: [2092-8-3] Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) / Sulfa(Sulfonamide Antibiotics) Attending:[First Name3 (LF) 633] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 59 year old woman with no PMH presents with 5 days of abdominal pain and nausea, and one day of nausea/hematemesis. . 5 days ago patient experienced [12-31] loose non bloody bowel movements per day, assocaiated with mild intermittent lower abdominal pain. Three days ago, she noted shaking and felt hot and sweaty, thought she hd a temperature, but did not have a thermometer. This evening around 7:00 pm she became acutely nauseous and vomiting with BRB. With her second emesis, she vomited > 1 cup BRB. She then had 4 more episodes of hematemesis, < 1 cup. . Denies dizziness, lightheadedness, syncope, chest pain. No recent travel or food experiementation. She does note a tick bite to her right thigh about 1 week ago. She removed it promptly, and did not have any rash. . On arrival to the ED VS were 97.1 98 102/59 15 99% RA. NGT was placed, removed mild BRB and coffee grounds, cleared after 500cc lavage. Guaiac negative brown stool. Hct 40. Called GI, thought likely [Doctor First Name 329] [Doctor Last Name ] tear, would consider endoscopy in am. Started on pantoprazole bolus + drip, 2 18g PIVs placed. Given 2L NS. Admitted to ICU for UGIB. . On arrival to the MICU, she feels shaky, but nausea is improved since arrival. Past Medical History: None Social History: Works at a law firm. Smokes 8 cigarettes/day. Drinks 2 beers/day. Family History: Father with type II DM and bladder cancer, mother with lung cancer. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM: VS: 98.0, 100-110/60-76, 73-86, 18, 95% on 4L Gen: Well-appearing, alert, and communicative HEENT: MMM Lungs: Minimal crackles anteriorly R>L. Heart: RRR, no murmuirs, no rubs Abd: Soft, nontender, nondistended Ext: Trace pedal edema, edema of right hand, clubbing of fingers. No further rashon legs Pertinent Results: ADMISSION LABS: [2152-4-30] 09:30PM BLOOD WBC-15.6* RBC-4.54 Hgb-13.8 Hct-40.6 MCV-89 MCH-30.3 MCHC-33.9 RDW-11.8 Plt Ct-189 [2152-4-30] 09:30PM BLOOD Neuts-87.7* Lymphs-6.1* Monos-5.6 Eos-0.4 Baso-0.2 [2152-4-30] 09:30PM BLOOD PT-12.4 PTT-29.8 INR(PT)-1.1 [2152-4-30] 09:30PM BLOOD Glucose-126* UreaN-17 Creat-0.9 Na-128* K-3.6 Cl-89* HCO3-25 AnGap-18 [2152-4-30] 09:30PM BLOOD ALT-59* AST-51* AlkPhos-68 TotBili-0.6 . DISCHARGE LABS: [2152-5-6] 01:30PM BLOOD WBC-8.3 RBC-4.09* Hgb-12.1 Hct-38.0 MCV-93 MCH-29.6 MCHC-31.9 RDW-12.9 Plt Ct-359# [2152-5-5] 06:15AM BLOOD Neuts-79.3* Lymphs-15.4* Monos-4.7 Eos-0.1 Baso-0.5 [2152-5-1] 04:25AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL [2152-5-1] 05:15PM BLOOD Parst S-NEGATIVE [2152-5-6] 01:30PM BLOOD Glucose-94 UreaN-10 Creat-0.6 Na-138 K-4.5 Cl-103 HCO3-27 AnGap-13 [2152-5-5] 06:15AM BLOOD ALT-49* AST-59* AlkPhos-63 TotBili-0.4 . MICROBIOLOGY: [2152-5-1] Urine culture: mixed flora [2152-5-1] Blood culture: no growth to date [2152-5-1] Influenza A/B nasopharyngeal swab: negative [2152-5-1] Lyme serology: pending [2152-5-1] H. pylori Ab: negative [2152-5-1] Urine Legionella Ag: negative [2152-5-2] Blood culture: no growth to date [2152-5-3] Blood culture: no growth to date [2152-5-3] Blood culture (mycolytic): no growth to date [2152-5-3] Stool culture/C. diff: pending . IMAGING: [2152-4-30] CXR: The lung apices are not depicted. NG tube ends in the gastric antrum in appropriate position. The lungs are clear, the cardiomediastinal silhouette and hila are normal. There is no pleural effusion and no pneumothorax. Partially visualized abdomen shows normal bowel gas pattern. EGD [2152-5-1]: Esophagitis in the lower third of the esophagus Small hiatal hernia Friability and erythema in the antrum and stomach body compatible with gastritis Ulcer in the pylorus Ulcers in the duodenal bulb Otherwise normal EGD to third part of the duodenum Recommendations: Prilosec 40mg [Hospital1 ] Advance diet as tolerated. Avoid NSAIDs. Serial hcts. Active type and cross. GI bleeding is unlikely the cause of the patient's current hypotensive episodes and warrents further investigation for a possible infectious cause. Given the clear history of NSAID use, follow up egd is not required but would check a h pylori serology and treat if positive. Would need a test of cure 4 weeks post h pylori serology as well. . [2152-5-1] CTA chest: 1. No PE. 2. Mild pulmonary edema. 3. Upper lobe peribronchovascular airspace filling could be edema or a manifestation of more severe airspace abnormality in the lower lungs, mostly consolidation, partially atelectasis, due to aspiration, multifocal pneumonia, or less likely hemorrhage. In the setting of a recent transfusions, transfusion reaction may be contributory. 4. Esophageal wall thickening, with diffuse infiltration of the mediastinal fat which may reflect inflammatory change or confluent lymphadenopathy, though the progression from normal mediastinal contours on [4-30] favors a rapidly evolving inflammatory process. There is no finding to suggest esophageal perforation. . [2152-5-2] CXR: As compared to the previous radiograph, there is a massive increase in extent and severity of multifocal pneumonia. The resulting very widespread parenchymal opacities are more extensive on the right than on the left and show multiple air bronchograms. In addition, retrocardiac atelectasis has newly appeared, and there is a small right pleural effusion. The opacities are better displayed on the CTA examination, performed yesterday at 9:41 p.m. Moderate cardiomegaly. Brief Hospital Course: 59 year old woman with no known medical history who presented with subjective fevers, abdominal pain, and hematemesis and developed hypoxic respiratory failure. Clinical picture likely consistent with an initial gastroenteritis with emesis likely leading to aspiration pneumonia and hematemesis. # Hematemesis: EGD revealed mild esophagitis, a non-bleeding 7mm ulcer in the pylorus, and several superficial non-bleeding ulcers ranging in size from 3mm to 5mm in the duodenal bulb. This was likely due to aspirin use and recurrent emesis. H. pylori antibody is negative. Her HCT continued to rise and she was transitioned from a pantoprazole gtt to pantoprazole 40mg PO Q12h. # Hypoxemic Respiratory Failure: Patient developed fevers and new hypoxia on [5-1]. She was empirically treated for pneumonia with ceftriaxone. CT chest showed likely multifocal pneumonia which was possible due to aspiration. Given these findings, antibiotics were broadened to vanc/levo/flagyl and ID was consulted. The vanc was discontinued on [5-3] and the patient was discharged with PO levo and flagyl for likely aspiration pneumonia. Her pulmonary status improved significantly during hosptialization and she was satting 100% on RA at discharge. # Volume overload: the patient received over 12L of IV fluids in the ICU in the setting of hypotension (BP 80/40s with fever, mottled legs, likely sepsis with pulmonary source). After pt stabalized, she was gently diuresed. # Diarrhea/Abdominal Pain: Likely viral gastroenteritis as this resolved during the hospitalization. Stool cultures, including C diff, were negative. # Tick Bite: Recent tick bite removed quickly. Lyme serologies were negative and smear was negative for babesiosis although ANAPLASMA PHAGOCYTOPHILUM was negative. . # Transaminitis: Very mild transaminitis (50s). No RUQ pain, no hyperbilirubinemia. Likely related to viral gastroenteritis/acute infectious process. Transitional issues/INcidental radiographic findings. -Pt will require primary care follow up: has not seen a PCP [Last Name (NamePattern4) ] 10 years. Would follow LFT's as well. -Pt has recently decided to stop smoking. Outpatient support should be provided to support this goal. -Pt still mildly volume overload at discharge. She was mobilizing and self-diuresing effectively and will follow up with PCP closely to see if she would benefit from lasix. -PT WAS NOTED TO HAVE ESOPHAGEAL WALL THICKENING ON CT WITH CONFLUENT LYMPHADENOPATHY THAT FAVORED AN INFLAMMATORY PROCESS. This will likely require further work up Medications on Admission: None Discharge Medications: 1. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 6 Days RX metronidazole 500 mg Every 8 hours Disp #18 Tablet Refills:0 2. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg twice a day Disp #60 Tablet Refills:2 3. Levofloxacin 750 mg PO DAILY RX Levaquin 750 mg daily Disp #6 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Pneumonia- multifocal Ulcers of the stomach and duodenum (upper small intestine). Diarrhea Gastroenteritis Pulmonary Edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were treated in the hospital for pneumonia and vomitting up of blood clots that likely developed because of vomitting, diarrhea, and fevers (possibly due to a stomach flu) as well as high doses of aspirin that worsened your stomach and small intestine ulcers. It is important that you complete the course of antibiotics for treatment of your pneumonia. Please take Levofloxacin 750 mg by mouth daily and metronidazole 500 mg by mouth every 8 hours for six more days. As you know, you were given many liters of fluids through your veins while you were in the intensive care unit because you were so sick. You will continue to urinate out this fluid within the next several days. Because you vomitted blood, we took a look at your esophagus, stomach, and upper small intestines with a camera. We saw that you have an ulcer in your stomach and several ulcers of your upper small intestine. To help treat your ulcers, it is important that you start to take Prilosec (omeprazole) 40mg twice a day. It is also important that you avoid all non-steroidal anti-inflammatory drugs, including ibuprofen, alleve, and aspirin. You may take tylenol. You developed new diarrhea in the hospital. This is most likely likely due to antibiotics and should resolve as your gut flora return. You can take yogurt or lactobacillus supplements to accelerate this process. If your diarrhea gets worse or you develop any fevers, please see your doctor. Finally, it is important that you begin to see a primary care doctor regularly. Please follow-up regarding this hospitalization with [First Name4 (NamePattern1) 1022] [Last Name (NamePattern1) ] NP (see appointment below). At that time, you will also be set up with a primary care doctor. We have made the following changes to your medications: START Levofloxacin 750 mg by mouth daily and metronidazole 500 mg by mouth every 8 hours for six more days. START Pantoprazole 40mg by mouth twice a day Followup Instructions: Name: NP [First Name4 (NamePattern1) 1022] [Last Name (NamePattern1) ] Location: [Hospital ] Medical Group Address: [Month (only) 66695], [Hospital1 ],[Numeric Identifier 66696] Phone: [Telephone/Fax (1) 66697] Appointment: Monday [2152-5-8] 10:40am This is a follow up appointment for your hospitalization. You will be reconnected with your primary care provider after this visit.	[ "5070", "51881", "0389", "99592", "5990", "2761", "3051" ]
Admission Date: [2187-7-5] Discharge Date: [2187-7-16] Date of Birth: [2112-3-8] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [2187-7-10] - AVR (19mm [Doctor Last Name ] Pericardial), Aortic Root Replacement, CABGx1 (Vein to Right coronary artery) History of Present Illness: Mrs. [Known lastname 20246] is a 75 year old female with known aortic stenosis who has had worsening DOE. A recent echo showed her aortic valve area to be 0.57cm2, moderate MR and a normal ejection fraction. She underwent a cardiac catheterization which revealed one vessel coronary artery disease. She is now transferred for surgical management. Past Medical History: Hyperlipidemia HTN Type 2 Diabetes Social History: Ms. [Known lastname 20246] was born in [Location (un) ]. She was married 52 years, husband deceased 5 [Name2 (NI) 1686] ago of cancer. She worked throughout her live, for many years in a shoe factory, then in the restaurant business. She has 4 children, and currently lives with her eldest son. She performs all ADLs. Stopped smoking some 12 [Name2 (NI) 1686] ago (50 [Name2 (NI) 1686] of 1.5ppd) Family History: 9 siblings, she is the only one left; cancers, liver fialure, leukemia, CAD, HTN Physical Exam: tm 97.5, bp 114-156/53-68, p 62-69, r 16-18, 97% on room air Well appearing, NAD PERRL. OP clr JVP 9cm Regular, s1, IV/VI SEM with obliteration of S2. LCA b/l +bs. Soft. NT. ND. No LE edema. +clubbing. +bony deformities of DIP, PIP, b/l w/ limited ROM. No evidence of synovitis. Pertinent Results: [2187-7-6] Carotid duplex ultrasound: Right ICA stenosis falling in the 60-69% range. Left ICA stenosis in the 40-59% range. [2187-7-10] ECHO: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post CPB: A well-seated and functioning prosthetic aortic valve is seen. No leak, no AI. No MR, no [Male First Name (un) ]. Good biventricular systolic fxn. Aorta intact. Other parameters as pre-bypass. [2187-7-12] CXR The right internal jugular line was removed in the interval. The heart size is unchanged. There is no change in the position of the aortic valve. The left retrocardiac atelectasis again noted. The lung volumes are low, this might partially explain the perihilar _____ of the vessels, but mild pulmonary edema cannot be excluded. Small bilateral pleural effusion is not _____. Brief Hospital Course: Ms. [Known lastname 20246] was admitted to the [Hospital1 18] on [2187-7-5] via transfer for further management of her aortic stenosis and coronary artery disease. She was worked-up in the usual preoperative manner including a carotid duplex ultrasound which revealed a right ICA stenosis falling in the 60-69% range and a left ICA stenosis in the 40-59% range. A neurology consult was performed for right hand tingling. It was belived that her symptoms were most consistent with small vessel hypoperfusion due to her insufficient cardiac output. Higher then normal perfusions pressures were recommended during her bypass operation. On [2187-7-10], Ms. [Known lastname 20246] was taken to the operating room where she underwent coronary artery bypass grafting, an aortic root enlargement with an aortic valve replacement using a 19mm [Doctor Last Name ] pericardial valve. Postoperatively she was taken to the intensive care unit for monitoring. On postoperative day one, Ms. [Known lastname 20246] [Last Name (Titles) 5058] neurologically intact and was extubated without incident. On postoperative day two, she was transferred to the step down unit for further care and recovery. She tolerated beta blockade and remained in a normal sinus rhythm. Over several days, she continued to make clinical improvements with diuresis and made steady progress with physical therapy. Medical therapy was optimized and she was eventually discharged to home on postoperative day five. Medications on Admission: atenolol 100 qday glucophage 500 [Hospital1 ] lisinopril/hctz 20/12.5 lipitor 20 avandia 4mg qday Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 vial Refills:2 7. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:20 Tablet(s) Refills:0 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) Inhalation four times a day. Disp:1 vial Refills:2 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 10 days. Disp:20 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital6 486] Discharge Diagnosis: Aortic Stenosis and CAD s/p AVR/CABG HTN Diabetes mellitus Hyperlipidemia Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Follow-up with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] in [3-18] weeks. ([Telephone/Fax (1) 72869] Follow-up with cardiologist Dr. [Last Name (STitle) 5017] in 2 weeks. ([Telephone/Fax (1) 72870] Please call all providers for appointments. Completed by:[2187-7-17]	[ "4241", "41401", "25000", "2720", "4019", "V1582" ]
Admission Date: [2133-9-17] Discharge Date: [2133-9-22] Date of Birth: [2084-5-25] Sex: F Service: SURGERY Allergies: Penicillins / Codeine Attending:[Doctor First Name 5188] Chief Complaint: Abdominal pain, vomiting Major Surgical or Invasive Procedure: Right Chest tube placement at bedside History of Present Illness: 49 year old female with history of cervical cancer status post multiple (?26) abdominal surgeries for TAH/BSO and complications resulting in colostomy and urostomy presented to OSH on [2133-9-17] with one day of abdominal pain and vomiting. Per OSH report, also experienced chills, fevers, and decreased colostomy output. Noted to have WBC count 13.5. Abdominal CT was consistent with obstruction. In OSH received NS 1L, cipro IV, and narcotics for pain control. Received Narcan and was intubated "due to airway concern" - overdose on narcotic analgesics; ABG 7.20/73/77 on NC 4 LPM, anion gap 17. Also had R subclavian, NG tube placed. . In the [Hospital1 18] ED, T 98.4, HR 126, BP 137/100, RR 14, 99% on AC ventilation. Received propofol gtt, flagyl 500mg IV x1, and morphine 4mg IV. Past Medical History: Past Medical History: - Cervical CA s/p TAH/BSO w/incidental appy and damaged bladder ([2106]), s/p mult procedures repair ending in urostomy and colostomy - Depression - ?Hepatitis . Social History: Lives with boyfriend. On Disability due to multiple abdominal surgeries/complications. Denies alcohol, drug, or tobacco use. Family History: Noncontributory Physical Exam: Tmax: 37.7 ??????C (99.9 ??????F) Tcurrent: 36.1 ??????C (97 ??????F) HR: 106 (105 - 118) bpm BP: 145/91(105) {113/56(70) - 156/104(115)} mmHg RR: 19 (14 - 28) insp/min SpO2: 98% GEN: Well-appearing, well-nourished, HEENT: EOMI, sclera anicteric, no epistaxis or rhinorrhea, MMM NECK: No JVD, trachea midline CV: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Coarse breath sounds diffusely ABD: Multiple surgical incision scars; colostomy and urostomy bags in place; hypoactive bowel sounds; soft, not distended; difficult to assess for tenderness EXT: No C/C/E NEURO: responds to few questions (e.g. Are you in pain?); Moves all 4 extremities. SKIN: R subclavian in place and dressed; no jaundice, cyanosis, or gross dermatitis. No ecchymoses. . At Discharge: Vitals: 98.9, 81, 107/53, 18, 96% on RA GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB ABD: Soft, ND, slightly tender to palpation. +BS, passing flatus, +Stool Ostomy: stoma beefy red, viable with liquid yellow effluence Urostomy: conduit intact with clear yellow urine Extrem: no c/c/e Pertinent Results: [2133-9-19] 04:32AM BLOOD WBC-9.7 RBC-3.35* Hgb-11.8* Hct-33.9* MCV-101* MCH-35.3* MCHC-34.9 RDW-13.6 Plt Ct-223 [2133-9-17] 07:24PM BLOOD Neuts-81.9* Lymphs-14.2* Monos-3.3 Eos-0.3 Baso-0.3 [2133-9-19] 04:32AM BLOOD PT-12.8 PTT-25.8 INR(PT)-1.1 [2133-9-19] 04:32AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-144 K-3.3 Cl-106 HCO3-29 AnGap-12 [2133-9-19] 04:32AM BLOOD ALT-43* AST-39 LD(LDH)-216 AlkPhos-143* TotBili-1.1 [2133-9-19] 04:32AM BLOOD Calcium-8.7 Phos-2.3* Mg-1.9 [2133-9-18] 12:17AM BLOOD Type-ART Rates-/14 pO2-124* pCO2-50* pH-7.33* calTCO2-28 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2133-9-17] 07:32PM BLOOD Lactate-1.3 [2133-9-21] 04:50AM BLOOD WBC-6.6 RBC-3.02* Hgb-10.9* Hct-30.4* MCV-101* MCH-36.1* MCHC-35.8* RDW-13.3 Plt Ct-232 [2133-9-22] 05:34AM BLOOD Glucose-92 UreaN-5* Creat-0.7 Na-140 K-3.9 Cl-106 HCO3-28 AnGap-10 [2133-9-22] 05:34AM BLOOD Calcium-9.0 Phos-3.3# Mg-2.1 . Brief Hospital Course: 49 year-old female with history of cervical cancer and many abdominal surgeries s/p colostomy and [Hospital 80011] transferred from OSH for further management of suspected small bowel obstruction. Admitted to Medical ICU. . # Abdominal pain, nausea ?????? Surgery involved. At this time diagnosis of SBO suspected, although surgeons are waiting to see CT abdomen from OSH to solidify diagnosis. Supported by large number of abdominal surgeries patient has had (-> risk for adhesions). Also with mildly elevated transaminases and alk phos. Differential also includes gastroenteritis, cholecystitis, cholangitis. Mildly febrile and with leukocytosis. Given history of possibile pneumobilia on CT at OSH hospital, ddx also includes biliary-enteric anastomosis or fistula. ?history of hepatitis. - intially NPO - NGT to low continuous suction, removed [9-20] and started on sips - Hydrate with IVF until adequate PO - Pain control (minimize narcotics) . #Pneumothorax: Pt had PTX most likely [1-3] line placement at OSH. Chest-tube was placed and almost complete resolution of PTX. -chest tube to suction until [9-20] - placed to waterseal -chest tube removed [9-21] without complication . # Respiratory failure ?????? Pt previously intubated for hypercarbic respiratory failure. Likely secondary to narcotics. Pt successfully extubated and on 4L NC on [9-18] . # [Name (NI) 3674] pt with Hct of 33.9 down from 38.1. Likely dilutional from fluids and blood loss from chest tube placment. . # Acute renal failure ?????? Creatinine 0.7 today, much improved from admission. History of vomiting and poor PO intake, this may be secondary to dehydration. Urine output >30 cc per hour. - Continue to hydrate - Maintain UOP >30cc/hr . # UTI - UA with positive nitrite, trace ketones, >50 WBCs, and many bacteria. Given one dose of ciprofloxacin in ED. Given that patient has ileostomy, she will likely always have a 'dirty' UA. - Hold off on treating at this time as may just be a contaminant - Follow urine culture . Patient was successfully extubated in ICU. Continued with confusion. Restraints applied. Remained NPO with IVF. Mental status cleared slowly. Transferred to Stone 5 for further management on [9-20]. . [9-20] -Pt pulled NGT out due to agitation r/t naroctic medications. Maintained in 2 point restraints overnight. Mental status much improved in morning. Ostomy with gas but no stool. KUB repeated-resolving ileus. . [9-21] -Abdomen slightly distened. Started on clear liquids. Tolerating well. No N/V. Right chest tube removed at bedside, uncomplicated. CXR completed 2 hours after, lungs clear, no evidence of pneumothorax. Ostomy RN contact[Name (NI) ] to assist with management of leaking ostomy and urostomy. Assisted OOB with nursing. Ambulated without assist. Lives independently with boyfriend. Diet advanced to regular food in evening. Tolerated well. . [9-22] -Continues to tolerate Regular food. Ostomy and Urostomy putting out adequate amounts of urine/stool. Pain well controlled with oral medication. Abdominal pain decreased. Ostomy continues to leak even with efforts of Ostomy RN due to patient's anatomy. Plan for discharge home today with VNA for continued management of Ostomy appliance and skin assessment. Medications on Admission: Seroquel 25mg PO BID Zantac 150mg PO QHS Cymbalta 60mg PO BID Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain: Not to exceed 4gm per day. . 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months: Take with Hydrocodone. Disp:60 Capsule(s) Refills:0 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Do not exceed 4000mg of Acetaminophen in 24hrs. Disp:45 Tablet(s) Refills:0 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Take with Hydrocodone. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Primary: Small bowel obstruction Post-extubation confused related to medications Right pneumothorax-Chest tube inserted. UTI Acute renal failure . Secondary: Depression, hepatitis C, cervical CA, TAH/BSO-Bladder injury (urostomy & Colostomy) Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid driving or operating heavy machinery while taking pain medications. You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. [Name8 (MD) ] MD if output greater than 2 liters or under 500ml in 24 hours. . Urostomy: -Continue with urostomy managment prior to admission. . Diet: -Continue with a low residue diet until your follow-up appointment with your PCP. [Name10 (NameIs) ] to Hand out provided to you by nursing for guidance. Followup Instructions: 1. Follow-up with PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 48826] in 1 week and as needed. [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190] Completed by:[2133-9-22]	[ "51881", "2851", "5849", "5990" ]
Admission Date: [2189-10-30] Discharge Date: [2189-11-3] Date of Birth: [2165-9-16] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: asthma exacerbation Major Surgical or Invasive Procedure: none History of Present Illness: 24F with h/o asthma who presented with asthma exacerbation, transfered from [Hospital Unit Name 153]. Over the past week, the patient had presented to [Hospital1 18] EW 3 times for asthma flare. She was started on advair and given a 3-day prednisone [Hospital1 15123]. 3 days ago she presented with continued difficulty breathing and was admitted for IV solumedrol. Her peak flow in EW was 240. She was placed on continuous nebs x one hour and her peak flow improved to 340. ABG x 2 (second one done on room air after neb treatment) normal. . Pt states she was diagnosed with asthma at age 7 and was hospitalized at that time. Since then, she has never been hospitalized for her asthma and has never been intubated. She normally uses her albuterol inhaler 10 times per day and 3 times per night. She denies recent URI or other exacerbating factors of her asthma. She has never seen a pulmonologist an nor had PFTs. Her baseline peak flow is ~300 Past Medical History: * asthma since age 7, no intubations * seasonal allergies Social History: Employed in administrative work. No tobacco, no etoh. Family History: Significant for asthma, DM, hypertension, CAD. Physical Exam: V: 98.1 98.6 BP 138/70, HR 80, R 18, O2 98% RA Gen: Markedly wheezy young female, breathing mildly labored, soft voice, with moderate accessory muscle use HEENT: EOMI, sclera anicteric. Oropharynx clear. Neck: supple, no JVP at 90 degrees. CV: Tachycardic but regular, with normal S1, S2 with physiologic split, no murmurs, rubs or extra heart sounds. Chest: Reduced at bases, polyphonic inspiratory and expiratory wheezes scattered across chest. Abd: +BS, soft, nontender, nondistended. Ext: no edema. 2+ pulses throughout Pertinent Results: [2189-10-30] 12:50PM GLUCOSE-153* UREA N-13 CREAT-0.7 SODIUM-135 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-22 ANION GAP-18 [2189-10-30] 12:50PM WBC-8.7 RBC-3.86* HGB-11.9* HCT-34.1* MCV-88 MCH-30.8 MCHC-34.9 RDW-13.3 [2189-10-30] 12:50PM PLT COUNT-256 [2189-10-30] 01:11AM TYPE-ART PO2-109* PCO2-29* PH-7.53* TOTAL CO2-25 BASE XS-3 [2189-10-29] 10:15PM WBC-10.0# RBC-4.37 HGB-13.1 HCT-39.6 MCV-91 MCH-29.9 MCHC-33.0 RDW-13.3 [2189-10-29] 10:15PM NEUTS-81.4* LYMPHS-14.7* MONOS-3.7 EOS-0 BASOS-0.1 [2189-10-29] 10:15PM D-DIMER-297 Brief Hospital Course: #Asthma exacerbation: It was felt that the patient's symptoms of chest tightness, wheeze, and difficulty breathing were consistent with an exacerbation of her asthma. Initial evaluation in the emergency department included a negative D-dimer, chest X-ray which was clear, and blood gas which revealed normal oxygenation. The history obtained did not identify a clear precipitant to the flare. However, given the patient's repeated evaluations for this asthma flare in the past week, it was felt that admission for IV steroids, MDI teaching, and optimization of outpatient regimen was warranted. Her acute management involved albuterol nebs q2h and IV solumedrol 80 mg q8h which was transitioned to po prednisone 120 mg on the first hospital day. Fluticasone/salmeterol had been recently added the previous week to the patient's regimen; this was continued in house. Peak flows rapidly improved on this therapy. The patient was educated about the proper use of MDI, and she was arranged for outpatient pulmonology and PCP followup to further optimize her outpatient regimen. The patient was discharged on a slow prednisone [Month/Day/Year 15123]. She was then transferred to the [Hospital Unit Name 153] in respiratory distress with audible wheezing, agitation, and peak flows of 150s (baseline~300s). She failed 5 nebulizer treatments on the floor and was transferred to [Hospital Unit Name 153]. Upon admission to [Hospital Unit Name 153], she was in visible respiratory distress, not able to speak in complete sentences, just able to whisper. . In the [Hospital Unit Name 153], the patient was started on IV solumedrol 60 q 8 and q2 standing nebs. She was also started on Advair and Singulair. She markedly improved with this treatment, able to speak adequately, w/o SOB, with peak flows reaching into 320s. The next morning, she was saturating 96% on room air, with only few diffuse exp wheezes remaining. On day 2 of the [Hospital Unit Name 153], she was given a dose of IV solumedrol and started on Prednisone 60 PO qd. She was called out to the floor. . On the floor, the patient tolerated Q4 hour nebs and denied shortness of breath at rest. She did complain of new onset vertigo, felt to be labyrnthitis. She was started on meclizine and was able to ambulate and tolerate PO. The patient also complained of dysuria and a urine culture grew out P.mirablis. She was given a 3 day course of bactrum. Since the patient had neither a PCP nor [Name Initial (PRE) ] pulmonologist, she was arranged to see Dr. [Last Name (STitle) ] in [Hospital 191] clinic and Dr. [Last Name (STitle) ] in Pulmonology clinic as an outpatient. She is to return to clinic this week for check-up and obtain PFTs before her appointment with Dr. [Last Name (STitle) ]. She was administered Pneumovax before discharge. She was sent home on a 10 day prednisone [Last Name (LF) 15123], [First Name3 (LF) ] asthma action plan, a peak flow meter, and advair prescriptions. Medications on Admission: Albuterol MDI Serevent (just started [10-25]) Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed. 2. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Capsule(s) Refills:2 3. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO Q24 () for 10 doses: Please take 5 pills for 2 days, then 4 pills for the next 2 days, then 3 pills for the next 2 days, then 2 pills for the next 2 days, and then 1 pill for the next 2 days. Disp:30 Tablet(s) Refills:0 5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp:42 Tablet(s) Refills:0 8. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Asthma exacerbation UTI Discharge Condition: good, breathing comfortably on room air. some dyspnea with exertion. some vertigo with head movement. Discharge Instructions: Please call or return if you have an increase in shortness of breath, wheezing, or dizziness. . Please take all medications as prescribed. You have also been prescribed an antibiotic for a UTI. You should use your peak flow meter daily and use your asthma action plan to treat yourself. . Please follow up with your doctors (see info below). You will see me in clinic in [Month (only) ] as a new patient visit; however you should go to clinic this Friday for a check-up. . You received a flu vaccine (Pneumovax) while in the hospital. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2189-11-6] 11:00 . Provider: [Name10 (NameIs) 1571] BREATHING TESTS Where: [Hospital6 29] PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 612] Date/Time:[2189-11-20] 9:40 . Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] PULMONARY EXAM ROOM IS (NO CHARGE) Where: IS (NO CHARGE) Date/Time:[2189-11-20] 10:00 . [2189-12-29] 02:00p [Last Name (LF) 7869],[First Name3 (LF) ] [Hospital 191] MEDICAL UNIT [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472]	[ "5990" ]
