Split (3)

train · 39.4k rows

text stringlengths 215 55.7k	label list
Admission Date: [2192-10-22] Discharge Date: [2192-10-30] Date of Birth: [2119-1-11] Sex: F Service: CARDIOTHORACIC Allergies: Ciprofloxacin / Nickel Sulfate Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [2192-10-25] Off Pump Coronary Artery Bypass Grafting Surgery utilizing the LIMA to LAD, SVG to OM, and SVG to PDA [2192-10-22] Cardiac Catheterization History of Present Illness: Ms [Known lastname 34850] is a 73-y/o lady w PMHx sig for DM2, known CAD (s/p cath in [2185] and [2189] - occluded LAD, 50-70% lcx, 60%rca, tx'd medically), chronic systolic CHF (LVEF ~35%), and recent hospital admission at [Hospital1 2177] in [8-/2192] for similar sxs (found to have NSTEMI, CHF exacerbation and PNA, s/p viability study showing inferior infarct and basal inferior ischemia, scheduled for ICD placement in [10/2192], but pt decided to switch care). Pt was in his USOH after discharge, but about a week PTA, she began experiencing progressive SOB at rest, but no chest pain. She was admitted to OSH on [10-18], and was found have CHF exacerbation (BNP 1550), treated subsequently with furosemide diuresis. Found to have troponin 0.58, and EKG showing anterolateral and inferior ST depressions. Pt was transferred to [Hospital1 18] for cath. Past Medical History: Coronary Artery Disease, Chronic Systolic Heart Failure NIDDM Hypertension COPD Dyslipidemia Rheumatoid Arthritis Descending thoracic aortic aneurysm (4.8 cm) History of Pneumonia Pulmonary Nodules Diverticulosis s/p Ventral Hernia Repair Social History: Lives with daughter. [Name (NI) 6934] with walker. Independent in ADLs. Smoking: 50-70 py, quit in [8-/2192] EtOH: denies Drugs: denies Family History: Multiple siblings had CAD. Physical Exam: Admit PE - 98.2, 103/48, 70, 18 Gen: Elderly lady in NAD, back HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with normal JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge: vitals: T98.4 HR 96 BP 131/63 RR 20 O2sat 99%-RA Gen: WF, NAD, appears stated age HEENT: NCAT, EOMI Lungs: crackles b/l bases, otherwise clear CV: RRR, no murmur or rub Abd: NABS, soft, non-tender, nondistended Ext: trace edema Incisions: sternotomy- c/d/i no erythema or drainage, LEVH- minimal serous drainage from inferior stab incision, knee site c/d/i Pertinent Results: [2192-10-22] 04:15PM BLOOD WBC-8.2 RBC-3.77* Hgb-11.3* Hct-32.9* MCV-87 MCH-29.9 MCHC-34.2 RDW-14.0 Plt Ct-329 [2192-10-22] 04:15PM BLOOD PT-14.9* PTT-21.7* INR(PT)-1.3* [2192-10-22] 04:15PM BLOOD Glucose-114* UreaN-24* Creat-0.7 Na-139 K-4.0 Cl-101 HCO3-29 AnGap-13 [2192-10-22] 04:15PM BLOOD ALT-14 AST-17 AlkPhos-71 Amylase-45 TotBili-0.6 [2192-10-22] 04:15PM BLOOD Albumin-3.6 [2192-10-24] 05:05AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.2 [2192-10-22] 04:15PM BLOOD %HbA1c-6.1* [2192-10-23] 05:20AM BLOOD Digoxin-0.5* [2192-10-30] 05:48AM BLOOD WBC-12.0* RBC-3.11* Hgb-9.0* Hct-26.3* MCV-85 MCH-28.8 MCHC-34.1 RDW-17.9* Plt Ct-345# [2192-10-30] 05:48AM BLOOD Plt Ct-345# [2192-10-25] 03:40PM BLOOD PT-16.2* PTT-31.3 INR(PT)-1.4* [2192-10-28] 07:50AM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-136 K-4.4 Cl-98 HCO3-25 AnGap-17 [2192-10-23] CT CHEST WITH CONTRAST 1. 9 x 11 right upper lobe nodule is adjacent to the tracheal wall with no residual fat plane on one image, worrisome for primary lung cancer, should be further evaluated with PET CT. Scattered borderline lymph nodes up to 8 mm in the right upper paratracheal region. 2. Mild emphysema. Diffuse bronchial wall thickening. 3. Focal areas of fibrosis and bibasilar atelectasis. 4. Severely atherosclerotic aorta with aneurysmal dilatation of the descending aorta. Rim-like calcification of the aorta with asymmetric thrombus of the descending thoracic aorta. 5. Coronary artery calcifications. 6. Fluid-density lesion in the right cardiophrenic angle, could be a pericardial cyst, could also be further evaluated by PET CT. [2192-10-23] CAROTID SERIES Moderate plaque with a left 60-69% carotid stenosis. On the right, there is a less than 40% stenosis. 1. Coronary angiography of this left dominant system revealed severe native three vessel coronary disease. The LMCA had no obstructive coronary disease. The LAD was totally occluded proximally. The LCX had a 95% mid vessel stenosis. OM1 had an ostial 60% and 90% mid stenosis. The LPDA was non-obstructed. The RCA had severe diffuse disease up to 80% in the mid-portion with collaterals to the LAD. 2. Limited resting hemodynamics revealed normal systemic arterial pressure with an SBP of 133 mm Hg. Brief Hospital Course: From the ED, the patient went to cardiac catheterization which showed severe 3vCAD - LMCA had no obstructive; LAD was totally occluded proximally; LCX had a 95% mid vessel stenosis; OM1 had an ostial 60% and 90% mid stenosis; LPDA was non-obstructed; RCA had severe diffuse disease up to 80% in the mid-portion with collaterals to the LAD. No stenting was done. Cardiac surgery was consulted to evaluate for CABG. CT chest, carotid ultrasound, PFTs and urinalysis were performed to assess the candidate's status for surgery. CT chest revealed a 1cm nodule, noted previously at the OSH. Thoracic surgery and pulmonology evaluated the nodule and felt it could be worked up as an outpatient. She was brought to the operating room on [10-25] where she underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. In summary she had an off pump CABGx3 with LIMA-LAD, SVG-OM, SVG-PDA. . She tolerated the operation well and following surgery she was transferred to the CVICU for invasive hemodynamic monitoring in stable condition. She remained hemodynamically stable in the immediate post-op period, her anesthesia was reversed she was weaned from sedation, awoke neurologically intact and extubated. She was transferred to the step down unit on POD 1. Chest tubes and pacing wires were discontinued without complication. On POD 3 the patient developed rapid atrial fibrillation to the 140s. She was given a loading dose of oral amiodarone, 600mg, and electrolytes were repleted. Beta blocker was titrated as tolerated and the patient did convert to sinus rhythm. The remainder of her hospital course was uneventful and on POD5 she was discharged to rehabilitation at Lifecare [Location (un) 5165]. Medications on Admission: Aspirin 325mg PO daily, Digoxin 0.125mg daily, Metoprolol succinate 50mg PO daily, Lisinopril 20mg PO daily, Isosorbide Mononitrate SR (Imdur) 30mg PO daily, Metformin 500mg PO BID, Simvastatin 10mg PO daily, Furosemide 40mg PO daily, Magnesium Oxide daily, Esomperazole 40mg PO daily, Colace 100mg PO daily, Hydroxychloroquine 200mg PO daily, RISS, Heparin SQ TID, Was also on ceftriaxone on transfer (?) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 4. 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 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:60 Tablet(s) Refills:0 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 200mg twice daily for 1 week, then 200 mg daily. Disp:60 Tablet(s) Refills:0 9. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:60 Tablet(s) Refills:0 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:1 12. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:60 Tablet Sustained Release(s) Refills:2 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) 5165] Discharge Diagnosis: Coronary Artery Disease - s/p Off Pump CABG Chronic Systolic Heart Failure NIDDM Hypertension COPD Dyslipidemia Rheumatoid Arthritis Pulmonary Nodule Carotid Diseases Discharge Condition: Good 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 or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: [Hospital 409] clinic in 2 weeks Dr. [Last Name (STitle) ] in 4 weeks, call for appt Dr. [Last Name (STitle) ] [Last Name (STitle) ] [1-29] weeks, call for appt Dr. [Last Name (STitle) 17321] in [1-29] weeks, call for appt Completed by:[2192-10-30]	[ "41401", "9971", "42731", "4280", "496", "25000", "412", "4019", "2724" ]
Admission Date: [2163-2-2] Discharge Date: [2163-2-17] Date of Birth: [2085-4-10] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old female with a history of chronic obstructive pulmonary disease with recent right total knee replacement in [2162-11-25]. Rehabilitation stay complicated by a left hip fracture. Status post open reduction/internal fixation in [2162-12-26]. Her surgeries were performed in [State 531], and she was initially in rehabilitation there, but she was later transferred to [Hospital6 85] in [Location (un) 86] because this facility is closer to her family. At [Hospital3 ], she was found to have a temperature of 102.5 degrees Fahrenheit as well as a desaturation to 89% on room air and 95% on 2 liters with decreased breath sounds at both bases. The patient was transferred to [Hospital1 188] for was of the fevers. Blood cultures were drawn at rehabilitation, and she received 1 gram of cefepime intravenously en route. On arrival in the Emergency Department, the patient complained of low back pain that was related to position, and she stated this had been going on for weeks. She also complained about two days of abdominal pain. She denied nausea, vomiting, diarrhea, or constipation. She also reported about one week of a cough productive of yellow and green sputum with no hemoptysis. She reported worsening dyspnea above her baseline. She denied headache, chest pain, melena, bright red blood per rectum, dysuria, or any new rashes. Urinalysis was consistent with a urinary tract infection. An abdominal computed tomography showed no diverticulitis but a question of left lower lobe consolidation. She was started on levofloxacin and metronidazole. She also received hydrocortisone 100 mg intravenously times one because she takes steroids chronically, and it was felt she may need stress-dose steroids. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease and asthma. 2. Diabetes mellitus (on insulin). 3. Total knee replacement on the right on [2162-12-17]. 4. Left hip fracture; status post pinning in [2162-11-25]. 5. Hypertension. 6. Diverticulitis. 7. Chronic renal insufficiency (with an unknown baseline creatinine). 8. History of urinary tract infection. 9. Remote thyroidectomy; now hypothyroid. 10. Depression. MEDICATIONS ON ADMISSION: 1. Prednisone 5 mg by mouth once per day. 2. Zocor 40 mg by mouth once per day. 3. Lantus insulin 20 units subcutaneously at hour of sleep. 4. Toprol-XL 25 mg by mouth once per day. 6. Multivitamin one tablet by mouth once per day. 7. Iron sulfate 325 mg by mouth twice per day. 8. Lisinopril 20 mg by mouth once per day. 9. Clonidine 0.1 mg by mouth twice per day. 10. Synthroid 50 mcg by mouth once per day 11. Advair 1 puff inhaled once per day. 12. Protonix 40 mg by mouth once per day. 13. Ritalin 2.5 mg by mouth in the morning. ALLERGIES: She has an allergy to SULFA. SOCIAL HISTORY: No tobacco. No alcohol. She lives in [State 16269] with her husband. REVIEW OF SYSTEMS: Positive for heartburn. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed her temperature was 103.8 degrees Fahrenheit, her blood pressure was 146/80, her pulse was 136, her respiratory rate was initially 34 and later 16, her oxygen saturation was 98% on room air. In general, she was an upset female in no acute distress. She was complaining of back pain. Head, eyes, ears, nose, and throat examination revealed the mucous membranes were slightly dry. The neck was supple. There was no lymphadenopathy. The lungs had diffuse scattered rhonchi, and there were decreased breath sounds at both bases. Cardiovascular examination revealed a regular rate and rhythm. No murmurs. The abdomen was obese. Slight bilateral left quadrant tenderness. There was no rebound or guarding. There were normal active bowel sounds. Extremity examination revealed no clubbing, cyanosis, or edema. Dorsalis pedis pulses were 1 to 2+ bilaterally. On neurologic examination, she was alert and oriented times three with no focal signs. Back revealed no costovertebral angle tenderness. PERTINENT LABORATORY VALUES ON PRESENTATION: Complete blood count revealed her white blood cell count was 19.8 (with 90% neutrophils and 5% lymphocytes), her hematocrit was 33.9, and her platelets were 432. Chemistry-7 revealed sodium was 135, potassium was 5.1, chloride was 101, bicarbonate was 22, blood urea nitrogen was 20, creatinine was 1.2, and blood glucose was 186. Aspartate aminotransferase was 32, her alanine-aminotransferase was 15, her alkaline phosphatase was 117, and her total bilirubin was 0.4. Her lipase was 14 and amylase was 17. Albumin was 2.6. Lactate was 2.8. Urinalysis revealed a specific gravity of 1.018, large blood, nitrite positive, moderate leukocyte esterase, 500 protein, trace ketones, more than 50 red blood cells, and more than 50 white blood cells. PERTINENT RADIOLOGY/IMAGING: A computed tomography of the abdomen revealed no appendicitis. There was sigmoid diverticulosis with no diverticulitis. There were hyperdense right renal cysts. There was a left lower lobe consolidation thought to represent atelectasis versus pneumonia. A chest x-ray showed a right lower lobe consolidation. IMPRESSION: The patient is a 77-year-old woman with diabetes, chronic obstructive pulmonary disease, and recent orthopaedic procedures who presented from rehabilitation with fever, back pain, and hypoxia. SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. FEVER ISSUES: The patient's blood cultures from [Hospital6 85] grew methicillin-resistant Staphylococcus aureus. The patient was started on vancomycin with gentamicin added for synergy. Sources were felt to be either the patient's newly installed prostheses, her heart, or her back. Plain films of the prostheses were unremarkable, and there was no significant pain upon moving her right knee or left hip. She did not have effusions on examination, nor were the joints warm or tender. Attention was next turned to the possibility of endocarditis. A transesophageal echocardiogram was planned for [2-7], but it could not be performed because of lack intravenous access and the patient's confusion. Therefore, a transthoracic echocardiogram was performed on [2-9] which showed global left ventricular hypokinesis with an ejection fraction of 25%; most consistent with multivessel coronary artery disease. There was 1 to 2+ tricuspid regurgitation with a right atrium to right ventricular gradient to 36 mmHg. There was 2+ mitral regurgitation. No vegetations were seen. The possibility of an infectious focus in the patient's back was evaluated. A magnetic resonance imaging of the lumbar spine was a poor study because of motion artifact that showed abnormal signal from L1 to L5 with probable epidural abscess, osteomyelitis, and L5-S1 discitis. It was unclear how this abscess developed. On [2-17], the patient was placed under general anesthesia and had a repeat magnetic resonance imaging to further delineate the focus of infection. This clearly demonstrated an L5-S1 discitis with an epidural abscess and osteomyelitis. The patient was taken to the operating room, and the area was debrided by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1338] of Neurosurgery. The remainder of the postoperative course will be dictated in an Addendum. 2. BACTEREMIA ISSUES: As mentioned, the patient had blood cultures positive for methicillin-resistant Staphylococcus aureus. These remained positive despite vancomycin and gentamicin therapy from [2-2] through [2-7]. From [2-8] through [2-11], repeat blood cultures were sterile. On [2-15], gentamicin was discontinued because her creatinine increased to 1.6. There was concern for gentamicin toxicity. The patient was afebrile from [2-3] through the time of this dictation ([2-17]). 3. QUESTION OF ASPIRATION PNEUMONIA ISSUES: The patient was noted to have increasing oxygen requirements with thick secretions. Given the patient's depressed mental status (see below), there was concern for aspiration pneumonia. A chest x-ray showed bibasilar atelectasis that had increased on the right along with a right-sided effusion. Her oxygen saturation was 98% on a 35% face mask. She was started on piperacillin tazobactam for broad coverage of nosocomial pathogens. A sputum culture grew methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa that was resistant to levofloxacin and sensitive to piperacillin tazobactam. The patient's oxygen saturation improved, and on [2-14] was up to 99% on 1 to 2 liters. Her secretions improved on [2-14] and were essentially resolved by [2-15]. She did not spike a temperature. On [2-17], the piperacillin tazobactam was discontinued because of a concern of acute interstitial nephritis. 4. CHANGE IN MENTAL STATUS ISSUES: Over the first week of the hospitalization, the patient's mental status deteriorated. She became confused, disoriented, unable to follow commands, and pulled at her tubes and lines. This was felt to be secondary to delirium from infection. When studies needed to be performed, she was given Haldol intermittently with moderate-to-good affect. 5. ATRIAL FIBRILLATION ISSUES: The patient was briefly in atrial fibrillation with a rapid ventricular response. She did not have a known history of atrial fibrillation. Her ventricular rate was in the 150s, but she was not hemodynamically unstable. She was briefly on a diltiazem drip with good control, and she ultimately spontaneously converted to a normal sinus rhythm. The diltiazem was discontinued, and she was loaded on amiodarone 400 mg by mouth twice per day which should be halved in one week. 6. CONGESTIVE HEART FAILURE ISSUES: The patient was found to have an ejection fraction of 25% and 2+ mitral regurgitation. There was no known prior history of congestive heart failure. It was unclear when the patient developed systolic dysfunction. It was presumed that she had multivessel coronary artery disease from the multifocal wall motion abnormalities noted on echocardiogram. The patient was continued on beta blockade, and ACE inhibitor and furosemide was started to decrease preload and afterload. However, when the patient's renal function worsened the ACE inhibitor and Lasix were discontinued. She was not felt to be in any significant amount of pulmonary edema at any time up to the point of this dictation. 7. ACUTE RENAL FAILURE ISSUES: The patient had deteriorating renal function from [2-13] when her creatinine was 1.1 to [2-17] when it was 2.1. The urine was evaluated by the Nephrology team and felt to be bland sediment. Urine eosinophils were positive but rare. Because of the possibility of acute interstitial nephritis, piperacillin was discontinued. Gentamicin-induced acute tubular necrosis remained a possibility. Her fractional secretion of sodium was 6.9%, so a prerenal problem was unlikely. 8. ANEMIA ISSUES: The patient had an anemia that was of unclear etiology. She was transfused 2 units of packed red blood cells on [2-8] when her hematocrit was 27.5. Her hematocrit increased appropriately with the transfusion. It remained stable at approximately 30. 9. ORAL HERPES SIMPLEX VIRUS ISSUES: The patient developed oral lesions that were felt to be consistent with herpes simplex virus. These were cultured, and at the time of this dictation there had been virus isolated. However, she was empirically started on acyclovir due to the high likelihood of this being herpes. 10. CHRONIC OBSTRUCTIVE PULMONARY DISEASE/ASTHMA ISSUES: The patient has been on prednisone 5 mg by mouth once per day for a long time, and this was continued. She was given stress-dose steroids immediately prior to surgery. 11. HYPOTHYROIDISM ISSUES: The patient was continued on Synthroid 50 mcg by mouth once per day. 12. ACCESS ISSUES: On [2-7], the patient was without peripheral access, and multiple attempts were unsuccessful to achieve access. A right subclavian line was placed on [2-7] and was removed on [2-17]. A right internal jugular line was planned for intraoperative placement. 13. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was evaluated by the Swallow Service who felt that she was a high aspiration risk due to impaired swallow function. An nasogastric tube was placed, and she received approximately three days of full-strength tube feeds prior to proceeding to the operating room for epidural abscess debridement. The Swallow Service recommended percutaneous endoscopic gastrostomy tube placement in the event her swallowing function does not recover following the operation. 14. COAGULOPATHY ISSUES: The patient had an INR of approximately 2 for the first and second weeks of her hospitalization which was likely secondary to malnutrition and vitamin K deficiency in her diet. She was given vitamin K and the coagulopathy resolved. 15. PROPHYLAXIS ISSUES: The patient was maintained on heparin subcutaneously for deep venous thrombosis prophylaxis. 16. CODE STATUS: Full. NOTE: The remainder of the hospital stay will be dictated in an Addendum. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Name8 (MD) 2734] MEDQUIST36 D: [2163-2-17] 17:57 T: [2163-2-17] 19:38 JOB#: [Job Number 55039]	[ "5990", "42731", "4240" ]
Admission Date: [2151-11-28] Discharge Date: [2151-12-1] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins Attending:[First Name3 (LF) 2736] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization PA catheter placement History of Present Illness: 86 F NH resident with no previous diagnosis of CAD. Presents with 2 weeks of intermittent chest pain, worse on the day of presentation. Describes the pain as a pressure, heaviness, non-radiating. Associated with nausea, emesis, and diaphoresis, but no SOB. . On arrival, EMS found her seated in chair, vomiting. O2 sat 96% on 4L by NC. 12-lead ECG showed anterior ST elevations. Received ASA, SL NTG x 3, morphine 4 IV, with no relief in pain. . In [Hospital1 18] ED, received Plavix 600, metoprolol 5 IV x 2, heparin IV bolus, and Integrillin IV bolus. Sent for cath, which revealed ostial LAD TO which was POBA'ed. IABP placed given depressed CI. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Depression requiring ECT GERD Osteoporosis Diverticulosis Dementia ? Hypothyroid Social History: Social history is significant for the absence of tobacco use. There is no history of alcohol abuse or recreational drug use. She was previously employed as a bank clerk, but retired at the age of 65. Family History: Her mother died of heart disease at the age of 66. Physical Exam: VS: T , BP 83/51, assisted/augmented 82/137, HR 64, RR 21, O2 100% on NRB Gen: elderly female in NAD, resp or otherwise. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: Cool. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Radial 2+, DP/PT dopplerable Left: Radial 2+, DP/PT dopplerable Pertinent Results: [2151-11-28] 06:35PM BLOOD WBC-10.6 RBC-4.18* Hgb-12.5 Hct-36.7 MCV-88 MCH-29.8 MCHC-34.0 RDW-15.0 Plt Ct-556* [2151-11-30] 04:25AM BLOOD WBC-9.7 RBC-3.29* Hgb-9.8* Hct-28.3* MCV-86 MCH-29.9 MCHC-34.8 RDW-14.9 Plt Ct-254 [2151-11-28] 06:35PM BLOOD PT-14.4* PTT-150* INR(PT)-1.3* [2151-11-30] 04:25AM BLOOD PT-14.8* PTT-79.3* INR(PT)-1.3* [2151-11-28] 06:35PM BLOOD Glucose-187* UreaN-13 Creat-0.9 Na-132* K-5.8* Cl-96 HCO3-21* AnGap-21* [2151-11-30] 04:25AM BLOOD Glucose-127* UreaN-16 Creat-0.9 Na-131* K-4.4 Cl-101 HCO3-21* AnGap-13 [2151-11-29] 02:30AM BLOOD ALT-63* AST-477* CK(CPK)-1354* AlkPhos-11* TotBili-0.2 [2151-11-30] 04:25AM BLOOD ALT-44* AST-140* CK(CPK)-763* AlkPhos-53 TotBili-0.3 [2151-11-28] 06:35PM BLOOD CK-MB-192* MB Indx-20.7* [2151-11-28] 06:35PM BLOOD cTropnT-1.27* [2151-11-29] 02:30AM BLOOD CK-MB->500 cTropnT-14.15* [2151-11-29] 11:03AM BLOOD CK-MB-229* MB Indx-13.9* [2151-11-29] 04:36PM BLOOD CK-MB-102* MB Indx-48.8* cTropnT-4.02* [2151-11-29] 09:59PM BLOOD CK-MB-60* MB Indx-7.2* cTropnT-4.10* [2151-11-30] 04:25AM BLOOD CK-MB-32* MB Indx-4.2 cTropnT-3.37* [2151-11-28] 11:04PM BLOOD Calcium-9.1 Mg-1.9 [2151-11-30] 04:25AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.9 [2151-11-29] 03:30PM BLOOD %HbA1c-6.0* [2151-11-30] 04:25AM BLOOD Osmolal-275 [2151-11-29] 11:03AM BLOOD TSH-3.1 [2151-11-30] 04:25AM BLOOD TSH-2.7 . ECG initially demonstrated SR with RBBB & anterolateral ST elevations up to 4mm in v2-v6, I & aVL. Qs v1-v5, I & aVL. . TELEMETRY demonstrated: SR in 70s. . CARDIAC CATH performed on [11-28] demonstrated: . LMCA: LAD: 100% origin with R -> L collats to very distal LAD LCx: nl RCA: nl . HEMODYNAMICS: . RA: 13 PA: 43/19/29 PCW: 25 . [2151-11-29] ECHO EF 30% The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with severe hypo/akinesis of the distal half of the septum and anterior walls and distal inferior and lateral walls. The apex is mildly aneurysmal and dyskinetic. The basal segments contract well. No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate thickening and redundancy/systolic anterior motion of the mitral valve chordae. The estimated pulmonary artery systolic pressure is normal. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Symmetric left ventricular hypertrophy with extensive regional systolic dysfunction c/w CAD (mid-LAD lesion). Increased LVEDP. . [2151-11-30] CXR FINDINGS: Compared to the film from the prior day, there is a new left effusion with new left lower lobe volume loss. A femoral Swan-Ganz catheter with tip in the right pulmonary artery is unchanged. The alveolar infiltrate on the right has improved, but there continue to be interstitial markings that are increased in both upper lobes. There is some moderate right effusion that has also increased. IMPRESSION: Likely CHF with volume loss in the left lower lobe. While the alveolar infiltrate on the right has improved, the increased interstitial markings and bilateral pleural effusions have worsened. Brief Hospital Course: 86 F w/o PMH of CAD presents with lg anterior STEMI. Hospital course complicated by: . # STEMI: Presentation ECG showed ST elevations across anterior precordial as well as high lateral leads, unfortunately already with Qs. Presentation CK was already near 1000. Cath showed 1vd with TO of ostial LAD. s/p POBA. Received ASA, Plavix, statin, heparin gtt, integrillin x 18h. Initially started metoprolol & captopril but then held [1-8] hypotension. ECHO showed depressed EF w/ apical aneurysm so heparin ggt was continued with plan for transition to coumadin. . # Respiratory: Was hypoxic/hypoxemic throughout hospital stay. CXR showed ? RML PNA so was initially started on levo for CAP coverage but then Vanc was added as she continued to spike fevers and also with concern for line infection given her R femoral line/PA catheter. . # Pump: EF 30%. Was continued on heparin ggt with eventual transition to prevent apical thrombus. . On [11-30] a family meeting was held and the decision was made to change goals of care to comfort measures only as this was thought to be consistent with her wishes given her poor prognosis. She had been very uncomfortable while in the CCU and wished to be "left alone". She was initially treated with morphine boluses and then transitioned to morphine ggt as she continued to have respiratory distress. She passed on [2151-12-1] with her granddaughter at her bedside. Medications on Admission: ASA 81 MVI Lactulose 15 cc qam Bupropion 100 [Hospital1 ] Fosamax 70 qwk Vit D 800 qd Sennakot qd Prilosec 20 qd Aricept 10 qhs Seroquel 75 qhs Remeron 7.5 qhs Trazodone 50 qhs Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA	[ "41401", "311", "53081", "2449", "4280" ]
Admission Date: [2119-1-21] Discharge Date: [2119-1-24] Date of Birth: [2085-3-30] Sex: F Service: MEDICINE Allergies: Codeine / Cefaclor / Sulfa (Sulfonamides) / Ambien Attending:[First Name3 (LF) 465] Chief Complaint: suicidal ingestion of lithium Major Surgical or Invasive Procedure: none History of Present Illness: In brief, this is 33 y/o woman h/o Bipolar disorder who presented with a suicidal ingestion of lithium (100 tabs ) and also some tamezepam and Klonopin. on [12-21]. At [Hospital3 ] her level was 3.0. Received then activated charcoal and Golytely then transfer for possible HD. On arrival level 4.3. . In the MICU, she has been stable, no HD required and her levels have been trending down to 1.6. Renal has been following. In patient psychiatry service was also consulted. . Currently she feels well, mild abset stomach but otherwise ok.Denied any suicidal ideation but does endorse depression and agress with need for inpatient psychiatry hospitalization after cleared medically. Past Medical History: h/o Bulimia (dx at 22 or 23) Bipolar disorder (dx at 22 or 23) Insulin dependent DM (dx 7 yrs ago, not well-controlled) HCV---unknown status Hypothyroidism Social History: Pt lives with her friend's mom. She does not work currently, but is planning on starting nursing school in [Month (only) ]. She denies any tobacco or EtOH. Has h/o remote crack use (none since [2112]). Family History: Mom with DM, depression (untreated), substance abuse Dad with DM, depression (untreated) Physical Exam: GEN: flushed, in NAD HEENT: PERRL, EOMI, no nystagmus. OP clear, no tongue fasc. Dry MM. NECK: supple, no LAD LUNGS: CTA b/l CV: regular and tachy, no mrg ABD: soft, NT, ND, naBS, no HM EXT: no edema, calf tndr. NEURO: A&Ox3. CNs II-XII intact. Motor: UE prox [6-17], UE dist [6-17], LE prox [6-17], LE dist [6-17]. Sensation to light touch and proprioception intact. FNF wnl. No tremor or asterixis. DTRs 2+ at patella, brachioradialis b/l SKIN: multiple excoriations over b/l EU Pertinent Results: [2119-1-20] 11:50PM URINE RBC-1 WBC-[7-23]* BACTERIA-RARE YEAST-RARE EPI-1 [2119-1-20] 11:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-TR [2119-1-20] 11:50PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.016 [2119-1-20] 11:50PM PLT COUNT-116* [2119-1-20] 11:50PM MICROCYT-2+ [2119-1-20] 11:50PM NEUTS-70.9* LYMPHS-24.2 MONOS-2.8 EOS-1.9 BASOS-0.2 [2119-1-20] 11:50PM WBC-7.0 RBC-5.19 HGB-13.7 HCT-38.7 MCV-75* MCH-26.4* MCHC-35.4* RDW-15.0 [2119-1-20] 11:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2119-1-20] 11:50PM URINE GR HOLD-HOLD [2119-1-20] 11:50PM URINE HOURS-RANDOM [2119-1-20] 11:50PM URINE HOURS-RANDOM [2119-1-20] 11:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2119-1-20] 11:50PM estGFR-Using this [2119-1-20] 11:50PM GLUCOSE-333* UREA N-13 CREAT-0.8 SODIUM-138 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12 [2119-1-21] 03:17AM LITHIUM-3.1# [2119-1-21] 03:17AM GLUCOSE-235 UREA N-11 CREAT-0.7 SODIUM-140 POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-24 ANION GAP-12 [2119-1-21] 05:39AM PLT COUNT-121* [2119-1-21] 05:39AM WBC-8.5 RBC-4.99 HGB-13.1 HCT-37.6 MCV-76* MCH-26.3* MCHC-34.8 RDW-15.1 [2119-1-21] 05:39AM LITHIUM-2.6* [2119-1-21] 05:39AM CALCIUM-8.9 PHOSPHATE-2.5* MAGNESIUM-1.6 [2119-1-21] 05:39AM ALT(SGPT)-80* AST(SGOT)-52* ALK PHOS-134* TOT BILI-1.0 [2119-1-21] 05:39AM GLUCOSE-185* UREA N-10 CREAT-0.7 SODIUM-138 POTASSIUM-3.2* CHLORIDE-106 TOTAL CO2-25 ANION GAP-10 [2119-1-21] 11:36AM LITHIUM-2.1* [2119-1-21] 11:36AM SODIUM-139 POTASSIUM-3.4 [2119-1-21] 08:10PM LITHIUM-1.6* [2119-1-21] 08:10PM SODIUM-138 POTASSIUM-3.2* . Imaging: X ray: no acute cardiopulmonary process. . [1-21] ECG Sinus tachycardia Diffuse nonspecific ST-T wave abnormalities . Labs on discharge: [2119-1-24] 10:50AM BLOOD WBC-8.5 RBC-4.92 Hgb-13.3 Hct-37.3 MCV-76* MCH-27.0 MCHC-35.6* RDW-15.3 Plt Ct-156 [2119-1-24] 10:50AM BLOOD Glucose-256* UreaN-15 Creat-0.7 Na-138 K-3.7 Cl-104 HCO3-26 AnGap-12 [2119-1-22] 07:08AM BLOOD ALT-74* AST-63* AlkPhos-160* TotBili-1.5 [2119-1-24] 10:50AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.6 [2119-1-22] 07:08AM BLOOD Lithium-1.3 Brief Hospital Course: ASSESSMENT/Plan: 33F with h/o Bipolar disorder presents after a suicidal ingestion of lithium. . # LITHIUM OD: Level down to 1.3 12/10, no need to continue to follow - d/c IVF [1-22] and Renal is now signed-off - neuro exam normal . # Depression: have re-started Klonopin [Hospital1 ] and effexor 75 mg XL po daily per psychiatry recs - recommend inpatient psychiatric treatment - 1:1 sitter for safety - propranolol for acathesia - consider seroquel 50 mg po qhs prn for sleep with 2 additional 50 mg doses if needed . # ELEV LFTs: history HCV. Abdominal exam benign. MRI [2117] showed changes consistent with cirrhosis and portal hypertension. Also showed multiple bright lesion within the liver that were more consistent with degerative or displastic nodules. Last viral load at [Hospital1 18] 15,200,000 IU/mL /[2117] Genotype 1 - outpatient GI follow-up regarding treatment although given psych problems might not be a good candidate . # DM: 90 U Lantus qhs, Humulog 10 U with each meal and with Humulog sliding scale for 1 hour after each meal . # Vaginal [Female First Name (un) ]: c/o white discharge and vaginal pruritis - treated with fluconazole 150 mg po X 1 . # hypothyroidism: will continue levoxyl . # Thrombocytopenia: appears chronic. Likely [3-17] hep c. - outpatient follow-up . # F/E/N: Regular diet, replete lytes prn . # PPx: heparin sub q, bowel regimen prn . # DISPO: to inpatient psychiatry . # Communication: with friend [Name (NI) 1785] [Name (NI) 45820] (best friend) ([Telephone/Fax (1) 51404]. PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 30375]. Psychiatric meds: CNS [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 51405] . Medications on Admission: Relafen 500 mg po bid Abilify 30 mg po daily Tamezapam 30 mg po daily Effexor 150mg daily Insulin 90units lantus qhs + Novolog SS Neurontin 300 mg po qid Seroquel 200 mg po tid and 400 mg po qhs Levoxyl 50 mcg daily Klonopin 1mg daily Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Insulin Glargine 100 unit/mL Solution Sig: Ninety (90) U Subcutaneous at bedtime. 7. Humalog 100 unit/mL Solution Sig: Ten (10) U Subcutaneous before breakfast, lunch and dinner: plus Sliding Scale attached for 1 hour after each meal. Discharge Disposition: Extended Care Discharge Diagnosis: Suicide attempt Lithium overdose Elevated Liver function tests DM2, without complication Hypothyroidism Thrombocytopenia Depression Discharge Condition: Hemodynamically stable. Ambulatory. Discharge Instructions: Please take all medications as instructed. There were several changes made to your current medications regimen. If you experience any fever, nausea, vomiting, lightheadedness, chest pain, shortness of breath, or any other concerning symptoms please seek medical attention immediately. Followup Instructions: Please make a follow-up appointment with your Primary Care Doctor, Dr. [Last Name (STitle) ] within the next 2 weeks. Tel ([Telephone/Fax (1) 5938]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472]	[ "2875", "V5867" ]
Admission Date: [2162-1-19] Discharge Date: [2162-1-23] Date of Birth: [2120-1-3] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1936] Chief Complaint: DKA Major Surgical or Invasive Procedure: none History of Present Illness: This is a 42 yo F with DM1 and h/o DKA and CVA on anticoagulation who presents with a sudden onset of vomiting this am. Per the patient, she forgot to take her lantus last night, as she fell asleep early and didn't awake till this morning. She reports having a sinus infection and cough last week, but denies any abdominal pain, f/c, possibly a small amount of diarrhea. . In the ED, initial vs were: 97.3 88 132/72/20 98%ra. FS on arrival was 359 and chemistries showed a gap of 19. Labs were also significant for a leukocytosis of 19,000. Lactate 3.2 -> 2.0 with IVF. Patient was given Insulin 10 units of regular and was started on an insulin gtt at 6 units per hour, Ativan 2mg IV and Zofran. She also received 3L NS and when the next FS returned at 135, she was started on a D5 gtt. . On arrival to the ICU, the patient notes that she feels much better. She denies any symptoms currently, aside from thirst and hunger. Her nausea has resolved. She denies f/c/n/v/d, abdominal pain, chest pain, palpitations, shortness of breath. She has no sick contacts. She has a past history of etoh abuse, and she notes that her triggers for her past episodes of DKA was etoh. She claims that her last drink was 3 weeks ago. Past Medical History: Type 1 DM, last a1c was 11.2 in [3-24] CVA 5y ago, on anticoagulation - assumed stopped given INR, but PCP was planning to check hypercoagulable work up while she was off, last INR was 1.0 [2162-1-18] History of substance abuse, etoh abuse h/o DKA (thought to have been brought on at times by etoh) Anxiety Depression Social History: smokes tobacco, 1ppdx20yrs. lives at home with her twin 6 year old boys and husband. ?emotional abuse from husband - in the middle of a divorce. No IVDU. Occ MJ. Family History: . Family History: Mother died of pancreatic cancer. Father had DM1. Physical Exam: Vitals: T: 99.8 BP:109/82 P: 85 R: 16 O2: 100%ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, 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: very subtle left lower extremity weakness in plantar/dorsi flexion. Pertinent Results: [2162-1-19] 09:00AM WBC-19.6* RBC-5.25 HGB-16.2* HCT-45.9 MCV-87 MCH-30.9 MCHC-35.3* RDW-13.3 [2162-1-19] 09:00AM NEUTS-93.2* LYMPHS-5.2* MONOS-1.0* EOS-0.2 BASOS-0.4 [2162-1-19] 09:00AM PLT COUNT-277 [2162-1-19] 09:00AM PT-13.1 PTT-22.5 INR(PT)-1.1 [2162-1-19] 09:00AM HCG-<5 [2162-1-19] 09:00AM GLUCOSE-241* UREA N-21* CREAT-1.1 SODIUM-139 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-16* ANION GAP-23* [2162-1-19] 09:00AM ALT(SGPT)-23 AST(SGOT)-25 CK(CPK)-92 ALK PHOS-58 TOT BILI-1.6* [2162-1-19] 09:00AM CALCIUM-10.0 PHOSPHATE-2.0* MAGNESIUM-2.0 [2162-1-19] 09:27AM LACTATE-3.2* Brief Hospital Course: Assessment and Plan: 42 yo F with DM1 and h/o DKA and CVA presenting with DKA . # DKA - The patient has a history of multiple admissions for DKA and admits to poor medication compliance. Missed evening insulin prior to admission. No clear infectious trigger found however patient presented with elevated WBC. Urine culture and CXR negative. Pt previously has had DKA in setting of EtoH use however screen her was negative. Cardiac enzymes negative. On arrival to unit she was continued on insulin gtt@ 0.1 units/kg/hour. FS improved and she once tolerating po she was transitioned to Lantus 30U QHS and SSI. Plan for referral to [Last Name (un) ] as outpatient. . # H/o CVA - PCP wanted to check protein S, protein C, ATIII, APC, lupus anticoagulant, APLA panel, homocysteine, and Lpa and carotid u/s as she had stopped taking her coumadin. Per the patient, she had only stopped her coumadin for 4 days as she had run out and started taking it again last night. Therefore we will have to defer to her PCP, [Name10 (NameIs) ] will continue the coumadin while in house. . # Anxiety/Depression - SW consult. There seems to be ?verbal abuse at home and going through divorce currently. Plan for family meeting today. . # H/o substance abuse - SW consult. Thiamine, folate, MVI. Consider CIWA scale. Checking serum/urine tox screens. . # FEN: IVF, replete electrolytes, regular diabetic diet Medications on Admission: Lantus 30 units qpm Novolog SS Coumadin 8mg monday, wednesday,thursday Coumadin 6mg [Name10 (NameIs) 1017], [Name10 (NameIs) ], saturday Hydroxyzine 25mg TID PRN Simvastatin 40mg daily Trazodone 50mg qHS PRN Citalopram 60mg daily Buspirone 5mg TID Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Insulin Glargine 100 unit/mL Solution Sig: Thirty Eight (38) units Subcutaneous at bedtime. Disp:1 bottle Refills:2 4. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: according to sliding scale. 5. Warfarin 6 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: on tuesday, thursday, saturday. 6. Warfarin 4 mg Tablet Sig: Two (2) Tablet PO once a day: on monday, wednesday, [Last Name (LF) ], [First Name3 (LF) ]. 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Buspirone 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for anxiety for 1 weeks: Do not take this medication before driving as it will increase your risk of having an accident. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: diabetic ketoacidosis Discharge Condition: good Discharge Instructions: You were admitted to the hospital because you had diabetic ketoacidosis due to poorly controlled blood sugars. It is very important that you take your medications as directed to prevent this from happening again. If you have any difficulty taking your medications or questions please call your doctors. Medications: 1) Your glargine was increased to 38 units at night. 2)Please continue to follow a sliding scale. 3) You have been restarted on your home dose of coumadin. Your INR was 1.6 on the day of discharge. Please have your INR checked on Monday as your coumadin level is still low. Please have it checked at the [Hospital1 2025] coumadin clinic as you usually do. Return to the Emergency Department if you have: - vomiting - shortness of breath - dizziness or feinting - heart palpitations Followup Instructions: You have been scheduled for an appointment at the [Hospital ] Clinic [Location (un) 86] on Tuesday, [1-26]. Please call ([Telephone/Fax (1) 4847] to confirm your appointment time. Please bring your discharge paperwork with you to this appointment. Have your INR checked at your usual coumadin clinic at [Hospital1 2025] on Monday. Your INR was 1.6 on saturday [1-23]. You had been getting warfarin 8mg on [1-19] - [1-22] while you were in the hospital. Completed by:[2162-1-26]	[ "3051", "V5867", "V5861" ]
Admission Date: [2129-4-5] Discharge Date: [2129-4-8] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 598] Chief Complaint: s/p MVC right frontal SAH, left occipital SAH, RLE pain, abd pain. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 95459] is an 86 year old male who presented to [Hospital1 18] ED s/p MVC in which he was the restrained passenger, his wife, Ms. [Known lastname 95459] was the driver. On presentation he reported abdominal pain. In addition he reported right sided headache and mild nausea. He denied change in vision, dizziness, neck pain, and upper extremity symptoms. He reported recent history of LBP and RLE radiation to lateral thigh that was improving with PT. He reported worsening of this thigh pain with new medial thigh pain. He denied LE numbness/paresthesias. CT head revealed small foci of subarachnoid hemorrhage in the right fronal anterior. CT spine revealed no subluxation or fracture. No acute intraabdominal pathology or injury was noted. Past Medical History: Aortic stenosis, DM, gout, LBP, hypercholesterolemia, colon CA s/p colostomy Social History: Lives with wife [Name (NI) ] [Name (NI) 95459]. No EtOH. Family History: Non-contributory Physical Exam: VS: 99.1 98.8 79 100/60 18 98RA GA: alert and oriented x 3 HEENT: hematoma over right forhead, extraocular movements intact, PERL CVS: normal S1, S2, no murmurs Resp: CTAB [Last Name (un) ]: soft, NT, ND Ext: moves all 4 limbs spontaneously, right leg swelling, duplex negative for DVT. Pertinent Results: [2129-4-5] 04:55PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2129-4-5] 01:58PM LIPASE-41 [2129-4-5] 01:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2129-4-5] 01:58PM WBC-5.3 RBC-4.13* HGB-13.1* HCT-37.8* MCV-91 MCH-31.7 MCHC-34.7 RDW-16.8* [2129-4-5] 01:58PM PT-12.9 PTT-30.5 INR(PT)-1.1 [2129-4-5] 01:58PM PLT COUNT-120* [2129-4-5] 01:55PM GLUCOSE-174* LACTATE-1.9 NA+-145 K+-4.0 CL--104 TCO2-29 Brief Hospital Course: Mr. [Known lastname 95459] was admitted to the trauma service in the tSICU for Q1hr neurological monitoring. His neurological exam remained unchanged. Neurosurgery was consulted and recommended repeat head CT. On HD#2 Mr.[Known lastname 95459] [Last Name (Titles) 1834] repeat CT head which was unchanged from his previous CT head on HD#1 which showed two small subarachnoid hemorrhages: right occipital and right frontal. On HD#2 he was transferred to the floor. Serial neuro exams and CT head imaging remained stable. He was assessed by physical therapy who determined he would require continued physical therapy. He was screened for rehabilitation center placement. On HD#3 right leg swelling was note but duplex US was negative for DVT. This swelling was attributed to trauma acquired during his car accident. At discharge he was tolerating a regular diet and ambulating with assistance. He will follow-up with Dr. [Last Name (STitle) 739] in clinic with a repeat Head CT prior to his appointment. Medications on Admission: Colchicine, metoprolol 5O', allopurinol 300', glypizide 10", Januria 100', colace 100', tylenol prn, ASA 81', lorazepam Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Januvia 100 mg Tablet Sig: One (1) Tablet PO daily (). Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: right frontal/right occipital hematoma, RLE trauma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-18] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Followup Instructions: Please call Dr. [Last Name (STitle) 17816] [Telephone/Fax (1) 88] for f/u in 4weeks. Follow-up CT head on [2129-5-3]. Please present to [Hospital1 18] [Hospital Ward Name ] radiology for follow-up CT head. Please call Trauma clinic @ [Telephone/Fax (1) 2359] for follow-up. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601*]	[ "25000", "4241", "4019" ]
Admission Date: [2143-11-17] Discharge Date: [2143-11-25] Date of Birth: [2143-11-17] Sex: F Service: NEONATOLOGY HISTORY: Baby Girl [Known lastname ] is a 38-6/7 week infant born on [2143-11-17]. She was born to a 20-year-old gravida 1, now para 1 mother by spontaneous vaginal delivery with Apgar scores of 8 at one minute and 8 at five minutes. Her birthweight was 3.095 kg (6 pounds 13 ounces). PRENATAL SCREENS: Blood type B positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, and group B strep status positive. ANTEPARTUM COURSE: The maternal history and pregnancy were notable for late prenatal care at 25 weeks and a history of opioid dependence with OxyContin and Suboxone early in the pregnancy (mom denies use in past 6 months). The baby's urine tox screen was negative. ADMISSION PHYSICAL EXAMINATION: The infant received tactile stimulation, bulb suctioning and free-flow O2 in the delivery room. She was initially admitted to the neonatal intensive care unit for mild grunting and O2 sats of 83% in room air, at which point nasal cannula O2 was started. The baby was active and alert. Her weight was 3.095 (6 pounds 13 ounces). Breath sounds were clear with scattered crackles, mild grunting and no retractions. Her heart rate was regular with no murmur, and femoral pulses were 2+ bilaterally. The abdomen was benign without hepatosplenomegaly. The hips were stable. The clavicles intact. Neurologically, she was alert and moving all extremities, and reflexes were symmetric. Her overall tone was increased. HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY: Initially, the baby was placed in nasal cannula O2 for scattered crackles and O2 sats of less than 85% in room air. Presently, the breath sounds are clear and equal, no grunting, flaring or retracting. 1. CARDIOVASCULAR: She has had a regular rate and rhythm, no murmur and 2+ femoral pulses bilaterally. 1. FLUIDS, ELECTROLYTES AND NUTRITION: She is tolerating ad lib feedings of Carnation Good Start well. Her weight on day of discharge is 2.835 kg (6 pounds 4 ounces). 1. INFECTIOUS DISEASE: Since mom was group B strep positive with inadequate intrapartum antibiotic prophylaxis, a sepsis evaluation was done on [Location (un) ]. The CBC was white count of 12.7, RBC 5.36, hemoglobin 16.5, hematocrit 51.2, with 54 neutrophils, 2 bands, 39 lymphs, 2 monos, 2 eos, 2 basos, 1 atypical, a platelet count of 430. Blood cultures are negative to date. No antibiotics were necessary. 1. GASTROINTESTINAL: Her bilirubin on [2143-11-18] was 8.2/0.3/7.9. 1. NEUROLOGICAL: [Location (un) ] has had overall increased tone. She was started on neonatal opium solution on [2143-11-19], on day of life #2. She is presently receiving 0.55 mL of 0.4 mg/mL solution q. 4h. [Location (un) ] has been followed by occupational therapy and has received appropriate developmentally supportive care. 1. SENSORY - AUDIOLOGY: Hearing screening was performed on [2143-11-18] with automated brainstem responses. The baby passed the hearing screen bilaterally. 1. PSYCHOSOCIAL: [Hospital1 69] social work has been involved with this mother. The contact social worker is [Name (NI) 5036] [Name (NI) 4467]. She can be reached at ([Telephone/Fax (1) 24237]. A 51A has been filed with [Hospital1 3597] DSS, phone ([Telephone/Fax (1) 75732], and the contact social worker's name is [Name (NI) ]. CONDITION ON DISCHARGE: Good. DISPOSITION: [Hospital3 ]. PRIMARY CARE PEDIATRICIAN: [Hospital 2274] Pediatrics at [Location (un) 75733], [Location (un) 1456], [Numeric Identifier 66777], phone ([Telephone/Fax (1) 75734]. CARE RECOMMENDATIONS: 1. Feedings at discharge: Good Start q. 3-4h. 2. Medications: Neonatal opium solution (0.4 mg/mL, 0.55 mL q. 4h.). 3. State newborn screening sent on [2143-11-18], results pending. 4. Immunizations received: Hepatitis B vaccine [2143-11-20]. 5. Car seat test not applicable. 6. Immunizations recommended: a. Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following 3 criteria: 1) Born at less than 32 weeks; 2) Born between 32 weeks and 35 weeks with 2 of the following: Daycare during RSV season; a smoker in the household; neuromuscular disease; airway abnormalities; or school-aged siblings; 3) Chronic lung disease. b. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for all household contacts and out-of-home caregivers. FOLLOW-UP RECOMMENDATIONS: 1. Pediatric care. 2. VNA. 3. Early intervention. DISCHARGE DIAGNOSES: 1. Term, average for gestational age female. 2. Neonatal abstinence syndrome. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 60989], [MD Number(1) 75735] Dictated By:[Doctor Last Name 55781] MEDQUIST36 D: [2143-11-25] 13:58:04 T: [2143-11-25] 14:54:06 Job#: [Job Number 75736]	[ "V053", "V290" ]
Admission Date: [2146-8-29] Discharge Date: [2146-9-3] Date of Birth: [2098-5-9] Sex: M Service: Cardiothoracic Surgery ADMITTING DIAGNOSIS: Coronary artery disease requiring revascularization. HISTORY OF PRESENT ILLNESS: This is a 48-year-old man in generally good health with a new onset of dyspnea on exertion and angina who underwent a cardiac catheterization on [8-29] which revealed two vessel coronary artery disease with an ejection fraction of 40%. There was disease in the proximal LAD with a stenosis at D1 of 70% and 95% osteal D1 lesion, 95% distal RCA lesion with occluded PDA, mild PVB disease and collaterals left to right. Given these findings, he was referred to Dr. [Last Name (STitle) 1537] for coronary artery bypass grafting. PAST MEDICAL HISTORY: Significant for hypercholesterolemia. PAST SURGICAL HISTORY: Significant for appendectomy. MEDICATIONS: Included Gemfibrozil, Atenolol, Aspirin. HOSPITAL COURSE: The patient was admitted to the [Hospital1 346] on [2146-8-29] where he underwent a CABG times three as follows: LIMA to LAD, left radial to D1 saphenous vein graft to PDA performed by Dr. [Last Name (STitle) 1537], assisted by Dr. [Last Name (STitle) 11743]. Postoperative ejection fraction was 50-55%. The patient was transferred to the cardiothoracic surgery recovery unit on Nitroglycerin and Neo-Synephrine. The patient had a temperature immediately postoperatively and sputum cultures were sent that grew out gram negative rods for which she was subsequently treated with Levofloxacin. The patient otherwise did well and was transferred to the floor by postoperative day #3. He did have another fever spike on postoperative day #3 at which point the Levofloxacin was begun for the gram negative rods in the sputum. He also had one episode where he complained of epigastric pain and EKG was obtained which demonstrated a right bundle branch block. Enzymes were recycled and were downward trending. He did undergo a blood transfusion on postoperative day #4 for a hematocrit of 20 and tachycardia with mild hypotension. The patient otherwise did very well. By postoperative day #5 was without complaints. On physical exam, heart rate was 85, blood pressure 116/70, clear to auscultation on the right with bronchial breath sounds at the left base and egophony. His sternum was stable with a regular rate and rhythm. His abdomen was soft. His extremities were with minimal edema. Given these findings and the fact that he was ambulating extremely well, it was felt that he was stable for discharge. He was discharged on Lopressor 12.5 mg po bid, potassium chloride 20 mEq po q d for 7 days, Lasix 20 mg po bid for 7 days, Colace 100 mg po bid, Zantac 150 mg po bid, Aspirin 81 mg po q d, Motrin prn, Imdur 30 mg po q d, Niferex 150 mg po q d and Levofloxacin 500 mg po q d for 7 days for treatment of a potential hospital acquired pneumonia as well as Percocet. The patient was instructed to follow-up with Dr. [Last Name (STitle) 1537] in [1-9] weeks as well as his primary care provider [Last Name (NamePattern4) ] [1-9] weeks. DISCHARGE DIAGNOSIS: 1. Hypercholesterolemia. 2. Coronary artery disease, status post CABG times three performed on [2146-8-29]. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 4720] MEDQUIST36 D: [2146-9-3] 15:21 T: [2146-9-3] 15:28 JOB#: [Job Number 35153]	[ "41401", "2859", "2720", "3051" ]
Admission Date: [2184-3-11] Discharge Date: [2184-3-14] Date of Birth: [2134-11-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1850] Chief Complaint: seizure Major Surgical or Invasive Procedure: intubation History of Present Illness: 49 yoF w/ metastatic breast cancer (brain, spine, bone, liver) presents from OSH s/p seizure. According to her ex-husband, her sx began at ~ 4 p.m., when she developed worsening HA, N/V, and increased lethargy; she received Decadron 4 mg PO X1 at home in addition to 2 mg IV morphine. There was no witnessed seizure activity, bowel/bladder incontinence at home. She was transported to OSH, where she was noted to be lethargic w/ ~ 2 min sz activity (exact character not recorded). She was intubated for airway protection and received Ativan 1 mg IV X 2, Decadron 10 mg IV X 1, Fosphenytoin 16 mg IV X 1 and transported to [Hospital1 18] for further management. Of note, at her last visit w/ her neuro-oncologist Dr. [Last Name (STitle) 724] [2184-3-9], she received 5th induction dose of DepoCyte. Past Medical History: 1) Metastatic breast cancer diagnosed in [2172]. - s/p lympectomy [2172], right mastectomy [2175] - arimide [6-/2179] for bone mets - s/p adriamycin X 2 cycles [3-14] - taxotere, zometa, neulasta - whole braine irradiation [Date range (2) 107438] to [2178] cGY - s/p ventricular access devise placement [2183-12-17] - s/p lumbar spine and cervical spine irradiation - receiving DepoCyst and Navelbine. She was last seen by her oncologist [2184-3-9] 2) s/p appy 3) shingles Social History: divorced w/ 3 children; lives in [Hospital1 107439] with ex-husband. [Name (NI) ] tobacco, alcohol, or other drug use. Uses walker at home Family History: Paternal aunt died of breast cancer. Physical Exam: Gen: chronically-ill appearing middle-aged female, intubated, sedated HEENT: Pupils equal and minimally reactive to light, (+) papilledema bilaterally, (+) corneal reflex, (+) gag, ETT tube in place, neck supple, no JVD Cardiac: RRR, no M/R/G appreciated Chest: Left SC portocath site C/D/I Pulm: Coarse BS throughout Abd: hypoactive BS, soft, ND, liver edge 3 cm below RCM Ext: No C/C/E, warm with good cap refull bilaterally Neuro: Pupils equal and minimally reactive to light, (+) corneal reflex, (+) gag, small movements of all 4 extremities to painful stimuli, 1+ DTR [Name (NI) ] and [Name2 (NI) ] bilaterally, toes upgoing right, equivocal left Pertinent Results: [2184-3-13] 04:18AM BLOOD WBC-1.3# RBC-3.21 Hgb-10.5* Hct-29.4* MCV-92 MCH-32.9* MCHC-35.9* RDW-17.1* Plt Ct-105* [2184-3-13] 04:18AM BLOOD Plt Ct-105* [2184-3-13] 04:18AM BLOOD Glucose-106* UreaN-9 Creat-0.3* Na-137 K-3.1* Cl-103 HCO3-27 AnGap-10 [2184-3-11] 11:30AM BLOOD ALT-319* AST-68* LD(LDH)-533* CK(CPK)-53 AlkPhos-389* Amylase-26 TotBili-1.3 [2184-3-13] 04:18AM BLOOD Calcium-7.2* Phos-1.8* Mg-2.5 [2184-3-11] 09:24AM BLOOD Type-ART Rates-18/ Tidal V-500 FiO2-100 pO2-529* pCO2-29* pH-7.43 calHCO3-20* Base XS--3 AADO2-177 REQ O2-38 Intubat-INTUBATED CT Head: 1. Numerous extra- and intra-axial lesions scattered throughout the brain, with associated edema. When compared to [2183-10-10] the amount of surrounding edema may be slightly decreased. Many of these lesions now are partially calcified, a finding which may reflect the patient's whole-brain radiation therapy. No evidence of shift of normally midline structures or increased mass effect. EKG: Sinus rhythm. Inferolateral ST-T wave changes. No previous tracing available for comparison. Brief Hospital Course: Ms. [Known lastname ] is a 49 yo female with metastatic breast cancer presenting with headache, nausea, vomiting, atypical movements thought due to posturing or ?seizure. These symptoms occured 2 days after receiving her fifth dose of intrathecal chemotherapy. She was intubated for airway protection. Mental status change/?seizure: Most likely cause of mental status changes and posturing/?seizure due to increased intracranial pressure secondary to inflammation from DepCoyte. Head CT largely unchanged. LP on [3-11] noted elevated opening pressure of 30cm. LP removed 40cc of clear CSF, that was not infected (note: liposomal prepartion of Depcyte will artificially elevate wbc count). She was maintained on Decadron 4mg q6hr and Keppra 250mg [Hospital1 ]. Pt became less stuperous after her LP and was extubated on HD#2. Neuro exam s/p extubation was relatively normal except for weakness R ([3-16]) and L(4+/5) weakness. Pt notes she had a stroke and has R sided weakenss as a result. Pt felt her overall condition has continued to worsen, with persistent malignant cells in her CSF, and pt elected to go home with hospice. Medications on Admission: 1) Decadron 4 mg PO TID 2) Zofran prn 3) Keppra 250 mg PO BID 4) Depcyt 5) Navelberine 6) Ativan Discharge Medications: 1. lorazepam as directed 2. morphine as directed 3. Keppra as directed 4. Decadron as directed 5. oxygen as directed 6. heparin flush 7. sodium chloride flush Discharge Disposition: Home With Service Facility: Hospice of [Hospital3 ] Discharge Diagnosis: Primary: 1. Elevated intracranial pressure and inflammation s/p lumbar puncture of 40cc CSF 2. Metastatic breast cancer Discharge Condition: poor Discharge Instructions: --take all medications as prescribed --call physician for uncontrolled pain Followup Instructions: Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]/ONCOLOGY-CC9 Where: [Hospital 4054] [Hospital ]/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2184-3-16] 11:00 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: [Hospital6 29] [Hospital6 ]/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2184-3-16] 11:00 Provider: [Name10 (NameIs) 17246] [Name11 (NameIs) ], RN Where: [Hospital6 29] [Hospital6 ]/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2184-3-16] 11:30 [First Name8 (NamePattern2) 1176] [Name8 (MD) 1177] MD [MD Number(2) 5799]	[ "5990" ]
Admission Date: [2126-5-23] Discharge Date: [2126-5-28] Date of Birth: [2064-7-28] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 61-year-old gentleman with a known history of coronary artery disease who was admitted preoperatively for a CABG. He had no complaints of chest pain, shortness of breath, nausea, vomiting, or fever. He had been cathed prior to admission on [Month (only) 547] which showed a RCA 60% lesion, a left main 60% lesion, diagonal one 70%, OM 40%, and an ejection fraction of 35%. When he had his episode of crushing chest pain he went up to the emergency room at his local hospital and was transferred to [Hospital1 18] for emergent catheterization. HISTORY OF PRESENT ILLNESS: Includes herniated disc and an elevated cholesterol as well as a history of bradycardia. The patient also was a previous smoker who is status post an ST- elevation MI. PREOPERATIVE LABORATORY DATA: White count of 9.2, hematocrit of 40.9, platelet count of 122,000. PT of 13.4, PTT of 28.8, INR of 1.1. Repeat platelet count the following day was 142,000. Urinalysis showed some hematuria, but no urinary tract infection. Sodium of 141, K of 3.8, chloride of 108, bicarbonate of 28, BUN of 13, creatinine of 1.0, with a blood sugar of 97. Anion gap of 9. CK of 358. ALT of 52, AST of 174, alkaline phosphatase of 53, total bilirubin of 0.4, lipase of 21. Troponin T also preoperatively was 2.69 two weeks prior to admission. Additional preoperative laboratories revealed an albumin of 3.7, calcium of 8.7, phosphorous of 2.9, magnesium of 1.9, cholesterol of 173, HbA1C of 6.4%, triglycerides of 97. PREOPERATIVE RADIOLOGIC STUDIES: EKG showed sinus bradycardia with PAC's at a rate of 53 with a possible acute IMI. Please refer to the official report dated [2126-5-10]. A preoperative echocardiogram status post his myocardial infarction showed a moderately dilated RA, mild LA enlargement, no LV mass or thrombus, moderate regional LV systolic dysfunction, normal ascending, transverse, and descending thoracic aorta, no AS, no AI, 1 to 2+ MR, and trivial TR. Please refer to the official report dated [2126-5-10]. PHYSICAL EXAMINATION ON ADMISSION: He was in sinus rhythm at 66 with a blood pressure of 132/72 on the left and 149/68 on the right. He appeared well. His heart was regular in rate and rhythm. The lungs were clear bilaterally. His abdomen was soft. He had 2+ bilateral femoral pulses without any extremity edema. HOSPITAL COURSE: He was also seen by Dr. [Last Name (STitle) ] in consultation, and on the 14th he underwent a CABG with a LIMA of the LAD, a vein graft to the diagonal, a vein graft to the OM. He was transferred to the cardiothoracic ICU in stable condition on a Neo-Synephrine drip at 0.1 mcg/kg/min and a propofol drip at 30 mcg/kg/min. He was extubated later that afternoon. On postoperative day 1, he was hemodynamically stable with a blood pressure of 106/45. His creatinine was stable at 1.0 with a hematocrit of 25.9. He was doing very well. He was started on beta blockade. He was weaned off his Neo- Synephrine. He began Lasix diuresis, and his Swan was discontinued. Later that afternoon he was transferred out to [Hospital Ward Name 121] Two. He began his aspirin and Plavix therapy. His Hemovac drain was removed, his chest tubes were removed, and her epicardial pacing wires were removed. He was alert and oriented with a nonfocal exam. His lungs were clear. His heart was regular in rate and rhythm. His incisions were clean, dry, and intact. He began to work with the nurses and physical therapy on increasing his ambulation and his stamina. He also had a drug-eluting stent to his mid RCA and then was transferred post catheterization on an Integrilin drip for evaluation for surgery. The initial preoperative evaluation was done on [2126-5-10]. On postoperative day 3, his last chest tube was removed. He was doing very well. His Lopressor was increased. He continued to be out of bed and working with a physical therapist and continued to make excellent progress. He was switched over to p.o. Percocet for pain control. On postoperative day 4, he remained in a sinus rhythm and was hemodynamically stable. His Lasix was decreased to 20 daily. His sternum was stable, and the incisions looked good. His hematocrit dropped slightly from 25 to 24.5. He was up approximately 4 kilograms from his preoperative weight. He continued with diuresis. On the 19th he did a level 5 with the physical therapist and plans were made to discharge him home. His hematocrit remained stable at 25, and cleared a level 5. DISCHARGE STATUS: He was discharged on the 19th in stable condition to home with VNA services. On the day of discharge, his exam was unremarkable. The sternum was stable. The incisions looked good. His blood pressure was 130/68. In sinus rhythm at 75. Saturating 96% on room air. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting x 3. 2. Status post right coronary artery drug-eluting stent. 3. Status post myocardial infarction. 4. Elevated cholesterol. 5. Herniated disc. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. twice a day. 2. Enteric coated aspirin 81 mg p.o. once a day. 3. Percocet 5/325 1 to 2 tablets p.o. q.[5-15].h. p.r.n. (for pain). 4. Plavix 75 mg p.o. once a day. 5. Thiamin 100 mg p.o. once daily. 6. Folic acid 1 mg p.o. daily. 7. Lipitor 10 mg p.o. daily. 8. Metoprolol 25 mg p.o. twice a day. 9. Lasix 20 mg p.o. daily (x 7 days). 10. Potassium chloride 20 mEq p.o. once a day (for 7 days). 11. Iron complex 150 mg p.o. once a day. 12. Vitamin C 500 mg p.o. twice a day. DISCHARGE FOLLOWUP: The patient was instructed to follow up in our [Hospital 409] Clinic in 2 weeks post discharge. To see his primary care physician [Name Initial (PRE) ] [Last Name (NamePattern4) ]. [Last Name (STitle) 26225] - in 3 to 4 weeks post discharge and to make an appointment with Dr. [Last Name (STitle) ] to see him for his postoperative surgical visit in the office in 4 weeks. CONDITION ON DISCHARGE: The patient was discharged to home in stable condition on [2126-5-28]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1714], [MD Number(1) 1715] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2126-6-26] 13:53:23 T: [2126-6-27] 15:43:20 Job#: [Job Number 60996]	[ "41401", "4019", "2720", "V4582" ]
Admission Date: [2163-9-11] Discharge Date: [2163-9-14] Date of Birth: [2107-5-26] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 896] Chief Complaint: "Hemoptysis" Major Surgical or Invasive Procedure: None History of Present Illness: 56 year old male with history of interstitial lung disease (?Asbestosis), multiolobar PNA in ?[2159], hypertension, hyperlipidemia, GERD, obstructive sleep apnea and ocular pemphigoid who presents from [Hospital6 3105] with hemoptysis. The patient has had intermittent hemoptysis since [2162-12-22], which prompted work-up that resulted in his ILD diagnosis (all performed at [Hospital3 ]). The patient developed fevers (101F), severe coughing with hemoptysis, lightheadedness two days ago. When he presented to OSH ED yesterday, he was mildly febrile at 100.6F, tachycardic 90-100s, hypoxic to 84% on room air and confused (alert and oriented X2). He had labs drawn with mild leukocytosis (WBC 11.9), Hct 27.9 (unclear baseline), platelets 180. Na 139, K 4.1, BUN 56, Creatinine 1.5. He responded to 4L nasal cannula --> O2 sat 94%. CTA was performed which ruled out pulmonary emboli but demonstrated ground glass opacities and a calcified granuloma in the right apex. He did not receive antibiotics prior to transfer but was transfused one unit and volume resuscitated for hypotension with BP initially 70-85/39-44, then SBP90s. He also received 1 gram tylenol for his fever. Of note patient reports occasional night sweats drenching sheets, cough productive of yellowish-grey sputum and sharp chest pain which is worse with inspiration. He denies recent travel or sick contacts. Upon arrival to the [Hospital1 18] ED, initial VS: T99.5, HR80, BP106/66, RR16, 98% on 4L. His hematocrit post-transfusion was 29.0. He was hemodynamically stable with systolics in 110s-120, and was treated for community-acquired pneumonia with ceftriaxone and azithromycin; blood and urine cultures drawn. The patient was guaiac negative. Interventional Pulmonary was made aware and had no recommendations at this time. Vital signs upon transfer: T99.4, HR80, BP118/64, 94% on 4L NC. . Past Medical History: * Interstitial lung disease * Hypertension * Ocular pemphigoid * Anziety/depression * Neck/lower back disc disease with chronic pain * GERD * Hyperlipidemia * Obstructive sleep apnea * Severe community acquired pneumonia [2158-12-22] requiring ICU admission (left AMA secondary to lack of sleep, general uneasiness in ICU setting) * Recurrent aspiration pneumonias Social History: - Lives with his girlfriend and previously works as an electrician with possible exposure to asbestosis. - No recent travel, no incarceration. - Tobacco: Never - Alcohol: Denies - Illicits: Denies Family History: Family History: Mother died of lung cancer in her 50s, was life long smoker. Physical Exam: ADMISSION EXAM: Vitals: T:99.9 BP:155/76 P:86 R:18 O2:96% RA General: Alert, oriented, no acute distress. Coughing, bedside cup has sputum with yellowish-grey discoloration, no frank blood or streaking. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Course breath sounds over basilar posterior lung fields with occasional expiratory wheezes CV: Regular rate and rhythm, S1 S2 clear and of good quality, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: GEN: Sitting up in bed in NAD.. HEENT: EOMI, OP clear. PERRL. NECK: Supple, no LAD, no JVD. COR: +S1S2, RRR, no m/g/r. PULM: Coarse breath sounds halfway up lung field with monophonic expiratory wheeze. [Last Name (un) ]: +NABS in 4Q. Soft, NTND EXT: Warm, well-perfused. DP+ bilaterally. No c/c/e. Pertinent Results: ADMISSION LABS: [2163-9-11] 01:05AM BLOOD WBC-9.2 RBC-3.53* Hgb-10.1* Hct-29.0* MCV-82 MCH-28.7 MCHC-34.9 RDW-14.8 Plt Ct-188 [2163-9-11] 08:15AM BLOOD Neuts-85.6* Lymphs-10.4* Monos-1.9* Eos-1.9 Baso-0.2 [2163-9-11] 01:05AM BLOOD PT-14.1* PTT-24.8 INR(PT)-1.2* [2163-9-11] 01:05AM BLOOD Glucose-110* UreaN-46* Creat-1.1 Na-143 K-4.0 Cl-107 HCO3-26 AnGap-14 [2163-9-11] 08:15AM BLOOD Calcium-8.7 Phos-1.2* Mg-2.0 [2163-9-11] 08:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2163-9-11] 02:05AM BLOOD Lactate-1.2 DISCHARGE LABS: [2163-9-12] 04:00AM BLOOD WBC-6.6 RBC-3.69* Hgb-10.6* Hct-29.9* MCV-81* MCH-28.6 MCHC-35.4* RDW-14.4 Plt Ct-208 [2163-9-13] 07:35AM BLOOD WBC-5.5 [2163-9-13] 07:35AM BLOOD Ret Aut-2.3 [2163-9-13] 07:35AM BLOOD Na-135 K-4.2 Cl-97 [2163-9-13] 07:35AM BLOOD Iron-30* Imaging: [9-11] CXR PA/Lat: IMPRESSION: Non-specific subtle increase of opacity in the left lower lobe, could represent either early infection or small amount of alveolar hemorrhage. [9-11] CT Chest W/O Contrast: 1. Diffuse peribronchial ground-glass opacities are visualized at all lobes of both lungs, but greatest throughout the left lower lobe. These findings are suggestive of an infectious or inflammatory process. Atypical infections, including mycobacterial infections, are included as differential considerations. 2. Esophageal thickening with a small hiatal hernia, suggestive of an inflammatory process. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: 56yo M PMHx of uncertain interstitial lung disease, obstructive sleep apnea p/w fevers reporting "hemoptysis", found to not have any signs of hemorrhagic process, nor any signs of blood in sputum, started on a rule out for TB and transferred to the floor. ACTIVE DIAGNOSES: # Multifocal pneumonia: Patient has reports of hemoptysis, but sputum during stay yellowish-grey, guaiac negative. Given his radiographic findings and outpatient fever, the patient was treated with empiric cefpodoxime and azithromycin. His case was discussed with interventional pulmonology and reviewed CT of his chest, a bronchitis was most likely etiology but given apical granuloma (see below on pulmonary imaging) it was felt that the patient warranted a TB rule-out. Upon transfer from the MICU to the floor the patient was saturating in the low 90s on room air and his productive cough had improved. He was discharged on cefpodoxime & azithromycin (to complete a 10-d course). # Apical granulomas: Patient w h/o L apical granuloma on prior CT chest ([2159]) and on wet read of admission chest CT. He appeared to have a small right apical granuloma. Given his prior stay in prison & his presenting symptoms, it was felt that he should be ruled out for active TB. He had 3 AFB negative sputum samples at the time of discharge. # Iron deficiency anemia: Mr. [Known lastname 70832] was found to have heme occult positive brown stools, but H/H remained stable at 29-31. Iron saturation was ~10% with ferritin in the 80s. He had undergone recent colonoscopy and EGD so this was not pursued. Repeat HCT should be checked in follow-up. # Esophageal thickening: Noted on CT scan. Patient reported some intermittant GERD symptoms. EGD done 1 month prior was normal by his report. CHRONIC DIAGNOSES: # Interstitial lung disease: The patient reports that he has asbestosis and is being followed by an outpatient pulmonologist. He was encouraged to discuss his recent admission with his pulmonologist after discharge. # Hypertension: The patient was continued on Amlodipine and Atenolol # Psychiatric Disorder NOS: Patient was noted to have pressured speech, flight of ideas, and tangential thinking during his admission. He was continued on his home medications including clonazepam, soma, cymbalta, and ambien. TRANSITIONAL ISSUES: # Follow-Up: The patient should follow-up with his outpatient pulmonologist in [2-24] weeks as well as his primary care physician. [Name10 (NameIs) ] discharge, he was given an appointment for outpatient pulmonary function tests. Medications on Admission: * Gemfibrozil 600mg daily * Atenolol 25mg daily * Amlodipine 10mg daily * Prilosec 40mg daily * Clonazepam 0.1mg three times daily * Soma 350mg three times daily * Cymbalta 60mg daily * Ambien 10mg daily * Morphine 30mg PO three times daily * Trazodone 50mg daily * Motrin 800mg three times daily Discharge Medications: 1. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 8 days. Disp:32 Tablet(s) Refills:0 2. azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 3 days. Disp:6 Tablet(s) Refills:0 3. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 9. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO three times a day: This medication may sedate you, please only take as prescribed by your PCP and do not drive while on this medication. 10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Senna Lax 8.6 mg Tablet Sig: 1-2 Tablets PO once a day. 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing: please discuss how to use with pharmacist. Disp:1 inhaler Refills:0 14. ibuprofen Oral 15. Soma Oral Discharge Disposition: Home Discharge Diagnosis: 1. Pneumonia 2. Interstitial lung disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 70832], you were admitted for pneumonia. You had a CT of your chest which showed an atypical pneumonia and findings possible of TB. You were treated with IV and then PO antibiotics with great improvement in your symptoms. You were ruled out for active tuberculosis by induced sputums. Your ambulatory oxygen at discharge was 88% on room air. You were asymptomatic with this. If this gets lower you may need home oxygen. Please discuss this with your primary care physician and pulmonologist. You should take azithromycin for an additional 3 days and cefpodoxime for an additional 8 days. You were written for an albuterol inhaler. Please discuss with your pharmacist and primary care physician how to use this medication. No other changes were made to your medications. Followup Instructions: Please contact your primary care physician tomorrow and set up an appointment for within the next 1 week. His name and number are [Last Name (LF) 70833],[First Name3 (LF) 177] C. [Telephone/Fax (1) 50168]. Please discuss your pneumonia and GI symptoms. You should also follow up with your pulmonogist in the next couple of weeks. If you would like, appointments were made for our pulmonary physicians. If you wish to cancel them please call the numbers below to cancel. Department: PULMONARY FUNCTION LAB When: MONDAY [2163-10-3] at 1:10 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PFT When: MONDAY [2163-10-3] at 1:30 PM Department: MEDICAL SPECIALTIES When: MONDAY [2163-10-3] at 1:30 PM With: DR. [Last Name (STitle) ] / DR. [Last Name (STitle) 611] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5849", "486", "4019", "53081", "2724" ]
Admission Date: [2136-3-19] Discharge Date: [2136-5-16] Date of Birth: [2136-3-19] Sex: F Service: Neonatology HISTORY: [Female First Name (un) 57810] is a 29 and [2-28] week twin A girl who was delivered on [2136-3-19], via C-section at 1390 grams. She delivered to a 29-year-old gravida I, para 0, now II mother with the following prenatal labs: Maternal blood type O positive antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, GBS status unknown. [Hospital 37544] medical history is notable for [Doctor Last Name 1193] Chiari malformation, status post neurosurgical repair at age 18. Pregnancy was significant for preterm labor and premature rupture of membranes of twin B. She received a complete course of betamethasone. The twins delivered via C-section given a concern for clinical chorioamnionitis after prolonged rupture of membranes for 6 weeks. [Female First Name (un) 57810] emerged at the abdomen vigorous with spontaneous crying. She was dried, suctioned, stimulated. Apgar 8 and 9. She was admitted to the NICU for respiratory distress and prematurity at 29 weeks. PHYSICAL EXAMINATION: Upon admission, weight was 1390 grams, 75th percentile, length 38 cm, 25th to 50th percentile, head circumference was 29 cm. HOSPITAL COURSE: Respiratory: [Female First Name (un) 57810] was intubated for 2 [Known lastname ]. She received Surfactant x1. She extubated to CPAP and then advanced to room air. She never required significant amounts of oxygen. She remained on caffeine from [Known lastname ] of life 2 to 24. Cardiovascular: She has a PPS murmur. No echocardiograms were performed. She received no medications for patent ductus arteriosus. FEN and GI: She attained full enteral feeds by [Known lastname ] of life 9. She received 8 [Known lastname ] of total parenteral nutrition. Her maximum bilirubin was 8.3 for which she received phototherapy. Heme: Her last hematocrit was drawn on [4-30], was 27.9 with a reticulocyte count of 5.6. She has remained on iron. She never received any blood transfusions. ID: Given the concern for maternal clinical chorioamnionitis, she received 7 [Known lastname ] of ampicillin and gentamicin. Blood cultures were no growth to date. A LP was performed which showed glucose of 68, protein of 145, 59 RBCs, 4 WBCs, no polys, 34 lymphs, 97 monos. CSF culture was negative. Neurology: Her initial head ultrasound on [Known lastname ] of life 5 was normal. Her subsequent [Known lastname ] of life 30 head ultrasound was also normal. She passed her hearing screen with automated auditory brainstem responses on [5-14]. Eyes were examined most recently on [5-7], revealing mature retinal vessels. A follow-up examination is recommended in 6 months. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 38676], Pedatrics at [Hospital1 ], ([Telephone/Fax (1) 67162]. CARE RECOMMENDATIONS: 1. Feeds at discharge will include breast milk 24 consisting of 4 kilo/cals per ounce made with Enfamil powder. 2. Medications include 0.5 cc of iron and 1 cc of Gold Mine multivitamins. 3. She passed her car seat position test on [5-14]. 4. State newborn screening status initially had an elevated 17OHP on [3-22] which normalized by a follow-up screen sent on [2136-4-30]. 5. She received her hepatitis B vaccination on [2136-4-27]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1, born at less than 32 weeks, 2, born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings or 3, with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza was recommended for household contacts and out of home caregivers. [Name (NI) ] 2 month vaccinations are due at her first pediatrician appointment. 7. Follow-up appointments should include early intervention, pediatrician, ophthalmology. DISCHARGE DIAGNOSES: 1. Prematurity at 29 weeks. 2. Respiratory distress syndrome resolved. 3. Sepsis evaluation resolved. 4. Hyperbilirubinemia resolved. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (NamePattern1) 67163] MEDQUIST36 D: [2136-5-15] 15:22:11 T: [2136-5-15] 19:25:34 Job#: [Job Number 67164]	[ "7742", "V053", "V290" ]
Unit No: [Numeric Identifier 69723] Admission Date: [2100-9-24] Discharge Date: [2100-9-24] Date of Birth: [2100-9-24] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname ], twin #2, was born at 30 and 4/7 weeks gestation to a 35 year-old, Gravida II, Para 0 now II mother. The mother's prenatal screens were blood type A negative, antibody negative, Rubella immune, RPR nonreactive, hepatitis surface antigen negative and Group B strep unknown. This pregnancy was remarkable for this twin with a 2 vessel cord and congenital heart disease by prenatal testing, consisting of tricuspid atresia with dominant left ventricle and large ventricular septal defect. An amniocentesis for both twins. This twin also was noted to have intrauterine growth restriction and oligohydramnios. The mother had a complete course of betamethasone on [2100-9-7]. She presented on the day of delivery with spontaneous rupture of membranes and progressive preterm labor. The delivery was by Cesarean birth. Apgars were 6 at 1 minute and 7 at 5 minutes. The birth weight was 1,270 grams and the birth head circumference was 28 cm. PHYSICAL EXAMINATION: Admission physical examination reveals a preterm infant, cyanotic with respiratory distress, with subcostal and intercostal retractions. Her oxygen saturation, with supplemental oxygen, her saturation increased to the mid 80s. She is growth restricted. Her anterior fontanel is soft and flat, positive molding. The left eyelid is fused. The right cornea is cloudy. Ears are normal set. High arched palate. Neck supple. Clavicles intact. Lungs clear. Heart was regular rate and rhythm, no murmur. Femoral pulses present. Abdomen soft. Present bowel sounds. Normal genitalia for preterm female. HOSPITAL COURSE: Respiratory status: The infant was intubated soon after admission to the NICU with a peak inspiratory pressure of 20; a positive end expiratory pressure of 5, a IMV rate of 22 and a FI02 of 28 to 35. Her venous blood gas prior to transfer was a pH of 7.35 and a C02 of 39. Per cardiology her saturations were kept in the mid 80s. She received 2 normal saline boluses; each 10 ml/kg for a mean blood pressure in the 20's. After the boluses, her mean pressures increased to the 30's to low 40's range. Her heart rate is 140 to 150. Fluids, electrolytes and nutrition: She has a double lumen umbilical venous catheter placed with its tip on x-ray being at the RA junction. She is receiving total fluids of IV dextrose at 80 ml/kg/d. Her blood glucose was 111. Her ionized calcium is 1.07. Hematology: The infant's blood type is A negative. DAT is negative. She has received no blood product transfusion during this NICU stay. Hematocrit on admission is 43.9. Her platelet count is 166,000. Infectious disease status: At the time of admission, her white count is 12.1 with a differential of 23 polys and 0 bands. A blood culture was obtained. Sensory: Audiology screening is not done and is recommended prior to discharge. Psychosocial: Parents have been updated. They received extensive prenatal counseling prior to this delivery. The infant was baptized at the parents request prior to transfer. Guarded condition. She is transferred to [Hospital3 1810] cardiac care unit. PRIMARY PEDIATRIC CARE PROVIDER: [Name10 (NameIs) ] yet identified. CARE RECOMMENDATIONS AFTER DISCHARGE: The patient is discharged on n.p.o. status. Medications are: Ampicillin 190 mg IV every 12 hours. Gentamycin 4 mg IV every 24 hours with levels of peak and trough to be obtained around the third dose. Intravenous fluids of total fluids of 80 ml per kg per day consisting of parenteral nutrition at 50 ml/kg per day and 10% dextrose with 1/2 unit of heparin per ml and additionally 0.45 normal saline with 1/2 unit of heparin per ml at 1 ml an hour. State newborn screen was sent prior to transfer. She has received no immunizations. RECOMMENDED IMMUNIZATIONS: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. DISCHARGE DIAGNOSES: 1. Prematurity, 30 and 4/7 weeks gestation. 2. Twin #2. 3. Respiratory distress syndrome. 4. Rule out sepsis. 5. Rule out genetic syndrome. 6. Congenital heart disease, tricuspid atresia with dominant left ventricle and large ventricular septal defect. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2100-10-5] 23:12:58 T: [2100-10-6] 05:49:41 Job#: [Job Number 69724]	[ "V290" ]
Admission Date: [2140-5-11] Discharge Date: [2140-6-2] Date of Birth: [2080-6-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 17865] Chief Complaint: Respiratory failure s/p aspiration Major Surgical or Invasive Procedure: Intubation at outside facility Right PICC, s/p removal Left IJ temporary dialysis line, s/p removal s/p percutaneous tracheostomy Right sided chest tube for PTX s/p removal History of Present Illness: 59M with h/o anemia and H. pylori gastritis, remote pancreatitis s/p partial pancreatectomy, admitted to OSH with aspiration after EGD under propofol sedation s/p intubation x 2 with continued respiratory acidosis and difficulty ventilating sent here directly to MICU for continued management. . The patient went to outside facility today for elective EGD for f/u biopsies for H. pylori gastritis diagnosed during admission [2-/2140] for UGIB. Last PO intake was at 10pm the night prior. He was sedated wtih propofol for the procedure and at the end of procedure had episode of desaturation to 80%, vomiting of bilious gastric contents and aspiration. Was intubated, and had bronch which was showing thick white secretions and food particles in right main stem s/p suctioning. Sent to ICU where patient was quickly extubated, but found later to be sweaty, with stridor, and unresponsive on BIPAP so was given solumedrol, and reintubated with #7 ETT. Had difficulty ventilating patient, with PIPs 67, plateau pressure of 38, so vent settings adjusted to pressure control settings and s/p paralysis with vecuronium and rebronch. CXR found to have bilateral patchy infiltrate. ABG was 7.0/106/119 with O2 sat of 82-86%. Initially hypertensive, then hypotensive. Patient initially on vasopressin, being given bicarb gtt, on versed gtt at 6mg/hr. Bedside TTE was normal EF. Also given levofloxacin, flagyl, and IV solumedrol. For access, patient with RIJ and aline. Most recent ABG was 7.06/87/67. Last dose of vecuronium was at 6:30pm. . On arrival to the MICU, patient was intubated, sedated, off any pressors or bicarb gtt. Initial vent settings PEEP 16, FiO2 100. TV around 350, MV 8. ABG showed 6.91/127/187. Lactate 2.6, Hct 44.9, Cr 1.7, WBC 1.5 with 37 bands. Past Medical History: - Gastritis h/o recent H. pylori. Patient with admission in [2-/2140] with acute UGIB, found to have chronic active H. pylori s/p tx with Prevpac. Plan for PPI x 3 months and repeat EGD in [Month (only) 547] to assess for H. pylori (normal colonoscopy [2138]) - severe iron deficiency anemia - remote pancreatitis s/p partial pancreatectomy (in 20s, unclear etiology) - Hypothyroidism - Hyperlipidemia - Lyme disease treated in [2138] - Anxiety Social History: Retired accountant, married. Moderate alcohol use, 4 drinks daily, no tobacco or IVDU. Very functional prior to admission Family History: NC Physical Exam: Vitals: T:96.7 BP:106/76 P:117 R:20 18 O2:95% Initial vent settings PEEP 16, FiO2 100. TV around 350, MV 8 General: Intubated, sedated HEENT: PERRL Neck: supple, RIJ in place Lungs: Fair air movement bilaterally and at apices, with expiratory wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: old midline scar, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: cool, nonedematous, good DP pulses, L a-line in place Pertinent Results: CXR [2140-6-2]: FINDINGS: In comparison with study of [6-1], there is little interval change. Monitoring and support devices remain in place. Continued bilateral pulmonary opacification, most coalescent at the left base, consistent with pneumonia superimposed and vascular congestion. . CXR [2140-5-29]: A tracheostomy tube is present. A right subclavian central line is present, tip overlying proximal SVC. An enteric tube is present, tip extending beneath diaphragm off film. The lungs are hyperinflated. The heart is slightly enlarged. There are extensive irregular patchy opacities in both lungs, most pronounced at left greater than right bases. The appearance is similar to [2140-7-25], although probably slightly worse at the left base. The appearance is compatible with an acute process superimposed on chronic changes and includes ARDS. The possibility of a small component of superimposed CHF cannot be excluded. . EKG: Sinus tachycardia without ST/T wave changes . [2140-5-19] CT Chest/Abd/Pelv: IMPRESSION: 1. Diffuse bilateral pulmonary consolidation, likely reflective of ARDS in combination with infection/aspiration, slightly worsened from the prior study. 2. Moderate right pleural effusion, increased in size. 3. Right internal jugular vein thrombus. 4. Anasarca, with perihepatic and pelvic free fluid. . [2140-6-2] 04:12AM BLOOD WBC-7.0 RBC-2.64* Hgb-8.1* Hct-23.1* MCV-88 MCH-30.9 MCHC-35.3* RDW-16.3* Plt Ct-320 . [2140-5-26] EKG: Sinus rhythm. Consider right atrial abnormality. Non-diagnostic Q waves in leads I and aVL. Since the previous tracing of [2140-5-15] P wave amplitudes are more prominent. . [2140-5-17]: FINDINGS: Note is made that this is a limited examination performed at the patient's bedside. Limited views of the liver demonstrate no focal abnormality. There is no biliary dilatation and the common duct measures 0.4 cm. The portal vein is patent with hepatopetal flow. No gallstones are identified. No ascites is seen in the right upper quadrant. IMPRESSION: No biliary dilatation identified. . [2140-5-13] ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). There may be focal inferior hypokinesis but cannot adequately assess regional wall motion. The right ventricular cavity is dilated and free wall motion may be impaired but not well visualized. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve leaflets are not well seen. No mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: 59M with h/o anemia, recent H.pylori gastritis transferred for severe hypercapneic respiratory failure on ventilator at OSH after aspiration episode during elective EGD procedure found to be in septic shock, DIC, and difficulty with mechanical ventilation. . # Hypercarbic and hypoxic respiratory failure: Severe respiratory acidosis with difficulty ventilating at OSH with evidence of aspiration during EGD. Admit CXR showing bilateral patchy infiltrates and breathing most likely [2-23] aspiration pneumonitis with severe bronchospasm. Bronchospasm and obstruction made him very difficult to ventilate and pCO2 on arrival was >120. Upon arrival to our hospital, he had very elevated pulmonary pressures and was found to have a right pneumothorax, which required chest tube placement. Multiple ventilator modes were attempted, heliox, high-dose steroids and frequent nebs without significant improvement. Bronchoscopy showed very friable mucosa, no bleeding or mucus. BAL was positive for pan sensitive Kleb Pneumo and Ecoli for which he was treated with Meropenem for 8 day course. He was ultimately paralyzed for 4 days to help with ventilation and oxygenation. CVVH was started to help manage the acidosis and pt was slowly weaned from high ventilator support. Unfortunately, given prolongued intubation he has a steroid/ICU myopathy and required perc. tracheostomy placed in the OR by interventional pulmonology. He has remained intermittently febrile and CXR on [5-29] showed a new LLL infiltrate in setting of the setting of resolving bilateral infiltrates. Sputum was positive for K.pneumo that is pan sensitive. He has been treated with 4 days of Levofloxacin for [Month/Day (4) 16630] and will need another 10 days to complete the course. He has been able to tolerate up to 2-3hrs of trach collar at a time but will likely need trach downsize in the near future. Otherwise, he has been rested on AC or pressure support overnight. VBG from [6-2] on pressure support showed 7.32/43/93. . # Sepsis: Patient with leukopenia with 35 bands, hypotension requiring pressors, tachycardia, elevated lactate (peak 4.6). He required massive resuscitation with IVF and was empirically treated with Vanc/Cefepime. Infectious work up was negative, except for E coli/Kpneumo in BAL ([2140-5-12]). Additional infectious work up included blood cultures, urine culture, mycolytics, galactomanan, beta-glucan, CT of chest, abdomen and pelvis that showed sludge in the gallblader without signs of cholangitis. Pt developed elevated bilirubin up to 5.6 with alk phos of 213 that improved on its own. Given that we were sitll having difficulty ventilating him we broaded him to Vanc/Meropenem. There was concern for DIC given anemia and thrombocytopenia. Heme-onc was consulted and thought it was marrow suppression was secondary to infection and vancomycin may be contributing to thrombocytopenia. Infectious disease were consulted and agreed with a 2-week course of Vanc Meropenem which he completed. Patient initially was neutropenic and later developped a WBC count up to 34. Subsequent repeat extensive work up was negative until sputum turned positive for K Pneumo and CXR showed new LLL infiltrate consistent with [Year (4 digits) 16630]. Patient. WBC has trended down with the above interventions and has been within normal range during the last few days. . # H. pylori gastritis s/p repeat EGD: Per records, EGD at OSH on day of admission for repeat biopsies for H. pylori which was diagnosed in [2-/2140] during admission for UGIB and treated with Prevpak and PPI. Patient has been on PPI throughout the whole admission. He has had guaiac positive stools intermitently. We started treatment for H. Pylori with levofloxacin/clarithromycin/pantoprazole (D1 = [6-1]) for 14 days. He will need to continue pantoprazole indefinitely. . # Acute renal failure: Pt was initially started on CVVH for the respiratory acidosis and volume overload. Furthermore, he was hypotensive and received IV contrast. After resolution of his sepsis, he received UF for aggressive volume removal. He was then transitioned to intermittent HD, which he tolerated well. However, in the setting of persistent fevers and his UOP increasing we decided to pull the line. He has been off HD since [5-28] and his UOP has continued to increase. (over 1500ccs in last 24hrs) He has been negative in the last 2 days and furthemore his electrolytes have been within normal range. There is no indication for HD at this time. The renal team feel that given his improving UOP, stable lytes and improving creatinine (7.8 today) that he will not need hemodialysis. In the meantime he can receive lasix as needed for SOB. . # Anemia: Pt was admitted with an HCT of 44 that slowly had been drifting down. He has had two episodes of oropharyngeal bleeding, from mucositis, which was thought secondarily to prolongued intubation. He has been guaiac positive, no BRBPR. He alwasy has bumped adequately to transfusions. It was thought bleeding from gastritis as well as anemia of chronic diseases. Our goal for transfusion has been >21. His las HCT was 23. He has not received any blood transfusion in 2 days. EGD is not an option given that it precipitated all these events. . # Hypothyroidism: TSH at OSH was 4.66. We continued his levothyroxine at current dose. . #. RIJ clot - Pt was found to have a RIJ clot on a CT scan looking for infection. Therefore, he was started on heparin and kept on it until it was decided if he was going to need HD/CVVH (for line placement). We started coumadin 2 mg on day of discharge and pt will need PT/INR followed closely until INR >2, then heparin gtt may be stopped. . #. Oropharyngeal bleeding - Pt had bleeding from palate, which was thought secondarely to prolongued intubation. Pt was examined by ENT, who did not see any visible lesion suspecting of malignancy or infection. . #. Thrombocytopenia - Pt developped thrombocytopenia that coincided with sepsis and later with administration of Vancomycin. His PLT count improved after stopping vancomycin and currently his PLTs are 320. . #. Gastric outlet obstruction - Pt initially underwent an EGD that caused him to aspirate given that his stomach was full of food. It is possible that he has a component of gastric outlet obstruction or dysmotility dysorder. We had a lot of difficulty advancing his tube feeds given high residuals. We tried metoclopramide without any improvement and ultimately had the feeding tube advanced to jejunum. . #. [Name (NI) 16630] - Pt has been in the ventilator for 22 days in this hospital. Pt was started on [2140-5-29] for a 14-day of antibiotic therapy given that in one of the multiple infectious work up for persistent fever pt was found to have a LLL infiltrate. We initially started with cefepime and once we had the results of the sputum culture for pan-sensitive kleibsiella with narrowed to levofloxacin (last day [6-13]) . #. Persistent fever - Pt had been febrile almost daily while in the hospital. Fever spikes have been decreasing with time. He was spiking up to 101 on CVVH, then 102 w/o CVVH and lower every day. Now pt has been afebrile for 48 hours. We have done an exhaustive infectious work up and removed all indwelling lines, exchanged foley. We found the LLL infiltrate and positive sputum, currently we are treating the [Month/Year (2) 16630] for 14 day course of Levofloxacin. Medications on Admission: Celexa 20mg daily MVI daily Iron supplementation Levothyroxine 50mcg daily Medications on Transfer (Ground [Location (un) 7622]): - Versed gtt at 6mg - Given 1L NS - Fentanyl IV 200mg - Vecuronium 7mg IV (last 6:30pm) - Albuterol neb x 2 - Tylenol 650mg PR Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash [Location (un) ]: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 2. Insulin Lispro 100 unit/mL Solution [Hospital1 ]: 1-12 units Subcutaneous ASDIR (AS DIRECTED): please adjust per sliding scale. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: 6-8 Puffs Inhalation Q1H (every hour) as needed for wheezing. 4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [Hospital1 ]: One (1) Appl Ophthalmic TID (3 times a day). 5. Levothyroxine 50 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [1-23] Drops Ophthalmic PRN (as needed) as needed for dry eyes; pt not blinking. 8. Acetaminophen 650 mg/20.3 mL Solution [Month/Day (2) ]: One (1) PO Q8H (every 8 hours) as needed for pain, fever. 9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [Month/Day (2) ]: One (1) PO BID (2 times a day). 10. Calcium Acetate 667 mg Capsule [Month/Day (2) ]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [Month/Day (2) ]: One (1) Inhalation [Hospital1 ] (2 times a day). 12. Sodium Chloride 0.65 % Aerosol, Spray [Hospital1 ]: [1-23] Sprays Nasal TID (3 times a day) as needed for nasal dryness. 13. B Complex-Vitamin C-Folic Acid 1 mg Capsule [Month/Day (2) ]: One (1) Cap PO DAILY (Daily). 14. Clarithromycin 250 mg/5 mL Suspension for Reconstitution [Month/Day (2) ]: One (1) PO BID (2 times a day) for 14 days: Last day day [6-15]. 15. Citalopram 20 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 16. Warfarin 2 mg Tablet [Month/Year (2) ]: One (1) Tablet PO Once Daily at 4 PM: adjust [Name6 (MD) ] rehab MD. 17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 18. Levofloxacin 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q48H (every 48 hours) for 10 days: last day [6-13]. 19. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [Month/Year (2) ]: Seven [Age over 90 10973]y (730) units/hr Intravenous continuously until INR>2. 20. Outpatient Lab Work Please draw PT/INR on [6-3] & [6-5], forward results to rehab MD for recommendations regarding adjustment of coumadin. Stop Heparin gtt when INR>2 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: 1. Hypercarbic Respiratory Failure 2. Aspiration PNA 3. Septic Shock 4. Acute renal failure requiring temporary CVVH 5. RIJ associated DVT 6. Steroid/ICU myopathy 7. [Hospital6 16630] with pan sensitive Kleb Pneumo 8. Oropharyngeal bleeding 9. Thrombocytopenia 10. Gastric Outlet obstruction 11. Pneumothorax s/p right sided chest tube Discharge Condition: Mental Status: s/p tracheostomy, unable to speak but mouthing words and answering questions appropriately Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted after an aspiration event with severe hypercarbic respiratory failure. You have been managed in the ICU for for last 3 weeks and you are improving signficantly with regards to breathing, kidney function and mental status. You will need ongoing physical rehabilitation and support for weaning from the ventilator. . You will need follow up with pulmonary, renal and gastroenterology after you are discharged from the rehab facility. Please see below for contact numbers to the outpatient clinics. Followup Instructions: You will be followed closely by the rehab physicians for your respiratory and physical therapy needs. . You will need follow up with gastroenterology for your gastritis and the mild gastric outlet obstruction. Please call the gastroenterology unit at ([Telephone/Fax (1) 2233] to schedule a follow up appointment. . When you are being prepared for discharge from rehab, please call the pulmonary clinic to schedule a follow up appointment at ([Telephone/Fax (1) 3554]. . Please call the renal clinic at ([Telephone/Fax (1) 10135] to schedule a follow up appointment.	[ "5070", "0389", "99592", "5845", "78552", "2767", "2875", "V5861", "2449" ]
Admission Date: [2112-4-5] Discharge Date: [2112-4-8] Service: NEUROLOGY Allergies: Penicillin G Attending:[First Name3 (LF) 5018] Chief Complaint: Code Stroke Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a [Age over 90 ] year old man with a history of CAD, high cholesterol, hypertension, now presenting as a code stroke. The patient is a poor historian and unfortunately has few notes to confirm his medical history. His son provides the details of the event. The patient awoke this morning at 4:30 am and went about his daily routine. He was talking and interacting with the son. Around 7 am, the patient began to wash the dishes and the son left to walk to the corner grocery store. When he returned around 7:30 am, his mother informed him that his father had fallen to the ground. He walked into the kitchen to discover the patient lying on the floor, not moving his left side and slurring his speech. He was following simple commands The son activated EMS and he was taken to an OSH. A head ct did not reveal any evidence of infarct or hemorrhage. There he was found to be in afib, they decided against iv-tpa and started him on heparin. He was transferred to [Hospital1 18] ED for further care. He arrived here at 1:56 pm, a code stroke was activated at 2:01 pm. I arrived at the bedside within 3 minutes. ROS: no recent fevers, chills, or urinary problems (according to the son who observes him on a daily basis) Past Medical History: -CAD s/p cabg -high cholesterol -high blood pressure -elevated PSA in past -COPD Social History: Lives with wife, primary caregiver for her. Family History: Unknown. Physical Exam: Physical Exam Vitals: 98.6 130 120/70 18 98% RA General: older man in no acute distress Neck: supple Lungs: clear to auscultation CV: irregular rhythm Abdomen: non-tender, non-distended, bowel sounds present Ext: warm, no edema Neurologic Examination: Mental Status: Awake but keeps eyes closed; looks primarily toward the right, intermittantly following simple commands; talking and will repeat but with phonemic errors and significant dysarthria; inattentive to left side Cranial Nerves: Blinks to threat on right, no blink on left; right pupil reacts 3 to 2 mm, left pupil more sluggish 3 to 2.5 mm; eyes move rightward, difficulty getting eyes to pass midline left, left facial droop Motor: Increased tone on right; more flaccid tone on left (arm more so than leg); right arm and leg full strength; left arm and leg 2/5 strength (not anti-gravity) No pronator drift on right Sensation was intact to noxious stimuli on left (and right as well) Reflexes: B T Br Pa Pl Right 2 2 2 2 1 Left 2 2 2 1 1 Toe up on the left side Coordination shows good fnf on right, unable to perform on left Gait exam deferred Pertinent Results: [2112-4-5] 02:20PM PT-13.1 PTT-27.7 INR(PT)-1.1 [2112-4-5] 02:20PM PLT COUNT-247 [2112-4-5] 02:20PM WBC-11.7* RBC-5.08 HGB-15.7 HCT-46.3 MCV-91 MCH-31.0 MCHC-34.0 RDW-14.7 [2112-4-5] 02:20PM TSH-2.2 [2112-4-5] 02:20PM TRIGLYCER-64 HDL CHOL-49 CHOL/HDL-3.8 LDL(CALC)-123 [2112-4-5] 02:20PM ALBUMIN-4.4 CHOLEST-185 [2112-4-5] 02:20PM CK-MB-17* MB INDX-6.3* cTropnT-0.47* [2112-4-5] 02:20PM LIPASE-16 [2112-4-5] 02:20PM ALT(SGPT)-27 AST(SGOT)-48* LD(LDH)-256* CK(CPK)-268* ALK PHOS-505* AMYLASE-45 TOT BILI-0.9 [2112-4-5] 02:20PM GLUCOSE-143* UREA N-34* CREAT-1.1 SODIUM-141 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [2112-4-5] 02:30PM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [2112-4-5] 02:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2112-4-5] 02:30PM URINE COLOR-Pink APPEAR-Hazy SP [Last Name (un) 155]-1.007 [2112-4-5] 05:52PM LACTATE-2.2* [2112-4-5] 06:29PM %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE [2112-4-5] 11:01PM CK-MB-11* MB INDX-5.3 cTropnT-0.78* [2112-4-5] 11:01PM CK(CPK)-207* [2112-4-5] 11:13PM freeCa-1.12 [2112-4-5] 11:13PM O2 SAT-94 [2112-4-5] 11:13PM LACTATE-1.5 [2112-4-5] 11:13PM TYPE-ART PO2-144* PCO2-37 PH-7.42 TOTAL CO2-25 BASE XS-0 INTUBATED-NOT INTUBA NON-CONTRAST HEAD CT SCAN: There is hypodensity of the right caudate nucleus and right putamen, extending into the subinsular white matter on the right side. The right caudate nucleus is enlarged compared to the left side, and the contours of the hypodensity suggest edema consistent with recent infarction of this tissue. Furthermore, there are areas of relative [Name (NI) 99906] compared to the normal brain parenchyma within the hypodense infarct, raising the possibility of small areas of hemorrhage within the infarct. There is no evidence of extra-axial hemorrhage. There is no shift of the normally midline structures. The ventricles and sulci are prominent, consistent with involutional change. There is a small rounded hypodensity within the left cerebral peduncle, likely representing either a vascular space or an old lacunar infarction, and there is lacunar infarction in the inferior right cerebellum. The visualized paranasal sinuses and mastoid air cells are clear. There are dense vertebrobasilar and carotid calcifications. There are densities at the periphery of the left globe, probably indicating scleral banding. Soft tissues are otherwise unremarkable, as are osseous structures. IMPRESSION: 1. Recent infarction of the right caudate, putamen, extending into the subinsular white matter on the right side. Correlate with clinical history. 2. Isodense areas within the infarcted tissue, which may represent small areas of hemorrhage or spared brain parenchyma. The findings of acute infarction and possible hemorrhage within the infarcted tissue were discussed with Dr. [Last Name (STitle) 14944] at the immediate conclusion of the exam. [Age over 90 ]-year-old man with dyspnea and hypoxia, CVA, AFib. Evaluate for edema or infiltrate. CHEST, PORTABLE: Prior studies obtained at an outside office are not available for comparison. The heart is enlarged. The mediastinal and hilar contours are unremarkable. There is haziness of the pulmonary vasculature with more patchy opacities throughout the left lung. Sternal wires are identified from prior cardiac surgery. There are no large pleural effusions. IMPRESSION: Cardiomegaly with CHF. The patchy opacities throughout the left lung likely represent asymmetric pulmonary edema. Differential diagnosis includes multifocal pneumonia superimposed on CHF and followup after treatment is recommended. MRI OF THE BRAIN: Diffusion-weighted images demonstrate a large area of restricted diffusion corresponding to the right middle cerebral artery territory, including the right basal ganglia, insular cortex and portions of the right frontal, parietal, and temporal lobes. The apparent infarcted tissue occupies a much larger region than seen on the head CT scan of the prior day. There is susceptibility effect noted within the right putamen and the infarcted tissues are slightly effaced. There is no shift of the normally midline structures. There is mild mass effect on the right lateral ventricle. There is a smaller rounded area of restricted diffusion at the left temporo- occipital junction region. There is elevated T2 and FLAIR signal at this locale, suggesting a more subacute small infarct. There are small foci of increased T2 and FLAIR signal within the cerebral periventricular white matter, consistent with chronic microvascular ischemia. MRA OF THE BRAIN: TECHNIQUE: 3-D time-of-flight imaging of the distal vertebral and internal carotid arteries were obtained, including the circle of [Location (un) 431]. 3-D reformatted images are provided. MRA OF THE BRAIN: As expected in this case of right middle cerebral artery infarction, no flow is seen within the right middle cerebral artery beyond the M1 segment. In addition, no flow is visualized within the distal left vertebral artery, nearly to the junction point with the basilar artery. A small amount of residual flow is seen within the superior-most left vertebral artery. Of note, there is no evidence of infarction of the territory supplied by the posterior circulation. There are no areas of aneurysmal dilation clearly appreciated. IMPRESSION: 1. Large acute right middle cerebral artery territory infarction, significantly increased in size compared to infarcted tissue seen on recent head CT of one day previous. 2. Evidence of hemorrhagic transformation within the right putamen. 3. MRA shows occlusion of the right middle cerebral artery beyond the most M1 segment. 4. No flow is visualized within the left vertebral artery, except at the immediate junction of the left vertebral artery with the basilar artery. Brief Hospital Course: [Age over 90 ] yo man with hx htn, cad s/p cabg, COPD, who presented with sudden onset left hemiplegia, found to be in new afib; initial exam with inattention, lethargy, dysarthria, left arm and leg weakness, and head ct with new right subcortical stroke; also found to have demand NSTEMI with peak troponin 0.78, pneumonia versus asymmetric pulmolnary edema with high O2 requirement and tenuous sats, and low initial pressures requiring fluid boluses, worsened respiratory status. Brain MRI/A with Right M1 occlusion, large area of infarct +DWI including basal ganglia; hemorrhagic transformation R putamen. No flow in left vert. (NOTE: also lots of atrophy, big vents). The patient was admittd to the ICU and was diuresed; cardiology was consulted for aflutter vs afib at presentation and ?indication for anticoag vs antiplatelet. The patient's respiratory status remained tenuous throughout the admission thought secondary to CHF (versus pneumonia) and he showed no major improvement from the stroke. His heart rate remained high despite diltiazem drip; his pressure was often tenuous. He was made CMO on [4-7] via family discussion with Dr. [Last Name (STitle) 26687]/ICU attending. He passed away at 8:55 am on [4-8] - exam with no spont breath/heart sounds, pupils fixed and 5mm, no brainstem reflexes. The patient's son was at the bedside and declined autopsy. Medications on Admission: -asa 325 -imdur 30 qd -metoprolol 12.5 [Hospital1 ] -triamterene/hctz -lipitor Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: expired immediate cause of death: resp arrest x hours, secondary: chf exacerbation x days, stroke x days Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2112-4-8]	[ "496", "42731", "41071", "4280", "2720", "V4581", "4019" ]
Admission Date: [2112-1-11] Discharge Date: [2112-1-16] Date of Birth: [2028-11-25] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1572] Chief Complaint: CHF exacerbation Major Surgical or Invasive Procedure: Right and left heart cathterization. History of Present Illness: This is an 83 year old gentleman with CAD s/p stent x 2 (LAD, RCA), s/p pacemaker for LBBB/syncope, HTN, h.o. MI ([2070]) presented to the ED from his cardiologist's office with worsening shortness of breath. . He was feeling in his usual state of health until two weeks ago when he noted progressive dyspnea on exertion that was apparent at rest. He has had no medications changes, changes in diet. He has had no symptoms of chest pain recently and has not required use of his SL NTG. His symptoms have been associated with exacerbation of an underlying cough that is worse at night and associated w/ clear phlegm and chronic blood streaking. He reports worsening intermitant abdominal cramping and diarrhea. He denies fevers but notes night-time chills. He has had no episodes of chest pain during this period. He denied symptoms of heart failure including symptoms of PND, orthopnea or peripheral edema. He is able to lie flat with one pillow. Last friday, his son was concerned regarding his father's increasing shortness of breath and called his cardiologist Dr. [Last Name (STitle) ] who recommended coming in for his regularly scheduled appointment today. . His recent cardiac history is significant for a recent hospitalization in [Month (only) 116] of this year. He had a full workup done including a coronary angiogram that showed significant stenosis to the RCA and LAD, with two drug-eluting stents placed.He was noted to have a new MR murmur at this time. An outside echo at that time was reported to have an EF of 20%. Unfortunately, an echocardiogram was not done here. It was felt that it was most likely ischemic and his medical regimen was adjusted. This [2111-8-5] he had a repeat echocardiogram done that shows an EF of 43%, 4+ mitral regurgitation as well as a significant elevated PA pressures . At his cardiology appointment today, his shortness of breath acutely decompensated. He was placed on an oxygen face mask with desaturations to the 70s. He was referred to the emergency department where vital signs were significant for HR 97 190/130 41 70% on facemask. Chest x-ray showed hypervolemia, pulmonary vascular congestion. A ABG was obtained which showed respiratory acidosis with a pH 7.20, pCO2 69, pO2 31, HCO3 28, lactate 2.1.(felt to be venous) CBC showed no abnormalities, chemistry panel showed Cr 1.7 and hyperglycemia. A nitro gtt was started, he was given 40mg IV lasix and 4mg of morphine. He put out 250 cc urine prior to tranfer to the CCU. An EKG was significant for old LBBB and HR 65. He was started on Bipap with saturation of 99%. . . REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, black stools or red stools. He denies recent fevers. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: h.o. systolic dysfunction (EF 40%) severe MR/TR - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: CAD s/p stent to PTCA, LAD stent x 1 (30-40% inflow stenosis), RCA stent x 1 ([2110]) (started on plavix, carvedilol, asa 325 and atorvastatin) - PACING/ICD: [Company 1543] Sigma single chamber pacemaker w/ unipolar lead for LBBB and syncope 3. OTHER PAST MEDICAL HISTORY: status post knee surgery, status post hernia repair CHF BPH status post recent right eye cataract removal h.o. knee surgery h.o. hernia repair BPH h.o. OD cataract removal chronic mild renal failure Social History: - Tobacco history: He quit tobacco in [2074] - ETOH: Significant alcohol excess - Illicit drugs: Denies illicit drug use. He lives alone. He is widower. He does not use a walker or a cane. He has two sons with whom he is close. Family History: Significant for father with an MI at the age of 69. He also has a son who has had an MI and PTCA. Physical Exam: ADMISSION VS: 96.0 64 159/134 100% on BIPAP GENERAL: Oriented, breathing labored however appropriate and able to converse. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Elevated JVP, difficult to ascertain height given BIPAP machine CARDIAC: Distant heart sounds, over breath sounds. RR. Normal S1, S2. [1-10] SM loudest at apex. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were labored with accessory muscle use. Diffuse crackles throughout lung fields. No wheeze or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: CXR [2112-1-11] FINDINGS: AP upright portable chest radiograph is obtained. A single-lead pacer device appears unchanged and the distal portion of the lead is poorly assessed given underpenetration. There is pulmonary vascular congestion and pulmonary edema with bilateral small pleural effusions, right greater than left. No definite pneumothorax. Bony structures appear grossly intact. . IMPRESSION: Findings compatible with congestive heart failure. .. CXR [2112-1-12] FINDINGS: In comparison with the study of [1-11], there is mild improvement of the still substantial congestive heart failure. Single-lead pacer device is again seen. . . Echo [2112-1-12] The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with distal septal and anterior hypokinesis. The remaining segments contract normally (LVEF = 40-45%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Moderate to severe mitral regurgitation. Mild pulmonary hypertension. . Compared with the prior study (images reviewed) of [2111-8-12], severity of mitral and tricuspid regurgitation has decreased. Pulmonary pressures are lower. . CT Torso w/o Contrast [2112-1-14] 1. Moderate calcification within the aortic arch, in this patient who is preop for mitral valve replacement. 2. Small nonhemorrhagic right pleural effusion with adjacent atelectasis. 3. Subpleural ground glass opacities, which can be seen with nonspecific interstitial pneumonitis (NSIP). . Dental Panoramex: Results not available for viewing . MRSA SCREEN (Final [2112-1-14]): No MRSA isolated. . Staph aureus Screen (Final [2112-1-15]): NO STAPHYLOCOCCUS AUREUS ISOLATED. . [2112-1-16] 08:25AM BLOOD WBC-5.1 RBC-4.02* Hgb-12.9* Hct-37.5* MCV-93 MCH-32.0 MCHC-34.3 RDW-14.9 Plt Ct-152 [2112-1-16] 08:25AM BLOOD Plt Ct-152 [2112-1-11] 02:50PM BLOOD PT-12.3 PTT-24.4 INR(PT)-1.0 [2112-1-16] 08:25AM BLOOD Glucose-93 UreaN-32* Creat-1.6* Na-141 K-4.5 Cl-102 HCO3-27 AnGap-17 [2112-1-13] 05:08PM BLOOD Creat-2.1* Na-137 K-4.2 Cl-99 [2112-1-11] 02:50PM BLOOD Glucose-197* UreaN-29* Creat-1.7* Na-139 K-4.6 Cl-101 HCO3-24 AnGap-19 [2112-1-15] 05:45AM BLOOD ALT-15 AST-21 LD(LDH)-191 AlkPhos-93 TotBili-0.6 [2112-1-12] 06:21AM BLOOD CK(CPK)-37* [2112-1-11] 09:30PM BLOOD CK(CPK)-43* [2112-1-12] 06:21AM BLOOD CK-MB-3 cTropnT-<0.01 [2112-1-11] 09:30PM BLOOD CK-MB-3 cTropnT-<0.01 [2112-1-11] 02:50PM BLOOD proBNP-[2099]* [2112-1-16] 08:25AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.1 [2112-1-11] 02:50PM BLOOD Calcium-9.7 Phos-4.8* Mg-2.0 [2112-1-12] 01:49PM BLOOD %HbA1c-5.8 eAG-120 [2112-1-12] 06:21AM BLOOD Triglyc-75 HDL-95 CHOL/HD-1.6 LDLcalc-45 [2112-1-11] 03:03PM BLOOD Lactate-2.1* Brief Hospital Course: HOSPITAL COURSE: This is an 83 year old gentleman with CAD (DES to LAD, RCA in [2111-4-4]), with a pacemaker pacemaker for LBBB/syncope, HTN, h.o. MI ([2070]) who presented for management of acute decompensation fo systolic and diastolic heart failure to the cardiac intensive care unit. He was initially diuresed with a lasix gtt. AN echo following admission demonstrated moderate to severe mitral regurgitation, mild regional left ventricular systolic dysfunction and mild pulmonary hypertension. A left heart cath which revealed unchanged coronary anatomy when compared to prior. The patient was evaluated by cardiac surgery for possible future mitral valve replacement. . ACTIVE ISSUES # ACUTE DECOMPENSATION OF SYSTOLIC AND DIASTOLIC DYSFUNCTION: The patient presented from his cardiologist's office with acute on chronic progresive dyspnea, crackles on lung exam and elevated BNP, a CXR consistent with pulmonary edema and requiring BIPAP concerning for left sided heart failure. The etiology of acute on chronic failure felt to be secondary to worsening MR in the context of marked systolic hypertension versus restenosis of LAD [Name Prefix (Prefixes) ] [Last Name (Prefixes) 23318] infection. He acutely flashed while tachycardic and hypertensive while visiting his cardiologist representing acute presentation. Cardiac enzymes were cycled and negative. He was initially aggressively diuresed with a lasix gtt on admission with net -2.5 liters overnight. He was weaned off BIPAP to 2 liter nasal cannula within several hours and was saturating well on nasal cannula by HD 3. An echo on HD 2 demonstrated EF 40-45%, with moderate to severe mitral regurgitation,(systemic BP 137) mild regional left ventricular systolic dysfunction and mild pulmonary hypertension.([2111-8-5] RVSP in the 60's) Overall echo demonstrated improvement in the severity of mitral and tricuspid regurgitation and lower pulmonary pressures when compared to most recent echo in [2111-8-5] but at a lower systolic blood pressure. The lasix gtt was stopped on HD 3 after diuresis of 3.5 liters and a mild acute on chronic renal dysfunction. On HD4 a left heart cath showed right dominant system with no flow limiting disease (patent stent sites) and LVEDP of 10 mmHg, RVEDP of 9 mmHg, CI of 2 l/min/m2 and a mildly elevated SVR and PVR at 1621 dynes-sec/cm5 and 211 dynes-sec/cm5 respectively. Cardiac Surgery was consulted to evaluate the patient for future mitral valve replacement. Initial studies including a CT torso without contrast and dental panoramex were performed while the patient was inhouse. Future discussion regarding possible mitral valve replacement will continue in the outpatient setting. His lasix was increased to daily dosing and carvedilol was doubled. Lisinopril will be restarted in outpatient setting following renal function. . # CORONARY ARTERY DISEASE: History of CAD status post DES to LAD and RCA in [Month (only) 547] of last year after presenting with symptoms of syncope post-micturition. He was started on plavix, carvedilol, asa 325, lisinopril and atorvastaton at that time. On admission, no symptoms of chest pain. Cardiac enzymes were cycled and negative. Lisinopril held in setting of acute rise in BUN and creatinine after diuresis and to be restarted in the outpatient setting by his cardiologist. Carvedilol was doubled. . # RHYTHM: In sinus rhythm on admission with old left bundle branch block. He has a single chamber pacemaker long ago placed for managment of LBBB with syncope. His heart rate and rhythm were monitored throughout the admission and he was continued on is home regimen of carvedilol which was doubled to 25 mg [Hospital1 ]. . # HTN: History of hypertension. Hypertensive on admission to cardiologist office today. He was continued on home regimen as outlined above. . # ACUTE ON CHRONIC RENAL INSUFFICIENCY: History of elevated creatinine during past admissions felt to be pre-renal. Elevated creatinine above 1.5 baseline per cardiologist report likely in the setting of acute decompensation of heart failure and poor forward flow. In the setting of diuresis mild acute on chronic renal insufficiency tolerated with creatinine increase from 1.7 to 2.1 and a mild metabolic contraction alkalosis. Diuresis and lisinopril held prior to discharge and renal function improved to 1.6 at the time of discharge. . # HEMOPTYSIS/ COUGH: History of chronic hemoptysis with evaluation by ENT in [2109]. Recommendation at that time was to have formal evaluation by pulmonology. Remote smoking history. No documentation of prior rheumatologic work-up. The patient reports intermittant hemoptysis with worsening symptoms of cough recently concerning for worsening pulmonary artery hypertension. No focal consolidation apparent on admission CXR or sx of fever. He has had a flu shot this year. . TRANSITIONAL ISSUES: # Medical Management: Lisinopril to be restarted following f/u of renal function. Carvedilol doubled to 25mg [Hospital1 ] and Lasix increased to daily dosing. # Code: Full Medications on Admission: 1. Atorvastatin 40 mg daily 2. Carvedilol 12.5 mg [Hospital1 ] 3. Plavix 75 mg daily 4. Furosemide 20 mg qMon,Wed,[Last Name (LF) ],[First Name3 (LF) ] 5. Lisinopril 40 mg daily 6. Aspirin 325 mg daily Discharge Medications: 1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: 1. Acute on chronic heart failure 2. Mitral valvue regurgitation 3. Acute on chronic renal failure. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. You were admitted for shortness of breath, which was due to worsening of your heart failure. You were determined to have worsening mitral valvue regurgitation. You received lasix during your admission, and the pulmonary edema or fluid in your lungs improved. You will need to continue your heart failure medications as an outpatient. The directions for these medications are: Lasix 20 mg daily Carvedilol 25 mg twice daily Lisinopril 20 mg daily 2. You were also evaluated by Dr. [Last Name (STitle) 28946] of Cardiothoracic surgery. You will need to follow-up with Dr. [Last Name (STitle) 28946] as an outpatient. His office will give you a call this week to let you know of your appointment. 3. It is very important that you take your medications as prescribed. 4. It is very important that you keep all of your doctors [Name5 (PTitle) 4314]. 5. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [Last Name (LF) 578],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 579] Address: [Hospital1 ], [Location (un) ],[Numeric Identifier 19604] Phone: [Telephone/Fax (1) 6937] Appt: Please call Dr [Last Name (STitle) ] office to set up a follow up appt from your hospital stay within 1 week. Dr.[Name (NI) 103400] office will call you this week for a follow-up appointment.	[ "5849", "4280", "4240", "40390", "2875", "5859", "V1582", "V4582" ]