Admission Date: [2199-7-10] Discharge Date: [2199-7-12] Service: MEDICINE HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 71329] is a 76-year-old gentlemen with a history of coronary artery disease, hypertension, hypercholesterolemia, status post recent L3-S1 laminectomy who was in his usual state of health until the night of admission when he had an episode of emesis after taking his OxyContin medication. Initially, his emesis consisted only of food and there was no evidence of blood. However, over the next couple of hours, he had a couple of additional episodes of emesis now with bright red blood. He also described feeling somewhat dizzy, as well as cold and clammy. He therefore presented to the [Hospital6 649] Emergency Room. REVIEW OF SYSTEMS: Negative for any history of prior melena or hematochezia. He denied any chest pain, shortness of breath, palpitations, abdominal pain. He denied any prior history of gastrointestinal bleeding in the past. He denied any history of known liver disease. He does take enteric coated aspirin at home but denied any other nonsteroidal agents. He denied any history of alcohol use. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [2180], status post four vessel coronary artery bypass graft in [2194]. 2. Hypercholesterolemia. 3. Hypertension. 4. Hypothyroidism. 5. Status post L3-S1 laminectomy [5-19]. 6. Nephrolithiasis. 7. Status post septoplasty. ALLERGIES: Tetanus shot. MEDICATIONS ON ADMISSION: 1. Levoxyl. 2. Lipitor 10 mg po q.h.s. 3. OxyContin. 4. Zantac. 5. Enteric coated aspirin 325 mg po q.d. SOCIAL HISTORY: The patient has a remote history of tobacco. He drinks about two martinis per week. He is married. PHYSICAL EXAMINATION: He was in no acute distress. Temperature 97.9. Heart rate 77. Blood pressure 156/81. Respiratory rate 18. Oxygen saturation 98% on room air. On head, eyes, ears, nose and throat exam, his mucous membranes were moist. Her sclera were anicteric. His oropharynx was clear. He had no lymphadenopathy. His lungs were clear to auscultation. His heart had a regular rate and rhythm with a soft 1/6 systolic murmur. His abdomen had normal active bowel sounds with soft, nontender and nondistended. He had no hepatosplenomegaly. His rectal exam was guaiac negative with no masses. On his extremities, there was no edema. He had a scar from an old gunshot wound on his left arm. LABORATORIES: White blood cell count 5.4, hematocrit 33.1 (down from 34.8 one month ago), immune cell volume 90, RDW 14, platelets 227,000, PT 12.6, INR 1.1, PTT 31.7. Sodium 140, potassium 4.4, chloride 106, bicarbonate 21, BUN 27, creatinine 1.5, glucose 121. Electrocardiogram: Normal sinus rhythm, rate 75, normal axis, prolonged PR interval at 234 milliseconds, other intervals normal. Q wave in III and aVF, T wave inversions in III, aVL, aVF. There was no change from his baseline electrocardiogram from [2199-5-22]. HOSPITAL COURSE: In the Emergency Department, the patient underwent an nasogastric lavage which revealed bright red blood which did not clear with one liter of normal saline. He underwent emergent upper endoscopy which revealed [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear which was oozing blood at the GE junction. He underwent a successful ejection with epinephrine and BICAP electrocautery with good hemostasis. He was transfused with a total of two units of packed red blood cells. His hematocrit subsequently remained stable in the 30-33 range over the next 48 hours. His aspirin was held and it was recommended by the Gastrointestinal Service that this continue to be held for one week after discharge. He was started on Protonix 40 mg intravenous b.i.d. which was then switched over to 40 mg po q.d. for discharge. He was started on clears on hospital day two and his diet was advanced and he was tolerating full cardiac diet by the day of discharge. DISPOSITION: The patient was discharged to home in stable condition. DISCHARGE INSTRUCTIONS AND FOLLOW-UP: 1. The patient will hold on taking his aspirin for one week after discharge and then resume his prior dose. 2. His Zantac will be discontinued and he will be discharged on Protonix (see below). 3. He will follow-up with his primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 172], within a couple of weeks after discharge. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po q.d. 2. Levoxyl. 3. Lipitor 10 mg po q.d. 4. OxyContin. 5. He will hold on taking his aspirin for one week after discharge, then he will resume enteric coated aspirin 325 mg po q.d. DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed secondary to [Doctor First Name ]-[Doctor Last Name ] tear. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Name8 (MD) 13249] MEDQUIST36 D: [2199-7-16] 21:10 T: [2199-7-16] 21:10 JOB#: [Job Number 109121] cc:[Last Name (NamePattern1) 109122]	[ "4019", "2720", "41401", "V4581" ]
Admission Date: [2179-1-31] Discharge Date: [2179-2-6] Date of Birth: [2118-6-11] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1838] Chief Complaint: R-sided weakness Major Surgical or Invasive Procedure: s/p tPA History of Present Illness: Code Stroke: Neurology at bedside within 3 min from code stroke activation. Time (and date) the patient was last known well: 20:00 NIH Stroke Scale Score: -17- t-[MD Number(3) 6360]: Yes Time t-PA was given 22:46 I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. NIH Stroke Scale score was 17: 1a. Level of Consciousness: 0 1b. LOC Question: 1 1c. LOC Commands: 2 2. Best gaze: 1 3. Visual fields: 2 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 4 6a. Motor leg, left: 0 6b. Motor leg, right: 3 7. Limb Ataxia: 0 8. Sensory: 1 9. Language: 1 10. Dysarthria: 1 11. Extinction and Neglect: 0 Reason for Consult: aphasia, rightsided plegia History of Present Illness: Mr. [Known lastname 13165] is a 61yo LHM with a history of atrial fibrillation (not on coumadin), psychotic disorder, type II DM, hypertension, history of left MCA aneurysm and resulting SAH s/p aneurysmal clipping via left frontotemporal craniotomy in [2161] by Dr. [Last Name (STitle) 1128] at [Hospital1 2025], post stroke epilepsy managed on dilantin monotherapy who presents today as a code stroke for complaints of right sided weakness. The history is provided by the wife, who provides a patchy history. At baseline, Mr. [Known lastname 13165] is quite independent. He enjoys watching TV, he can ambulate without difficulties and has no baseline speech or language deficits. Off late, he has been experiencing some generalized weakness due to fatigue. He has been compliant with his medications. The patient was in this state of health until approximately 8pm this evening. His wife was with him watching TV until about 8PM. She briefly stepped away to use the bathroom, and when she returned, he was lying on the couch with his right arm and leg hanging over the couch. He was unable to move his right arm volitionally, and he was complaining "I can't breathe". She immediately called 911. On arrival to the ED, his fingerstick was 209. Review of systems: Unable to obtain from the patient himself as he is in quite a bit of distress, significantly dysarthric. He was given tpA (for further details see Stroke Fellow's note) and admitted to the neuro ICU Past Medical History: - Psychotic disorder NOS(?): Was briefly noted on discharge summary from [2162]. Currently on low dose fluphenazine. Tried to obtain more history from the wife about this, but she was clueless about this particular diagnosis. - Atrial fibrillation: Has been noted in the past, coumadin was deferred due to falls - MCA aneurysmal subarachnoid hemorrhage: Clipped in [2161] by Dr. [Last Name (STitle) 1128] at the [Hospital1 2025]. Op report was faxed over from [Hospital1 2025], but it does not include the make/model of the clip used. A left frontotemporal craniotomy approach was used. A large amount of blood clot was removed from the area in question. - Post stroke seizures: Admitted to neuromedicine in [2162] under attending Dr. [Last Name (STitle) 10442] where he presented with aphasia and right hemiparesis. His CT scan showed quite a bit of frontotemporal encephalomalacia at that time. He received an LP (unremarkable)as well as EEG monitoring which showed numerous bursts of semi-rhythmic 2 to 4 hertz activities, which occurred every few seconds involving broad regions of the left hemisphere, especially the left central and left anterior temporal regions. These were intermixed with focal slowing and occasional sharp wave discharges. He was started on dilantin therapy. His symptoms improved thereafter. He has since never presented to the [Hospital1 18]. His wife today reports that his seizures tend to occur once a year, and generally involve loss of consciousness with shaking of both arms and legs. - Hypertension Social History: Currently, Mr. [Known lastname 13165] is unemployed (he didn't work after his aneurysmal rupture). He quit smoking in [2172], and had been smoking 1ppd since his early 20s. He walks at home with a cane, and occasionally uses a bath seat at home to shower. He does not drink or do illicit drugs. He has three grown children. Family History: Negative for seizures or strokes. Physical Exam: Admission Physical Exam: Vitals: 97.8, 144/98, 80, 16, 100% General: Awake, cooperative, in mild distress. Intermittently stares blankly and may laugh at times inappropriately. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no masses or lymphadenopathy Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: Obese, soft, NT/ND, no masses or organomegaly noted. Extremities: warm and well perfused, poor nail hygiene Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert and makes good eye contact. Significantly dysarthric, and intermittently grimaces and closes his eyes in distress. Can tell me his name, and that the month is [Month (only) 956], and that his wife's name is [Name (NI) ]. [Name2 (NI) ] reports that he is in [Hospital3 2576]. He follows simple midline commands. At times, he stares blankly at my face. Difficult to test [Location (un) 1131]. Comprehends well, and repeats well but with significant dysarthria. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VF testing was limited by mental status, possibly a right homonymous hemianopsia noted III, IV and VI: Right gaze palsy V: Facial sensation intact to light touch. VII: Right facial droop involving forehead VIII: Hearing grossly intact IX, X: Difficult to test specifically [Doctor First Name 81]: Difficult to test specifically XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Left arm and leg are antigravity and withdraw to pain. Right arm is plegic below the deltoids and distally. Right leg is antigravity. He would often continuous kick his right leg up to maintain it upright. -Sensory: Difficult to test formally. Senses noxious stimuli in all four extremities without difficulty. -DTRs: Diffusely hyporeflexic, Plantar response: downgoing -Coordination/Gait: Finger nose finger was intact on the left, gait not tested. DISCHARGE Physical Exam: Vitals: Tm 98.5, Tc 97.3, BP 125/87, HR 100, RR 13, SO2 93% CPAP, FSG 100/103/89/104 General: Awake, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no masses or lymphadenopathy Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: Obese, soft, NT/ND, no masses or organomegaly noted. Extremities: warm and well perfused, poor nail hygiene Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake, alert and makes good eye contact. Significantly dysarthric. Can tell me his name, and that the month is [Month (only) 956], it is [2178], and that his wife's name is [Name (NI) ]. [Name2 (NI) ] reports that he is in [Hospital1 18]. He follows simple midline commands. At times, he stares blankly. Difficult to test [Location (un) 1131]. Comprehends well, and repeats well but with significant dysarthria. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VF testing was limited by mental status, possibly a right homonymous hemianopsia but hard to test formally III, IV and VI: EOMI but prefers left gaze, can't bury on right V: Facial sensation seems to be intact to light touch bilaterally but hard to formally test VII: Right facial droop VIII: Hearing grossly intact bilaterally IX, X: Palate midline [Doctor First Name 81]: Shoulder shrug normal on left, no shrug on right XII: Tongue protrudes in midline. Good mvmts in both directions. -Motor: Normal bulk, tone throughout. Left arm and leg are [4-24]. Right arm and leg are 0/5 throughout. -Sensory: Difficult to test formally. Senses noxious stimuli in all four extremities without difficulty. Appears to have sensation to light touch in all four extremities. -DTRs: Diffusely hyporeflexic, Plantar response: downgoing on left, upgoing on right. -Coordination/Gait: Finger nose finger was intact on the left, untestable on right, gait not tested. Pertinent Results: Reports: [2179-1-31] EKG: Atrial fibrillation with a controlled ventricular response. Delayed R wave transition in the anterior precordial leads. Non-specific inferior and anterolateral ST-T wave changes. No previous tracing available for comparison. [2179-1-31] CTA Head: IMPRESSION: 1. No acute intracranial abnormality. 2. Encephalomalacic changes in left MCA distribution with ex vacuo dilatation of the left lateral ventricle. 3. Hyperdensity seen in the expected location of proximal left MCA may represent a hyperdense MCA sign; however, CTA images are suboptimal. 4. Unremarkable CT perfusion study. [2179-2-1] EEG: IMPRESSION: This is an abnormal continuous ICU monitoring study because of nearly continuous left temporal epileptiform discharges at times briefly periodic. This finding is indicative of a potential epileptogenic focus in the region. Background is diffusely slow indicative of a mild to moderate encephalopathy. The background activity is asymmetric with more slowing over the left hemisphere suggestive of diffuse cortical and subcortical dysfunction in this region. Note is made of sinus tachycardia in this recording. [2179-2-1] TTE: No clot in left Atrium. Markedly dilated RA with no ASD. Mild symmetric LVH. LVEF is low normal at 50-55%. An abnormality with the posterior aortic root was seen, can't r/o aortic dissection. [2179-2-1] NCHCT: IMPRESSION: 1. No evidence of hemorrhage. 2. Stable encephalomalacia in the left MCA territory. [2179-2-1] Carotid U/S: IMPRESSION: Right ICA 80-99% stenosis, left ICA less than 40% stenosis. [2179-2-2] EEG: IMPRESSION: This is an abnormal continuous ICU monitoring study because of continuous and frequently periodic left temporal epileptiform discharges. At times, generalized or right frontocentral epileptic discharges are also present in the recording. These findings are indicative of multiple areas of cortical irritability with potential epileptogenicitiy mainly in the left temporal region. In addition, background activity was slow in the left hemisphere indicative of diffuse subcortical dysfunction in this region. Furthermore, background activity was also mildly slow over the right hemisphere indicative of a mild encephalopathy of non-specific etiology. No electrographic seizure is present in the recording. Note is made of borderline tachycardia throughout the record. Compared to prior day's recording, this EEG is worse digital extension of periodic epileptiform discharges the rest of the left hemisphere and occasional discharges in the right hemisphere. Potential causes for worsening of electrographic activity are metabolic abnormalities and alternatively occurrence of new structual lesions. Clinical correlation is advised. [2179-2-2] CTA H/N: IMPRESSION: 1. Evolving infarct in posterior half of the left MCA territory.No evidence of hemorrhage transformation. 2. Chronic infarction with encephalomalacic changes along the anterior half of the left MCA territory with ex vacuo dilatation of the left lateral ventricle. 3. High grade short segment stenosis of proximal right ICA as described above. [2179-2-3] NCHCT IMPRESSION: 1. Evidence of evolving acute infarction in the superior division of the left MCA is unchanged from the most recent exam, with no evidence of hemorrhagic conversion. A focal area of spared cortex is present at the vertex. 2. Unchanged cystic encephalomalacia and ex vacuo ventricular dilatation related to prior left MCA infarct, with associated marked wallerian degeneration. [2179-2-3] EEG: Report Pending [2179-2-4] EEG: Report Pending [2179-2-5] EEG: Report Pending [2179-2-5] MRI: Large area of diffusion abnormality in the left anterior and middle cerebral artery territories with some edema and mild rightward shift by 3-4mm representing acute infarct- extent better seen than prior CT studies. There are scattered foci of negative susceptibility within the area of acute infarct which may relate to blood products or mineralization; however, these did not look dense enough to be considered as hemorrhage on prior CT head of [2-3]- hence, consider non-contrast CT head to assess for any interval hemorrhage. Brief Hospital Course: Assessment: Mr. [Known lastname 13165] is a 61yo LHM with a history of atrial fibrillation (not on coumadin [1-21] falls), psychotic disorder, type II DM, hypertension, history of left MCA aneurysm and resulting SAH s/p aneurysmal clipping via left frontotemporal craniotomy in [2161] by Dr. [Last Name (STitle) 1128] at [Hospital1 2025], post stroke epilepsy managed on dilantin monotherapy who presented as a code stroke for complaints of right sided weakness and slurred speech found to have possible salvagable areas of brain tissue in the periphery of the left MCA territory, so was given tPA. The patient did not improve following tPA. While in house the patient had increased activity on his EEG so he was kept longer to titrate his antiepileptics. He was started on Keppra 1000 [Hospital1 ] which improved his EEG dramatically. An MRI was obtained which confirmed both MCA and ACA infarcts and likely some hemorrhagic conversion. He was discharged to rehab for continued care. # NEURO: We followed general post-tPA precautions in the ICU including letting BP autoregulate, monitoring pt on telemetry, avoiding arterial puncture, antiplatelets and anticoagulation for 24 hrs and keeping tight glycemic control with the HOB at 30 degrees for aspiration control but to also maximize cerebral perfusion. Unfortunately pt was unable to get an MRI until [2179-2-5], as his aneurysm clip was of questionable material and therefore could not be confirmed it was MRI compatible until this time. While here, we obtained an EEG given pt's hx of post-stroke seizures, which showed frequent L temporal spikes/PLEDs, but no definitive seizure activity. We increased his dilantin from his home dose to 150mg TID. Because he continued to have increased activity on LTM he was started on Keppra 1000 mg [Hospital1 ] which improved his EEG dramatically. Unfortunately, on d/c the patient still remains completely plegic on the right side. Additionally he has a worsened expressive aphasia and questionable sensory loss on the right side (please see PE for more details). This patient is at high risk for further stroke. He is now back on his Aspirin 325 mg daily. His PCP was [Name (NI) 653] and this patient has not been a candidate for anticoagulation given his frequent falls and non-compliance with medications (related to his psychosis). However, if this patient ends up in a nursing home and is wheel chair bound he would very likely benefit from anticoagulation, whether it be coumadin or dabigatran. If this were to be started it should not be before the [8-17] (2 weeks from onset of hemorrhage). If coumadin/dabigatran is started his aspirin should be stopped at that time. # Cardiovascular: we initially held pt's home antihypertensives to allow BP to autoregulate as much as possible. He was started on Metoprolol [Hospital1 ] for his A Fib. While in the unit he did have some episodes of A Fib with RVR which responeded to pushes of metoprolol. His metoprolol tartrate was uptitrated to 37.5 [Hospital1 ] and both his rate and pressures were very good from there forward. He was persistently in A Fib on tele throughout his admission. We obtained a TTE which showed no clot. After discussion with pt's PCP [Last Name (NamePattern4) ] [2179-2-3] it was determined to decide his anticoagulation following his stay in rehab. The PCP is very involved, knows the patient well and would like to be involved in the anticoagulation situation. # Respiratory: Pt uses CPAP at home which he was continued on in house. He had no other acute issues. # Endo: pt's hemoglobin A1C and lipids were within goal, but his triglycerides were elevated to he was started on a low dose statin. He was put on an ISS while here to maintain euglycemia. TRANSITIONAL CARE ISSUES: 1. The decision of whether or not to anticoagulate this patient or not following a stay in rehab should be made in the near future. He is at very high risk for further embolization and would likely benefit from anticogulation if he is not falling and being given his meds regularly. If started it should not be before [2179-2-16]. Additionally, his aspirin should be stopped at the time anticoagulation is started. 2. Patient will need monitoring of his phenytoin while in rehab. This should be checked the week of [2179-2-8] as his dose was changed while in house. Goal of 15-20. 3. Patient will need CPAP while at rehab. 4. Final MRI and EEG reads are pending and can be followed up by PCP or in neurology clinic. Medications on Admission: Atenolol 100mg daily Phenytoin 400mg daily (ER? DR?) Gabapentin 600mg TID Lasix 40mg daily Aleve PRN Fluphenazine 10mg daily Discharge Medications: 1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO three times a day. 8. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Left MCA and ACA Ischemic Stroke Atrial Fibrillation Hypertension Obstructive Sleep Apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Completely plegic on right side, some right sided neglect, non-fluent aphasia, with anomia for low frequency words, but with preserved comprehension. Discharge Instructions: Dear Mr. [Known lastname 13165], You were admitted to the [Hospital1 18] inpatient Neurology service because of your trouble speaking and right sided weakness. You were diagnosed with a stroke and given tPA, a drug that helps break up clots. Unfortunately, your neurological deficits were not helped by this drug. You were also noted to have increased electrical activity on your EEG, so we added another anti-seizure medication. At this time you are ready to continue your recovery at a rehab facility. The following changes were made to your medications: STOP Lasix: we were not sure why you were taking this medication and it can be restarted at the discretion of your rehab Physicians or your primary Physician STOP [Name9 (PRE) 13166] (If you need a pain med tylenol would be a better choice) CHANGE your phenytoin dose to 150 mg three times daily START Levetiracetam 1000 mg three times daily START simvastatin 10 mg daily START docusate sodium 100 mg twice daily START Senna 8.6 mg twice daily START Heparin 5000 units Subcutaneously while at rehab Additionally, we think you would benefit from anticoagulation with either coumadin or dabigatran but no earlier than [2179-2-16]. We have spoken with your primary Physician and we will defer the decision to starting this medication to him. Thank you for letting us participate in your care. We wish you a speedy recovery. Followup Instructions: Department: NEUROLOGY When: MONDAY [2179-3-22] at 3:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD [Telephone/Fax (1) 2574] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "25000", "4019", "42731", "32723" ]
Admission Date: [2152-8-4] Discharge Date: [2152-8-9] Date of Birth: [2074-2-1] Sex: M Service: MEDICINE Allergies: Streptokinase Attending:[First Name3 (LF) 783] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: 78 yo M with PMH significant for NIDDM, HTN,and atrial fibrillation (not on coumadin since [2095]), who was transferred from OSH in Nantuckett to [Hospital1 18] MICU for management of PE in the bilateral pulmonary arteries. The pt is now transferred to medicine service for further management as the pt has been stabilitzed. Pt presented to OSH w/2 wk h/o progressive SOB, severe 2-3 days prior to that admission. The pt was SOB both at rest and on exertion with "labored breathing". The pt denies CP at that time. The pt was found to have bilat PEs on CT at the OSH. At the OSH, O2 sat 89% on RA. ABG: 7.47/34/66 on 3 lt O2. Received heparin gtt, albuterol and Lasix. Trop 0.20. INR 1.15. Transferred to [Hospital1 18] MICU. Venous duplex of the LLE revealed occlusive thrombus within a branch of the L popliteal vein. The pt has been continued on heparin gtt and started on coumadin in the MICU. . Recent trip from [Hospital1 6687] to NY, but was already SOB at the time. ROS: Denies CP/N/V Past Medical History: Afib (was on coumadin, but stopped it) NIDDM HTN Spinal stenosis/DJD Ventral hernia bilat TKRs COPD Social History: Ex-smoker (quit tob in his twenties, but continued smoking occ cigars until a few years ago). Occ EtOH. No IVDA. Married. Family History: NC Physical Exam: PE: T 97.4, HR 116, BP 153/104, RR 35, O2 sat 100% NRB NAD PERRL, MMM CTAB Tachy, [Last Name (un) 3526] [Last Name (un) 3526], no MRG S/NT/obese. Ventral hernia. OB (-). [Location (un) ] L>[Initials (NamePattern4) ] [Last Name (NamePattern4) 5813] -. . On Tranfer to floor: PE: Tm/c 97 P80-113 BP 137-164/78-92 R 18-28 Sat 95%RA I:428 O: 925 General: obese [Male First Name (un) ], lying in bed, NAD, appearing tachypneic with slightly short-winded sentences HEENT: PERRL, MMM Neck: JVP 7-8 cm, obese, supple CV: distant heart sounds, [Last Name (un) 3526] [Last Name (un) 3526], no m/r/g Lungs: CTAB, diminished breath sounds throughout Ab: soft, nontender, obese, umbilical hernia. Extrem: no c/c/e, 2+ DP/PT pulses, LE cool, negative [Last Name (un) 5813] Neuro: CN II-XII grossly intact, sensation intact to LT, strength 5/5 throughout Pertinent Results: ECG in MICU on arrival: Afib, tachy, RAD, S1Q3T3. CXR (OSH): No acute CO process. CTA chest (OSH): Extensive pulm emboli involving R and L pulm arteries, bilateral lobar and segmental arteries. Bilateral calcified pleural plaques (? asbestos exposure). LENIs: obstructing clot in branch of L popliteal vein likely within L posterior tibial vein . [2152-8-4] 08:50PM GLUCOSE-233* UREA N-14 CREAT-1.0 SODIUM-138 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14 [2152-8-4] 08:50PM CK(CPK)-62 [2152-8-4] 08:50PM CK-MB-NotDone cTropnT-0.07* [2152-8-4] 08:50PM WBC-14.0# RBC-4.96 HGB-16.6 HCT-47.7 MCV-96 MCH-33.5 MCHC-34.8 RDW-13.3 [2152-8-4] 08:50PM NEUTS-74.5* LYMPHS-20.7 MONOS-4.2 EOS-0.4 BASOS-0.2 [2152-8-4] 08:50PM MACROCYT-1+ [2152-8-4] 08:50PM MACROCYT-1+ [2152-8-4] 08:50PM PT-18.2* PTT-150* INR(PT)-2.2 Brief Hospital Course: Briefly, this is a 78 yo M with PMH significant for afib, HTN, and DM who presented for further management of PEs in bilateral pulmonary arteries diagnosed at OSH. Pt still subtherapeutic on coumadin at the time of discharge. . 1) PE: Per OSH record, the pt had extensive bilateral pulmonary artery embolisms extending into the segmental arteries. Lower extremity duplex at our hospital revealed a L posterior tibial vein thrombus, which is the likely etiology for the pulmonary embolisms. TTE was negative for thrombus and revealed EF >55%. Pt was continued on a heparin gtt with goal PTT 80-100, and started on coumadin 5 mg po qhs. Ultimately the coumadin was increased to 7.5 mg po qhs given his subtherapeutic INR (goal [1-20]). The pt was discharged home with a prescription for lovenox injections to cover him for 5 days while his INR becomes therapeutic. The pts wife was instructed on proper lovenox injection technique. The pt is to follow up with his PCP in [Name9 (PRE) 18344] for coag checks and coumadin adjustment over the next week. Consideration may be given to a hypercoaguable workup as an outpt (ie. r/o malignancy with PSA and colonoscopy screening). . 2) HTN: The pts home dose metoprolol was increased to 75 mg po BID for SBP in the 150s. . 3) Afib: Apparently pt has not been on coumadin since [2095]. As stated above, the pt was started on coumadin and bridged with heparin. He was discharged home with Lovenox bridge. . 3) NIDDM: The pt was on a RISS while inpatient. He was discharged home on his home glyburide regimen. Given h/o DM, pt was started on daily ASA. Medications on Admission: Home Meds: Glyburide 5 mg [Hospital1 ] Verapamil 120 mg qd Lopressor 50 mg qam, 25 mg qpm Advair On transfer from MICU: alb nebs bisacodyl colace heparin gtt SSI Protonix Coumadin 5 Ambien prn Metoprolol 25 qpm, 50 q am Discharge Medications: 1. Lovenox 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous twice a day for 5 days. Disp:10 syringes Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:2 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:10 Tablet(s) Refills:0 5. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:10 Tablet(s) Refills:0 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:60 Tablet, Chewable(s) Refills:2 7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 8. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation every six (6) hours as needed for wheezing. 9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:180 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Submassive bilateral pulmonary emboli Discharge Condition: Stable hemodynamically and from a respiratory standpoint, with 95% oxygen saturation on room air at rest and with ambulation Discharge Instructions: Please continue all medications as prescribed and follow up with Dr. [Last Name (STitle) ]. Your wife will need to administer the Lovenox for at least the next five days, once in the morning and once in the evening. If she has difficulty doing this, she should contact Dr. [Last Name (STitle) 18345] office or the [Hospital6 18346] Emergency Room immediately. If you develop shortness of breath, chest pain or bleeding, please go to the Emergency Room immediately for evaluation. You will remain on the coumadin for at least 6 months and will need to have your blood checked frequently to make sure it is thin enough. Your goal INR is 2.0-3.0. Dr. [Last Name (STitle) ] will want you to have this checked Thursday AM, Friday AM and Sunday AM, with your coumadin dose adjusted based on the results (Dr. [Last Name (STitle) ] will adjust the dose). Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] on Thursday at your scheduled appointment. Call his office at [Telephone/Fax (1) 18347] with any questions. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "496", "25000", "4019" ]