Admission Date: [2172-4-24] Discharge Date: [2172-5-10] Date of Birth: [2105-6-19] Sex: M Service: NEUROLOGY Allergies: Penicillins / Clindamycin / Dilaudid Attending:[First Name3 (LF) 2569] Chief Complaint: Headache Major Surgical or Invasive Procedure: cerebral angiogram History of Present Illness: Reason for Consult: Called by Emergency Department to evaluate ICH Pt. name is [Known firstname ] [Name (NI) ]. HPI: The pt is a 66 year-old RHM w/ HL/DM and ? HTN who developed sudden onset R sided retroorbital HA, nausea, took tylenol without relief. Within minutes developed L sided weakness and L facial droop, but apparently was responding appropriately and following commands, albeit slowly. His wife noted his speech was like speaking w/ a mouth full of marbles. He seemed unsettled, moving things around on the kithchen counter w/o purpose. EMS was called. He was able to walk to the ambulance, but needed support and direction. At [Hospital3 10310] Hospital GCS was 15, BP was 139/63 but ranged between 139 - 167 systolic. Pt. developed worsening nausea, emesis and pounding HA around 21.30, BP at that time was noted as 204/95. CT head revealed a large R frontal IPH w/ SAH. He was tx w/ fosphenytoin 1g, intubaed (etomidate, succinyl choline, versed) and started on ativan gtt. Transferred to [Hospital1 18]. VS here on propofol were 118/51 83 on CMV/AC. Exam was notable for GCS of 5, unresponsive to verbal, grins to noxious, eyes midline brisk, no deviation, present corneal and gag w/o VOR, w/o localization to noxious, brisk flexor on R to noxious away from stimulus and R flex on nox to LUE. RLE w/ brisk withdrawal, while, LLE w/ grin and RLE flx. L toe is up and tone LLE >> RLE. Per discussion w/ wife, there were no prodromal symtptoms or signs. He was in USOH, watching a Bruins game. No new medications, no hx of drug use. He was not straining at the time, no hx of recent trauma. . Past Medical History: [ ? ] HTN [ + ] HL [ + ] DM [ - ] Afib [ - ] prior CVA/TIA/ICH Social History: Lives in [Location 14663] MA w/ wife. Is a retired electrical company manager, now volunteers at the police office Family History: bio father unknown. Mother's side: [ + ] HTN [ - ] HL [ - ] DM [ - ] CVA/TIA [ - ] CAD/PVD [ pancreatic, breast ] Cancer [ - ] Intracerebral anneurysms/AVM [ - ] Connective tissue disorders ([Last Name (un) 42664] Dahnlos, Marfans, PKD) Physical Exam: Vitals: T: 97.1 P:83 R: 16 BP: 118/51 SaO2: 100% on CMV assist General: Obtunded. HEENT: NC/AT, no scleral icterus noted Neck: Supple. Pulmonary: CTA bilaterally, laterally Cardiac: RR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities: warm, dry, no edema; clubbing present Pulses: 2+ radial, DP bilaterally. Neurologic: GCS of 5 (eye opening 1, motor 3, verbal 1) off propofol x 10 minutes. MS: unresponsive to verbal, grins to noxious. Eyes midline briskly reactive 4->2, no deviation. Present are corneal and gag, there is no VOR. -Motor/sensory: Normal bulk. No posturing. Increased tone in LLE > LUE. LUE not antigravity, extends to noxious and causes RUE to flex w/o localization. RUE withdraws briskly to noxious, flexor. LLE, trace triple flexion to noxious sluggishly, RLE flexes briskly to nox applied at LLE. RLE to nox brisk withdrawal away from stiumuls. -DTRs: diffusely brisk in b/l UEs symmetrically as of right now, LLE 3+, RLE 2+. Plantar response: RIGHT - flexor LEFT - extensor Pertinent Results: 141 104 21 164 AGap=13 ------------[ 4.1 28 1.0 CK: 118 MB: 2 Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Pending 15.5 12.9 39 210 N:84.6 L:10.1 M:3.5 E:1.5 Bas:0.3 PT: 12.0 PTT: 23.4 INR: 1.0 EKG at OSH: NSR, no sT/T changes. Hematology [2172-5-5] 04:30AM BLOOD WBC-12.1* RBC-3.69* Hgb-10.8* Hct-32.0* MCV-87 MCH-29.3 MCHC-33.9 RDW-13.0 Plt Ct-413 [2172-5-4] 05:20AM BLOOD WBC-15.6* RBC-3.95* Hgb-11.7* Hct-34.3* MCV-87 MCH-29.6 MCHC-34.1 RDW-13.0 Plt Ct-370 [2172-5-3] 06:20AM BLOOD WBC-11.1* RBC-3.85* Hgb-11.1* Hct-33.2* MCV-86 MCH-28.7 MCHC-33.3 RDW-12.8 Plt Ct-302 [2172-5-2] 06:00AM BLOOD WBC-10.9 RBC-3.43* Hgb-10.1* Hct-29.8* MCV-87 MCH-29.4 MCHC-33.8 RDW-12.8 Plt Ct-291 [2172-5-1] 04:30AM BLOOD WBC-10.8 RBC-3.39* Hgb-10.0* Hct-29.4* MCV-87 MCH-29.6 MCHC-34.1 RDW-12.8 Plt Ct-252 [2172-4-30] 02:07AM BLOOD WBC-14.2* RBC-3.57* Hgb-10.3* Hct-30.1* MCV-84 MCH-28.7 MCHC-34.1 RDW-12.7 Plt Ct-243 [2172-4-29] 02:27AM BLOOD WBC-13.1* RBC-3.70* Hgb-10.3* Hct-31.0* MCV-84 MCH-27.9 MCHC-33.2 RDW-12.7 Plt Ct-223 [2172-4-28] 02:10AM BLOOD WBC-15.7* RBC-3.44* Hgb-9.5* Hct-29.2* MCV-85 MCH-27.7 MCHC-32.5 RDW-12.9 Plt Ct-185 [2172-4-27] 01:25AM BLOOD WBC-16.7* RBC-3.53* Hgb-10.2* Hct-30.3* MCV-86 MCH-28.9 MCHC-33.6 RDW-13.0 Plt Ct-183 [2172-4-25] 02:08PM BLOOD WBC-12.0* RBC-3.72* Hgb-11.1* Hct-32.5* MCV-87 MCH-29.8 MCHC-34.2 RDW-12.9 Plt Ct-212 [2172-4-25] 01:42AM BLOOD WBC-15.6* RBC-3.84* Hgb-11.5* Hct-33.6* MCV-87 MCH-29.9 MCHC-34.1 RDW-13.0 Plt Ct-265 [2172-4-24] 06:03AM BLOOD WBC-14.9* RBC-4.12* Hgb-12.4* Hct-36.0* MCV-88 MCH-30.1 MCHC-34.4 RDW-12.9 Plt Ct-267 [2172-4-23] 11:30PM BLOOD WBC-15.5* RBC-4.50* Hgb-12.9* Hct-38.8* MCV-86 MCH-28.7 MCHC-33.2 RDW-12.8 Plt Ct-210 Coags [2172-5-5] 04:30AM BLOOD Plt Smr-NORMAL Plt Ct-413 [2172-5-4] 05:20AM BLOOD Plt Smr-NORMAL Plt Ct-370 [2172-5-3] 06:20AM BLOOD Plt Smr-NORMAL Plt Ct-302 [2172-4-25] 01:42AM BLOOD Plt Ct-265 Chem 7 [2172-5-5] 04:30AM BLOOD Glucose-138* UreaN-25* Creat-0.8 Na-131* K-4.3 Cl-97 HCO3-26 AnGap-12 [2172-5-4] 05:20AM BLOOD Glucose-54* UreaN-24* Creat-0.7 Na-136 K-4.2 Cl-99 HCO3-25 AnGap-16 [2172-5-3] 06:20AM BLOOD Glucose-161* UreaN-21* Creat-0.8 Na-136 K-4.2 Cl-99 HCO3-26 AnGap-15 [2172-5-2] 06:00AM BLOOD Glucose-260* UreaN-22* Creat-0.7 Na-132* K-4.3 Cl-97 HCO3-27 AnGap-12 [2172-5-1] 04:30AM BLOOD Glucose-176* UreaN-20 Creat-0.8 Na-135 K-4.2 Cl-100 HCO3-29 AnGap-10 [2172-4-30] 02:07AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-137 K-4.0 Cl-103 HCO3-26 AnGap-12 [2172-4-28] 02:10AM BLOOD Glucose-163* UreaN-21* Creat-0.9 Na-139 K-3.9 Cl-105 HCO3-26 AnGap-12 [2172-4-26] 02:20AM BLOOD Glucose-195* UreaN-20 Creat-0.8 Na-139 K-3.8 Cl-105 HCO3-24 AnGap-14 [2172-4-24] 06:03AM BLOOD Glucose-186* UreaN-19 Creat-1.0 Na-137 K-4.5 Cl-103 HCO3-26 AnGap-13 [2172-4-24] 02:18PM BLOOD CK(CPK)-102 [2172-4-24] 02:18PM BLOOD CK-MB-2 cTropnT-<0.01 [2172-4-24] 06:03AM BLOOD CK-MB-2 cTropnT-<0.01 [2172-4-23] 11:30PM BLOOD cTropnT-<0.01 [2172-5-5] 04:30AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.2 [2172-5-4] 05:20AM BLOOD Calcium-8.0* Phos-4.5 Mg-2.3 [2172-5-3] 06:20AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.1 [2172-5-2] 06:00AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.0 Cholest-114 [2172-5-1] 04:30AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.1 [2172-4-30] 02:07AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.0 [2172-4-29] 02:27AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.0 [2172-4-28] 02:10AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.8 [2172-4-27] 01:25AM BLOOD Calcium-7.5* Phos-2.0* Mg-2.1 [2172-4-26] 02:20AM BLOOD Calcium-8.1* Phos-1.5* Mg-1.6 [2172-4-25] 01:42AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.2 [2172-4-24] 06:03AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8 [2172-5-2] 06:00AM BLOOD %HbA1c-7.4* eAG-166* [2172-5-4] 01:59PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG [2172-4-25] 02:08PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-1000 Ketone-15 Bilirub-NEG Urobiln-1 pH-5.5 Leuks-NEG [2172-4-24] 01:39AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2172-5-4] 01:59PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [2172-4-25] 02:08PM URINE RBC-[7-16]* WBC-[7-16]* Bacteri-FEW Yeast-NONE Epi-0-2 [2172-4-24] 01:39AM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Radiologic Data: CT from OSH 2130 reveals a 4.5 x 3.9 x 5.0 cm R frontal hemorrhage in MCA/ACA territory, w/ SAH in frontal lobes w/ mild masse effect on R frontal [Doctor Last Name 534] w/o IVH. [Hospital1 18] CT head and CTA C- head: large right frontal parenchymal hemorrhage w/ subarachnoid blood similar to prior study. New/increased left hemispheric SAH (2:22, 2:18). Mass effect on right lateral ventricle. 2mm leftward shift of midline structures. New intraventricular hemorrhage right > left lateral ventricles. CTA: patent carotid, vertebral arteries, patent Circle of [Location (un) 431]. No aneurysm identified MRI +/- [2172-4-27]; IMPRESSION: Redemonstration of a large right frontal intraparenchymatous hematoma as described in detail above, causing effacement of the sulci, and mild midline shifting towards the left, approximately 2.9 mm of shifting is demonstrated in the transverse projection. After the administration of gadolinium contrast, there is evidence of prominent arterial and venous vessels surrounding the inferior aspect of the hemorrhage with a prominent single vessel coursing along the lateral aspect of the hematoma and slightly increased flow voids in this area, the possibility of an underlying vascular malformation cannot be completely excluded, other entities occult by the hematoma are also considerations, followup is recommended. No significant areas with magnetic susceptibility are identified to suggest amyloid angiopathy, however, this entity cannot be completely ruled out. Cerebral angiogram [4-29] FINDINGS: Left common carotid arteriogram showed normal carotid bifurcation. Normal filling of the internal carotid along the cervical, petrous, cavernous and supraclinoid portions. Both anterior and middle cerebral arteries were seen and appeared normal. There was no aneurysm or arteriovenous malformation seen. There was normal venous phase of the study. The external carotid artery with its branches were normal with no dural AVF. Right common carotid arteriogram showed some atherosclerotic changes in the common carotid and proximal internal carotid with no significant stenosis. There was normal filling of the internal carotid along the cervical, petrous, cavernous and supraclinoid portions. There was some displacement of intracranial vessels due to mass effect from the right frontal bleed with area of reduced vascularity representing the area of intracerebral hemorrhage. There was early bifurcation of the right middle cerebral artery. The anterior cerebral artery was seen and appeared normal. There was no aneurysm or arteriovenous malformation. The venous phase of the study was normal with prominent superficial cortical veins. Right external carotid artery showed normal filling of the vessel and its branches with no evidence of dural AV fistula. Left vertebral arteriogram showed normal filling of the dominant distal vertebral artery. Basilar appears normal in course and caliber. The left PICA, both AICAs, SCAs and PCAs were seen and appeared normal. The right PCA appears smaller than the left PCA. There was no aneurysm or arteriovenous malformation. IMPRESSION: Diagnostic cerebral angiogram was done, which did not show any aneurysm, arteriovenous malformation, or dural AV fistula to account for the patient's intracerebral hemorrhage. CXR [4-30] FINDINGS: As compared to the previous examination, there is no relevant change. The Dobbhoff tube is in unchanged position, with the tip projecting over the distal part of the stomach. The course and position of the left-sided central venous access line is also unchanged. Unchanged size of the cardiac silhouette with mild retrocardiac atelectasis. No newly appeared focal parenchymal opacities CXR [5-1] IMPRESSION: Improving left lower lobe pneumonia. CT head [5-5] IMPRESSION: 1. No significant change in the previously noted right frontal hematoma with surrounding edema and mass effect on the right lateral ventricle with 3.4 mm leftward shift of the midline structures. No new acute intracranial hemorrhage. No acute fracture. 2. Small amount of fluid/mucosal thickening in the left side of the sphenoid sinus. CT torso [5-7] (prelim) chest: small left effusion w/ relaxation atelectasis. right base atelectasis. no pulm nodule or mass. no consolidation. small scattered nodes but no mediastinal or hilar adenopathy by size criteria. dobhoff reaches stomach. airways widely patent. abd/pelv: no evidence of malignancy. liver, spleen, kidneys, adrenals and pancreas appear normal. min biliary studge. msall and large bowel normal in caliber and appearance. air in bladder, correlate with catheterization. atherosclerosis without aneurysm EEG [5-8] pending Brief Hospital Course: Hospital course by problem; . Neurology; The patient was admitted to the neurology ICU for q1h neurochecks. His SBP was maintained 100-160 mmHg and HOB greater than 30 degrees. He was started on keppra 500 mg [Hospital1 ] for seizure prophylaxis. Serial CT head imaging remained stable. An MRI brain was concerning for possible AVM, but subsequent conventional angiogram did not show any evidence of vascular malformation. The most likely cause of bleed is either hypertension or amyloid angiopathy. He was noted to be drowsy with fluctuating lvel of consciousness while in the hospital. He underwent MRI for evaluation followed by CT torso to rule out underlying mass , both of which did not show any evidence of underlying mass/ malignancy. He had unwitnessed fall on [5-5] in the afternoon, after which he had CT scan which did not show evidence of change in size of bleed or new bleed. He was initially started on keppra which was later stopped as he developed rash. he underwent EEG which was normal . Resp; The patient required intubation for airway protection but was extubated [4-28] without difficulty. He was noted to have left lower zone infiltrate on chest Xary and was started on broad spectrum antibiotics (cipro and vanco). After transfer to floor, he was noted to have rising wbc on [5-3] and [5-4], however he did not have fever. The trend was closely monitered and it showed downward trend on [5-5]. . ID; The patient spiked fevers to 103 on [4-25] and had leukocytosis. Blood and urine cultures have been negative to date. One sputum sample grew gram positive rods. CXR showed a possible LLL infiltrate. He was started on vancomycin and ciprofloxacin for presumed ventilator-associated pneumonia [4-25] and antibiotics were stopped after a course of 11 days as he showed clinical and lab signs of resolution and developed skin rash. . CV; The patient required phenylephrine to maintain MAP > 70 early in the hospital course but has been normotensive since extubation. His home ace-inhibitor has been resumed. . Endo; The patient was maintained on a regular insulin sliding scale and NPH. His home glyburide has been resumed. Derm- he developed rash over left arm followed by anterior abdominal wall and also on legs. The most likely cause is thought to be medication induced, either due to vancomycin, ciprofloxacin or keppra. This should be watched closely in next few days. OT/PT/Rehab; He was evaluated by rehab team. He was unable to pass speech and swallow test and was on tube feeds till [5-6]. It was discussed with family and it was decided to proceed with PEG tube for feeding issues. he underwent PEG tube on [2172-5-8]. As his mental status improves, his ability to take POs should be reassessed. OT/PT recommended for extended care facility for further care. Medications on Admission: - Glyburide 5mg [Hospital1 ] - Quinipril 5mg daily - Metformin 500mg [Hospital1 ] - Simvastatin 40mg daily - ASA 81 daily Discharge Medications: 1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for eye care. 2. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for eye care. 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Quinapril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for temp > 101, pain. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for c. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for Thrush. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [2-8] Inhalation Q6H (every 6 hours) as needed for wheezing. 15. Insulin Lispro Subcutaneous Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Right frontal bleed, ? hypertensive in origin Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Lethargic but arousable Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted for evaluation of stroke. You had CT scan of brain as well as MRI which showed bleed in right frontal lobe of brain. You were evaluated by neurosurgery and underwent angiogram which did not show evidence of AVM or aneurysm. The most likely cause of bleed is thought to be related to hypertension. You were dound to have pneumonia for which you were treated with antibiotics. You were started on medication called keppra for prevention of seizures which was later stopped while in the hospital as you developed rash , most likley to either antibiotics or keppra. You underwent PEG tube placement for feeding. You underwent CT scan of torso which did not show evidence of mass. You underwent EEG which showed ... Please take your medications as prescribed. Please call 911/ your doctor if questions. Please follow up with the appointments as scheduled. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2172-6-15] 2:30 Please call [Last Name (LF) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 67627] PCP's office after discharge for follow up. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575]	[ "2761", "4019", "25000", "2724" ]
Admission Date: [2106-12-11] Discharge Date: [2106-12-18] Date of Birth: [2049-4-15] Sex: M Service: MEDICINE Allergies: Percocet / Codeine / Aspirin Attending:[First Name3 (LF) 943] Chief Complaint: Weakness and fatigue Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 57 year old male with end stage liver disease secondary to Hep C cirrhosis and alcohol abuse. He was discharged one day prior to this admission after being treated for hepatic encephalopathy. He slept well that night, but then became weak and lethargic. He vomited twice on the day of admission and as per his wife, he [Name2 (NI) ] poor urine output. He has been taking his lactulose and has been having watery stools every 2 hours. Denises hematemesis, hematochezia, dysuria, SOB, or CP. Past Medical History: -Hepatitis C Cirrhosis (diagnosed in [2100]) - no liver bx done; risk factors: suspected unprotected sex, tattoo; No interferon/ribavirin due to insurance reasons. Variceal bleeding in [February 2106] (7 units required), EGD revealed Grade-II varices but no acute bleeding. Encephalopathy and mild ascites; [2106-11-17] EGD: 4 cord varices (one was Grade III), 3 bands placed; MELD score 29 ([2106-11-24]); 19 ([2106-9-1]) -COPD - [2106-11-16] PFTs normal -Surgeries for Hernia (bilateral), Varicose veins -cellulitis -chest pain [2100] - cath: minor CFx, LAD disease Social History: Patient has not drank alcohol since [2106-3-9]. Prior alcohol intake since adolescence, 6-7 beers/day; period of abstinence from age 34-44; does not like AA. Currently denies tob, OMR states 3 packs /day for 30 yrs; quit within last year. No IVD abuse Tattoos + Lives w/ his girlfriend [First Name4 (NamePattern1) ] [Name (NI) ]) of 13 yrs in [Location (un) 7661], MA MassHealth insurance; disability income - does not work currently, former painter Does not drive Family History: No hx of liver disease in family Physical Exam: VS- 97.0, 75, 105/58, 12, 100% RA Gen: overweight, jaundiced, palmar erythema, spider nevi Lungs: CTA B/L Heart: RRR, Grade 2 SEM heard best at apex Abd: mildly tender RLQ, no rebound or guarding, liver mildly enlarged, guiac negative Ext: 1+ pedal edema Neuro: + asterixis, CN 2-12 grossly in tact, + full body tremors Pertinent Results: [2106-12-10] 05:00AM [Month/Day/Year 3143] WBC-4.7 RBC-2.60* Hgb-9.8* Hct-27.9* MCV-108* MCH-37.6* MCHC-35.0 RDW-17.6* Plt Ct-74* [2106-12-15] 12:50PM [Month/Day/Year 3143] WBC-5.2 RBC-2.02* Hgb-7.1* Hct-22.4* MCV-111* MCH-35.5* MCHC-31.9 RDW-17.9* Plt Ct-98* [2106-12-15] 07:56PM [Month/Day/Year 3143] WBC-4.9 RBC-1.72* Hgb-5.3# Hct-15.6# MCV-91# MCH-31.0# MCHC-34.0 RDW-25.9* Plt Ct-50* [2106-12-15] 10:10PM [Month/Day/Year 3143] WBC-4.7 RBC-2.02* Hgb-6.2* Hct-18.2* MCV-90 MCH-30.5 MCHC-33.9 RDW-20.1* Plt Ct-29* [2106-12-15] 11:24PM [Month/Day/Year 3143] Hct-25.2# Plt Ct-91# [2106-12-16] 01:00AM [Month/Day/Year 3143] Hct-27.5* Plt Ct-153# [2106-12-16] 05:39PM [Month/Day/Year 3143] Hct-29.7* Plt Ct-81* [2106-12-17] 02:00AM [Month/Day/Year 3143] WBC-5.5 RBC-1.78# Hgb-5.4# Hct-15.4# MCV-87 MCH-30.4 MCHC-35.1 RDW-16.8* Plt Ct-40* [2106-12-17] 02:27AM [Month/Day/Year 3143] WBC-4.7 RBC-1.32# Hgb-4.0# Hct-11.5# MCV-88 MCH-30.3 MCHC-34.6 RDW-17.3 Plt Ct-27* [2106-12-18] 09:33AM [Month/Day/Year 3143] WBC-9.9 RBC-3.21* Hgb-10.2* Hct-26.6* MCV-83 MCH-31.7 MCHC-36.9* RDW-16.3* Plt Ct-46* [2106-12-18] 02:30PM [Month/Day/Year 3143] WBC-6.4 RBC-1.95# Hgb-5.9# Hct-16.4# MCV-85 MCH-30.1 MCHC-35.6 RDW-17.2* Plt Ct-86* [2106-12-18] 03:30PM [Month/Day/Year 3143] WBC-6.0 RBC-1.78* Hgb-5.4* Hct-15.1* MCV-85 MCH-30.6 MCHC-36.1* RDW-17.9* Plt Ct-76* [2106-12-10] 05:00AM [Month/Day/Year 3143] PT-20.7* PTT-150* INR(PT)-3.0 [2106-12-18] 03:30PM [Month/Day/Year 3143] Plt Ct-76* [2106-12-10] 05:00AM [Month/Day/Year 3143] Glucose-106* UreaN-42* Creat-1.5* Na-127* K-4.3 Cl-98 HCO3-20* AnGap-13 [2106-12-10] 05:00AM [Month/Day/Year 3143] ALT-87* AST-91* LD(LDH)-268* AlkPhos-106 TotBili-7.5* [2106-12-17] 02:00AM [Month/Day/Year 3143] ALT-311* AST-709* AlkPhos-72 Amylase-82 TotBili-6.8* [2106-12-18] 01:20AM [Month/Day/Year 3143] ALT-819* AST-2104* AlkPhos-124* TotBili-12.8* [2106-12-11] 05:15PM [Month/Day/Year 3143] Osmolal-283 [2106-12-13] 05:35AM [Month/Day/Year 3143] Ammonia-55* [2106-12-17] 12:31AM [Month/Day/Year 3143] Cortsol-55.9* [2106-12-18] 02:35PM [Month/Day/Year 3143] Type-ART pO2-127* pCO2-31* pH-7.39 calHCO3-19* Base XS--4 [2106-12-18] 08:28AM [Month/Day/Year 3143] Type-ART pO2-112* pCO2-42 pH-7.35 calHCO3-24 Base XS--2 [2106-12-18] 02:35PM [Month/Day/Year 3143] Glucose-50* Lactate-11.7* K-4.5 Cl-96* [2106-12-18] 08:28AM [Month/Day/Year 3143] Glucose-73 Lactate-6.5* K-4.5 [2106-12-18] 06:06AM [Month/Day/Year 3143] Glucose-108* Lactate-6.2* Brief Hospital Course: The patient was admitted to the hepatobiliary service on [2106-12-11]. His encephalopathy was thought to be baseline as well as due to dehydration. A RUQ ultrasound revealed no portal vein thrombosis. He was afebrile with a normal WBC, but was pan-cultured anyway. UA was negative. Hematocrit was stable at 30. Ceftriaxone was started empirically for possible peritoneal infection. Lactulose was continued. He was aggressively hydrated. He also had a createnine of 2.1 (baseline 1.5) and a sodium of 124 (baseline 132). His FeNa was < 1%, so this was likely pre-renal. He could not have a feeding tube placed due to recent bleeding, and required supervised oral feeding. His MELD on admission was 31. Ceftriaxone was discontined HD 2 (no signs of infection). Lactulose was titrated so as to get [4-9] BMs daily. On HD 2, createnine was down to 1.6. Physical therapy saw him and felt he should progress to be discharged home. On HD 5, he became lightheaded and dropped to his feet while walking. Denied loss of consciousness. Thought to be due to orthostasis. His BP was 60/palp and HR was 110. He was helped back to bed and his HR and BP returned to [Location 213] (SBP 100, HR 90). His CMV viral load was negative. His Hct was 22, so he was transfused 2 units RBCs for [Location ] loss anemia. His INR was 3.0, so he was transfused 3 units of FFP to correct his coagulopathy. A CT scan revealed a right-side retroperitoneal hematoma. At that time, he was transferred to the trnasplant surgery serivce and sent to the ICU. On HD 6, the patient was intubated. A central venous catheter and arterial line were placed. From this point on, this patient required aggressive transfusion of RBCs, FFP, platelets and Cryo. Over the night, his Hct dropped to 15, then rose to 18, then 25, then 27. His platelets went fro 50 to 29 to 91 to 153. His INR went from 3.3 to 2.8 to 2.5 to 0.6. He required 11 units of RBCs, 2 of platelets, 4 of FFP, 1 of cryo and 1 of factor 7. On HD 7, his Hct dropped from 28 to 11 over 3 hours. He did not have guiac + stools and hig NG tube outpuit was [Last Name (LF) 63675], [First Name3 (LF) ] his [First Name3 (LF) ] loss anemia was though to be entirely due to his retroperiotneal hematoma. TIPS and surgery were considered, but the mortality was thought to be too high. Over the day, he reuired 9 units of RBCs, 2 platelets, 4 FFP, 2 cryo and 1 of factor 7. A dialysis catheter was placed for CVVHD. Vancomycin, levofloxacin, and fluconazole were begun empirically. The goal was to transfuse [First Name3 (LF) ] products to keep Hct > 27, Plt > 75, and INR < 2.0. He required maximum pressor support (neosynepherine, vasopressin and levophed). Despite extremes in transfusion of [First Name3 (LF) ] products, we were not able to stop his bleeding. A family meeting was arranged and the decision was made to hold all pressor support and [First Name3 (LF) ] products. He died later that night. Medications on Admission: atrovent, albuterol, flovent, protonix, flonase, quinine, lactulose, lasix, aldactone Discharge Disposition: Expired Discharge Diagnosis: cirrhosis, retroperitonel hematoma, death Discharge Condition: dead Completed by:[2107-4-1]	[ "51881", "5845", "2851", "0389", "2761", "496", "5119" ]
Admission Date: [2186-6-23] Discharge Date: [2186-7-6] Date of Birth: [2120-1-2] Sex: M Service: MEDICINE Allergies: Pneumovax 23 Attending:[First Name3 (LF) 905] Chief Complaint: pneumonia, hypoxia, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 66-yo man with paroxysmal atrial fibrillation, hepatitis C, h/o C.diff colitis, and a recent pneumonia, discharged [2186-6-21] on Vanc / Zosyn, who was found by his family to be more hypoxic and tired than usual so they brought him into the ED. His wife found him to be more sick than usual at about 4pm today, needing more supplemental O2 than prior (2L --> 3-4L), feeling warm and looking [Doctor Last Name 352]. She called EMS, who brought him in to the ED today. . On arrival in the ED, VS - Temp 101.4F, 148/78, HR 98, R 28, SaO2 99% NRB. He received Tylenol 650mg PR x2. Blood Cx sent x2, UA negative. He was initially weaned down to 4L NC, but desaturated to the 80s so was re-started on the NRB with improvement to the mid-90s. Lactate was 2.6 and CXR showed a possible right basilar pneumonia and a coiled PICC line. He subsequently became hypotensive to the high-70s but was fluid responsive. His PICC line was pulled and sent for Cx and a RIJ CVL was placed, and he got 4L NS IVF with SBPs 95-100. ID was curbsided regarding Abx coverage, and he received Vancomycin, Meropenem, and Tobramycin for broad coverage. He is admitted to the MICU for sepsis. He did not require any vasopressor support. . On arrival to the ICU, he feels well and has no complaints. He acknowledges fever but denies SOB, chest pain, abdominal pain, nausea, diarrhea, or swelling. Past Medical History: - Paroxysmal Atrial Fibrillation - History of C diff colitis - Bipolar Affective Disorder - History of resolved hepatitis B - History of rheumatic heart disease - History of right MCA aneurysm clipped in [2167] at [Hospital1 112] - History of pernicious anemia - Gastroesophageal reflux disease Social History: He lives with his wife. Questionable history of alcohol abuse (did abuse alcohol >20 years ago). He has not smoked for one month but previously has a 40 pack year history. Previously on 2L O2 at home but not prior to this hospitalization. Family History: His father had lung cancer and his mother had congestive heart failure. Physical Exam: VS: Temp 96.9F, BP 112/87, HR 85, R 17, SaO2 96%NRB; CVP 4 GENERAL: NAD HEENT: PERRL, dry MM NECK: supple LUNGS: +crackles @ left base, decreased BS on right HEART: irreg irreg, nl S1-S2, [3-24] SM ABDOMEN: +BS, soft/NT/ND, no rebound/guarding EXTREM: 2+ BLE pitting edema SKIN: no rash NEURO: A&Ox3, strength 5/5 throughout, sensation grossly intact throughout . Pertinent Results: Pertinent labs: [2186-6-23] 06:15PM BLOOD WBC-8.3 RBC-3.52* Hgb-11.4* Hct-35.0* MCV-99* MCH-32.4* MCHC-32.6 RDW-16.6* Plt Ct-162 [2186-6-23] 06:15PM BLOOD Neuts-68.9 Lymphs-22.5 Monos-7.1 Eos-1.1 Baso-0.4 [2186-6-23] 06:15PM BLOOD PT-16.1* PTT-39.9* INR(PT)-1.4* [2186-6-23] 06:15PM BLOOD Glucose-125* UreaN-8 Creat-0.8 Na-139 K-3.6 Cl-103 HCO3-25 AnGap-15 [2186-6-23] 06:15PM BLOOD ALT-9 AST-47* CK(CPK)-48 AlkPhos-253* TotBili-1.0 [2186-6-23] 06:15PM BLOOD Lipase-63* [2186-6-23] 06:15PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-1333* [2186-6-23] 06:15PM BLOOD Albumin-3.0* Calcium-8.4 Phos-2.5* Mg-2.2 [2186-6-26] 03:46AM BLOOD IgG-815 IgA-198 IgM-93 [2186-6-28] 03:15AM BLOOD HIV Ab-NEGATIVE [2186-6-28] 03:15AM BLOOD Vanco-20.6* [2186-6-23] 06:15PM BLOOD Vanco-15.5 [2186-6-23] 06:15PM BLOOD Digoxin-0.5* [2186-6-27] 04:14AM BLOOD Valproa-23* [2186-6-23] 06:27PM BLOOD Lactate-2.6* [2186-6-28] 03:42PM BLOOD B-GLUCAN-Test >500 pg/mL * . Labs on discharge: Na139 Cl103 BUN9 Na4.7 Bicarb30 Creatinine0.7 WBC4.22 H/H 10/30.5 plts 138 . Blood cx: [2186-7-2] 1:43 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. . PICC line and central line tips negative on [6-23] & [6-28] Bloox cx pending [7-3] & [7-4], blood cx neg from [6-23], [6-24], [6-28] C diff negative x3 Ucx [7-2] grew yeast . [2186-7-3] CXR: FINDINGS: In comparison with the study of [7-1], there is some increasing opacification at the right base medially with silhouetting of the hemidiaphragm, consistent with right middle lobe consolidation. Mild atelectatic changes at the left base with blunting of the costophrenic angle persist. Upper lung zones remain clear. . [6-23] CXR: IMPRESSION: Limited study due to patient motion. 1. Possible right basilar pneumonia. Recommend repeat radiograph of the chest to confirm with more optimized technique. 2. Interval slight retraction of the right PICC which is looped in the right subclavian vein. . [2186-6-26] ECHO: 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 aortic valve leaflets are moderately thickened/deformed. No discrete vegetation is seen, but cannot be excluded due to suboptimal image quality and diffuse aortic valve thickening. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2186-6-14], the findings are similar. CLINICAL IMPLICATIONS: Based on [2184] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . [6-27] Video swallow IMPRESSION: Moderate-to-severe oral and mild pharyngeal dysphagia resulting in penetration and aspiration due to premature spillover, delayed swallow initiation, and mildly reduced laryngeal valve closure. . [6-27] CT head NONCONTRAST CT HEAD: There is no intra- or extra-axial hemorrhage, shift of normally midline structures, edema, mass effect, or evidence of acute infarct. Evidence of previous right pterional craniotomy and vascular clip in the right ICA are unchanged since [2186-6-16]. Periventricular and subcortical white matter hypodensity represent chronic microvascular infarction, unchanged since [2186-6-16]. The paranasal sinuses and mastoid air cells are unremarkable. IMPRESSION: No acute intracranial process. . [6-27] LE U/S IMPRESSION: No evidence of bilateral lower extremity DVT, although there is limited visualization of the calf veins bilaterally. . [6-28] CT Chest IMPRESSION: 1. Stable right middle lobe consolidation with interval increase in right middle lobe volume loss without evidence of endobronchial lesion. Several enlarged and numerous prominent mediastinal lymph nodes not significantly changed from the prior study and likely reactive in nature. 2. Interval increase in bilateral pleural effusions right greater than left. 3. Multiple bilateral 3-6 mm nodules, unchanged compared to the prior study. A followup CT is recommended in one year to ensure two-year stability. 4. Findings consistent with cirrhosis and portal hypertension. Brief Hospital Course: Assessment and Plan: 66M with a history of pAF, c.diff colitis, recent pneumonia, admitted to the ICU with recurrent PNA/sepsis and found to have RML/RLL PNA & and being empirically tx for c diff colitis. . # Pneumonia: The patient was admitted with high fever, hypoxia, and hypotension. His CXR showed evidence of a RML/RLL pneumonia thought to be due to aspiration given dysphagia on swallow study. He was treated with a 14 day course of meropenem which was completed today. He does have pleural effusions but no thoracentesis was done given that it was difficult to position the patient and there was not enough fluid to safely tap. He was gently diuresed during his admission. His CT scan showed pulmonary nodules that need to be followed up as an outpatint. Given his repeated pneumonias checked HIV Ab and IgG both unremarkable. His b-glucan came back at >500 pg/mL. Given his clinical improvement and no known reason for immunocompromise he was not treated for a fungal infection. This lab should be redrawn in [4-19] weeks after discharge to ensure that it improves. A galactomannan was drawn while he was in the ICU and should be followed up as an outpatint. He was placed on a dysphagia diet given concern for repeat aspiration PNA and failure of swallow study. He required 3L of oxygen at the time of discharge (he had 2L oxygen requirement prior to admisison). . # Fever/ Sepsis: Pt has septic physiology in the ED and MICU. She grew gram + cocci in clusters in 1 bottle anaerobic from [2186-7-2] and was started on vancomycin IV which she received for one day until it came back coag negative staph. His last fever was [2186-7-3]. All other blood cx have been negative. His urine cx was negative (except for [Female First Name (un) ]). His fever/sepsis was treated with a 14 day course of meropenem as detailed above under the PNA section. . # Diarrhea: The patient had diarrhea while in the ICU. He was empirically treatment for c.diff although he was c diff negative x3 during this hospitalizatoin. He had 5 BM the day prior to discharge some of which were loose stools. Given his completion of meropenem on [2186-7-6] the patient will be given an additional 7 day course of flagyl with the last dose the eveing of [2186-7-13]. His diarrhea may not be c diff in origin and could just be due to his meropenem. . # Anisicoria: Anisicoria was noticed on exam with R eye dilated more than left. This is an old finding for the patient as he has a PCOM aneurysm compressing CN III. . # Paroxysmal atrial fibrillation: The patient is being continued on his home dose of Flecainide and Digoxin. His metoprolol was decreased to [Hospital1 ] on [7-1] given occassional low HR and at times his metoprolol still needs to be held for decreased BP. He is being continued on aspirin. Per a discussion the ICU team had with his PCP and cardiology he is not being anticoagulation given his history of falls. On the medicine floor he did not have a fib with RVR, however, he is at higher risk for RVR given that he was started on ritalin. However, given his decreased affect and the positive effect of ritalin on his energy level we have continued the ritalin. . #Anemia: His HCT has been stable at approximately 30. The anemia is macrocytic and likely from liver disease. His recent B12/Folate were within normal limits. His ferrous sulfate supplement should be continued. . # Psych: The patient has bipolar disorder and has been stable on Depakote for several years with no recent changes. In the ICU there was concern for somnolence and his flat affect and his Zyprexa was discontinued. Given his decreased energy level he was started on ritalin ([2186-6-30]) which he has responded to. His outpatient psychiatrist Dr. [Last Name (STitle) 1968] is aware of these changes. I spoke with Dr. [Last Name (STitle) 1968] about our concern for his depression and he was started on citalopram 20mg daily ([2186-7-3]) which should be increased to 30mg daily (on [2186-7-10]) if he does well on it. Given his history of bipolar disorder he needs to be closely monitored for symptoms of mania since his zyprexa was stopped and citalopram was started. He varied from A & O x2 to 3. He does not always participate when asked date. His mental status can wax and wanes sometimes with the patient not always answering questions in an appropriate time frame especially in evening. His affect is flat and his thinking is very slow. . Severe dry eyes and keratitis: also saw the patient and found severe dry eyes and keratitis of the right eye. Continue aritifical tears. . # ? Liver disease: There is concern for liver disease given AP 408, AST 89, INR 1.4, and mild thrombocytopenia. He was Hep C Ab neg. His Hep B serologies were consistent with prior infection (surface and core Ab+). He hoes have a remote history of heavy alcohol use. He needs outpatient liver follow up after he leaves rehab. . # Bradycardia/Hypotension: he had a few short episodes of bradycardia and hypotension on arrival to ED which resolved. He has some low BPs in the ICU. He also had some SBP in the high 80s/low 90s while on the medicine floor and he was assymptomatic. . # Nutrition: He is on a dysphagia diet: PO diet nectar thick liquids, soft solids, and pills whole with puree or nectar thick liquid. He aspirated liquids when he takes large sips. At rehab he can take small sips of regular liquids between meals if he is undersupervison. He still has severe LE edema which is likely influenced by poor nutrition. . # Prophylaxis: -DVT: heparin sc. No anticoagulation for A fib (see above) -Stress ulcer: H2 blocker . # Code status: Full code . # Emergency contact: wife makes health care decisions [Name (NI) ] [Known lastname 2933] [Telephone/Fax (1) 2938] (home), [Telephone/Fax (1) 2945] (cell) . FOLLOW UP NEEDED by PCP AFTER DISCHARGE: -galactomannan -repeat b-glucan in [4-19] weeks -liver follow up -psychiatry follow up Medications on Admission: MEDICATIONS (per d/c summary [2186-6-21]) - Aspirin 325mg PO daily - Cholyestyramine-Sucrose 4grams PO BID - Divalproex 500mg PO QAM - Divalproex 1000mg PO QPM - Digoxin 125mcg PO daily - Ferrous sulfate 325mg PO daily - Olanzapine 5mg PO daily - Ranitidine 75mg PO daily - MVI daily - Flecainide 50mg PO Q12hrs - Vancomycin 1gram IV Q12hrs (5 more days) - Piperacillin-Tazobactam 4.5gram IV Q8hrs (5 more days) - Tylenol 325-650mg PO Q6hrs PRN fever, pain - Metoprolol 25 mg TID (had been held at home) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO once a day. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 10. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule, Sprinkle PO QAM (once a day (in the morning)). 11. Divalproex 125 mg Capsule, Sprinkle Sig: Eight (8) Capsule, Sprinkle PO QPM (once a day (in the evening)). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for empiric tx for cdiff for 7 days. 14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [2-17] Drops Ophthalmic QID (4 times a day). 15. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): at 8 am and 3 pm. 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold BP<100 or HR<55. 18. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days: continue until [2186-7-10] and then discuss with Dr. [Last Name (STitle) 1968] (psychiatrist) about increasing dose to 30mg daily. . Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 620] Discharge Diagnosis: Primary diagnosis: -RML and RLL pneumonia -Diarrhea presumptive c diff (negative x3) -Abnormal liver enzymes -Severe dry eyes and keratitis -Depression -Dysphagia . Secondary Diagnosis: - Paroxysmal Atrial Fibrillation - History of C diff colitis - Bipolar Affective Disorder - History of hepatitis C - History of rheumatic heart disease - History of right MCA aneurysm clipped in [2167] at [Hospital1 112] - History of pernicious anemia - Gastroesophageal reflux disease Discharge Condition: Stable. A & O x2 to 3 (does not always participate when asked date). Mental status can wax and wanes sometime with the patient not always answering questions in an appropriate time frame- especially in evening. Flat affect. Very slow thinking. Discharge Instructions: You were admitted with increased oxygen requirement and decreased blood pressure and found to have a new pneumonia. You went to the ICU and you were treated with a 14 day course of meropenem which has been completed. Your pneumonia is likely a result of aspiration and a swallow study showed that your are aspirating thin liquids. You are being discharged on the following diet: nectar thick liquids, soft solids, pills whole with puree or nectar thick liquids. You can have regular liquids between meals but ONLY IF YOU TAKE SMALL SIPS AND SOMEONE SUPERVISES YOU. If you take large sips you will likely aspirate again. You also developed diarrhea and you were treated with flagyl although your stool never tested positive for c diff. You need to take 7 more days of flagyl to continue to treat your diarrhea. Followup Instructions: Please make a follow up appointment to see your PCP [Name9 (PRE) ],[First Name3 (LF) 2946] [Name Initial (PRE) ]. [Telephone/Fax (1) 2205] after you leave rehab . Please call your psychiatrist Dr. [Last Name (STitle) 1968] and make a follow up appointment for after you leave rehab. . Please discuss with your PCP seeing [Name Initial (PRE) ] liver specialist after you leave rehab. . The patient needs a b-glucan drawn in Mid/End of [Month (only) ] to trend it. [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2186-7-6]	[ "5070", "5119", "42731", "53081", "2859", "42789", "2875" ]
Admission Date: [2129-10-21] Discharge Date: [2129-10-28] Date of Birth: [2087-11-5] Sex: F Service: MEDICINE Allergies: Amoxicillin / Bactrim DS Attending:[First Name3 (LF) 3256] Chief Complaint: fever, cough, SOB Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: Ms. [Known lastname 11455] is a previously healthy 41yo female who presents now with a 5-day history of fevers to as high as 103, intermittent N/V/D, and a 2-day history of progressively worsening shortness of breath and cough. Patient was in her usual state of health until 5 days PTA, when she developed fever with chills/diaphoresis. Took acetaminophen and ibuprofen with some relief. The following day developed nausea and had two episodes of vomiting. Two days PTA, developed mild non-productive cough, and continued to have fevers to as high as 103. Per her report, was evaluated in her [Hospital 6435] clinic, given anti-emetics, and told her lung exam was unremarkable. However, she continued to have progressive dyspnea and worsening cough, and went back to [Hospital 6435] clinic earlier this morning. Given concern for patient's declining respiratory status, she was sent to [Hospital1 ] [Location (un) 620] ED for further evaluation. . At [Location (un) 620], O2 sats were initially 79% on RA, and improved only to 80s on 3L NC. Patient was placed on NRB, with improvement in O2 sats to mid 90s. Labs were notable for leukopenia (WBC 2.9) with neutrophil predominance, hyponatremia (Na 120), and hypokalemia (K 2.7), and lactate of 3.8. Patient was given 3L NS. CXR demonstrated right sided PNA, and patient was given levofloxacin 750mg x1. Given respiratory distress, was felt patient needed admission to an ICU, and as there were no ICU beds available at [Location (un) 620], patient transferred to [Hospital1 18]. . In the ED here, initial VS were: 98.7 114 150/68 22 97% on NRB. Patient's labs were not redrawn, as they had been drawn just several hours prior at [Hospital1 ] [Location (un) 620]. Repeat CXR showed a right basilar consolidation with ill-defined patchy opacities in the left lung base concerning for multifocal pneumonia, as well as a moderate-to-large right pleural effusion. Patient had a flu swab done, and received vanco/ceftriaxone, Tamiflu. Given respiratory distress, patient transferred to MICU for further management. Vitals prior to transfer 110 105/62 26 96% NRB. . On arrival to the MICU, patient still short of breath, but overall reports improvement in symptoms. States she has some occasional chest discomfort secondary to coughing, but is otherwise chest pain free. Of note, her children, ages 2 and 5 months, have both had cold symptoms including fever, which started a few days before the patient's symptoms began. One daughter diagnosed with PNA today as well. . Review of systems: (+) Per HPI. Decreased PO intake. Some loose stools, but patient denies any bloody or dark tarry stools. Had myalgias several days prior to admission. (-) Denies headache, rhinorrhea, congestion, sore throat, frank chest pain, abdominal pain, dysuria. Past Medical History: Past Medical History: amenorrhea, PCOS . Past Surgical History: adenoids removed [2093], deviated septum [2105] Social History: Social History: Patient is married, and lives at home with her husband and 2 daughters. Was breast feeding until day of admission. Not currently working, previously worked in office job. - Tobacco: None - Alcohol: Social - Illicits: None Family History: Family History: Father - MI at age 58. Mother - hypothyroidism. Physical Exam: ADMISSION EXAM: Vitals: T: 98.6 BP: 117/59 P: 117 R: 25 O2: 95% NRB General: awake, alert, oriented, labored breathing but able to speak in sentences, no significant accessory muscle use HEENT: PERRL, sclera anicteric, slightly dry MM, oropharynx clear Neck: supple, JVP not elevated CV: tachycardic but regular, normal S1 + S2, no murmurs, rubs, gallops Lungs: decreased breath sounds on right to mid-lung fields with dullness to percussion and egophany, no wheezing or rhonchi, scattered crackles left base Abdomen: bowel sounds present, soft, NT, ND, no organomegaly, no guarding or rebound tenderness GU: foley in place draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [2129-10-21] 05:14PM BLOOD WBC-3.0# RBC-3.93 Hgb-11.5* Hct-32.0* MCV-82# MCH-29.3 MCHC-35.9* RDW-13.1 Plt Ct-362 [2129-10-21] 05:14PM BLOOD Neuts-78* Bands-17* Lymphs-3* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2129-10-21] 05:14PM BLOOD PT-14.8* PTT-29.2 INR(PT)-1.3* [2129-10-21] 05:14PM BLOOD Glucose-84 UreaN-7 Creat-0.6 Na-135 K-3.7 Cl-95* HCO3-28 AnGap-16 [2129-10-21] 05:14PM BLOOD ALT-91* AST-82* AlkPhos-105 TotBili-0.5 [2129-10-21] 05:14PM BLOOD Calcium-8.3* Phos-1.7* Mg-2.0 [2129-10-21] 09:22PM BLOOD Type-ART pO2-51* pCO2-38 pH-7.47* calTCO2-28 Base XS-3 [2129-10-21] 09:22PM BLOOD Lactate-2.5* MICROBIOLOGY: [10-21] Blood cultures: pending [10-21] Influenza A/B by DFA (Nasopharyngeal swab): negative [10-21] Urine legionella antigen: negative [10-22] Sputum culture: GRAM STAIN (Final [2129-10-22]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [2129-10-24]): SPARSE GROWTH Commensal Respiratory Flora. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. [10-24] Blood culture: pending [10-25] Blood culture: pending CXR [10-21]: Right basilar consolidation with ill-defined patchy opacities in the left lung base concerning for multifocal pneumonia. Moderate-to-large right pleural effusion. CT Chest [10-21]: 1. Multifocal pneumonia including right middle and lower lobar consolidation. 3. Small nonhemorrhagic right pleural effusion. CXR [10-22]: Large right lower lobe consolidation associated with small amount of pleural effusion and multifocal opacities including both the entire right lower lobe, right middle lobe, and multiple foci in the left lower lobe appear grossly unchanged with potential interval worsening of the right mid lung consolidation. Mediastinal position is unchanged. There is no pneumothorax. There is, on the other hand, worsening of the left lower lobe consolidation with obscuration of the diaphragm that might be consistent with atelectasis, although rapid progression of infection would be another possibility. CXR [10-23]: Heart size and mediastinum are stable. Bilateral consolidations in particular involving lower lobes are unchanged associated with pleural effusion overall progressing since [2129-10-21] and consistent with progression of multifocal infection. No pneumothorax is seen. Brief Hospital Course: 41yo previously healthy female who presents now fever and hypoxic respiratory distress in the setting of multifocal pneumonia. . # Multifocal PNA leading to hypoxic respiratory distress: Patient's symptoms, exam findings, fever, leukocytosis with bandemia, and evidence of multifocal PNA on chest imaging confirmed diagnosis. Patient was initially started on broad spectrum abx with vanco/levofloxacin/ceftriaxone to cover for CAP and possible post-viral PNA. She was continued on oseltamivir until flu swab came back negative. Blood cultures at OSH positive for pan-sensitive strep pneumo, and sputum culture here showed GPCs in pairs. Antibiotics were narrowed to ceftriaxone. The patient was continued on a NRB to maintain sats in the mid 90s initially, and as her respiratory status slowly improved she was weaned to 4L NC prior to transfer to general floor. She receieved an influenza vaccine prior to transfer from MICU. On the floor, she was weaned to room air. A PICC line was placed for 4 weeks total IV antibiotic therapy. In addition, patient continued to spike fevers, and ultrasound of lungs showed loculated pleural effusion. Thoracentesis was performed draining 400cc of cloudy fluid which was gram stain negative. A TTE was performed given presence of disseminated strep pneumo (urine, blood and sputum), and was negative for vegetation. TEE was not pursued, instead patient was treated presumptively for 4 weeks. On the day of discharge, ultrasound of lungs showed only minor reaccumulation of fluid. #. Transaminitis: Etiology unclear, and no [Name (NI) 5283] tenderness or hepatomegaly on exam. Thought to be secondary to viral illness. AST/ALT trended down during admission. Alk phos trended up, likely due to ceftriaxone. Alk phos was stable at the time of discharge and will be monitored closely while patient is on ceftriaxone. #. Hyponatremia: Possibly secondary to hypovolemia in setting of acute febrile illness, slightly decreased PO intake. Also considered possibility of SIADH in setting of pulmonary process, though Na corrected quickly with IVF administration suggesting hypovolemia likely etiology. Sodium was stable throughout the remainder of admission. #. Hypokalemia: Etiology unclear, possibly secondary to GI losses in setting of recent diarrhea. [Month (only) 116] also be secondary to metabolic acidosis and increased urinary losses. Improved with potassium repletion and remained stable for the remainder of admission #. Hypophosphatemia: Resolved with aggressive repletion. #. Tachycardia: Likely multifactorial in setting of febrile illness and possible volume depletion given recent decreased PO intake. Improved with IVF administration and resolution of fevers. #. Transitional issues: - Patient will be followed by OPAT for IV antibiotics. She has VNA services for administration of antibiotic for 4 weeks, ending [2129-11-21]. She will have weekly CBC with diff, LFTs, and BUN/Cr checked. - Patient will need a chest x-ray in one to two months to evaluate for resolution of pleural effusion and fibrosis. If evidence of subtotal lung re-expansion, patient will need to be seen by thoracic surgery. Medications on Admission: None Discharge Medications: 1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: One (1) INH Inhalation q4-6h PRN as needed for shortness of breath or wheezing. Disp:5 packets Refills:0 2. guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours). Disp:1800 ML(s) Refills:2 3. 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 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID: prn as needed for constipation. Disp:30 Tablet(s) Refills:0 5. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: One (1) piggyback Intravenous Q24H (every 24 hours) for 22 days: ending [2129-11-21]. Disp:22 piggyback Refills:0 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily). Disp:30 dose Refills:2 8. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety for 7 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: Primary diagnosis: Disseminated strep pneumo pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname 11455], It was a pleasure taking care of you during your recent admission at [Hospital1 18]. You were admitted because you had a severe pneumonia causing you to have difficulty breathing. You were treated with IV antibiotics, and improved. You had fluid surrounding your lungs which was drained and did not reaccumulate. You had an echocardiogram of your heart which was normal. You will be discharged on IV antibiotics to be taken for a total of 4 weeks, ending [2129-11-21]. Your primary care doctor should perform a chest x ray in 1 month to evaluate your lungs. Please continue the following medications on discharge: - Ceftriaxone 2g IV daily until [2129-11-21] - Albuterol/ipratropium inhaler every 6 hours as needed for shortness of breath - Ibuprofen as needed for pain - Guaifenesin every 6 hours for the next 2 days, then as needed - Miralax daily - Senna/colace as needed for constipation - Bisacodyl as needed for bad constipation not responsive to senna/colace Please be sure to use the incentive spirometer and [Initials (NamePattern4) ] [Last Name (NamePattern4) 20743] every hour for the next several days. Call your primary care doctor and return to the hospital if you develop a fever greater than 101.0, or develop worsening shortness of breath. Followup Instructions: Department: INFECTIOUS DISEASE When: WEDNESDAY [2129-11-2] at 10:00 AM With: [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: [Last Name (LF) ],[First Name3 (LF) ] M. Location: [Hospital1 ] HEALTHCARE - UPPER FALLS Address: [Street Address(2) ], [Location (un) ],[Numeric Identifier 14512] Phone: [Telephone/Fax (1) 3393] Appointment: Wednesday [2129-11-2] 1:15pm Department: INFECTIOUS DISEASE When: WEDNESDAY [2129-11-23] at 11:30 AM With: [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "5119", "2761" ]
Admission Date: [2180-5-6] Discharge Date: [2180-5-8] Date of Birth: [2129-9-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1115] Chief Complaint: nausea / vomiting Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 50 yoM w/ a h/o DMI, ESRD on HD, presenting with nausea/vomiting, found to be in DKA. He states he has had 4 episodes of n/v this a.m. Since then has had a slight sore throat but rest of ROS is completely negative. No F/C, no sweats, no cough, SOB, chest pain, abd pain, diarrhea or constipation, rashes, or other sypmtoms. He has had q1h urinary frequency and thirst. No lightheadedness. The patient states that he has been taking 10u of lantus qhs and sliding scale, since discharge from [Hospital1 18] on [5-4] his BG have been around 300+. . Of note the patient was recently admitted ([Date range (1) 29120]) for DKA and gastroenteritis. He was admitted to the MICU for an insulin drip and hyperkalemia, he was transitioned to sc insulin and discharged. In addition he had initiated HD on that admission (had a AV fistula placed in the past in anticipation of this. In addition he was treated with levofloxacin for possible RLL pneumonia. . In the ED, initial VS: T 98.4 HR 85 BP 156/85 RR 18 O2sat: 100% RA. He had some peaked T waves in the ER, normal QRS duration. He was given calcium gluconate. J point elevation on EKG, so cardiac enzymes sent as well. Femoral line was placed in the ER, 10u insulin x 1 given, then 7u/hr. He rec'd 2 L NS. Past Medical History: - Diabetes, insulin dependent x 24 years - Hypertension. - ESRD on HD Social History: Currently employed in 2 nursing homes. No hx of EtOH, smoking. Has issues coping w/ insulin regiment yet denies financial hardships as a cause. Instead, likely due to miscommunication; pt is from [Country 2045] & may not necessarily understand the ramifications of poor glycemic control & has poor vision. Family History: Grandmother diagnosed w/DM2. Father is alive at 68 and is "never sick". Mother died suddenly at 37. Siblings w/sickle cell. 1 child w/DM1. Physical Exam: On admission Vitals - T: 97.4 BP: 186/81 HR: 88 RR: 14 02 sat: 97% RA GENERAL: NAD, AOx3 HEENT: MM slightly dry, OP clear, JVP 9cm, neck no lymphadenopathy CARDIAC: RRR, 2/6 SEM at the USB LUNG: CTAB ABDOMEN: soft, NT, ND, no masses or organomegaly EXT: WWP, chronic venous stasis changes NEURO: AOx3, grossly normal On discharge VS: 98.1, 124/81, 81, 16, 98%RA F/S: 86 (yesterday - 246, 287) Gen: NAD, AAOx3 HEENT: PERRLA, EOMI, MMM, Op clear, JVP 9 cm, no LAD CV: S1S2, RRR, 2/6 SEM at upper sternal border Chest: CTA b/l Abd: soft, ND, NT, +BS, no HSM Ext: fistula in LUE, +bruit, +thrill, no e/c/c Neuro: AAOx3, CN II-XII grossly intact Pertinent Results: CHEST (PORTABLE AP) Study Date of [2180-5-6] 5:52 PM FINDINGS: As compared to the previous radiograph, the pre-existing right lower lobe opacity has completely resolved. On the left, the pre-existing opacity has improved, but is still clearly visible. Blunting of the costophrenic sinus suggests the presence of a small left-sided effusion. Whenever possible, findings should be reevaluated with an AP and lateral chest radiograph. CBC [2180-5-8] 05:48AM BLOOD WBC-10.7 RBC-2.76* Hgb-7.7* Hct-22.9* MCV-83 MCH-27.9 MCHC-33.7 RDW-17.0* Plt Ct-287 [2180-5-7] 03:06AM BLOOD WBC-14.2# RBC-2.85 Hgb-7.8* Hct-23.6* MCV-83# MCH-27.4 MCHC-33.1 RDW-16.4* Plt Ct-354 [2180-5-6] 12:35PM BLOOD WBC-9.2# RBC-2.77* Hgb-7.7* Hct-24.8* MCV-90# MCH-27.7 MCHC-30.9# RDW-15.8 Plt Ct-267 Chemistry [2180-5-8] 05:48AM BLOOD Glucose-62* UreaN-61* Creat-9.6* Na-140 K-4.7 Cl-102 HCO3-25 AnGap-18 [2180-5-7] 03:06AM BLOOD Glucose-21* UreaN-56* Creat-8.6* Na-142 K-3.9 Cl-103 HCO3-28 AnGap-15 [2180-5-6] 10:53PM BLOOD Glucose-354* UreaN-57* Creat-8.4* Na-136 K-4.8 Cl-100 HCO3-23 AnGap-18 [2180-5-6] 08:09PM BLOOD Glucose-603* UreaN-56* Creat-8.4* Na-133 K-4.2 Cl-96 HCO3-24 AnGap-17 [2180-5-6] 05:07PM BLOOD Glucose-773* UreaN-57* Creat-8.6* Na-129* K-4.9 Cl-90* HCO3-22 AnGap-22* [2180-5-6] 02:00PM BLOOD Glucose-906* UreaN-54* Creat-8.6* Na-126* K-6.4* Cl-86* HCO3-19* AnGap-27* [2180-5-6] 12:35PM BLOOD Glucose-887* UreaN-55* Creat-8.8# Na-125 K-7.2* Cl-85* HCO3-21* AnGap-26* [2180-5-8] 05:48AM BLOOD Calcium-9.2 Phos-7.0# Mg-2.2 [2180-5-6] 08:09PM BLOOD Calcium-8.7 Phos-3.7# Mg-2.0 [2180-5-6] 12:35PM BLOOD Calcium-9.1 Phos-5.4# Mg-2.2 LFT [2180-5-6] 05:07PM BLOOD ALT-17 AST-14 AlkPhos-103 TotBili-0.2 Cardiac Enzymes [2180-5-7] 03:06AM BLOOD CK-MB-3 cTropnT-0.27* [2180-5-6] 10:53PM BLOOD CK-MB-3 cTropnT-0.23* [2180-5-6] 02:00PM BLOOD CK-MB-3 cTropnT-0.22* Brief Hospital Course: 50 yo M with DMI, ESRD on HD, HTN, admitted for nausea and vomiting, found to be in DKA . #. DKA - On admission patient was found to have ketones in his urine. He is a type I diabetic. Patient says that he was been taking his insulin as directed since his discharge 1 week ago. It is unclear what precipitated this last episode of DKA. Infectious workup was negative. He was initially admitted to the ICU for insulin drip for which he required a high initial rate of insulin (29/hr initially, then 21/hr). His anion gap closed and patient was transitioned back to his home insulin regimen and called out to the floor. He reports that he sticks to a diabetic diet and has had diabetic teaching through the [Last Name (un) ], but also describes regularly having [Company ], [Last Name (un) ] [Doctor Last Name ], and [Last Name (un) ]. Nutrition saw him on this admission and provided further reinforcement on what constitutes a diabetic diet. His home lantus was increased from 14 units to 16 units at night. Patient was set up with a follow up appointment with his PCP and at the [Hospital ] Clinic. . #. Anemia - likely related to ESRD and epo deficient state. Patient has refused transfusions in the past as well as on this admission. He will continue on epo at HD sessions. TSH, folate, and B12 were drawn for work up of his anemia and results were still pending on discharge. These will be communicated with his PCP once they return. . #. ESRD - Patient did not receive HD on this admission; the renal team followed the patient. He is set up to start outpatient HD on [2180-5-9] as an outpatient and will continue on a Tuesday, Thursday, Saturday schedule. . #. Hypertension - patient was continued on carvedilol and furosemide . #. Hypercholesterolemia - patinet was continued on simvastatin . #. Code - DNR/DNI per patient Medications on Admission: Lanthanum 500 mg po tid with meals Aspirin 81 mg po daily Carvedilol 12.5 mg po bid Amlodipine 10mg po daily Lantus 14units sc qhs Furosemide 80 mg po daily Colace 100 mg po bid B Complex-Vitamin C-Folic Acid 1 mg po daily Humalog sliding scale Simvastatin 20 mg po daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lantus 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. 5. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous qAC and qHS: dose humalog insulin according to sliding scale. 6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet, Chewable(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Diabetic ketoacidosis Secondary Diagnosis: Diabetes Mellitus, type I ESRD on HD (Tues, Thurs, Sat schedule) Hypertension Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to [Hospital1 69] for nausea and vomiting. You were found to be in diabetic ketoacidosis. You were initially admitted to the intensive care unit for continuous monitoring. Your blood sugars gradually improved. Please be sure to eat healthy, check your blood sugar regularly, and take your insulin as it has been prescribed to you. Your medications have changed, please make note of the following changes: - please increase your lantus insulin from 14 units to 16 units at bedtime daily The rest of your medications have not changed, please continue to take them as originally prescribed Please keep all your medical appointments and dialysis sessions. If you experience chest pain, shortness of breath, or any other worrisome symptoms, please return to the emergency room. Followup Instructions: MD: Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Specialty: Primary Care Date/ Time: [5-10] at 10:45am Location: [Street Address(2) 82189] , [Location (un) 2268] Phone number: [Telephone/Fax (1) 9470] MD: Dr [Last Name (STitle) ] [Name (STitle) 27172] Specialty: Nephrology Date/ Time: [5-12] at 9:30am Location: [Last Name (un) ] Phone number: [Telephone/Fax (1) 3637]	[ "40391", "V5867", "2767", "2724", "4280" ]
Admission Date: [2192-7-3] Discharge Date: [2192-7-9] Date of Birth: [2116-2-6] Sex: F Service: [Hospital1 139] B Medicine HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old female who was found at nursing home on the morning of admission having vomited a large amount of coffee ground emesis which was reportedly guaiac positive. The patient also was very congested with decreased O2 saturations to the low 80s on room air. The patient was started on supplemental O2 with no increase in her O2 saturations. The patient's primary care provider was notified and the patient was given levofloxacin 500 po x1. The patient was then noted to have a sudden decrease level of consciousness with a heart rate on the pulse oximeter noted to be down to 44. After about 30 seconds, the patient's heart rate improved to 98. The patient was then transported to [Hospital6 2018] Emergency Room. In the Emergency Room, the patient was alert and oriented x1 with bilateral rales and positive coffee ground emesis x2. Furthermore, the patient also had a few more episodes of decreased responsiveness with heart rates in the 40s and systolic blood pressures to the 80s. The electrocardiogram obtained at that time showed that the patient was bradycardic secondary to Mobitz type I AV block as well as ST depressions in V1 and AVL. The patient's chest x-ray at this time was negative for any acute process. PAST MEDICAL HISTORY: 1. Hypothyroidism 2. Seizure disorder 3. Schizo-affective disorder 4. Chronic obstructive pulmonary disease 5. Depression 6. Duodenal ulcer 7. Gastroesophageal reflux disease 8. Esophagitis 9. Dementia with dependent ADLs ADMISSION MEDICATIONS: 1. Vitamin C 500 mg [Hospital1 ] 2. Cogentin 1 mg [Hospital1 ] 3. CaCO3 500 mg tid 4. Synthroid 0.1 mg qd 5. Miacalcin nasal spray 6. Risperdal 2 mg [Hospital1 ] 7. Valproic acid 500 mg [Hospital1 ] and 750 mg q hs 8. Zinc 220 mg qd 9. Vitamin D 400 mg [Hospital1 ] ALLERGIES: No known drug allergies. VITAL SIGNS: Temperature was 98??????. Pulse was 109. Blood pressure 121/48 and O2 saturation was 97% on 4 liters. GENERAL: The patient was in no apparent distress lying in bed. HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and reactive to light. Extraocular muscles are intact. Moist mucous membranes. CHEST: Rancorous breath sounds bilaterally. CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops. ABDOMEN: Soft, nondistended, nontender and positive bowel sounds. EXTREMITIES: There was no cyanosis or clubbing. The patient has 1+ edema bilaterally in her lower extremities. RECTAL: Guaiac positive in the Emergency Department. NEUROLOGIC: The patient was alert and oriented x1. ADMISSION LABS: CBC: White blood count was 6.0, hematocrit 42.1, platelets 158. CK was 32. Troponin was 0.4. Electrolytes: Sodium 138, potassium 4.5, chloride 99, bicarbonate 30, BUN 18, creatinine 0.5, glucose 187. HOSPITAL COURSE: The day of admission the patient was admitted to the Medical Intensive Care Unit due to the episodes of coffee ground emesis as well as the episodes of bradycardia and unresponsiveness with hypotension. 1. CARDIAC: An echocardiogram was obtained on the date of admission which showed preserved biventricular systolic function as well as aortic sclerosis. Left ventricular ejection fraction was greater than 55%. Cardiology and EP was consulted to evaluate the patient for a pacemaker based on her new cardiac conduction abnormality. Due to the patient's long history of dementia, the primary care physician had discussion with health care proxy and decided that the pacemaker placement would not occur. Cardiology and primary care provider agreed that this will not significantly change the patient's quality of life at this time. The patient failed to have any more bradycardic episodes throughout her stay. 2. GASTROINTESTINAL/FLUIDS, ELECTROLYTES AND NUTRITION: The patient had coffee ground emesis on admission and as well in the Emergency Room. The patient had no further episodes throughout her stay. The patient's hematocrit remained stable. The patient had nasogastric lavage which was negative. The patient was begun on tube feeds on [7-4] and progressed to goal without difficulty. Subsequently, after the patient was transferred to the floor, speech and swallow evaluation was performed on [2192-7-6] which the patient failed. Her baseline diet consisted of nectar thick liquids as well as pureed solids. Due to the patient's upper airway congestion and phlegm production, it is believed that she was unable to take appropriate swallows. This will be repeated on the date of discharge and recommendations will be made. The nasogastric tube will be pulled prior to the patient returning to the nursing home. The patient's electrolytes were checked q day and repleted as necessary. 3. PULMONARY: On the day after admission, the patient had a follow up chest x-ray which showed interval development of a left lower lobe consolidation and collapse as well as possibly a small left pleural effusion. Given the rapid change from her unremarkable chest x-ray on admission, this is likely aspiration pneumonia as related to her emesis. The patient was begun on levofloxacin, Flagyl intravenous. The patient is unable to give a strong cough in order to produce a good sputum culture. The culture which was obtained was contaminated was oropharyngeal flora. The patient's O2 saturations improved throughout her stay and the patient requires some suctioning in order to clear the phlegm in the back of her throat. In addition, the patient's white blood cell count spiked to 32.9 and subsequently has come down throughout her stay to a normal white blood count of 7.1. 4. ENDOCRINE: The patient has hypothyroidism and her TSH was checked and was within normal limits at 0.77. Therefore, her current dose of Synthroid will be continued. 5. CODE STATUS: DNR/DNI DISCHARGE CONDITION: Improved, stable DISCHARGE STATUS: The patient is to be discharged back to the [Hospital3 6560] Home facility. DISCHARGE DIAGNOSES: 1. Resolved upper gastrointestinal bleed 2. Aspiration pneumonia 3. Newly diagnosed cardiac conduction abnormality - type 1 AV block DISCHARGE MEDICATIONS: 1. Albuterol nebulizer solution 1 nebulizer q6h prn wheezing 2. Ipratropium bromide nebulizer 1 nebulizer q6h wheezing 3. Levothyroxine sodium 100 mcg po qd 4. Valproic acid 500 mg po bid and 750 mg po q hs 5. Flagyl 500 mg po q8h x8 days 6. Levofloxacin 500 mg po qd x8 days 7. Colace 100 mg po bid 8. Senna 1 tablet po bid prn constipation 9. Protonix 400 mg po bid 10. Risperdal 2 mg [Hospital1 ] 11. Cogentin 1 mg [Hospital1 ] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8829], M.D. [MD Number(1) 8830] Dictated By:[Last Name (NamePattern1) 8831] MEDQUIST36 D: [2192-7-7] 12:27 T: [2192-7-7] 13:15 JOB#: [Job Number 8832] cc:[Hospital3 8833]	[ "5070", "2449", "42789" ]
Admission Date: [2123-9-24] Discharge Date: [2123-10-1] Date of Birth: [2072-5-20] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Bilateral arm heaviness Major Surgical or Invasive Procedure: CABG on [2123-9-27] History of Present Illness: Mr. [Known lastname ] is a 51yo male w/ PMH of HTN and hyperlipidemia, not on any medications, who presented to his PCP earlier this week after having an episode of bilateral arm heaviness while on his regular 2 mile walk. No CP, heaviness, or tightness, no diaphoresis, SOB or difficulty breathing. No pain radiating up to his jaw. No lightheadedness or dizziness, no n/v/abd pain. Stopped his walk early and went back home. Had to see his PCP for BP check, told PCP, [Name10 (NameIs) 62894] ex stress test which showed multiple ST depressions while exercising. Atenolol, [Name10 (NameIs) ], Lipitor started. Scheduled for cath which happened today. Found to have 3VD. Plan is for OR on Monday. . ROS: as above; no additional sx of cough, congestion, rhinorrhea, sore throat; no HA, dizziness, or lightheadedness. No f/c/night sweats/weight loss. No n/v/d/constipation/reflux/dysphagia. No BRBPR or hematuria. No numbness or tingling in hands or feet. No syncope. Past Medical History: 1. HTN - diagnosed 6-10 years ago, attempting to control w/ diet and exercise 2. Hyperlipidemia - last cholesterol 265 Social History: Lives w/ wife in [Name (NI) 14663]. No children. Works as a stone [Doctor Last Name 3456]. Active, walks 2 mi/day. No tob, occ EtOH ([11-30] drinks 3x/week), occ marijuana, no other illicits. Family History: F d of MI in his 80s; mother and sister both have HTN. No fam hx of cancer, DM. Physical Exam: VS - Tm + Tc 97.6, BP 137/61 (122-151/76-80), HR 74 (65-77), RR 20, sats 98% on RA Gen: Well appearing middle aged man in NAD, sitting up in chair. Neck: No JVD. No carotid bruits. CV: RR, normal S1, S2. No m/r/g. Lungs: CTAB, no crackles/wheezes/rhonchi. Abd: Soft, NTND. + BS. No masses or HSM. Ext: No c/c/e. 2+ PT and radial pulses bilaterally. Ext warm and dry. R groin site c/d/i. No bruit, no ecchymosis. Neuro: CN II-XII grossly intact. Pertinent Results: On admission: WBC 12.4, Hct 42.0, MCV 85, Plt 265 PT 12.7, INR(PT)-1.1 Na 137, K 3.7, Cl 102, HCO3 24, BUN 13, Cr 0.9, Glu 103, Anion Gap 15 ALT 17, AST 17, LDH 163, Alk Phos 93, Tbili 0.7, Albumin 4.0 %HbA1c-5.1 . EKG [9-24]: Sinus rhythm. Diffuse nonspecific ST-T wave abnormalities . CXR [9-25]: The heart is normal in size. The aorta is tortuous. There is no prominence of the pulmonary vasculature to suggest congestive heart failure. There are no pleural effusions. The lung fields are clear, and there is no focal opacity to suggest infiltrate. The surrounding osseous and soft tissue structures are grossly unremarkable. IMPRESSION: Tortuous aorta. No acute pulmonary process. [2123-9-29] 06:14AM BLOOD WBC-10.4 RBC-2.98* Hgb-9.0* Hct-25.0* MCV-84 MCH-30.3 MCHC-36.1* RDW-13.4 Plt Ct-181 [2123-10-1] 06:45AM BLOOD Hct-30.1* [2123-9-29] 06:14AM BLOOD Plt Ct-181 [2123-10-1] 06:45AM BLOOD Glucose-101 UreaN-11 Creat-0.9 Na-138 K-4.6 Cl-100 HCO3-25 AnGap-18 [2123-9-24] 08:00PM BLOOD ALT-17 AST-17 LD(LDH)-163 AlkPhos-93 TotBili-0.7 [2123-9-29] 06:14AM BLOOD Mg-2.0 [2123-9-24] 08:00PM BLOOD %HbA1c-5.1 [Hgb]-DONE [A1c]-DONE [2123-9-26] 07:05AM BLOOD HDL-40 CHOL/HD-4.3 Brief Hospital Course: 51yo male with new diagnosis of 3VD by cath on [9-24]. To OR today for CABG. . 1. CAD a. Perfusion - No evidence of ischemia. To OR today for CABG. - appreciate CT [Doctor First Name ] consult and preop orders - cont beta [Last Name (LF) 7005], [First Name3 (LF) ], ACE I, lipitor - no anticoagulation b. Pump - No evidence of pump dysfunction on exam. ECHO not done over weekend despite being ordered. - ordered ECHO, pending c. Rhythm - EKG shows NSR w/ HR in 70s. Tele has had no alarms. - cont on tele . 2. HTN: Cont ACE I, beta [First Name3 (LF) 7005] for now. . 3. Hyperlipidemia: Total chol 172, HDL 40. HgbA1C 5.1. - cont lipitor . 4. FEN: Had been on regular heart healthy diet but has been NPO after midnight for OR today. No IVF for now. Check lytes daily, replete to keep K >4, Mg >2. . 5. PPX: PPI for GI ppx, no DVT ppx as pt ambulatory. No bowel regimen for now [12-30] diarrhea. . 6. Access: peripheral IV . 7. Code: FULL . 8. Dispo: To OR today for CABG. Had cabg x3 on [9-27] with Dr. [Last Name (STitle) ]. transferred to CSRU in stable condition on a titrated neosynephrine drip. Extubated later that day and remained on a neo drip on POD #1. Swan removed, diuresis and beta blockade started. Transfused one unit PRBCs for HCt of 26.4 and transferred to the floor to begin increasing his activity level. Chest tubes were removed, iron and Vit. C started. Pacing wires removed without incident on POD #3. Hemodynamically stable and alert and oriented. Made rapid progress on the floor. Lopressor increased to 50 mg [Hospital1 ] on day of discharge: HR 97 in SR, BP 160/88. Discharged to home with services on POD #4. Medications on Admission: Atenolol 25mg PO QD Lipitor 40mg PO QD [Hospital1 ] 325mg PO QD Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 2. Potassium Chloride 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 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company ] Discharge Diagnosis: s/p cabg x3 hypertension elev. chol. Discharge Condition: stable Discharge Instructions: may shower over incisions and pat dry no lotions, creams , or powders on incisions no driving for one month no lifting greater than 10 pounds for 10 weeks Followup Instructions: see Dr. [Last Name (STitle) ] in [11-29] weeks see Dr. [Last Name (STitle) ] in the office in 4 weeks [Telephone/Fax (1) 170] Completed by:[2123-10-1]	[ "41401", "4019", "2724" ]
Admission Date: [2198-5-2] Discharge Date: [2198-5-16] Date of Birth: [2133-11-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5644] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: 1. bronchoscopy with bronchial brushings and biopsies 2. pleuroscopy with pleural biopsies 3. placement of chest tube 4. pleurodesis x2 History of Present Illness: Pt is a 64y/o M with tobacco history and asbestos exposure who has noticed increasing SOB since [Month (only) 956]. He noted that his SOB started as he was going upstairs to the second level of his home, when he would feel winded. At around the same time, a cough developed, which was often productive of clear or yellow sputum in the morning. He denies bloody sputum. He notes that his SOB and cough worsened over the next few months. In [Month (only) 547], he was seen for a stress test and a CXR was performed, which showed the pleural effusion. This was tapped, which yielded about 2 L and pt noted symptomatic improvement. Cytology was negative; effusion was exudative. Pt was admitted for bronchoscopy because of the concern for the RUL mass seen and because of the recurrent R pleural effusion. Denies fevers, chills, chest pain, diaphoresis. SOB feels like breathing more frequently, more shallowly, with some wheezing. SOB worse with sitting up, and with any movement or exertion. Past Medical History: 1. dyspnea x 6 months 2. diabetes mellitus 3. coronary artery disease s/p CABG [2190], stent [2192], positive stress test 4. hypogonadism 5. h/o urinary retention in setting of UTI 6. recurrent R pleural effusion 7. h/o surgical removal of kidney stone in [2168] 8. Dupuytren's contractures Social History: Pt is a real estate executive for a restaurant company. Lives with his wife, has 4 children. Smoked 2.5ppd x22 years, quit in [2167]. Asbestos exposure. No pets. Denies alcohol or recreational drug use. Family History: M - DM, reproductive cancer, ? [Last Name ] problem F - lost at sea in [2152] no other cancer or asthma Physical Exam: VS: Tm 98.6 Tc 98.0 133/52 85 26 93% 3L NC Gen: elderly male, somewhat rapid breathing with talking, frequent shallow dry coughing, does not appear uncomfortable HEENT: PERRL, EOMI, OP clear, MMM, tender anterior cervical LAD about 1cm in size, 2 cm smooth mobile mass on R posterior neck CV: RRR, nl S1/S2, no murmurs appreciated Pulm: dullness to percussion on R side with tubular breath sounds, decreased breath sounds on R; on L, end-expiratory wheezes over area of lung [2-1] way up; coarse breath sounds diffusely on L Abd: soft, mildly distended, nontender, +BS, no masses Ext: no edema Neuro: A&O x3, 5/5 strength in all 4 extremities Pertinent Results: Admission labs: CBC: WBC-17.6# RBC-4.10 HGB-12.4* HCT-36.4* MCV-89 MCH-30.2 MCHC-34.0 RDW-13.6 NEUTS-78* BANDS-11* LYMPHS-4* MONOS-4 EOS-0 BASOS-1 ATYPS-2* METAS-0 MYELOS-0 HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL PLT COUNT-624* coags: PT-13.2 PTT-24.1 INR(PT)-1.2 electrolytes: GLUCOSE-206* UREA N-15 CREAT-0.7 SODIUM-137 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16 CALCIUM-9.3 PHOSPHATE-2.6* MAGNESIUM-1.5* chest CT [5-2]: IMPRESSION: 1) Again seen is a large right pleural effusion. Additionally, there is persistent narrowing of the right main stem bronchus with associated postobstructive consolidation, which appears similar to the prior study. 2) Cholelithiasis. chest/abdomen/pelvis CT: [5-9]: IMPRESSION: 1) Narrowing of the right main stem bronchus, unchanged, however, complete consolidation of the inferior segments of the right lower lung lobe. Improved aeration of the right upper lobe. 2) Interval placement of right-sided chest tube with decreased right pleural fluid. New low-density loculations within the remaining right pleural fluid. New small right hydropneumothorax. 3) No foci of disease within the abdomen or pelvis. 4) Cholelithiasis without evidence for cholecystitis. head CT: [5-9]: no evidence of intracranial mets [5-10] LE Dopplers: IMPRESSION: No evidence of DVT. [2198-5-10] bone scan: IMPRESSION: Tracer uptake in the right ribs compatible with prior trauma. No evidence of metastatic disease. CXR: IMPRESSION: Right-sided post-procedure change and slight enlargement of right pleural effusion. No evidence of pneumothorax. Pathology: [5-2] bronchial washings: Atypical glandular-apearing epithelial cells, cannot exclude non-small cell carcinoma. [5-4] pleural biopsy: poorly differentiated adenocarcinoma; the tumor cells show staining for cytokeratin-7, but no staining for cytokeratin-20, TTF-1, prostate-specific antigen, or prostatic acid phosphatase. This immunophenotype is not specific for any one site of origin. However, the histologic features of this tumor and this immunophenotype could be consistent with a lung origin. Absence of staining for the prostate markers and the cytokeratin-7 positivity rule out a prostatic origin. The histologic appearance makes a gastrointestinal or pancreatico-biliary origin unlikely. [5-4] pleural fluid, cell block: adenocarcinoma Brief Hospital Course: 1. adenocarcinoma - Pt had recurrent right pleural effusion and a mass seen on CT scan; given his past history of smoking and asbestos exposure, concern was clearly for malignancy. Pt underwent bronchoscopy with BAL. Bronchial biopsies were consistent with well-differentiated adenocarcinoma. As pt had recurrent R pleural effusion, a pleuroscopy was performed, which showed studding of parietal pleura with small masses, which were biopsied and found to be consistent with poorly differentiated adenocarcinoma. Pt underwent talc pleurodesis; the first attempt was unsuccessful, so a second trial of talc pleurodesis was performed, and the chest tube had little output after [2-1] days and was successfully removed. Hem/onc was consulted as the biopsy results returned positive for carcinoma. Staging CT scans and a bone scan were performed, which showed no evidence of metastasis. As pt had an acute infectious process, namely the pneumonia discussed below, chemotherapy was not an option while in the hospital. XRT was consulted, as well, with the thought that perhaps tumor debulking would help to relieve a postobstructive pneumonia. However, with further analysis of the CT scan, it was felt that inflammation from the VATS procedure and inflammation from the pneumonia were the causes of obstruction, and XRT would not improve the situation, and may in fact be harmful. At the time of discharge, pt had appointments in place to see hem/onc and XRT the following day. 2. postobstructive pneumonia - Pt completed a 7 day course of levo/flagyl but continued to have increased O2 requirements (up to 10L NC, satting in the low 90s) and was febrile. A repeat chest CT scan showed increased consolidation in the RLL. Pt was therefore placed on Zosyn/vanco, with a plan for a 2-week course total. He was also treated with albuterol/atrovent nebs while in the hospital, and was discharged with MDIs. Further, pt had question of O2 requirement overnight, though physical therapy documented sats in the low 90s on room air during the daytime. Pt had home O2 delivered prior to discharge. He had a PICC placed for the rest of his course of Zosyn/vanco. Pt's Tmax in the 24 hours prior to discharge was <100.0. 3. diabetes mellitus type 2, poorly controlled - Pt was continued on rosiglitazone, metformin, and glyburide. Metformin was held prior to CT scans. Pt was also placed on RISS, and fingersticks were checked 4 times daily. Pt was noted to have increased hyperglycemia, requiring up to 20 units glargine, thought to be due at least partially to his acute infection, as well as due to the holding of metformin. He was discharged on oral hypoglycemics and instructed to check his fingersticks and call his PCP [Last Name (NamePattern4) ] >350. 4. CAD s/p CABG and stent - Pt was continued on atenolol, statin, and ACE I. Pt will need to be restarted on aspirin as an outpatient. 5. Code - full at this time Medications on Admission: atorvastatin atenolol lisinopril aspirin tamsulosin prilosec metformin glyburide rosiglitazone B12 Discharge Medications: 1. Home oxygen Continuous 2L Nasal cannula For portability pulse-dose system 2. Atorvastatin Calcium 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Glucosamine 1,000 mg Tablet Sig: One (1) Tablet PO qd () as needed for oa. 11. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q12H (every 12 hours) for 7 days. Disp:14 gram Refills:0 12. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 7 days. Disp:21 Recon Soln(s) Refills:0 13. Metformin HCl 1,000 mg Tablet Sig: One (1) Tablet PO qAM. 14. Metformin HCl 1,000 mg Tablet Sig: 1.5 Tablets PO qPM. 15. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours. Disp:1 inhaler Refills:2 16. spacer for metered dose inhaler Disp: 1 Refills: 2 Discharge Disposition: Home With Service Facility: Critical Care Discharge Diagnosis: Primary: 1. adenocarcinoma, likely of lung 2. post-obstructive pneumonia Secondary: 1. diabetes mellitus type 2 2. coronary artery disease Discharge Condition: stable, tolerating po, RA sat 87-92% ambulating Discharge Instructions: Please call your PCP with any increased shortness of breath, chest pain, more sputum production, or if your glucose is consistently >300. Please keep all of your appointments and take all of your medications. You may resume your metformin when you return home and you should check your fingersticks two to three times per day and call your PCP if they are elevated. Followup Instructions: Provider: [Name10 (NameIs) ],[First Name3 (LF) ] MULTI-SPECIALTY MULTI-SPECIALTY THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[2198-5-17] 3:00 Provider: [Name10 (NameIs) 2502],[Name11 (NameIs) ] HEMATOLOGY/ONCOLOGY-CC9 Where: [Hospital 4054] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2198-5-17] 3:00 Provider: [Name10 (NameIs) ],[First Name3 (LF) ] MULTI-SPECIALTY MULTI-SPECIALTY THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[2198-5-17] 4:00	[ "25000", "V4581" ]
Admission Date: [2159-12-16] Discharge Date: [2159-12-28] Date of Birth: [2086-10-31] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Speaking difficulty and last time seen well was 8.30am and was then brought as code stroke at 1.53pm from [Location (un) 75749], MA via [Location (un) ]. Major Surgical or Invasive Procedure: None History of Present Illness: 73yo M h/o CAD s/p CABG, HTN, hyperlipidemia and DM2 who was last known well at 8:30am today, according to the history given by the patient's wife when he presented at [Hospital3 ] Hospital. She returned home at 10:30am to find him unable to speak with slurred speech as well and a right facial droop. He was taken to [Location (un) 21541] Hospital and was already outside the three-hour window for IV tPA and airlifted here for consideration of further therapies. Past Medical History: CAD s/p CABG, HTN, hyperlipidemia and DM2 Social History: Denies EtOH, tobacco or drugs Family History: NA Physical Exam: VS 198/109 94 19 100% Gen Awake, cooperative, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted 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. Attentive to our exam. Speech is non-fluent, with impaired naming, [Location (un) 1131] and comprehension but relatively intact repetition. Normal prosody. There were multiple paraphasic errors in the form of neologisms when the patient tried to read or name. Cannot follow simple commands. Responds to both sides of space equally. Moderate dysarthria. CN CN I: not tested CN II: blinks to threat bilaterally, no extinction. Pupils 3->2 b/l. CN III, IV, VI: EOMI no nystagmus CN V: intact to LT throughout CN VII: R facial droop CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [Doctor First Name 81]: shrug asymmetric CN XII: unable to assess Motor Decreased tone in the right arm. Mild R pronator drift (fingers curl on the right hand). Holds both arms up for 10 seconds and both legs for 5. Sensory intact to LT, PP throughout. No extinction. Reflexes deferred Coordination unable to assess Gait deferred, due to need to get the patient to the scanner and interventional suite CODE STROKE SCALE: Neurologic (NIHSS): 7 1a. LOC: alert, responsive (0) 1b. LOC questions: knew age and name of month (0) 1c. LOC commands: closed eyes and gripped with (nonparetic) hand (2) 2. Best gaze: No gaze palsy (0) 3. Visual: No visual loss (0) 4. Facial Palsy: normal, symmetrical movements (1) 5a. Left arm: No drift (0) 5b. Right arm: no drift (0) 6a. Left leg: No drift (0) 6b. Right leg: no drift (0) 7. Limb ataxia: not assessed due to lack of comprehension 8. Sensory: no sensory loss bilaterally (0) 9. Language: severe aphasia (2) 10. Dysarthria: moderate (1) 11. Extinction/inattention: None (0) Pertinent Results: [2159-12-16*] 07:31PM BLOOD WBC-12.4 RBC-4.76 Hgb-13.9* Hct-40.0 MCV-84 MCH-29.2 MCHC-34.7 RDW-17.0* Plt Ct-270 [2159-12-17] 01:52AM BLOOD WBC-16.6* RBC-4.83 Hgb-13.8* Hct-40.3 MCV-83 MCH-28.6 MCHC-34.3 RDW-17.2* Plt Ct-272 [2159-12-19] 04:14AM BLOOD WBC-15.1* RBC-4.00* Hgb-11.7* Hct-33.2* MCV-83 MCH-29.1 MCHC-35.1* RDW-17.0* Plt Ct-217 [2159-12-21] 05:06AM BLOOD WBC-10.3 RBC-4.19* Hgb-11.8* Hct-34.6* MCV-83 MCH-28.2 MCHC-34.1 RDW-16.7* Plt Ct-237 [2159-12-23] 02:52AM BLOOD WBC-14.0* RBC-4.81 Hgb-13.3* Hct-40.1 MCV-83 MCH-27.8 MCHC-33.3 RDW-16.7* Plt Ct-266 [2159-12-24] 06:30AM BLOOD WBC-13.6* RBC-4.94 Hgb-14.0 Hct-41.4 MCV-84 MCH-28.3 MCHC-33.8 RDW-17.1* Plt Ct-364 [2159-12-24] 06:30AM BLOOD PT-13.9* PTT-26.7 INR(PT)-1.2* [2159-12-20] 04:07AM BLOOD PT-13.5* PTT-30.3 INR(PT)-1.2* [2159-12-16] 07:31PM BLOOD PT-13.3 PTT-35.6* INR(PT)-1.1 [2159-12-19] 02:11PM BLOOD Ret Aut-1.7 [2159-12-16] 07:31PM BLOOD Glucose-153* UreaN-16 Creat-0.7 Na-140 K-5.4* Cl-111* HCO3-20* AnGap-14 [2159-12-19] 04:14AM BLOOD Glucose-173* UreaN-15 Creat-0.9 Na-142 K-3.6 Cl-108 HCO3-25 AnGap-13 [2159-12-22] 03:49AM BLOOD Glucose-133* UreaN-16 Creat-1.0 Na-139 K-3.7 Cl-102 HCO3-28 AnGap-13 [2159-12-24] 06:30AM BLOOD Glucose-145* UreaN-15 Creat-1.1 Na-138 K-4.1 Cl-100 HCO3-29 AnGap-13 [2159-12-16] 07:31PM BLOOD ALT-18 AST-35 LD(LDH)-494* CK(CPK)-191* AlkPhos-60 Amylase-43 TotBili-0.4 [2159-12-16] 07:31PM BLOOD CK-MB-4 cTropnT-<0.01 [2159-12-17] 04:03AM BLOOD CK-MB-3 cTropnT-<0.01 [2159-12-17] 11:08AM BLOOD CK-MB-3 cTropnT-<0.01 [2159-12-16] 07:31PM BLOOD Albumin-3.0* Calcium-7.5* Phos-3.3 Mg-1.9 [2159-12-19] 04:14AM BLOOD calTIBC-208* Ferritn-194 TRF-160* [2159-12-17] 01:52AM BLOOD %HbA1c-6.0* [2159-12-17] 01:52AM BLOOD Triglyc-186* HDL-30 CHOL/HD-4.6 LDLcalc-72 [2159-12-16] 07:31PM BLOOD TSH-1.6 [2159-12-16] 07:31PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CTA: 1. Ischemia in the distribution of the entire left ACA and MCA by mean transit time criteria, and a smaller area of presumed irreversible injury by blood volume criteria. 2. Total occlusion of the left internal carotid artery from its origin with partial reconstitution at the cavernous portion with attenuation of the M1 segment of the left MCA and occlusion of the superior division. 3. Emphysema. TTE: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (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 valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Mr. [Known lastname ] was admitted to the ICU for closer monitoring. He was taken to the Neuro-interventional suite were he received IA tPA and MERCI. After the procedure his blood pressure goals were <185 systolic and <105 diastolic. PRN labetalol was initially used to maintain his pressure. In the first 24 hours after the procedure, he was not instrumented to avoid bleeding and antiplatelet/anticoagulation was avoided. The following day he had an MRI/MRA which showed a L MCA infarct. His stroke work-up included being monitored on tele. During his hospital course, he developed afib and was treated with metoprolol, aspirin and Plavix. No Coumadin was used given concern for the increased risk of bleeding. A TTE was negative for PFO or thrombus. His LDL was 72 and he was treated with simvastatin. He was continued on Plavix for his CAD and stent history and aspirin for stroke prevention. He was also maintained euglycemic and normothermia with Tylenol and SSI. His afib was rate controlled with metoprolol TID and low dose lisinopril for his CAD. During his hospitalization he was also found to have a staph UTI. He was treated initially with Nafcillin and then switched to Bactrim DS for a 10 day course. An NG was placed after his infarct and he was started on TF. After several days, it was evident that his dysarthria and dysphagia would not improved quickly enough to ensure his ability to safely take PO, therefore a PEG was placed by IR. In regards to his afib, he was started on Coumadin 10 days out from his infarct with no bridging with heparin. He will need his INR checked regularly with a goal INR of [2-17]. The aspirin should be stopped when the INR is greater than 1.9. On discharge he remained significantly dysarthric and expressively aphasic. He also had weakness but antigravity movement of his R arm and fingers. The R leg was clearly antigravity. He will follow-up with Dr. [Last Name (STitle) ] as an outpatient. Medications on Admission: Metoprolol Lisinopril HCTZ Vytorin Nexium Discharge Medications: 1. Clopidogrel 75 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 40 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) for 4 days. 7. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 8. Lisinopril 5 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO DAILY (Daily). 9. Coumadin 2.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital of [Location (un) ] & Islands - [Location (un) 6251] Discharge Diagnosis: Stroke Afib Dysphagia Aphagia Dysarthria R arm weakness Discharge Condition: Stable, no focal neurological deficts Discharge Instructions: 1. Please take all medications as prescribed 2. Please call your doctor or come to the closest ED if you have new symptoms 3. Please continue coumadin with a goal INR of [2-17]. Stop the aspirin when the INR is > 1.9 Followup Instructions: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2160-2-25] 1:30 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "5990", "42731", "V4581", "25000", "2724", "4019" ]
Admission Date: [2198-3-21] Discharge Date: [2198-3-26] Service: MEDICINE Allergies: glyburide Attending:[First Name3 (LF) 2265] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 87 yo M HTN, DM, CAD, HL, heavy tobacco abuse, recently diagnosed primary squamous cell of the lung that presented to ER with reaction to chemotherapy. Lung cancer was diagnosed incidentally in [Month (only) 1096] when a mass was found on rib films after a fall. He initiated Cycle 1 Day 1 of weekly carboplatin AUC/Taxol with concurrent radiation on [2198-3-21]. About 30 minutes into treatment, he became nauseated with right-sided chest pain, facial flushing and vomited. He was given solumedrol 125 mg IVP, zofran 8 mg with resolution of vomiting and flushing within 15 minutes. VS prior to ER transfer was 130/70, HR 86, pOx 99 % on RA. His chest discomfort persisted. On arrival to the ER, his initial ECG was NSR at [Street Address(2) 92500]-elevations or frank ischemic changes. CXR was unchanged from prior. He was seen by Atrius cards with plan to observe overnight in the ED, with serial ECGs and biomarkers. His trop trended < 0.01 with rise to 0.03 --> 0.08 --> 0.09. In the morning, the patient developed 10/10 chest pain with nausea and vomiting suddenly. ECG showed deep T-wave depressions in lateral leads. Patient was given SLNGT, morphine without much relief. He was taken urgently to the cath lab. In the cath lab he was found to have three vessel disease including left main, LAD and RCA. He received bare metal stents to the proximal left main and the LAD. He continued to have chest pain after the procedure. He was then transferred to the CCU after angioseal. On the unit, he was comfortable but appeared fatigue. He had no complaints aside from [5-3] right sided non pleuritic chest pain that was ongoing. Additional history: - On arrival to the ED, he had pulse ox in high 80s with diffuse wheezes and left lung with increased consolidation. CXR showed no acute cardiopulmonary abnormality and known lung mass. He was given ceftiraxone, azithromycin, solumedrol, and duoneb. Hypoxemia resolved with above interventions. He had also received steroids prior to starting chemotherapy. - He had a foley placed during lung biopsy, with subsequent urinary retention after removal of foley. He required foley placement on [3-17]. Past Medical History: - Diabetes Type 2, complicated by nephropathy Last A1c 6.5 on [2198-2-13] - Hypertension - Squamous cell carcinoma of the lung He slipped at the end of [2197-11-23] when he was going up stairs and developed left flank pain. He had left hip and left rib Xray which did not show fractures but a 5cm LUL lung mass. CT on [2198-1-2] showed a spiculated 5.5x5.1cm mass within the apical posterior segment with encasement of the left upper lobe pulmonary artery. The tumor also appears to abut the main artery. No evidence of significant mediastinal adenopathy but extensive coronary arterial calcification on CT scan. [2198-2-26] EBUS biopsy of LUL lung mass showed squamous cell lung carcinoma. - Prior MI - [2155] at LMH, just heparin no stents - History of tobacco abuse - Hyperlipidemia Last lipid panel dated [2197-11-15] Chol 121, HDL 36, LDL 67, TG 90 - Chronic pain - Osteoarthritis - Benign prostatic hypertrophy with obstruction - History of CVA - History of colonic polyp Social History: retired truck driver, lives alone, manages his own medications 1-2ppd for 60+ years, now smoking about [12-25] PPD Denies alcohol of illicit drugs Family History: Brother Myocardial Infarction Other legionaires Sister pneumonia Physical Exam: VS: 98.6 143/67 82 18 97% GENERAL: Alert and oriented, no acute distress HEENT: JVP not elevated. PERRL. Anicteric. NECK: supple CARDIAC: RRR, no murmurs/rubs/gallops LUNGS: CTAB, no w/ra/rh ABD: soft, non-distended, +TTP over lower abdomen EXT: no edema, small amount of bleeding, no bruit Pertinent Results: [2198-3-26] 03:00AM BLOOD WBC-17.0* RBC-3.84* Hgb-10.1* Hct-32.8* MCV-86 MCH-26.3* MCHC-30.8* RDW-13.4 Plt Ct-395 [2198-3-26] 03:00AM BLOOD PT-11.6 PTT-64.2* INR(PT)-1.1 [2198-3-26] 03:00AM BLOOD Glucose-168* UreaN-19 Creat-0.8 Na-133 K-4.0 Cl-97 HCO3-28 AnGap-12 [2198-3-24] 06:13AM BLOOD CK-MB-3 cTropnT-0.11* [2198-3-23] 05:05AM BLOOD CK-MB-8 cTropnT-0.22* [2198-3-22] 09:35PM BLOOD CK-MB-9 cTropnT-0.22* [2198-3-22] 10:30AM BLOOD cTropnT-0.09* [2198-3-22] 03:00AM BLOOD cTropnT-0.08* [2198-3-21] 10:00PM BLOOD cTropnT-0.03* [2198-3-21] 03:45PM BLOOD cTropnT-<0.01 [2198-3-25] CTA CHEST Again seen is a mass in the left upper lobe that is larger on the current examination when compared to the PET scan from [1-20], [2197]. It currently measures 3.5 x 9.5 cm, on the sagittal projections. When comparing to the coronal images from [1-2], [2197] it currently measures 9.3 cm, having previously measured 7.9 cm. There is now increased extension to the posterior superior chest wall. There is persistent encasement and near total occlusion of the left upper lobe pulmonary artery. There is encasement of the lingula and lower lobe pulmonary arterial branches with increased compression on the lingular branches, however these branches are all patent. The right upper lobe bronchus is totally encased by tumor as seen previously. However, on the current examination the lingular bronchus is also encased and occluded which is new. The previously seen pulmonary nodule in the left upper lobe is slightly larger, now measuring 9 mm, having previously measured 7 mm (3:33). The heart size is slightly enlarged. The aorta is normal in size. The main pulmonary artery is dilated up to 3.2 cm with enlargement of the right main pulmonary artery as well. This likely is due to shunting of flow to the right due to compression on the left pulmonary arteries. No filling defect is seen within the central pulmonary arteries to suggest a pulmonary embolism. There are again seen pleural calcifications. There is a small left pleural effusion. Limited evaluation of the upper abdomen demonstrates calcified and noncalcified atherosclerotic plaque involving the aorta and the visualized branching vessels. There is a new 2 x 2 cm left adrenal mass. Again seen are bilateral renal cysts, the largest is an exophytic left renal cyst measuring up to 5 cm. No lytic or blastic lesions are seen in the visualized bones. IMPRESSION: 1. Enlarging left upper lobe mass with persistent occlusion of the left upper lobe pulmonary artery and bronchus with new occlusion of the lingular bronchus. 2. New left adrenal mass concerning for metastasis. 3. No evidence for pulmonary embolism. [2198-3-23] ECHO The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is an inferobasal left ventricular aneurysm. Overall left ventricular systolic function is well preserved (LVEF 60%). However, the basal segment of the inferior free wall is akinetic (mildly aneurysmal) and the basal segment of the posterior wall is hypokinetic. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. The aortic valve is not well seen. There is mild aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [2198-3-22] CARDIAC CATH 1. Selective coronary angiography of this right dominant system demonstrated left main and three vessel disease. The LMCA had a 70% distal stenosis. The LAD had a 90% proximal and mid 40% stenosis. The LCX mid 80%, 100% distal (filling via left to left collaterals). The RCA proximal 70% stenosis, mid 90% and distal 99%. TIMI 2 distal flow, competitive because of left to right collaterals. 2. Limited resting hemodynamics demonstrated elevated systemic arterial pressures at the central aortic level 158/58 mmHg. 3. Left ventriculography was deferred. 4. Successful PCI to distal left main and ostial LAD stenosis (70% left main) with deployment of a 3.5 x 18 mm Integrity bare metal stent. 5. Successful PCI to proximal LAD 90% calcified stenosis with deployment of a 3.0 x 15 mm and a 3.0 x 12 mm Integrity bare metal stents. Brief Hospital Course: 87 yo M HTN, DM, CAD, HL, heavy tobacco abuse, recently diagnosed primary squamous cell of the lung that presented to ER with chest pain and was found to have three vessel disease on cath, PCI with two bare metal stents. . # NSTEMI Chest pain started initially while undergoing his first round of chemotherapy with carboplatin/taxol. His chest pain improved in the ED, and troponins and ECGs were unremarkable. He was observed overnight, then in the morning had 10/10 chest pain with lateral ST changes. He was taken to the cab lab where he was sound to have three vessel disease. Given his poor operative candicacy, he underwent successful PCI to distal left main and ostial LAD stenosis with bare metal stents. He was loaded with plavix, and started on aspirin rather than aggrenox. Atenolol was switched to metoprolol and simvastatin to atorvastatin 80mg. Heparin and nitro drips were continued post-cath due to ongoing chest pain. His chest pain resolved with 24 hours and the nitro drip was stopped. Heparin was continued due to history suggestive of a PE, and was stopped after this was ruled out. # Hypoxia/Dyspnea He was initially hypoxic on arrival to the ED and for the beginning of his stay in the CCU. There was a concern that he could have a pneumonia or a PE given his chest pain. He was initially treated with ceftriaxone and azithromycin but this was stopped given lack of fever and WBC. He was continued on the heparin drip after cath for concern of possible PE. CTA performed on [3-25] showed no evidence of PE. Heparin drip was initially continued due to concern of compression of pulmonic artery, but was then stopped prior to discharge. . # Squamous cell cancer of the lung Originally diagnosed in [Month (only) 1096] with incidental finding on rib films after a fall. He began chemotherapy but developed chest pain. After a discussion with his Atrius oncologist, it was decided that he wouldn't be appropriate for further chemotherapy. A CTA repeated yesterday shows interval enlargement of lung cancer, with possible adrenal met and compression of pulmonary arteries as well. He was supposed to receive his second dose of radiation on Monday [3-26], but he preferred to go home instead and will followup with radiation oncology as an outpatient. . # DM2 - Last A1c 6.2 on [2-4]. Held metformin due to concern for [Last Name (un) ] from dye load. Placed on insulin sliding scale. Restarted metformin as an outpatient. . # Benign prostatic hypertrophy with obstruction A foley was placed earlier in [Month (only) 958] due to obstruction after lung biopsy was performed. He has continued to have the foley since then. This was discontinued in the hospital, but he was unable to urinate significantly. He was straight cathed intermittently. A foley was replaced when he was unable to urinate and he was discharged with plan to followup with urology. Medications on Admission: Aggrenox 200-25mg 1 capsule [Hospital1 ] Atenolol 25mg daily Enalapril 20mg 2 tabs daily Simvastatin 20mg daily Metformin 1000mg [Hospital1 ] Zofran 8mg PRN Dexamethasone 10mg IV Famotidine 20mg IV Paclitaxel 66mg IV Carboplatin 130mg IV Lorazepam 0.5mg daily Percocet q6hr PRN Doxycycline 100mg [Hospital1 ] for 10 days (for UTI stopped recently) Dutasteride (Avodart) 0.5mg daily Tamsulosin 0.4mg daily Omeprazole 20mg daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. 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:0 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. enalapril maleate 20 mg Tablet Sig: Two (2) Tablet PO once a day. 6. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 7. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO once a day. 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Non-ST elevation myocardial infarction Lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a heart attack. You had a procedure done to evaluate the arteries that supply your heart, and were found to have several blockages. You had several stents placed to open up some of these blockages. . You also had a CT scan to evaluate your lungs. You did not have any blood clots in your lung, however there was evidence that your cancer has progressed. It will be very important that you follow-up with your outpatient doctors. . You also continued to have difficulty urinating, so we replaced your foley catheter (this catheter drains urine from your bladder). . Please STOP the following medications: Aggrenox (this will be replaced by aspirin) Atenolol (this will be replaced by metoprolol) Simvastatin (this will be replaced by atorvastatin) Omeprazole (you can discuss other options with your primary care physicians that are safer in heart disease) Please START the following medications: Aspirin 325mg daily Plavix (clopidogrel) 75mg daily Lisinopril 5mg daily Atorvastatin 80mg daily Followup Instructions: Name: [Last Name (LF) 13775],[First Name3 (LF) 1037] A. Specialty: INTERNAL MEDICINE Location: [Location (un) 2274]-[Location (un) ] Address: 26 CITY [Doctor Last Name ] MALL, [Location (un) ],[Numeric Identifier 6086] Phone: [Telephone/Fax (1) 31019] Appointment: FRIDAY [3-30] AT 2:20PM You will be seeing Nurse [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for this appointment. Name: [Last Name (LF) ], [Name8 (MD) ] NP Specialty: UROLOGY Location: [Location (un) 2274]-[Location (un) ] Address: 26 CITY [Doctor Last Name ] MALL, [Location (un) ],[Numeric Identifier 6086] Phone: [Telephone/Fax (1) 90474] Appointment: WEDNESDAY [4-4] AT 10:45AM Name: [Last Name (LF) 63933], [Name8 (MD) ] NP Specialty: CARDIOLOGY Location: [Location (un) 2274]-[Location (un) 2277] Address: [Location (un) ], [Location (un) ], [Numeric Identifier 718] Phone: [Telephone/Fax (1) 2258] Appointment: TUESDAY [4-10] AT 1PM Name: [Last Name (LF) ], [Name8 (MD) ] MD Specialty: HEMATOLOGY/ONCOLOGY Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3468] We are working on a follow up appointment with Dr. [First Name (STitle) ] within 1-2 weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above Please call Dr.[Name (NI) 83416] office regarding your plans for radiation treatment. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2273]	[ "41071", "5849", "2761", "41401", "2724", "4019", "412", "3051" ]
Admission Date: [2181-2-17] Discharge Date: [2181-2-21] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2291] Chief Complaint: frequent suctioning Major Surgical or Invasive Procedure: None History of Present Illness: 88 year old female with recent acute on chronic left SDH, recent SAH s/p coiling of right PCA artery aneurysm, hydrocephalus with VP shunt, acute respiratory failure secondary to large thoracic mass (benign thyroid nodule) requiring trach, severe dysphagia with PEG placement, ?GI bleed, DVT with IVC filter placement transferred from OSH for anemia and admitted to MICU for increasing respiratory secretions. . Patient had been at [Hospital3 ] prior to transfer and per report patient noted to have Hct 23.8 and concern for GI bleed and was sent to OSH for blood transfusion. There VS: 100.4 114/66 80 94% RA. There was question of allergic rxn (?seizures) to blood in the past so OHS transferred her to [Hospital1 18]. Prior to transfer patient had CXR with concern for a RLL pneumonia. Given 750mg of levoquin. . In the ED, initial VS were 100 98 106/54 26 94%. 18g and 20g were placed for access. Exam notable for rectal exam: no stool in the vault, very trace guiac + effluent. Pulmonary exam with coarse breath sounds bilaterally, scattered rhonchi, pink secretions from trache collar. Patient received PR tylenol for temp of 100.8. Abx were not continued as suspicion for PNA low. . On arrival to the MICU, patient comfortable without complaint with cough, SOB, CP. . Of note, anemnia/dark tarry stools has been chronic issue and per previous DC summaries patient with recent EGD and C-scope wnl. Previously, initial positive guaiac tests thought secondary due to manipulation of her PEG tube, . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Subarachnoid hemorrhage s/p coiling of R PCA aneurysm Hydrocephalus s/p VP shunt Respiratory failure requiring trach placement Thoracic mass: biopsied - benign thyroid nodule Hyperthyroidism with goiter Anemia - prior black stools with no source found from EGD/c-scope Deep vein thrombosis s/p IVC filter Hypertension Atrial fibrillation Social History: Originally from [Country 13622] Republic, Spanish-speaking. Prior to her prolonged hospitalization in [Month (only) 1096] she was living with her daughter and granddaughter and was very independent. Currently she is at [Hospital3 ]. She walks with a cane or walker at baseline. No history of tobacco or alcohol use. Family History: CAD Physical Exam: Admission Physical: General: Alert, oriented, no acute distress, comfortable, pleasant, breathing comfortably on trach mask 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: Rhonchorus breath sounds bilaterally, no wheezes, rales 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: non-focal, moving all four extremities with sensation intact Pertinent Results: LABS: Admission Labs: [2181-2-17] 12:55AM BLOOD WBC-8.0# RBC-2.80* Hgb-8.7* Hct-25.4* MCV-91 MCH-31.2 MCHC-34.5 RDW-16.2* Plt Ct-475* [2181-2-17] 12:55AM BLOOD Neuts-77.2* Lymphs-11.9* Monos-5.8 Eos-4.6* Baso-0.4 [2181-2-17] 12:55AM BLOOD PT-12.4 PTT-30.5 INR(PT)-1.1 [2181-2-17] 12:55AM BLOOD Ret Aut-3.9* [2181-2-17] 12:55AM BLOOD Glucose-119* UreaN-25* Creat-1.0 Na-139 K-4.6 Cl-102 HCO3-28 AnGap-14 [2181-2-17] 12:55AM BLOOD ALT-12 AST-15 LD(LDH)-147 AlkPhos-77 TotBili-0.3 [2181-2-17] 06:42AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8 Iron-15* [2181-2-17] 12:55AM BLOOD Hapto-330* [2181-2-17] 06:42AM BLOOD calTIBC-250* Ferritn-41 TRF-192* Discharge Labs: Thyroid function tests: [2181-2-19] 06:40AM BLOOD T3-65* Free T4-1.5 [2181-2-19] 06:40AM BLOOD TSH-0.34 MICRO: [2181-2-17] URINE CULTURE-FINAL negative [2181-2-17] MRSA SCREEN-FINAL negative [2181-2-17] Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2181-2-17] Blood Culture, Routine-PENDING STUDIES: CXR [2181-2-17]: IMPRESSION: 1. Grossly stable thyroid goiter causing widening of the right paratracheal stripe. 2. Unchanged elevation of the right hemidiaphragm and bibasilar atelectasis. 3. No evidence of pneumonia or acute pulmonary edema. Brief Hospital Course: 88 year old female with recent acute on chronic left SDH, recent SAH s/p coiling of right PCA artery aneurysm, hydrocephalus with VP shunt, acute respiratory failure secondary to large thoracic mass (benign thyroid nodule) requiring trach, severe dysphagia with PEG placement, ?GI bleed transferred from OSH for anemia and admitted to initially to the MICU for increasing respiratory secretions. She was stable for transfer to the medicine floor within one day. ACTIVE ISSUES BY PROBLEM: # Respiratory secretions: On arrival to MICU, patient's secretions were minimal and she had no signs of respiratory distress. Initial concern for ?PNA vs tracheitis however patient without leukocytosis or fevers (except initial temp of 100, no recurrence). CXR without focal infiltrate. Previous sputum cultures have grown pseudomonas; however this likely represents colonization rather than infection, so it was felt that repeat sputum cultures would not be helpful in this clinical setting. Antibiotics were not started. Secretions appear to be coming from both oropharyngeal and pulmonary sources, however they are clear and she is able to expectorate them extremely well on her own. She was seen by the Interventional Pulmonary team, who had no further recommendations or plans for interventions at this time. Pt was continued on trach mask and required suctioning every 6-8 hours. Guaifenesin and saline nebs were initiated to help break up the thickened sputum. This regimen, along with albuterol, should be continued at her rehab facility. # Normocytic Anemia: Likely due to a very slow lower GI bleed. Admission HCT 25.4, with baseline HCT ~28-30. Exam in ED guaiac + but without overt melena or BRBPR. Previous GI work-up with unrevealing EGD (documented in [11-27] operative note) and reportedly normal colonoscopy at [Hospital3 ] in [2176]. PEG lavage on arrival to the MICU guaiac negative. Previous vitamin B12, folate wnl. Iron studies suggested iron deficiency anemia, for which she was continued on her iron supplementation. She was transfused one unit PRBC's for Hct 22 with appropriate response to 25. After transfer to the medicine floor, hct continued to remain stable. She did have more dark brown guaiac positive stools. It is likely that she has a very slow GI bleed that is causing her anemia, more likely lower rather than upper GI given the guaiac negative PEG lavage. As this appears to be a chronic issue that is relatively stable, it is recommended that she continue to have her hemoglobin/hematocrit followed and could have a repeat colonoscopy for further work up, however will defer to her PCP or the rehab medical director for further management. # Dysphagia: Secondary to esophageal narrowing by large thyroid mass and difficulty swallowing (noted to have likely aspirations in the past). PEG tube in place. Initially held tube feeds in the setting of possible GI bleed, however these were restarted on hospital day 2 with no issues. Speech and swallow consult was obtained, however they deferred further evaluation to her speech therapist at [Hospital3 ], as they have been working with her for 3 months now on this issue. She remained NPO and on tube feeds for her stay in the hospital. # Substernal goiter, hyperthyroidism: TFTs sent while inpatient, which appear improved (however less reliable in acute illness): TSH 0.34, freeT4 1.5, and T3 65. ENT team was notified of her admission and requested an appointment be made for her with Dr. [Last Name (STitle) 1837] for evaluation for resection of thyroid mass. This appointment will be on ###, after which the ENT, IP, neurology, and endocrine teams will need to decide on the best future course of action. CHRONIC INACTIVE ISSUES: # DVT s/p filter placement: placed on heparin SC # Seizure disorder: Continued keppra, with prn Ativan. # Hyperthyroidism: Continued methimazole. # History of Atrial Fibrillation. CHADS 2. Anticoagulated with ASA. TRANSITION OF CARE ISSUES: - Resp secretions: will need suctioning at least every [5-25] hours, continue with saline nebs, albuterol/ipratropium nebs, and guaifenesin - Goiter, Hyperthyroidism: appears to be in euthyroid state now, may now be a surgical candidate. Has ENT appt with Dr. [Last Name (STitle) 1837] for surgical eval, after which ENT, IP, neurology, and endocrine teams will decide on the best future course of action for removal of thyroid mass - Anemia: slow GI bleed most likely, should have hemoglobin/hematocrit checked 2x/weekly. Transfuse for hct <21, hemodynamic instability, or symptoms. - Dysphagia: should continue to work with speech/swallow therapist at [Hospital1 ] to determine when it may be safe to try PO nutrition again. - FULL CODE this admission Medications on Admission: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. levetiracetam 750 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO twice a day. 3. lorazepam 0.5 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO Q6H (every 6 hours) as needed for mouth movements. 4. docusate sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: One Hundred (100) mg PO BID (2 times a day). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 6. methimazole 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 7. senna 8.8 mg/5 mL Syrup [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed for constipation . 8. acetaminophen 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO every six (6) hours as needed for pain. 9. heparin (porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) ml Injection three times a day: for DVT prophylaxis. 10. aspirin 325 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: One (1) Tablet, Delayed Release (E.C.) PO once a day: Please do not start taking until [2181-1-28]. . 11. Ferrous Sulfate 300mg PO BID 12. Latanoprost 0.005% 1drop each eye qhs 13. Solumedrol IV 40mg q12hr (never received at [Hospital1 ], not continued during this hospitalizations) Discharge Medications: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. lorazepam 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO every six (6) hours as needed for for mouth movements. 3. docusate sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: One Hundred (100) mg PO BID (2 times a day). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) neb inhalation Inhalation Q6H (every 6 hours) as needed for sob, wheezing. 5. methimazole 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 6. senna 8.8 mg/5 mL Syrup [Last Name (STitle) ]: Five (5) ml PO twice a day as needed for constipation. 7. acetaminophen 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO every six (6) hours as needed for pain. 8. aspirin 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 9. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [Last Name (STitle) ]: Three Hundred (300) mg PO BID (2 times a day). 10. latanoprost 0.005 % Drops [Last Name (STitle) ]: One (1) Drop(s) each eye Ophthalmic HS (at bedtime). 11. levetiracetam 100 mg/mL Solution [Last Name (STitle) ]: 1500 (1500) mg PO BID (2 times a day). 12. guaifenesin 100 mg/5 mL Syrup [Last Name (STitle) ]: Ten (10) ML PO Q6H (every 6 hours). 13. sodium chloride 3 % Solution for Nebulization [Last Name (STitle) ]: Fifteen (15) ML(s) (1 nebulization) Inhalation Q6H (every 6 hours). 14. ipratropium bromide 0.02 % Solution [Last Name (STitle) ]: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob, wheezing . 15. heparin (porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) injection (5000 units) Injection three times a day: Can discontinue if patient is able to ambulate 3x daily. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: Primary diagnoses: Chronic respiratory failure Dysphagia Anemia likely secondary to slow gastrointestinal bleed Substernal goiter Hyperthyroidism Secondary diagnoses: Deep vein thrombosis Seizure disorder Atrial fibrillation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to the hospital for increased respiratory secretions and low blood counts. We did blood tests and xrays, and we do not believe that you have have a lung infection. The increased secretion is partly due to the benign thyroid mass and difficulty swallowing. Your low blood counts are likely coming from a very small and very slow bleed in your intestines. You got 1 unit of blood and your blood counts have been very stable. Your doctor may decided if you should have a colonoscopy as an outpatient for further evaluation. Changes made to your medications: START guaifenesin 10 ml every 6 hours START saline nebulizations every 6 hours START ipratropium nebulizations every 6 hours as needed for shortness of breath or wheezing It was a pleasure to take care of you at [Hospital1 ]! Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] M Location: GREATER [Hospital1 ] FAMILY HEALTH CENTER Address: [Location (un) ], [Hospital1 ],[Numeric Identifier 66038] Phone: [Telephone/Fax (1) 82128] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. We are working on a follow up appointment in Otolaryngology with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1837] for your hospitalization. You must follow up within 1 week of discharge. The office will contact you at the facility with the appointment information. If you have not heard within 2 business days please call the office at [Telephone/Fax (1) 41]. Department: RADIOLOGY When: THURSDAY [2181-3-1] at 2:00 PM With: CAT SCAN [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: NEUROSURGERY When: THURSDAY [2181-3-1] at 2:45 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 7746], MD [Telephone/Fax (1) 3666] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: NEUROLOGY When: WEDNESDAY [2181-3-28] at 2:00 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 Department: INTERVENTIONAL PULMONARY When: TUESDAY [2181-4-3] at 9:00 AM With: [First Name8 (NamePattern2) ] [Doctor Last Name ] Building: DE [Hospital1 ] BUILDING ([Hospital Ward Name ] COMPLEX), [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name 23] Garage Department: ENDOCRINOLOGY When: TUESDAY [2181-4-3] at 11:20 AM With: [First Name11 (Name Pattern1) 1409] [Last Name (NamePattern4) 91212], MD [Telephone/Fax (1) 1803] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name ] Garage	[ "2851", "42731", "4019", "V5861" ]