Admission Date: [2173-6-12] Discharge Date: [2173-6-27] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: CODE STROKE Major Surgical or Invasive Procedure: MRI/MRA head MRA neck endotracheal intubation History of Present Illness: The pt is an 87 year-old right-handed woman with a prior history of stroke who presented with alteration in mental status. The pt was unable to offer a history at the time of my encounter. Therefore, the following history is per the primary team, the medical record, and the pt's daughter. She had been in her usual state of health until approximately 1440 today. At that time, she was sitting in her wheelchair [Location (un) 1131] the newspaper when her daughter suddenly saw the pt's right arm moving abnormally (not clear if rhythmically). The pt's face appeared "contorted" and her eyes were clamped closed. Her extremities appeared turned in and clinched together except for her right arm that was moving abnormally for an uncertain amount of time. Her daughter had never witnessed such an event in the past. She became concerned and called EMS who brought the pt to the [Hospital1 18] ED. Code stroke was called at 1530 and neurology was immediately at the bedside. NIHSS was documented as follows: Past Medical History: -multiple strokes, most significant event around 10 years ago with resultant left hemiparesis. Has been wheelchair bound since that time. -atrial fibrillation, warfarin was discontinued 10 days PTA for supratherapeutic level -history of congenital heart defect (unclear of exact etiology) -nephrolithiasis -history of blood clot in small bowel -congestive heart failure, EF unknown Social History: Lives with daughter wheelchair bound at baseline. Dependent on others for ADLs. No history of tobacco, alcohol, illicit drug use. Family History: - Physical Exam: Vitals: T: 98.6F P: 64 R: 16 BP: 125/46 SaO2: 99% NRB General: Lying in bed with eyes closed and NRB in place. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: No JVD or carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregularly irregular rhythm, nl. S1S2, no murmur noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 1+ radial, DP pulses bilaterally. Neurologic: -mental status: Opens eyes transiently to verbal or noxious stimuli, but very inattentive. Oriented to self only. Language nonfluent with intact repetition for one word phrases, inconsistently follows commands. -cranial nerves: PERRL 3 to 2mm. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. VFF to threat. EOMI. Left facial droop. Tongue protrudes in midline. -motor: Atrophic musculature throughout. Tone is spastic on the left. Dense left hemiplegia. Withdraws to noxious stimuli on the right and is at least antigravity strength throughout on the right(formal strength testing limited by impersistence). No adventitious movements noted. -sensory: Grimaces to noxious stimuli in all four extremities. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 3 3 3 3 0 R 3 3 3 3 0 Plantar response was extensor bilaterally. Pertinent Results: Laboratory Data: 6.5> 13.4 <177 MCV 99 40.7 PT: 12.2 PTT: 29.4 INR: 1 Na:143 K:5.2 Cl:110 TCO2:21 Glu:80 Lactate:3.3 BUN 29 Creatinine 1.8 UA positive Radiologic Data: NCHCT: Large area of encephalomalacia in MCA territory on the right. No evidence of hemorrhage or evolving infarction. Brief Hospital Course: In brief, the patient is an 87 year old woman with history of right MCA stroke who was admitted with signs and symptoms consistent with seizure activity potentially related to a new cerebral infarct whose course was complicated by asystolic arrrest, and anoxic brain injury. 1.) Neurologically, as mentioned above patient has history of right MCA stroke with residual left hemiplegia. Differential for her acute mental status change included seizure, infectious, metabolic, cardioembolic with clot dissolution. An MRI an acute ischemic event to left insula and the left parietotemporal lobe. An EEG showed encephalopathy and frequent posterior temporal-occipital sharp and slow wave discharges but no clear seizure activity. There were no witnessed convulsive seizures during the admission. As the patient had a good clinical description and reason for seizure focus, she was started on Keppra 500IV [Hospital1 ] and increased up to 750mg [Hospital1 ] after 72 hours. Fasting lipid profile was acceptable and was not started on statin. She was normotensive. Her mental status did not improve significantly during the admission. She continued to be largely unresponsive only very rarely speaking, and never responding appropriately. It was thought that she was debilitated by the old right hemisphere infarct combined with the new left sided infarct. As her quality of life prior to admission was questionable, her daughter requested palliative care involvement. Patient's UTI undergoing treatment and recent acute stroke were discussed with palliative care. After discussing with palliative care, the daughter requested continuing all non invasive medical care to see if there would be any improvement. On [6-17], the daughter requested a trial of tube feeds for 12-24 hours to see if this would improve the patient's strength and ability to interact. ON [6-18] she requested that the tube feeds be continued throughout the weekend. Repeat CT [6-18] showed evolving infarct in the distribution seen on MRI, and no new processess. A second EEG study [6-19] showed continued intermittent spike/waves from the area of the old infarct, but no epileptiform activity. Her course was further complicated as she suffered an asystolic arrest on [2173-6-22] which was of unclear etiology but could relate to depressed mental status with resulting aspiration pneumonia/pneumonitis. Following this event she was transferred to the MICU team, however she recovered no meaningful neurologic function. In discussions with her daughter following the arrest, her code status was confirmed to be DNR. Her GCS and brainstem function over 3 days were consistent with very poor prognosis for recovery. She could not complete an apnea test secondary to abrupt development of hypotension that recovered following early termination of the test. EEG showed no cortical activity at 30 minutes. Cerebral blood flow studies revealed a trace amount of blood flow. Ultimately, the patient's condition worsened and she expired. The family was notified. Autopsy was declined. Arrangements were made for the patient to be flown to [Country ] for burial arrangements. . Patient has history of afib and was subtherapeutic on admission. Telemetry showed intermittent afib/flutter. She was ruled out for MI with 3 consecutive cardiac enzymes. Heparin drip was started and titrated for goal PTT of 40-60, and patient was unable to take coumadin due to failed swallow studies. . Infectious Disease: patient had positive Urinalysis for infection and cultures grew Ecoli sensitive to ceftriaxone. Infection was treated with rocephin 1gm IV daily. . GI: she failed swallow study on [6-14] and she was maintained NPO. NG tube feeds were initially not started per daughter's request as patient had previous poor baseline. However, as explained above daughter requested tube feeds [6-17]. . Renal: There were no acute issues on presentation, however following her arrest she developed acute non-oliguric renal failure likely secondary to ATN. Endocrine: TSH was normal. HbA1c: 5.6 Disp: As above. The patient was pronounced dead on [2173-6-27]. Medications on Admission: -sertraline 50mg po daily -mirtazapine 15mg po qhs -warfarin 3mg po qhs (on hold for the past 10 days) -pantoprazole 40mg po daily -folate 1mg po daily -atenolol 12.5mg po daily Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Primary: Seizure Stroke Cardiac Arrest Anoxic brain injury aspiration pneumonitis Secondary: urinary tract infection atrial fibrillation Discharge Condition: expired Discharge Instructions: NA Followup Instructions: NA	[ "4280", "42731", "5845", "5990", "5070", "51881", "V5861" ]
Admission Date: [2126-8-31] Discharge Date: [2126-9-14] Date of Birth: [2045-8-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: right basal ganglia hemorrhage with intraventricular extension Major Surgical or Invasive Procedure: ventriculostomy History of Present Illness: 81 year-old man with a history of frontal infarct, HTN, dyslipidemia, and thrombocytopenia on Aggrenox presented to an OSH this afternoon after reportedly being found "unresponsive" at the side of a swimming pool. He was last seen at baseline at ~2:30 pm, and there was no apparent trauma involved. He was taken to [Hospital3 1280] Hospital for urgent evaluation. On arrival to [Hospital3 1280], the patient reportedly was hypertensive with slurred speech, a right facial droop, a flaccid left arm, and right-sided "tremor/seizure." He was sedated and intubated, and ultimately maintained on Propofol. A right basal ganglionic hemorrhage with extensive intraventricular spread was seen on non-contrast CT. He was loaded with Dilantin. The patient had bradycardia into the 30s that improved with atropine, though pressure was preserved. Of note his platelet count was 71 and INR was 1.1. On arrival to [Hospital1 18], the patient was bradycardic, again requiring atropine. He became hypotensive as well, requiring epinephrine, then a dopamine drip. Neurosurgery and Neurology consults were called for further evaluation. Past Medical History: - carpal tunnel b/l - BPH - barrett's esophagus - right hearing aid - ?glaucoma in left eye - h/o TIAs - memory problems - parasomnias - OCD, depression, anxiety - HTN - hypercholesterolemia Social History: Lives w/wife, 5 children, live in the area Family History: NC Physical Exam: General: elderly man, eyes closed HEENT: NC/AT, sclerae anicteric, orally intubated Neck: supple, no nuchal rigidity Lungs: clear to auscultation CV: bradycardic, regular rhythm, no MMRG Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, no edema, pedal pulses appreciated Skin: no rashes Neurologic Examination: Mental Status: Eyes closed, unresponsive to voice, though seems to internally rotate left arm at shoulder with sternal rub Cranial Nerves: Optic disc margins difficult to appreciate due to miosis; no blink to threat bilaterally. Pupils unreactive to light, 2 mm on left, 1.5 mm on right. No response to nasal tickle. Doll's eyes and corneals absent. Facial appears symmetric though difficult to assess accurately. No gag. Motor: Normal bulk, reduced tone throughout. Intermittently seems to internally rotate left arm at shoulder, otherwise no spontaneous movement. Sensation: Withdraws right arm and leg more briskly to noxious than left side. Pertinent Results: Non-contrast head CT here, wet read: "right basal ganglia hemorrhage, extending into the lateral, third, fourth ventricle worst than the OSH study performed earlier today. There is extension into the bilateral foramen of Luschka, patient at risk of obstructive hydrocephalus. No midline shift or herniation." [2126-8-31] 07:30PM FIBRINOGE-311 [2126-8-31] 07:30PM PLT COUNT-113* [2126-8-31] 07:30PM PT-13.2 PTT-27.5 INR(PT)-1.1 [2126-8-31] 07:30PM WBC-4.9 RBC-3.92* HGB-12.5* HCT-36.2* MCV-92 MCH-32.0 MCHC-34.6 RDW-13.3 [2126-8-31] 07:30PM freeCa-1.06* [2126-8-31] 07:30PM GLUCOSE-117* LACTATE-1.0 NA+-139 K+-3.6 CL--100 TCO2-28 [2126-8-31] 07:30PM TYPE-[Last Name (un) ] PH-7.39 COMMENTS-GREEN TOP [2126-8-31] 07:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2126-8-31] 07:30PM AMYLASE-49 [2126-8-31] 07:30PM UREA N-18 CREAT-0.9 [2126-8-31] 08:45PM TYPE-ART TEMP-35.3 RATES-/14 TIDAL VOL-500 PEEP-5 O2-100 PO2-477* PCO2-42 PH-7.43 TOTAL CO2-29 BASE XS-3 AADO2-208 REQ O2-42 INTUBATED-INTUBATED VENT-CONTROLLED [2126-8-31] 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2126-8-31] 09:50PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 Brief Hospital Course: A/P: 81 year old male s/p hemorrhagic stroke with likely aspiration pneumonia, fever-resolved, and continued increased respiratory effort. Intubated for hypoxia and hypercarbia plus increasing work of breathing. Family meeting held and decided to go to CMO on [2127-9-14]. Pt was pronounced dead from respiratory failure [2-23] hemorrhagic stroke and aspiration pneumonia at 15:30 on [2126-9-14]. Family declined autospy. 1. Pneumonia: likely aspiration, Serratia and Haemophillus positive sputum. Now intubated - D/C??????d Vanc and Zosyn on [9-9]. Continue Cipro for Serratia positive sputum on [9-6]; H.flu and yeast on [9-7]. - mouth care - Ventilated - Family has decided to go to CMO on [2126-9-14]- Increased sedation with fentanyl - holding suctioning to spare Pt pain 2. Hemorrhagic CVA 3. Psych: On Donepeizil, escitalopram, Zyprexa - Agitated. Now on PRN low dose olanzapine with good effect and fentanyl sedation 4. Pulastile mass on the head at the site of CSF shunt: - Neurosurgery following, will not intervene 5. ECG changes: resolved - CEs negative -Continue beta blocker, statin. 6. Thrombocytopenia: Resolved Medications on Admission: -Aggrenox -Simvastatin -Lisinopril -Aricept -Depakote -Klonopin -Doxazosin -Proscar -PPI -Abilify -Folate Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2126-9-14]	[ "5070", "51881", "4019", "42789", "2724" ]
Admission Date: [2122-4-22] Discharge Date: [2122-5-6] Service: MEDICINE Allergies: Amoxicillin / Tegretol / Dilantin Kapseal / Heparin Agents / Benzodiazepines Attending:[First Name3 (LF) 3565] Chief Complaint: Reason for MICU admission: Chronic ventillation Major Surgical or Invasive Procedure: Rigid Bronchoscopy for Y-stent placement Rigid Bronchoscopy for Y-stent removal Central Venous Line Insertion Sigmoidoscopy History of Present Illness: Mr. [Known lastname 34384] (a.k.a. "[Doctor Last Name ]") is an 86 M with a history of CVA with chronic right-sided weakness, seizure disorder subsequent to CVA, hypertension now off meds, CHF with unknown current LVEF (last 75% in [2117]), recent ED visit for urinary retention secondary to urethral stricture who presents for a planned admission for re-evaluation of the airways following Y-stent removal at his last hospitalization on [2122-3-21]. . During his last hospital admission, he was found to have a post-obstructive pneumonia presumed secondary to partial tracheal stent occlusion noted on bronchoscopy. The Y-shaped stent was removed and granulation tissue debrided from the left mainstem bronchus. He was then discharged to [Hospital 100] Rehab, where he has been chronically ventillated (his baseline prior to his last admission was ventillation only overnight from 10 PM - 6 AM). He is readmitted now for rigid bronchoscopy to assess airway and determine need for replacement airway stent. Because he is on the ventillator he requires ICU admission. . Per [Hospital 100] Rehab paperwork, recent active issues include fevers, thrombocytopenia, edema, diarrhea, and variable mental status. According to his daughter, his baseline functional status prior to his last admission was on ventillator at night only, out of bed to wheelchair in the day though no longer walking (left "good" leg is too weak to support his weight, though he can move his foot), living at home with his wife and full-time nursing aides. He has expressive aphasia since his stroke and at his best can speak only a few words at a time; recently he has had significant secretions when the vent is capped so he has not been speaking, but can nod yes/no to questions and communicate with facial expressions. . ROS: Given aphasia, complete review of systems is not possible. His aide who is with him and was with him at rehab confirms that he has had recent watery diarrhea, which has been improving since Monday. He denies any pain including abdominal pain. Denies uncomfortable breathing. Past Medical History: 1) Tracheomalacia, status post stent x 2 with failure secondary to stent migration. Status post trach revision [3-27]. Status post T-tube removal on [2115-6-26]. [2119-11-9]: Silicone Y-stent revision and replacement. Tracheostomy stoma revision. 2) Status post stroke in [2109] with TIA; right upper extremity weakness resulting. 3) Hypertension. 4) Seizure disorder. 5) History of MRSA. 6) Hemorrhoids. 7) Arthritis. 8) Depression. 9) History of CHF. 10) CRI Social History: Married and lived at home with wife (also with medical problems) with full-time private nursing care prior to this recent hospitalization and stay at [Hospital 100] Rehab. Forced to retire in [2109] following CVA from his work as businessman (had an Exxon franchise). Has three children; his two daughters [Name (NI) 553] [Last Name (NamePattern1) 54905] and [First Name8 (NamePattern2) 54906] [Name (NI) 54907] serve as his co-health care proxies; he also has a son involved in his care. He has a remote history of social smoking but never a heavy smoker. No recent alcohol. Caregivers provide all ADLs. Prior to this admission, he would occasionally take some puree by mouth for pleasure but TF provide nutrition. Family History: NC Physical Exam: ADMISSION VS: Temp: 97.7 BP: 128/70 HR:70 RR:21 O2sat 100% on FiO2 0.3 GEN: Appears comfortable, NAD, following commands, nodding head yes/no HEENT: PERRL, anicteric, MMM, op without lesions though difficult to visualize back of mouth as patient cannot open fully Neck: Supple, no JVD RESP: Diminished BS at left base, referred ventillation noises, no wheeze or rales CV: RR, S1 and S2 wnl, no m/r/g ABD: Mildly distended, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: Non-pitting edema of feet and right hand (per aide, unchanged since arriving at rehab). 2+ DP pulses. NEURO: Able to squeeze hand on left though weak grip. Can move left foot though very weak. Not moving right side which is baseline. Facial droop also baseline. Pertinent Results: TTE [4-27]: The left atrium and right atrium are moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>65%). Right ventricular chamber size and free wall motion are normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Mild aortic regurgitation. Compared with the prior study (images reviewed) of [2117-10-29], the multivalvular regurgitation is now seen and there now appears to be lack of atrial systolic function. In the absence of a history of systemic hypertension, these raise the suggestion of an infiltrative process such as amyloid cardiomyopathy. CT a/p [4-27] 1. Proctitis, without evidence of megacolon. 2. Multi-segmental collapse of the bilateral lower lobes, with foci of ground glass opacity in the aerated lung, consistent with aspiration or infection. There are associated moderate-sized simple pleural effusions. 3. Mediastinal lymphadenopathy, likely reactive. 4. Nonspecific renal hypodensities might represent cysts though ultrasound evaluation is suggested for further characterization when clinically appropriate. Bronch [4-27] Severe granulation tissue formation at distal end of left limb of the Y-stent. Thick putrulent secretions sent for microbilogy. Y-stent removed without difficulty. [2122-4-25] 10:10 am SPUTUM Source: Endotracheal. FINAL REPORT [2122-4-30] GRAM STAIN (Final [2122-4-26]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2122-4-30]): MODERATE GROWTH Commensal Respiratory Flora. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. GRAM NEGATIVE ROD(S). SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. GRAM NEGATIVE ROD #3. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ 8 I MEROPENEM------------- 8 I PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S [2122-4-27] 6:49 pm BRONCHIAL WASHINGS FINAL REPORT [2122-5-4] GRAM STAIN (Final [2122-4-27]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2122-5-4]): >100,000 ORGANISMS/ML. Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # 319-3364S ON [2122-4-25]. KLEBSIELLA PNEUMONIAE. ~3000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. FURTHER WORKUP ON REQUEST ONLY. DR. [First Name (STitle) 13258], S ([Numeric Identifier 13259]) REQUEST FOR WORK UP ON [2122-4-29]. 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. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. PROTEUS MIRABILIS. ~1000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. FURTHER WORKUP ON REQUEST ONLY. DR. [First Name (STitle) 13258], S ([Numeric Identifier 13259]) REQUEST FOR WORK UP ON [2122-4-29]. sensitivity testing performed by Microscan. CIPROFLOXACIN (>=2 MCG/ML), SULFA X TRIMETH (>=2 MCG/ML), MEROPENEM (<=1.0 MCG/ML). STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. ~1000/ML. SENSITIVE TO CHLORAMPHENICOL (<=8 MCG/ML) Intermediate TO TIMENTIN (64 MCG/ML). CEFTAZIDIME , CHLORAMPHENICOL , TIMENTIN sensitivity testing performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| PROTEUS MIRABILIS \| \| STENOTROPHOMONAS (XANTHOMON \| \| \| AMIKACIN-------------- 32 I AMPICILLIN------------ =>16 R AMPICILLIN/SULBACTAM-- =>32 R <=8 S CEFAZOLIN------------- =>64 R 16 I CEFEPIME-------------- R 4 S CEFTAZIDIME----------- =>64 R <=1 S =>16 R CEFTRIAXONE----------- R <=4 S CIPROFLOXACIN--------- =>4 R R GENTAMICIN------------ <=1 S =>8 R LEVOFLOXACIN---------- 1 S MEROPENEM-------------<=0.25 S S NITROFURANTOIN-------- =>64 R PIPERACILLIN/TAZO----- I <=8 S TOBRAMYCIN------------ =>16 R =>8 R TRIMETHOPRIM/SULFA---- <=1 S R <=1 S Flex Sig: Patchy areas of mild erythema and granularity were seen in the rectum. Impression: Abnormal mucosa in the colon Otherwise normal EGD to sigmoid colon Recommendations: Healing Proctitis Noted Likely due to ischemia though distribution unusual. No psudomembranes seen, no mass lesion seen. Brief Hospital Course: 86 M with history of tracheobronchomalacia s/p tracheostomy and stent placement on ventillator overnight at baseline with recent admission for post-obstructive left-sided pneumonia followed by removal of stent who presented for planned rigid bronchoscopy. His hospital course was prolonged by sepsis secondary to pseudomonas pneumonia, illeus and protitis. 1. Tracheobronchomalacia s/p Y-stent removal [2-/2122]: Since his prior admission for post-obstructive pneumonia during which his Y-stent was removed (see operative report note above), he has been chronically ventillated in rehab. Y stent placed under rigid bronchoscopy by IP during admission. Patient initially did well on trach mask, but then developed copious secretions concerning for a VAP. He was covered with ceftazadine and vancomycin and sputum grew pseudomoas. He progressively worsened (see shock below) and ultimately Y-stent was removed in OR by IP on [2122-4-27] without intraoperative complication. Mr. [Known lastname 34384] remained on the vent for several more days and was aggressively diuresed. He tolerated trach mask on [4-25] and [5-4]. 2. Septic Shock/ventilator associated pneumonia - While in the ICU for monitoring after his Y-stent placement, Mr. [Known lastname 34384] developed worsening pulmonary secretions and chest x-ray was concerning for pneumonia/VAP. He was started empirically on Vancomycin and Cefepime. He developed worsening hypotension with transient requirement of pressors. He was aggressively resuscitated with 9L IVF with improvement in blood pressure. Cefepime was changed to Ceftazadime based on previous sensitivities for pseudomonas. Mr. [Known lastname 34384] [Last Name (Titles) 54908] over the course of [2-26] days. Repeat sputum culture grew Pseudomonas, Klebsiella and stenotrophomonos. The pseudomonas was the only organism that grew with >10,000 cfu. The others were felt to be colonizers. His 14-day course of ceftazidine will complete on [5-11]. 2. Hematachezia - On hospital day 4, Mr. [Known lastname 34384] was found to have hematachezia. His hematocrit was stable. In the presence of dilated bowel loops on KUB and grimmacing to abdominal palpation; surgery was consulted for concern of obstruction vs. other acute process. He was placed on bowel rest. CT abdomen and pelvis showed no obstruction, concern for proctitis. He had a flexible sigmoidoscopy which showed resolving proctitis, perhaps secondary to ischemia. There was no active bleed and no psuedomembranes. C. diff swab was negative x 3. Symptoms were most likely [2-25] proctitis and associated ileus. 3. History of C. Diff - Recent diarrhea at reheab, C. difficile culture negative per report in rehab paperwork, remaining bacterial stool studies cancelled. On admission, was continued on PO Vancomycin. After worsening abdominal symptoms, he was started on IV Flagyl as well. Remained C. Diff negative throughout admission. The flagyl was stopped but we elected to continue the po vancomycin for the duration of the ceftazidine course. 4. Seizure disorder. Developed post-CVA per daughter. Continued phenobarbital during admission. 5. CHF. Most recent echocardiogram in our system is from [2117], with preserved systolic function and LVEF of 75%. 6. Hypervolemia - Mr. [Known lastname 34384] is ~10L positive for his hospital admission, diuresing as tolerated with IV Lasix. On day of discharge, he was recieving Lasix 40 mg IV BID with plans to diurese 2L in 24h period. He should continue to be diuresed with IV Lasix as tolerated. Medications on Admission: - Albuterol/ipratropium inhaler 8 puff Q6H - Chlorhexidine 5 ml TID swish & spit - Nystatin 5 mL [Hospital1 ] swish & spit - Phenobarbital 240 mg G-tube QHS - Tamsulosin 0.4 mg PO QHS - Vancomycin 125 mg PO QID - Acetaminophen 650 mg G-tube Q6H for pain or fever - Bisacodyl 5 mg PO daily PRN constipation - Senna 8.6 mg PO QHS PRN constipation - Bacitracin topical ointment apply daily Discharge Medications: 1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Continue for 2 weeks after completion of antibiotics. 2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day): swish and spit. 3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. 4. ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours): LAST DAY [5-11]. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for consitpation. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation Q4H (every 4 hours). 10. phenobarbital 20 mg/5 mL Elixir Sig: Sixty (60) mL PO HS (at bedtime): (dose =240mg qHS). 11. furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Tracheobronchmalacia Respiratory Failure Pneumonia Proctitis/Lower GI Bleed Atrial Fibrillation with Rapid Ventricular Response Hypernatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital after an elevtive procedure to place a new stent in your airway for treatment of tracheobronchomalacia. After the procedure you developed a pneumonia as well a low blood pressure. Your stent was removed and you were given antibiotics and supportive therapy with IV fluids. You also developed a lower GI bleed (blood per rectum). Surgery and Gastroenterology evaluated you and CT scan of your abdomen showed Proctitis (inflammation of the very distal bowel). You were treated empirically for C. Diff infection. You improved without intervention. You are being discharged to a long term facility for further care since you require intermittant time on the ventilator (at night). Weigh yourself every morning, [Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please arrange to see your outpatient physicians once you are discharged from the hospital.	[ "0389", "78552", "99592", "5845", "2760", "2875", "4280", "40390", "5859", "2859", "311", "V1582" ]