Admission Date: [2101-6-2] Discharge Date: [2101-6-8] Date of Birth: [2044-11-16] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 922] Chief Complaint: Dyspnea on exertion/ Paroxysmal nocturnal dyspnea Major Surgical or Invasive Procedure: coronary artery bypass grafting x4 (left internal mammary artery grafted to left anterior descending artery/Saphenous vein grafted to Obtuse Marginal #1/#2/Posterior descending artery)-[2101-6-2] History of Present Illness: 56 year old female with known coronary artery disease, status post stenting, cardiomyopathy, and two recent CHF admissions ([Month (only) ]/[March 2101])reports progressive dyspnea on exertion and Paroxysmal Nocturnal Dyspnea referred for cardiac catheterization for further evaluation.Cath report revealed multivessel coronary disease. Dr.[Last Name (STitle) 914] was consulted for Coronary revascularization. Past Medical History: CAD s/p MI and LAD stenting in [2092] with repeat stenting for ISR PVD LE claudication s/p left leg angioplasty for an ischemic leg per patient report ?[2096] Cardiomyopathy Chronic systolic heart failure s/p admissions [Month (only) ] and [2101-3-20] Diabetes mellitus Hypertension per records from outside MD (patient reports this to be inaccurate) Hyperlipidemia Past Surgical History= [2069] Cholecystectomy s/p abdominal aortic aneurysm repair at the [Hospital 882] hospital approximately 15 years ago (per patient report) Social History: Lives with:HUSBAND & DAUGHTER [Name (NI) ]:CAUCASIAN Tobacco:QUIT 1MONTH AGo: 2PPD X40 YRS ETOH:NONE Family History: Family History: (parents/children/siblings CAD < 55 y/o):FATHER S/P MI AND DIED AGE 55 Physical Exam: Physical Exam Pulse:64 Resp:18 O2 sat: 99%RA B/P Right: 161/63 Left:168/61 Height:5'4" Weight:150 lbs General:Alert & oriented Skin: Dry [] intact [X] HEENT: PERRLA [X] EOMI [X], No dentures Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] No Murmur, gallops or rubs. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:1+ Left:1+ PT [Name (NI) 167]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right:NO Left:NO Pertinent Results: [2101-6-7] 06:15AM BLOOD WBC-10.9 RBC-3.90* Hgb-11.3* Hct-34.6* MCV-89 MCH-28.9 MCHC-32.5 RDW-15.4 Plt Ct-290 [2101-6-2] 12:45PM BLOOD WBC-15.3# RBC-2.40# Hgb-7.1# Hct-20.5# MCV-85 MCH-29.4 MCHC-34.4 RDW-15.6* Plt Ct-310 [2101-6-5] 01:09AM BLOOD PT-13.8* PTT-29.5 INR(PT)-1.2* [2101-6-2] 12:45PM BLOOD PT-14.7* PTT-34.3 INR(PT)-1.3* [2101-6-7] 06:15AM BLOOD Glucose-78 UreaN-43* Creat-1.7* Na-139 K-3.9 Cl-102 HCO3-25 AnGap-16 [2101-6-3] 03:29AM BLOOD Glucose-77 UreaN-19 Creat-1.3* Na-140 K-4.2 Cl-112* HCO3-20* AnGap-12 [2101-6-4] 04:56PM BLOOD ALT-18 AST-27 LD(LDH)-374* AlkPhos-58 Amylase-16 TotBili-0.8 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 26] [Hospital1 18] [Numeric Identifier 82554] (Complete) Done [2101-6-2] at 9:39:05 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] C. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2044-11-16] Age (years): 56 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Valvular heart disease. ICD-9 Codes: 440.0, 424.1, 424.0 Test Information Date/Time: [2101-6-2] at 09:39 Interpret MD: [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD Test Type: TEE (Complete) 3D imaging. Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 6507], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 30% to 40% >= 55% Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness and cavity size. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (?#). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. 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 TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is moderately depressed (LVEF=35-40 %). There is moderate anterior wall and antero-septal hypokinesia. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Slightly improved global and focal LV systolci function with background inotropic support. 2. Trace MR and trace TR. 3. Intact aorta Electronically signed by [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD, Interpreting physician [Last Name (NamePattern4) ] [2101-6-2] 17:12 [Known lastname ],[Known firstname 26] [Medical Record Number 82555] F 56 [2044-11-16] Radiology Report RENAL U.S. PORT Study Date of [2101-6-4] 10:20 AM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2101-6-4] 10:20 AM RENAL U.S. PORT; DUPLEX DOP ABD/PEL LIMITED Clip # [Clip Number (Radiology) 82556] Reason: LOW UO SP CABG,EVAL FOR STENOSIS [Hospital 93] MEDICAL CONDITION: 56 year old woman with low uo s/p CABG REASON FOR THIS EXAMINATION: stenosis Provisional Findings Impression: GWp SAT [2101-6-4] 4:52 PM PFI: 1. Limited portable renal ultrasound demonstrating no hydronephrosis, no nephrolithiasis and no solid renal mass. 2. Right renal artery resistive index measured at 0.85, 0.76, 0.78 and infrarenal flow with resistive indices 0.77, 0.79 and 0.80. 3. Left renal artery resistive index measured at 0.87, 0.88 with elevated velocities measured at 160, 200 cm/sec. Velocities and resistive indices in the intrarenal portion appear normal at 0.71, 0.84, and 0.84. Final Report INDICATION: 56-year-old woman with low urine output status post CABG, query stenosis. COMPARISON: None available. PORTABLE RENAL ULTRASOUND: Grayscale and color Doppler son[Name (NI) 493] images were obtained that demonstrate the right kidney to measure 10.8 cm pole to pole and the left 10.3 without evidence for hydronephrosis, nephrolithiasis, or renal mass. On the right main renal artery demonstrates flow velocity between 71 and 87 cm/sec and resistive index measured at 0.85 and 0.76. Infrarenally, the upper, mid, and lower velocities are measured at 76, 62 and 103 cm/sec and the resistive indices 0.79, 0.77 and 0.80. Right renal venous flow is normal. On the left, the main renal artery velocity is measured at 200 and 166 cm/sec, with resistive index at 0.88 and 0.87. The interlobar velocities are measured in the upper, mid and lower pole at 83, 56 and approximately 40 cm/sec. Resistive indices are measured at 0.84, 0.71, and 0.70. A Foley catheter is demonstrated within the decompressed bladder. IMPRESSION: 1. No son[Name (NI) 493] evidence for hydronephrosis, left nephrolithiasis, or renal mass. 2. Normal arterial and venous flow demonstrated at the right kidney. 3. In this limited portable son[Name (NI) 493] study, there are elevated velocities and elevated RIs demonstrated in the left renal artery concerning for stenosis. Consider MRA for further evaluation. A non contrast MRA examination is possible if patient's renal function precludes administration of contrast. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) 5206] [Name (STitle) ] DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 21884] Approved: SUN [2101-6-5] 4:17 PM Imaging Lab Brief Hospital Course: On [6-2] Mrs.[Known lastname 29390] underwent coronary artery bypass grafting x4 (left internal mammary artery grafted to left anterior descending artery/Saphenous vein grafted to Obtuse Marginal #1/#2/Posterior descending artery) with Dr.[Last Name (STitle) 914]. Cross clamp time= 97 minutes/ Cardiopulmonary bypass time= 132 minutes. Please refer to Dr[Last Name (STitle) 5305] operative report for further details. She was transferred to the CVICU hemodynamically stable requiring Milrinone to optimize cardiac output. She awoke neurologically intact and was extubated on POD#1. She was weaned off inotropes. Beta-blockers optimized per Blood Pressure tolerance. All lines and drains were discontinued in a timely fashion. Psychiatry was consulted for postoperative delirium. She continued to progress and on POD# 4 was transferred to the step down unit for further monitoring. Her rhythm went into rapid atrial fibrillation and was treated with Amiodarone. She converted to sinus rhythm, no anticoagulation required. She was diuresed for right pleural effusion evident on chest xray. The remainder of her postoperative course was essentially uncomplicated and on POD# 6 she was cleared for discharge to rehab for further strength, endurance and increase in daily activities. All follow up appointments were advised. Pt. should have a MRA as an outpt. for follow up of possible left renal artery stenosis. Please restart metformin when creatinine has normalized. Medications on Admission: Glyburide 5mg one tablet twice a day Plavix 75mg daily every morning Atenolol 25mg daily every morning Imdur 30mg daily every morning Lisinopril 5mg daily every morning Furosemide 40mg one tablet every morning Simvastatin 20mg one tablet every morning Metformin 500mg one tablet twice a day Ecotrin 81mg daily every morning Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: 400 mg [Hospital1 ] until [6-12], then 400 mg daily for 7 days, then 200 mg daily ongoing. 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing/sob. 11. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: please assess for dose reduction after one week. 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): please assess for dose reduction when oral lasix is decreased. 14. Humalog insulin per sliding scale QID. Discharge Disposition: Extended Care Facility: Life Care Center - [Location (un) 3320] Discharge Diagnosis: status post coronary artery bypass grafting x4 (left internal mammary artery grafted to left anterior descending artery/Saphenous vein grafted to Obtuse Marginal #1/#2/Posterior descending artery)-[2101-6-2] -myocardial infarction /LAd stenting '[2092] -lower extremity claudication, s/p Left leg angioplasty '[96] -Cardiomyopathy -CHF: [Month (only) ].& [March 2101] -Diabetes Mellitus -Hypertension -hyperlipidemia - postop acute renal failure -s/p Choleycystectomy'[69] Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incision dry no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness, drainage, or weight gain of 2 pounds in 2 days or 5 pounds in one week Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks, please call for appointment# [Telephone/Fax (1) ] Dr. [Last Name (STitle) 5310] in [2-22] weeks, please call for appointment Dr [Last Name (STitle) ],[Last Name (un) 82557] M. [Telephone/Fax (1) 82558], Please call for appt to be scheduled in [1-21] weeks; NOTE: should have MRA as outpatient to follow up on possible left renal artery stenosis Completed by:[2101-6-8**]	[ "41401", "5845", "2762", "2761", "4280", "42731", "2859", "25000", "4019", "2724", "412", "V4582" ]
Admission Date: [2196-4-11] Discharge Date: [2196-4-19] Date of Birth: [2152-9-20] Sex: M Service: CARDIOTHORACIC Allergies: Bactrim Attending:[First Name3 (LF) 922] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2196-4-15] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, AVG to PDA) History of Present Illness: 43 y/o male who had new onset chest pain while fishing. Transported to OSH and found to have elevated Troponin without EKG changes. Underwent cath which revealed severe three vessel disease. Transferred to [Hospital1 18] for surgical intervention. Past Medical History: Coronary Artery Disease/Myocardial Infarction s/p PCI 4 yrs ago, Hyperlipidemia, Hypertension, Chronic Kidney Disease (Cr 2.9) secondary to Glomerulonephritis Social History: Quit smoking as teenager ([2-7] pk yr hx). Occ. ETOH use. Family History: Mother died from MI at 50. Father died from MI at 59. Physical Exam: VS: 57 13 148/54 Gen: NAD Skin: Unremarkable HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM, -JVD, -Carotid Bruit Chest: CTAB Heart: RRR -murmurs Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [2196-4-11] CNIS: 1. There is less than 40% stenosis in the right internal carotid artery. 2. There is no stenosis within the left internal carotid artery. [2196-4-15] Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the inferolateral wall. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. MR increased to mild to moderate (1+-2+) with raising of the SBP to 170mm Hg (phenylephrine and Trendelenburg position). POSTBYPASS: LV systolic function appears hyperdynamic (LVEF>55%). RV systolic function is preserved. MR remains mild. The study is otherwise unchanged from prebypass. [4-17] CXR: The patient is status post sternotomy. There is prominence of the cardiomediastinal silhouette and increased retrocardiac density. There are small bilateral effusions. No CHF. These findings are all unchanged compared with [2196-4-16]. There is a small left apical pneumothorax that is more apparent on today's examination than on [2196-4-16] and that appears similar to [2196-4-15]. [2196-4-11] 05:11PM BLOOD WBC-6.5 RBC-3.72* Hgb-10.9* Hct-31.3* MCV-84 MCH-29.2 MCHC-34.7 RDW-12.9 Plt Ct-101* [2196-4-19] 10:45AM BLOOD WBC-9.5 RBC-3.86* Hgb-11.4* Hct-33.0* MCV-86 MCH-29.5 MCHC-34.5 RDW-12.7 Plt Ct-297 [2196-4-11] 05:11PM BLOOD PT-12.7 PTT-29.2 INR(PT)-1.1 [2196-4-15] 01:29PM BLOOD PT-14.3* PTT-46.4* INR(PT)-1.2* [2196-4-11] 05:11PM BLOOD Glucose-101 UreaN-42* Creat-2.8* Na-142 K-4.6 Cl-109* HCO3-24 AnGap-14 [2196-4-18] 05:26PM BLOOD Glucose-94 UreaN-58* Creat-3.4* Na-137 K-4.3 Cl-99 HCO3-24 AnGap-18 Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname ] was transferred from OSH to [Hospital1 18] following his cardiac cath. He was continued on his medications at time of transfer (including Heparin and Nitro) and underwent usual pre-operative work-up. Plavix was stopped and he received medical management pre-operatively until Plavix washout. He required nephrology consult secondary to his chronic kidney disease. On [4-15] he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Beta blockers and diuretics were initiated on post-op day one and he was gently diuresed towards his pre-op weight. Chest tubes were removed on post-op day one. On post-op day two he had episodes of atrial fibrillation which were treated with beta blockers and amiodarone. He required blood transfusion on post-op day three d/t low HCT (20.5). Later on this day he was transferred to the telemetry floor for further care. Epicardial pacing wires were removed. Over the next couple of days he worked with physical therapy for strength and mobility. On post-op day four he was discharged home with VNA services. Medications on Admission: [Last Name (un) 1724]: Plavix 75mg qd, Atenolol 50mg qd, Zocor, Avalide, Corgard 20mg qd MAT: Plavix 75mg qd, NTG gtt, Aspirin 325mg qd, Lopressor 50mg TID, Heparin gtt, Mucomyst 600mg q12, Intergrillin gtt Discharge Disposition: Home With Service Facility: [Hospital3 6011] Care Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Post-operative Atrial Fibrillation PMH: Myocardial Infarction s/p PCI 4 yrs ago, Hyperlipidemia, Hypertension, Chronic Kidney Disease (Cr 2.9), Chronic Glomerulonephritis Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks Dr. [Last Name (STitle) 78145] in [2-7] weeks Dr. [Last Name (STitle) 78146] in [1-6] weeks Completed by:[2196-4-19]	[ "41071", "9971", "2851", "41401", "2767", "42731", "2724", "40390", "5859" ]
Admission Date: [2138-12-28] Discharge Date: [2139-1-4] Date of Birth: [2077-10-31] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization and IABP insertion [12-29] Coronary artery bypass grafting with left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to posterior diagonal artery. [12-30] History of Present Illness: Mr. [Known lastname 39868] is a 61 year old gentleman with a PMH signficant for CAD s/p [Known lastname 7792] in [2-21] with cardiac catheterization x2 and PTCA in [2123], HTN, [Hospital 39871] transferred from OSH for chest pain with ECG changes. The patient states that he developed chest pain yesterday morning described as [8-24] chest pressure radiating to both arms associated with dyspnea. He denies any other associated symptoms including diaphoresis, nausea, or vomiting. These symptoms lasted for approximately 30 minutes until EMS arrived and symptoms were relieved with sublingual nitroglycerin. He was taken to OSH where he was found to have ST depressions in the lateral leads. Overnight, he continued to have chest pain that was requiring additional doses of SL nitroglycerin, so he was started on a nitroglycerin gtt and transferred to OSH CCU. This morning, he continues to have lateral ST depressions although biomarker negative and was transferred to [Hospital1 18] for PCI. Of note, EMS reports that during transfer from OSH to [Hospital1 18], his nitro gtt was stopped mom[Name (NI) 11711] and the patient developed chest pain. Prior to transfer, the patient was also plavix loaded, treated with lovenox, and started on an integrillin gtt. Of note, the patient was hospitalized at [Hospital1 18] in [2138-2-16] for hematemesis secondary to [Doctor First Name ]-[Doctor Last Name ] tear with a hct of 13 complicated by a [Doctor Last Name 7792] that was medically managed. Currently, the patient is chest pain free without anginal equivalent. He also denies any shortness of breath, diaphorersis, n/v, or pain radiation to his arms or jaw. * 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: PMH:Hypertension, hyperlipidemia, coronary artery disease s/p [Doctor Last Name 7792]/PTCA, Anemia, Hematemesis [2-15] [Doctor First Name ]-[Doctor Last Name ] tear/esophogeal varices-banding, ETOH abuse, Anxiety, h/o hepatic encephalopathy Social History: Alcohol Quit 2/[2138]. In past drank 1 pint/day Tobacco: Quit [2123], prior 3 ppd x 25 years. Occupation: retired Lives with wife, [Name (NI) ], in [Name (NI) 39869]. One daughter. Denies any IV, illicit, or herbal drug use. Family History: Mother died at 80yo of MI Physical Exam: Admission VS 97.9 119/79 77 18 97%2L nc Gen: Age appropriate male in NAD HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate or erythema. Neck supple without cervical LAD. CV: Nl S1+S2. ?S4. PMI at 5th intercostal space at midclavicular line. No precordial heave. JVP flat. Lungs: CTAB Abd: S/NT/ND +bs Ext: No c/c/e. Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Discharge VS 98.2 106/67 62 18 95%RA General: pleasant to speak with Chest: Lungs clear. Sternum stable, dry and intact. Slight erythema at distal pole COR: Regular Abdomen: soft and nontender with normoactive bowel sounds Extremities: trace edema Pertinent Results: [2138-12-28] 09:02PM CK(CPK)-47 [2138-12-28*] 09:02PM CK-MB-NotDone cTropnT-0.02 [2138-12-28] 03:52PM GLUCOSE-80 UREA N-15 CREAT-1.0 SODIUM-140 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14 [2138-12-28] 03:52PM WBC-6.7 RBC-3.64# HGB-11.7# HCT-32.0* MCV-88# MCH-32.0 MCHC-36.4* RDW-14.2 [2138-12-28] 03:52PM PLT COUNT-180 [2138-12-28] 03:52PM PT-14.7* PTT-145.4* INR(PT)-1.3* [Known lastname ],[Known firstname ] [Medical Record Number 39872] M 61 [2077-10-31] Cardiology Report C.CATH Study Date of [2138-12-29] BRIEF HISTORY: This is a 61 year old male witwh hypertension, hyperlipidemia, coronary artery disease with 2 prior NSTEMIs who developed rest angina. He was evaluated at an outside facility and found to have ST depressions laterally on ECG, without cardiac enzyme elevation. He was referred for cardiac catheterization for persisting chest pain. INDICATIONS FOR CATHETERIZATION: CAD. Rest angina. PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 5 French left [Last Name (un) 2699] catheter, advanced to the ascending aorta through a 5 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 5 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Intra-aortic balloon counterpulsation: was initiated with an introducer sheath using a Cardiac Assist 9 French 30cc wire guided catheter, inserted via the right femoral artery. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM RIGHT CORONARY 1) PROXIMAL RCA DISCRETE 100 ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD DISCRETE 90 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 80 8) DISTAL LAD DISCRETE 80 9) DIAGONAL-1 DIFFUSELY DISEASED 12) PROXIMAL CX NORMAL 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 15) OBTUSE MARGINAL-2 DISCRETE 100 TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 01 hour36 minutes. Arterial time = 01 hour36 minutes. Fluoro time = 3 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 100 ml, Indications - Renal Premedications: Versed 0.5mg iv Fentanyl 50mcg iv Integrilin 10.8 ml/hr iv Nitroglycerine 100mcg/min iv Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 0 units IV Other medication: Nitroglycerine 60mcg/min iv Atropine 0.5mg iv Nitroglycerine 0.4mg sl Cardiac Cath Supplies Used: 8.0MM ARROW, IABP ULTRA FIBEROPTIX CATHETER 40CC - ALLEGIANCE, CUSTOM STERILE PACK - [Company ], LEFT HEART KIT 5.0MM [Company ], MULTIPACK COMMENTS: 1. Selective coronary angiography of this right dominant system revealed severe 3 vessel coronary artery disease. The LMCA was not obstructed. The LAD had serial stenoses: 90% proximal, 80% mid and distal. D1 had diffuse disease. The LCX did not have obstructive disease, but OM1 had severe diffuse disease, and OM2 was occluded in the mid portion. The RCA was occluded proximally, with left to right collaterals to the PDA. 2. Limited resting hemodynamics revealed normal systemic arterial pressures with a central aortic pressure of 104/62 mm Hg. 3. A 8F 40cc intraaortic baloon pump was placed and positioned at the level of the carina, with good diastolic augmentation. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful placement of an intraaortic balloon pump. ATTENDING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. REFERRING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. CARDIOLOGY FELLOW: [Last Name (LF) ],[First Name3 (LF) ] H. ATTENDING STAFF: [Last Name (LF) ],[First Name3 (LF) ] M. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 39873]Portable TTE (Complete) Done [2138-12-29] at 3:43:38 PM FINAL Inpatient DOB: [2077-10-31] Age (years): 61 M Hgt (in): 70 BP (mm Hg): 95/53 Wgt (lb): 145 HR (bpm): 80 BSA (m2): 1.82 m2 Indication: Abnormal ECG. Chest pain. Coronary artery disease. ICD-9 Codes: 786.51, 414.8, 424.0 Test Information Date/Time: [2138-12-29] at 15:43 Interpret MD: [Name6 (MD) ] [Name8 (MD) 4082], MD Test Type: Portable TTE (Complete) Son[Name (NI) 930]: [First Name4 (NamePattern1) 1022] [Last Name (NamePattern1) ], RDCS Doppler: Full Doppler and color Doppler Test Location: West CCU Contrast: None Tech Quality: Adequate Tape #: 2008W058-1:06 Machine: Vivid [7-22] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.7 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Right Atrium - Four Chamber Length: 4.5 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.4 cm Left Ventricle - Fractional Shortening: 0.38 >= 0.29 Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 7 < 15 Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Arch: 3.0 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 256 ms 140-250 ms Findings Images obtained on IABP 1:1. LEFT ATRIUM: Normal LA and RA cavity sizes. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Normal aortic diameter at the sinus level. Focal calcifications in aortic root. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. Conclusions The left atrium and right atrium are normal in cavity size. 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. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. CLINICAL IMPLICATIONS: Based on [2137] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4083], MD, Interpreting physician [Last Name (NamePattern4) ] [2138-12-29] 16:34 Brief Hospital Course: Patient with known coronary artery disease, seen at outside hospital. He had persistent lateral ST depressions at OSH, although he has been cardiac biomarker negative, given ECG and persistent chest pain when off nitroglycerin gtt, concerning for ACS. He was plavix loaded and started on ASA, statin, beta blocker, integrillin gtt, lovenox, and nitro gtt and transferred to [Hospital1 18] for cardiac catheterization. The patient was taken to cardiac cath on [2138-12-29] which showed 3 vessel disease and serial LAD lesions. An intra-aortic balloon pump was placed and the patient was transferred to the CCU to await cardiothoracic surgery. He was initially chest pain free after the cath. He was taken to CT surgery the morning of [2138-12-30] where he had coronary artery bypass grafting x3 with left internal mammary to left anterior deceding artery, saphenous vein graft to obtuse marginal and saphenous vein graft to posterior diagonal artery. Please see OR report for details. He tolerated the operation well and was transferred to the intensive care unit in stable condition. He remained hemodynamically stable in the immediate post-op period was neurologically intact and extubated within hours of arrival to ICU. He continued to progress and his Intra aortic ballon pump was removed on POD1. On POD2 he was transferred to the stepdown floor for continued care and monitoring. He experienced some paroxysmal atrial fibrillation and was started on Coumadin. His medications were titrated, activity progressed and on POD 5 he was discharged home with visiting nurses. Medications on Admission: Aspirin 325 mg daily Metoprolol 50 mg po bid Ursodiol 0.5 mg [Hospital1 ] simvastatin 20 mg daily lisinopril 5 mg daily Omeprazole 20 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s)* Refills:0 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days. Disp:24 Capsule(s) Refills:0 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:0 8. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: Take 7.5 mg [1-4] and [1-5]. Dr[Name (NI) 9654] office will call with dose to take after those days. Disp:75 Tablet(s) Refills:0 9. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day: please take 7.5 mg [1-4] and [1-5]. Dr[Name (NI) 9654] office will call with dose to take after. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: s/p CABGx3(LIMA-LAD, SVG-OM, SVG-PDA)[12-30] s/p cardiac catheterization and IABP insertion [12-29] PMH:Hypertension, hyperlipidemia, coronary artery disease s/p [Month/Year (2) 7792]/PTCA, Anemia, Hematemesis [2-15] [Doctor First Name ]-[Doctor Last Name ] tear/esophogeal varices-banding, ETOH abuse, Anxiety, h/o hepatic encephalopathy Discharge Condition: Patient was discharged in stable condition. Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. No powder creams or lotions on incision site. Take all medications as prescribed. Call for any fever, redness or drainage from wound sites. Followup Instructions: [Hospital 409] clinic in 2 weeks Dr [Last Name (STitle) ] in 4 weeks Dr [Last Name (STitle) 7047] 1-2 weeks for cardiology follow up. He will also follow your INR. VNA will draw labs with results to his office, and they will call with dose. Dr [Last Name (STitle) 12832] in [2-16] weeks Completed by:[2139-1-4]	[ "41401", "9971", "42731", "4019", "2724", "V4582", "412" ]
Admission Date: [2120-6-12] Discharge Date: [2120-7-1] Date of Birth: [2064-4-27] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11415] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: [2120-6-12]: Insertion tibial traction pin left proximal tibia. [2120-6-13]: Left gamma nail [2120-6-19]: Total vertebrectomy at T12, Fusion T11-L1, Anterior cage placement at T12, Segmental instrumentation from T11-L1, Autograft [2120-6-20]: Posterior T9-L2 fusion, Multiple thoracic and lumbar laminotomies, Segmental instrumentation T9-L2, Autograft, Epidural catheter placement. [2120-6-24]: IVC filter placement History of Present Illness: The patient is a gentleman who sustained a fall from a roof and was seen at an outside hospital where he was found to have an intertrochanteric fracture in addition to a femoral shaft fracture. He has been transferred to our care and is undergoing trauma work up. Past Medical History: HTN Social History: spanish speaking Family History: NC Physical Exam: Upon discharge: AVSS NAD A+O CTA b/l RRR S/NT/ND+BS spine: incisions c/d/i LLE: incision c/d/i +[Last Name (un) 938]/FHL/AT SILT brisk cap refill Pertinent Results: [2120-6-12] 11:17PM TYPE-ART TEMP-37.2 TIDAL VOL-500 PEEP-5 O2-50 PO2-169* PCO2-54* PH-7.30* TOTAL CO2-28 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED [2120-6-12] 11:17PM LACTATE-3.1* [2120-6-12] 11:17PM O2 SAT-98 [2120-6-12] 03:12PM GLUCOSE-265* LACTATE-2.7* NA+-142 K+-4.7 CL--101 TCO2-28 [2120-6-12] 03:00PM UREA N-11 CREAT-1.2 [2120-6-12] 03:00PM AMYLASE-38 [2120-6-12] 03:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2120-6-12] 03:00PM WBC-18.3* RBC-5.11 HGB-15.3 HCT-44.0 MCV-86 MCH-30.0 MCHC-34.8 RDW-12.7 [2120-6-12] 03:00PM PLT COUNT-237 [2120-6-12] 03:00PM PT-12.3 PTT-20.6* INR(PT)-1.1 [2120-6-12] 03:00PM FIBRINOGE-286 PELVIS WITH JUDET VIEWS [2120-6-12] 7:40 PM PELVIS WITH JUDET VIEWS Reason: evaluate for fx [Hospital 93] MEDICAL CONDITION: 56 M s/p fall from 15 feet REASON FOR THIS EXAMINATION: evaluate for fx EXAM ORDER: Pelvis. HISTORY: Status post fall. PELVIS: Three views including Judet views show mildly displaced left intertrochanteric fracture. No other fracture is seen. Mild osteoarthritic changes are seen in both hips. The sacroiliac joints are unremarkable. The symphysis pubis appears normal. IMPRESSION: Left intertrochanteric fracture. FOOT AP,LAT & OBL LEFT [2120-6-12] 7:40 PM FEMUR (AP & LAT) LEFT; TIB/FIB (AP & LAT) LEFT Reason: evaluate for fx [Hospital 93] MEDICAL CONDITION: 56 year old man s/p fall REASON FOR THIS EXAMINATION: evaluate for fx EXAM ORDER: Femur and tibia and fibula. HISTORY: Status post fall. LEFT FEMUR: AP and lateral views show minimally displaced left intertrochanteric fracture. There is also comminuted and displaced distal femoral shaft fracture. The distal fragment shows one shaft-width posterior displacement with 1 cm overriding. The left tibia and fibula are intact. The external fixator hardware partially obscures the tibia and fibula. A note is made of a linear ossific density at the posterior aspect of the lateral malleolus, which may represent avulsion injury. Additional ankle views can be obtained for further evaluation. [Hospital 93] MEDICAL CONDITION: 56 year old man with fall from height REASON FOR THIS EXAMINATION: r/o fx CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 56-year-old man status post fall, from height. T-spine CT without contrast with multiplanar reformation. No comparison. FINDINGS: There is extensively communicated burst fracture of the T12 vertebral body, with a large retropulsion fragment in the spinal canal, compressing the spinal cord with marked narrowing of the spinal channel. There is comminuted fracture of the spinous process and lamina of T12. The fracture lines of the T12 vertibral body extends to both superior and inferior endplates. No definite fracture is identified at the other levels. There is calcification of ligamentum flavum. In the visualized portion of the lung bases, note is made of bilateral pleural effusion with atelectasis. IMPRESSION: 1. Burst fracture of T12 with large retropulsion fragment narrowing spinal canal and compressing spinal cord at the level. Comminuted fracture of the spinous process and lamina of T12. 2. Bilateral pleural effusion and atelectasis. Brief Hospital Course: The patient was admitted to the trauma service on [2120-6-12]. A tibial traction pin was placed in his left tibia in the emergency room to stabilize his fracture. He was taken to the operating room on [2120-6-13] for a left gamma nail. He tolerated the procedure well. He remained intubated and was taken to the recovery room in stable condition. Once anesthesia was comfortable with his respiratory status he was extubated. While in the PACU he was noted by anesthesia and nursing to have seizure like behavior. Neurology was consulted and he was given a loading dose of dilantin. A repeat head CT and an EEG were done, both of which were essentially normal. The patient was transferred to the floor stable. He was transfused PRBC's for post operative anemia. On [2120-6-19] he was taken to the operating room with Dr. [Last Name (STitle) 363] for anterior fusion. He returned to the operating room on [2120-6-20] with Dr. [Last Name (STitle) 363] for posterior fusion. He experienced some distention post-operatively and an NG tube was placed with minimal relief of distention. Repeated KUBs were negative fr obstruction. His subsequent hospital course was complicated by a eft pleural effusion with chest tube placement, s/p removal on [6-22]. A CXR will need to be repeated within the next week to monitor resolution of the effusion. The pt was also diagnosed with a UTI and for which he was treated with Ciprofloxacin for 7 days. He also was found to have urinary retention and was started on Tamsulosin. A voiding trial should be attempted. He then experience an episode of CP but trop was negative and no EKG were present. Medical management was pursued of the CP and Metoprolol and Aspirin were started as well as Lisinopril for better BP control. Lisinopril and Metorpolol were titrated as tolerated. The pt'c course was also complicated by hyponatremia. Urine and serum osm were consistent with SIADH. This was attributed to posttraumatic SIADH with hyponatremia, but further w/u needs to be pursued if the problem [Name (NI) 68118]. The pt was fluid restricted and serum sodium slowly improved. Fluid restriction needs to be continued and normalization of sodium. The pt was followed for his seizure disorder by neurology. Dilantin is being tapered off as the seizures were thought to be posttraumatic only. The pt's fluid overloaded was attributed to poor nutrition and hyponatremia. The pt's nutrition improved as his clinical status improved and the pt was autodiuresing. The pt's anemia postoperative remained stable. DVT prophylaxis was not given, due to high risk of bleeding. The pt had an IVC filter placed postoperatively for prevention of PE. Pain was adequately managed on current regimen. Pt was maintained on sliding scale for hyperglycemia. Medications on Admission: atenolol 25mg po daily zyrtec prn Discharge Disposition: Extended Care Facility: St [Hospital ] Healthcare Center - [Hospital1 189] Discharge Diagnosis: L intertrochanteric fracture L distal femur fracture T12 burst fracture Seizure Discharge Condition: Stable Discharge Instructions: Please keep incisions clean and dry. Dry sterile dressings daily as needed. If you notice any increased pain, swelling, drainage, temperature >101.4, shortness of breathe, or room. Take all medications as prescribed. Please follow up as below. Call with any questions. Physical Therapy: PWB on LLE, otherwise WBAT Treatments Frequency: Dry sterile dressing daily as needed . Site: MIDLINE LUMBAR & RIGHT OF LUMBAR (INFERIOR) Description: INCISIONAL WOUND INTACT WITH STERI-STRIPS, NO DRAINAGE OR SX OF INFECTION Care: COVER WITH DSD, CHANGE DAILY OR PRN.KEEP CLEAN AND DRY. . Site: LEFT TRUNK Description: INCISIONAL WOUND INTACT WITH STERI-STRIPS, NO DRAINAGE OR SX OF INFECTION Care: COVER WITH DSD, CHANGE DAILY OR PRN.KEEP CLEAN AND DRY. . Physical therapy as per instructions Continued titration of BP meds for optimal control Dilantin titration as instructed Continue fluid restriction for hyponatremia Followup Instructions: Please follow up with your PCP two weeks after discharge from the rehab center. . Please follow up with Dr. [Last Name (STitle) 1005] in 2 weeks. Call [Telephone/Fax (1) ] for an appointment. . Please follow up with Dr. [Last Name (STitle) 363] in 2 weeks. Call [Telephone/Fax (1) ] for an appointment. . Please follow up with Dr. [First Name (STitle) ] in [1-1] months. Call [Telephone/Fax (1) 541] for an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417]	[ "5119", "5990", "2851", "4019" ]
Admission Date: [2195-5-24] Discharge Date: [2195-5-26] Date of Birth: [2123-10-9] Sex: M Service: Neurology IDENTIFYING DATA: A 71-year-old ambidextrous male transferred the Intensive Care Unit with a right basal ganglia and thalamic hemorrhage. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 13448] is a 71-year-old ambidextrous, though mainly left handed, male who was in his usual state of health until the morning of [5-24]. He awoke and was doing some work at his desk when he leaned over to get some papers and fell to the ground secondary to left sided weakness. He could not do anything with the left arm at all and had some movement of the left leg. He could not bear weight on the left leg. He lay on the ground for a few hours until his son came home and called 911. He denied any headaches, nausea, vomiting, numbness or tingling. He stated that he thought he had double vision intermittently, but could not be more specific. The double image was of objects seen side to side, but he could not say if any particular direction of gaze made this worse. He was seen in the Emergency Department by the neurology and stroke service where his exam was notable for a right gaze preference, left homonymous hemianopia versus left hemi-spacial visual neglect, a left facial droop, flaccid left arm with strength in all muscle groups except for minimal movement of the fingers and 4 to 4+/5 strength in left hip flexion and hamstrings. There was minimal left foot dorsiflexion. There was extinction to double .............. stimulation on the left. An MRI revealed a 2 cm right sided basal ganglia bleed with some extension to the thalamus. His blood pressure initially was 190/110, so he was admitted to the Intensive Care Unit for intravenous labetalol and frequent neurologic checks. He did well over the first night with rapidly improved strength in the left arm. He no longer had any complaints of diplopia. He was therefore transferred to the neurology floor for further care. PAST MEDICAL HISTORY: 1. Hypertension for at least five to six years, but he stopped taking Norvasc six months ago secondary to presyncopal feeling. 2. Known right ICA stenosis 3. Status post left carotid endarterectomy - unclear if this was symptomatic or not. Performed by Dr. [Last Name (STitle) 1476] in [2189]. 4. Status post coronary artery bypass graft in [2191] 5. Possible hypercholesterolemia MEDICATIONS: No medications at home. Aspirin and Norvasc prescribed in the past. Labetalol drip in the MICU transitioned to po Lopressor 25 mg tid. ALLERGIES: No known drug allergies. SOCIAL HISTORY: More than 50 pack year smoker, drinks one to two cans of beer per day, works as a doorman a few days per week and lives with his wife. [Name (NI) ] has seven children and four grandchildren. PHYSICAL EXAM: VITAL SIGNS: Blood pressure 130/80, heart rate 70s, temperature 98??????. HEAD, EARS, EYES, NOSE AND THROAT: Head was normocephalic, atraumatic. NECK: Supple without bruits. CARDIOVASCULAR: Regular rate and rhythm with no murmurs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Warm without cyanosis, clubbing or edema. NEUROLOGIC: He was alert, oriented and attentive. He was able to do the months of the year backwards without difficulty. Language was fluent with intact naming, [Location (un) 1131], repetition and comprehension. Praxis was normal and there was no right left confusion. Cranial nerve exam: The right pupil was 1.5 mm, left 2 mm. Both were reactive to light. Visual fields were full, though he explores the left hemi-space less and requires encouragement to look to the left. Extraocular movements revealed some limitation of vertical gaze with both up and down gaze. There was some improvement to down gaze with vestibular ocular reflex (tilting head backwards). Smooth pursuit was interrupted by saccades when pursuing to the right. Saccadic eye movements were hypometric to the left. There is a flattened nasolabial fold on the left. Sensation was intact in the face. Tongue and palate movements were normal. Sternocleidomastoid and trapezius were full. Bulk and tone were full. There was a left pronator drift and isolated asterixis of the left hand, as well as occasional myoclonic movements of the left hand. Strength was [3-12] in the left deltoid, 5-/5 triceps, 4+/5 finger extensors and hand intrinsics. Strength was full in the left lower extremity and muscle groups on the right were full. Reflexes were 3+ on the left, 2+ on the right in both the arms and legs. There was a withdrawal response to plantar stimulation with the left foot, but right plantar reflex was flexor. Pinprick was mildly decreased in a patchy distribution over the left arm and leg. Joint position sense was intact throughout. Vibration was decreased to the knees bilaterally. Rapid alternating movements and fine finger movements were slow on the left. There was some dysmetria out of proportion to weakness with finger to nose testing on the left arm. MRI revealed acute hemorrhage in the right basal ganglia extending into the thalamus. There was changes of small vessel disease. There was absence of flow signal in the right intracranial internal carotid artery with markedly diminished flow signal within the right middle cerebral and anterior cerebral arteries. LABS: White blood count 8, hematocrit 34, BUN 21, creatinine 1.9, albumin 3.3. Liver function tests were within normal limits. HOSPITAL COURSE: In summary, Mr. [Known lastname 13448] is a 71-year-old man with untreated hypertension over the last six months. He presented with an acute right basal ganglia bleed with some extension to the thalamus. This location favored a hypertensive etiology. His symptoms rapidly improved as documented by his initial exam (stated in the history of present illness) compared to his exam the next day upon transfer to the neurology floor. He remained stable with blood pressures in the range of 130 to 160. His goal blood pressure at this point should now be between 120 to 150 mmHg. Further drops of blood pressure acutely would not be prudent, particularly in the setting of pre-existing right internal carotid artery occlusion. In roughly two to three weeks, the patient should be restarted on aspirin. He was seen by physical therapy who felt that he was an excellent rehabilitation candidate. Therefore, accommodations will b.e made to transfer the patient to an acute rehabilitation setting. DISCHARGE MEDICATIONS: 1. Thiamine 100 mg po qd 2. Folate 1 gm po qd 3. Lopressor 25 mg po tid, to hold for a systolic blood pressure less than 140 4. Zantac 150 mg po bid 5. Colace 100 mg po bid 6. Tylenol prn DISCHARGE DIAGNOSES: 1. Right basal ganglia 2. Thalamic presumed hypertensive hemorrhage 3. Left sided residual ataxic hemiparesis Please note that arrangements will need to be made for new outpatient primary care upon discharge from the rehabilitation setting. [Last Name (LF) ],[First Name3 (LF) ] J.S. 13-244 Dictated By:[Name8 (MD) 98668] MEDQUIST36 D: [2195-5-26] 13:07 T: [2195-5-26] 14:25 JOB#: [Job Number ]	[ "4019", "41401", "3051", "V4581" ]
Admission Date: [2145-12-27] Discharge Date: [2146-1-14] Date of Birth: [2093-12-19] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 2969] Chief Complaint: Esophageal cancer with pelvic mass. Major Surgical or Invasive Procedure: [2146-1-11]: Direct laryngoscopy, Gelfoam injection of right vocal cord and bilateral superior laryngeal nerve block. [2145-12-31]: Flexible bronchoscopy with therapeutic aspiration. [2145-12-27]: Exploratory laparotomy, pelvic washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy. [2145-12-27]: EGD, transthoracic esophagogastrectomy ([Last Name (un) 62523]) with cervical anastomosis. Total abdominal hysterectomy. History of Present Illness: Mrs. [Known lastname 3501] is a 51-year-old female who was found to have an advanced stage T3, N1 esophageal cancer. The patient underwent adjuvant chemoradiation treatment with 5FU and Cisplatin for her squamous cell cancer of the esophagus, and a repeat breast scan showed inadequate response to preoperative chemoradiation. The patient also had an impressive pelvic mass which was thought to be an uterine fibroid, and a combined approach for her hysterectomy and esophagectomy was scheduled for the patient who was recently seen by Dr. [Last Name (STitle) ] and Dr. [First Name (STitle) 1022] from OB/GYN. Past Medical History: Esophageal cancer with pelvic mass. Pulmonary Embolism Right Vocal Cord paralysis and ineffective cough. Right hydronephrosis s/p stent placement [2145-8-31] and removal [2146-1-12] Social History: Married, 2 daughters, lives in [Name (NI) 1456]. Works for [Doctor First Name ] book distributor. HABITS: Rare etoh. Smoked 1 ppd x 16 years, quit [2126]. Family History: FH: [Name (NI) ] aunt with "abdominal cancer". Father died of MI age 50, and mother died of MS complications at age 51 Physical Exam: general: frail appearing feamle in NAD. HEENT: voice quality is raspy, cough is weak d/t vocal cord paralysis which has now been medialized. Neck incision healing well. Chest: course breath sounds. weak cough. COR: RRR S1, S2 Abd; abd incision healing. j-tube site w/ slight area of erythema around tube. Extrem: no edema Skin: stage 2 on coccyx neuro: weepy and emotionally fragile after prolonged hosp stay. Pertinent Results: CHEST TWO VIEWS [2146-1-8] CLINICAL INFORMATION: Chest tube removal. FINDINGS: A left-sided chest tube has been removed. There is a tiny residual left apical pneumothorax. There is a patchy opacity in the lingula and a small residual left pleural effusion. There is a small left lower lobe consolidation. There is a small right pleural effusion with atelectasis at the right base. A right large bore catheter terminates in the superior vena cava. Two access needles are present. There is a right middle lobe infiltrate, unchanged from prior study. Heart is top normal in size. Mediastinum is within normal limits. There is a faint right upper lobe infiltrate as well. None of these have changed since prior study. IMPRESSION: 1. Tiny residual left-sided pneumothorax status post chest tube removal. 2. Multifocal patchy airspace opacities, unchanged since prior study. Brief Hospital Course: Pt was admitted and taken to the OR for EGD, Esophagectomy, hysterectomy and liver nodule resection on [2145-12-17]. An epidural was placed at the time of surgery and bilteral chest tubes to suction and an anastomotic JP in the neck. Pt remained intubated and was admitted to the SICU for ongoing management and ventilator support. POD#0 HCT 23.6 w/ EBL in OR 800cc- rec'd PRBC. On peri-op levo and flagyl. POD#1 remained intubated w/ shallow rapid breathing, and low TV's. Required aggressive pul tiolet. required volume resusitation for low BP and low U/O. HR remains 120's despite volume resusitation- started on lopressor. trophic tube feeds were initiated via J-tube. POD#2 extubated w/ weak cough, voice and tacypnea, w/ shallow rapid breathing. Required aggressive pul tiolet. Chest tubes to water seal. POD#3 remains tacypneic, tacycardic. on epidural but having breakthru pain. Toradol added. remains on lopressor. Desaturation to 80%. Stat CXR w/ PTX w/ chest tubes on water seal. Placed back to sxn w/ resolution of PTx. O2 sats remained low. CTA done which revealed bilat PE. started on IV heparin. POD#4 bronch for pul tiolet- copious secretions in left lung. Evaluated by ENT-right vocal cord immobile; left cord function intact. chest tubes placed to water seal. POD#5 HCT 24- rec'd PRBC. right chest tube placed to water seal and then d/c'd w/ stable CXR POD#6 tube feeds increasing to goal. epidural d/c'd. Pain controled w/ PCA. Left chest tube d/c'd.- CXR w/ large PTX- chest tube replaced and placed to sxn. Swallow eval done w/ evidence of aspiration ? d/t cord immobility vs overall weakness. strict NPO until video swallow can be done. POD#8 No evidence of bowel function. Remains on IV heparin for PE. chest tube to water seal w/ stable CXR. [Name (NI) 1094] PTT failing to be therapeutic on large amounts of IV heaprin. thought to have possible Anti 3 deficiency- given FFP w/ approp increase in PTT and decrease in IV heparin requirement. POD#9 GU evaulated patient re; urethral stents which were placed for hydronephrosis during last admission. presently urien clean, no flank pain. Per GU stents to removed as out pt. Pt transferred to floor from ICU. POD#10 tacycardia persists 150's- lopressor increased w/ improved HR. TF to goal. Chest tube clamping trial. urine culture + for UTI- levaquin/vanco started. POD#11 chest CXR w/o PTX- chest tube d/c'd. POD#12 chest tube d/c'd w/ stable CXR. POD#13 c/o abd pain, nausea, emesis. Hypoactive bowel sounds. Pt refusing laxatives and enemas. vanco d/c'd and remained on levaquin for UTI. POD#14 KUB -full of stool. Tube feeds d/c'd. Iv hydration. Given goltely via J-tube and soap suds enemas w/ good results after 12 hrs. ENT injected right vocal cord for medialization. Heparin gtt held for procedure and for 24 hrs post procedure. Notified by nursing of stage II decub on buttocks. POD#15 PT recommended long term acute care rehab upon d/c. Right urethral stent d/c'd by urology. POD#16 Heparin gtt resumed w/ therapeutic PTT. POD17 evaulated by speech and swallow and passed for pureed diet w/ thin liquids and meds crushed. No evidence of aspiration. POD#18 heaprin gtt d/c'd. started on lovenox 50 [Hospital1 ] and coumadin 3mg. Medications on Admission: hydromorphone, lorazepam, nystatin, Zofran, Protonix, Compazine, docusate sodium, acetaminophen, Senokot Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Hospital1 ]: 5-10 MLs PO Q6H (every 6 hours) as needed. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: One (1) Inhalation Q4H (every 4 hours) as needed. 3. Lorazepam 2 mg/mL Syringe [Hospital1 ]: .5-1 mg Injection Q8H (every 8 hours) as needed for agitation. 4. Bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal DAILY (Daily) as needed. 5. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours). 6. Acetylcysteine 20 % (200 mg/mL) Solution [Hospital1 ]: 3-5 MLs Miscellaneous Q6H (every 6 hours). 7. Magnesium Hydroxide 400 mg/5 mL Suspension [Hospital1 ]: Thirty (30) ML PO BID (2 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 9. Ondansetron HCl (PF) 4 mg/2 mL Solution [Last Name (STitle) ]: Four (4) mgs Injection Q8H (every 8 hours) as needed. 10. port a cath Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 11. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Ten (10) mls PO TID (3 times a day). 12. port a cath Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Indwelling Port (e.g. Portacath), non-heparin dependent: Flush with 10 mL Normal Saline daily, PRN, and when de-accessing, per lumen. 13. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 14. Levofloxacin in D5W 750 mg/150 mL Piggyback [Last Name (STitle) ]: 750mg Intravenous Q24H (every 24 hours) for 6 days. 15. Warfarin 3 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO Once Daily at 4 PM: monitor INR. 16. Ascorbic Acid 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) for 14 days: via j-tube in elixir. 17. Zinc Sulfate 220 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO DAILY (Daily) for 14 days: via j-tube elixir. 18. Magnesium Hydroxide 400 mg/5 mL Suspension [Last Name (STitle) ]: Thirty (30) ML PO BID (2 times a day). 19. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Ten (10) mls PO TID (3 times a day) as needed. 20. regular insulin per sliding scale 21. Enoxaparin 60 mg/0.6 mL Syringe [Last Name (STitle) ]: Fifty (50) mg Subcutaneous Q12H (every 12 hours): stop when INR therapeutic. Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: Esophageal cancer with pelvic mass. Pulmonary Embolism Right Vocal Cord paralysis and ineffective cough. Right hydronephrosis s/p R & L stent placement [2145-8-31] and R removed [2146-1-12], L to be removed next week or as outpatient Discharge Condition: Deconditioned Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 4741] if experience: -Fever > 101 or chills, increased cough, or chest pain -Develop nausea, vomiting, difficulty swallowing, abdominal pain -Incision develops drainaged, increased tenderness or redness -You may shower. No tub bathing or swimming for 6 weeks -Head of the bed should be 30 degress at all times -Humidified air -pureed foods and thin liquids by mouth Followup Instructions: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 7613], MD Phone:[Telephone/Fax (1) 5777] Date/Time:[2146-1-27] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD Phone:[0-0-] Date/Time:[2146-2-1] 11:00 on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center, [Location (un) 24]. Report to the [Location (un) 861] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Follow-up with Dr. [First Name (STitle) ] in clinic [Telephone/Fax (1) 41] call for an appointment Coumadin follow-up with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 79694] [Telephone/Fax (1) 79695]. Please call prior discharge from rehab for an appointment for their coumadin clinic. Follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3748] Urology [Telephone/Fax (1) 3752] for Left renal stent removal Completed by:[2146-1-18]	[ "5990", "2851" ]
Admission Date: [2114-3-10] Discharge Date: [2114-3-16] Date of Birth: [2083-3-2] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 64] Chief Complaint: Right leg pain Major Surgical or Invasive Procedure: ORIF of Right distal femur fracture History of Present Illness: 31-year-old man shot with an apparent handgun earlier in the day. He has had a neurologic exam and shows severe compromise from the level of the injury down as is annotated in the notes. His thigh was quite swollen. X-rays showed supracondylar fracture with no evidence of intra- articular fracture, but quite distal. Past Medical History: Denies Social History: ETOH-occasional TOB-+ IVDA-denies Family History: NC Physical Exam: Gen-alert/oriented,NAD VS-afebrile/VSS CV-RRR Lungs-CTA bilat Abd-soft NT/ND Ext-RLE;incision clean/dry/intact ant/post wound without purulent discharge. No [Last Name (un) 938]/FHL/At at baseline since injury. decreased sensation over deep/superficial and tibial Nerves. +DPP Pertinent Results: [2114-3-10] 11:17PM WBC-17.4# RBC-3.83 HGB-10.2* HCT-29.6* MCV-77# MCH-26.8 MCHC-34.7 RDW-22.8* [2114-3-10] 11:17PM GLUCOSE-161* UREA N-7 CREAT-0.8 SODIUM-139 POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-23 ANION GAP-10 Brief Hospital Course: Patient was admitted on [2114-3-10] from gunshot wound to right leg. Patient was evaluated by the orthopedic service and found to have right distal femur fracture. Patient was taken to OR on [2114-3-10] for I&D and ORIF. Surgery went without complications, please see op-note. Post-op patient was transferred from post-op holding area to orthopedic floor without complications. Patients HCT did drop to 20 on [2114-3-12] patient was then given 2 units PRBC. HCT had responded appropriately. Patient continued to progress. Pain remained controlled. Exam of lower extremity had remained unchanged, decreased ROM to [Last Name (un) 938]/FHL/AT as well as decreased sensation. Patient continued to progress appropriately. Pain remained controlled. Patient remained afebrile/VSS. Patient was discharged in stable condition. Medications on Admission: denies Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. 2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 3 weeks. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 3 weeks. Disp:21 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Right distal femur fracture. Discharge Condition: stable Discharge Instructions: Please cont with non-weight bearing right leg. [Doctor Last Name ] brace at all times. Oral pain medication as needed. Lovenox for anti-coagulation x 3weeks. Cont with physical therapy. please call/return if any fevers, increased dishcarge from incision, or trouble breathing. Physical Therapy: Activity: Out of bed w/ assist Right lower extremity: Non weight bearing [Doctor Last Name ] brace: At all times Knee immobilizer should be pulled all the way up to the groin. Rom as tolerated with physical therapy. Treatments Frequency: Dry sterile dressing once daily. Suture to be removed at follow-up appt. Xeroform to anterior and posterior open wounds. Please do not soak or scrub incision. Please pat incision dry after getting wet. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 1005] 2weeks, please call for appt. [Telephone/Fax (1) 1228] Follow-up with Dr.[Last Name (STitle) 5385] as needed, please call for appt. [Telephone/Fax (1) 28541] Completed by:[2114-3-16]	[ "2851" ]