Admission Date: [2142-12-15] Discharge Date: [2143-1-1] Date of Birth: [2105-6-2] Sex: M Service: MEDICINE Allergies: Codeine / Zosyn Attending:[First Name3 (LF) 1148] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: NG tube placement PICC line placement Central line placement Intubation History of Present Illness: Mr. [Known lastname 1007] is a 37 year old male with history of idiopathic pancreatitis who presents from [Hospital 15405] with necrotizing pancreatitis. He initially presented on [12-13] with one day history of severe abdominal pain/LLQ pain/epigastric pain radiating to left scrotum. Also with nausea and dry heaves but no emesis. Went to ED for evaluation and found to have elevated amylase (424 --> 681) and lipase (1245 --> 1154). CT scan of abdomen demonstrated significant necrotizing pancreatitis with significant abnormal pleural fluid. Patient was hypotensive and was on dopamine intially but weaned off after recieving approximately 4L of IVF's over 2 days. He also become tachycardic to 170's and was treated with lopressor 5mg IV, repeated an unclear number of times. He also had a recurrent fever (Tm 105) and was hypoxia with O2 sats in low 90's on 6-8L high flow. He was seen by gastroenterology and treated with aldactone 50 [Hospital1 ] and lasix for ascites and to improve urine output. He had been receiving dilaudid 2-4 mg IV Q2H prn for pain. Because of the worsening CT scan on [12-15] and clinical deterioration, patient transferred to [Hospital1 18] for further management. Pt arrived on floor looking comfortable and without respiratory distress. Related no abdominal pain d/t pain meds. No chest pain, SOB, or other discomforts. + fevers, no chills. No URI sxs, no dysuria. Past Medical History: 1)Idiopathic Pancreatitis - Seen by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3315] in [2134] - First in [2130] after heavy ETOH, second [2131] after a car accident and light ETOH, another after fatty foods (not ETOH), another after ERCP (amylase range of 1800-[2135], pain relieved by brief hospitalization). - ERCP found a normal common bile duct and biliary system but was unable to cannulate the pancreatic duct. - MRCP with no pancreatic divisum ([2134]) - CF gene negative 2)Kidney Stones 3)GERD 4)UTI 5)Spinal stenosis s/p fusion in [2123] 6)HTN 7)Seasonal allergies 8)Ulnar nerve entrapment surgery in [2132] Social History: +tob, pt states no ETOH recently but told surgery that he drinks a 6pk of beer a day and told attending 1 br/day on occasion. no IVDU. lives at home with wife and 18mnth old child. Family History: Non-contributory Physical Exam: Gen: sleepy, arousable Vitals: 101.3, 141/83, 120, 20, 98% on 50% HEENT: PERRL, EOMI, anicteric sclera, MM dry, OP clear Neck: supple, no LAD, no thyromegaly Cardiac: tachy, regular, NL S1 and S2, no MRGs Lungs: CTAB post, no crackles Abd: distended, tense, tender in lower quadrants and epigastric, +ascites and dullness, no caput or spiders, no asterixis, no HSM Ext: warm, 2+ DP pulses, no C/C/E Neuro: CN III-XII intact, MAE, alert to person, time, but thought at [Hospital3 ] Pertinent Results: Laboratory results: [2142-12-16] 03:04AM BLOOD WBC-8.5 RBC-4.34* Hgb-13.1* Hct-38.0* MCV-88 MCH-30.2 MCHC-34.5 RDW-14.2 Plt Ct-149* [2143-1-1] 05:57AM BLOOD WBC-8.1 RBC-3.60* Hgb-10.6* Hct-31.9* MCV-89 MCH-29.4 MCHC-33.1 RDW-13.6 Plt Ct-473* [2142-12-16] 03:04AM BLOOD PT-13.5* PTT-36.1* INR(PT)-1.2* [2142-12-16] 03:04AM BLOOD Glucose-153* UreaN-15 Creat-0.5 Na-142 K-4.0 Cl-111* HCO3-27 AnGap-8 [2143-1-1] 05:57AM BLOOD Glucose-70 UreaN-13 Creat-0.4* Na-136 K-4.1 Cl-100 HCO3-28 AnGap-12 [2142-12-16] 03:04AM BLOOD ALT-28 AST-53* LD(LDH)-472* AlkPhos-51 Amylase-552* TotBili-0.7 [2143-1-1] 05:57AM BLOOD ALT-37 AST-22 AlkPhos-244* Amylase-127* TotBili-0.3 [2142-12-16] 03:04AM BLOOD Lipase-628* [2143-1-1] 05:57AM BLOOD Lipase-95* [2142-12-16] 03:04AM BLOOD Albumin-2.7* Calcium-7.4* Phos-1.0* Mg-1.9 [2143-1-1] 05:57AM BLOOD Calcium-8.6 Phos-4.2 [2142-12-18] 02:30AM BLOOD VitB12-1299* Folate-11.5 [2142-12-16] 08:44PM BLOOD Triglyc-238* CT scan abd/pelvis ([2141-12-15]): Severe pancreatitis, prominent areas of nonengancement are seen involving the pancreas suggestion possible necrotic changes (enhancement of head, protion of tail, patchy through body). No interval change in the extensive amount of fluid within the abdomen and pelvis. Increased amount of pleural fluid. Liver with fatty infiltration. Some minmal fatty sparing surrounding the gallbladder and gallbladder is minimally dilated. Low density foci throughout the spleen. One or two small stones in left kidney and rounded hyperdensity in right kidney d/t small cyst. Brief Hospital Course: Mr. [Known lastname 1007] is a 37 year old male with h/o pancreatitis who presents with necrotizing pancreatitis, now with delirium suspected [1-11] alcohol withdrawal, although pt and family deny alcohol use. 1)Necrotizing pancreatitis - 40% necrotized on admission CT scan to our institution, with preservation of pancreatic head and tail. Possible etiologies include ETOH, gallstones (none seen on admission CT scan), obstruction (ruled-out with RUQ u/s), hypertriglyceridemia (triglycerides only mildly elevated in 200s), hypercalcemia, drugs (unlikely; pt only taking atenolol at home), infection, and trauma (no history of trauma). Most likely ETOH, although patient and his family adamantly deny EtOH other than a drink at [Holiday ]. Repeat CT showed overall improved appearance of pancreas although there is some organization of pancreatic inflammation. He was initially kept NPO with NGT to suction. He subsequently received post-pyloric tube feeds while intubated, but pulled out his NGT following extubation. As pancreatic enzymes trended downwards and his clinical status improved, his diet was advanced. He also completed a 7d course of Meropenem for necrotizing pancreatitis. Surgery followed him closely throughout his hospital stay. 2)Fevers: Patient presented with persistent fevers throughout his hospital stay. Daily blood and urine cultures were unrevealing. Both pancreatitis and withdrawal can cause fever. Ruled out acalculous cholecystitis with RUQ US. Patient also presented with diarrhea, but c.diff was negative. He was empirically started on Flagyl and Zosyn but the latter was stopped due to development of a rash. 3)Delirium/? ETOH withdrawal: Per psychiatric evaluation and high benzodiazepine requirement, acute mental status changes likely secondary to EtOH withdrawal. Constellation of symptoms includes tachycardia, tremulousness, agitation, coupled with a history of recurrent pancreatitis. Head CT without intracranial abnormalities. He was placed on empiric thiamine, folate, and B12. The patient was intubated electively for airway protection since he required large doses of sedatives. At time of discharge his mental status had returned to baseline. 4)Respiratory: On admission, patient was tachypneic despite large doses of BZDs for withdrawal and as a result, was electively intubated. He was successfull extubated once his clinical status improved and his BZD requirement was decreased. Cxray showed large L pleural effusion, likely secondary to pancreatitis. 5)Hyperglycemia: Likely new onset diabetes secondary to necrosis of his pancreatic beta cells. Now with new insulin requirement > 100 units per day while on TPN. He was initially maintained on insulin gtt with increasing requirements but was transitioned to a sliding scale as his clinical status improved. He no longer required insulin at time of discharge. 6)HTN: Patient was started on low dose beta-blocker and was discharged on Atenolol. 7)FEN: Patient was initially maintained on TPN and tube feeds. Once he self d/c'ed his NGT his diet was slowly advanced with help of nutrition. At time of discharge patient was able to tolerate regular diet without any complications. Medications on Admission: Atenolol 50 mg PO QD Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Necrotizing pancreatitis Altered mental status Respiratory failure Hypertension Hyperglycemia Discharge Condition: Stable Discharge Instructions: 1)You are scheduled for an appointment with a gastroenterologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 174], for follow-up care for your pancreatitis: [2143-1-14] 8:20am 2)Please schedule a follow-up appointment with your PCP [Name Initial (PRE) 176] 1 week of your discharge from the hospital. 3)Please take all medications as listed in your discharge instructions. Your dose of Atenolol has been changed to 25mg once daily. 4)Please avoid high contents of fat and carbohydrates in your diet. 5)If you experience fevers, chills, sweats, abdominal pain, nausea, vomiting, chest pain, shortness of breath or any other concerning symptoms, please go to the Emergency Room or contact your PCP [Name Initial (PRE) 2227]. Followup Instructions: Provider: [First Name4 (NamePattern1) 1386] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2143-1-14] 8:20	[ "5119", "4280", "51881", "25000", "53081", "3051", "V5867" ]
Admission Date: [2165-7-29] Discharge Date: [2165-7-30] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 832] Chief Complaint: Vomiting, airway protection. Major Surgical or Invasive Procedure: 1. EGD 2. Intubation History of Present Illness: 88 yo male with history of HTN and gastric surgery with recent upper GI bleeding and known gastric bezoar who recently started having symptoms of epigastric discomfort and large volume emesis presented as an outpatient for EGD today for possible removal of gastric bezoar. Upon EGD, there was a large amount of residual fluid in stomach with evidence of pyloric stenosis. As a result, his symptoms were thought secondary to gastric outlet obstruction, and a pyloric stenosis dilatation was performed. He was intubated throughout the procedure. After the procedure, he vomiting large amount of fluid. An OGT was placed. He was felt to be a high risk for aspiration and was therefore admitted to the ICU for observation overnight. . On the floor, patient is intubated and sedated. . Review of systems: Unable to obtain. Past Medical History: Hypertension ?Prediabetic Gastrectomy with "[2-23]" removed and vagotomy for PUD Gastric bezoar UGIB [2-20] PUD s/p EGD with clipping H.pylori s/p antibiotics Hx SBO Hepatitis B infection - cleared, no hx cirrhosis Social History: Exercises six days per week, lives by himself. Careful with his diet. - Tobacco: None - Alcohol: Previously heavy drinker, now 1-2 beers/day. - Illicits: None Family History: Noncontributory. Physical Exam: Admission PE: Vitals: 94.6 48 96/53 12 100% on FiO2 50% Vent: 50% 12 500 5 on MMV General: Intubated, sedated, no acute distress, does not open eyes to verbal or noxious stimuli HEENT: Sclera anicteric, pupils constricted but symmetric, MMM, oropharynx clear, +OGT Neck: supple, JVP with respiratory variation, no LAD Lungs: Rhonchi at bases, right>left. CV: Bradycardic with regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, small midline abd incision well healed, soft, non-tender, non-distended, no rebound tenderness or guarding, no organomegaly GU: + foley draining yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge PE: VS: GEneral: HEENT: Neck: Lungs: CV: Abdomen: GU: Ext: Pertinent Results: Admission Labs: pH 7.40 pCO2 47 pO2 56 HCO3 30 BaseXS 2 Lactate:0.9 CBC: 5.4/11.9/33.4/171 MCV 95 N:69.5 L:22.1 M:5.9 E:2.0 Bas:0.4 Chem 7: 132/3.5/98/28/14/0.8<80 Chem 10: Ca: 8.5 Mg: 2.1 P: 3.6 PT: 14.2 PTT: 31.0 INR: 1.2 Micro: none Images: [2165-7-29] EGD: Large amounts of residual food was found in the stomach, could not be suctioned. The prepyloric area appeared edematous and friable. Pylorus was very tight and could not be traversed by scope. Multiple large capacity biopsies were obtained from prepyloric area. The pylorus was then dilated with 12-15mm CRE balloon with good result. Post dilation, the scope was passed to the duodenum with little resistance. Duodenum: Mucosa: Normal mucosa was noted. Impression: Normal mucosa in the esophagus. Large amount of food residual in the stomach. Pyloric stenosis s/p balloon dilation. friable swollen prepyloric gastric folds, biopsies. Normal mucosa in the duodenum. Pathology: [2165-7-29] pyloric stenosis biopsy pending Brief Hospital Course: 88 yo M with HTN, prior PUD s/p partial gastrectomy admitted with pyloric stenosis and gastric outlet obstruction. The patient presented after being found on work-up for vomiting to have a bezoar and pyloric stenosis. He underwent ERCP with findings of pre-pyloric friable and inflamed gastric mucosa. Biopsies of this area were taken. The stomach had large quantity residual liquids which could not be suctioned. Initially the endoscope could not be passed through the pylorus though after balloon dilatation, the scope passed easily into the duodenum. Post-procedure, the patient had vomiting. Out of concern for risk of aspiration, the patient was intubated. He was successfully extubated a few hours later. By the following morning, the patient was tolerating a full liquid diet without any nausea or vomiting and had normal oxygen saturation on room air. The patient will follow-up as scheduled with her primary care doctor [First Name (Titles) ] [Last Name (Titles) ]. He, his daughter and his primary care doctor were personally made aware of the pending biopsies - results can be obtained by calling Dr.[Name (NI) 2798] office at ([Telephone/Fax (1) 10532] in [11-1] days. There is concern for an underlying malignancy though scarring related to prior gastrectomy is possible. He will continue on her pre-admission PPI. The patient has chronic anemia, HLD and hypertension. He will follow-up with his primary care doctor for further care of these issues. Medications on Admission: Lisinopril 20mg daily Multivitamin 1 tab daily Omeprazole 20mg [Hospital1 ] Discharge Medications: Heparin 5000 units SC TID Pantoprazole 40 mg IV q24 Discharge Disposition: Home Discharge Diagnosis: Post-procedural vomiting Pyloric Stenosis Hyponatremia Hypertension Anemia Discharge Condition: Stable, extubated Discharge Instructions: You had an upper endoscopy to evaluate your stomach. You were found to have a narrowing of the outlet of the stomach, called pyloric stenosis. The gastroenterologists used a balloon to make the opening bigger. After the procedure, you vomited. We were worried that the vomit might travel into your lungs, so a tube was placed into your stomach to suction out the vomit and another tube was placed into your airways to protect your lungs. You did well on the ventilator and improved. You were extubated and sent to the floor. Followup Instructions: Follow-up with your [Hospital1 ] for further evaluation of pyloric stenosis.	[ "2761", "4019", "2724" ]
Admission Date: [2194-7-29] Discharge Date: [2194-10-31] Date of Birth: [2194-7-11] Sex: F Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: [Known lastname ] [Known lastname 8389] is the third born of triplets, former 1210 gram product of a 28 [1-2] week gestation pregnancy. Mother is a 38-year-old gravida I, para 0 woman. Pregnancy was achieved by in [Last Name (un) 5153] fertilization. Pregnancy was complicated by pre-term labor from 23 weeks. The mother was treated with betamethasone, magnesium sulfate, Indocin and nifedipine. Rupture of membranes occurred on the day of delivery, prompting delivery by cesarean section. Prenatal screens: Blood type O positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, group beta strep status unknown, rubella immune. This infant, third born of triplets, emerged with good cry, received blow-by oxygen and facial continuous positive airway pressure. Apgars were 7 at one minute and 8 at five minutes. She was admitted to the Neonatal Intensive Care Unit at [Hospital1 1444], stabilized, and transferred to [Hospital3 1810] on the day of birth. She was readmitted on day of life 18, [2194-7-29]. PHYSICAL EXAMINATION: Upon admission, premature, non-dysmorphic infant, anterior fontanel soft and open, clavicles and palate intact, positive red reflex bilaterally, grunting, flaring and retracting, requiring intubation. Symmetrical thorax. Heart rate regular, no murmur. Abdomen soft, nontender, three vessel cord, no hepatosplenomegaly. Genitalia normal female, patent anus, hips stable. Activity was appropriate, with reflexes and tone consistent with gestational age. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The infant was intubated shortly after birth and placed on ventilatory settings of peak inspiratory pressure of 24, over a positive end expiratory pressure of 5, intermittent mandatory ventilatory rate of 25, 100% oxygen. The infant was transferred to [Hospital3 1810], where she received a total of four doses of surfactant. She was readmitted to [Hospital1 69] on [2194-7-29] on nasal continuous positive airway pressure. She continued on that through day of life 23, when she was changed to nasal cannula oxygen. She remained in nasal cannula oxygen through day of life number 100, and has been in room air since [2194-10-19]. She was treated with Diuril for her chronic lung disease. She also was treated with caffeine for apnea of prematurity. The caffeine was discontinued on [2194-8-20]. The Diuril was discontinued on [2194-10-29]. At the time of this dictation, she is comfortable in room air, breathing in the 40s to 50s. 2. Cardiovascular: [Known lastname ] required treatment for presumed patent ductus arteriosus with indomethacin. She was also treated initially with dopamine for hypotension. Both issues resolved. She has maintained normal heart rates and blood pressures through the remainder of her admission. There are no murmurs audible at the time of discharge. 3. Fluids, electrolytes and nutrition: Enteral feedings were started in the first week of life and gradually advanced to full volume. [Known lastname ] has had multiple feeding problems, consisting of poor oral-motor skills and also gastroesophageal reflux. She was treated with Reglan and Zantac, which were discontinued on [2194-10-24] when she was changed over to the Enfamil AR formula. Her reflux has been improved, but she still is dependent upon nasogastric feeds. She is being transferred to [Hospital3 1810] for surgical placement of a percutaneous endogastric tube. Recent weight was 3.52 kg. [Known lastname 43897] electrolytes have remained within normal limits. She was treated with potassium chloride supplements while she was on the Diuril, and this has now been discontinued. 4. Infectious Disease: [Known lastname ] was treated presumptively for sepsis in the first week of life. Her only other infectious disease issue has been pseudomonas skin colonization. 5. Gastrointestinal: As previously noted, [Known lastname ] is having a surgically-placed percutaneous endogastric tube placed. 6. Hematology: [Known lastname ] is blood type A positive, Coombs negative. She has received two transfusions of packed red blood cells on [2194-7-29] and [2194-8-27]. Her most recent hematocrit was on [2194-10-23] and was 35.3%. 7. Neurology: [Known lastname ] had bilateral germinal matrix hemorrhages noted on ultrasounds at [Hospital3 1810]. A follow-up head ultrasound performed on [2194-8-14] showed resolving germinal matrix hemorrhages and normal ventricular size. 8. Sensory: Audiology: Hearing screening was performed with automated auditory brain stem responses. [Known lastname ] passed in both ears on [2194-9-16]. Ophthalmology: Initial eye examination was performed on [2194-8-13], showing immature retinas to Zone [Date Range 1105]. A follow-up examination two weeks later on [2194-8-27] showed mature retinas. Follow up is recommended at eight months of age. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Transferred to [Hospital3 1810] for surgery. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 43888], Pediatric Associates, [Street Address(2) 43892], [Location (un) 1887], [Numeric Identifier 43898], phone number [Telephone/Fax (1) 40227], fax number [Telephone/Fax (1) 43899]. CARE RECOMMENDATIONS: 1. Feedings: Nothing by mouth for on call for the operating room. When feeding, Enfamil AR 28 calories/ounce, 4 calories by median chain triglyceride oil. 2. Medications: Fer-in-[Male First Name (un) ] 0.3 cc by mouth once daily, 25 mg/ml dilution. 3. Car seat position screening not yet performed. 4. State newborn screening status: State screens have been sent on three occasions, [8-10], [8-20] and [2194-8-26]. All results are within normal limits. 5. Immunizations received: Initial hepatitis B vaccine, acellular pertussis/diphtheria/tetanus, hemophilus influenza, and injectable polio vaccine were administered on [2194-9-9]. The second hepatitis B vaccine was administered on [2194-10-14]. 6. Immunizations recommended: Synagis respiratory syncytial virus 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 gestation; (2) Born between 32 and 35 weeks, with plans for day care during respiratory syncytial virus 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 pre-term infants with chronic lung disease once they reach six months of age. Before this age, the family and other care givers should be considered for immunization against influenza to protect the infant. 7. Follow-up appointments: Ophthalmology at eight months of age. DISCHARGE DIAGNOSIS: 1. Prematurity at 28 2/7 weeks gestation 2. Triplet number three of triplet gestation 3. Respiratory distress syndrome 4. Suspicion for sepsis 5. Presumed patent ductus arteriosus 6. Apnea of prematurity 7. Anemia of prematurity 8. Gastroesophageal reflux 9. Chronic lung disease DR.[Last Name (STitle) 37692],[First Name3 (LF) 37693] 50-454 Dictated By:[Last Name (Titles) 37585] MEDQUIST36 D: [2194-10-30] 21:52 T: [2194-10-31] 00:00 JOB#: [Job Number 43900]	[ "53081", "V053" ]
Admission Date: [2152-4-15] Discharge Date: [2152-5-2] Date of Birth: [2077-4-6] Sex: F Service: MEDICINE Allergies: Penicillins / IV Dye, Iodine Containing Contrast Media / morphine Attending:[First Name3 (LF) 7591] Chief Complaint: transferred from outside hospital for concern of acute leukemia Major Surgical or Invasive Procedure: Bone marrow biopsy [2152-4-15] PICC Line placement and removal History of Present Illness: 75 year old woman with diabetes and h/o early stage breast cancer s/p lumpectomy, XRT, and tamoxifen x 5 years transferred to [Hospital1 18] for possible acute leukemia. In brief, she was in her usual state of excellent health until 1 month PTA when she developed a diarrheal illness (nonbloody) for a week with fevers, night sweats, and fatigue. She was seen by her PCP who prescribed her a short course of ciprofloxacin complicated by tendonitis. This diarrhea resolved on antibiotics but she had persistent nightly fevers and progressive fatigue. A week and a half ago, she again saw her PCP who felt she had sinusitis due to complaint of fatigue and HA. She was prescribed a course of azithromycin but did not improve. Prior to admission, she developed new sharp left flank pain and presented to [Hospital 1562] Hospital ED. Initial labs there were notable for a WBC of 62 with 45% blasts, LDH 1770, PLT 73, HCT 32, INR 1.1, PT 11.6, PTT 20.6, and FS of 400. In [2152-1-2], her WBC had been 8.8, Hct 44, PLT 329. She was given IVF and allopurinol 300 mg PO x 1, toradol for pain, and transferred to [Hospital1 18]. She also received diclofenac prior to labs for flank pain. At this time she is anxious about her new diagnosis but has no localizing complaints. She endorses un-quantified weight loss, night sweats x 1 month, nightly fevers x 1 month, and new left flank pain. She has no HA, vision changes, numbness, tingling, bleeding, bruising, or other complaints. Inital VS in ED were: 98.9 105 149/81 16 97%. She had no HA, vision changes, numbness, tingling, bleeding, bruising, or other complaints. Past Medical History: - Breast cancer, early stage, s/p lumpectomy and XRT in [2139], tamoxifen x 5 years, s/p R axillary LND - Diabetes - No h/o heart disease Social History: - Tobacco: Denies - Alcohol: Denies - Illicits: Denies - Occupation: Seamstress - Exposures: Denies - Social supports: Lives with husband Family History: - Mother: [Name (NI) ] cancer, + CAD - Father: [Name (NI) ] into his 90s - Daughter: Down's syndrome Physical Exam: Admission physical exam: VS: 99.0 105 144/80 20 98% on RA GEN: well-appearing elderly woman in NAD ECOG: 1 HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary LAD, no thyromegaly, no conjunctival pallor or petechiae on palate CV: RRR, no MRG PULM: CTAB b/l, no crackles or wheezes ABD: BS+, soft, tender LUQ, spleen is palpable; no hepatomegaly appreciated LIMBS: Mild 1+ pitting edema both ankles up to [1-4] of tibia. No clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown or bruises. NEURO: AAOx3, CN2-12 grossly intact, mm strength 5/5 b/l throughout . Discharge physical exam: 97.9, 152/86, 97, 20, 98% RA GEN: well-appearing elderly woman in NAD HEENT: MMM, no OP lesions CV: RRR, no MRG PULM: CTAB b/l, no crackles or wheezes ABD: BS+, soft, palpable spleen; no hepatomegaly LIMBS: Mild 1+ pitting edema both ankles up to [1-4] of tibia, mildly worse on right (stable) SKIN: No rashes or skin breakdown or bruises. Pertinent Results: Admission labs: =============== [2152-4-15] 01:30PM BLOOD WBC-63.2* RBC-3.72* Hgb-10.3* Hct-30.1* MCV-81* MCH-27.8 MCHC-34.3 RDW-17.1* Plt Ct-86* [2152-4-15] 01:30PM BLOOD Neuts-9* Bands-4 Lymphs-11* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* Other-75* [2152-4-15] 09:13PM BLOOD PT-12.6* PTT-22.8* INR(PT)-1.2* [2152-4-15] 09:13PM BLOOD Fibrino-244 [2152-4-19] 04:00AM BLOOD Gran Ct-2920 [2152-4-15] 01:30PM BLOOD Glucose-287* UreaN-15 Creat-0.7 Na-137 K-3.2* Cl-100 HCO3-22 AnGap-18 [2152-4-15] 01:30PM BLOOD ALT-27 AST-35 LD(LDH)-1772* AlkPhos-83 TotBili-0.5 [2152-4-15] 01:30PM BLOOD Lipase-18 [2152-4-15] 01:30PM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.9 Mg-1.7 UricAcd-7.5* [2152-4-18] 04:01AM BLOOD %HbA1c-10.0* eAG-240* [2152-4-18] 11:51AM BLOOD Acetone-NEGATIVE [2152-4-17] 04:05AM BLOOD Type-[Last Name (un) ] pH-7.44 [2152-4-15] 06:57PM BLOOD BCR/ABL GENE REARRANGEMENT, QUANTITATIVE PCR, CELL-BASED-Test POSITIVE Imaging: ======== [2152-4-15] Abdominal US: IMPRESSION: 1. Splenomegaly measuring up to 14.5 cm. No free fluid. 2. Status post cholecystectomy. Bone marrow biopsy: =================== SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: PRECURSOR B-ACUTE LYMPHOBLASTIC LEUKEMIA MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The smear is adequate for evaluation. Red blood cells are decreased in number and show moderate to severe anisocytosis and mild poikilocytosis. Spherocytes, microcytes and rare schistocytes are seen. Polychromatophils are frequently seen, and rare nucleated RBCs are also seen The white blood cell count appears increased and dominated by an immature blast population, that has a high N:C ratio, bluish, scant, agranular, vacuolated cytoplasm, irregular nuclear contours and sieve like chromatin with 2-3 nucleoli. Platelet count appears decreased. Differential shows 72 % blasts. 