Admission Date: [2183-9-13] Discharge Date: [2183-9-18] Date of Birth: [2103-6-2] Sex: F Service: MEDICINE Allergies: Shellfish Derived Attending:[First Name3 (LF) 425] Chief Complaint: fall Major Surgical or Invasive Procedure: [9-13]: trans-venous pacing [2183-9-16]: Dual chamber [Company 1543] Pacemaker Placement History of Present Illness: 80 yo female with history of CAD s/p 4 vessel CABG, DM2, and HLD who presented to an OSH s/p fall and found to have a new SAH and meningeal bleed. Patient lives with her daughter who heard a loud thump early on morning of admission and found her mother fully dressed in the bathroom lying on the floor with her face turned toward the bathtub. She was initally disoriented but was able to get her mother to the bed before she was taken to the hospital. Patient does not remember the incident only afterwards being on the bed. After the fall she had a headache, she was nauseated, and was noted to have increasing confusion throughout the day. She was not having any changes in vision, sensation, dysarthria, dysphagia, or weakness upon admission. Patient was brought to an outside hospital and found to have subarachnoid hemorrhage, transferred to [Hospital1 18] for further managment. Patient appeared somewhat confused on admission, endorsed to a little dizziness, with improvement in nausea and headache symptoms. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: 4 vessel CABG at [Hospital3 2358] -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: DM type II Appendectomy Social History: Lives with daughter. [Name (NI) ] smoking, EtOH, ilicit drug use Family History: heart disease Physical Exam: On Admission to T-SICU: O: T:97 BP: 97/42 HR: 50 R 14 O2Sats 100 Gen: WD/WN, comfortable, NAD. HEENT: Pupils:R eye surgical pupil 3->2. Left eye 2-1.5 cm Neck: Supple. Nontender Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert X 3, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [1-5] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-7] throughout. No pronator drift Sensation: Intact to light touch and propioception bilaterally. Decreased vibration in lower extremities Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes upgoing BL Coordination: normal on finger-nose-finger PHYSICAL EXAM ON ADMISSION TO CCU: VS: T: 99.2, BP: 168/72, HR: 67, RR: 22, O2 sats 98% on NC GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. right pupil 2mm ovoid, larger than L, L reactive to light, EOMI. NECK: Supple with JVP flat. CARDIAC: Normal rate, regular rhythm. 2/6 SEM at R+LUSB, LLSB and apex. No thrills, lifts. 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. EXTREMITIES: No edema, no clubbing, 2+ pulses SKIN: No lesions, warm dry. NEURO: Cranial nerves [2-14] intact grossly with the exception of her right pupil (may be due to cataract surgery). Otherwise no focal deficits. 5/5 strength, normal sensation. Gait not assessed. PULSES: Right: Carotid 2+ Radial 2+ Left: Carotid 2+ Radial 2+ . Physical Exam on Discharge: VS: 99.4 afebrile overnight, 132/50 (127-150/52-64) 62 (59-67) 18 99% RA I/O; 8 hr: 0/300ml 24 hr: 680/2500 GENERAL: Elderly woman in NAD. Having clear in depth conversation with me this morning, alert and oriented. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. NECK: Supple with JVP flat. CARDIAC: Normal rate, regular rhythm. [3-8] early peaking SEM at R+LUSB, radiates to carotids and apex. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No edema, no clubbing, 2+ pulses b/l NEURO: Cranial nerves [2-14] intact with the exception of her right pupil (larger than left). Otherwise no focal deficits. 5/5 strength, normal sensation. Able to mobilize to commode. Pertinent Results: [9-13] CT Head: IMPRESSION: 1. Allowing for interscan differences, there is no significant short- interval change. 2. Known subarachnoid hemorrhage in the right Sylvian fissure and suprasellar cistern. 3. No significant mass effect, and no evidence of developing hydrocephalus. 4. Sell-circumscribed right frontovertex extra-axial hematoma. . CTA HEAD W&W/O C & RECONS Study Date of [2183-9-13] 7:01 PM IMPRESSION: 1. No significant change in the overall amount or distribution of the acute subarachnoid hemorrhage, in an "aneurysmal" distribution. 2. This likely relates to acute rupture of a 5.0 x 3.5-mm saccular aneurysm at the bifurcation of the right MCA, with no other aneurysm seen to involve the vessels of the circle of [Location (un) 431] or their major branches. 3. Well-defined extraaxial hematoma at the right frontal vertex, as well as a possible component of subdural hemorrhage along the floor of the right middle cranial fossa, likely related to the reported history of recent fall, which may in turn relate to the aneurysmal hemorrhage. 4. No finding to specifically suggest acute vasospasm or territorial infarction. . CT HEAD W/O CONTRAST Study Date of [2183-9-13] 11:56 PM IMPRESSION: 1. Allowing for interscan differences, there is no significant short- interval change. 2. Known subarachnoid hemorrhage in the right Sylvian fissure and suprasellar cistern. 3. No significant mass effect, and no evidence of developing hydrocephalus. 4. Sell-circumscribed right frontovertex extra-axial hematoma. . CT Torso W/CONTRAST Study Date of [2183-9-14] 12:00 AM IMPRESSION: 1. No acute traumatic injury. 2. Moderate degenerative changes in the thoracolumbar spine, most prominent in the lower lumbar region. 3. Moderate cardiomegaly with moderate coronary artery calcification. The patient is status post open chest surgery. 4. Tiny gallbladder sludge without acute cholecystitis. . Portable TTE (Complete) Done [2183-9-15] at 11:46:58 AM Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CT HEAD W/O CONTRAST Study Date of [2183-9-15] 12:57 AM FINDINGS: Redemonstrated within the right frontal vertex is a hyperattenuating well-marginated 2.4 cm extra-axial hematoma that is stable in both size and appearance since the prior examination. In addition, a moderate amount of subarachnoid hemorrhage seen layering in the right sylvian fissure extending to the suprasellar cistern and along the temporal cortices is unchanged in extent. There is no new focus of hemorrhage. Ventricles are unchanged in size and configuration, with no evidence of intraventricular hemorrhage extension or worsening or hydrocephalus. The [Doctor Last Name 352]-white matter differentiation is preserved. Redemonstrated are prominent bifrontal extra-axial CSF spaces. There is no acute fracture. The visualized portions of the paranasal sinuses and mastoid air cells remain well aerated. IMPRESSION: 1. Allowing for differences in technique, no interval change since examination from [2183-9-13] of a moderate amount of subarachnoid hemorrhage layering within the right sylvian fissure, along both temporal cortices and the suprasellar cistern. 2. Stable well-circumscribed right frontal vertex extra-axial hematoma. . EEG [2183-9-15] FINDINGS: ROUTINE SAMPLING: The recording began at 8 in the morning on the 13th and showed a very low voltage record bilaterally. At 8:55 that morning there emerged some rhythmic 3 Hz slowing primarily in the right parietal area, waxing and [Doctor Last Name 688] over the next minute or so. By video, the patient had rhythmic shaking of the left arm with some semi-voluntary appearing movement of the trunk and right side, as well. After the first 20 seconds or so, the left arm movement appeared to be more of a jerking. Electrographically and clinically, the seizure did not appear to spread beyond that area. The same seizure pattern recurred at 9:21. This episode lasted over a minute and had similar clinical manifestations. The record remained of low voltage with mostly faster frequencies for the rest of the recording, with background voltages remaining stable and symmetric. Relative frequency analysis showed more delta activity relative to [Name2 (NI) 14595] activity late in the morning and again for the hour just before the end of the study, but these activities remained quite symmetric. SPIKE DETECTION PROGRAMS: Showed no clear epileptiform discharges. SEIZURE DETECTION PROGRAMS: Showed primarily muscle artifact. PUSHBUTTON ACTIVATIONS: There were three. The first was at 9:21 and showed the second focal seizure, as described above. The second pushbutton event was a repetition of the same seizure 10 seconds later. The third was another six minutes later and showed some spike and slow activity broadly over the left hemisphere. By video, there was some continued jerking of the left arm. SLEEP: No normal waking or sleeping patterns were evident. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: This EEG recording monitored cerebral function from 8 in the morning until near 4 p.m. on the [1-15]. It showed two electrographic seizures, the second with some evidence of spread to the contrlateral side. Both seizures appeared to begin in the right central parietal area and lasted for just a few minutes. Otherwise, the background rhythm was of low voltage and remained symmetric throughout the study. There were no other epileptiform features. . CTA [2183-9-17] * Preliminary Report * No evidence of new hemorrhage or infarction. Stable appearance of extra-axial hematoma and interval resorption of a significant portion of subarachnoid blood. Stable appearance of 5 x 3.5 mm right MCA bifurcation aneurysm with no evidence of intracerebral vasospasm. . . . Neurophysiology Report EEG Study Date of [2183-9-15] . OBJECT: ROE, EKG, VIDEO, [9-15] TO [2183-9-16]. THERE WERE THREE PUSHBUTTON ACTIVATIONS. . FINDINGS: ROUTINE SAMPLING: The recording began at 8 in the morning on the 13th and showed a very low voltage record bilaterally. At 8:55 that morning there emerged some rhythmic 3 Hz slowing primarily in the right parietal area, waxing and [Doctor Last Name 688] over the next minute or so. By video, the patient had rhythmic shaking of the left arm with some semi-voluntary appearing movement of the trunk and right side, as well. After the first 20 seconds or so, the left arm movement appeared to be more of a jerking. Electrographically and clinically, the seizure did not appear to spread beyond that area. The same seizure pattern recurred at 9:21. This episode lasted over a minute and had similar clinical manifestations. The record remained of low voltage with mostly faster frequencies for the rest of the recording, with background voltages remaining stable and symmetric. Relative frequency analysis showed more delta activity relative to [Name2 (NI) 14595] activity late in the morning and again for the hour just before the end of the study, but these activities remained quite symmetric. . SPIKE DETECTION PROGRAMS: Showed no clear epileptiform discharges. SEIZURE DETECTION PROGRAMS: Showed primarily muscle artifact. PUSHBUTTON ACTIVATIONS: There were three. The first was at 9:21 and showed the second focal seizure, as described above. The second pushbutton event was a repetition of the same seizure 10 seconds later. The third was another six minutes later and showed some spike and slow activity broadly over the left hemisphere. By video, there was some continued jerking of the left arm. SLEEP: No normal waking or sleeping patterns were evident. CARDIAC MONITOR: Showed a generally regular rhythm. . IMPRESSION: This EEG recording monitored cerebral function from 8 in the morning until near 4 p.m. on the [1-15]. It showed two electrographic seizures, the second with some evidence of spread to the contrlateral side. Both seizures appeared to begin in the right central parietal area and lasted for just a few minutes. Otherwise, the background rhythm was of low voltage and remained symmetric throughout the study. There were no other epileptiform features. Brief Hospital Course: [Known firstname ] [Known lastname ] is an 80 year old female with CAD s/p CABG, HTN, HLD, and DMII that was transferred from an outside hospital after an episode of syncope and fall, where she was found to have an acute subarachnoid hemorrhage and transferred to [Hospital1 18] for further management. . #Bradycardia, syncope: The patient was initially admitted to the Trauma ICU for monitoring and management of her acute subarachnoid hemorrhage. However, the night of admission she developed bradycardia that progressed to an asystolic arrest, received CPR for approximately 30-45 seconds and spontaneously recovered without atropine or epinephrine. Initially a temporary transvernous pacer wire placed through a Right IJ, but patient accidentally removed it, so transcutaneous pacer pads were placed which patient did not end up needing overnight. Permanent [Company 1543] dual chamber (AV leads) pacemaker was implanted [2183-9-16]. Her bradycardia was believed to be secondary to sick sinus syndrome. She received Vancomycin post-operatively for 2 days and did not experience any immediate complications from the pacemaker placement. . # Subarachnoid Hemorrhage: Upon admission, she was found to have a 5 x 3.5 mm right MCA bifurcation aneurysm and a new subarachnoid hemorrhage on head CT. The bleed was believed by Neurosurgery team to be most likely secondary to head trauma after her fall, not secondary to aneurysm. She was initially admitted to the Trauma SICU with Neurosurgical consult. She was initially monitored with Q1 hour neuro checks, intervals were gradually lengthened as patient showed no neurological deficits. After asystolic episode described above, patient was transferred to CCU. Shortly after arrival to the CCU she developed a fever, delerium and was having left sided partial seizures. She was seen by neurosurgery and was started on Keppra and an EEG was done for several hours. EEG over eight hours showed "two electrographic seizures, the second with some evidence of spread to the contrlateral side. Both seizures appeared to begin in the right central parietal area and lasted for just a few minutes." She had no witnessed repeat seizures the following day. Repeat CT on [2183-9-15] showed no interval change in the size of intracranial hemorrhage. Her fever and delerium resolved, and were most likely believed to be secondary to her intracranial bleed. CTA was performed on [2183-9-17] and showed no evidence of cerebral vasospasm, partial resorption of the bleed, and a stable ovoid aneursym. Re-construction of the CTA still pending. Patient was alert and oriented with normal neurological exam, as described above, upon discharge. . # Urinary Tract Infection: Patient was febrile and delirious on transfer from TICU. Out of concern for a possible UTI by urine analysis, she received one dose of levofloxacin in the TICU and then received a 3 day course of Bactrim in the CCU. Urine cultures were all negative. Pneumonia was unlikely as chest x-ray did not reveal an infiltrates. Her fever resolved and her delerium improved. . # Hypertension: Due to episodes of bradycardia prompting permanent pacemaker placement, her home antihypertensives including atenolol, imdur, and lisinopril were held. Additionally, neurosurgery recommended allowing her blood pressures to autoregulate and run slightly higher than normal secondary to her intracranial lesion. Her home antihypertensives were held upon discharge and can be restarted as an outpatient according to her neurosurgeon and primary care physician's recommendations. . # Diabetes: She was maintained on an insulin sliding scale during her admission and her glucophage was resumed upon discharge. . # CAD with history of CABG: Her home aspirin and plavix were held in context of her intracranial bleed. Her primary care physician was [Name (NI) 653] to investigate whether she had a prior PCI/indication for plavix. It is known that she had PTCA in [2182-11-3]. Her PCP will investigate further and restart plavix once her bleed is stable if clinically indicated. Her aspirin will resume upon follow up with neurosurgery. She was continued on pravastatin for hyperlipidemia. . #Follow up: Neurosurgery team should follow-up on final read of CTA and 3D reconstruction which was not available at time of discharge. Patient has followup appointment set with Primary Care Physician. . The patient was full code for this admission. . Medications on Admission: Glucophage 500 mg [Hospital1 ] IMDUR 120 mg qday Plavix 75 mg PO daily Atenolol 25 mg PO daily Pravastatin 40 mg PO qHS B12 500 mcg qday Aspirin 81 mg daily Lisinopril 10 mg PO daily Discharge Disposition: Home Discharge Diagnosis: Subarachnoid hemorrhage Bradycardia Asystolic arrest Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], You were brought to the hospital because you were experienced a fainting spell which resulted in a fall that caused bleeding in your brain. You heart also stopped and you briefly required CPR. It was determined that you required a permanent pacemaker, which was placed without complications. Because of the bleeding in your brain you also expereienced seizures which were treated with medication. You also had a brief episode of fevers and there was concern for a possible urinary tract infection and you received antibiotics. Imaging showed that your bleeding stablized and you were able to be discharged from the hospital in stable condition to complete your recovery. . The following changes were made to your medications: - Please START taking Keppra 500mg [Hospital1 ] for seizure prophylaxis - Please STOP taking aspirin for now. You can restart this medication as directed by your primary care physician. [Name Initial (NameIs) ] Please STOP taking plavix for now. You can restart this medication if your primary care physician tells you to. - Please STOP taking lisinopril for now. You can restart this medication when your neurosurgeon and primary care doctor tell you to. - Please STOP taking your Imdur for now. You can restart this medication when your neurosurgeon and primary care doctor tell you to. - Please STOP taking your atenolol for now. You can restart this medication when your PCP tells you to. - You can take Tylenol 325mg 1-2 tabs every 6 hours as needed for headache or pain. - Please continue to take all of your other home medications as prescribed. . Please be sure to keep all follow-up appointments with your PCP and other health care providers. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your primary care physician and other health care providers. . Please follow-up with your primary care physician and [Name9 (PRE) 87491] should [Location (un) 1131] the final results of CTA (special imaging of your head)which were not available at time of discharge. . Department: CARDIAC SERVICES (Device clinic) When: THURSDAY [2183-9-25] at 10:00 AM With: [First Name11 (Name Pattern1) 539] [Last Name (NamePattern4) 13861], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: CARDIAC SERVICES When: THURSDAY [2183-9-25] at 10:40 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Primary Care Physican: [Last Name (LF) ],[First Name3 (LF) ] J [Telephone/Fax (1) 63780] Wednesday, [10-1] at 1:45pm [Location 9583], MA . Neurosurgery: Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] The office of Dr. [First Name (STitle) ] will call you with an appointment -- if you do not hear from them by tomorrow, Friday, [9-19], please call their office. ([Telephone/Fax (1) 79734] Completed by:[2183-9-18]	[ "5990", "V4581", "25000" ]
Admission Date: [2158-9-4] Discharge Date: [2158-9-10] Date of Birth: [2100-11-11] Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 4327] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization Intra-aortic balloon pump History of Present Illness: 57 male-to-female transgender patient on estrogen developed chest pain with diaphoresis at rest while at an AA meeting. Pain described as substernal and radiating to bilateral elbows and was [5-28] in severity. Also had some associated nausea, no vomiting. Ambulance was called, and she was given 2 SL ntg in route. No aspirin was given in field. Pain [2156-2-21] when she presented to the ED. Initial vitals in the ED were 97.8, 76, 111/74, 30, and 100% on 4L NC. EKG demonstrated 2-3mm ST elevations in II, III, aVF and 1-2mm ST elevations in V5-V6 with ST depressions in V1-V3 and aVL. Labs were significant for a WBC of 15.8 and a troponin of <0.01. In the ED, the patient was given Plavix 600mg, aspirin 324mg, Integrilin 16.2 mg bolus, then 2mg/kg/min, morphine 5 mg IV, and heparin bolus and drip. Patient was taken to the cath lab. Cath was significant for occlusion of the distal left circumflex, thought to be responsible for the symptoms and EKG changes. Intervionalists were not able to pass a wire throught the left circ. Therefore, an intra-aortic balloon pump was placed to increase perfusion to the coronary arteries and to decrease cardiac O2 demand. Plan is to continue balloon pump for 48 hours, to allow completion of the infarct, and for cardiac surgery to take her for possible CABG. In the cath lab, integrilin was stopped, as was Plavix and nitro. On arrival to the floor, patient had [12-27] pain in the left shoulder blade. Pain increased to [3-28] throughout the next hour. Balloon pump was on. Bedside ECHO showed no obvious effusion. REVIEW OF SYSTEMS On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. She has been walking [4-23] miles per day. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, + Hypertension in 30s that was initially treated with antihypertensives, but these were stopped when patient lost 30 lbs and no longer had to take antihypertensives 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -male-to-female transgender on estrogen and spironolactone (gets them off the internet) -used to get healthcare at CrossRoads in [Location (un) ], but has not been in 1.5 years due to lack of health insurance Social History: -Tobacco history: smokes currently [12-19] - [2-19] pack daily, ~30 pack-year history of smoking -ETOH: none in 22 years -Illicit drugs: none in 22 years -Lives with her sister currently. [Name2 (NI) ] two children are 30 and 32 years old. She used to work as a upholsterer and had her own business, which she lost after she transitioned and began living full-time as a woman 5 years ago. She does not currently have health insurance. She is being trained to be a CNA and wants to work with geriatric LGBT populations. Family History: Father and both of mother's parents with a history of heart disease; otherwise non-contributory. Physical Exam: VS: 98.1, 71, 108/62, 11, 100% on 4L by NC GENERAL: WDWN M-to-F trans woman 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: JVP difficult to assess given large neck. CARDIAC: Normal heart sounds difficult to assess given the loud IABP sounds. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly. ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. Femoral bruits difficult to assess given loud IABP sounds. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ PT dopplerable Left: DP dopplerable PT dopplerable Pertinent Results: EKG: Sinus rhythm at 75 bpm. Normal axis. 2-3mm STE in II, III, aVF, 1-2mm ST elevations in V5-V6; ST depressions in aVL, V1-V3. . CARDIAC CATH: - Coronary angiography: right dominant - LMCA: Large and ectatic with a 30% distal left main - LAD: The LAD was a diffusely diseased vessel. It had a 50% stenosis in its proximal segment, a diffuse (30 mm) 70-80% stenosis in the mid LAD; and minor lumen irregularities in the distal LAD. There was a large bifurcating diagonal branch. - LCX: The LCx was ectatic in its proximal segment. There was a large bifurcating OMB. In the mid-distal LCX, there was an abrupt cutoff with staining of contrast consistent with an acute occlusion. No distal collaterals were seen. The area of myocardium at risk distal to the occlusion is relatively small. - RCA: The was a 70% stenosis in the proximal RCA followed by a large ectatic segment of mid RCA. There was a 90% distal RCA stenosis and diffuse disease into the LAD and posterolateral branches. There was TIMI 3 flow into the distal vessel. - Interventional Details: -- The procedure was performed from the right radial artery without complications -- Unfractionated heparin and eptifibatide (terminated at the end of the procedure) were used for anticoagulation. -- The EKG changes were suggestive on an interolateral STEMI. There was TIMI 3 flow into the distal RCA and an acute occlusion to the distal LCx. Using a 2.5 mm balloon, multiple wires were used (BMW, Prowater, Pilot-50, Choice PT) to attempt to cross the occlusion without success. There was distal staining consistent with dissection but no evidence of perforation. No balloon inflations were performed. After prolonged attempts, the procedure was aborted due to the small area of subtended myocardium (despite diffuse EKG changes). The RCA was also a potential culprit vessel but had TIMI 3 flow and would not account for the EKG changes. -- An IABP was placed from the right femoral artery without complications. This resulted in an improvement of her pain. . CXR (ED): Single portable view of the chest. No prior. Lungs are clear of focal consolidation or large effusion. The cardiomediastinal silhouette is within normal limits. Osseous and soft tissue structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. . LABORATORY DATA: [2158-9-4] 9:25p PT: 11.3 PTT: 119.0 INR: 1.0 . [2158-9-4] 9:12p 139 105 21 109 AGap=21 4.1 17 1.0 . Trop-T: <0.01 . 96 15.8 14.4 297 42.8 N:69.2 L:24.7 M:3.7 E:1.8 Bas:0.4 . ECHO [2158-9-5]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior and inferolateral segments. The remaining segments contract normally (LVEF = 45%). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Brief Hospital Course: 57 yo F (male to female transgender) on hormone therapy who presented w/ CP and was found to have STEMI. # STEMI: Infero-posterior STEMI based on EKG and cath findings w/ total occlusion of distal left Cx. Unfortunately, the cardiac interventionalists were unable to pass a wire through the occlusion, so pt was allowed to complete infarct prior to definitive revascularization, which will take place during the next hospitalization. Cath showed 3VD (LCx as above, LAD w/ 50% proximal stenosis, 70-80% stenosis in the mid LAD, RCA w/ 70% proximal and 90% distal stenosis). To increase coronary perfusion and decrease O2 demand, an intra-aortic balloon pump was placed in the cath lab. The patient did well on the balloon pump, and her symptoms of chest pain resolved the following day. She was treated with heparin while on the pump. The pump was weaned and finally removed on [9-6]. Regarding medical management, the patient was treated with aspirin 325mg daily, atorvastatin 80mg daily, and metoprolol tartrate 12.5 TID (switched to 37.5mg of metoprolol succinate daily on discharge). Smoking cessation was encouraged, and the patient was prescribed the nicotine patch. We held off on starting an ACEI during this admission. We also held the patient's home spironolactone (in favor of metoprolol) and estrogen (due to the increased risk of MI). Troponin peaked at 3.44, and CK-MB peaked at 132. Cardiac surgery was consulted, and they advised CABG, which is scheduled to be performed to days following discharge. # Nicotine Dependence: Currently smokes 0.5-0.75 packs per day. Transdermal nicotine 14mg daily was prescribed, and it was decreased to 7mg daily prior to discharge. We encouraged continued smoking cessation and stressed the importance of smoking cessation, especially with concurrent estrogen use. Transitional Issues: # Hormone Therapy: The patient is a pre-operative male-to-female transgender woman and was taking estrogen and spironolactone. She understands that estrogen may have increased her MI risk and has agreed to stop taking this medication at least until after ther CABG. She has also agreed to stop taking the spironolactone while we add and adjust other medications that affect her blood pressure. Future providers should consider restarting both of these medications because they are important priorities for the patient. # Follow Up: After the admission for the CABG, the patient should be discharged with cardiology follow up and PCP follow up. A referral to [Hospital6 ] might be especially useful for this patient, given their experience with transgender health and hormone therapy. # Insurance: The patient does not currently have health insurance. She met with social work about this, who have started the process of trying to get her health insurance. This should be followed up during the next admission. # CODE: Confirmed full # EMERGENCY CONTACT: sister [Name (NI) ] [Name (NI) 112191] [Telephone/Fax (1) 112192] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Estrogens Conjugated 2 mg PO DAILY 2. Spironolactone 200 mg PO DAILY Discharge Medications: 1. Nicotine Patch 7 mg TD DAILY RX nicotine 7 mg/24 hour Please apply 1 patch daily daily Disp #14 Unit Refills:0 2. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 3. Mupirocin Nasal Ointment 2% 1 Appl NU [Hospital1 ] Duration: 5 Days please start after collecting Staph screen 4. Aspirin EC 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:2 5. chlorhexidine gluconate NF* 2 % Topical daily Duration: 3 Days 6. Metoprolol Succinate XL 37.5 mg PO DAILY RX metoprolol succinate [Toprol XL] 25 mg 1.5 tablet(s) by mouth daily Disp #45 Tablet Refills:2 Discharge Disposition: Home Discharge Diagnosis: ST-Elevation Myocardial infarction (heart attack) Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to the hospital for a heart attack. You were taken to the catheterization lab, and a blockage was found in your left circumflex coronary artery. However, we were unable to clear this blockage. You had an intra-aortic balloon pump placed in order to help your heart function during and immediately after the heart attack. The pump was removed, and you remained stable without complications following the heart attack. You were evaluated by cardiac surgery. They plan to do "bypass" surgery on Tuesday, [2158-9-12], to help your heart muscle get blood because you have blockages in your arteries. Please come to the [Hospital Ward Name 517] Admissions Department in the Clinical Center building on Tuesday at 6am for the surgery. Do not eat after midnight the night before. Please shower daily using the chlorhexidine soap that we will give you. Also please use the mupirocin ointment that we will give you in your nostrils twice a day. The estrogen that you were taking may have contributed to your risk of a heart attack. Therefore, please stop taking the estrogen at least until after the bypass surgery. Also, stop taking the spironolactone at least until after the bypass surgery, as this medication can affect your blood pressure. Cigarette smoking increases your risk of heart disease. Please continue to stay quit from smoking. You can use nicotine patches at least until your next hospitalization. STOP: - spironolactone - estrogen START: - metoprolol 12.5 mg twice a day - atorvastatin 80 mg daily - aspirin EC 325 mg daily - nicotine patch 7 mg daily - mupirocin 2% ointment to the nostrils twice daily - chlorhexidine soap daily If you need to speak with a physician, [Name10 (NameIs) ] contact Dr. [Last Name (STitle) ] through the cardiology clinic at ([Telephone/Fax (1) 20575]. Followup Instructions: - The cardiac surgery team plans to do 'bypass' surgery on Tuesday, [2158-9-12]; please come to the [Hospital Ward Name 517] Admissions Department on Tuesday at 6am for the surgery - After the surgery, the cardiac surgery team should help you get set up with a cardiologist and a primary care doctor; you might consider going to [Hospital6 *] for a primary care doctor, as their doctors have experience with hormone therapy and transgender health more generally	[ "41401", "3051" ]
Admission Date: [2164-2-14] Discharge Date: [2164-2-22] Date of Birth: [2101-7-4] Sex: M Service: MEDICINE Allergies: Aspirin / Erythromycin Base / Iodine; Iodine Containing / Cottonseed Oil / Ceftazidime / Clindamycin / Naloxone Attending:[First Name3 (LF) 17865] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: This is 62 year old male with history of transverse myelitis complicated by paraplegia who presents with two days of shortness of breath. The patient has had a complicated recent history involving a leg fracture sustained while moving in his wheel chair. This was not treated surgically. He also has a sacral decub which was treated with 2 weeks of cipro then 2 weeks of levofloxacin. Over the past two days he has been having increasing shortness of breath. He has oxygen at home which he normally does not use. He has been using up to 4L 1 day PTA. He reports no fevers of chills. He has been taking his temp and no documented fevers. He does not endorse ant chest pain. His wife notes that although his right leg is constantly swollen from the fracture, his left leg has been having increasing swelling over the past few days. His wife also notes that he has been increasingly lethargic over the past few days as well. In the ED, he recieved Vanc and Zosyn. CTA neg for PE but showed no central PE but Bibasal GGO and more consolidative opc w/enlarged subcarinal [Last Name (un) ] ? pna. Upon arrival to the floor his sats were in the 80s on NC and he required a NRB to attain sats in the 90s. An ABG was performed 7.49/44/141. He was given 20mg IV lasix. He was eventually able to be placed on a 40% venturi mask. His oral temp was 99.7. He was short of breath when not on the NRB. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: TRANSVERSE MYELITIS: [1-2] virus in 90s. CHRONIC PAIN CHRONIC UTI NEUROGENIC BLADDER DEPRESSION ASTHMA CONSTIPATION NASAL POLYPS BURSITIS - R HIP DECUBITUS ULCER [Doctor Last Name ] SYNDROME Social History: Lives with wife and has two children. Completely dependent upon wife for ADLs, recently has been largely bed bound. PhD in physics, worked at Bell laboratories. Denies tobacco, EtOH, and drugs. Family History: Non-contributory Physical Exam: Vitals - T: 100.3 po BP: 110/75 HR: 113 RR: 20 02 sat: 100% NRB GENERAL: Thin, NAD HEENT: PERRL, MM dry CARDIAC: s1s2 RRR LUNG: fine crackles bilaterally ABDOMEN: soft, NT/ND EXT: [1-3]+ pitting edema to knees bilaterally NEURO: A&O x 3 DERM: scattered erythema over the LLE, + warmth; sacral decub with packing Pertinent Results: ADMISSION LABS [2164-2-14] 12:30PM WBC-16.4# RBC-3.61 HGB-9.6* HCT-29.3* MCV-81* MCH-26.4# MCHC-32.6 RDW-13.8 NEUTS-87.3 LYMPHS-6.7* MONOS-4.3 EOS-1.5 BASOS-0.2 [2164-2-14] 12:30PM GLUCOSE-149* UREA N-5* CREAT-0.5 SODIUM-129* POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-31 ANION GAP-12 [2164-2-14] 12:30PM CK(CPK)-33* [2164-2-14] 12:30PM cTropnT-<0.01 [2164-2-14] 06:45PM LACTATE-1.1 DISCHARGE LABS [2164-2-22] 05:43AM BLOOD WBC-16.5* RBC-3.91* Hgb-10.2* Hct-33.3* MCV-85 MCH-26.2* MCHC-30.8* RDW-14.0 Plt Ct-588* Neuts-91.3* Lymphs-5.8* Monos-2.8 Eos-0.1 Baso-0.1 [2164-2-22] 05:43AM BLOOD PT-17.7* PTT-74.6* INR(PT)-1.6* [2164-2-22] 05:43AM BLOOD Glucose-181* UreaN-21* Creat-1.1 Na-140 K-3.5 Cl-98 HCO3-31 AnGap-15 Calcium-8.8 Phos-4.6* Mg-2.4 [2164-2-22] 05:43AM BLOOD Triglyc-252* [2164-2-16] 05:30AM BLOOD PREALBUMIN- 2 IMAGING CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [2164-2-14] 2:22 PM 1. No pulmonary embolus. 2. Progressed interstitial lung disease including honeycombing, cylindrical bronchiectasis, and diffuse ground-glass opacification predominantly in the lower lobes. Nonspecific interstitial pneumonia is a primary diagnostic consideration, with the possibility of superimposed aspiration suggested particularly in light of the patulous esophagus. Although unlikely given age, connective tissue disease may also present in this manner. It would be atypical however to present at this advanced age. 3. Meidastinal adenopathy. Given relative dramatic sizes, felt out of proportion to be reactive nodes. Follow up CT in [2-3] months recommended to further evaluate. 4. Large hiatal hernia with patulous esophagus. Contributes to possibility of superimposed aspiration. Portable TTE (Complete) Done [2164-2-15] at 11:13:00 AM FINAL The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal regional and global biventricular systolic function. Mild mitral regurgitation. There appears to be a mass that is external to the lateral and posterior sides of the right atrium. This mass is indenting/compressing the right atrium without causing hemodynamic compromise. This is probably the same mass/lymhpadenopathy seen on the recent chest CT. BILAT LOWER EXT VEINS PORT Study Date of [2164-2-15] 8:04 AM Limited study. Deep venous thrombosis in the left proximal and mid femoral vein. TIB/FIB (AP & LAT) RIGHT Study Date of [2164-2-15] 5:49 PM Angulated and minimally displaced fractures involving the proximal metaphyses of the tibia and fibula. CHEST (PORTABLE AP) Study Date of [2164-2-21] 11:00 AM In comparison with the study of [2-19], there is little interval change. Again there is striking dilatation of the tracheobronchial tree. Bibasilar areas of opacification persist, consistent with consolidation superimposed upon underlying interstitial lung disease. Brief Hospital Course: 62M quadraparetic s/p transverse myelitis, sent to ICU from floor for hypoxia and closer monitoring/nursing care. # Hypoxia: CTA r/o PE but showed mostly dependent ground glass opacity and concern for aspiration pneumonia pneumonitis vs CAP vs ILD (less likely as spares apices) vs pulmonary edema. Leukocytosis of 16.4, lactate 1.1. He was initially started on broad spectrum antibiotics including Vanco/Zosyn/Levaquin. These were narrowed to Levoquin / Vanco on [2-21] given no cultures had grown out. The exact etiology of his hypoxia remained somewhat unclear throughout his hospitalization but is likely multifactorial including interstitial disease, likely silent aspiration and anxiety. He was started on steroids while inpatient, with plan to have this tapered by his primary care. # LE Edema: Pt with notable LE edema upon exam which by report was new. Bilateral, with some erythema which could represent venous stasis vs cellulitis. Ultrasound revealed DVT in his left leg. He was started on a heparin drip for this while inpatient. Upon discharge, continued anticoagulation was discussed with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Lovenox was not a reasonable option due to his minimal subcutaneous fat. He was also taking minimal oral intake. Given this, his PCP recommended discharged without anticoagulation but plan to consider it should his underlying poor health status change. # Sacral decubiti: Multiple sacral decubiti, with some concern of osteomyelitis per wife. Was [Name2 (NI) 38511] with levaquin as outpatient, scheduled for Plastics evaluation as oupatient prior to admission. Was seen by Wound Care and Plastics who left recommendations but did not think surgical intervention was warranted given his overall decompensated state. With these interventions, his wounds showed interval improvement and he was dishcarged with VNA services. # Tibula /fibular fracture: Fracture sustained falling from WC. This was not treated surgically. Continued in boot per Ortho recommendations. # Chronic pain: Pt is on several medications, including methadone, dilaudid and Fentanyl. His medications were changed while inpatient and included IV Fentanyl. Given minimal subcutaneous fat, it is also unlikely that his Fentanyl patches were working. This was discussed extensively with the patient and his wife, and they plan to continue to address his pain issues as an outpatient with his PCP. # Anxiety: Patient with significant anxiety. As outpatient is reportedly on Alprazolam, Diazepam and Clonazepam. During hospitalization would become very agitated. Ultimately started on IV Ativan and Haldol PRN. Discharged on Haldol PRN. Medications on Admission: Albuterol Sulfate 0.083 % Nebulization tid prn Albuterol Sulfate 90 mcg 1-2 puffs q 4 hrs prn AllanEnzyme 830,000 unit/gram-10 % Spray, Non-Aerosol Alprazolam 0.25 mg Tablet [12-2] tid prn Baclofen 30mg [Hospital1 ] and 2 qhs prn BARD TOUCHLESS PLUS UNISEX CATHETER 14 FR FIVE TIMES PER DAY AS DIRECTED Becaplermin 0.01 % Gel daily Bupropion 100 mg SR [Hospital1 ] Zyrtec 10 mg Tablet daily Ciprofloxacin 500 mg [Hospital1 ] starting [2164-1-30] Clonazepam 0.5 mg TID Diazepam 5 mg Tablet [Hospital1 ] prn Fentanyl 25 mcg/hour Patch 72 hr QOD Fentanyl 50 mcg/hour Patch 72 hr prn 2-3 days Fentanyl 100 mcg/hour Patch 72 hr 2 patches q2 dats Fentanyl Citrate 400 mcg Lozenge on a Handle [12-2] qid prn Fentanyl Citrate 800 mcg Lozenge on a Handle use as directed when 400 mc is not adequate for pain control qid prn breakthrough pain FLOVENT 220MCG Aerosol 4 PUFFS TWICE A DAY - TAPER AS DIRECTED Fluconazole 200 mg one-3 Tablet(s) by mouth qd prn Hydrocortisone 2.5 % Cream apply to affected area [Hospital1 ] prn Hydromorphone 4 mg Tablet 0.5 to 2 tid prn pain Ipratropium-Albuterol 0.5 mg-2.5 mg/3 mL lactulose 10 gram/15 mL Solution 2 OZ by mouth twice a day Levofloxacin [Levaquin] 500 mg daily [2164-2-10] Levothyroxine 100 mcg daily LIPITOR 20MG daily Methadone 10 mg Tablet [2-1] [Hospital1 ] for pain Methenamine [Last Name (un) ]-Sod Biphos [Utac] 500 mg-500 mg 2 [Hospital1 ] Mexiletine 150 mg TID Montelukast 10 mg daily Mupirocin Calcium [Bactroban] 2 % Cream qd or prn Nystatin 100,000 unit/mL 1 teaspoon tid prn Omeprazole 20 mg Capsule daily Polyethylene Glycol 17 grams TID prn Theophylline 600 mg Tablet Sustained Release daily Beano Ascorbic Acid Discharge Medications: 1. Alprazolam 0.25 mg Tablet Sig: 0.5 - 1 Tablet PO every six (6) hours as needed for anxiety. 2. Duragesic 75 mcg/hr Patch 72 hr Sig: Three (3) patches Transdermal EVERY OTHER DAY (Every Other Day): This medication may not be absorbing given your decreased body fat; discuss discontinuing with Dr. [Last Name (STitle) ]. 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) NEB Inhalation three times a day as needed for shortness of breath or wheezing: Resuming home regimen. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: Resuming home regimen. 6. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for agitation. Disp:20 Tablet(s) Refills:0 7. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO once a day: This medication will be tapered by your primary care. Disp:40 Tablet(s) Refills:1 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing: Resuming prior regimen per Dr. [Last Name (STitle) ]. 9. Oxygen therapy Patient needs Nonrebreather and humidified facemask. Provide up to 10L/min O2 for oxygen saturation > 92%. Patient may be weaned to nasal cannula and room air as directed by primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Dyspnea, Hypoxia, Anxiety, Deep vein thrombosis Secondary: Paraplegia, Transverse myelitis, tracheomegaly Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted with difficulty breathing and increasing oxygen needs at home. You were found to have a blood clot in your leg and changes on your lung imaging which could have be due to infection or an inflammatory process. Your blood clot in your leg was discussed with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], who recommended no anticoagulation (blood thinning) at this time given your other illnesses. Your medications have been changed while you were in the hospital because you weren't taking many oral medications. These have been discussed with your primary care, Dr. [Last Name (STitle) ]. As your oral intake improves, you may resume some of these medications. You should continue to discuss this with Dr. [Last Name (STitle) ]. Please keep all outpatient appointments. Call your primary care physician if you develop fever, chills, abdominal pain, worsening difficulty breathing or any other symptom which is concerning you. Followup Instructions: Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] to schedule a follow-up appointment after your discharge. His phone number is [Telephone/Fax (1) 38512].	[ "5070", "51881", "5849", "49390", "311" ]
Admission Date: [2106-5-15] Discharge Date: [2106-5-26] Date of Birth: [2053-9-14] Sex: M Service: CHIEF COMPLAINT: Confusion and hypoxia. HISTORY OF PRESENT ILLNESS: This is a 52-year-old, African-American male with a history of mild mental retardation, depression, psychosis, asthma, and restrictive lung disease on a home oxygen requirement of three liters. He presented from home after feeling confused this morning. At baseline, Mr. [Known lastname ]' pulmonary disease leaves him with a chronic, nonproductive cough and limits him from walking any length of time or climbing stairs. He was in his usual state of health until the morning of admission when he awoke and felt confused and lethargic. He was unable to eat his breakfast which he states demonstrates a major deviation from baseline. According to his mentor, he has had episodes of confusion where he is unable to recall the day of the week. This has been happening intermittently over the course of the week prior to admission. Upon arrival to the Emergency Department, his oxygen saturation was 97 percent on three liters oxygen. At the time of this interview, he denied worsening shortness of breath, and in fact, says that this is a good day for his breathing. He also denies increase in the severity of his cough from baseline, chest pain, pleuritic chest pain, headache, nausea, vomiting, diarrhea, melena, bright red blood per rectum, abdominal pain, dysuria, fever, chills, night sweats or unexplained loss of weight. The patient has had a medication change in the past couple of weeks. His outpatient psychiatrist, Dr. [Last Name (STitle) 23168], discontinued his Paxil and risperidone and started him on Zyprexa 15 mg q.6:00 p.m. instead. Mr. [Known lastname ] has a known mixed restrictive obstructive lung disease of unknown etiology and is followed by the pulmonary team at [Hospital1 346], in particular by [First Name4 (NamePattern1) 4648] [Last Name (NamePattern1) ], M.D. His baseline chest x-ray shows an interstitial pattern with a patchy infiltrate on the left lower lobe. He has a history of multiple presentations to this hospital with symptoms of shortness of breath, confusion, and chest x-rays that show an interstitial pattern. He has been treated empirically multiple times for pneumonia and asthma flares. He was intubated once in [2101] at which time he had a pneumonia with empyema. PAST MEDICAL HISTORY: His past medical history is significant for restrictive lung disease with his last pulmonary function test on [2106-2-5] with an FEV1 of 0.92 liters, 36 percent of predicted and an FVC of 1.5 liters which is 36 percent of predicted. His TLC is 40 percent of predicted, and DLCO 15 percent of predicted as reported on [2105-10-21]. His oxygen saturations tend to run approximately 91 percent in room air. It decreases to 86 percent in room air with exercise. He is followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] of the Pulmonary Service. It is unclear of the exact nature of his disease. It may be a complicated picture including an interstitial lung process of unknown etiology as well as obstructive sleep apnea, asthma, and possibly a neuromuscular disorder as well. The patient has a history of Methicillin resistant Staphylococcus aureus and pneumonia. He had a last empyema which required thoracotomy and decortication in 02/[2101]. He was intubated and required hospitalization in the Medical Intensive Care Unit at that time. He also has a history of hypertension. The patient had an electrocardiogram in [1-/2106] which showed a right ventricular dilation. He has a history of depression with psychosis. The patient is noted to have a self-inflicted abdominal wound where he stabbed himself in the stomach in [2100]. It was apparently after his father had passed away. He was admitted for psychiatric hospitalization in [2102] with auditory hallucinations and again in [5-/2105] with a hypomanic episode. He has a history of mild mental retardation, history of gastrointestinal bleed from internal hemorrhoids, total left hip replacement status post septic arthritis of that hip, hernia repair, cervical stenosis of C3-4 with bilateral hand weakness. He has a history of obstructive sleep apnea which was confirmed by a sleep study prior to admission. He has a history of corneal ulcer status post right corneal transplant. He has stasis dermatitis on bilateral lower extremities followed by Dermatology with negative .................... in the past. MEDICATIONS: His medications on admission included albuterol two puffs q.i.d., Flovent two puffs b.i.d., Singular ten puffs p.o. q.h.s., Serevent two puffs t.i.d., [Doctor First Name ] 60 mg p.o. b.i.d., Cardura 2 mg p.o. q.h.s., Monopril 10 mg p.o. q.day, Lasix 40 mg p.o. q.day, Neurontin 300 mg p.o. q.a.m., 600 mg p.o. q.h.s., Zyprexa 15 mg p.o. q.6:00 p.m., Tylenol 100 mg p.o. q.i.d. p.r.n., Detrol 2 mg p.o. q.day, prednisolone acetate eye drops one drop to both eyes t.i.d. ALLERGIES: The patient is allergic diltiazem and lactose. FAMILY HISTORY: His father died of a myocardial infarction at age 87. Mother died of cancer. The patient also reports asthma in his sister. SOCIAL HISTORY: The patient has attended special needs classes through the ninth grade and worked in hospitals as a housekeeper. He is currently in a mentor program and lives with a family and attends the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 13089] Center five days per week. He has a caseworker whose name is [Name (NI) ] [Name (NI) 4427]. He states he has a number of friends at the senior center program and denies drug and alcohol use now and in the past. PHYSICAL EXAMINATION: Temperature on admission was 99.3, blood pressure 104/77, pulse 104, respiratory rate 18, oxygen saturation 97 percent on three liters oxygen nasal cannula. Generally, he was awake and alert, breathing comfortably, pleasant, oriented to place and cooperative with exam. HEENT exam revealed pupils are equal, round, and reactive to light, extraocular movements intact, oropharynx clear, moist mucous membranes. His neck had no jugular venous distention and was supple with full range of motion. His lungs revealed some inspiratory crackles, left greater than right and decreased lung sounds at the right base. Cardiovascular exam revealed a regular rate and rhythm, slightly tachycardiac, normal S1 and S2; no murmurs, rubs or gallops appreciated. His abdomen had a large midline scar, positive bowel sounds, soft and obese, nontender and nondistended. His extremities had evidence of chronic stasis dermatitis, no edema or cyanosis, and his neurological exam was nonfocal. LABORATORY DATA: On admission, his white count was 6.4, hematocrit 34.9, platelets 240. Sodium 144, potassium 5.4, chloride 103, bicarbonate 33, BUN 38, creatinine 1.4, glucose 91, CK 242, MB 7, troponin of less than 0.3, ALT 102, AST 53, alkaline phosphatase 376, total bilirubin 0.3, theophylline 4.6. His urinalysis was unremarkable. Chest x-ray shows slight left ventricular enlargement, right pleural effusion, and a lower lobe infiltrate possibly consistent with consolidation. His electrocardiogram showed normal sinus rhythm at 109 beats per minute with a normal axis and some new T wave inversions changed from prior electrocardiogram in leads V2-V4. HOSPITAL COURSE: Briefly, this is a 52-year-old male with severe asthma, obstructive sleep apnea, restrictive lung disease, and a psychiatric history with a recent psychiatric medication change who presented with episodes of confusion, lethargy, and hypercarbia. PROBLEM #1: Pulmonary: The patient was admitted with confusion and elevated bicarbonate. His pulmonary picture was likely multifactorial. He has a history of obstructive sleep apnea confirmed by a sleep study as well as both severe restrictive lung disease of unknown etiology and asthma. The patient also has a history of multiple elevated CK enzymes in the past thought to be from a muscle source as well as a markedly abnormal EMG which raised the concern of a neuromuscular component to his hypercapnia. The patient is followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] from Neurology. Of note, his vital capacity decreases 25 percent when he lies flat compared to sitting upright. At the time of admission, the patient was on three liters of oxygen via nasal cannula chronically at home which he started several months ago. However, the patient had refused BI-PAP because he did not tolerate it. At the time of his initial presentation, the patient had an oxygen saturation in the high 90s and described his breathing as comfortable. Because of the concern about a possible left lower lobe infiltrate on his chest x-ray, a fever, and a cough, the patient was treated with a seven-day course of levofloxacin. Initially during his hospitalization, he was not on BI-PAP and had multiple episodes at night where he would desaturate into the 60s when lying flat on his three liters of oxygen. He is a carbon dioxide retainer, and one night after his oxygen was increased to ten liters per minute because of his desaturation, the patient became somnolent and confused. He was briefly transferred to the Medical Intensive Care Unit for observation and placed on BI-PAP with resolution of his confusion and somnolence. The patient was then continued on BI-PAP at night which he tolerated very well initially. During the remainder of his hospitalization, the patient also had a high resolution chest CT to rule out pulmonary embolism which showed no evidence of pulmonary embolism. He was continued on his metered dose inhalers and theophylline and had no evidence of worsening of his asthma throughout his hospital course. He also had no evidence of congestive heart failure on exam and was not felt to have congestive heart failure as a contributing factor to his hypoxia. He was scheduled for a muscle biopsy to further evaluate his possible neuromuscular disease, but the patient had become increasingly psychotic by that time and was unable to consent for the procedure. During the last five days of his admission, he remained stable from a pulmonary point of view on his home three liters of oxygen. He did, however, start to refuse his BI-PAP at night as he became more agitated and paranoid, although he did not have evidence of desaturation at night after he had completed a course of levofloxacin. PROBLEM #2: Cardiovascular: Mr. [Known lastname ] has no known history of coronary artery disease and has had no signs or symptoms of congestive heart failure while at [Hospital1 190]. His electrocardiogram in the Emergency Department, however, did show some evidence of right heart strain as well as some T wave inversions in leads V2-V4 that were not present on a prior electrocardiogram. He was ruled out for myocardial infarction with multiple enzymes which were notable, however, for the fact that his CKs were elevated, although his MB fractions were quite low, again indicating possible chronic myositis. The patient had no episodes of chest pain throughout his hospitalization. His electrocardiogram was rechecked several times and was stable without any changes from the electrocardiogram done in the Emergency Department. He had a transthoracic echocardiogram done during admission which showed an ejection fraction of 65 percent. It also showed some evidence of right ventricular hypokinesis consistent with pressure overload and revealed some underlying pulmonary hypertension. PROBLEM #3: Gastrointestinal: The patient was noted to have mildly elevated liver function tests during his admission, but he did not complain of any gastrointestinal symptoms of abdominal pain. A right upper quadrant ultrasound was obtained which showed no evidence of gallstones or biliary obstruction but did show mildly dilated common bile duct. If his liver function tests remain elevated in the future, he can get an MRCP as an outpatient. PROBLEM #4: Psychiatric: This patient has mild mental retardation as a baseline as well as an extensive psychiatric history including manic depression with psychotic episodes. Two weeks prior to admission, his Paxil and risperidone were discontinued by his outpatient psychiatrist, and he was started on Zyprexa 15 mg p.o. q.6:00 p.m. It was given at 6:00 p.m. to minimize morning sleepiness. On the day of admission, the patient seemed alert and calm and was very pleasant and answered questions appropriately. His mental status declined over several days into his hospital course when he was febrile and had become acutely hypercarbic secondary to being on ten liters of oxygen which caused him to retain carbon dioxide. He was felt, at that time, to be delirious secondary to his metabolic issues. His thyroid function was normal. His B12 had recently been checked and was also normal as were his electrolytes. A head CT was done which showed no evidence of intracranial pathology. He was treated with BI-PAP briefly in the Medical Intensive Care Unit and had resolution of his hypercapnia and resolution of his mental status as well. He was transferred back to the floor; however, he was felt to be still more confused and less alert in the mornings compared to the afternoons. His evening dose of Neurontin was decreased to 300 mg q.p.m. He was then evaluated by Psychiatry who thought, at that time, that his mental status issues were still largely metabolic in nature. His Zyprexa was decreased to 7.5 mg q.6:00 p.m., down from 15 mg p.o. q.6:00 p.m. to try to improve his confusion in the morning. After his Zyprexa was decreased, he began to be more agitated, paced around his room, muttered to himself, and hallucinated. He would speak to people who were not present and began to act very hypervigilant, fearful, and somewhat paranoid. Psychiatry again came to evaluate him, and his Zyprexa dose was then increased to 10 mg p.o. q.6:00 p.m. The last several days of his hospital course were significant in that the patient remained medically stable; however, he continued to have evidence of increasing psychosis. He began to refuse his BI-PAP again at night and became very distrustful at times alternating with times when he would not want to be left alone. It was felt that his medical issues were stable and that his [Last Name 16423] problem was becoming psychiatric and that he would benefit from transfer to an inpatient psychiatric facility. PROBLEM #5: Fluids, electrolytes and nutrition: The patient had a slightly elevated potassium on admission and was treated with Kayexalate in the Emergency Room. His potassium remained stable throughout the rest of his hospital course. He was continued on a lactose-free diet. PROBLEM #6: Renal: His creatinine was 1.4 on admission which was increased over baseline of 1.0, but it returned to baseline of 1.0 with good oral intake of fluids during his hospital course. DISCHARGE STATUS: Discharge to [Hospital3 672] Hospital for inpatient psychiatric treatment. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: Albuterol two puffs q.i.d., Flovent two puffs b.i.d., Singular 10 mg p.o. q.h.s., Serevent two puffs b.i.d., [Doctor First Name ] 60 mg p.o. b.i.d., Cardura 2 mg p.o. q.h.s., Monopril 10 mg p.o. q.day, Lasix 40 mg p.o. q.day, Neurontin 300 mg p.o. q.a.m., 300 mg p.o. q.h.s., Zyprexa 10 mg p.o. q.h.s. at 6:00 p.m., Tylenol p.r.n., Detrol 2 mg p.o. q.day, Haldol 1-2 mg p.o./intramuscularly q.6 hours p.r.n. agitation, prednisolone acetate eye drops one drop to both eyes t.i.d., oxygen three liters nasal cannula all the time. Do not exceed three liters. BI-PAP at night for obstructive sleep apnea. DISCHARGE DIAGNOSIS: 1. Restrictive lung disease. 2. Asthma. 3. Obstructive sleep apnea. 4. Carbon dioxide retention. 5. Methicillin resistant Staphylococcus aureus precautions. 6. Hypertension. 7. Depression with psychosis. 8. Mild mental retardation. 9. Neuromuscular disease of unclear etiology. 10. Corneal ulcers. 11. Cervical stenosis. DR.[First Name (STitle) ],[First Name3 (LF) 2515] 12-927 Dictated By:[Last Name (NamePattern1) 1203] MEDQUIST36 D: [2106-5-26] 14:51 T: [2106-5-26] 15:01 JOB#: [Job Number 94248]	[ "49390", "2767", "4168" ]
Admission Date: [2197-5-4] Discharge Date: [2197-5-17] Date of Birth: [2143-11-7] Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Shellfish / Fish Product Derivatives Attending:[First Name3 (LF) 3190] Chief Complaint: low back pain Major Surgical or Invasive Procedure: Anterior C4-7 Spinal Fusion/ Posterior laminectomy and fusion C4-7 History of Present Illness: 53F with severe RA, recently diagnosed cervical spine stenosis at BUMC after presenting with RUE numbness and tingling presents today with increased low back pain and bilateral LE weakness. Saw Dr. [Last Name (STitle) 363] of orthopedic surgery yesterday, and was ordered for outpatient spine MR, but her low back pain was worse leading to a fall x2 yesterday [2-15] weakness. No fever, chills, SOB, CP, +vomiting x1 yesterday, no loss of bowel or bladder control. Past Medical History: Rheumatoid arthritis asthma pyelonephritis horseshoe kidney RLL nodule cervical spinal stenosis with cord edema dx 2 weeks ago by MR Social History: Denies EtOH, tobacco, illicits Family History: NC Physical Exam: T 98.1 HR 88 BP 139/78 RR 20 O2Sat Gen: pleasant, lying in bed, +cervical collar HEENT: anicteric, MMM, OP clear CV: regular, no mrg Lungs: CTAB on anterior exam Abd: soft NTND +BS Rectal: normal tone, no stool Ext: strength severely limited in all extremities [2-15] pain -- RUE worse than LUE. Sensation intact to light touch throughout. Neuro: AOx3, strength limited as above, +clonus Pertinent Results: Chemistries [2197-5-4] 10:50AM GLUCOSE-204* UREA N-19 CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-17 CBC [2197-5-4] 10:50AM WBC-9.5 RBC-4.24 HGB-11.5* HCT-36.3 MCV-86 MCH-27.2 MCHC-31.7 RDW-17.6* [2197-5-4] 10:50AM NEUTS-84.7* BANDS-0 LYMPHS-9.2* MONOS-4.0 EOS-1.6 BASOS-0.5 [2197-5-4] 10:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [2197-5-4] 10:50AM PLT COUNT-309 Coags [2197-5-4] 10:50AM PT-13.5 PTT-23.9 INR(PT)-1.1 C-Spine MR IMPRESSION: 1) Multilevel cervical spondylosis. Central canal stenosis at C3-C4 through C6-C7 associated with central cord edema. Grade 1 anterolisthesis of C3 on C4. 2) Unusual configuration of the dens worrisome for a fracture deformity although there is no marrow edema to suggest acute injury. Thickened soft tissue in at the atlantoaxial joint suggests pannus. Correlation with CT is recommended. CT C-spine IMPRESSION: Changes in the odontoid process from rheumatoid arthritis. No evidence of atlantoaxial subluxation. No acute fracture visible by CT. There may be ligamentous laxity and instability from degenerative change, and this cannot be assessed with the static imagese acquired. L-Spine MR IMPRESSION: Bilateral L5 spondylolysis with grade 1/grade 2 anterolisthesis of L5 on S1. Resultant narrowing of the bilateral neural foramen at that level. Probable prominent synovial tissue versus fibrosis projecting toward the right neural foramen; a nonemergent contrast-enhanced lumbar spine MRI may be useful for further characterization. [2197-5-8] Cervical Decompression PROCEDURE PERFORMED: 1. Total laminectomy of C4, C5, C6 and C7. 2. Fusion C4 - C7. 3. Autograft. Brief Hospital Course: Cervical Spinal Stenosis The patient presented with cervical spinal stenosis with associated cord edema between C3 and C7. Additionally, a C-spine MR [First Name (Titles) ] [Last Name (Titles) 12039] of a dens fracture but a CT c-spine did not corroborate this finding. The patient was seen by Dr. [Last Name (STitle) 363] of ortho spine in the emergency department, and a cervical decompression was planned; meanwhile the patient was admitted for pain control. The patient was started on oxycontin and this was titrated up to 20mg [Hospital1 ]. She was given initially morphine and then oxycodone for breakthrough pain. She was started on a beta-blocker preop. She underwent an uncomplicated cervical decompression on [2197-5-8]. Post operatively she was briefly on a morphine pca. She worked with the physical therapists. She was transferred to the ortho-spine service, and was taken back to the OR on ... for an anterior stabilization. Low Back Pain The patient also has L5-S1 disc bulge and neural foraminal stenosis per L-spine MR, likely contributing to her low back pain. Her pain was managed as above. Physical therapy was consulted. Left calf pain The day after surgery the patient complained of pain in her left calf, and on exam, the calf was more firm than the other side. She undewent a left-sided LENI which did not show a DVT. Her pain resolved, and she was able to ambulate with PT. Rheumatoid arthritis The patient was continued on her outpatient medications; her naproxen was held prior to surgery. In addition to her daily 10mg of prednisone, she was given stress dose steroids the day of her surgery. Asthma The patient was contined on her outpatient inhalers. Ulcerative keratitis The patient said that she no longer used the prednisolone eye drops. Diabetes The patient was continued on avandia (held while she was NPO), and additionally a long acting insulin and a HISS were added. Medications on Admission: Albuterol q6h prn Flovent 2 puffs [Hospital1 ] Klonapin 1mg qhs Darvacet 1 tab q4-6 hrs prn Tylenol 3 Naproxyn 500 [Hospital1 ] Fosamax 70 weekly Prilosec 20 daily Prednisone 10 daily Plaquenil 400 daily Arava 20 daily Avandia 4mg daily Prednisolone drops for eyes [Hospital1 ] Discharge Medications: Diazepam 5 mg PO Q6-8H:PRN spasm Prochlorperazine 10 mg PO/IV Q6H:PRN [5-14] @ 1355 View Lisinopril 5 mg PO DAILY hold for sbp <130 Lactulose 30 ml PO Q8H:PRN titrate to 1 BM daily [5-14] @ 1355 View Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose Bisacodyl 10 mg PO/PR DAILY:PRN Senna 1 TAB PO BID Metoprolol 25 mg PO BID hold for HR <60 and SBP <100 Sarna Lotion 1 Appl TP TID: Zolpidem Tartrate 5 mg PO HS:PRN Oxycodone (Sustained Release) 20 mg PO q12 Acetaminophen 650 mg PO Q6H Docusate Sodium 100 mg PO BID Albuterol [1-15] PUFF IH Q6H:PRN Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] Clonazepam 1 mg PO QHS Hydroxychloroquine Sulfate 400 mg PO DAILY Arava NF 20 mg Oral daily Alendronate Sodium 70 mg PO QFRI Pantoprazole 40 mg PO Q24H Prednisone 10 mg PO DAILY [5-14] Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Cervical spinal stenosis with cord compression s/p surgical decompression Low back pain Rheumatoid arthritis Asthma Discharge Condition: Stable Discharge Instructions: Please take your medications as prescribed. Followup Instructions: Please see Dr. [Last Name (STitle) 363] in follow up as needed. Keep the following appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6719], M.D. Where: [Hospital6 29] [Hospital3 1935] CENTER Phone:[Telephone/Fax (1) 253] Date/Time:[2197-5-26] 9:00 Provider: [First Name11 (Name Pattern1) 20] [Last Name (NamePattern4) 7176], MD Where: LM [Hospital Unit Name 4275] Phone:[Telephone/Fax (1) 2226] Date/Time:[2197-5-29] 2:30 Provider: [Name10 (NameIs) ] SCAN Where: [Hospital6 29] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2197-6-26] 11:30	[ "25000", "2859", "49390" ]