11% neutrophils, 5% bands, 3% monocytes, 7% lymphocytes, 1% eosinophils, 0% basophils; 1% nRBC. Aspirate Smear: The aspirate material is hemodiluted. Touch preparations are generous and are used for bone marrow aspirate descriptions. The aspirate material is dominated by immature lymphoblasts as described in the peripheral blood. Myeloid and erythroid cells are rare and when seen exhibit normal maturation. Megakaryocytes are rare to absent. A 500 cell differential shows: 72% Blasts, 2 % Promyelocytes, 1% Myelocytes, 3% Metamyelocytes, 4% Bands/Neutrophils, 1% Plasma cells, 6% Lymphocytes, 11% Erythroid. Clot Section and Biopsy Slides: The core biopsy material is adequate for evaluation. It consists of a marrow with a cellularity of 90%. The dominant cell population (80-90%) is immature blasts as described above. M:E ratio estimate in the sparse bone marrow hematopoietic tissue is normal. Erythroid and myeloid precursors within this sparse cell population mature normally. Megakaryocytes are present and are normal. ADDITIONAL STUDIES: Flow cytometry: Pre B-ALL. Cytogenetics: [Location (un) 5622] chromosome positive. Discharge labs: =============== [2152-5-2] 05:25AM BLOOD WBC-4.0# RBC-2.71* Hgb-8.5* Hct-25.0* MCV-92 MCH-31.5 MCHC-34.1 RDW-23.1* Plt Ct-43* [2152-5-2] 05:25AM BLOOD Neuts-41* Bands-9* Lymphs-46* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [2152-5-2] 05:25AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL [2152-5-2] 05:25AM BLOOD PT-10.3 PTT-22.7* INR(PT)-0.9 [2152-4-27] 05:30AM BLOOD Fibrino-118* [2152-5-2] 05:25AM BLOOD Gran Ct-[2140]* [2152-5-2] 05:25AM BLOOD Glucose-114* UreaN-25* Creat-0.6 Na-140 K-3.6 Cl-104 HCO3-28 AnGap-12 [2152-5-2] 05:25AM BLOOD ALT-44* AST-16 LD(LDH)-181 AlkPhos-52 TotBili-0.8 [2152-5-2] 05:25AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.0 UricAcd-2.8 Brief Hospital Course: 75 year old pleasant woman with diabetes and h/o early stage breast cancer s/p lumpectomy, XRT, and tamoxifen x 5 years transferred to [Hospital1 18] due to concern for leukemia and found to have precursor B-ALL ([Location (un) ] chromosome positive). Her stay was complicated by hyperglycemia and hypertension. She required to be in the ICU for insulin drip for hyperglycemia in setting of dexamethasone in addition to hypertension for which antihypertensives were added/uptitrated. She was discharged in stable condition on prednisone and dasatinib with close follow up. # Precursor B-ALL [Initials (NamePattern4) ] [Last Name (NamePattern4) 5622] Chromosome: Initial concern for leukemia based on peripheral blasts. Per bone marrow and oncological studies, she was found to have precursor B-ALL with [Location (un) 5622] Chromosome positive. Initially she was on aggressive IV fluids, allopurinol and hydroxyurea. Hydroxyurea was subsequently dsicontinued. She received Prednisone 110 mg daily (day 1 [4-16]) in addition to Dasatinib (BCR-abl inhibitor) 70 mg twice daily (day 1 [4-21]). EKG was monitored and there was no QTc prolongation throughout hospital course and multiple periodic EKGs. QTc prior to discharge was 392 on [2152-4-28]. Omeprazole 40 mg daily was started in the setting of taking steroids in house but this was switched to randitine on discharge because ranitidine is less potent than PPI and acid suppression can inhibit dasatinib absorption. Would consider starting PCP prophylaxis as outpatient if indicated. She will continue dasatinib and prednisone and f/u with Dr. [Last Name (STitle) 410]. She was on Day 16/24 high dose prednisone course and will taper as an outpatient. # DM-2: exacerbated in the setting of steroid therapy with underlying diabetes. HgbA1c 10% reflects poor diabetic control prior to admission. Her BG went up to 600's requiring her to be in the ICU for insulin drip. This was gradually switched to NPH and standing humalog regimen in addition to Insulin sliding scale. She developed hypoglycemia down to 40's and 60's on 2 occasions which were symptomatic and one drop to 60s that was asymptomatic. Per patient she did not have hypoglycemia previously. Insulin regimen was modified. Throughout her stay [Last Name (un) ] was aware and involved in the care provided to the patient. They made several adjustments to her regimen to avoid AM hypoglycemia and provide best control at home without the use of a sliding scale. She was discharged on insulin NPH 70/30 @ 35 units qAM, metformin 500mg po BID with breakfast and dinner, glyburide 10mg with breakfast and 5mg with dinner, and no sliding scale. She will have a follow up with [Hospital ] clinic as outpatient for further titration. # Hypertension - BP was elevated as high as 190s, Likely [2-3] steroid use. Responded well to 100mg x1 labetalol while in the ICU. Was started on labetalol 100mg TID. Probably can stop once steroids are stopped. Labetalol was uptitrated to 200 mg [Hospital1 ] with better control. Also, was started on amlodipine 5 mg daily which was uptitrated to 10 mg daily. She remained well-controlled with SBP 120-140s on this regimen with the exception of one evening where she jumped to SBP 180s. This was thought to be [2-3] volume overload, as she was 5 lbs up from admission, so she was given additional dose of labetalol as well as lasix after which pressures improved to 130-150s. She should cont to follow as an outpatient. # TLS: Was initially managed by IVF and allopurinol. Her LDH and uric acid gradually down trended. She received a few units of cryoprecipitate for fibrinogen < 100. Fibrinogen was stable at low 100-130's after that. No recurrence of this, so she was discharged without allopurinol. # Thrombocytopenia ?????? No active signs of bleeding, no abrupt Hct changes. Trended down from chemo but never required a transfusion (transfusion threshold was <10K). Lowest count was 12. At discharge, she had been in upper 20s-40s for several days. # anemia: likely [2-3] disease and subsequent treatment. She received one unit PRBC early on in hospitalization after which she was stable. Prior to discharge, she was given a 2nd unit PRBC for a Hct 22.3 even though she was above the transfusion threshold in anticipation of sending her home so she would have some room to drop in the event that her counts decreased. # Hypofibrinogenemia: pt received 3u total cryprecipitate during her stay. INR wnl. fibrinogen remained stable after that. # Elevated liver enzymes: could be medication effect, possibly aztreonam, which she was on from [Date range (1) 30278] for neutropenic fever. Liver US [4-15] was normal. LFT's trended down and were normal at the time of d/c with the exception of ALT 44. # neutropenic Fever: [4-15] developed fever in setting of neutropenia and aztreonam was started. no growth on blood cultures. urine culture showed mixed flora. Portable CXR didn't reveal pneumonia. aztreonam was stopped on [4-22] and she subsequently remained afebrile. # L-sided abdominal pain: Likely [2-3] splenomegaly from ALL. Relieved with low dose oxycodone prn # H/o breast CA: early stage breast cancer s/p lumpectomy, XRT, right sided LND and tamoxifen x 5 years. Avoided use of right arm for lines. Transitional issues: --If remains hypertensive after discontinuation of steroids, consider switching anti-hypertensives to ACEI --follow up with [Last Name (un) ] for diabetic management --follow up with [Doctor Last Name 410] and have blood counts checked; give neupogen or transfuse if indicated --taper steroids starting [2152-5-10] --if leukemia returning, consider stopping ranitidine because it can decrease effect of dasatinib Medications on Admission: Glyburide 5mg daily Metformin 500mg daily (finished 4/5 days of z-pak PTA) Discharge Medications: 1. Glucometer: 1 glucometer for blood sugar measurement at home Diagnosis: Type 2 diabetes mellitus, steroid therapy; 250.00 2. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 4. glyburide 5 mg Tablet Sig: as directed Tablet PO BID (2 times a day): Take 10mg (two tabs) in AM with breakfast and 5mg (one tab) in PM with dinner. . Disp:90 Tablet(s) Refills:0 5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please take with breakfast and dinner. . Disp:60 Tablet(s) Refills:0 6. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Thirty Five (35) units Subcutaneous qAM. Disp:1000 units Refills:0 7. prednisone 10 mg Tablet Sig: Eleven (11) Tablet PO DAILY (Daily): taper as directed by your hematologist. Disp:3300 Tablet(s) Refills:0 8. dasatinib 70 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. FreeStyle Test Strip Sig: One (1) strip Miscellaneous QACHS: Dx Code: 250.00. Disp:120 strips Refills:0 10. FreeStyle Lancets Misc Sig: One (1) lancet Miscellaneous QACHS: Dx 250.00. Disp:120 lancets Refills:0 11. 0.5mL syringe, disposable, with 31 gauge needle Sig: one syringe daily for insulin administration; Dispense # 30 syringes with needles; DIAGNOSIS: Type 2 diabetes, steroid therapy; 250.00 12. ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA Discharge Diagnosis: Precursor B-Acute Lymphoblastic Leukemia, [Location (un) 5622] chromosome positive Tumor lysis Diabetes Hypertension Anemia Thrombocytopenia Hypofibrinogenemia Slightly elevated liver enzymes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [Known lastname 3776], It was a great pleasure taking care of you as your doctor. As you know you were transferred from outside hospital to [Hospital1 18] given the concern for acute leukemia. During your stay, your received steroids and a chemotherapy pill called Dasatinib. We were checking your blood frequently for tumor lysis which was managed by IV fluids and allopurinol. In the setting of your underlying diabetes, prednisone raised your blood glucose so high that it required you to stay in the ICU for insulin drip which was transitioned to insulin regimen. Also, your blood pressure was high and we started you on anti-hypertensive agents, amlodipine and labetalol. Your liver enzymes were slightly elevated, most likely a medication side effect. They were down-trending and improving during your stay. We made the following changes in your medication list: - Please START amlodipine 10 mg daily - Please START labetalol 200 mg twice daily - Please START dasatinib 70 mg twice daily - Please START prednisone 110 mg daily - Please START INSULIN 70/30, 35 units every morning - Please start Metformin 500mg twice a day with breakfast and dinner - Please start glyburide 10mg with breakfast and 5mg with dinner - please start ranitidine 75mg twice a day Please follow with your appointment as illustrated below. Followup Instructions: Department: BMT/ONCOLOGY UNIT When: THURSDAY [2152-5-4] at 11:30 AM [Telephone/Fax (1) 447] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: Main Garage Department: HEMATOLOGY/BMT When: MONDAY [2152-5-8] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 3749], MD [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: BMT CHAIRS & ROOMS When: MONDAY [2152-5-8] at 10:00 AM You should also follow up withe [Hospital ] Clinic next week. An appointment was requested for you and the clinic is working on this. They should call you with the time/date for your appointment, but if you do not hear from them by the end of the day, please call [Doctor First Name ] at [Telephone/Fax (1) 25521] to ensure you have been scheduled.	[ "4019", "2875" ]
Admission Date: [2120-10-18] Discharge Date: [2120-10-28] Date of Birth: [2059-5-7] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: DOE Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD, SVG->OM, PDA) [10-22] History of Present Illness: 61 yo M with 1 month of progressive DOE with vague chest discomfort with radiation to neck. Cath at [Hospital3 ] with 3VD, transferred for CABG. Past Medical History: HTN, dyslipidemia, GERD, BPH Social History: lives with wife quit tobacco 16 years ago denies eoth Family History: father with sudden cardiac death Physical Exam: HR 55 RR 18 BP right 120/75 NAD Lungs CTAB CV RRR Abdomen soft/NT/ND Extrem warm, no edema No carotid bruits Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 76034] (Complete) Done [2120-10-22] at 9:36:35 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. Division of Cardiothoracic [Doctor First Name ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2059-5-7] Age (years): 61 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Chest pain. Coronary artery disease. Hypertension. ICD-9 Codes: 402.90, 786.51, 440.0 Test Information Date/Time: [2120-10-22] at 09:36 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5209], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW4-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aortic Valve - Peak Velocity: 3.0 m/sec <= 2.0 m/sec Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. Dynamic interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild global LV hypokinesis. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with 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. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. Conclusions PRE-CPB:1. The left atrium is normal in size. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 50 %). The anteroapical wall is hypokinetic. 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. 7. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 8. The tricuspid valve leaflets are mildly thickened. 9. There is no pericardial effusion. POST-CPB: On infusion of nitroglycerine. Preserved LV systolic function post-cpb. LVEF now 50% with anteroapical hypokinesis.. Normal RV systolic function. MR remains trace. RADIOLOGY Final Report CHEST (PORTABLE AP) [2120-10-24] 11:22 AM CHEST (PORTABLE AP) Reason: evaluate pneumo s/p chest tube removal [Hospital 93] MEDICAL CONDITION: 61 year old man s/p CABGx3 REASON FOR THIS EXAMINATION: evaluate pneumo s/p chest tube removal HISTORY: Chest tube removal, to evaluate for pneumothorax. FINDINGS: In comparison with the study of [10-22], the chest tube, Swan-Ganz catheter, endotracheal tube, and nasogastric tubes have all been removed. No evidence of pneumothorax. Residual atelectatic changes seen at the left base. DR. [First Name8 (NamePattern2) 1569] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11006] Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2120-10-28] 06:05AM 8.8 3.24 10.3* 29.3* 90 31.6 35.0 13.8 362 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2120-10-28] 06:05AM 98 21* 1.3* 138 4.5 104 25 14 Brief Hospital Course: Mr. [Known lastname ] remained on a heparin drip while awaiting plavix washout. He was taken to the operating room on [2120-10-22] where he underwent a CABG x 3. He was transferred to the ICU in critical but stable condition. He was extubated the morning of POD #1. He was transferred to the floor later on POD #1. His chest tubes and wires were d/c'd. He developed abdominal distention and general surgery was consulted. He had a large amount of stool on KUB and had a vigorous bowel regimen which was successful. He was discharged to home in stable condition on POD#6. Medications on Admission: lipitor 40, lisinopril 40, norvasc 10, clonidine 0.2 TID, flomax, proscar 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. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:0 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 2 weeks. Disp:28 Capsule, Sustained Release(s) Refills:0 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4hrs as needed. Disp:50 Tablet(s) Refills:0 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:[2112] ML(s) Refills:0 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO three times a day. Disp:135 Tablet Sustained Release 24 hr(s) Refills:2 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:14 Tablet(s) Refills:0 13. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] vna Discharge Diagnosis: CAD now s/p CABG PMH:HTN, dyslipidemia, GERD, BPH Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [Last Name (STitle) ] 2 weeks Dr. [Last Name (STitle) 76035] 2 weeks Dr. [Last Name (STitle) ] 4 weeks Completed by:[2120-10-29]	[ "41401", "4019", "53081", "2720" ]
Admission Date: [2171-4-23] Discharge Date: [2171-4-27] Date of Birth: [2171-4-23] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: [Known lastname 29843] [Known lastname 34834] is a former 2.12 kg product of a 35-6/7 week gestation pregnancy born to a 38-year-old G2 P1 now 2 woman. Prenatal screens: Blood type O positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group B Strep status unknown. The pregnancy was uncomplicated until the day of delivery when the mother noted decreased fetal movement. She was evaluated with a biophysical profile, which was [4-11]. She was taken to cesarean section for nonreassuring fetal status. Rupture of membranes occurred at delivery and with clear fluid. There was no maternal fever. The infant emerged with some tone and respirations. Apgars were 6 at 1 minute and 8 at 5 minutes. He was initially watched in the Labor and Delivery suite. A one hour glucose was 30 mg/dl, and he was also noted to have a low temperature. He was admitted to the Neonatal Intensive Care Unit for further observation and treatment. PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 2.12 kg, 25th percentile, length 17.5", 25th percentile, head circumference 34 cm, 25th percentile, heart rate 142, respiratory rate 52. General: Normocephalic, nondysmorphic preterm male in room air. Head, eyes, ears, nose, and throat: Anterior fontanel open. Palate intact. Red reflex present bilaterally. Symmetric facial features. Neck is supple. Chest: Lungs are clear to auscultation bilaterally. Cardiovascular: Regular, rate, and rhythm, no murmurs, rubs, or gallops. Abdomen is soft with active bowel sounds, no masses or distention, three vessel cord. Spine: Midline, no sacral dimple or hair [Hospital1 ]. Hips stable. Clavicles intact. Anus patent. Neurologic: Good tone. Moved all extremities. Normal suck and gag reflexes. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: Infant required nasal cannula O2 briefly, and had weaned back into room air on day of life #1. His respirations remained easy in the 40s to 50s. He did not have any episodes of spontaneous of apnea and bradycardia. 2. Cardiovascular: No murmurs were noted. Initial blood pressure had a mean of 31 mmHg. Normal saline bolus was administered with resolution of the hypotension. 3. Fluids, electrolytes, and nutrition: Infant was initially NPO, maintained on 10% dextrose. Initial whole blood glucoses were 25-47. He received boluses of D10 and an infusion at 80 cc/kg/day. By day of life #1, his glucoses had stabilized and enteral feedings were started. He breast-fed or took Enfamil 20 adlib. He had adequate urine and stool output. Weight on the day of transfer is 2.145 kg. Serum electrolytes on day of life #1 had a sodium of 134, potassium of 3.4, chloride of 96, and a total CO2 of 25. 4. Infectious disease: Due to the unknown beta Strep status, and the initial presentation with hypoglycemia and respiratory distress, infant was evaluated for sepsis. A white blood cell count was 22,200 with a differential of 32% polymorphonuclear cells and 5% band neutrophils. A blood culture was obtained, and intravenous ampicillin and gentamicin were started. The blood culture was no growth at 48 hours, and the antibiotics were discontinued. 5. Hematological: Hematocrit at birth was 49.9%. Infant did not require any transfusions of blood products. 6. Gastrointestinal: Infant required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life #3 with a total of 11.1/0.3 mg/dl with an indirect of 10.8 mg/dl. Phototherapy was continued for approximately 36 hours. Bilirubin prior to discharge to the newborn nursery was a total of 10.1/0.3 with an indirect of 9.8. Plan was to recheck another rebound bilirubin at 6 a.m. on [2171-4-28]. 7. Neurology: Infant maintained a normal neurological exam during admission, and there are no neurological concerns at the time of discharge. Sensory: Audiology: Hearing screening was performed automated auditory brain stem responses. Infant passed in both ears. 8. Psychosocial: Parents were very involved and visited often during infant's admission in the Neonatal Intensive Care Unit. Mother was breast-feeding comfortably. CONDITION ON TRANSFER: Good. TRANSFER DISPOSITION: To the newborn nursery for continuing care. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Street Address(1) ] Pediatrics, [Location (un) 40647], [Location (un) 5176], [Numeric Identifier 55215], phone number [Telephone/Fax (1) 37376]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feedings: Adlib breast-feeding with supplemental Enfamil 20 if needed. 2. No medications. 3. Car seat position screening was performed. Infant was observed for 90 minutes in his car seat without any evidence of bradycardia or oxygen desaturation. 4. State Newborn Screen was sent on [2171-4-26] with no notification of abnormal results to date. 5. Immunizations received: Hepatitis B vaccine was administered on [2171-4-27]. 6. Immunizations recommended: 1. Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1) Born at less than 32 weeks, 2) born between 32 and 35 weeks with two of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3) with chronic lung disease. 2. 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. DISCHARGE DIAGNOSES: 1. Prematurity at 35-6/7 weeks gestation. 2. Suspicion for sepsis ruled out. 3. Unconjugated hyperbilirubinemia. Reviewed By: [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36250] Dictated By:[Last Name (Titles) 37548] MEDQUIST36 D: [2171-4-28] 20:03 T: [2171-4-29] 05:03 JOB#: [Job Number 56296]	[ "7742", "V053" ]
Admission Date: [2156-4-20] Discharge Date: [2156-5-6] Date of Birth: [2110-1-10] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5341] Chief Complaint: Elevated intracranial pressure Major Surgical or Invasive Procedure: VP shunt History of Present Illness: This is a 46 y/o M with h/o metastatic melanoma s/p C&D, radiation and on [Doctor Last Name 1819] study of DTIC plus or minus sorafenib who was admitted electively for a VPS placement ([2156-4-20]). Procedure went well without complications. About 48 hours later, patient decompensated and the CT scan showed multiple areas of hemorrahge thorughout the brain. After Family meeting with Hem onc, neurosurgery and Neurology it was decided that given his youth they will press ahead with radiation if his clinical status and CT scans were stable. If CT scans showed significant hemorrhage, further aggressive treatment would be stopped. Patient was trasfered to NSICU on [4-23] for IV BP management. He developed SIADH. On [4-24] patient was only arousable to sternal rub per neurology notes. It was felt to be a result of peak edema from his bleed on [4-21]. Today, apparently patient has been more arousable to voice, talking and moving all 4 extremities. Patient transfered to [Hospital Unit Name 26481] for brain radiation in the AM. Plan for 10 sessions. Past Medical History: Oncologic History Melanoma [Initials (NamePattern4) 10834] [Last Name (NamePattern4) ] level dx in [2142] - right lateral thigh. [5-5] Resection of inguinal mass that showed evidence of melanoma and positive lymph nodes and extracapillary extention. Bronchoscopy with biopsy + for metastatic melanoma on lung nodules. [8-4]: Started Chemotherapy with clinical trial C1 DTIC +/- SORAFENIB [1-/2156]: visual disturbances. MRI right occipital small lesion. [2-/2156]: Prior to Cyberknife procedure- b imaging showed bleed 3x3 cm. Resected on [2-12]/[2156]. [3-8]: cyberknife to resection cavity. [2156-4-14]: Headaches, N/V x 2 3 days. LP OP of 32 cm H2o, removed 30 cc. cytology confirmed presence of malignant cell. Past Medical History: Metastatic Melanoma as above Left shoulder surgery Arthoscopic surgery on left knee Social History: From past d/c summary: "He has a bachelor's degree. He is a systems administrator. He is single. He has smoked on and off for 20 years, about two to five cigarettes a day. He drinks about anywhere from zero to five drinks a week, and he denies any recreational drug use. Strong family support." Family History: From past d/c summary: "His mother is alive at 86 with breast cancer. His father died at 82 of perhaps a melanoma related death although this is uncertain, and his brother is 58 and does not have any medical conditions that he is aware of." Physical Exam: On arrival to [Hospital Unit Name 153]: T 98 BP 150 /70 HR 102 RR 17 Sats 97 % RA General: Patient in non apparent distress, somnolent but arousable. HEENT: No JVD, no lymphadenopathy, scalp wound covered- clean PEERLA CV: RRR, s1-s2 normal, tachycardic. Lungs: Clear to auscultation bilaterally Abdomen: BS+, soft, non tender, non distended. Surgical wound clean Extremities: No peripheral edema, distal pulses strong bilaterally. Neuro: Alert, oriented to name, no to place or date. Moving 4 extremities spontaneously. Cranial nerves- grossly intact, mouth and tongue in midline. Face symmetric, no dysarthria. Bilaterall upgoing bilaterally, DTR +/++++ Pertinent Results: [2156-4-20] CT head: 1. Interval ventriculoperitoneal shunt catheter placement. 2. Interval subarachnoid hemorrhage, as described. While this subarachnoid hemorrhage likely relates to that procedure, hemorrhage related to underlying leptomeningeal disease in this melanoma patient cannot be entirely excluded. Close followup is recommended. . [2156-4-22] CT head: IMPRESSION: Interval development of several parenchymal hemorrhages compared to two days previous. Subarachnoid hemorrhage unchanged. There is interval development of mass effect on the right lateral ventricle. . [4-23], [4-24], [4-26], [4-27], [5-1] CT head Scans: No significant interval change. . [2156-4-25]: Chest X ray INDICATION: Question aspiration event. Heart size remains normal. There is stable mediastinal lymphadenopathy in the aorticopulmonary window. The lungs demonstrate no focal areas of consolidation to suggest the presence of aspiration or evolving pneumonia. . [2156-4-28] ECHO: Mild left ventricular cavity enlargement with preserved global and regional biventricular systolic function. No valvular pathology or pathologic flow identified. . [2156-5-2] RUQ US: Limited right upper quadrant study. No evidence of stones, gallbladder wall thickening, or pericholecystic fluid. No evidence of acute cholecystitis. . [4-24], [4-25], [4-26], [4-30], [5-1], [5-2], [5-4] CXR: evidence of atalectasis, no consolidations. . [2156-5-3] CT L spine: 1. No CT evidence of osseous or epidural metastatic disease. Please refer to the follow-up lumbar spine MRI for evaluation of intrathecal disease. 2. L5/S1: Degenerative disk disease and endplate changes, with disk bulge, endplate and facet joint osteophytes resulting in neural foraminal stenosis and possible exiting nerve root impingement. 3. Possible free fluid in the pelvis. . [2156-5-3] MRI L spine: 1. Diffuse thickening of the cauda equina from L1 through S1 levels which enhances following gadolinium administration and is highly suggestive of metastatic disease involving the entire cauda equina. There is also thickening of the nerve roots individually seen within the thecal sac. 2. Degenerative changes seen at L5-S1 level with small central disc protrusion and moderate stenosis of the foramina. 3. Large degenerative Schmorl's node involving the superior endplate of L1. 4. Increased T2 signal seen on sagittal images involving the lower thoracic cord. Correlation with gadolinium-enhanced MRI of the thoracic spine would be recommended. 5. The findings are consistent with diffuse metastatic disease most likely from metastatic melanoma involving the cauda equina. Correlation with CSF findings would be recommended with follow-up. Brief Hospital Course: Mr. [Known lastname 61665] was admitted [2156-4-11] for elective placement of VP shunt to relieve elevated intracranial pressure caused by metastatic melanoma and it's treatment. Following placement of the shunt, he developed multiple areas of intracranial hemorrhage with resulting elevation of his intracranial pressure. He was started on Mannitol and dexamethasone, and transferred to the [Hospital Unit Name 153] to receive palliative whole brain radiation. Initially his [Hospital Unit Name ] status was alert, agitated, disoriented at times. Shortly after transfer to the [Hospital Unit Name 153] he became less responsive. He was also spiking fevers. Given concern for possible shunt infection he was treated empirically with vancomycin. He continued to spike through this, and was started on ceftriaxone as well for broader gram negative and anaerobe coverage. He began whole brain XRT, and tolerated 5 treatments well. However, during this time he had an episode of desaturation, hypotension, fever, and tachycardia. He was intubated for airway protection, and his antibiotic coverage broadened with flagyl as he was thought to be septic, with possible aspiration pneumonia. His antibiotics were subsequently changed to vanco and zosyn to provide broader coverage including psudomonas. He was successfully extubated after 48 hours. Throughout this he was pan-cultured multiple times, with no clear source of infection identified. He did have sparse growth of coag + staph on one sputum culture, but no other positive cultures. He was subsequently afebrile. . Shortly after extubation, Mr. [Known lastname 61665] [Last Name (Titles) ] status improved dramatically: he was much more alert, answering questions, but still confused. Unfortunately his neurological exam also began to change around this time. He was no longer moving his lower extremities, with no reflexes, and no withdrawal to pain. He also had diminished rectal tone. Emergent CT was unrevealing, so an MRI was performed. This showed extensive tumor involvement of his entire cauda equina. The case was discussed with neuro-oncology, oncology, neuro, and it was felt that there was no possible treatment. A family meeting was held with Mr. [Known lastname 61665] Oncology and ICU doctors, his brother, and some close family friends to discuss his poor prognosis, and clarify goals of care. It was decided to change his code status to DNR/DNI. . He was tranfer to the floor with the goal of weanign fo his manitol to attempt to send him home with hospice or to a hospice facility. On the floor, patient became more somnolent and also his respiratory stauts became very tenous. He started having increased work of brathing, chest x ray show a new left lower lobe consolidation that was concerning for aspiration. After talking with family members, they re-confirm goals of care and patient's goal of care was directed towards confort. Morphine dripped was started for air hunger and patient past away peacefully with family by his side. is to continue current medical treatments at this time, with the goal of comfort. He was then transferred to the oncologic service for weaning of his mannitol to attempt to send him home with hospice or to a hospice facility. Medications on Admission: Keppra 1000 [Hospital1 ], Sorafenib 200 [Hospital1 ], DTIC every 3 weeks and ativan PRN. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a Completed by:[2156-5-11]	[ "51881", "0389", "99592", "4019" ]
Admission Date: [2173-2-24] Discharge Date: [2173-2-26] Date of Birth: [2109-12-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7055] Chief Complaint: CC: CP and SOB Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: HPI: 63 yo M with h/o HTN, HL, CVA in [2157], MI in [2157], [2167] and [2168] as well as CABGx4 in [2167] who underwent routine stress testing in [2172-7-13] which was significant for ischemia. He was asymptomatic at the time and chose to postpone catheterization. Over the past 3 months, he has reported progressively worsening achy chest pain that radiates into both shoulders and is associated with SOB, but not nausea, diaphoresis or palpitations. The symptoms develop after walking for 10 minutes, sooner if he walks too quickly, and initially resolved with rest over 10-15 minutes. Recently, the chest pain has become more frequent ([12-14] x per day), and is no longer relieved with rest, but requires [12-14] nitros. As a result of these symptoms, he presented for cath on [2173-1-20] at [Location (un) 20338] which showed LAD 60% proximal stenosis, RCA diffusely diseased with 90% discrete PDA. LIMA-Diag occluded, SVG-LAD occluded, radial graft-OM 40-50% stenosis, SVG-RCA occluded. He was subsequently transferred to [Hospital1 18] for intervention. R heart cath showed RA mean 8, PCWP 9. L heart cath showed serial 90% lesions in a tortuous vessel with the PLB /PDA having origin 90% lesions. He received 2 Cypher stents to the proximal RCA and a Cypher stent to the distal PDA with occlusion of the PLB and rescue angioplasty. In the process, the PDA was perforated with extravasation of dye, likely into the myocardium. A stat TTE was ordered which showed no evidence of pericardial effusion. He was subsequently sent to the CCU for monitoring. On admission to the CCU, he was hypertensive with SBP in 170s. He was started on a NTG drip with drop in SBP to 80s and HR to 40s. He received 0.5 mg atropine and bolus 250 cc NS with hemodynamic stabilization. The interventional fellow was present during the episode of hypotension and bradycardia. ROS: Pt denies PND, orthopnea, edema, lightheadedness Past Medical History: PMH: [2173-1-20] - cardiac catheterization after (+) stress test showed LAD 60% proximal stenosis, RCA diffusely diseased with 90% discrete PDA. LIMA-Diag occluded, SVG-LAD occluded, radial graft -OM 40-50% stenosis, SVG-RCA occluded. [2157] MI and balloon angioplasty @ [Hospital1 112] [2167] MI and CABG (LIMA-diag, SVG-LAD, SVG-RCA, radial graft-OM) [2168] MI and cath showed occluded RCA, used medical therapy HTN High Cholesterol CAD CVA [2157] with loss of vision on the left diverticulitis [2157] s/p spine surgery and DJD in spine Social History: Social History: Married for 27 years with four sons. His son and wife will drive him to and from the procedure. Family History: Family History: (+) [Name (NI) 41900] CAD Mother died of MI at age 54. Physical Exam: Ht: 5'7" Wt: 176 lbs Pulsus 12. BP 112/68 HR 70 RR 18 O2Sat 99% 2L NC Gen: Tan, WDWN man lying in bed in NAD JVP: not visualized while lying flat CV: RRR, nl s1, s2, no m/g/r Lungs: CTAB, no w/r/r from chest Abd: BS+, soft, NT, ND Ext: R fem PA cath and arterial sheath in place. 2+ DP and PT BL Neuro: A&O, moving all 4 ext Pertinent Results: CK(CPK) [2173-2-26] 06:40AM 143 [2173-2-25] 09:15PM 179* [2173-2-25] 04:30PM 213* [2173-2-25] 12:50PM 165 [2173-2-25] 03:52AM 134 [2173-2-25] 12:31AM 85 CPK ISOENZYMES CK-MB MB Indx cTropnT [2173-2-26] 06:40AM 7 0.24 [2173-2-25] 09:15PM 10 5.6 0.22 [2173-2-25] 04:30PM 14 6.6 0.25 [2173-2-25] 12:50PM 17 10.3 [2173-2-25] 03:52AM 13 9.7 [2173-2-25] 12:31AM 7 LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [2173-2-25] 03:52AM 123 160 38 3.2 53 EKG pre-cath: NSR at 65, LAD, poor R wave progression, TWI in III Studies: [2173-2-24] Post-cath TTE PERICARDIUM: No pericardial effusion. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. Conclusions: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. C.CATH Study Date of [2173-2-24] BRIEF HISTORY: [Doctor Last Name ] presents for PCI of the RCA. He has a h/o CABG in [2166]. He pressetned with recent onset angina with an angiogram in [State 108] showing occluded LIMA to D, SVG to LAD and SVG to RCA. His radial graft to the OM is patent. He is a non smoker and had hypercholesterolemia. INDICATIONS FOR CATHETERIZATION: For PCI of the RCA. PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the right femoral vein, using a 6 French pulmonary wedge pressure catheter, advanced to the PCW position through an 8 French introducing sheath. Cardiac output was measured by the Fick method. Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 French [Doctor Last Name ] 0.75 catheter, advanced to the ascending aorta through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French [Doctor Last Name ] 0.75 and a 6 French [Doctor Last Name ] .75 catheter, with manual contrast injections. Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 2 hours 10 minutes. Arterial time = 2 hours 6 minutes. Fluoro time = 42 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 230 ml Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 3000 units IV Other medication: Atropine 600 mcg Fentanyl 150 mg Integrilin 14.6 cc TNG 200 mcg TNG 500 mc Midazolam 2.5 mg Cardiac Cath Supplies Used: - GUIDANT, WHISPER - GUIDANT, WHISPER - [Name (NI) ], PT [Name (NI) ], 300CM - GUIDANT, WHISPER - GUIDANT, WHISPER 1.5 [Company ], MAVERICK, 15 2.0 GUIDANT, VOYAGER 15 2.5 [Company ], QUANTUM MAVERICK, 8 3.25 [Company ], QUANTUM MAVERICK, 20 1.5 GUIDANT, VOYAGER 15 6 CORDIS, IM 6 CORDIS, [Doctor Last Name ] .75 150CC MALLINCRODT, OPTIRAY 150CC 2.5 CORDIS, CYPHER OTW, 13 3.0 CORDIS, CYPHER OTW, 33 3.0 CORDIS, CYPHER OTW, 23 ATTENDING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. REFERRING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. CARDIOLOGY FELLOW: [Last Name (LF) 64143],[First Name3 (LF) 64144] ATTENDING STAFF: [Last Name (LF) ],[First Name3 (LF) ] A. Brief Hospital Course: 63 yo M with h/o HTN, HL, CVA in [2157], MI in [2157], [2167] and [2168] as well as CABGx4 in [2167] presenting for elective interventional cath of RCA lesion complicated by jailing of the PDA and subsequent perforation. The patient has an extensive CAD history with LAD 60% proximal stenosis, RCA diffusely diseased with 90% discrete PDA. LIMA-Diag occluded, SVG-LAD occluded, radial graft-OM 40-50% stenosis, SVG-RCA occluded. He is s/p repeat cath with 2 Cypher stents to the proximal RCA and a Cypher stent to the distal PDA with occlusion of the PLB and rescue angioplasty. In the process, the PDA was perforated with extravasation of dye, likely into the myocardium. He received no integrillin following his catheterization given the perforation. A STAT echo after catheterization showed no evidence of pericardial effusion. His pulsus was monitored Q6 the day following catheterization without elevation. His CK peaked at 213 with a peak troponin T leak of 0.25 (normal 0-0.01) post-procedure and was down to 143 at time of discharge. A repeat echocardiogram the day following catheterization showed only a trivial/physiologic pericardial effusion and normal ejection fraction of > 55%, normal RV and LV cavity size. His lipitor was increased to 40 once a day, his norvasc was decreased to 2.5 once a day and his imdur was decreased to 30 once a day, otherwise he was continued on his pre-cath medications including metoprolol 100 in the AM, 50 in the PM, ramipril 10 QD, and niacin, as well as aspirin and plavix. Medications on Admission: toprol 100mg qam and 50mg qpm lipitor 20mg daily ASA 325mg daily altace 10mg daily Plavix 75mg daily Norvasc 7.5mg daily imdur 60mg daily Niacin, KCL, Magnesium Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). Disp:30 Tablet(s) Refills:2 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:30 Tablet(s) Refills:2 6. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 8. Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day: resume your home dose of potassium. 10. Mag-Oxide 400 mg Tablet Sig: resume your home dose Tablet PO once a day: resume your home dose of magnesium. 11. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Niacin Powder Sig: continue your home dose PO once a day. Discharge Disposition: Home Discharge Diagnosis: Unstable angina Coronary Artery Disease Discharge Condition: Good Discharge Instructions: 1. Always take your aspirin and plavix. Please consult your cardiologist before before making any changes to these medications. 2. Please take all medications as prescribed. Your lipitor has been doubled to 40 mg once a day. Your norvasc has been decreased to 2.5 once a day, and your imdur has been decreased to 30 once a day. 3. Please keep all follow-up appointments. 4. Please seek medical attention if you develop chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills or have any other concerning symptoms. 5. Do not drive for 1 week. No heavy lifting or vigorous activity for the next 2 weeks. Please talk to your cardiologist before beginning an exercise regimen. Followup Instructions: Please follow-up with your cardiologist DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 66022] ([Telephone/Fax (1) 66023], within the next 1-2 weeks. Please follow-up with your primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 66024], within the next 2-4 weeks. Completed by:[2173-2-26]	[ "41401", "2720", "4019" ]
Admission Date: [2152-3-23] Discharge Date: [2152-3-31] Date of Birth: [2072-12-24] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 79-year-old gentleman with a longstanding history of coronary artery disease. He had an initial percutaneous transluminal coronary angioplasty of his left circumflex in [2137]. In [2139], he had a catheterization that showed 100 percent right coronary artery occlusion and a subtotal circumflex lesion with a percutaneous transluminal coronary angioplasty done. At the same time, he had a mild left anterior descending occlusion with some venous obstruction. Over the past few months, he has had increasing angina with exertion. On [2152-1-11], he had an exercise tolerance test that was positive with ST depressions with inferoposterior ischemia. His angina is primarily between his scapula and back. He was referred for cardiac catheterization which was done on [2152-1-28]. This revealed an ejection fraction of 60 percent. He had a mildly dilated aortic root, right-dominant system, left main with a 20 percent occlusion, diagonal with 70 percent, ramus with 80 percent, circumflex with 95 percent, left anterior descending with 70 percent, with distal left anterior descending 90 percent occlusion, obtuse marginal with 80 occlusion, right coronary artery with 100 percent, and posterior descending artery with 70 percent. No mitral regurgitation or aortic stenosis. At that time, he was referred for bypass surgery. PAST MEDICAL HISTORY: 1. Glaucoma. 2. Tuberculosis. 3. Ventral hernia. 4. Question of lumbar stenosis. 5. Coronary artery disease (with percutaneous transluminal coronary angioplasty in [2137] and [2139]). 6. Left-sided headaches (with question of temporal arteritis). 7. Left carotid disease. 8. Diverticulitis. 9. Hypertension. 10. Hiatal hernia with gastroesophageal reflux disease. 11. Elevated cholesterol. 12. Benign prostatic hypertrophy. PAST SURGICAL HISTORY: 1. Tonsillectomy and adenoidectomy (as a child). 2. Colon polypectomy. 3. Bilateral laser eye surgery. ALLERGIES: SULFA (causes hot flashes). PHYSICAL EXAMINATION ON PRESENTATION: The patient's height was 5 feet 9 inches tall, his weight was approximately 175 pounds, blood pressure in the left arm was 180/66, and his right arm blood pressure was 188/80. Cardiovascular examination revealed a rate and rhythm. Normal first heart sounds and second heart sounds. There was a 2/6 systolic ejection murmur. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. Left upper quadrant diverticula and ventral hernia. Extremities were warm and well perfused. There were no varicosities. Good circulation, sensation, mobility. Pulse examination revealed right and left femoral were 2 plus, right and left dorsalis pedis pulses were 2 plus, right and left posterior tibialis were 2 plus, and right and left radial pulses were 2 plus. Neurologically, the pupils were equal, round, and reactive to light and accommodation. Cranial nerves II through XII were grossly intact. A nonfocal examination. Head, eyes, ears, nose, and throat examination revealed the extraocular movements were intact. The sclerae were anicteric and not injected. There were buccal mucosa. Neck examination revealed there was no jugular venous distention. There were no bruits. PERTINENT LABORATORY VALUES ON THE DAY OF DISCHARGE: White blood cell count was 10.2, his hematocrit was 32.9, and his platelets were 349. Potassium was 4.7, his blood urea nitrogen was 16, and his creatinine was 0.8. PERTINENT RADIOLOGY/IMAGING: Last chest x-ray revealed a small bilateral effusion. No congestive heart failure. No pneumothorax. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted on [3-23] and underwent a coronary artery bypass graft times three. He was extubated that afternoon. He was initially A- paced at 80 with an underlying sinus bradycardia at a rate of 50. On postoperative day three, he went into atrial flutter. After 5 mg of intravenous Lopressor, he had a nine second pause with conversion to a sinus rhythm. That day, he had three subsequent pauses of about six seconds each, and the Electrophysiology Service was consulted. On [3-26], he had some atrial fibrillation and atrial flutter with a rate in the 80s to 90s. On the evening of [3-27], he went into an accelerated idioventricular rhythm and was subsequently A-paced at 80. He continued in a normal sinus rhythm with some episodes of accelerated idioventricular rhythm, but he was asymptomatic. On [3-27], the patient was started on 12.5 mg of by mouth Lopressor (per Electrophysiology). They did not recommend a pacemaker or defibrillator placement. The patient was transferred to the inpatient floor on [3-29]. His chest tubes had been removed on [3-26], and his cardiac pacing wires were removed on [3-29]. He had been followed throughout his hospital course by the Physical Therapy Service. His chest tubes had come out on the [3-26]. The patient was cleared for home by the Physical Therapy Service on [3-30]. CONDITION ON DISCHARGE: Vital signs revealed his pulse was 65 (in a sinus rhythm), his blood pressure was 138/64, his respiratory rate was 18, and his oxygen saturation was 95 percent on room air. His temperature maximum was 99.3 degrees Fahrenheit. His weight on discharge was 79 kilograms. Preoperatively 79 kilograms as well. The patient was alert, awake, and oriented times three. The sternal incision was clean, dry, and intact with a stable sternum. Bilateral lower extremity vein harvest sites were clean, dry, and intact with moderate ecchymosis on the right thigh. Cardiovascular examination revealed a rate and rhythm. Respiratory examination revealed the lungs sounds were clear. There were scattered rhonchi on the right side. Gastrointestinal examination revealed there were positive bowel sounds. The abdomen was soft, nontender, and nondistended. Extremity examination revealed some trace lower extremity edema. DISCHARGE STATUS: The patient was discharged to home with Visiting Nurses Association on [3-30] in stable condition. DISCHARGE DIAGNOSES: 1. Coronary artery disease; status post coronary artery bypass graft times three. 2. Postoperative bradycardia. 3. Glaucoma. 4. Tuberculosis. 5. Status post induced right pneumothorax with scarring. 6. Hypertension. 7. Elevated cholesterol. 8. Benign prostatic hypertrophy. MEDICATIONS ON DISCHARGE: 1. Metoprolol 25mg by mouth twice per day. 2. Lasix 20 mg by mouth once per day (times seven days). 3. Potassium chloride 20 mEq by mouth every day (times seven days). 4. Colace 100 mg by mouth twice per day. 5. Zantac 150 mg by mouth twice per day. 6. Aspirin 325 mg by mouth once per day. 7. Percocet 5/325-mg tablets one to two tablets by mouth q.4h. as needed. 8. Lipitor 20 mg by mouth once per day. 9. Cozaar 25 mg by mouth once per day. DISCHARGE INSTRUCTIONS-FOLLOWUP: 1. The patient was instructed to follow up with Dr. [Last Name (STitle) 1275] in one to two weeks. 2. The patient was instructed to follow up with Dr. [First Name (STitle) 1075] in one to two weeks. 3. The patient was instructed to follow up with Dr. [First Name (STitle) ] [Last Name (Prefixes) 1276] in one month. 4. The patient was also to be seen for a wound check in two weeks. [Doctor Last Name ] [Last Name (Prefixes) ], MD 2351 Dictated By:[Last Name (NamePattern1) 1277] MEDQUIST36 D: [2152-3-31] 14:13:30 T: [2152-3-31] 15:57:37 Job#: [Job Number 1278]	[ "41401", "4019", "2720" ]
Admission Date: [2190-5-7] Discharge Date: [2190-5-10] Date of Birth: [2125-4-13] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: transfer from Lakes [Hospital 12018] Medical Center for cath Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 65 year old woman admitted on the 9th to Lakes [Hospital 12018] Hosp with severe dyspnea on exertion, wheezing. She also notes orthopnea and restlessness at night. She denies swelling in her legs, chest pain, cough, palpitations, syncope. She does note 3 weeks of diarrhea and some URI symptoms. VS there were notable for hypoxia of 91 % on RA. She was treated for COPD exacerbation and found to have LV impairment on echo. She ruled out for MI with serial troponins. Her stool was sent for cdiff and is pending at time of transfer. . She was transferred to [Hospital1 18] for cath. Cath showed a nonischemic cardiomyopathy with very elevated filling pressures, a PCW of 38. She was started on a nitro gtt in the cath lab and given lasix 40 IV. After this her PCW pressure dropped to 15. On arrival to ICU her PCW was 13 and she had diuresed 1200 cc since given lasix in cath lab. She denied any complaints. Past Medical History: Iron definecy anemia Kidney stones Gallstones h/o pneumonia Cholecystectomy s/p cataract surgery Recent diarrhea x 3 weeks resolved yesterday Anxiety s/p C section. Social History: significant for 1.5 PPD tobacco, pt says she is planning on quitting, no significant ETOH use, no drug use. Married, lives with husband. Family History: History of CAD on her father side, her father died at 64 years old of CAD/MI. Her cousing died of heart related problems in 40's. Physical Exam: VS: T 98.1 BP 143/74 HR 99 RR 14 O2100%4L Gen: Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Elevated JVP CV: Tachy, nl S1, S2, +systolic murmur, 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. R groin line in place Skin: No stasis dermatitis, ulcers. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: EKG demonstrated SR, rate 100, nl axis, nl int, LVH, TW falttening in V5-6, LAE . 2D-ECHOCARDIOGRAM performed on [2190-5-7] at Lakes Regional demonstrated: Mod MR, LVH, nondilated LV, generalized HK, EF 25-30%, RV normal, mild pulmonic insuff, mild TR, Est RV pressure 55-60, mod pulm htn, no effusion . TTE performed on [5-8] demonstrated: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (ejection fraction 20-30 percent). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-29]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . CARDIAC CATH performed on [2190-5-7] demonstrated: normal LMCA, LAD, LCX, 60% mid RCA spasm . HEMODYNAMICS: PA sat 59% Ao 164/82 RA 11, PA 27/20(23) PCW 38 CO 3.62, CI 2.65 . CXR [5-8]: Single frontal radiograph of the chest labeled upright demonstrates a Swan-Ganz catheter from an inferior approach with distal tip overlying the descending left pulmonary artery. The cardiomediastinal silhouette is within normal limits. Biapical opacities demonstrated right greater than left, likely scarring. There is indistinctness of the pulmonary vasculature which may be secondary to mild interstitial pulmonary edema versus chronic interstitial lung disease, correlation with prior examinations is recommended. There is no evidence of pleural effusion or pneumothorax. More focal opacity in the left mid lung zone which may be secondary to focal atelectasis, infection, or focal edema, or neoplasm, followup to resolution is recommended. Visualized osseous structures are intact. There is a metallic clip overlying the right upper quadrant, likely from prior cholecystectomy. . OSH labs: WBC 17 (93%PMN, 1%bands, 4%L, 2%M), hct 30.2, plt 342 INR pending, K 3.9 creat 1.0, trop normal TSH 0.37, FT4 0.95, TCHol 232, LDL 166, HDL 49, TG 86, INR 0.96, PTT 20.7, PT 12.1 Brief Hospital Course: 65 yo F with no previous cardiac history with new non-ischemic cardiomyopthy of unknown etiolgy with elevated right sided filling pressures in the cath lab, now improved after nitro and lasix. . 1) Pump: Patient was found to have a significantly depressed EF of 20-30% and elevated filling pressures in cath lab from her nonischemic cardiomyopathy. DDX includes viral myocarditis, celiac disease, lupus, hypo/hyperthyroidism. Thyroid tests normal at OSH. She did have symptoms of URI and gastroenteritis that could be associated with a viral syndrome causing viral myocarditis. She also had iron def anemia which is seen with celiac disease which can rarely cause a cardiomyopathy. TTG was sent off for this reason and was pending on discharge. She was placed on a nitro gtt and continued on ACEI for afterload reduction. She had a good response to lasix in the cath lab with improvement in her PCWP. She was then started on lasix 20mg PO daily. She was also continued on low dose BB, later switched to Toprol XL. . 2) ? hypertension- no reported history of HTN, however patient did have LVH on echo at OSH (not seen on TTE here, however evident on EKG). Hypertension is a possible etiology of her newly diagnosed cardiomyopathy. She was continued on lisinopril as above and her lopressor was titrated up for BP control. . 3) CAD: Had clean coronaries on cath making ischemic etiology of her CM very unlikely. She denied chest pain and did not have ischemic changes on EKG. Given her cardiac risk factors of age, smoking, ? HTN and hyperlipidemia she was continued on ASA 81 mg and started on statin. . 4) Rhythm: Followed on tele with no significant arrythmias noted. . 5) Hyperlipidemia: Started statin after LFTs had been checked. . 6) Elevated FS: Likely were from solumedrol she was receiving at OSH for presumed asthma flare. Unlikely that she had asthma flare, more likely her SOB was from her cardiomyopathy and elevated filling pressures. Steroids were not continued on arrival to [Hospital1 18] and her FS normalized. . 7) Iron def anemia: Confirmed with iron studies, continued FeSO4. Patient will need a workup for anemia (colonoscopy) as an outpatient. . 8) FEN: low salt diet . 9) PPX: pneumoboots, PPI . 10) Access: PIV . 11) Code: full Medications on Admission: Home medications: Protonix 40 mg daily MVI Prozac . Medications on transfer: Aspirin 325mg daily Prozac 10mg daily Lasix 20mg IV daily Aspirin 325mg daily Lopressor 12.5mg daily Protonix 40mg daily KCL 20meq daily Metamucil 1 packet Altace 2.5mg daily Solumdrol 60mg IV q 12 hours Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Nonischemic cardiomyopathy, s/p cardiac cath with clean coronaries 2. Hypertension, newly diagnosed 3. Diarrhea, watery . Secondary Diagnosis: 1. Iron deficiency anemia 2. Gallstones Discharge Condition: Afebrile. Hemodynamically stable. Ambulating. Tolerating PO. Discharge Instructions: You have been treated for a heart condition called cardiomyopathy. A study to look at your heart vessels was performed (cardiac catheterization). It did not show any occluded vessels. We were unable to determine the cause of your heart failure. . You have been started on several new medications (Aspirin, Lisinopril, Metoprolol, Lasix, Atorvastatin, potassium) which you should continue after discharge. . You have also been found to be iron deficient causing chronic anemia (low blood levels). *It is very important that you follow up with your PCP for further workup.* You will need to have a procedure called a colonoscopy which is a routine screening test for colon cancer. . Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, nausea/vomiting, spontaneous bleeding or any other concerning symptoms. . Please take all your medications as directed. . Please keep you follow up appointments as below. Followup Instructions: Please follow up with your primary care doctor ([Last Name (LF) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 66238]) within 1-2 weeks, Dr.[Name (NI) 73159] office should call you back tomorrow, otherwise please call to make an appointment. *You need further workup for your iron-deficiency anemia, weight loss and night sweats.* . Please also follow up with [Last Name (LF) ],[First Name3 (LF) ]-[Doctor First Name 10588] [Telephone/Fax (1) 11254] within 2 weeks. Completed by:[2190-5-10]	[ "496", "4019", "3051", "25000" ]