Admission Date: [2194-3-8] Discharge Date: [2194-3-18] Date of Birth: [2132-9-20] Sex: F Service: CARDIOTHORACIC Allergies: Atropine / Zosyn Attending:[First Name3 (LF) 165] Chief Complaint: Dyspnea on exertion, transferred from OSH. Major Surgical or Invasive Procedure: [2194-3-12] - s/p CABGx4(LIMA->LAD, SV Grafts->[Last Name (LF) ], [First Name3 (LF) ], RCA) [2194-3-8] - Cardiac Catheterization History of Present Illness: Patient is a 61 yo F with a history of MI, and IDDM diabetes who presented to an outside hospital with the onset of worsening dyspnea on exertion. Apparently she was in her usual state of health (dyspnea with significant exertion) when she began feeling vague chest dull pain similar to her previous MI (approx Thursday AM). The pressure continued on and off until presentation. Notably the pressure again started night prior to admission approx at 5 PM and lasted "all night". When she noticed that she was more short of breath with walking to the mailbox this morning, she came to the ED. She has not had any dizziness, light headedness, presyncope/syncope, nausea, vomitng, fever, chills. She also noted last night feeling weak and took 4 glucose pills (did not check FS). This morning she found that she had a glucose of >400 and gave herself 2U insulin and repeat FS was 230s. . At the outside hospital she was found to have ECG changes c/w ST elevations in inferior leads and labs notable for Trop I > 50, CK > 1200 with MBI 7.6% started on aspirin 325 mg, Plavix 300 mg, Integrelin bolus +drip (1040AM), heparin bolus + drip (3000U, 600Ugtt). Additionally she was given levofloxacin 500 mg for suspicion of pneumonia on CXR as well as morphine and nitroglycerin for CP. . On arrival to the [Hospital1 18] ED, initial vitals were 76 114/54, 18, 98% RA. She was given Integrillin 2 mcg/kg/min (briefly), heparin 600 U/hr gtt, mucomyst 600 mg x 1, 1/2 NS with 1 amp Na HC03, 300 mg plavix. . On arrival to the CCU, she had no chest pain, no shortness of breath. Only had right shoulder pain after laying on the cath table. Past Medical History: CAD Hypertension. Insulin-dependent diabetes mellitus, dx at age 13, pump started [2183-9-6]. Status post bilateral laser surgery to eyes. Status post bilateral cataract surgery, corneal transplants Pacemaker placement: DDD [Company 1543] pacemaker, Prodigy DR S7860, last interrogated on [2-24] with 1.5-3.5 battery life, not pacer dependent. DM w/ Eye Manifestation, type 1, last HbA1C 7.4: [3-1] Hypercholesterolemia Anemia, unspecified Chronic kidney disease, stage 3 Social History: significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: BP 117/71 HR 83 RR 18 O2 96% 4L 62" 131 # Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. eccentric pupil, reactive, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 11 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 ?S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at right base Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No edema, ?clubbing. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP [11-26]+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP [11-26]+ PT 2+ Pertinent Results: [2194-3-8] 01:50PM BLOOD WBC-9.4 RBC-3.55* Hgb-11.0* Hct-31.2* MCV-88 MCH-30.9 MCHC-35.2* RDW-14.8 Plt Ct-138* [2194-3-9] 05:10AM BLOOD WBC-8.2 RBC-3.19* Hgb-9.9* Hct-27.9* MCV-88 MCH-30.9 MCHC-35.3* RDW-14.7 Plt Ct-135* [2194-3-9] 06:44PM BLOOD Hct-32.1* [2194-3-8] 01:50PM BLOOD Neuts-74.2* Lymphs-21.3 Monos-4.4 Eos-0 Baso-0.2 [2194-3-8] 01:50PM BLOOD PT-14.7* PTT-121.6* INR(PT)-1.3* [2194-3-8] 01:50PM BLOOD Glucose-119* UreaN-64* Creat-1.9* Na-138 K-4.9 Cl-102 HCO3-24 AnGap-17 [2194-3-8] 01:50PM BLOOD CK(CPK)-1740* [2194-3-8] 06:15PM BLOOD ALT-436* AST-650* AlkPhos-64 Amylase-200* DirBili-0.2 [2194-3-9] 05:10AM BLOOD ALT-392* AST-460* CK(CPK)-1023* AlkPhos-63 TotBili-0.5 [2194-3-9] 06:44PM BLOOD CK(CPK)-577* [2194-3-8] 01:50PM BLOOD cTropnT-5.65* [2194-3-8] 11:58PM BLOOD CK-MB-66* MB Indx-4.9 cTropnT-4.43* [2194-3-8] 01:50PM BLOOD Calcium-9.5 Phos-4.7* Mg-3.4* [2194-3-8] 11:58PM BLOOD Calcium-8.3* Mg-3.0* Cholest-103 [2194-3-8] 06:15PM BLOOD %HbA1c-7.3* [Hgb]-DONE [A1c]-DONE [2194-3-8] 11:58PM BLOOD Triglyc-55 HDL-50 CHOL/HD-2.1 LDLcalc-42 . Admission CXR: FINDINGS: Portable upright chest radiograph is reviewed and compared to [2187-5-20]. Cardiac size is not enlarged. Mediastinal and hilar contours are unremarkable. Pulmonary vasculature is not enlarged. There is ill-defined airspace opacity, with air bronchograms within the right upper lobe, likely the posterior segment, and also probably in the right lower lung field. The left lung is clear. There is no pleural effusion or pneumothorax. Right- sided pacemaker and two leads overlying the heart are unchanged in position since prior exam. Osseous structures are unremarkable. IMPRESSION: Right upper lobe pneumonia. . ECHO [3-11]: INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional LV systolic dysfunction. False LV tendon (normal variant). Mildly depressed LVEF. No resting LVOT gradient. LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - akinetic; mid inferolateral - hypo; inferior apex - akinetic; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior akinesis and inferolateral hypokinesis. Overall left ventricular systolic function is mildly depressed. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [2194-3-8] Cardiac Catheterization 1. Selective coronary angiography in this right dominant system revealed three vessel coronary artery disease. The LMCA had mild disease. The LAD had a 90% stenosis in the mid vessel and a 50% stenosis in the mid vessel. The LCx had a 90% ostial lesion and a 70% lesion in the mid vessel. The RCA had a 40% proximal stenosis, 60% mid vessel stenosis, and 60% distal stenosis. 2. Left ventriculography was deferred. 3. Resting hemodynamics demonstrated elevated left and right sided filling pressures with an LVEDP and RVEDP of 21 mmHg and 17 mmHg, respectively. There was pulmonary arterial hypertension with a PA pressure of 50/22 (systolic/diastolic in mmHg). Cardiac index was severely depressed at 1.5 l/min/m2. Cardiology Report ECHO Study Date of [2194-3-12] PATIENT/TEST INFORMATION: Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Status: Inpatient Date/Time: [2194-3-12] at 12:02 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW210-0:00 Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) ] [Name (STitle) ] MEASUREMENTS: Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%) Aorta - Valve Level: 2.4 cm (nl <= 3.6 cm) Aorta - Ascending: 2.7 cm (nl <= 3.4 cm) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. A mass/thrombus associated with a catheter/pacing wire in the RA or RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV cavity size. Severe regional LV systolic dysfunction. Moderately depressed LVEF. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial 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. Conclusions: PRE-BYPASS: The left atrium is normal in size. 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. A mass/thrombus associated with a catheter/pacing wire is seen in the right atrium and/or right ventricle. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Electronically signed by [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD on [2194-3-12] 14:35. [Location (un) ] PHYSICIAN: (07-05674FRADIOLOGY Final Report CHEST (PA & LAT) [2194-3-18] 11:48 AM CHEST (PA & LAT) Reason: evaluation of pleural effusion [Hospital 93] MEDICAL CONDITION: 61 year old woman with acute CAD s/p CABG. Please page [First Name8 (NamePattern2) ] [Doctor Last Name ] at [Numeric Identifier 8570] with abnormalities. Pt still in the OR, please perform when in the CSRU. REASON FOR THIS EXAMINATION: evaluation of pleural effusion PA AND LATERAL CHEST INDICATION: Evaluate pleural effusion. FINDINGS: Compared with 4/23, the small right pleural effusion appears unchanged. There is now increased patchy atelectasis/infiltrate at the left lung base. Even allowing for lower lung volumes, the pulmonary vascularity appears mildly engorged, consistent with mild CHF. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: TUE [2194-3-18] 10:58 PM Brief Hospital Course: Mrs. [Known lastname 8571] was admitted to the [Hospital1 18] on [2194-3-8] via transfer for further management Plavix, aspirin and heparin were continued. She underwent a cardiac catheterization which revealed severe three vessel disease. Given the severity of her disease, the cardiac surgical service was consulted for surgical revascularization. She ruled in for a myocardial infarction and heparin, plavix and aspirin were continued. Mrs. [Known lastname 8571] was worked-up in the usual preoperative manner including a carotid duplex ultrasound which showed normal internal carotid arteries. She was transfused with red blood cells for preoperative anemia. On [2194-3-12], Mrs. [Known lastname 8571] was taken to the operating room where she underwent coronary artery bypass grafting to four vessels. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, she awoke neurologically intact and was extubated. The [Last Name (un) ] diabetes service was consulted to assist with her postoperative hyperglycemia and elevated preoperative hemoglobbin A1c. They followed her throughout her postoperative course. Aspirin, beta blockade and a statin were resumed. On postoperative day two, she was transferred to the step down unit for further recovery. She was gently diuresed towaards her preoperative weight.Chest tubes and pacing wires removed. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She developed a large left pleural effusion for which she underwent thoracentesis of 600cc on [3-17]. Insulin pump was managed by the [Last Name (un) ] service with the pt. Cleared for discharge to home with VNA on POD #6. Pt. is to make all follow-up appts. as per discharge instructions. Medications on Admission: Altace 10 mg QDay Humalog 100 U/ml as directed Lasix 40 Qday Lipitor 40mg 1 once a day Glucagon 1mg prn Niferex 100mg/5ml 5 ml [Hospital1 ] Humalog 300 U/3ml before meals Calcium 600mg twice a day Toprol Xl 50mg once a day Zetia 10mg 1 time per day Cosopt 0.5-2% 1 as directed both eyes qd Isosorbide Dinitrate 10mg three times a day One Touch Ultra - Lancets Lancet as directed Aspirin 81mg Pred Forte 1% once a day Folic Acid 0.4mg once a day Xalatan 0.005% once a day both eyes Coenzyme Q10 50mg 1 per day Vitamin C 500mg twice a day Plavix 75mg 1/2tab every other day Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). Disp:1 bottle Refills:2 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:1 bottle Refills:2 8. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 12. Altace 5 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:0 13. insulin pump continue and follow up with [Hospital ] Clinic 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please take twice daily for 1 week and then decrease to once a day . Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary artery disease s/p CABG X 4 IDDM Osteomyelitis Chronic renal insufficiency pacemaker HTN Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for temp>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 634] for 1-2 weeks. [Telephone/Fax (1) 8572] Make an appointment with Dr [Last Name (STitle) 8573] for 2 weeks [Telephone/Fax (1) 8572] Make an appointment with Dr. [First Name (STitle) ] in 4 weeks.[Telephone/Fax (1) 170] Make an appointment with [Last Name (un) ] follow-up. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2194-3-27]	[ "41071", "5119", "486", "41401", "40390", "2859" ]
Admission Date: [2141-7-5] Discharge Date: [2141-8-3] Date of Birth: [2114-4-7] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 6088] Chief Complaint: Compartment syndrome Major Surgical or Invasive Procedure: [2141-7-5] Left lower and upper extremity fasciotomies [2141-7-10] Left lower extremity debridement, Left medial thigh closure [2141-7-14] Left lower extremity debridement [2141-7-21] Left lower extremity debridement History of Present Illness: 27M presents to an OSH with significantly increasing left lower extremity pain, numbness and tingling. Patient reports passing out at home two days ago, after drinking, and waking up one day prior to admission, with numbness and tingling in the left foot. He reports increasingly worsening pain, with loss of function and sensation. He also reports a painful rash which started in the left lower extremity extended upward into the groin and abdomen. There are also some blisters on this rash. He reports otherwise being in his usual state of health. Past Medical History: IV drug abuse, bilateral inguinal hernias as a child Social History: IV drug use, theough denies for the past six months, occasional alcohol, half a pack a day of tobacco. Family History: negative for any vascular history Physical Exam: Vital Signs: Temp: 98.2 RR: 18 Pulse: 91 BP: 167/96 Neuro/Psych: Oriented x3, Affect Normal, abnormal: Appears in moderate discomfort. Neck: No masses, Trachea midline. Skin: No atypical lesions. Heart: Regular rate and rhythm, abnormal: Negative for any murmur. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, Guarding or rebound. Extremities: No femoral bruit/thrill, abnormal: Left lower leg with edemetous anterior compartment and fasciotomies on the medial and lateral sides. Moderate tenderness to palpation. Minimal tenderness passive motion. 10 x 4 cm erythematous patch on the lateral lower leg. Scattered blistering. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. Popiteal: P. DP: P. PT: P. LLE Femoral: P. Popiteal: P. DP: N. PT: D. Pertinent Results: [2141-7-6] 07:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [2141-7-6] 07:00PM BLOOD HCV Ab-POSITIVE* Cardiovascular Report ECG Study Date of [2141-7-5] 4:39:10 PM Sinus tachycardia. Peaked P waves with rightward P axis consistent with right atrial abnormality. Low limb lead voltage. Delayed precordial R wave transition. No previous tracing available for comparison. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 113 154 80 294/386 65 33 41 [2141-7-5] LENIES IMPRESSION: No evidence of deep venous thrombosis in the left or right lower extremities. On the left, the popliteal vein is narrowed due to overlying soft tissue swelling; however, is patent. 8.28.2 CXR FINDINGS: As compared to the previous radiograph, the patient has received a new double-lumen central venous catheter over a left-sided approach. The tip projects over the right atrium, there is no evidence of complications, notably no pneumothorax. All pre-existing monitoring and support devices, including the endotracheal tube and tunneled hemodialysis line, has been removed. CBCs [2141-8-3] 07:15AM BLOOD WBC-6.0 RBC-3.00* Hgb-8.7* Hct-26.2* MCV-87 MCH-28.9 MCHC-33.1 RDW-13.3 Plt Ct-538* [2141-8-2] 06:55AM BLOOD WBC-6.9 RBC-3.18* Hgb-9.4* Hct-27.6* MCV-87 MCH-29.5 MCHC-33.9 RDW-13.4 Plt Ct-573* [2141-8-1] 07:10AM BLOOD WBC-6.7 RBC-3.05* Hgb-8.9* Hct-26.9* MCV-88 MCH-29.1 MCHC-33.1 RDW-13.4 Plt Ct-515* [2141-7-31] 07:05AM BLOOD WBC-6.5 RBC-3.08* Hgb-8.9* Hct-26.9* MCV-88 MCH-29.0 MCHC-33.1 RDW-13.3 Plt Ct-502* [2141-7-30] 03:14AM BLOOD WBC-5.3 RBC-3.26* Hgb-9.6* Hct-28.8* MCV-88 MCH-29.3 MCHC-33.2 RDW-13.5 Plt Ct-450* [2141-7-28] 04:01AM BLOOD WBC-5.3 RBC-2.98* Hgb-8.8* Hct-26.3* MCV-88 MCH-29.7 MCHC-33.6 RDW-13.5 Plt Ct-424 [2141-7-27] 05:40AM BLOOD WBC-4.9 RBC-3.27* Hgb-9.5* Hct-28.9* MCV-88 MCH-29.1 MCHC-33.0 RDW-13.5 Plt Ct-437 [2141-7-26] 03:04AM BLOOD WBC-4.2 RBC-3.06* Hgb-8.9* Hct-26.5* MCV-87 MCH-29.1 MCHC-33.6 RDW-14.0 Plt Ct-402 [2141-7-25] 03:37AM BLOOD WBC-8.1 RBC-3.56* Hgb-10.3* Hct-31.3* MCV-88 MCH-29.0 MCHC-32.9 RDW-14.1 Plt Ct-539* [2141-7-24] 07:07AM BLOOD WBC-6.2 RBC-3.24# Hgb-9.4# Hct-28.3* MCV-87 MCH-28.9 MCHC-33.2 RDW-14.5 Plt Ct-424 [2141-7-23] 07:05AM BLOOD Hct-27.4* [2141-7-22] 04:55PM BLOOD Hct-27.0# [2141-7-22] 06:18AM BLOOD WBC-7.4 RBC-2.40 Hgb-7.2* Hct-21.3* MCV-89 MCH-30.2 MCHC-34.0 RDW-13.9 Plt Ct-449* [2141-7-21] 05:55PM BLOOD Hct-24.7* [2141-7-21] 06:17AM BLOOD WBC-8.7 RBC-2.46* Hgb-7.2* Hct-21.5* MCV-87 MCH-29.1 MCHC-33.4 RDW-13.9 Plt Ct-398 [2141-7-20] 06:35AM BLOOD WBC-11.5* RBC-2.86* Hgb-8.4* Hct-24.5* MCV-86 MCH-29.2 MCHC-34.0 RDW-14.1 Plt Ct-423 [2141-7-19] 06:50AM BLOOD WBC-11.0 RBC-2.88* Hgb-8.5* Hct-24.8* MCV-86 MCH-29.7 MCHC-34.4 RDW-14.4 Plt Ct-460* [2141-7-18] 05:15AM BLOOD WBC-14.8* RBC-3.21* Hgb-9.5* Hct-27.1* MCV-85 MCH-29.5 MCHC-34.9 RDW-14.6 Plt Ct-522* [2141-7-17] 07:25AM BLOOD WBC-17.3* RBC-3.30* Hgb-9.8* Hct-28.3* MCV-86 MCH-29.6 MCHC-34.5 RDW-14.7 Plt Ct-468* [2141-7-16] 06:45AM BLOOD WBC-17.2* RBC-3.10# Hgb-9.0# Hct-26.6# MCV-86 MCH-28.9 MCHC-33.8 RDW-14.9 Plt Ct-345 [2141-7-15] 06:04AM BLOOD WBC-16.8 RBC-2.41* Hgb-6.9* Hct-20.1* MCV-83 MCH-28.7 MCHC-34.4 RDW-15.3 Plt Ct-351 [2141-7-14] 02:08PM BLOOD WBC-17.5* RBC-2.78* Hgb-8.1* Hct-23.2* MCV-84 MCH-29.1 MCHC-34.9 RDW-15.1 Plt Ct-423 [2141-7-14] 02:38AM BLOOD WBC-17.8* RBC-3.03* Hgb-8.7* Hct-25.3* MCV-83 MCH-28.7 MCHC-34.4 RDW-15.1 Plt Ct-329 [2141-7-13] 03:07PM BLOOD WBC-14.6* RBC-3.20* Hgb-9.1* Hct-26.6* MCV-83 MCH-28.6 MCHC-34.3 RDW-14.7 Plt Ct-302# [2141-7-12] 08:50PM BLOOD WBC-12.9* RBC-3.03* Hgb-8.5* Hct-24.9* MCV-82 MCH-28.2 MCHC-34.3 RDW-14.7 Plt Ct-197 [2141-7-12] 03:59AM BLOOD WBC-11.4* RBC-3.04* Hgb-8.6* Hct-25.3* MCV-83 MCH-28.4 MCHC-34.2 RDW-13.7 Plt Ct-179 [2141-7-11] 04:57AM BLOOD WBC-10.6 RBC-3.03* Hgb-8.5* Hct-25.2* MCV-83 MCH-28.2 MCHC-33.9 RDW-13.5 Plt Ct-208 [2141-7-10] 01:03PM BLOOD WBC-9.9 RBC-3.29* Hgb-9.6* Hct-27.4* MCV-83 MCH-29.3 MCHC-35.2* RDW-13.3 Plt Ct-174 [2141-7-10] 03:52AM BLOOD WBC-11.9* RBC-3.55* Hgb-10.1* Hct-29.7* MCV-84 MCH-28.4 MCHC-33.9 RDW-13.5 Plt Ct-183 [2141-7-9] 04:05AM BLOOD WBC-12.0* RBC-3.94* Hgb-11.4* Hct-33.4* MCV-85 MCH-28.9 MCHC-34.2 RDW-13.3 Plt Ct-229 [2141-7-8] 03:56AM BLOOD WBC-9.8 RBC-4.24* Hgb-12.2* Hct-35.2* MCV-83 MCH-28.8 MCHC-34.7 RDW-12.9 Plt Ct-210 [2141-7-7] 03:56AM BLOOD WBC-8.7 RBC-4.28* Hgb-12.5* Hct-35.9* MCV-84 MCH-29.2 MCHC-34.8 RDW-13.0 Plt Ct-182 [2141-7-6] 02:36AM BLOOD WBC-11.9* RBC-4.32* Hgb-12.5* Hct-36.0# MCV-83 MCH-28.9 MCHC-34.7 RDW-12.9 Plt Ct-185 [2141-7-5] 10:51PM BLOOD WBC-8.2# RBC-3.46# Hgb-10.0# Hct-28.7# MCV-83 MCH-28.8 MCHC-34.8 RDW-12.9 Plt Ct-186 [2141-7-5] 03:55PM BLOOD WBC-23.2* RBC-5.93 Hgb-16.8 Hct-50.1 MCV-85 MCH-28.3 MCHC-33.5 RDW-12.9 Plt Ct-310 Basic Metabolic Profiles [2141-8-3] 07:15AM BLOOD Glucose-87 UreaN-15 Creat-1.5* Na-138 K-4.7 Cl-97 HCO3-38* AnGap-8 [2141-8-2] 06:55AM BLOOD Glucose-86 UreaN-16 Creat-1.6* Na-138 K-4.4 Cl-98 HCO3-36* AnGap-8 [2141-8-1] 07:10AM BLOOD Glucose-83 UreaN-13 Creat-1.4* Na-141 K-3.9 Cl-100 HCO3-36* AnGap-9 [2141-7-31] 07:05AM BLOOD Glucose-97 UreaN-14 Creat-1.4* Na-142 K-3.9 Cl-103 HCO3-33* AnGap-10 [2141-7-30] 03:38PM BLOOD Glucose-101* UreaN-16 Creat-1.5* Na-143 K-4.3 Cl-103 HCO3-35* AnGap-9 [2141-7-30] 03:14AM BLOOD Glucose-85 UreaN-18 Creat-1.6* Na-142 K-3.8 Cl-103 HCO3-32 AnGap-11 [2141-7-29] 02:00PM BLOOD Na-142 K-3.8 Cl-104 [2141-7-29] 02:57AM BLOOD Glucose-94 UreaN-21* Creat-1.7* Na-140 K-3.7 Cl-103 HCO3-30 AnGap-11 [2141-7-28] 01:15PM BLOOD UreaN-26* Creat-1.8* Na-143 K-3.8 Cl-104 [2141-7-28] 04:01AM BLOOD Glucose-111* UreaN-32* Creat-1.9* Na-140 K-4.1 Cl-103 HCO3-33* AnGap-8 [2141-7-27] 05:40AM BLOOD Glucose-102* UreaN-40* Creat-2.6* Na-138 K-4.6 Cl-100 HCO3-27 AnGap-16 [2141-7-26] 03:04AM BLOOD Glucose-104* UreaN-42* Creat-2.8* Na-139 K-4.5 Cl-101 HCO3-33* AnGap-10 [2141-7-25] 03:37AM BLOOD Glucose-110* UreaN-41* Creat-3.2* Na-136 K-4.3 Cl-98 HCO3-29 AnGap-13 [2141-7-24] 07:07AM BLOOD Glucose-94 UreaN-35* Creat-3.1* Na-137 K-4.7 Cl-97 HCO3-31 AnGap-14 [2141-7-23] 07:05AM BLOOD Glucose-99 UreaN-28* Creat-3.1# Na-138 K-4.3 Cl-99 HCO3-32 AnGap-11 [2141-7-22] 06:18AM BLOOD Glucose-97 UreaN-55 Creat-5.0* Na-133 K-3.9 Cl-96 HCO3-29 AnGap-12 [2141-7-21] 06:17AM BLOOD Glucose-98 UreaN-46* Creat-4.3# Na-131 K-4.3 Cl-93* HCO3-31 AnGap-11 [2141-7-20] 06:35AM BLOOD Glucose-130* UreaN-89* Creat-6.8# Na-128 K-4.6 Cl-90* HCO3-27 AnGap-16 [2141-7-19] 06:50AM BLOOD Glucose-105* UreaN-67* Creat-5.7# Na-127 K-4.7 Cl-90* HCO3-29 AnGap-13 [2141-7-18] 05:15AM BLOOD Glucose-94 UreaN-115* Creat-8.3* Na-125* K-5.5* Cl-86* HCO3-22 AnGap-23* [2141-7-17] 09:07PM BLOOD Glucose-86 UreaN-109* Creat-8.1* Na-125* K-5.8* Cl-86* HCO3-23 AnGap-22* [2141-7-17] 04:10PM BLOOD Glucose-85 UreaN-101* Creat-7.6* Na-121* K-5.5* Cl-85* HCO3-20* AnGap-22* [2141-7-17] 07:25AM BLOOD Glucose-90 UreaN-94* Creat-7.4# Na-127 K-5.3* Cl-87* HCO3-24 AnGap-21* [2141-7-16] 06:45AM BLOOD Glucose-89 UreaN-76* Creat-5.5# Na-129 K-4.4 Cl-91* HCO3-27 AnGap-15 [2141-7-15] 06:04AM BLOOD Glucose-99 UreaN-93* Creat-6.9# Na-126 K-5.5* Cl-91* HCO3-25 AnGap-16 [2141-7-14] 02:08PM BLOOD Glucose-91 UreaN-122* Creat-8.6* Na-127* K-5.9* Cl-91* HCO3-22 AnGap-20 [2141-7-14] 02:38AM BLOOD Glucose-85 UreaN-110* Creat-7.9* Na-127* K-5.3* Cl-89* HCO3-23 AnGap-20 [2141-7-13] 03:07PM BLOOD Glucose-89 UreaN-92* Creat-7.0# Na-129 K-4.9 Cl-90* HCO3-25 AnGap-19 [2141-7-12] 08:50PM BLOOD Glucose-92 UreaN-64* Creat-4.9# Na-130 K-4.1 Cl-93* HCO3-25 AnGap-16 [2141-7-12] 03:59AM BLOOD Glucose-100 UreaN-98* Creat-7.1# Na-129 K-4.2 Cl-90* HCO3-25 AnGap-18 [2141-7-11] 04:57AM BLOOD Glucose-93 UreaN-62* Creat-5.0* Na-131* K-4.3 Cl-92* HCO3-26 AnGap-17 [2141-7-10] 01:03PM BLOOD Glucose-99 UreaN-66* Creat-6.0* Na-133 K-4.9 Cl-94* HCO3-25 AnGap-19 [2141-7-10] 03:52AM BLOOD Glucose-90 UreaN-61* Creat-5.9* Na-131* K-4.9 Cl-91* HCO3-27 AnGap-18 [2141-7-9] 05:05PM BLOOD Na-129* K-5.5* Cl-92* [2141-7-9] 10:49AM BLOOD Na-129* K-5.8* Cl-93* [2141-7-9] 04:05AM BLOOD Glucose-96 UreaN-49* Creat-5.7* Na-134 K-5.9* Cl-94* HCO3-28 AnGap-18 [2141-7-8] 05:48PM BLOOD Na-132* K-5.9* Cl-94* [2141-7-8] 03:56AM BLOOD Glucose-100 UreaN-39* Creat-4.9* Na-134 K-5.7* Cl-96 HCO3-26 AnGap-18 [2141-7-7] 09:20PM BLOOD Na-133 K-5.4* Cl-97 [2141-7-7] 10:53AM BLOOD Glucose-100 Na-128* K-5.3* Cl-96 HCO3-28 AnGap-9 [2141-7-7] 03:56AM BLOOD Glucose-100 UreaN-35* Creat-3.9* Na-127* K-5.4* Cl-97 HCO3-26 AnGap-9 [2141-7-7] 12:23AM BLOOD Na-128* K-4.9 Cl-99 [2141-7-6] 05:08AM BLOOD Glucose-79 Na-130* K-5.1 Cl-96 [2141-7-6] 02:36AM BLOOD Glucose-70 UreaN-55* Creat-4.7* Na-132* K-5.3* Cl-98 HCO3-23 AnGap-16 [2141-7-5] 10:51PM BLOOD Glucose-260* UreaN-55* Creat-4.4* Na-131* K-5.3* Cl-100 HCO3-23 AnGap-13 [2141-7-5] 10:00PM BLOOD Glucose-104* UreaN-56* Creat-4.5* Na-135 K-5.3* Cl-101 HCO3-22 AnGap-17 [2141-7-5] 07:35PM BLOOD Glucose-78 UreaN-56* Creat-4.8* Na-131* K-6.9* Cl-101 HCO3-19* AnGap-18 [2141-7-5] 03:55PM BLOOD Glucose-91 UreaN-53* Creat-5.0* Na-130* K-7.2* Cl-92* HCO3-22 AnGap-23* Calcium, Magnesium, Phosphorus [2141-8-3] 07:15AM BLOOD Calcium-9.9 Phos-4.0 Mg-2.1 [2141-8-2] 06:55AM BLOOD Calcium-10.0 Phos-3.6 Mg-2.1 [2141-8-1] 09:50PM BLOOD Calcium-10.5* [2141-8-1] 07:10AM BLOOD Calcium-10.3 Phos-3.2 Mg-1.8 [2141-7-31] 07:05AM BLOOD Calcium-11.6* Phos-3.5 Mg-2.0 [2141-7-30] 03:38PM BLOOD Calcium-12.1* Phos-3.2 Mg-1.9 [2141-7-30] 03:14AM BLOOD Calcium-12.3* Phos-4.0 Mg-1.4* [2141-7-29] 02:00PM BLOOD Calcium-12.7* [2141-7-29] 02:57AM BLOOD Calcium-12.8* Phos-4.3 Mg-1.6 [2141-7-28] 01:15PM BLOOD Calcium-13.6* Phos-5.4* Mg-1.6 [2141-7-28] 04:01AM BLOOD Calcium-13.6* Phos-6.2* Mg-1.8 [2141-7-27] 01:00PM BLOOD Calcium-13.8* [2141-7-27] 05:40AM BLOOD Calcium-14.2* Phos-7.4* Mg-1.8 [2141-7-26] 03:04AM BLOOD Albumin-2.4* Calcium-12.3* Phos-6.8* Mg-2.0 [2141-7-25] 03:37AM BLOOD Calcium-11.4* Phos-7.1* Mg-2.1 [2141-7-24] 07:07AM BLOOD Calcium-10.3 Phos-6.5* Mg-2.0 [2141-7-23] 07:05AM BLOOD Calcium-9.2 Phos-5.0* Mg-2.0 [2141-7-22] 06:18AM BLOOD Calcium-8.2* Phos-5.8* Mg-2.2 [2141-7-21] 06:17AM BLOOD Calcium-8.1* Phos-5.4# Mg-2.2 [2141-7-20] 06:35AM BLOOD Calcium-8.0 Phos-8.2* Mg-2.3 [2141-7-19] 06:50AM BLOOD Calcium-7.1* Phos-7.5# Mg-2.2 [2141-7-18] 05:15AM BLOOD Calcium-7.0 Phos-10.7# Mg-2.3 [2141-7-17] 07:25AM BLOOD Calcium-7.9 Phos-8.9* Mg-2.3 [2141-7-16] 06:45AM BLOOD Calcium-7.5* Phos-7.6* Mg-2.2 [2141-7-15] 06:04AM BLOOD Calcium-7.0* Phos-8.2# Mg-2.2 [2141-7-14] 02:08PM BLOOD Calcium-7.1 Phos-10.1# Mg-2.4 [2141-7-14] 02:38AM BLOOD Calcium-7.7 Phos-8.5# Mg-2.4 [2141-7-13] 03:07PM BLOOD Calcium-7.8 Phos-6.9# Mg-2.4 [2141-7-13] 11:58AM BLOOD Albumin-2.3 Iron-47 [2141-7-12] 08:50PM BLOOD Albumin-2.6* Calcium-6.9* Phos-4.9# Mg-2.2 [2141-7-12] 03:59AM BLOOD Calcium-7.2 Phos-6.8* Mg-2.6 [2141-7-11] 04:57AM BLOOD Calcium-7.2* Phos-6.6# Mg-2.4 [2141-7-10] 01:03PM BLOOD Calcium-6.9 Phos-8.6* Mg-2.5 [2141-7-10] 03:52AM BLOOD Calcium-7.1* Phos-7.7* Mg-2.4 [2141-7-9] 05:05PM BLOOD Mg-2.3 [2141-7-9] 04:05AM BLOOD Calcium-7.3* Phos-8.5# Mg-2.4 [2141-7-8] 05:48PM BLOOD Mg-2.0 [2141-7-8] 03:56AM BLOOD Calcium-7.4 Phos-5.7* Mg-1.9 [2141-7-7] 09:20PM BLOOD Mg-1.9 [2141-7-7] 10:53AM BLOOD Calcium-7.6* [2141-7-7] 03:56AM BLOOD Albumin-1.9* Calcium-7.8* Phos-4.2# Mg-1.7 [2141-7-6] 04:34PM BLOOD Calcium-6.2* [2141-7-6] 11:54AM BLOOD Calcium-5.9* [2141-7-6] 02:36AM BLOOD Calcium-6.5* Phos-6.7* Mg-2.2 [2141-7-5] 10:51PM BLOOD Calcium-5.8* Phos-6.0# Mg-2.1 [2141-7-5] 03:55PM BLOOD Albumin-3.3 Calcium-7.4* Phos-7.7* Mg-2.8* [2141-8-3] 08:31AM BLOOD freeCa-1.31 [2141-8-2] 07:32AM BLOOD freeCa-1.31 [2141-8-1] 10:21PM BLOOD freeCa-1.37* [2141-7-31] 07:19AM BLOOD freeCa-1.43* [2141-7-30] 02:23PM BLOOD freeCa-1.56* [2141-7-29] 02:18PM BLOOD freeCa-1.64* [2141-7-29] 03:09AM BLOOD freeCa-1.63* [2141-7-28] 01:24PM BLOOD freeCa-1.59* [2141-7-28] 04:06AM BLOOD freeCa-1.79* [2141-7-27] 09:54AM BLOOD freeCa-1.84* [2141-7-10] 01:11PM BLOOD freeCa-0.92* [2141-7-9] 05:16PM BLOOD freeCa-0.93* [2141-7-9] 04:27AM BLOOD freeCa-0.95* [2141-7-9] 12:11AM BLOOD freeCa-0.93* [2141-7-8] 05:57PM BLOOD freeCa-0.92* [2141-7-8] 04:05AM BLOOD freeCa-0.97* [2141-7-7] 09:27PM BLOOD freeCa-1.00* [2141-7-7] 04:13AM BLOOD freeCa-1.01* [2141-7-7] 12:35AM BLOOD freeCa-1.08* [2141-7-6] 05:19AM BLOOD freeCa-1.04* [2141-7-6] 02:44AM BLOOD freeCa-0.93* [2141-7-5] 10:59PM BLOOD freeCa-0.84* [2141-7-5] 09:15PM BLOOD freeCa-1.02* [2141-7-5] 08:52PM BLOOD freeCa-0.87* HIV/hepatitis viral titers [2141-7-26] 12:55PM BLOOD HIV Ab-NEGATIVE [2141-7-6] 07:00PM BLOOD HCV Ab-POSITIVE* [2141-7-6] 07:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE toxicology on admission [2141-7-5] 03:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: This patient is a 27-year-old gentleman who two days prior to admission was found down by his mother for an indeterminate period of time, but felt greater than 10 hours, secondary to narcotic abuse and alcohol intoxication. On presentation to the ER he had an elevated CK of greater than 160,000 and a creatinine of 5 and a cool mottled left foot with absent Doppler signals and no motor sensation below-the-knee. It was felt he had developed a compartment syndrome in the setting of likely being in the same position for several hours and was brought urgently to the OR for left lower extremity fasciotomies. Cardiovascular He had a fasciotomy done for his compartment syndrome. He required subsequent debridements (three) where necrotic muscle in the lateral compartment was heavily debrided. It was felt he suffered severed, likely irreparable damage to his superficial peroneal nerve. His deep peroneal nerve, on the other hand, recovered somewhat with respect to sensation. His tibial nerve was less clear, but at least some sensation was present during his stay over the medial plantar branch cutaneous distribution. He never recovered motor function during his stay. He will have his sutures removed in two weeks time w/ Dr. [Last Name (STitle) ] as an outpatient. At this time, he will also discuss the possibility of a skin graft for the fasciotomy sites. During his stay, his edema over the left lower extremity was controlled with furosemide. Renal Upon admission he was found to have a severely elevated CK. His creatinine was also elevated, and so he was diagnosed with acute renal failure secondary to rhabdomyalysis. The renal service was consulted for management of his severe rhabdomyolysis, and subsequent anuric - oliguric [Last Name (un) ], hyperkalemia, hyperphosphatemia and hypocalcemia. Hemodialysis was immediately initiated to remove myoglobin. He was aggressively volume resuscitation until euvolemic requiring intubation and CVP monitoring in the ICU. Over time his renal function improved. He was last dialyzed on [2141-7-22]. On discharge, his urine output was 2L/day with cr 2.8 and BUN 43. During his stay he also developed critical hypercalcemia and non-critical hyperphosphatemia. He was sequestered with phosphate binders to prevent calciphylaxis. He was also flushed with high flow normal saline fluids to clear the calcium. He was given furosemide at increased dosage during this time to control the subsequent edema in his left lower extremity. His calcium eventually returned to within normal range. He will need to be followed closely by the nephologists at the [Hospital1 ]. Pain Pain remain controlled throughout his stay. He was seen by chronic pain service on the day of discharge and was put on a finalized regimen of gabapentin 600 mg TID, oxycodone SR 20 [Hospital1 ], and oxycodone 5-10 mg every 6 hours. He is to follow up with his primary care provider for further management of his pain issues. Social Mr. [Known lastname 20825] has no insurance, and as such we began the process of obtaining insurance. From a disposition perspective, he will go to [Hospital ] rehabilitation. Medications on Admission: 1. Methadone 5 mg PO DAILY Discharge Medications: 1. Gabapentin 600 mg PO TID 2. Methadone 5 mg PO DAILY 3. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain 4. Oxycodone SR (OxyconTIN) 20 mg PO Q12H 5. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Compartment Syndrome Acute Renal Failure Rhabdomyolysis Hypercalcemia Hyperphosphatemia Sinus tachycardia Chronic Pain - does not require follow up with our pain clinic Anemia requiring transfusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital secondary to pain, swelling and decreased circulation to your right lower extremity You were diagnosed with compartment syndrome and fasciotomies (opening of the skin) were performed to relieve the pressure in your left leg. Your kidneys were also noted to be failing related to the severe muscle damage from the lack of circulation. You were started on dialysis. Your kidney function had since returned and we stopped hemodialysis. You kidney function is slowly returning and will be closely monitored. We noticed damaged muscular tissue in the open areas on your calves which required you to return to the OR several times for debridement. You also had elevated levels of calcium, which we corrected with high flow fluids. You recovered well, but we will continue to monitor your calcium levels daily. You will follow up with us in two weeks time, where we will discuss options for your leg including possible plastic surgery to graft the open area. Followup Instructions: You have two follow up appointments. 1. Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] (please call for directions) Date/Time:[2141-8-10] at 11:15AM 2. You have a follow up appointment with renal with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4920] on Thursday, [8-17], at 2:30 pm. You will also see Dr. [Known firstname 122] [Last Name (NamePattern1) 96416] during this time. Location: [Hospital1 18] [Hospital Ward Name 121] [Location (un) 453] in West [Hospital ] Clinic Phone Number: [Telephone/Fax (1) 721] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 18672], M.D. Date/Time:[2141-8-17] 2:30	[ "5845", "2761", "2767", "42789", "2859", "3051" ]
Admission Date: [2154-3-21] Discharge Date: [2154-3-25] Date of Birth: [2078-9-5] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1406] Chief Complaint: Ascending aortic aneurysm, Aortic valve regurgitation. Major Surgical or Invasive Procedure: [2154-3-21]: Replacement of ascending aortic aneurysm with a 32-mm Gelweave graft with hypothermic circulatory arrest. History of Present Illness: This is a 75-year-old male who had presented last year with chest pain and workup revealed he had an ascending aortic aneurysm which measured up 5.5 cm in diameter. He had temporal artery biopsy which revealed giant cell arteritis and he was placed on steroids for which these were in the process of being tapered down prior to surgery. He presented again recently with chest pain and a repeat CT scan showed that there was maybe slightly increase in size of his ascending aortic aneurysm. He was admitted for scheduled replacement of the ascending aorta and possible Bentall depending on his intraoperative findings since his echocardiogram had shown that he had moderately dilated aortic sinus and mild-to- moderate aortic insufficiency. After the risks and benefits were explained to him he agreed to proceed and desired a tissue valve if the patient needed aortic valve replacement. Past Medical History: Ascending aortic aneurysm and aortitis Aortic regurgitation polymyalgia rheumatica giant cell arteritis Hypertension Gastroesophageal reflux Depression Asthma Alcohol abuse PSH: s/p femur fracture, s/p bilateral cataract surgery, s/p tonsillectomy, s/p malignant melanoma removal from neck, s/p basal cell carcinoma removal Social History: Retired optic engineer. Divorced, lives alone, adequate with IADL, does not drive. Tobacco: remote history of 1/2ppd smoking (quit 40 years ago) ETOH: 3 beers and 6 highballs per week, now reduced to 2 drinks/week Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Father died of an aneurysm. Father's family have history of MI. NO other significant family history Physical Exam: Pulse:79 Resp:16 O2 sat: 96% on RA B/P Right: 110/58 Left: Height: 6'0" Weight:195 General:NAD Skin: Dry [x] intact [] bil. LE have errythema and desquamation HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM [x]no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [] occ. Irregular [x] Murmur- 2/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]; no HSM; has occ. back muscular tenderness Extremities: Warm [x], well-perfused [x] Edema-none Varicosities:none, but chronic erythema and desquamation on bil. [Name Prefix (Prefixes) ] [Last Name (Prefixes) 72587]; very mild BLE spider veins Neuro: Grossly intact, MAE [4-18] strengths; nonfocal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: tr Left: tr PT [Name (NI) 167]: tr Left: tr Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: Intra-op TEE [2154-3-21] Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 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 root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. There are complex (mobile) atheroma in the descending aorta. The ST junction is well formed. There is NO aortic valve prolapse or flail segments. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results on [Known firstname ] [Known lastname ] before surgical incision.. POST-BYPASS: Normal bivemtricular systolic function. LVEF 55%. Ascenidng Aortic graft is intact. Mild to Moderate AI. Mild TR. Trivial MR> Intact thoracic aorta. [2154-3-25] 05:50AM BLOOD WBC-9.1 RBC-3.05* Hgb-10.6* Hct-30.8* MCV-101* MCH-34.7* MCHC-34.3 RDW-16.2* Plt Ct-307 [2154-3-23] 05:40AM BLOOD WBC-8.9 RBC-2.91* Hgb-10.0* Hct-28.9* MCV-99* MCH-34.5* MCHC-34.8 RDW-15.6* Plt Ct-269 [2154-3-25] 05:50AM BLOOD UreaN-19 Creat-0.8 Na-138 K-4.1 Cl-97 [2154-3-24] 06:15AM BLOOD UreaN-22* Creat-0.7 Na-138 K-3.9 Cl-101 [2154-3-25] 05:50AM BLOOD Mg-1.7 [2154-3-24] 06:15AM BLOOD Mg-1.7 Brief Hospital Course: The patient was brought to the operating room on [2154-3-21] and underwent Replacement of ascending aortic aneurysm with a 32-mm Gel weave graft with hypothermic circulatory arrest with Dr. [Last Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He was extubated, alert, oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. He weaned from inotropic and vasopressor support. He was administered IV stress-steroids converted to oral steroids on POD1. Beta blocker was initiated. He was gently diuresed toward his preoperative weight. He transferred to the telemetry floor in sinus rhythm and hemodynamically stable. Chest tubes and pacing wires were discontinued without complication. He tolerated a cardiac diet. Blood sugars were less than 150. The patient was evaluated by the physical therapy service for assistance with strength and mobility. His pain was well controlled with oral analgesics. He continued to make steady progress and was discharged to [Hospital3 537] on POD 4. Medications on Admission: Prednisone 15 mg PO daily lisinopril 15 mg daily Prozac 40 mg daily ASA 81 mg PO daily Omeprazole 20 mg daily cholecalciferol 1000 units daily calcium carbonate 800 mg daily multivitamin daily fosamax 70 mg q Sunday methotrexate 15 mg q Wednesday folic acid 1 mg daily metoprolol 37.5 mg qAM, 25 mg qPM Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: Ascending aortic aneurysm and aortitis Aortic regurgitation polymyalgia rheumatica giant cell arteritis Hypertension Gastroesophageal reflux Depression Asthma Alcohol abuse PSH: s/p femur fracture, s/p bilateral cataract surgery, s/p tonsillectomy, s/p malignant melanoma removal from neck, s/p basal cell carcinoma removal Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema- none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170], Wed. [2154-4-17] 1pm Please call to schedule appointments with your Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 19] Primary Care Dr. [First Name4 (NamePattern1) 16883] [Last Name (NamePattern1) 86989] [Telephone/Fax (1) 644] 4-5 weeks Follow-up with your Rheumatologist Dr. [Last Name (STitle) ] 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:[2154-3-25]	[ "4241", "4019" ]
Admission Date: [2116-1-20] Discharge Date: [2116-1-24] Date of Birth: [2088-7-28] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 301] Chief Complaint: [Known firstname ] [Known lastname 6164] is a 27 year-old female referred for the evaluation of gastric restrictive surgery in the treatment and management of morbid obesity. Major Surgical or Invasive Procedure: Status Post Laparoscopic Gastric Bypass History of Present Illness: [Known firstname ] has class III morbid obesity with weight of 304.1 lbs as of [2115-9-5] (initial screen weight [2115-6-24] was 305.1 lbs), height of 64.75 inches and BMI of 51. Her previous weight loss efforts have included Weight Watchers in [2113]/[2114] losing 13 lbs, [First Name8 (NamePattern2) 1446] [Last Name (NamePattern1) ] in [2108]/[2109] losing 30 lbs and [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] Loss with little results, prescription weight loss medication Meridia for one month with no weight loss, Slim-Fast for 2 weeks losing 4 lbs, [Doctor Last Name 1729] Diet for weeks with no weight loss and over-the-counter Ephedra-containing supplement for 4 weeks losing 10 lbs. She cannot maintain her lost weight for no more than one month. Her weight at age 21 was 200 lbs with her lowest adult weight 180 lbs and her highest being her initial screen weight of 305 lbs. She weighed 250 lbs in [2114]. She stated she developed significant [Last Name 4977] problem in childhood. Factors contributing to her excess weight include large portions, too many fats and carbohydrates, inconsistent meal schedules, stress, emotional and nervous eating, compulsive eating and lack of exercise. She denied history of eating disorders - no bulimia, anorexia, laxative or diuretic abuse. She has situational depression centered around her weight. Past Medical History: Her medical history is noted for cardiac arrhythmias (SVT) on beta-blocker for control, occasional weight-related back pain and iron deficiency buy recent blood work. Review of systems is relatively unremarkable except for palpitations. She denied chest pain, shortness of breath, dizziness or lightheadedness, abdominal pain, nausea/vomiting, diarrhea or constipation. She has menstrual irregularities. She denied heart disease, hypertension, diabetes, asthma, sleep breathing disorder, GERD, dyslipidemia, thromboembolism, polycystic ovary syndrome, osteoarthritis, thyroid or gallbladder disease. She has no surgical history. Social History: She smokes 3 cigarettes a week, no recreational drugs, [4-16] glasses of Bicardi/Budweiser a week and has one cup of coffee 5 days a week as well as glass of diet caffeine-free soda a day. She is a homemaker and CNA, single with one child age 6. Family History: Family history is noted for both parents living father age 58 with obesity; mother age 55 with hyperlipidemia, arthritis and obesity. Physical Exam: Per Dr. [Last Name (STitle) 28349] on [2115-9-23] Her blood pressure was 118/72 and pulse 82. On physical examination [Known firstname ] was casually dressed in no distress. Her skin was warm and dry with mild acne and very mild hirsutism. Sclerae were anicteric, conjunctiva clear,pupils were equal round and reactive to light, fundi were normal, mucous membranes were moist, tongue was smooth and pink, oropharynx was without exudates or hyperemia. Trachea was in the midline and the neck was supple without adenopathy, thyromegaly or carotid bruits, there was no JVD. Chest was symmetric and the lungs were clear to auscultation bilaterally. Cardiac exam was regular rate and rhythm with normal S1 and S2, no murmurs, rubs or gallops. Abdomen was obese but soft, non-tender, non-distended with normal bowel sounds and no masses, hernias, no incision scars. There was no spinal tenderness or flank pain. Extremities were without edema, venous insufficiency or clubbing. There was no evidence of joint swelling or inflammation. There were no focal neurological deficits. Pertinent Results: [2116-1-20] 06:00PM BLOOD Hct-33.5* [2116-1-23] 08:31AM BLOOD WBC-9.8 RBC-3.57* Hgb-10.1* Hct-29.5* MCV-83 MCH-28.2 MCHC-34.1 RDW-14.5 Plt Ct-278 [2116-1-22] 07:30AM BLOOD Plt Ct-454* [2116-1-23] 04:50AM BLOOD Glucose-81 UreaN-8 Creat-0.5 Na-138 K-3.7 Cl-102 HCO3-25 AnGap-15 [2116-1-23] 04:50AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8 [2116-1-22] 04:55AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9 [2116-1-22] 07:23AM BLOOD Type-ART pO2-125* pCO2-33* pH-7.44 calTCO2-23 Base XS-0 Brief Hospital Course: 27 year old female admitted for weight reduction surgery. On [2116-1-20] underwent a laparoscopic gastric bypass without complications. Postoperative day 1 - Patient had UGI showing post Roux- en- Y gastric bypass without evidence of leak. There is delay of passage of contrast into the distal jejunum at the expected region of jejunjejonostomy, likely related to postsurgical adynamic ileus. Nasogastric tube discontinued and she was started on bariatric stage one and tolerated well. Postoperative day 2 - Patient went into rapid svt, lopressor 5mg given x 3 without effect. Adensoine 6mg given resulting in conversion of sinus rhythm. ABG obtained which was normal. Denies shortness of breath. Patient transferred to Intensive care unit to monitor heart rate. Cardiology consult called. Patient placed on verapamil 40mg q6 hours. Progressed to Bariatric stage 2 diet. Postoperative day 3 - Patient feels well. Continues to be in sinus rhythm on verapamil. Transferred back to floor. Progressed to stage 3 diet. Patient out of bed and ambulating. Very little pain. Postoperative day 4 - Patient had good night and continues to be in sinus rhythm. One event this morning of transient sinus bradycardia noted on telemetry. When questioned patient was trying to move bowels at this time. EKG obtained with no change and cardiology called. They have seen her and feel that she is ready to go home. Discharge plans 1. Cardiac - Patient will take verapamil 40mg every 8 hours per cardiology. She is to follow up with Dr. [Last Name (STitle) ] in 4 weeks regarding further treatment of her SVT. Contact information has been given to patient. 2. Gastric bypass - Patient will be discharged on bariatric stage 3. She is to follow up with Dr. [Last Name (STitle) ] on [2115-2-12] Medications on Admission: Metoprolol 50mg po daily Vicodin PRN for back pain Discharge Medications: 1. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day. Disp:600 ml Refills:2 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:600 ML(s) Refills:0 3. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 4. Verapamil 40 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Status Post Laparoscopic Gastric Bypass Discharge Condition: Stable Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay in Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications, CRUSH ALL PILLS. You will be starting some new medications: 1. You will be given a prescription for pain medication, which may make you drowsy. Do not drive while taking pain medication. 2. You should begin taking a Flintstones chewable complete multivitamin. No gummy vitamins. 3. You will be taking Zantac liquid 150 mg twice daily for one month. Thismedicine prevents gastric reflux. 4. You will be taking Actigall 300 mg twice daily for 6 months. This medicine prevents you from having problems with your gallbladder. 5. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. Activity: No heavy lifting of items [11-25] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 304], MD Phone:[Telephone/Fax (1) 305] Date/Time:[2116-2-12] 10:00 Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 18800], RD Phone:[Telephone/Fax (1) 305] Date/Time:[2116-2-12] 10:30 Completed by:[2116-1-24]	[ "42789", "311" ]
Admission Date: [2146-7-9] Discharge Date: [2146-7-18] Date of Birth: [2125-1-10] Sex: F Service: SURGERY Allergies: Meperidine / Fentanyl Attending:[Last Name (NamePattern1) 4659] Chief Complaint: 24 hours of nausea and 10 hours of severe abdominal pain. Major Surgical or Invasive Procedure: Exploratory laparotomy, oversew of perforation, abdominal washout. History of Present Illness: The patient is a 21-year-old woman 3 years status post a gastric bypass in an outside institution with a known history of pouch ulcers via history on endoscopy x2. Despite that she has continued smoking and she takes nonsteroidal anti-inflammatory medications regularly. At approximately 8:00 a.m. on the morning of admission, she experienced sharp left lateral deep abdominal pain which then progressed to her back and over the course of the day has become slightly more diffuse and is quite severe in nature. She presented to an outside hospital. She had a CT scan which showed free air in her abdomen and some fluid in her pelvis. She was febrile, had an elevated white count and tachycardiac. On abdominal exam, she had diffuse pain throughout her abdomen. She did not have a rigid abdomen but she did have guarding and rebound diffusely. At this time she was taken to the operating room for exploratory laparotomy. Past Medical History: 1. gastric bypass surgery [2143] - lost 225 lbs since, was originally 360 lbs. done at [Hospital1 ] 2. gastric ulcers 3. "enlarged spleen" on imaging [2146] 4. L-eye corneal ulcer [2-28] contact use 5. h/o cocaine abuse 6. s/p L lumpectomy (benign pathology) in [2138] 7. s/p tonsilectomy 8. hx of headaches - eval by neuro [2144] 9. depression 10. iron-deficiency anemia Social History: living with parents, taking care of grandmother who has a fx of the hip. pt was previously a nursing student at [Location (un) 11177], moved back to [Location (un) 86] [4-8], "taking off" from studies. [3-30] drinks per week, smokes 1 ppd x 5 years, smokes marijuana occasionally; denies IV drug use. Last sexual relation 1yr ago, HIV (-) then. +tattoos. Family History: Mother - thyroid cancer, brain aneurysm. Father and brother healthy. Physical Exam: Tmax: 98.4 Tc: 98.1 HR: 85 BP: 99/65 RR: 18 O2: 96% on RA General: Patient appears well Neuro: Pain well controlled CV: RRR Pulm: CTAB Abd: Soft, non-tender, non-distended Incision: Staples removes, wound open to air with Steri-strips Pertinent Results: [2146-7-12] 08:00AM BLOOD WBC-15.8* RBC-3.77* Hgb-9.2* Hct-28.4* MCV-75* MCH-24.3* MCHC-32.2 RDW-20.3* Plt Ct-296 [2146-7-9] 09:06PM BLOOD WBC-23.6# RBC-4.10 Hgb-9.6* Hct-31.0* MCV-76* MCH-23.4* MCHC-30.9* RDW-20.1* Plt Ct-313 [2146-7-11] 10:37PM BLOOD Neuts-82.4* Lymphs-10.9* Monos-3.5 Eos-3.0 Baso-0.2 [2146-7-9] 09:06PM BLOOD Neuts-89.9* Lymphs-7.6* Monos-2.2 Eos-0.1 Baso-0.2 [2146-7-12] 08:00AM BLOOD Plt Ct-296 [2146-7-10] 01:56AM BLOOD PT-15.4* PTT-30.4 INR(PT)-1.4* [2146-7-9] 09:06PM BLOOD PT-14.3* PTT-28.2 INR(PT)-1.2* [2146-7-17] 06:20AM BLOOD Glucose-87 UreaN-3* Creat-0.6 Na-137 K-4.2 Cl-98 HCO3-29 AnGap-14 [2146-7-16] 08:25AM BLOOD Glucose-92 UreaN-4* Creat-0.4 Na-137 K-4.1 Cl-97 HCO3-25 AnGap-19 [2146-7-11] 03:16AM BLOOD Glucose-94 UreaN-5* Creat-0.5 Na-134 K-4.0 Cl-99 HCO3-30 AnGap-9 [2146-7-10] 01:56AM BLOOD Glucose-121* UreaN-5* Creat-0.5 Na-134 K-3.9 Cl-105 HCO3-24 AnGap-9 [2146-7-9] 09:06PM BLOOD Glucose-117* UreaN-6 Creat-0.6 Na-134 K-3.6 Cl-102 HCO3-24 AnGap-12 Radiology Report UGI SGL CONTRAST W/ KUB Study Date of [2146-7-15] 10:06 AM IMPRESSION: No evidence of leak at the anastomosis between the gastric pouch and Roux limb. Radiology Report CHEST (PORTABLE AP) Study Date of [2146-7-13] 8:24 AM The free air within the abdomen is consistent with a recent laparotomy. The NG tube tip is in the very proximal stomach and should be advanced. Lungs are clear and the mediastinal contour is unremarkable. Brief Hospital Course: The patient presented from an OSH with an ulcerated RNY site. She was pre-op'd and taken to the OR for an exploratory laparotomy, oversew of perforation, abdominal washout. She was then taken to the intensive care unit due to the late hour in the evening and her preop septic picture. She was NPO with IVF/PCA/Foley/NGT/JP and abx. . The patient's pain was poorly controlled with post operative morphine PCA, and a Ketamine infusion was added. A pain consult was obtained, and the Dilaudid PCA was increased to 0.5mg q6min no basal, max 5mg/hr and Ketamine was stopped. . She was transferred to the floor on POD 2. The NGT was left in place and the patient was maintained as NPO. On POD 5 a Swallow study was done indicating no leak. The NGT was removed at this time and the patient's diet was advanced as tolerated from sips to regular. She tolerated this well. Her meds were changed to po and homes meds restarted. Her foley was removed with out any issues. JP output decreased and this was also removed along with her staples and steri strips were placed. . All discharge paperwork was reviewed with the patient and all questions answered. She will follow up with Dr. [Last Name (STitle) ] in [1-28] weeks. Medications on Admission: 1. Seroquel - 600mg qhs 2. Trazadone 50mg prn - "for anxiety" 3. Iron - IV infusions at [Location (un) 2199] 4. Calcium - daily, unknown dose 5. Multivitamin - qd Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Do not take more than 4000 mg of Tylenol. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Perforation at the gastric pouch Roux-en-Y anastomosis. Discharge Condition: Stable, tolerating PO, pain well-controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Continue home meds as usual. The patient has been extensively counseled NOT to take any NSAID at all in the future and to immediately STOP SMOKIING. She understands that if she continues to take NSAID and to smoke that it will increase her risk of ulcers perforation in the future. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in 1 to 2 weeks ([Telephone/Fax (1) 8792]). [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ] MD, [MD Number(3) 4661] Completed by:[2146-7-27]	[ "3051" ]
Admission Date: [2149-3-25] Discharge Date: [2149-4-1] Date of Birth: [2074-4-26] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5569] Chief Complaint: Clotted AV Graft Hyperkalemia Major Surgical or Invasive Procedure: [2149-3-25]: Right femoral temporary dialysis line placement [2149-3-26]: IR LUE AVF thrombectomy c/b Radial art occlusion s/p extraction of thrombus. History of Present Illness: 74M well known to the transplant surgery service presents with clotted AVG of the left upper extremity and hyperkalemia to 6.8. According to patient he is unaware when graft lost it's pulse and thrill, but today at HD it was noted to be nonfunctioning. He was unable to be dialyzed and referred to [Hospital1 18] for thrombectomy. However, in the preop holding area patient preoperative labs were notable for K of 6.8. HE was given insulin 10 units iv and d50. Attempts at placing an HD line were unsuccessful he is currently awaiting IR placement of temporary HD line. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension . 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS (1) CAD s/p NSTEMI and stenting of the distal RCA, OM2 in [2-/2147] complicated by GIB and paroxysmal atrial fibrillation (2) s/p NSTEMI and unstable angina in [2148-10-2], cath showed compelte occlusion of all three stents placed in [2-/2147], stent placed in LCx (3) s/p unstable angina, [Year (4 digits) ] to LCx since LCx placed in [9-/2148] had instent stenosis . 3. OTHER PAST MEDICAL HISTORY: -Three vessel CAD: see above for details -Perioperative (bowel resection) vasospasm requiring cardiac cath with NTG -Mild-moderate MR [Name13 (STitle) 37625] EF: 45% with focal inferior-posterior wall motion abnormalities -ESRD on HD, Cr [2-18] at baseline -Ischemic Colitis: s/p SMA thrombectomy, with [Doctor Last Name 3379] pouch and end ileostomy. Also complicated by recent diversion colitis in 2/[2146]. -Peripheral [Year (4 digits) 1106] disease s/p aortobifemoral bypass [2131] -Raynauds -Dementia -Atrial fibrillation -H/o perioperative CVA: no deficits -Hyperlipidemia -HTN -H/o Achalasia s/p esophageal dilation -H/o VRE infection -Anemia -[2149-3-26] IR LUE AVF thrombectomy c/b Radial art occlusion with thrombus extraction . Social History: Patient lives with his wife. [Name (NI) ] outside help needed. Active at baseline. -Tobacco history: 40 pack years, quit 11 years ago -ETOH: None -Illicit drugs: None Family History: Comes from a family of 20 kids. Only 2 are still alive. Significant history of cardiac disease in the family. Physical Exam: VS: 56 139/58 18 O2 sat=98% RA NAD, Answers all questions, easily arousable but sleepy bradycardic crackles L> R Soft abdomen with ileostomy with gas and + Output, Nontender Ext: WWP, no edema. LUE with radial avf scar well healed with LUE AVG without pulse or thrill. 1+ radial bilaterally Pertinent Results: [2149-3-30] 04:19AM BLOOD WBC-6.2 RBC-3.33* Hgb-10.3* Hct-30.4* MCV-91 MCH-30.9 MCHC-33.9 RDW-16.8* Plt Ct-140* [2149-3-31] 05:15AM BLOOD PT-17.2* PTT-74.6* INR(PT)-1.5* [2149-3-30] 04:19AM BLOOD PT-14.8* PTT-57.3* INR(PT)-1.3* [2149-3-29] 04:16AM BLOOD PT-13.8* PTT-49.0* INR(PT)-1.2* [2149-3-30] 04:19AM BLOOD Glucose-95 UreaN-24* Creat-5.5# Na-139 K-3.6 Cl-96 HCO3-33 AnGap-14 [2149-3-30] 04:19AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.0 Brief Hospital Course: 74 y/o male admitted with non-functioning AV graft, found at HD. On admission labs the potassium was 6.8. At this time an attempt was made to place a temporary IJ line for emergent HD. Right IJ was very small in caliber and left IJ was unable to be wired. Procedure was stopped and the patient sent to IR to have femoral line placed given past history of bilateral aorto-[Hospital1 ] fems. Hemodialysis was performed via that line with post HD potassium of 4.3. On [2149-3-26], he underwent IR LUE AVF thrombectomy c/b radial art occlusion that requried consulting Dr. [Last Name (STitle) ] who performed extraction of thrombus with export device. He was treated w/ heparin, integrelin and TPA. Completion angiogram demonstrated patent radial and ulnar arteries. However, the left radial pulse was not palpable, but the ulnar was palpable. On [3-29], hemodialysis was successfully performed via the left arm AVG. On [3-30], the temporary right groin dialysis line was removed. He did experience bleeding at this site requiring a pressure dressing that was removed on [3-31]. No futher bleeding occurred at groin site. He was dialyzed again on [4-1] without incident via the left AVG. He remained on a heparin drip until [3-31]. Coumadin (5mg) was given on [3-30] and [3-31]. INR increased to 2.2 on [4-1]. After furhter review, long term coumadin was stopped given h/o of GI bleed 6months prior. He was to continue on aspirin and plavix given h/o cardiac stents. The left arm AVG had a thrill and was working well for dialysis on [4-1]. Vital signs were notable for sbp in 160-190 range. Amlodipine 5mg qd was started. He was tolerating food and ostomy was functioning well. PT assessed him and declared him safe for discharge to home. He will resume dialysis in [Location (un) ]. Of note, PT recommended a rolling walker and home PT. This was arranged prior to discharge. . Medications on Admission: aspirin 325 mg Tablet, Plavix 75 mg, amiodarone 200 mg', carvedilol 12.5 mg", lisinopril 7.5 mg', loperamide 2 mg ", pantoprazole 40 mg', lovastatin 10 mg', sevelamer HCl 800 mg"', 1337 mg "', isosorbide mononitrate 30 mg', Nephrocaps 1 mg'. Discharge Medications: 1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. loperamide 2 mg Capsule Sig: One (1) Capsule PO Q 12H (Every 12 Hours). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a day). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever: no more than 4000mg per day. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home with Service Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: ESRD thrombosed AVG left radial artery occlusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call Dr.[Name (NI) 8584] office [Telephone/Fax (1) 673] if you have any of the following: fever, chills, Left arm swelling, discoloration, numbness, increased pain or bleeding or you experience any bleeding from right groin old catheter site You can resume dialysis at [Location (un) ]. Dr. [Last Name (STitle) ] will manage your Coumadin dosing Followup Instructions: [Name6 (MD) 5536] [Name8 (MD) ], MD ([Hospital ] Care Center) Phone:[Telephone/Fax (1) 5537] Date/Time:[2149-4-21] 1:00 Completed by:[2149-4-1]	[ "40391", "2767", "42731", "2724", "V1582" ]