Admission Date: [2153-1-26] Discharge Date: [2153-2-19] Date of Birth: [2124-2-13] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1850] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Tracheal piece replacement GJ Tube placement Bronchoscopy History of Present Illness: 28 year-old quadrapedic female with severe mental retardation and cerebral palsy chronically trached who presented from OSH with respiratory distress. Pt was previously seen at [Hospital1 64975] for respiratory distress one day PTA and sent home on Keflex. She represented to the OSH with worsening secretions and continued labored breathing. ABG: 7.45/47/120 (35%). Pt usually recieves care at [Hospital1 ] (Chronic Care Service/Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4027] - [Telephone/Fax (1) 64976]) or [Hospital1 112], however, there was no available beds so the pt was transferred to [Hospital1 18] with concerns of worsening respiratory distress in setting of suspected PNA. She was recently admitted to [Hospital3 1810] from [1-2] - [1-13] for LLL PNA treated with Aztreonam and Clinda (pansensitive pseudomonas and [Doctor First Name ] as per ID fellow, Dr. [Last Name (STitle) 64977] at [Hospital1 ]). . In the ED the pt received ABX (Levofloxacin, Vanco and Flagyl), albuterol neb, and KCL 20 mEq. A central line was placed. Bld and urine cultures sent. WBC count noted to be 36 with 6 % bandemia. CXR revealed a possible subtle retrocardiac density. . The pt previously had a customized trach without a cuff which was found to have a leak in the ED. IP was consulted in the ED and the trach was changed to one with a cuff so the pt could be vented. During the procedure, significant amounts of granulation tissue was found distal to the trach impeding air flow (approximately 80% luminal obstruction). The new trach was pushed through the granulation tissue to 3cm above the carina. A bronchoscopy was performed in the ED demonstrated clearance of previously obstructing granulation tissue. Past Medical History: - severe mental retardation - CP - quadraplegia - Sz Dz (last 3 months ago) - chronic trach not vented; on 2.5 L trach mask - s/p PEG - scoliosis - chronic anemia - recent LLL PNA as above Social History: Lives at home with mother, spanish speaking only. By report no Tob/EtOH/DU. Family History: Noncontributory Physical Exam: HEENT: NC/AT, PERRL, EOM full, no scleral icterus noted, drooling, frothy sputum Neck: scolotic, supple, no JVD appreciated, trach with granulation tissue, no crepitus Pulmonary: tachypneic, course BS thru/o with exp wheezes, decreased BS at bases, excessive upper airway sounds Cardiac: Tachy with RR, nl. S1S2, no M/R/G noted Abdomen: soft, mild ND, hypoactiveactive bowel sounds, no masses or organomegaly noted, PEG site with SS drainage around site Extremities: contracted, trace pedal edema bilaterally, 1+ radial, DP and PT pulses b/l. Skin: WWP, no rashes or lesions noted. Neurologic: Alert and moves eyes in response to voice, non-verbal, does not follow commands, extremities contracted without movement Pertinent Results: STUDIES: OSH-> WBC 28.7/HCT 39.7/PLT 813; Na 129/K 2.9 (given 40 mEq through PEG)/CO2 30/BUN 6/Cr 0.7. . EKG: sinus tach, Rate 115, poor baseline . CXR [2153-1-25]: tracheostomy tube, which terminates 3 cm above the carina. There is marked kyphoscoliosis of the thoracic spine, making these views non-standard in orientation. Allowing for this rotation, there is no definite pleural effusion, pneumothorax, or consolidation. The heart size is difficult to assess. There may be subtle retrocardiac density. CT ABDOMEN W/O CONTRAST [2153-2-15] 2:45 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Reason: Evaluate for abscess, pt intubated, Field of view: 36 [Hospital 93] MEDICAL CONDITION: 29 year old woman with CP MR, with pseumdomonas growing, GJ Tube placed, pt intubated REASON FOR THIS EXAMINATION: Evaluate for abscess, pt intubated, CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Cerebral palsy, mental retardation, with pseudomonas infection, status post GJ tube placement. TECHNIQUE: Multidetector CT images of the chest, abdomen, and pelvis were obtained without oral or intravenous contrast. COMPARISON: None. CHEST CT WITHOUT IV CONTRAST: There is marked thoracic deformity due to severe scoliosis. A tracheostomy tube is present with tip of the tube at the thoracic inlet. The heart and great vessels are unremarkable. There is no lymphadenopathy. No consolidations are present. There is patchy dependent atelectasis. Several vague subcentimeter tiny nodular opacities are present at the right lung base. There are no pleural effusions. ABDOMEN CT WITHOUT IV CONTRAST: The liver, gallbladder, pancreas, spleen, adrenal glands, kidneys, and abdominal vasculature is unremarkable. There is marked scoliotic deformity of the thoracolumbar spine. A gastrojejunostomy tube is present with tip in the proximal jejunum. There is a skin defect overlying the right mid abdomen, with mild soft tissue density in the underlying abdominal wall. This is likely related to prior intervention. No fluid collections are present. There is no free abdominal air or fluid. PELVIS CT WITHOUT IV CONTRAST: The distal ureters and pelvic organs are unremarkable. A Foley is present within the bladder. There is marked deformity of both hips. No fluid collections are present. IMPRESSION: 1. No fever source identified. 2. Several tiny nodular opacities at the right lung base. These are nonspecific and are likely chronic, possibly due to old infection. Reason: please change G tube to G-J tube and remove J tube. Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 29 year old woman with CP and leaking J tube REASON FOR THIS EXAMINATION: please change G tube to G-J tube and remove J tube. HISTORY: 29-year-old woman with _____ and leaking J-tube site. The J-tube has previously been removed. Our aim is to convert the G-tube to a GJ tube. PHYSICIANS: [First Name8 (NamePattern2) ] [Doctor Last Name 26181] and [First Name8 (NamePattern2) ] [Doctor Last Name 380] performed the procedure with Dr. [Last Name (STitle) 380], the attending radiologist, being present and supervising throughout the procedure. PROCEDURE: Following written informed consent from the patient's mother, the patient was positioned supine on the angiography table. The preprocedure timeout was performed to confirm patient, procedure and site. Standard sterile prep and drape of the ventral abdomen and in situ gastrostomy catheter (18 French Foley catheter). The guidewire was passed through the Foley catheter and the Foley catheter was removed. The bright-tip vascular sheath was placed over the guidewire and with the aid of a Kumpe catheter, the pylorus was intubated and the wire and catheter were advanced through the duodenum and into the jejunum. The Kumpe catheter was then exchanged for an MPA catheter and the wire and catheter were advanced to the level of the jejunostomy. The jejunostomy was then intubated and efferent limb was cannulated using the dilator from the vascular sheath and a Bentson guidewire. Contrast injection through the MPA catheter in the afferent limb of the jejunostomy was then performed and this demonstrated the course of the bowel at what appears to be a loop jejunostomy. The guidewire was then advanced around the loop in from the afferent limb to the efferent limb. A 22 French MIC catheter was then advanced over the guidewire and positioned with its tip in the jejunum distal to the jejunostomy site. The balloon was positioned in the stomach and inflated with 7 cc of sterile saline. A dressing was applied. Contrast was injected through the tube and confirmed catheter tip positioned in the jejunum beyond the jejunostomy site and the position of the balloon within the stomach. The catheter was then flushed with saline to clear the contrast. There were no immediate complications. IMPRESSION: Successful replacement of the in situ gastrostomy catheter with a 22 French MIC catheter with balloon in the stomach, gastric port in the gastric antrum, and tip of catheter within the jejunum distal to the site of the jejunostomy. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) 54747] [Name (STitle) ] DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Approved: [Doctor First Name ] [2153-2-15] 1:39 PM Brief Hospital Course: Assessment - 28yo quadraplegic woman with cerebral palsy and severe mental retardation, chronic trach (not on home ventilation), who was admitted for respiratory distress and found to have a tracheal obstruction and possible PNA. . 1. Respiratory distress - etiology most likely tracheal obstruction from granulation tissue complicated by pulmonary disease, possibly PNA vs bronchitis. PE less likely in pt with chronic immobility. In ED, trach was changed with new trach pushed past the site of obstruction by interventional pulmonary. Pt was placed on PCV with good oxygenation. Per IP recs -> inflate cuff to goal manometry 20-30 and MV [6-21]. 7.0 ETT at bedside; if needed in emergency, can place through stoma to 12cm. During her hospital course, during trach care where the velcro securing device was removed she coughed out her trach tube, it was promptly replaced, and IP was consulted, a cxr confirmed it was in appropriate position and the cuff was reinflated with good maintenance of her oxygen saturation. She was to be maintained on intermittent trach collar and pressure spport, with attempts to maximize trach collar time as tolerated, she was also continued on albuterol and atrovent. . ## Pneumonia/fever - Initially thought secondary to PNA, then likely due to cellulitis around J tube site. She had Central line and this was discontinued given low grade fevers. The tip was sent for culture and showed no grwoth. She was started on vanc/ceftaz flagyl initially, sputum culture grew pseudomonas and received 5 days of this, however with worsening renal insufficiency and concern for AIN and pt with persistent infiltrates from previous records antibiotics were discontinued for pneumonia. [Doctor First Name ] likely colonizer as pt not on treatment from [Hospital1 ]; she was given albuterol, atrovent prn. She had a bronch done in the ICU ~1 week after the admission which showed no new pathology. WBC started rising again [2-12]. WBC was up to 25 [2-15] with low grade temp of 100.9 on [2-14].UA/Urine cx neg, but sputum from [2-12] growing 4 +GNR on gram stain and pseudomonas on culture. On [2-14] pt had L shift with 1%bands. CXR from [2-12] did not reveal any new changes, however it was of poor quality and no lateral view can be easily obtained. Pt received 1 dose ceftaz on [2-12], however given h/o AIN on this in the past, it was discontinued. The pt was started on meropenem on [2-14] to cover pseudomonal PNA, and on Vanc on [2-15] to cover for any potential line infection. The pt was taken for CT of the torso to further eval for loculated effusions and abdominal abscess on [2-15]. The CT did not reveal any absces. Her vancomycin was discontinue as there were no gram positive cocci isolated on cultures. She was continued on meropenem and levaquin was added for further persistent fevers and double gram negative coverage. She was continued on flagyll for empiric C diff coverage while her cdiff cultures were negative at time of discharge and her C diff toxinb B was still pending. She was discharged to finish 2 more days of meropenem and 4 more days of levaquin and to finish a 14 day course of flagyl for presumed c. diff . # Sepsis - On presentation unable to maintain UOP, goal > 30cc/hr. IVF kept pt's MAPs up briefly, but then fell, and UOP never at goal. On levophed briefly for presumed sepsis on presentation and titrated to MAP>70. She was titrated off levophed with good control of her pressures. . # J tube dislodgement - On presentation her J tube had fallen out, this was replaced by Interventional radiology on [2153-2-1]. There was significant bile drainage from around site. This was likely because the tract of Jtube was probably larger than the j tube. Surgery evaluated the pateint and on [2-7] changed tube for Malecot (larger diameter), then performed J tube check. Initially contrast never made it into the small bowel but just leaked out around it. Repeat study showed contrast in small bowel. IR decided to [Last Name (un) ] ther G tube to a G-J tube, however, given her anatomy and previous surgeries recommended that this would likely need to be done by surgery. Surgery has requsted records from [Hospital1 ] regarding previous abdominal surgeries, previous anti reflux surgery?, ? why she has G and a seperate J tube as well as her aspiration risk. These records need to be obtained prior to surgery at [Hospital1 18]. Patient's family asked that patient be transferred to [Hospital1 ] given all her care there previously. Tube feeds were held. On [2-12] the pts J tube was pulled, and on [2-13] a GJ tube was placed by IR. The pts J tube fistula site willl close over time and will need an ostomy bag over the site until then. Her G- tube was placed to suction. Her J-tube feedings were to be held until there was no drainaged from the J tube ostomy site. . # Erythema around J tube - Patient was noted to have erythema around the J tube site. This was thought likely inflammation from bile, expect improvement with replacement of ostomy bag. Given fevers there was concern for cellulitis she was started on vancomycin (PCN allergy) [2153-2-2]. This was discontinued on [2-12]. . # ARF - rise in Cr from 0.5 to 1.5 after admission. Urine lytes not consistent with prerenal. Rare eosinophils in urine initially and all potential meds were stopped as above, repeat showed no eos, so less likely AIN. Not post-renal by renal ultrasound. So most likely ATN from time of hypotension. Renal function improved gradually over time. . # CP, mental retardation - continue ativan prn, valium [Hospital1 ] #. Seizures - continue phenobarbitol, topamax . FEN - Patient was on TPN while inpatient, will consider Tube feeds when J tube ostomy site is decreasing. Monitor and replete lytes prn. PPx - Zantac, sc heparin, bowel regimen Access - very difficult, finally with L subclavian CVL. Do not remove line. Communication - pt's mother, [Name (NI) ] - [Telephone/Fax (1) 64978]; o/w can call brother at [Telephone/Fax (1) 64979], or father at [Telephone/Fax (1) 64980] Dispo - To rehab Code status - full, confirmed w/ pt's mother . Medications on Admission: - Phenobarb 88mg/44mg qAM/aPM - Topamax 100mg [Hospital1 ] - Atrovent Nebs [Hospital1 ] - Albuterol q4 - Ativan 2mg [Hospital1 ] - Valium 4 mg [Hospital1 ] - Zantac 150 [Hospital1 ] - Ca-Carbonate 1259 [Hospital1 ] - Nystatin/Myconazole/Hydrocort ointments - Neutraphos K 1 pkt tid - Miralax 17 daily - Bactroban to G-tube tid - Aveno soaks 10 min to G-tube tid Discharge Medications: 1. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane QID (4 times a day). 6. Lidocaine HCl 0.5 % Solution Sig: One (1) ML Injection Q1H (every hour) as needed for cough. 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 10. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 13. Diazepam 5 mg/mL Syringe Sig: 2.5 mg Injection [Hospital1 ] (2 times a day). 14. Phenobarbital Sodium 65 mg/mL Solution Sig: Ninety (90) mg mg Injection QAM (once a day (in the morning)). 15. Phenobarbital Sodium 65 mg/mL Solution Sig: Sixty Five (65) mg Injection QPM (once a day (in the evening)). 16. Lorazepam 2 mg/mL Syringe Sig: Two (2) Injection [Hospital1 ] (2 times a day) as needed. 17. Meropenem 1 g Recon Soln Sig: One (1) gm Intravenous Q8H (every 8 hours) for 2 days. 18. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Tablet(s) 19. Metoclopramide 10 mg IV Q6H 20. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 21. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 22. 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. Discharge Disposition: Extended Care Facility: [Hospital1 100] Rehabitation Discharge Diagnosis: Respiratory Distress Discharge Condition: Stable Discharge Instructions: Please take your medications as instructed If you experience increased fevers chills nausea vomitting, please contact your doctor Followup Instructions: None [First Name8 (NamePattern2) 1176] [Name8 (MD) 1177] MD [MD Number(2) 1851]	[ "0389", "5849", "2761", "99592" ]
Admission Date: [2109-11-25] Discharge Date: [2109-11-29] Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Bacitracin Attending:[First Name3 (LF) 4327] Chief Complaint: chest pressure, STEMI Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 17988] is an 87yo male with pmhx of pancreatic cancer s/p Whipple in [2105], htn, hld who is presenting with STEMI, which resolved with ASA and nitrates. The patient reports that he ate his dinner this evening without incident and then he did his physical therapy exercises without discomfort. He subsequently was watching hockey and at 8:50pm had chest pressure, diaphoresis and nausea. He took 2 baby aspirin and called 911. EMS gave him sublingual nitroglycerin and his pain improved. EKG done at that time showed NSR with STE in I, aVL, V2 and inferior inversions. Upon presentation to the ED, the patient was chest pain free and his EKG changes had largely resolved, with largely resolved STE in I and aVL. 1 mm STD still in inferior lead, STE in V2 likely posterior ST depression. The patient reports that at baseline, he is able to run some errands with his family and requires a cane to ambulate. He is able to walk up a flight of stairs but does endorse dyspnea with this exercise. He works with physical therapy and his exercise tolerance per PT notes is about 6 minutes walk on flat ground. He does endorse some exertional calf pain. He says that he has not had any episodes of chest pressure, pain or dyspnea over the preceeding weeks. . 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 pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes (with peripheral neuropathy), -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: none - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Pancreatic cancer diagnosed [7-/2106] s/p Whipple [2106-7-20], no evidence of recurrence on CT Torso in [2107-8-9] Chronic Kidney Disease with baseline Cr 1.3-1.5 Hypothyroidism Macular degeneration Remote hx of one episode of gout Anemia, with baseline Hct 26-30, on B12 s/p cholecystectomy s/p appendectomy h/o squamous cell carcinoma on scalp Vitamin D Deficiency Chronic back pain Social History: Lives with his wife and 2 daughters in [Name (NI) ]. Has a son in [Name (NI) ]. Uses a cane when he goes out of the home. Is relatively inactive. Denies current or past smoking, EtOH, drug use. Occupation: merchandise Family History: No history of pancreatic cancer. Father had stroke, MI (60). Mother had breast CA in her 70s. One brother had MI (40s) s/p CABG and lung cancer. Other brother has DM. Children are all healthy. Physical Exam: ADMISSION EXAM: . VS: T=97.6 BP=180/70 HR=75 RR=12 O2 sat= 97% 2L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [6-14] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Multiple keratotic lesions throughout dermis. No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: . [2109-11-25] 09:25PM BLOOD WBC-5.0 RBC-3.06* Hgb-9.5* Hct-27.6* MCV-90 MCH-31.1 MCHC-34.6 RDW-14.0 Plt Ct-154 [2109-11-25] 09:25PM BLOOD Neuts-57.5 Lymphs-36.6 Monos-3.5 Eos-2.0 Baso-0.4 [2109-11-25] 09:25PM BLOOD PT-10.6 PTT-29.6 INR(PT)-1.0 [2109-11-25] 09:25PM BLOOD Glucose-247* UreaN-39* Creat-1.5* Na-135 K-5.2* Cl-104 HCO3-23 AnGap-13 [2109-11-25] 09:25PM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9 . PERTINENT LABS AND STUDIES: [2109-11-25] 09:25PM BLOOD cTropnT-0.03* [2109-11-26] 05:07AM BLOOD CK-MB-7 cTropnT-0.41* [2109-11-26] 01:30PM BLOOD CK-MB-8 cTropnT-0.34* [2109-11-26] 05:07AM BLOOD CK(CPK)-92 [2109-11-26] 01:30PM BLOOD CK(CPK)-109 . ECHO [2109-11-26] The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Brief Hospital Course: 87M with HTN, T2DM, pancreatic cancer presenting with STEMI, medically managed without intervention. . ACUTE CARE: . # CORONARY ARTERY DISEASE - The patient's chest pain and EKG changes resolved with Aspirin and nitrates, thus, he was not taken emergently to the catheterization lab. The following morning, after discussion with his PCP, [Name10 (NameIs) ] patient opted for medical management of his myocardial ischemia. He was initially started on Plavix load, heparin drip, and nitroglycerin drip. He will continue on Aspirin, Plavix, Metoprolol, Atorvastatin, Lisinopril for medical management of ACS, and he will also take Imdur for treatment of chronic stable angina. . # NORMOCYTIC ANEMIA - The patient has a known baseline HCT of 26-30%. His hematocrit dropped to 22% this admission without obvious bleeding. Hematology recommended a goal hematocrit of 30% in the setting of coronary ischemia. The patient received 1 unit of packed red cells and his hematocrit was subsequently 28% and remained stable. He will follow-up with his outpatient Hematologist. . CHRONIC CARE: . # HYPERTENSION - Not on home regimen but elevated at presentation to hospital, was treated with Lisinopril and Metoprolol, as above. . # INSULIN-DEPENDENT TYPE 2 DIABETES MELLITUS WITH NEUROPATHY - HgA1C was 7% in [9-/2109], revealing good control of insulin-dependent diabetes. Maintained on ISS and Lantus while in house, and we continued his Gabapentin for neuropathy. . # PANCREATIC CANCER - The patient is status-post Whipple procedure and has pancreatic insufficiency. He is considered in remission although he no longer has surveillance imaging, as he has opted to not pursue further aggressive management. We continued Creon, vitamin repletion, metoclopramide and omeprazole - per his outpatient regimen. His hematologist did not feel that his hematocrit decline was related to his cancer. This was discussed with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD. . # CKD - The patient's baseline creatinine is 1.5 and this remained stale at time of presentation. . # HYPOTHYROIDISM - We continued his home Synthroid dosing. . # VITAMIN D DEFICIENCY - We continued his home vitamin D supplement. . TRANSITION OF CARE ISSUES: 1. No pending radiologic studies, laboratory data or microbiologic data at the time of discharge. 2. Will follow-up with outpatient Hematologist, Cardiologist and primary care physician. [Name10 (NameIs) ] appointments have been scheduled. 3. Will need hematocrit checked as an outpatient, to be followed by his primary care physician. Medications on Admission: GABAPENTIN - 100 mg Capsule - 1 (One) Capsule(s) by mouth at bedtime INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin Pen - inject 10 units or as directed subcutaneously once a day dispense 3 month supply LEVOTHYROXINE - 100 mcg Tablet - 1 Tablet(s) by mouth once a day LIPASE-PROTEASE-AMYLASE [CREON] - 60,000 unit-[Unit Number ],000 unit-[Unit Number ],000 unit Capsule, Delayed Release(E.C.) - 4 Capsule(s) by mouth three times a day METOCLOPRAMIDE - 5 mg Tablet - 1 Tablet(s) by mouth before meals OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One) Capsule, Delayed Release(E.C.)(s) by mouth once a day CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Tablet - 1 Tablet(s) by mouth daily CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider; OTC) - 250 mcg Tablet - two Tablet(s) by mouth Daily DOCUSATE SODIUM - (Prescribed by Other Provider) - Dosage uncertain MAGNESIUM OXIDE - 500 mg Tablet - 2 Tablet(s) by mouth twice daily MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - Tablet - one Tablet(s) by mouth daily VITAMIN A-VITAMIN C-VIT E-MIN [OCUVITE] - Tablet - One Tablet(s) by mouth Daily0 Discharge Medications: 1. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: Three (3) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Ten (10) units Subcutaneous at bedtime. 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO before meals. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 9. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. docusate sodium Oral 11. multivitamin-minerals-lutein Tablet Sig: One (1) Tablet PO once a day. 12. Ocuvite Tablet Sig: One (1) Tablet PO once a day. 13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 14. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:45 Tablet Extended Release 24 hr(s) Refills:2 15. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 16. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 17. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 18. Outpatient Lab Work Please check CBC and Chem-7 on Tuesday [12-2] with results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216] at Phone: [Telephone/Fax (1) 250] Fax: [Telephone/Fax (1) 4004] 19. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain: Take one tablet 5 minutes apart, do not take more than 2 tablets total. Disp:25 tablets Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary diagnoses: 1. Acute ST-elevation myocardial infarction 2. Acute on chronic normocytic anemia . Secondary Diagnoses: 1. Anemia of chronic disease 2. Hypertension 3. Inuslin-dependent diabetes mellitus 4. Pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], You were admitted because you had a heart attack. As you know, you opted to medically manage your heart attack and not proceed with a cardiac catheterization. You did not have further chest pain and you will continue your new medications at home. Please note the following changes to your medications: - START atorvastatin 80mg daily to lower your cholesterol - START clopidogrel 75mg daily to keep your arteries open - START metoprolol 37.5mg daily to lower your heart rate - START lisinopril 5mg daily to lower your blood pressure - START imdur 30mg daily to prevent chest pain - START aspirin 325mg daily to prevent another heart attack. - START nitroglycerin as needed if you have chest pressure at home. Take one tablet, then wait 5 minutes, you can take up to one more tablet if you still have chest pressure. Call 911 if you still have chest pressure after taking nitroglycerin. Continue to take the remainder of your medications as prescribed. Please be sure to follow up with your physicians. It was a pleasure taking care of you. Followup Instructions: Department: [Hospital3 249] When: MONDAY [2109-12-16] at 11:10 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2110-1-20] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2110-1-20] at 11:00 AM With: DR. [First Name8 (NamePattern2) 24186] [Last Name (NamePattern1) 24187] [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: CARDIAC SERVICES When: MONDAY [2109-12-30] at 9:20 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "41401", "40390", "2724", "5859", "2449", "V5867" ]
Admission Date: [2112-1-10] Discharge Date: [2112-1-13] Date of Birth: [2027-12-16] Sex: F Service: SURGERY Allergies: Lovenox / Sulfa (Sulfonamide Antibiotics) / Morphine Attending:[First Name3 (LF) 2534] Chief Complaint: abdominal pain, fever and chills Major Surgical or Invasive Procedure: [2112-1-11] Percutaneous cholecystotomy tube placement History of Present Illness: 84yF who presented in [12-24] with sepsis [1-27] cholecystitis. She had a percutaneous cholecystostomy drain placed. Unfortunately the patient self d/c'ed this drain on [12-27]. The GB was re-imaged and it did not appear adequately distended to necessitate replacement of drain. She was monitored clinically and seemed to be improving. She was discharged to rehab on was discharged to rehab on [12-31] on augmentin through [1-4]. Today at rehab she developed RUQ abdominal pain, fever and chills. No n/v/d, no cough, no CP/SOB reported by family. She was reportedly more lethargic than usual. ROS: Past Medical History: PMH: IBS, GERD,high cholesterol, high blood pressure,legally blind and hard of hearing, spinal stenosis with severe pain and limited mobility. PSH: Cornea surgery in [2102]. Colonoscopy five years ago normal by report. Hiatal hernia surgery for paraesophageal hernia. Social History: No tobacco, No ETOH Family History: non contributory Physical Exam: Temp 98.4 HR 104 BP 147/96 RA 22 GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes dry CV: RRR, PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, TTP RUQ, + guarding Ext: No LE edema, LE warm and well perfused Pertinent Results: [2112-1-10] 05:12PM WBC-5.4 RBC-3.19* HGB-9.9* HCT-29.5* MCV-92 MCH-31.2 MCHC-33.8 RDW-13.8 [2112-1-10] 05:12PM NEUTS-73* BANDS-4 LYMPHS-15* MONOS-2 EOS-5* BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2112-1-10] 05:12PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL [2112-1-10] 05:12PM PT-13.6* PTT-21.1* INR(PT)-1.2* [2112-1-10] 05:12PM ALT(SGPT)-22 AST(SGOT)-46* ALK PHOS-221* TOT BILI-0.6 [2112-1-10] 05:12PM GLUCOSE-103* UREA N-19 CREAT-1.3* SODIUM-138 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19 [2112-1-10] liver US : Distended gallbladder with gallbladder wall thickening and edema and containing sludge and stones with positive son[Name (NI) 493] [Name (NI) ] sign. Findings consistent with continued acute cholecystitis. As compared to the prior examination, gallbladder wall thickening has decreased. [2112-1-10] Chest Xray : Mild pulmonary vascular congestion with small right pleural effusion and probable adjacent atelectasis. Retrocardiac opacity also likely reflects atelectasis, but infection cannot be completely excluded. [2112-1-10] 5:12 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [2112-1-11]): GRAM NEGATIVE ROD(S). Brief Hospital Course: Mrs. [Known lastname 41411] was evaluated by the Acute Care team in the Emergency Room and admitted to the hospital with acute cholecystitis. She was admitted to the ICU, made NPO, hydrated with IV fluids and placed on broad spectrum antibiotics. Her WBC was 20K and blood cultures were done in the ER. Her admission chest xray showed a small right pleural effusion and a retrocardiac opacity that could represent atelectasis or pneumonia. She had no cough or other pulmonary symptoms. On [2112-1-11] she had a percutaneous cholecystotomy tube placed for drainage. A large amount of purulent , foul smelling fluid was aspirated and the drain was placed to gravity. Her admission blood cultures were positive for E Coli ([1-27]) and she was treated with Vancomycin and Zosyn. Her symptoms improved and her WBC gradually decreased. Her cholecystotomy tube drained 500cc the first day. Following transfer to the Surgical floor she continued to make good progress. She remained afebrile and was taking a regular diet without difficulty. Her Foley catheter was removed [2112-1-13] around 11am and she is due to void by 9pm. She will continue oral antibiotics for 10 more days The cholecystotomy tube drained 250cc in the last 24 hours. She will be discharged today with the drain in place and will follow up in the Acute care Clinic on [2112-1-28]. Medications on Admission: prednisolone acetate 1 %", brimonidine 0.15 % eye gtt"', tobramycin-dexamethasone 0.3-0.1 %eye ointment qhs, dorzolamide-timolol 2-0.5 %" eye gtt, aspirin 81, amlodipine 5, Lasix 20, lisinopril 10, omeprazole 20", simvastatin 20, heparin 5000IU sq"', tramadol 25mg prn, Discharge Medications: 1. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day): Both eyes. 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours): Both eyes. 3. tobramycin-dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)): Both eyes. 4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day): Both eyes. 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for Lower back pain: 12 hours on and 12 hours off. 6. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day: thru [2112-1-22]. 7. clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 8. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 9. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 14. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Ultram 50 mg Tablet Sig: [12-27] Tablet PO four times a day as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Acute cholecystitis E Coli bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital with an inflammed gallbladder. * Your symptoms resolved after percutaneous drainage and you are now able to eat regular food without having discomfort. * Your drain will remain in place and you will continue oral antibiotics for 10 days. * Continue to stay hydrated and eat regular food. * The nurses will empty your drain daily and record the amount and consistency of the output. Bring this record with you to your next appointment and the doctor will decide if the tube can be removed. * If you develop any increased pain or have any new symptoms or concerns, call your doctor or return to the Emergency room. Followup Instructions: Provider: [Name10 (NameIs) ] CARE CLINIC Phone:[Telephone/Fax (1) 2359] Date/Time:[2112-1-28] 1:45 Completed by:[2112-1-13]	[ "486", "4019", "53081" ]
Admission Date: [2151-2-24] Discharge Date: [2151-3-2] Date of Birth: [2107-9-13] Sex: F Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: This is a 43 year-old female who was transferred in from a hospital in [Location (un) 3844] after suffering a right breast bite by her 18 month old boy. She presented to an outside hospital with significant swelling and erythema that was rapidly progressive in her right breast. She was then transferred to [Hospital1 190] for urgent intervention due to the significantly progressive nature of this spreading erythema. Upon presentation, she was found to be hypotensive with her systolic blood pressure in the low 90's. PHYSICAL EXAMINATION: On admission, her temperature was 99.9 with a heart rate of 99 and normal sinus rhythm; blood pressure 91/51 not on any pressor agents. Respiratory rate of 18. Her saturation was 98% on assist control of 50% FI02, 530 by 20 and a PEEP of 5. At this time, she was toxic appearing and also appeared sedated. She was normocephalic, atraumatic, with pupils equally round and reactive to light. Her neck was without swelling or masses or erythema at this time and her right breast was significantly erythematous and swollen throughout with signs of necrotic tissue in the right breast. This erythema was demarcated at this point and was extending over to the left breast, up over the level of the clavicle and down her right flank. There was also warmth at the site and no obvious purulent drainage or signs of a punctum. The patient was sedated and this could not be assessed for tenderness. Her abdominal exam was non distended with normoactive bowel sounds and soft and nontender throughout. There was no rebound or guarding. Extremity exam revealed no clubbing, cyanosis or edema. Neurologic exam revealed normal tone in all the extremities. She could not be adequately assessed for strength at this time. HOSPITAL COURSE: At this time, the patient was brought to the operating room for urgent intervention by Dr. [Last Name (STitle) 10656] with a working diagnosis of abscess and cellulitis of the right breast. She underwent at this time a left breast incision and drainage of the abscess with extensive debridement of necrotic tissue and skin. This was done under general endotracheal anesthesia. An incision was made in the inferior aspect of the breast and a small amount of [Doctor Last Name 352] fluid was obtained that was sent for culture. Tissue from the breast was also sent for culture as well as biopsy at this time. Extensive loculations were broken up. However, no significant pus was noted. Hemostasis was achieved adequately. The wound was then irrigated and copiously packed with large Kerlix dressings with subsequent dressing changes to occur. There were no drains placed at this time. The patient was then aggressively resuscitated in the ICU and received approximately 5 liters since the incision and drainage. She was now on clindamycin, Zosyn and Vancomycin for broad spectrum empiric coverage. She was monitored carefully in the ICU for any signs of increasing erythema or signs of septic response. She was now, at this time, able to be weaned off of Levophed on this first postoperative day. Also at this time, plastic surgery was consulted to determine the extent of the final breast defect and the possible eventual reconstruction. Also infectious disease was consulted at this point due to this extensive infection and their recommendations at this point were to add Zosyn to the regimen but to continue the rest of the antibiotics until we had further data from the operating room cultures. They would continue to follow the patient throughout her hospital stay. On the afternoon of postoperative day number 1, the patient's cellulitis seemed to be increasing and there was concern at this point of necrotizing fasciitis. She was brought back to the operating room for a second debridement and to search for any other signs of infection or collection. At this point, general surgery was also consulted to participate in this case. Concern at this point was due to the continued septic physiology and despite aggressive surgical treatment the prior day and broad spectrum antibiotics. During this procedure, a counter incision was made below the inframammary crease and the area cellulitis that appeared to have spread from her prior procedure. This was carried down to the fascia and there appeared to be no signs of infection at the level of the fascia. Thus, the patient had an extensive debridement of this infected breast tissue and significant debridement occurred until the skin edges showed brisk bleeding and viability. The patient was then brought to the PACU and the surgical ICU on Levophed. There were no drains placed at this time and there were no complications to this second operative procedure. Of note, at this time, her laboratory values revealed a likely compromise of renal function with a creatinine of 2.0 on postoperative day number one. She had been admitted with a creatinine of 1.9 with no known baseline. She was also persistently acidemic during this time. The plan continued to consist of aggressive resuscitation with goal to wean off the pressors that she was requiring. At this point, we had an identification of organisms as gram positive cocci but was still awaiting speciation at this time. The patient, at this point, was also on vasopressin per suggestion of the following general surgery team. This was done to decrease the volume requirement slightly. She was maintained with a urine output of approximately 30 ml an hour and was continued on the antibiotics. On postoperative day number 3, [2-27], the patient was started on tube feeds to provide enteral nutrition and was continued on pressors. She had chest x-rays that revealed her to likely to be in ARDS versus pulmonary edema but she was maintaining her urinary output at this time. She was also carefully being followed by the surgical ICU team. Infectious disease continued to follow the patient who suggested continued antibiotics unless we gained speciation, at which point they would recommend tailoring them. On Sunday [2-28], the patient received a cortisone stimulation test which she did not respond to. Hydrocortisone was started shortly thereafter at a dose of 50 mg q.i.d. . Enzymes were also checked at this time, due to the fact that the patient received a small bolus of Levophed in the ICU. The enzymes were elevated at this time with a troponin T peaking at 0.51 initially and a CK MB fraction of 9.8. We followed these enzymes serially as they decreased during this time to 0.32 the following day. Cardiology was consulted at this point and did not suggest any treatment with anticoagulation or other additions. They attributed this likely to a demand ischemia at this time, due to septic physiology and the increased Levophed. On [2151-3-1], the patient received an echocardiogram that revealed a normal left ventricular function. She also received a Swan-Ganz catheter at this time with slightly elevated pulmonary capillary wedge pressures. This revealed her to more than likely be adequately resuscitation. This still did not explain her low urine output at this time with her adequate left ventricular function and her continued septic physiology requiring multiple pressors. Levophed and Vasopressin were being given at high doses. We were unable to wean these at this time. We again discussed the case with infectious disease and they suggested a follow-up ultrasound of her right breast. We were unable to find any other collections to drain and it appeared that her mastitis had largely resolved with no signs of erythema, no signs of pus and adequate drainage of the wound, with continued Kerlix dressing changes. Also of note, there were no signs of any vegetations on the transthoracic echocardiogram. Her urine output continued to be marginal at this time. Also checked during this time were thyroid and hormone levels which revealed her free T4 to be 0.5 which was decreased, leading to a possible thought of this being a failure of the pituitary and the adrenal access having failed the cortisone stimulation. She was continued on hydrocortisone although she had really no response to this and continued to need all of the pressors, with no signs of improvement of her hypotension at this time. Early in the morning of postoperative day number 5 and 4, the patient was noted to have developed a wide complex tachycardia on EKG. She then was given 100 mg of Lidocaine IV at which point she went into cardiac arrest. CPR was started. ACLS protocol was initiated and a code was called. At this time, she was asystolic and after being given epinephrine IV and attempts at CPR, she developed ventricular fibrillation and was defibrillated at this time. The first one was successful; however, then she relapsed into ventricular fibrillation again. She was then given 300 mg of Amiodarone. She was given insulin, glucose and calcium for hyperkalemia for cardiac protection. Her acidosis was attempted to be corrected with bicarbonate solution; however, the patient did not respond. The ACLS protocol was stopped at 5:37 a.m. and the patient was declared expired at this time. The husband was reached during this time and notified of the events. He declined an autopsy. The case was reported to the medical examiner as well and they also declined the case. Dr. [Last Name (STitle) 10656] also at this time immediately discussed the case with the husband and they discussed all the events that occurred. DISCHARGE DIAGNOSES: Right breast mastitis and subsequent expiration. DISPOSITION: Medical examiner denied case and patient's husband refused autopsy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [MD Number(2) 66091] Dictated By:[Last Name (NamePattern1) 15912] MEDQUIST36 D: [2151-3-2] 18:38:18 T: [2151-3-2] 19:23:44 Job#: [Job Number 66092]	[ "78552", "2762", "99592" ]
Admission Date: [2183-7-20] Discharge Date: [2183-7-28] Date of Birth: [2139-2-11] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Paroxysmal Nocturnal Dyspnea Major Surgical or Invasive Procedure: [2183-7-22] - Mitral Valve Repair (28mm [Last Name (un) 3843] [Doctor Last Name ] Ring)and repair of anterior mitral leaflet tear. History of Present Illness: Mr. [Known lastname 12262] is a 44-year-old gentleman with a history of paroxysmal nocturnal dyspnea. He underwent evaluation which showed a severely depressed LV function in the 20% to 30% range along with severe mitral regurgitation. He also underwent a cardiac MRI which confirmed the findings, and had a very low effective forward left ventricular output. He therefore was referred for surgery. Past Medical History: Hypertension Sleep Apnea Hernia Repair Social History: Lives with wife and 1 child. Works in fire protection. Drinks occassionally Family History: HTN and diabetes in parents Physical Exam: GEN: WDWN in NAD SKIN: Unremarkable HEENT: Unremarkable LUNGS: Bibasilar rales HEART: RRR, 4/6 systolic murmur apex->axilla ABD: Benign EXT: 2+ pulses. No varicosities Pertinent Results: [2183-7-25] 06:05AM BLOOD WBC-9.6 RBC-3.09* Hgb-8.3* Hct-25.3* MCV-82 MCH-26.9* MCHC-33.0 RDW-13.6 Plt Ct-187 [2183-7-25] 06:05AM BLOOD Plt Ct-187 [2183-7-25] 06:05AM BLOOD Glucose-138* UreaN-18 Creat-1.0 Na-139 K-4.3 Cl-104 HCO3-28 AnGap-11 [2183-7-20] CXR No evidence for CHF. [2183-7-24] CXR There has been interval removal of the endotracheal tube, nasogastric tube, right internal jugular venous access sheath and pulmonary artery catheter, and mediastinal drains. There is stable cardiomegaly. The mediastinal contours appear unchanged. Sternal suture wires in unchanged configuration, and valvular prosthesis. Small bilateral pleural effusions, new since the previous examination. No congestive heart failure. Minimal atelectasis at the left base. No pneumothorax. The osseous structures appear unchanged. [2183-7-21] Abdominal Ultrasound Normal abdominal ultrasound. No abdominal aortic aneurysm [2183-7-22] EKG Sinus rhythm at 93 Long QTc interval Since previous tracing of [2183-7-20], the rate has increased [Last Name (NamePattern4) 4125]ospital Course: Mr. [Known lastname 12262] was admitted to the [Hospital1 18] on [2183-7-20] for surgical management of his mitral valve disease. He was worked-up in the usual preoperative manner including an abdominal ultrasound which was negative for an abdominal aortic aneurysm. His renal arteries were normal as well and not a factor in his hypertension. On [2183-7-22], Mr. [Known lastname 12262] was taken to the operating room where he underwent a mitral vale repair utilizing a 28mm [Last Name (un) 3843] [Doctor Last Name ] annuloplasty band. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [Known lastname 12262] [Last Name (Titles) 5058] neurologically intact and was extubated. He was then transferred to the cardiac surgical step down unit for further recovery. Mr. [Known lastname 12262] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His drains and wires were removed per protocol. An ace inhibitor was started for afterload reduction. Beta blockade was titrated for optimal heart rate and blood pressure control. Mr. [Known lastname 12262] continued to make steady progress and was discharged home on postoperative day eight. He will follow-up with Dr. [Last Name (Prefixes) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Labetolol 300mg twice daily Lisinopril 25mg twice daily Norvasc 10mg daily Lasix 40mg daily Potassium 40mEq daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for 2 weeks. Disp:120 Tablet(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 2 weeks. Disp:80 Tablet(s) Refills:0 5. 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 6. 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 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:120 Tablet(s) Refills:2 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:360 Tablet(s) Refills:2 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] home care Discharge Diagnosis: Mitral regurgitation Discharge Condition: Good Discharge Instructions: you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month do not drive for 1 month Followup Instructions: Provider: [Last Name (Prefixes) 413],[First Name3 (LF) 412] [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month Provider: [Name10 (NameIs) 17010] cardiologist Appointment should be in [8-3] days Completed by:[2183-8-20]	[ "4240", "4019" ]
Admission Date: [2106-4-6] Discharge Date: [2106-4-15] Date of Birth: [2038-4-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1990] Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: Bedside debridement of ulcerations by plastic surgery team History of Present Illness: 68M with h/o t4 paraplegia x 2yrs, felt [3-13] "inflammatory spinal disease", with a chronic indwelling foley, sacral decubitus ulcers, presents to [Hospital1 18] from rehab after RN noted 1d of fever (tmax 101.8). [Name8 (MD) ] RN caring for pt at rehab, pt noted some mild abdominal discomfort (chronic), but otherwise denied any recent symptoms of cough, n/v, constipation, rash. Pt has been having chronic diarrhea (x3/day, x2-3/night) for past 1yr, etiology unclear. [Name2 (NI) 227] persistent fevers x24hrs, pt was brought to [Hospital1 18] ED. [Name8 (MD) ] RN BP prior to leaving rehab was 100/72. . Per pt, he notes chronic abdominal pain, "always there", diffuse, sharp, sometimes awakening him from sleep, no relation to food or BMs. somewhat worse over the preceding 4 months, but actually improving over the past few days. At present, he states his pain has completely resolved. ROS otherwise significant for +orthopnea, pt also notes nonproductive cough x 3 weeks, no flu sx (body aches, congestion, sore throat). Pt denies flut shot or pneumovax. +sick contacts (lives in [Hospital 100] Rehab). . Upon arrival in ED VS=100.4 100 87/51 12 95%RA. UA was c/w UTI, pt was started on vanco and zosyn, UCx and BCx sent. sacral ulcers felt to be stage 4, no evidence of superinfection. BP initially responded to 3L IVF (99/53), however after 3rd litre, BP down to 85/40, pt therefore received RIJ TLC, and possibly an additional 1L IVF bolus, afterwhich BP improved to 115/70. Pt was asymptomatic, mentating throughout without specific complaints. . Pt also noted moderate abdominal tenderness. CT ABD done which showed no acute processes. CXR unremarkable, EKG unremarkable (old Q in III, ?mild ST changes V1). . Pt admitted to ICU for further monitoring given hypotension. . Past Medical History: 1. Inflammatory disease of the spinal cord of uncertain etiology. MRA [10-16] negative for vascular malformation. Initial CSF analysis showed elevated protein (82) without oligoclonal bands. NMO blood titer negative, RPR negative, Lyme serology negative, [Doctor First Name ] negative, Ro and La negative, ACE level normal, neuromyelitis IgG negative, ESR 70, CRP 66.8. Ultimately treated with broad spectrum antibiotics, corticosteroids (two weeks of Solu-Medrol followed by a prednisone taper), and 5 days of mannitol without improvement. He is followed by neurology for a dense paraplegia (T4) with neuropathic pain, restrictive shoulder arthropathy, and a neurogenic bladder requiring a chronic indwelling foley. 2. Chronic sacral decubitus ulcer, previously treated with a VAC dressing 3. Multiple UTI (including Pseudomonas) 4. Pulmonary embolus [11-15] s/p IVC filter placement 5. Asthma 6. Two-vessel coronary artery disease s/p CABG 4-5 years ago 7. Systolic CHF (EF 25-30% on [2-15] TTE) 8. Repaired liver laceration 9. Chronic back pain 10. Vitiligo 11. Feeding tube 12. Depression 13. MRSA from sacral swab and sputum 14. Prior transient episodes of leg paralysis 15. Right frontal lobe brain lesion biopsied [11-15] and c/w gliosis; resolved on repeat imaging 16. Abnormal visual evoked potentials Social History: He moved here from [Country 3594] (after living in many different countries) in the [2068]. He is retired from a job in the maritime industry. Divorced 24 years ago. Three children. Quit smoking [2076]. Quit drinking [2080]. No history of illicit drug use or abuse. Family History: No stroke, aneurysm, no seizure, no AAA. Physical Exam: VS: 96.6 85 105/66 15 100%2L Gen: Well appearing male in NAD lying in bed. HEENT: JVD <6-8cm, MMM, lips slightly pale. Chest: CTA bilaterally, no w/r/r. CV: RRR, physiologic splitting S2, no r/g. 3/6 SEM @ LSB. Abd: Soft, nontender to deep palpation in all four quadrants, distended, tympanic (?gas), negative murphys sign, well-healed midline g-tube scar. Extremities: Warm, well perfused, no C/C. [2-10]+ edema bilaterally to knees. Skin: Vitiligo on hands. Large round 6x4 cm diameter pressure decubitus ulcer on sacrum and 4x3cm decub ulcer on left ischial tuberosity. Appears clean with granulation tissue in center, no s/sx of infection. no purulent drainage. Neuro: CN grossly intact. A&O x 3, pleasantly conversant. Pertinent Results: [2106-4-5] 11:50PM BLOOD WBC-9.08 RBC-4.37* Hgb-11.2* Hct-34.9* MCV-80* MCH-25.6* MCHC-32.0 RDW-15.1 [2106-4-8] 04:47AM BLOOD WBC-6.7 RBC-3.49* Hgb-8.9* Hct-28.5* MCV-82 MCH-25.6* MCHC-31.4 RDW-14.9 [2106-4-5] 11:50PM BLOOD Glucose-125* UreaN-11 Creat-0.5 Na-137 K-4.0 Cl-101 HCO3-27 AnGap-13 [2106-4-8] 04:47AM BLOOD Glucose-109* UreaN-5* Creat-0.4* Na-139 K-3.7 Cl-110* HCO3-23 AnGap-10 [2106-4-6] 10:27PM BLOOD CK-MB-5 cTropnT-0.08* [2106-4-6] 08:11AM BLOOD cTropnT-0.08* [2106-4-5] 11:50PM BLOOD CK-MB-NotDone cTropnT-0.09* [2106-4-8] 04:47AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0 [2106-4-6] 12:05PM BLOOD Cortsol-15.3 [2106-4-6] 12:05PM BLOOD CRP-122.0* [2106-4-6] 01:45PM BLOOD Lactate-1.4 [2106-4-6] 12:00PM BLOOD Lactate-0.7 [2106-4-6] 12:02AM BLOOD Lactate-1.7 CT ABD/Pelv [2106-4-6]: 1. Severe sacral and right ischial tuberosity decubitus ulcers. 2. No acute intra-abdominal inflammatory process. 3. Cholelithiasis. CXR [4-6] Bedside frontal chest radiograph is compared to [2106-1-2] and demonstrate clear lungs, normal pulmonary vasculature, and no evidence for pleural effusions. The heart and mediastinal contours, remarkable for tortuous aorta, are stable. This patient is status post median sternotomy. IMPRESSION: No acute cardiopulmonary process. EKGs: NSR, essentially unchanged from prior tracings WBC scan; IMPRESSION: 1. Unchanged appearance of residual sacrum with adjacent posterior focal radiotracer uptake, again apparently within adjacent soft tissues. However, given the proximity of the uptake, bony involvement with infection cannot be excluded. 2. Similar sclerotic appearance of right lower ischium and adjacent soft tissue thickening. Although the CT appearance suggests chronic osteomyelitis, immediately adjacent radiotracer activity has resolved and the bony abnormality appears unchanged. 3. New cellulitis along the right lower buttock, at the interface with the thigh and inferior to the prior site of infection. 4. More extensive radiotracer uptake in the left lower buttock, with fat stranding on CT suggesting cellulitis. Although the soft tissue abnormality extends to the ischial tuberosity, there is no CT evidence of bone destruction or abnormal bony radiotracer uptake in this area. [2106-4-6] 6:38 pm SWAB Source: left ischial tuberosity. FINAL REPORT [2106-4-10] GRAM STAIN (Final [2106-4-6]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2106-4-10]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). Susceptibility will be performed on P. aeruginosa and S. aureus if sparse growth or greater. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([8-/2404]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [2106-4-10]): NO ANAEROBES ISOLATED. [2106-4-6] 6:38 pm SWAB Source: sacral decubitus ulcer. FINAL REPORT [2106-4-10] GRAM STAIN (Final [2106-4-6]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2106-4-10]): ESCHERICHIA COLI. RARE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| PSEUDOMONAS AERUGINOSA \| \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S 4 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S 8 S PIPERACILLIN/TAZO----- <=4 S 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final [2106-4-10]): NO ANAEROBES ISOLATED. Brief Hospital Course: A/P: 67M h/o T4 paraplegia, recurrent UTIs [3-13] indwelling foley, multiple stage 4 decubs was admitted to ICU initially with fever to 101.8, transient hypotension that resolved with 3-4L IVF but continued on sepsis protocol. . # FEVER - Felt due to UTI and or osteomyelitis. Cx. all neg, but swab suggested colonization with mrsa; also seen on swab, pseudomonas and enterococcus. Emperically treated with vancomycin and zosyn given this information and prior culture data that was reviewed here. Tagged wbc scan as above. Plastic surgery consult evaluated wounds and felt that pt. did not have evidence of osteomyelitis. Plan two weeks of abx for empiric treatment for complicated UTI. Foley replaced. Follow up with [Month/Day (2) ] arranged for evaluation for suprapubic catheter. Follow up with plastic surgery also arranged. . # HYPOTENSION - resolved with IVF and treatment of infection as above. # H/O PE - s/p IVC filter, INR elevated, so warfarin held, then given 5 po vitamin K given sustained inr over 4.0. INR came down to 1.8 with this, so warfarin resumed. Otherwise, home medication regimen continued in hospital for other chronic medical issues as outlined in pmhx. and in medication list below. Medications on Admission: vitamin c 500mg po qdaily aspirin 81mg po qdaily baclofen 5mg po tid calcium carbonate 650mg po bid citalopram 40mg po qdaily pepcid 20mg po qdaily advair 250/50 IH [Hospital1 ] gabapentin 400mg po bid simethicone 80mg po tid simvastatin 40mg po qdaily tramadol 25mg po tid ursodiol 300mg po qdaily warfarin 3mg po qdaily prostat 30ml oral [Hospital1 ] (liquid protein supplement) . Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. gram 2. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 7 days. 3. Sodium Hypochlorite 0.25 % Solution Sig: One (1) Appl Miscellaneous ASDIR (AS DIRECTED) for 1 days: apply to ischial wounds only, for one day ([4-16]) in [Hospital1 ] wet to dry dsg changes. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [Hospital1 ] (2 times a day). 9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QDAILY (). 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 19. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [2-10] Tablet, Rapid Dissolves PO Q8H (every 8 hours) as needed. 20. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: UTI with sepsis Chronic sacral and ischial decubitus ulcerations Chronic, systolic, heart failure Hx. PE with SVC filter, on warfarin Discharge Condition: Stable Discharge Instructions: Return to the [Hospital1 18] Emergency Department for: Fever Hypotension Followup Instructions: Provider: [Name10 (NameIs) ] SURGERY CLINIC Phone:[Telephone/Fax (1) 4652] Date/Time:[2106-4-23] 1:30 For evaluation for suprapubic catheter placment: Provider: [Name10 (NameIs) ] UNIT Phone:[Telephone/Fax (1) 164] Date/Time:[2106-4-28] 9:30	[ "0389", "5990", "V4581", "4280", "V5861" ]
Admission Date: [2149-8-31] Discharge Date: [2149-9-1] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1271] Chief Complaint: fall Major Surgical or Invasive Procedure: None History of Present Illness: 89 y/o male on Coumadin, history of HTN and Afib, presented to OSH s/p fall today at home. He was noted to have a 4mm L SDH on CT scan and transferred to [Hospital1 18] for further neurosurgical workup. He states that while getting his cat out of his bedroom, he slipped on the [Last Name (un) ] floor and fell backwards and hit his head. He denies any loss of consciousness or focal neurological deficits at this time. Past Medical History: HTN, Afib, DJD, BPH, peripheral neuropathy, Lumbar stenosis, b/l cataract surgery Social History: Lives in [Location 47] MA, with wife, lives in a basement appt, must walk up stairs. Denies Tobacco, EtOH occasional and denies drug use. Family History: CVA - father, CAD - father/brother. [Name (NI) ] bleeding d/os Physical Exam: Physical Exam: Vitals: T:98.9F P:69 R: 14 BP:172/77 SaO2:98%RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, multiple skin lesions consistent with SK. Neck: Supple Pulmonary: deferred Cardiac: deferred Abdomen: soft, NT/ND. Extremities: No edema, warm and dry. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [Doctor Last Name 1841] backward without difficulty. Language is fluent with intact repetition and comprehension. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2.5mm b/l, surgical. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: slight L NLF, slight asymmetry on the smile. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. B/L UE tremor, noted. No asterixis noted. Strength - Full in UE throughout except for L delt, 4+/5. LEs 4+/5 R and L IP, [5-27] distally. -Sensory: Light touch - intact in UEs, [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] impaired, L intact. Pinprick - not examined Cold sensation - intact in LEs and UEs. Vibratory sense - impaired in RLE to knee where it is diminished, in LLE to knee where it is diminished. Proprioception - intact in UEs, impaired at toes b/l. No extinction to DSS. -DTRs: 0-1 throughout, symmetric. Plantar response was mute on R and L. -Coordination: Intention tremor, impaired FNF and HKS bilaterally. -Gait: Positive romberg, difficult to maintain balance even with eyes open. did not assess gait. Physical Exam on Discharge: A&O X3 Pupils R surgical L [3-24] minimally reactive Face symmetrical Tongue midline Negative Pronator Drift Motor B T D IP HAM QUAD [Last Name (un) ] AT [Last Name (un) 938] R 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 Pertinent Results: CT HEAD W/O CONTRAST Study Date of [2149-8-31] 12:31 PM Stable small left subdural hematoma CT C/L Spine [2149-8-31] IMPRESSION: 1. No evidence of acute fracture. 2. Extensive degenerative changes of the lumbar spine with canal stenosis as described above. If radiculopathy is present, MRI can be performed to assess for nerve root impingement. 3. Calcification of the descending aorta and its branches. CT head [2149-9-1] Stable CT scan of L SDH. Labs: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2149-9-1] 04:00AM 6.7 4.31* 13.2* 38.6* 90 30.7 34.2 12.8 149* PT:14.7 PTT:27.3 INR: 1.3 Brief Hospital Course: Patient is a 89 y/o male who sustained a fall after trying to take his cat out of the bedroom and tripping on his hardwood floors. He was sent to an OSH where a CT scan of the head showed a L SDH. He was then transferred to [Hospital1 18] for further neurosurgical workup. Upon arrival, patient was neurologically stable, had some difficulty with Romberg, difficulty maintaining balance with eyes open as well. Cranial nerves were intact and he had full motor strength. On [9-1], pt had a repeat head in the morning which was stable. Physical therapy and occupational therapy saw the pt today and decleared him safe to go home. Patient will be discharged home today. Medications on Admission: Digoxing 0.25mg daily, Metoprolol 50mg daily, Diovan 80mg daily, coumadin 2.5/5mg [Last Name (LF) ], [First Name3 (LF) ] EC 81mg, MVI. Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:30 Refills:2 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: L SDH Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have results faxed to [Telephone/Fax (1) 87]. ?????? 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. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) 739], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2149-9-1]	[ "4019", "42731", "V5861" ]

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