Admission Date: [2184-6-7] Discharge Date: [2184-6-16] Date of Birth: [2144-12-25] Sex: M Service: MEDICINE Allergies: Codeine Attending:[Doctor First Name 2080] Chief Complaint: septic shock Major Surgical or Invasive Procedure: Intubation Central line placement Arterial line placement Esophageal balloon placement Nasogastric tube feeds History of Present Illness: 39 y/o M with no significant [Hospital ] transferred from OSH with septic shock from bilateral PNA, intubated and on pressors. . Patient was seen by his PCP earlier today and diagnosed with bilateral PNA on CXR, given azithromycin. Several hours later he came back to the ED in acute respiratory distress. Initial VS: T97.9 P112 RR 25 BP69/28 o2 sat was 80% on 100% NRB. He was intubated and found to have thick copious secretions and started on vanc 1 g IV/levoquin 750mg IV/ceftriaxone 1 gram IV. CVL and a-line placed with administration of 6 L NS. An NG tube was placed which was somewhat traumatic. His WBC was 31 and creatinine 2.5. ABG at [Location (un) 620] was 7/70/200. At [Location (un) 620] he also received Morphine 1g IV, tordol 30mg IV, zofran 4mg, magnesium sulfate 2mg IV, rocurium, succinyl choline 120mg IV, etomidate 40mg, versed 9mg total, fentanyl 20mg x2. . On arrival to the ICU vitals were 97.6 105.69 (on levophed) RR20 81% on 500 x 18 PEEP 10 Fio2 of 100%. His ABG on arrival was 7.15/68/50/25. HI PEEP was increased to 22 and his repeat gas was 7.15/66/110. He was still paralized. . Review of systems: unable to obtain Past Medical History: Tonsilectomy after Mono when 20 yo Previous Sinus Infections Adenoids out at 5 yo for ear infections Social History: Was in the military between high school and college -occasional etoh use -no smoking -no illicits Family History: unable to obtain Physical Exam: Vitals: 97.6 105/69 (on levophed) RR20 81% General: Pupils equally round, eyes fixed, no corneal reflex HEENT: MMM, + dried blood in nares Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular and tachy, nl s1/s2, no m/r/g Ext: mildly cold extremities, 1+ distal pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [2184-6-7] 01:44AM BLOOD WBC-46.2* RBC-4.15* Hgb-13.2* Hct-38.1* MCV-92 MCH-31.8 MCHC-34.6 RDW-12.6 Plt Ct-261 [2184-6-7] 01:44AM BLOOD Neuts-76* Bands-13* Lymphs-2* Monos-5 Eos-1 Baso-0 Atyps-0 Metas-3* Myelos-0 [2184-6-7] 01:44AM BLOOD PT-18.0* INR(PT)-1.6* [2184-6-7] 03:05PM BLOOD FDP-10-40* [2184-6-7] 03:05PM BLOOD Fibrino-636* [2184-6-7] 01:44AM BLOOD Glucose-276* UreaN-24* Creat-2.0* Na-134 K-6.6* Cl-104 HCO3-24 AnGap-13 [2184-6-7] 01:44AM BLOOD ALT-72* AST-84* LD(LDH)-248 CK(CPK)-58 AlkPhos-87 Amylase-38 TotBili-4.3* DirBili-4.1* IndBili-0.2 [2184-6-7] 01:44AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2184-6-7] 01:44AM BLOOD Albumin-3.5 Calcium-6.9* Phos-2.5* Mg-1.8 Iron-13* [2184-6-8] 02:19AM BLOOD D-Dimer-2899* [2184-6-7] 03:05PM BLOOD D-Dimer-4445* [2184-6-7] 01:44AM BLOOD Hapto-156 [2184-6-7] 01:52AM BLOOD Glucose-258* Lactate-1.0 Na-134* K-6.0* . Discharge labs: [2184-6-16] 05:50AM BLOOD WBC-10.7 RBC-3.94* Hgb-12.1* Hct-34.4* MCV-88 MCH-30.7 MCHC-35.1* RDW-12.6 Plt Ct-469* [2184-6-16] 05:50AM BLOOD PT-15.0* PTT-28.2 INR(PT)-1.3* [2184-6-16] 05:50AM BLOOD Glucose-121* UreaN-15 Creat-1.1 Na-137 K-3.9 Cl-100 HCO3-27 AnGap-14 [2184-6-16] 05:50AM BLOOD ALT-40 AST-27 AlkPhos-148* TotBili-0.7 [2184-6-16] 05:50AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.2 . Urinalysis: [2184-6-7] 01:45AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 [2184-6-7] 01:45AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG . Bronchoalveolar lavage: [2184-6-7] 12:37PM OTHER BODY FLUID Polys-88* Lymphs-2* Monos-0 Macro-10* . Other tests: [2184-6-13] 07:02PM BLOOD HIV negative (NEGATIVE FOR HIV-1 ANTIBODIES. SAMPLE SHOWS REPEATED LOW LEVEL REACTIVITY BY EIA BUT NOT CONFIRMED BY WESTERN BLOT AT [Company ]. NO SPECIFIC HIV ANTIBODIES DETECTED.) . Microbiology: Blood cultures x 9, dated [2184-6-7] to [2184-6-11]: no growth Urine culture [2184-6-7]: no growth Sputum cultures x 3, dated [2184-6-7], [2184-6-8], and [2184-6-10]: no growth Urine legionella antigen [2184-6-7]: negative BAL [2184-6-7]: GRAM STAIN: 2+ PMNs. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE: NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii: NEGATIVE FUNGAL CULTURE: NO FUNGUS ISOLATED. Respiratory Viral Culture: No respiratory viruses isolated. Urine culture [2184-6-8]: ENTEROCOCCUS SP. ~1000/ML Urine culture [2184-6-10]: no growth Catheter tip [2184-6-12]: no growth . CXR [2184-6-6] There is an endotracheal tube whose distal tip is just above the clavicles, 6.7 cm above the carina. This could be advanced 1 to 2 cm for more optimalplacement. There remains a consolidation within the right upper lobe with margination of the inferior fissure. The feeding tube tip is well below the gastroesophageal junction. There is also some hazy opacity within the left mid lung field suggestive of developing infiltrate. . CXR [2184-6-15]: Chest findings are stable and there are some remaining parenchymal densities in the right upper lobe abutting the minor fissure. No other new infiltrates are seen and no pneumothorax is present. A left-sided PICC line is identified, seen to terminate overlying the SVC at the level of the carina. . Right upper extremity venous ultrasound [2184-6-11]: Occlusive thrombus seen within the right cephalic vein. No deep vein thrombosis seen in the remainder of the veins of the right arm. Brief Hospital Course: 39 y/o M with no significant [Hospital ] transferred from OSH with septic shock from bilateral PNA, intubated and on pressors. . #. Septic shock: The patient presented with septic shock and bilateral pulmonary infiltrates. He received 8.5L of IV fluid on admission and required the addition of norepinephrine to maintain his blood pressure. The patient was treated with vancomycin, azithromycin and ceftriaxone for community acquired pneumonia. He continued to spike high fevers for several days after admission. As his sepsis improved, the pressors were slowly weaned. The patient was transferred to the medical floor on [2184-6-14] in stable condition. . #. Hypoxic respiratory failure: Thought to be secondary to severe pneumonia. Thepatient initially was sedated and placed on ARDSnet ventilation. He continued to draw extremely high tidal volumes, requiring paralysis for the first 2 days of his admission. This was later discontinued, and the patient's sedation was weaned as well. He had several spontaneous breathing trials with were initially unsuccessful due to low tidal volumes and tachypnea, however he was successfully extubated on [2184-6-13]. The patient was breathing comfortably on room air at the time time of discharge. . #. Community-acquired pneumonia: The patient presented with bilateral infiltrates and septic shock. No microorganism was identified despite repeated blood, urine, and sputum culture, as well as bronchoaveolar lavage. The patient was treated with azithromycin, ceftriaxone, and vancomycin. He completed a 5-day course of azithromycin and was still on ceftriaxone and vancomycin at the time of discharge. A PICC was placed prior to discharge, with a plan to continue ceftriaxone and vancomycin until [2184-6-21] (14-day course). The PICC should be removed once the patient's antibiotic course is complete. . #. Acute renal failure: The patient had acute renal failure with a creatinine of 2.6 at the outside hospital. With fluid resuscitation this improved to his baseline of 1.0. . #. Hyperkalemia: The patient was hyperkalemic to 6.6 on presentation, with mildly peaked T waves in V2-V4 on EKG. Most likely secondary to renal failure. The patient was given Ca gluconate, insulin, glucose and albuterol on admission. His hyperkalemia improved without further intervention. . #. Transaminitis: Liver enzymes wereelevated on admission. This was thought to be related to shock liver in the setting of septic shock. The patient's liver enzymes trended down throughout his admission. However, the patient developed an elevated alkaline phosphatase on [2184-6-12]. He had no abdominal pain. The patient's alkaline phosphatase was trending down at the time of discharge. The patient should have his LFTs rechecked in the outpatient setting. . #. HIV testing: An HIV test was sent in the intensive care unit due to concern about the severity of the patient's pneumonia. This was done despite the absence of risk factors. The test was negative. (The [Doctor First Name ] showed weak reactivity, but the Western blot was negative.) Given the weakly-reactive [Doctor First Name ], this test should be repeated in [8-19] weeks to confirm negativity. . #. Hallucinations: The patient had some hallucinations on [2184-6-12] and [2184-6-13], just after extubation. This was thought to be due to benzodiazepine withdrawal (in the setting of sedation given while intubated) and responded well to diazepam. The patient was free of hallucinations and not requiring any diazepam at the time of discharge. . #. Right cephalic vein thrombosis: The patient developed an occlusive right cephalic vein thrombus while in the ICU. This caused right upper extremity swelling, which had resolved by the time of discharge. . #. Asthma: The patient has been diagnosed with asthma in the past, although he was not on any treatment prior to admission. The patient was given a prescription for albuterol at the time of discharge. Medications on Admission: flonase nasal spray daily Discharge Medications: 1. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 6 days: Last day = [2184-6-21]. Disp:QS Refills:0 2. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 8H (Every 8 Hours) for 6 days: Last day = [2184-6-21]. Disp:QS Refills:0 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for wheezing. Disp:1 inhaler Refills:0 4. 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. 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) puffs each nostil Nasal once a day. Discharge Disposition: Home With Service Facility: [Location (un) 511] Home Therapies Discharge Diagnosis: Primary: 1. Pneumonia 2. Septic shock 3. Respiratory failure . Secondary 1. asthma 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 pneumonia. You went into shock, and required ICU care that included a ventillator to help you breathe and medications to maintain your blood pressure. You received antibiotics for your pneumonia, and your symptoms improved. . We did not identify the cause of your pneumonia, but it was likely due to a bacterial infection. You were treated with 3 antibiotics, called azithromycin, ceftriaxone, and vancomycin. You had a special IV (called a PICC) placed in order to allow you to continue to get ceftriaxone and vancomycin at home. You will complete your course of ceftriaxone and vancomycin on [2184-6-21], at which point the PICC can be removed. . You had some elevations in your liver enzymes that improved during your hospitalization. You should have your liver enzymes rechecked with your primary care doctor. . There have been some changes to your medications: START ceftriaxone. Continue this until [2184-6-21]. START vancomycin. Continue this until [2184-6-21]. START albuterol as needed for wheezing. . Follow up with your primary care doctor within 1 week. Followup Instructions: Please call you primary care doctor Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 41961] and make an appointment to see him within 1 week.	[ "0389", "486", "51881", "5849", "78552", "2762", "99592", "49390", "2767" ]
Admission Date: [2145-11-9] Discharge Date: [2145-11-14] Date of Birth: [2067-10-31] Sex: M Service: CARDIOTHORACIC Allergies: Zestril / Clindamycin Attending:[First Name3 (LF) 1505] Chief Complaint: Asymptomatic Coronary Artery Disease with abnormal stress test Major Surgical or Invasive Procedure: [2145-11-9] Two Vessel Coronary Artery Bypass Grafting utilizing left internal mammary artery to left anterior descending, with vein graft to right coronary artery History of Present Illness: This is a 77 year old gentleman with hypertension, hyperlipidemia and diabetes is followed with annual surveillance stress tests by his PCP due to his cardiac risk factors. He denies any cardiac symptoms of chest pain, or dyspnea but does report sporadic hot flashes/diaphoresis, unrelated to activity over the last 8 months. His most recent stress test was abnormal so he has been referred for outpatient cardiac catheterization which revealed severe three vessel coronary artery disease. He was therefore referred for surgical revascularization. Past Medical History: Hypertension Hypercholesterolemia Diabetes Type II Cataracts Chronic anemia Anxiety Osteoporosis s/p Hernia repair s/p Excision Basal cell Social History: Occupation: Owns a hotel in [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1139]: quit [2102], currently smokes cigar 1x/week ETOH: 21 oz per week. [Doctor Last Name ] and wine with dinner when out Recreational drug use: NO - remote marijuana Family History: Father died of an MI at age 68. Physical Exam: Pulse: 60 SR Resp: 20 O2 sat: 100%-@LNP B/P Right: 157/87 Height: 5 feet 10 inches Weight: 170 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] MMM, normal oropharynx Neck: Supple [x] Full ROM [x] no [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: no Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] EdemaNone Varicosities: None [x] Neuro: A&Ox3, MAE, Grossly intact, nonfocal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: cath Left: 2+ Carotid Bruit: no Pertinent Results: [2145-11-9] Intraop TEE: PRE-BYPASS: The left atrium is normal in size. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POST BYPASS: Normal biventricular systolic function. LVEF 55%. Intact thoracic aorta. Brief Hospital Course: Mr. [Known lastname ] was admitted and underwent coronary artery bypass grafting by Dr. [Last Name (STitle) ]. Operative findings were notable for poor coronary distal targets. The circumflex/obtuse marginals were not suitable for bypass grafting. For additional surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Due to poor coronary distal targets, he was maintained on Plavix. His ICU course was otherwise uneventful, and he transferred to the step down unit on postoperative day one. Chest tubes and pacing wires were removed without complication. Respiratory: He was sucessfully extubated on [2145-11-9]. Aggressive pulmonary toilet, nebs, incentive spirometer he titrated off oxygen with saturations of 95% on room air. Cardiac: Beta-blockers were titrated as tolerated. He remained in sinus rhythm 70-90's. Blood pressure 100-130's, stable. He was not started on ACE due to unknown allergy. He was started on Plavix for incomplete revascularization and PCI/stenting of LCX, with Dr. [Last Name (STitle) ]. GI: H2 blockers and bowel regime. Nutrition: diabetic diet Renal: aggressive diuesis for volume overload. Good urine output. Renal function stable with normal limits basline Cre 1.0. Endocrine: insulin drip while in ICU with BS < 130. Once oral diet restarted he was transition to SC insulin and oral hyperglycemics with BS < 150. He was sent home with a perscription for a glucometer and diabetic teaching by VNA. Heme: he was transfused 1 Unit PRBC on [2145-11-10] for HCT 23 and 2 UPRBC for HCT 21 on [2145-11-13] with HCTincrease to 25. Pain: well controlled on PO pain medications Mobility; He was seen by physical therapy for strength and conditioning and cleared for discharge to home by Dr. [Last Name (STitle) 914] on POD# 5. Disposition:Home with VNA services Medications on Admission: ATENOLOL 100mg daily ATORVASTATIN 40 mg daily GLYBURIDE 5 mg daily ISOSORBIDE MONONITRATE 30 mg daily TRIAMTERENE-HYDROCHLOROTHIAZID 37.5 mg-25 mg daily ASPIRIN 81 mg daliy ERGOCALCIFEROL CENTRUM OMEGA-3 FATTY ACIDS Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for poor targets. Disp:30 Tablet(s) Refills:0 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days: for 10 days then follow-up with your doctor regarding dyazide. Disp:10 Tablet(s) Refills:0 7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days: take with lasix. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Omega 3-6-9 Fatty Acids 400-400-200 mg Capsule Sig: One (1) Capsule PO once a day. 9. Centrum 0.4-162-18 mg Tablet Sig: One (1) Tablet PO once a day. 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:30 Capsule, Sustained Release(s) Refills:2 14. glucometer glucometer and test strips One month supply 11 refills 15. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Coronary artery disease, s/p CABG Diabetes Mellitus Type II Hypertension Dyslipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 2+LE edema 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 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 -Take lasix 40 mg daily for 10 days with potassium then call your PCP regarding restarting your Dyazide. Followup Instructions: You are scheduled for the following appointments Surgeon: [Doctor First Name ] [Doctor Last Name ] [2145-12-2] 2:45PM [Telephone/Fax (1) 170] Cardiologist: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2145-12-9] 3PM Please call to schedule appointments with your Primary Care Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [4-5] weeks [Telephone/Fax (1) 10813] 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:[2145-11-14]	[ "41401", "4019", "2724", "25000" ]
Admission Date: [2184-5-24] Discharge Date: [2184-6-10] Date of Birth: [2126-12-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: septic shock transfer from OSH MICU for management of pancreatitis, sepsis, and ARDS Major Surgical or Invasive Procedure: Tracheal intubation at outside hospital Hemodialysis Temporary hemodialysis catheter placement Endoscopic ultrasound Bronchoscopy with bronchoalveolar lavage History of Present Illness: 57yo man presented to OSH [2184-5-17] with abdominal pain and nausea, also with some dyspnea on exertion. On admission he was noted to have pancreatitis and was admitted for management. A CT showed no common bile duct dilation, but stones were seen in the gallbladder with borderline gallbladder wall edema vs. peri-colicystic fluid. Several days after admission he became febrile, and was found to have klebsiella bacteremia. He developed worsening respiratory distress with hypoxia shortly after taking po barium contrast for a planned CT, at which time he was diagnosed with ARDS by films and intubated. Shortly after intubation he had a code for pulseless electrical activity. He was resuscitated, and after a day on pressors was weaned off successfully. His urine output decreased, however, and he developed acute renal failure. He was transferred to [Hospital1 18] for management with the possibility of requiring hemodialysis or cholecystectomy. Past Medical History: hypertension Social History: Polish, works as machine operator. Denies tobacco and alcohol. Wife and kids live in Poland. Family History: father with MI at 38yo, siblings with hypertension Physical Exam: On admission: VS: T 98 BP 140/80 HR 80 RR 20 97% Vent settings: AC 500x12 40% PEEP 8 Genl: Intubated, sedated HEENT: Pinpoint pupils Neck: + 9 cm JVD No TM CV: RRR nl s1s2, no mrg Lungs: rare soft wheeze Abd: tense, non tender Ext: 1+edema Neuro: Awakens to loud voice Pertinent Results: Admission labs: WBC-14.3* RBC-3.18* Hgb-10.1* Hct-28.8* MCV-91 MCH-31.9 MCHC-35.2* RDW-13.7 Plt Ct-93* Neuts-93* Bands-0 Lymphs-4 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 PT-14.8* PTT-23.2 INR(PT)-1.3* Glucose-112* UreaN-110* Creat-8.9* Na-137 K-4.6 Cl-98 HCO3-19* AnGap-25* ALT-63* AST-22 LD(LDH)-338* AlkPhos-66 Amylase-89 TotBili-0.5 Lipase-75* Albumin-2.6* Calcium-6.6* Phos-8.8* Mg-2.7* freeCa-0.9* Lactate-1.5 Type-[Last Name (un) ] pO2-163* pCO2-47* pH-7.23* calHCO3-21 Base XS--7 Comment-GREEN TOP Other labs: [2184-5-25] Iron-34* calTIBC-147* Hapto-272* Ferritn-686* TRF-113* [2184-5-24] Triglyc-713* [2184-5-26] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HCV Ab-NEGATIVE Discharge labs: WBC-8.5 RBC-3.27* Hgb-10.2* Hct-29.6* MCV-90 MCH-31.0 MCHC-34.3 RDW-14.0 Plt Ct-130* Glucose-95 UreaN-47* Creat-3.0* Na-134 K-4.7 Cl-96 HCO3-26 AnGap-17 Calcium-9.2 Phos-4.9* Mg-1.7 Imaging: CXR at OSH: b/l opacities CT at OSH: Pancreatic edema, no dilation of CBD MRA at OSH: no RAS, >1cm stone in gall bladder [5-25]: Renal Ultrasound: CONCLUSION: Kidneys are normal in size and appearance without hydronephrosis. Incidental note of splenomegaly, minimal ascites, and cholelithiasis. [5-25]: CXR: Lung volumes are low, bilateral essentially perihilar consolidation is symmetric, heart is enlarged and mediastinal veins and hila are dilated. Cardiogenic pulmonary edema would be the presumptive diagnosis. [5-25] CXR (to assess earlier ptx): 1. Normal position of tubes and lines. 2. Worsening of the bilateral pulmonary consolidations. 3. Left lower lobe atelectasis in addition to consolidations. 4. No evidence of pneumothorax. [5-25] KUB: IMPRESSION: No evidence of ileus [5-26] CXR: Lung volumes are low, bilateral essentially perihilar consolidation is symmetric, heart is enlarged and mediastinal veins and hila are dilated. Cardiogenic pulmonary edema would be the presumptive diagnosis. With benefit of a subsequent film, one can see a small medial and basal left pneumothorax. Given the history of a remote left-sided line placement, this may be longstanding [5-26] KUB: IMPRESSION: No evidence of small or large bowel obstruction. No progression of contrast through the colon [5-27] HIDA: IMPRESSION: No evidence of cholecystitis or common bile duct obstruction [5-31] MRCP: 1. No intra- or extra-hepatic biliary dilatation or pancreatic ductal dilatation. 2. Small (less than 2.5 x 2 cm) hypoenhancing area in the anterior pancreatic neck may represent an area of necrosis. Small amount of anterior peripancreatic fluid. No pancreatic ductal dilatation. 3. Cholelithiasis without findings of acute cholecystitis or choledocholithiasis on MRI. 4. Small amount of intra-abdominal ascites and small bibasilar pleural effusions. [6-3] EUS: Using a radial echoendoscope, the pancreas and surrounding structures were imaged. No lymph nodes identified in the region of the celiac axis. The pancreas was diffusely mildly hypoechoic with some focal stranding and mild increase in pancreatic duct wall echogenicity. No other features of chronic pancreatitis. At the level of the pancreatic head adjacent fluid collection identified - some peripancreatic ascites. No mass lesions within the pancreatic head identifed but within the head a mild diffuse area of reduced echogenicity more in keeping with edema was identified. GB wall not thickened but large solitary gallstone identified (2cm). CBD 3.3 mm PD 1.7 mm. Brief Hospital Course: 57yo man with pancreatitis, ARDS, Klebsiella bacteremia, gallstones, and acute renal failure status post pulseless electrical activity arrest, transferred from outside hospital with subsequent resolution of above problems. Hospital course is reviewed below by problem: 1. Klebsiella bacteremia - The patient came to [Hospital1 ] s/p septic shock w/ resuscitation at OSH. He was noted to have Klebsiella bacteremia. He was originally put on ceftriaxone, b/c Klebsiella sensitive to this at OSH, but vancomycin was added when he continued to spike temperatures. His line was removed and he became afebrile with negative blood cultures, thus the vancomycin was discontinued. On [5-27] meropenem was started, and on [5-29] ceftriaxone was discontinued. He was treated with a 14 day course of antibiotics, ending on [6-10] (day of discharge). Surveillance blood cultures were negative. He remained afebrile throughout the rest of his hospital stay. 2. Pancreatitis - Per OSH records, the patient had mild pancreatitis and a gallstone w/ thickened gallbladder wall but no frank evidence of cholecystitis. His pancreatic enzymes continued to trend down here and HIDA scan showed no evidence of cholecystitis. A pancreatic specialist was consulted. An MRCP showed evidence of cholelithiasis and a focal area of necrotizing pancreatitis for he underwent endoscopic ultrasound. This showed only peripancreatic fluid; the area of possible necrosis by MRCP appeared to be edema by EUS. A cholecystectomy may be indicated in the future, but not immediately given his recent events. He was tolerating a regular diet on discharge. He was discharged with a follow up appointment with Dr. [Last Name (STitle) 174], gastroenterologist. 3. respiratory failure - He was admitted with hypoxic respiratory failure and intubated at the OSH. This was thought to be secondary to ARDS in the setting of septic shock. Upon arrival to the [Hospital1 ], the ARDS seemed improved by CXR. His P/F ratio was 190 upon arrival, so lung protective ventilation was started. Within a few days, the P/F ratio had improved to the 300s so weaning trials with PS were started. On [5-30], he was successfully extubated. A bronchoscopy with BAL was performed on [5-27] without evidence of ventilator-associated pneumonia. 4. acute renal failure - On transfer, the patient had ARF of unknown etiology, possibly ATN from contrast. A renal u/s showed no hydronephrosis. He was followed by the renal service throughout the hospitalization. He was put on hemodialysis after temporary line placement on hospital day 2 given uremia and some delirium. His last dialysis was on [5-31]. His renal function continued to improve and his temporary dialysis catheter was pulled on [6-8] without complications. His creatinine was 3.0 on the day of discharge. 5. hypertension - In accordance with his history of hypertension, he was hypertensive in the ICU and restarted on his home medications for hypertension. He was discharged on clonidine patch, verapamil, metoprolol, and nifedipine. These can be adjusted by his PCP. 6. triglyceridemia - He was noted to have elevated triglycerides, which may have been a cause of his pancreatitis. Recommend outpatient treatment. 7. constipation - He had mild abdominal distension during the hospitalization. KUBs showed no ileus or obstruction. He was treated with lactulose, colace and senna with success. 8. anemia - The patient had low hematocrits that remained stable and did not require transfusion. He was gastroccult positive, but had no evidence of active bleed. It was thought this could be due to his OGT sucking against his stomach wall. He remained hemodynamically stable throughout the hospitalization. Would recommend outpatient EGD/colonoscopy. 9. cardiac murmur - He was noted to have a murmur that was not appreciated on admission exam. This may be due to increased flow with infection, but, if persistent, he would benefit from outpatient echocardiogram. Code status - full Medications on Admission: Meds @ home: Toprol, catapress, verapamil, hytrin, procardia . Meds @ OSH: cipro ([Date range (1) 13508]), zosyn ([Date range (1) 21720]), ceftriaxone [5-24]-, insulin drip, prop, fentanyl, erythromycin, reglan, risperdal Discharge Medications: 1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly Transdermal QSAT (every Saturday). 2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 3. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:30 Tablet Sustained Release(s) Refills:0 4. Terazosin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 17436] Home Care Discharge Diagnosis: Pancreatitis Klebsiella bacteremia Respiratory distress and arrest Status post pulseless electrical activity cardiac arrest Cholelithiasis Hypertension Acute renal failure Discharge Condition: Good; he is ambulating independently, afebrile, without complaints. Discharge Instructions: Please take all medications as prescribed. Follow up with Dr. [Last Name (STitle) 67064] and Dr. [Last Name (STitle) 174] as described. Call your doctor or go to the emergency room if you have any abdominal pain, nausea, vomiting, fevers, chills, lightheadedness, dizziness, chest pain, difficulty breathing, change in urination, or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 67064] ([Telephone/Fax (1) 67065]) on Wednesday, [2184-6-16] at 10am in the [Location (un) 5583] office, [Location (un) 67066]. Please ask Dr. [Last Name (STitle) 67064] to check your sugars and your kidney function. Please follow up with Dr. [Last Name (STitle) 174] ([Telephone/Fax (1) 1954]) on Tuesday, [7-6], [2184] at 9:40am in the [Hospital Ward Name 23] Building, [Location (un) 436] Medical Specialties.	[ "51881", "5845", "2762", "486", "4019", "2859" ]
Admission Date: [2167-11-3] Discharge Date: [2167-12-15] Date of Birth: [2107-2-13] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3561] Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: Chest tube placement and removal Pigtail chest catheter placement Pleuroscopy with pleural biopsy History of Present Illness: 60 year old woman with decompensated cirrhosis [1-20] hemochromatosis and NASH complicated by gastric varices, ascites, and hepatopulmonary syndrome. She is currently listed for tranplantation. She was recently discharged from [Hospital1 18] [8-28] for a long hospital stay initially for hyponatremia, complicated by fluid overload, respiratory failure, intubation, oliguric renal failure requiring CVVH, shock without clear etiology. All these issues resolved after 1 month stay and she was discharged to [Hospital3 ]. She seems to not have been thriving at rehab since her discharge with poor appetite, poor motivation, and poor progress. She saw Dr. [Last Name (STitle) 696] yesterday in hepatology clinic and was complaining of shortness of breath. Because of her hypoxia and known pleural effusion, Dr. [Last Name (STitle) 696] decided to admit her directly to the [Doctor Last Name 3271] [Doctor Last Name 679] service for further [Doctor Last Name ] candidacy work-up and evaluation as well as for a probable thoracentesis. . Her last set of vitals prior to transfer were 99 81 20 129/54 96%2LNC FS 108. On arrival to the floor the patient generally felt well and denied any complaints. She did have a recent "GI flu" on Monday with just symptoms of nausea and vomitting that seemed to have resolved. She also has had a recent dry cough x 1 week. . ROS: Denies fever, chills, headache, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria, hemoptysis, hematemesis, orthopnea, chest pain, sweats, edema. Past Medical History: 1) Cirrhosis - heterozygous HFE mutation, ascites, gastric varices. Also thought to be concominant component of NASH. 2) DMII, diet controlled 3) Gout Social History: Married with two children. She is on disability and previously worked as a cashier. Denies tobacco and illicit drug use. Drinks [1-21] alcoholic drinks per week. . Family History: Father had throat cancer, mother had lung cancer. Physical Exam: Physical exam on admission: VS - 97.9 100/50 89 20 95%3LNC GENERAL - Pleasant, chronically ill appearing woman in NAD HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric but injected, MMM, OP clear NECK - soft, supple, no LAD, JVD mildly elevated at 10cm at 45 degrees LUNGS - CTA on left, right base reduced breath sounds with dullness to percussion 1/3 up, no r/rh/wh, good air movement, resp unlabored HEART - PMI non-displaced, RRR, no RG, soft [1-24] SM, nl S1-S2 ABDOMEN - NABS, soft, mild RUQ TTP, +flank dullness with ascites, no rebound or guarding EXTREMITIES - WWP, no cyanosis/ecchymosis, 3+ pitting edema of bilateral lower extremities up to above the knees, +DP/PT pulses limited palpation by edema, no asterixis SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and sensation grossly intact Pertinent Results: 1. Labs on admission: [2167-11-3] 09:25PM BLOOD WBC-3.9* RBC-3.09* Hgb-9.4* Hct-28.9* MCV-94# MCH-30.5 MCHC-32.6 RDW-17.4* Plt Ct-151 [2167-11-3] 09:25PM BLOOD PT-16.1* PTT-43.6* INR(PT)-1.4* [2167-11-3] 09:25PM BLOOD ALT-16 AST-30 LD(LDH)-97 AlkPhos-103 TotBili-1.4 [2167-11-3] 09:25PM BLOOD Albumin-2.8* Calcium-11.3* Phos-2.8 Mg-1.5* [2167-11-4] 12:33PM BLOOD PTH-9* [2167-11-4] 06:35AM BLOOD AFP-2.5 [2167-11-5] 06:35AM BLOOD CEA-3.6 . 2. Labs on discharge: - CA [75]-9: 6 <37 U/mL - ACE 33 (reference [8-/2124]) - VITAMIN D, 25 OH, TOTAL 21 range 30-100 ng/mL - VITAMIN D, 25 OH, D3 15 ng/mL - VITAMIN D, 25 OH, D2 6 ng/mL [2167-11-4] 06:35AM BLOOD PEP-NO SPECIFI PPD - negative. . 3. Imaging/diagnostics: - CXR (PA/Lat) [2167-11-3]: Large right pleural effusion has minimally increased from [2167-8-26]. Cardiac size is obscured by the pleural effusion. There are atelectasis in the right lower lobe. There is no evidence of pneumothorax Left upper lobe opacities are consistent with atelectasis. NG tube tip is out of view passing the duodenum. . - Cytology pleural fluid: Negative for malignant cells. Numerous lymphocytes and red blood cells. . - Abdominal ultrasound with Doppler [2167-11-5]: 1. The portal veins are patent; however, the left portal vein demonstrates reversed flow, the main portal vein demonstrates bidirectional flow, and the right portal vein demonstrates forward flow. 2. Nodular coarsened hepatic architecture with no focal liver lesion identified. 3. Scant trace of ascites in the perihepatic space and large right pleural effusion. 4. Splenomegaly. . - CT chest w/ contrast [2167-11-5]: 1. Large right pleural effusion associated with severe atelectasis of the right lower and middle lobes. 2. Pulmonary edema. 3. Tiny left pleural effusion associated with basilar atelectasis. . - Echocardiogram [2167-11-6]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 70%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (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. There is no pericardial effusion. . - Cardiac MRI [2167-11-11]: Impression: 1. Likely iron deposition in myocardium, based on T2* images. However, as patient has normal cardiac function, the clinical relevance of this finding is uncertain. If indicated, a cardiac biopsy may assist in diagnosis. 2. Mildly increased left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was normal at 64%. The effective forward LVEF was normal at 61%. Poor quality LGE images, but no clear large areas of scarring or infarction. 3. Normal right ventricular cavity size and systolic function. The RVEF was normal at 72%. 4. Mild mitral regurgitation. 5. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was mildly increased. 6. Mild left atrial enlargement. 7. A note is made of a nodular liver, splenomegaly and ascites. There are bilateral pleural effusions, right greater than left. . Pleural biopsy ([2167-11-18]): Pleural tissue with chronic inflammation and foreign body. No malignancy identified. No granulomatous inflammation seen. Brief Hospital Course: [Doctor Last Name 3271]-[Doctor Last Name 679] and MICU [Location (un) ] Courses & MICU Green: 60 year old woman with cirrhosis [1-20] NASH complicated by gastric varices and ascites, Type 2 diabetes (diet controlled) and gout who is admitted from rehab after being seen in clinic for failure to thrive at rehab and recurrent pleural effusions. . # Hypoxia: On admission, 3L NC oxygen requirement with O2 sat in the mid-90s. Chronic right-sided pleural effusion is large in size. Thoracentesis was performed and 800cc of grossly bloody fluid was removed. Procedure prematurally terminated due to patient discomfort. Cytology did not show malignant cells. Patient developed tachypnea and 6L NC oxygen requirement on hospital day 2. ABG was 7.39/42/60. CT chest was obtained which showed pleural effusion and pulmonary edema. Thoracic surgery was consulted and placed a pigtail catherter. Patient unable to tolerate continuous suction and had another episode of respiratory distress overnight. Transferred to MICU. CXR there was positive for pulmonary edema. Patient treated with diuresis. Condition stabilized and patient transferred back to the floor. Pulmonary was consulted who suggested workup for TB and sarcoid. Sarcoid - ACE was within normal range, workup for TB was negative, including a PPD test. A Cardiac MRI was also performed to rule out fulminant cardiac fibrosis (secondary to hemochromatosis), but LV/RV function was marginally diminished, with some iron deposition noted of unclear clinical significance. Pleural biopsy was performed by interventional pulmonology to evaluate for the etiology of recurrent pleural effusion which showed chronic inflammation and foreign body. No malignancy identified. No granulomatous inflammation seen. On [11-21] the patient was transfered back to the MICU for hypoxia. Her breathing rapidly improved with diuresis with 40mg IV lasix. The pt received one dose of meropenem for a question of pneumonia. She subsequently grew stenotrophomonas and was treated with bactrim which was changed to levofloxacin given renal failure and hyperkalemia. Vent settings were weaned to 40% and PSV 5/5. Family meeting was held and overall goals of care discussed with patient and family on [12-13] and decision was made to make pt [Name (NI) 3225]. Patient was terminally extubated and vasopressors were discontinued. She passed away peacefully on the morning of [12-15] with her family at the bedside. # Hypercalcemia: Corrected serum calcicum was >12, in the context of failure to thrive, re-accumulating right pleural effusion was concerning for malignancy. She was hydrated with albumin. UPEP and SPEP were unremarkable. Hypercalcemia resolved. . #. Decompensated Cirrhosis from Hemachromatosis: No signs of encephalopathy or elevated liver enzymes on admission. Labs were trended daily. Maintained on tubefeeds for nutrition. Kept on lactulose. Hepatology was present on family meeting on [12-13] and overall prognosis was discussed as well as [Month/Year (2) ] listing. It was felt that patient would be unlikely able to recover enough to be listed for [Month/Year (2) ] in near future and she was made [Month/Year (2) 3225] as above. . #. [Last Name (un) ]: Patient developed [Last Name (un) ] likely secondary to contrast induced nephropathy and hypotension/ATN as well as underlying liver disease. She was started on CVVH and continued for approximately 36-48 hours. Indications included hyperkalemia as well as volume overload. CVVH discontinued and pt made [Last Name (un) 3225] as above. . # UTI: Klebsiella grew out on urine cx from [11-20]. Meropenem started. Completed course. #Hyponatremia - patient was hyponatremic, and even on tolvaptan during previous admissions. . #. Type 2 diabetes: Diet controlled and maintained on sliding scale. # Low Vitamin D: Was checked in setting of hypercalcemia. Found to be low at 21. Started on 50,000u weekly. Should continued for 6-8 weeks and be rechecked. #Depression - patient was seen by inpatient psychiatry consult due to noncompliance with PT and generally acting withdrawn and sad. She refused to see psychiatry but did agree to starting mirtazapine in the evenings which she tolerated well. Medications on Admission: 1) Ciprofloxacin 500mg PO Q24H 2) Furosemide 20mg PO Daily 3) Heparin 5000 units SC BID 4) Insulin Humulin R sliding scale 5) Lactulose 15mL PO TID 6) Metoprolol 12.5mg PO TID 7) Midodrine 10mg PO TID 8) Probenecide 500mg PO BID 9) Spironolactone 25mg PO Daily 10) Tramadol 25mg PO HS 11) Trazodone 75mg PO HS 12) Ursodiol 250mg PO TID 13) Vitamin D 400 units [Hospital1 ] 14) Multivitamins 1 tab PO daily 15) Protein supplement 1 scoop PO BID 16) Acetaminophen 650mg PO Q8H PRN Pain 17) Albuterol 1 NEB Q6H PRN SOB/Wheeze 18) Ipratropium 1 NEB Q6H PRN SOB/Wheeze 19) Magnesium Hydrox/aluminum hydrox/simethicone 15mL PO Q6H PRN GI upset 20) Ondansetron 4mg PO TID PRN Nausea 21) Senna 2 tabs PO HS PRN Constipation 22) Tramadol 25mg PO Q6H PRN Pain 23) Miracle Cream to sacrum daily 24) Anusol 2.5% cream PR TID 25) Artificial Tears 1 drop each eye TID Discharge Medications: Patient expired. Discharge Disposition: Extended Care Discharge Diagnosis: Patient expired. Discharge Condition: Patient expired. Discharge Instructions: Patient expired. Followup Instructions: Patient expired.	[ "0389", "5845", "51881", "78552", "99592", "5990", "2761", "25000", "311", "5859", "2767" ]
Admission Date: [2120-11-19] Discharge Date: [2120-11-22] Date of Birth: [2089-5-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9454] Chief Complaint: Acute mental status change, respiratory failure Major Surgical or Invasive Procedure: Endotracheal intubation [2120-11-19] Placement of arterial line History of Present Illness: Patient is a 31 yo man with PMHx sig. for narcotic abuse who presents with acute mental status changes. Per family, he was completely at his baseline at 3PM yesterday afternoon. Had no compliants. Also spoke to him at 8:30PM and was fine. Reportedly, he was at a friend's house last evening, and somehow made it back home, where he lives with his brother. His brother found him on his bed mildly responsive, gurgling, with labored respirations. He was also noted to have vomit all over him. EMS was called. He received 4 mg of narcan IM without response. He was brought to [Hospital ] Hospital, satting 86% on NRB (ABG 7.05/77/41) and intubated. RR was 34, pulse 128. CT head read as normal. CXR showed patchy infiltrates. U/A negative. He had a WBC of 22, glu 400. Pt was given azithromycin and CTX as well as Lasix 60 mg, 6 units of insulin. Urine positive for opiates. Pt was also noted to be in a fib with rate of 130s, converted after given diltazem 60 mg bolus and started on gtt. He also received a total of 12 mg of ativan for sedation. . Patient was medflighted to [Hospital1 18]. In the [Name (NI) ], pt is in sinus at rate of 85. BP 114/59, rectal T 100. ABG 7.27/57/76, satting 100% on AC 500x16, PEEP 10, on FiO2 100%. He is not on sedation. . ROS: Unable to obtain Past Medical History: History of narcotic, heroin abuse h/o depression, previously on Celexa, stopped 4 months ago Social History: History of heroin and narcotic abuse for years. Per his family, he has been clean for the last 8 months. He got a job yesterday. Smokes 1ppd. [Last Name ] problem with alcohol. Family History: No history of CAD, arrhythmias. Lymphoma in MGM, breast cancer throughtout mother's side Physical Exam: Not included in MICU admission note. PE before call out to floor: AFVSS Awake, alert, pleasant, no distress. Clean cut, muscular young man. CTAB, no adventitious lung sounds S1 S2 clear, no m/r/g Abd soft, NT ND No BLE edema. 5/5 strength and sensation in [5-11] extremities. Pertinent Results: OSH LABS: . 22>------< 244 49.8 75%N, 19%L, 5%M . 133 92 14 ---------------< 441 92 29 1.5 . LFTs WNL CEs: CK 126, CK MB 1.4, Trop 0.02 (0.0-0.04) Acetone negative Alcohol <5 Urine tox positive for opiates . LABS at [Hospital1 18], summarized WBC 8.7 stable --> 17% bandemia now resolved h/h 12.6/35.9 plts 159 PT 14.5 PTT 27.5 INR 1.3 Retic 1.6 Chems normal except Phos low at 1.9 BUN/Cr 7/0.9 CK 475 LFT's normal Lipase 26 normal MB x3 negative, Trop originally 0.09 --> now <0.01 Alb 3.3 Lactate 2.9 --> 1.1 UA negative Utox positive for opiates . IMAGES: CXR [2120-11-20] FINDINGS: As compared to the previous radiograph, there is a clear improvement. The lung volumes have increased, also increased is the transparency of the lung parenchyma. Some remnant right basal and left mid and lower lung opacities are seen, including some areas of retrocardiac atelectasis, but both the distribution and the severity is less extensive than on the previous radiograph. The size of the cardiac silhouette has slightly decreased. There is no evidence of overhydration and no evidence of newly appeared focal parenchymal opacities. On today's radiograph, the tip of the endotracheal tube projects 4 cm above the carina. The course of the nasogastric tube is unchanged. No evidence of pleural effusions . CXR [11-19] - Diffuse consolidation and nodules are concerning for metastatic disease or septic emboli, athough cavitation often present with septic emboli are not seen. . EKG [11-19] - Sinus rhythm. Short P-R interval. Normal tracing for age. No previous tracing available for comparison. Brief Hospital Course: 31 yo M with history of narcotic/heroin abuse found unresponsive, respiratory failure, intubated at OSH. . 1. Respiratory failure: Attributed to respiratory depression and neurogenic pulmonary edema in the setting of narcotic overdose. Elevated A-a gradient and ARDS criteria warranted low tidal volume ventilation. CXR on HD#2 showed resolution of diffuse left-sided patchy interstitial opacities. Weaned to PSV and extubated to nasal cannula on HD#2. Called out to floor in no distress, satting well on room air, no further issues. . 2. Aspiration pneumonia v. pneumonitis: As above. No signs of septic shock (briefly hypotensive after starting propofol, improved with weaning of dilt). Started on empiric ceftriaxone/clindamycin. Switched to levofloxacin on [11-21] for CAP coverage given persistent fever, cough, & hypoxemia. Discharged on short course of levofloxacin. . 3. HCT drop, plt drop. [Month (only) 116] have been dry. Stable since repeat. No schistocytes on smear. Hct stable on discharge. . 4. Atrial fibrillation: Likely secondary to hypoxemia. Converted to SR on diltiazem gtt which was discontinued upon arrival in the MICU. [Month (only) 116] benefit from outpatient echo to evaluate for structural heart disease. . 5. NSTEMI: Likely subendocardial ischemia in the contextof respiratory failure atrial fibrillation. Trending down the normal range without intervention. . 6. Substance Abuse: Social work consulted when pt stable on floor. Was given plenty of information regarding AA/NA. Medications on Admission: None Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 3 days. Disp:9 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Acute opiate overdose 2. Aspiration pneumonitis/pneumonia Discharge Condition: By the time of discharge, pt was awake, alert and satting well on room air, vital signs were stable and pt was deemed medically clear for discharge. Discharge Instructions: You were admitted to [Hospital1 18] with an opiate overdose, unresponsiveness, and respiratory failure. You were admitted to the intensive care unit where you were resuscitated and treated for an Aspiration Pneumonia. Your lungs were acutely injured but should recover well, please continue to take the Levofloxacin 750mg daily for another 3 days. We strongly advise you to avoid illicit drug use and continue to frequent your local AA/NA meetings. If you experience fevers, chills, night sweats, chest pain, shortness of breath or any other general worsening of condition, please call your PCP or come directly to the ED. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) ]. [First Name (STitle) 1447],[First Name3 (LF) 1569] by calling [Telephone/Fax (1) 44915]. Completed by:[2120-11-28]	[ "51881", "5070", "42731" ]
Admission Date: [2172-10-3] Discharge Date: [2172-10-8] Date of Birth: [2143-2-17] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8257] Chief Complaint: increased urinary frequency Major Surgical or Invasive Procedure: none History of Present Illness: 29 yo gravida 1, 14+5 weeks pregnant, who presents with 2 days of increased urinary frequency. The patient first noted increased urinary frequency with mild dysuria on Thursday this week after a scheduled antenatal check. The patient flew in from [Location (un) 9012] on the [10-2] in the early morning. After having Dim Sum in the late morning she developed non-bloody, non-bilious emesis x1. Since then, she also noticed increased urinary frequency and a pink discoloration of the urine. She also had episodes of loose stool, greenish in color, without blood. She denies recent Abx exposure. She presented to an OSH yesterday with increased urinary frequency and fever and was found to be hypotensive. She was given 2L of fluids and was transferred to [Hospital1 18] without further workup. . ROS: negative for CP, SOB, constipation, f/c/ns. Minimal amount of loose stool still present. No blood in the stool. Past Medical History: PRENATAL COURSE: no records, visiting from [First Name8 (NamePattern2) 3908] [Last Name (NamePattern1) ] [2172-3-29] by 14+5wk US PAST OBSTETRIC HISTORY G1 PAST MEDICAL HISTORY Migraines PAST SURGICAL HISTORY none Social History: lives in [Location 9012], came to visit parents in [Location (un) 86] works as pharmacist denies tobacco, alcohol, illicit drug use Family History: non-contributory Physical Exam: VS T 101 BP 76/42 HR 115 RR 25 O2Sat 95% Gen: NAD, AAOx3 HEENT: PERRLA, dry mm NECK: no LAD, no JVD COR: S1S2, regular rhythm, no m/r/g PULM: mild crackles b/l bases ABD: + bowel sounds, soft, nd, uterus palpable below umbilicus, mild L flank pain on palpation, + CVA tenderness Skin: warm extremities, no rash EXT: 2+ DP, no edema/c/c Pertinent Results: [2172-10-3] WBC-11.5 RBC-3.45 Hgb-11.3 Hct-31.2 MCV-90 Plt-171 Neuts-87 [2172-10-3] WBC-15.6 RBC-3.46 Hgb-11.4 Hct-31.0 MCV-90 Plt-138 [2172-10-5] WBC-12.7 RBC-3.28 Hgb-10.8 Hct-29.7 MCV-91 Plt-159 [2172-10-6] WBC-7.7 RBC-3.60 Hgb-11.6 Hct-32.8 MCV-91 Plt-191 Neuts-76.9 [2172-10-3] Hypochr-nl Anisocy-nl Poiklo-nl Macrocy-nl Microcy-nl Polychr-nl [2172-10-3] PT-16.9 PTT-40.5 INR-1.6 Fibrino-486 [2172-10-4] PT-16.2 PTT-37.5 INR-1.5 Fibrino-522 [2172-10-5] PT-13.2 PTT-26.1 INR-1.1 Fibrino-538 [2172-10-3] Glu-116 BUN-4 Cre-0.6 Na-135 K-2.7 Cl-108 HCO3-17 Gap-13 [2172-10-3] Glu-91 BUN-4 Cre-0.5 Na-135 K-3.7 Cl-112 HCO3-12 Gap-15 [2172-10-6] Glu-80 BUN-7 Cre-0.5 Na-134 K-3.6 Cl-102 HCO3-24 AnGap-12 [2172-10-3] ALT-34 AST-56 LD-190 AlkPhos-35 [Doctor First Name ]-56 TBili-0.4 Lipase-19 [2172-10-6] ALT-28 AST-25 [2172-10-6] Calcium-8.6 Phos-2.5 Mg-2.2 UricAcd-1.5 Iron-48 [2172-10-6] calTIBC-228 Ferritn-285 TRF-175 [2172-10-3] [2172-10-3] URINE Blood-MOD Nitrite-POS Protein-NEG Glucose-TR Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2172-10-3] URINE RBC-0 WBC-[7-19] Bacteri-MANY Yeast-NONE Epi-0-2 [2172-10-3] URINE CULTURE neg [2172-10-3] STOOL CULTURE c-diff neg [2172-10-3] BLOOD CULTURES pending Brief Hospital Course: 39 y/o G1P0 admitted at 14+5wks with pyelonephritis and hypotension. . ED course: In the ED, her urinalysis was found to be positive, consistent with the patient symptoms of urinary frequency and dysuria. Flank pain was noted on exam. Given her fever and flank pain, pyelonephritis was suspected and she was treated with IV Ceftriaxone. The patient was given an additonal 2L of fluids, however, she continued to have labile blood pressure when taken of fluids. The patient was also found to have a low potassium which was aggressively repleted. An US was done to assess her pregnancy and was consistent with a 14wks and 5d normal pregnancy. She was transferred to the ICU for further management of her hypotension in the setting of pyelonephritis. . ICU COURSE: UA initially showed 6-10 WBCs, positive nitrates, small [Known lastname ], and many bacteria, and improved with IV Zosyn. Urine culture was negative, but was sent after antibiotics. A renal ultrasound showed no hydronephrosis or perinephric abscess. She was treated with IV Zosyn. She was initially hypotensive to the 70s but treated with approximately 5L of IVFs. She subsequently became short of breath and tachypneic and a CXR showed volume overload. She was placed on CPAP briefly and then treated with lasix with improvement of shortness of breath. CVA tenderness and dysuria resolved with Zosyn. Her hypotension resolved and once stabilized, she was transferred to the antepartum service. . Mrs [Known lastname ] [Last Name (STitle) ] transferred to the antepartum service the evening of [2172-10-5]. She was afebrile and her blood pressure was 98/64. She had minimal pain and was tolerating a regular diet. Her oxygen saturation was 95% on room air. She was continued on IV Zosyn until [10-7] and was switched to po Augmentin. She remained afebrile and clinically had significantly improved. After 24 hours of po antibiotics, she was discharged home. She will continue po Augmentin to complete a 14 day total course. Following completion of Augmentin, she will start suppressive treatment with macrobid 100 mg qday for duration of pregnancy. Of note, she was also found to be anemic with a hematocrit ranging between 29-32. Iron studies were not entirely consistent with iron-deficiency anemia. Hemoglobin electrophoresis was still pending at the time of her discharge. She was discharged on [2172-10-8] and will follow up with her primary OB. Medications on Admission: Medications on admission: Tylenol prn Fioricet prn Prenatal vitamins Discharge Disposition: Home Discharge Diagnosis: pyelonephritis Discharge Condition: stable Discharge Instructions: Follow-up with your regular OB as scheduled. Call if fevers greater than 100.4, chills, or other worrisome symptoms. Call Dr. [Last Name (STitle) ] if you have any questions or concerns ([Telephone/Fax (1) 74573]) Followup Instructions: 1-2 weeks with your regular OB Completed by:[2172-10-8]	[ "0389", "99592", "2762", "2761" ]
Admission Date: [2176-5-30] Discharge Date: Date of Birth: [2176-5-30] Sex: M Service: NB NO DICTATION. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2176-8-24] 03:47:32 T: [2176-8-24] 04:00:44 Job#: [Job Number 57807]	[ "7742", "V290" ]
Admission Date: [2146-11-10] Discharge Date: [2146-11-19] Date of Birth: [2099-6-29] Sex: F Service: SURGERY Allergies: Penicillins Attending:[Doctor First Name 5188] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: explorator laparoscopy, excision of of incarcerated omentum and true cut liver biopsy History of Present Illness: The patient is a 47-year-old woman with a somewhat complicated recent medical history. The patient has had ascites known since approximately 1 year but she has not been willing to undergo further workup of the ascites. She has also been diagnosed with fibroids and the patient also suffers from menorrhagia. In addition, there has been some suspicion of a cystic lesion in the left ovary and at one point, there has been a suspicion of malignancy, but again, the patient has refused further workup. The patient also has evidence of endometriosis and underwent a recent laparoscopic exploration because of that at the [University/College 18328]Hospital and was diagnosed with grade 3 to 4 endometriosis, according to the patient. The patient was now admitted to the hospital with approximately 12 hour history of sudden onset of abdominal pain. Thus, she woke up at 2 AM this morning with abdominal pain diffusely distributed in the abdomen but mainly located in the upper part of the abdomen. Initially she had slight nausea, but she has not had any further nausea or vomiting. She has had regular bowel movements over the last couple of days. On admission, the patient was in relatively severe pain. Her abdomen was distended and quite tender and showed evidence of peritonitis. Her labs were remarkable for a hematocrit of 19. The patient is presently having her menstrual period, but is approaching the end of the present menstrual period. The patient was initially evaluated by emergency room physician, [Name10 (NameIs) ] by our service, and [Name10 (NameIs) ] also by Gynecology. Because of her gynecological history, evidence of the bleeding on admission (a hematocrit of 19, moderately hypotensive and tachycardiac) the patient was initially suspected to have bleeding into her abdomen from gynecological etiology. The patient was, therefore, taken to the operating room by Gynecology and explored. At the time of exploration, they found multiple adhesions in the abdomen consistent with endometriosis. Her uterus was enlarged as previously known and contained a lot of fibroids. However, no definitive bleeding source could be identified in the pelvis. It should be added also that at the time of start of the exploration, the patient had approximately 2.5 liters of bloody ascites-like fluid in the abdomen. Because, no definitive bleeding source was found in the pelvis or from the ovaries, we were called for intraoperative consultation and further exploration. Past Medical History: endometriosis depression mitral valve prolapse anemia diagnostic laparoscopy tonsillectomy adenoidectomy ascites Left ovarian complex mass about 7cm found [2144-12-23](CA-125 of 135) menorrhagic dysfunctional uterine bleeding hysteroscopy [4-/2144] Social History: no etoh no tobacco Family History: non-contributory Physical Exam: Gen: lying supine pale anxious moderate distress HEENT: anicteric, mouth mucous dry CV: tachy lungs: clear to auscultation Abd: firm, greater in bilateral upper quadrants than lower quadrants, distended, exquisitly tender in epigatrium, palpable umbilical hernia, exquisitly tender, non-reducible likely incarcerated, +peritoneal signs Rectal: heme negative, brown stool Ext: 2+ femoral pulses, 2+edema Pertinent Results: [2146-11-17] 07:45AM BLOOD WBC-9.1 [2146-11-15] 04:15AM BLOOD WBC-9.2 RBC-3.46* Hgb-10.0* Hct-30.8* MCV-89 MCH-29.1 MCHC-32.7 RDW-15.0 Plt Ct-323 [2146-11-14] 03:30AM BLOOD WBC-13.2* RBC-3.48* Hgb-10.2* Hct-30.5* MCV-88 MCH-29.4 MCHC-33.5 RDW-15.2 Plt Ct-332 [2146-11-13] 01:29AM BLOOD WBC-21.8* RBC-3.87* Hgb-11.6* Hct-34.8* MCV-90 MCH-30.0 MCHC-33.4 RDW-15.5 Plt Ct-385 [2146-11-12] 02:10PM BLOOD WBC-18.6* RBC-3.64* Hgb-10.7* Hct-32.2* MCV-88 MCH-29.4 MCHC-33.2 RDW-15.8* Plt Ct-355 [2146-11-12] 02:35AM BLOOD WBC-12.4* RBC-3.37* Hgb-10.0* Hct-30.3* MCV-90 MCH-29.6 MCHC-33.0 RDW-16.2* Plt Ct-324 [2146-11-11] 06:11PM BLOOD WBC-11.2* RBC-3.41* Hgb-10.2* Hct-30.4* MCV-89 MCH-29.9 MCHC-33.5 RDW-16.2* Plt Ct-312 [2146-11-11] 03:01PM BLOOD Hct-30.4* [2146-11-11] 05:59AM BLOOD WBC-7.5# RBC-2.85* Hgb-8.4* Hct-25.7* MCV-90 MCH-29.5 MCHC-32.8 RDW-15.7* Plt Ct-343 [2146-11-10] 11:00PM BLOOD Hct-29.5* [2146-11-10] 04:17PM BLOOD WBC-2.0* RBC-3.23# Hgb-9.7# Hct-29.8# MCV-92 MCH-30.1 MCHC-32.7 RDW-15.7 Plt Ct-371 [2146-11-10] 08:30AM BLOOD WBC-1.4# RBC-2.14# Hgb-6.1# Hct-19.9 MCV-93# MCH-28.4 MCHC-30.5* RDW-14.9 Plt Ct-486* [2146-11-14] 03:30AM BLOOD Neuts-83.5* Bands-0 Lymphs-8.9* Monos-6.3 Eos-1.1 Baso-0.2 [2146-11-10] 08:30AM BLOOD Neuts-64 Bands-20* Lymphs-13* Monos-2 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [2146-11-10] 08:30AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+ Schisto-OCCASIONAL [2146-11-15] 04:15AM BLOOD Plt Ct-323 [2146-11-14] 03:30AM BLOOD PT-12.6 PTT-26.3 INR(PT)-1.0 [2146-11-13] 02:55PM BLOOD PT-12.8 PTT-27.5 INR(PT)-1.0 [2146-11-13] 04:15AM BLOOD PT-13.3 PTT-28.1 INR(PT)-1.1 [2146-11-13] 01:29AM BLOOD Plt Ct-385 [2146-11-12] 02:10PM BLOOD Plt Ct-355 [2146-11-12] 02:10PM BLOOD PT-13.1 PTT-29.3 INR(PT)-1.1 [2146-11-12] 02:35AM BLOOD Plt Ct-324 [2146-11-12] 02:35AM BLOOD PT-13.9* PTT-33.6 INR(PT)-1.2 [2146-11-11] 06:11PM BLOOD Plt Ct-312 [2146-11-11] 06:11PM BLOOD PT-17.2* PTT-73.3* INR(PT)-1.9 [2146-11-11] 05:59AM BLOOD Plt Ct-343 [2146-11-10] 04:17PM BLOOD Plt Ct-371 [2146-11-10] 04:17PM BLOOD PT-14.8* PTT-36.3* INR(PT)-1.4 [2146-11-10] 08:30AM BLOOD Plt Ct-486* [2146-11-10] 08:30AM BLOOD PT-12.6 PTT-27.0 INR(PT)-1.0 [2146-11-10] 08:30AM BLOOD Gran Ct-1120* [2146-11-18] 10:45AM BLOOD K-3.6 [2146-11-17] 07:45AM BLOOD K-3.5 [2146-11-16] 05:50AM BLOOD Glucose-91 UreaN-10 Creat-0.4 Na-142 K-4.6 Cl-110* HCO3-26 AnGap-11 [2146-11-15] 10:01PM BLOOD K-3.4 [2146-11-15] 02:20PM BLOOD Glucose-117* UreaN-10 Creat-0.4 Na-140 K-3.3 Cl-101 HCO3-34* AnGap-8 [2146-11-15] 04:15AM BLOOD Glucose-97 UreaN-11 Creat-0.3* Na-143 K-3.1* Cl-104 HCO3-33* AnGap-9 [2146-11-14] 11:09PM BLOOD K-2.6* [2146-11-14] 03:30AM BLOOD Glucose-97 UreaN-15 Creat-0.4 Na-143 K-3.2* Cl-106 HCO3-30* AnGap-10 [2146-11-13] 02:55PM BLOOD Glucose-95 UreaN-13 Creat-0.4 Na-142 K-3.4 Cl-105 HCO3-26 AnGap-14 [2146-11-13] 11:21AM BLOOD K-3.2* [2146-11-13] 01:29AM BLOOD Glucose-84 UreaN-12 Creat-0.6 Na-140 K-2.8* Cl-102 HCO3-26 AnGap-15 [2146-11-12] 09:00PM BLOOD K-2.9* [2146-11-12] 02:10PM BLOOD Glucose-74 UreaN-14 Creat-0.6 Na-139 K-3.2* Cl-104 HCO3-23 AnGap-15 [2146-11-12] 02:35AM BLOOD Glucose-80 UreaN-15 Creat-0.5 Na-137 K-4.0 Cl-108 HCO3-22 AnGap-11 [2146-11-11] 06:11PM BLOOD Glucose-84 UreaN-14 Creat-0.5 Na-140 K-3.9 Cl-113* HCO3-22 AnGap-9 [2146-11-11] 05:59AM BLOOD Glucose-90 UreaN-15 Creat-0.5 Na-139 K-4.1 Cl-112* HCO3-21* AnGap-10 [2146-11-10] 11:00PM BLOOD K-4.5 [2146-11-10] 04:17PM BLOOD Glucose-135* UreaN-13 Creat-0.4 Na-143 K-3.2* Cl-118* HCO3-20* AnGap-8 [2146-11-10] 08:30AM BLOOD Glucose-117* UreaN-15 Creat-0.6 Na-139 K-3.4 Cl-108 HCO3-21* AnGap-13 [2146-11-13] 01:29AM BLOOD ALT-30 AST-36 LD(LDH)-265* AlkPhos-109 TotBili-0.7 [2146-11-12] 02:35AM BLOOD ALT-37 AST-39 AlkPhos-76 TotBili-0.7 [2146-11-11] 05:59AM BLOOD ALT-51* AST-52* AlkPhos-34* Amylase-17 TotBili-0.8 [2146-11-10] 08:30AM BLOOD ALT-38 AST-46* LD(LDH)-203 AlkPhos-44 Amylase-29 TotBili-0.3 [2146-11-11] 05:59AM BLOOD Lipase-10 [2146-11-10] 08:30AM BLOOD Lipase-15 [2146-11-14] 09:40AM BLOOD TSH-7.6* [2146-11-15] 02:20PM BLOOD T4-9.3 T3-94 [2146-11-14] 09:40AM BLOOD [Doctor First Name ]-NEGATIVE [2146-11-14] 03:46AM BLOOD Type-ART pO2-104 pCO2-44 pH-7.44 calHCO3-31* Base XS-4 [2146-11-13] 04:32AM BLOOD Type-ART O2-100 pO2-120* pCO2-43 pH-7.40 calHCO3-28 Base XS-1 AADO2-554 REQ O2-91 Comment-NON-REBREA [2146-11-14] 03:46AM BLOOD Lactate-0.8 [2146-11-14] 03:46AM BLOOD O2 Sat-98 [2146-11-14] 03:46AM BLOOD freeCa-1.06* Brief Hospital Course: Patient was admitted on [2146-11-10] and taken to OR for explorator laparoscopy, excision of of incarcerated omentum and true cut liver biopsy. Operative findings included ascites with old blood but no evidence of ongoing intrabdominal bleeding. The patient recieved two units of blood intraoperatively for blood loss anemia. The procedure was not diagnostic for source of abdominal pain. Although pain slowly resolved [Date Range ]. Post operatively the patient was placed in the ICU for close monitoring. Patient required multiple fluid boluses and had peristent tachycardia. [11-13] US showed: 1. Small right pleural effusion. 2. No ascites. 3. Sludge within the gallbladder which is otherwise unremarkable. 4. Patent hepatic vasculature. Patient was kept in ICU till [11-15]. By the time of step down to floor the fluid had caught up to the patient and she required some lasix for pulmonary edema. Note that cytology sent at time of procedure was negative for malignant cells. Pathology showed: I. Liver, core biopsies (A): A. Minimal portal and lobular chronic inflammation, see note. B. Minimal bile ductular proliferation. C. No increased fibrosis on trichrome and reticulum stain. D. No stainable iron identified. The [Hospital 228] hospital course on the floor was only remarkable for the moderate hypokalemia with a nadar of 2.6 while still in the unit on [11-14]. Otherwise, the patient slowly advanced her diet. POD#6 [11-18] Her staples were taken out, she was advanced to house diet, hep locked. Medications on Admission: desipramine iron tramadol Discharge Medications: 1. Desipramine HCl 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:30 Tablet(s) Refills:0 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p explorator laparoscopy, excision of of incarcerated omentum and true cut liver biopsy hypomagnesium hypocalcemia hypokalemia blood loss anemia endometriosis depression mitral valve prolapse anemia diagnostic laparoscopy tonsillectomy adenoidectomy ascites Left ovarian complex mass about 7cm found [2144-12-23](CA-125 of 135) menorrhagic dysfunctional uterine bleeding hysteroscopy [4-/2144] Discharge Condition: Good: afebrile, tolerating regular diet, ambulating without difficulty, pain well controlled on oral medication. Discharge Instructions: 1. Please monitor for the following: fever, chills, nausea, vomiting, inability to tolerate food/drink. If any of these occur, please contact your physician [Name Initial (PRE) 2227]. Followup Instructions: Please call Dr.[Name (NI) 6045] office for an appointment. [Telephone/Fax (1) 5189] [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190] Completed by:[2146-11-18]	[ "2851", "4240" ]
Admission Date: [2115-10-7] Discharge Date: [2115-10-16] Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 2817] Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: 83 female who presents with fall. Details of event unclear, patient has no recollection of antecedant events. Has large sternal bruise, thinks she fell on coffee mug. Currently comfortable - sternal pain controlled. Denies h/o anginal-type chest pain. SOB at baseline. No dysuria, LUTS. No recent changes in medications. Taking good POs by report. No prior events. Past Medical History: Limited: COPD on home 02 HTN Hyperlipidemia Afib on coumadin DM2 Gout Social History: Lives with daughter and son-in-law. [Name (NI) ] she is generally functional independently Family History: n/c Physical Exam: Vitals: 98.3, HR 84, BP 130/82, RR 20, 91% on 3L Gen: comfortable, eating crackers, nad HEENT: anicteric, MMM, PERRLA Neck: supple, no jugular venous distention; no carotid bruits CV: RRR, nl s1 and s2, no significant murmurs, rubs or gallops; Large area of ecchymosis over sternum. Lungs: Decreased breath sounds bilaterally, bibasilar crackles Abd: +bs, soft, ntnd; liver and spleen not palpated Ext: scattered ecchymoses; no edema. Full and symmetric pulses Neuro: alert, conversant, oriented; Gait deferred. Pertinent Results: [2115-10-7] 06:30PM GLUCOSE-88 UREA N-63* CREAT-1.7* SODIUM-139 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15 [2115-10-7] 06:30PM estGFR-Using this [2115-10-7] 06:30PM CK(CPK)-59 [2115-10-7] 06:30PM cTropnT-<0.01 [2115-10-7] 06:30PM CK-MB-NotDone [2115-10-7] 06:30PM WBC-6.5 RBC-4.49 HGB-14.5 HCT-42.4 MCV-94 MCH-32.2* MCHC-34.1 RDW-15.1 [2115-10-7] 06:30PM NEUTS-68.8 LYMPHS-18.5 MONOS-4.0 EOS-8.2* BASOS-0.5 [2115-10-7] 06:30PM PLT COUNT-143* [2115-10-7] 06:30PM PT-33.3* PTT-37.5* INR(PT)-3.6* CT Head: 1. No acute intracranial injury. 2. No skull fracture. 3. Moderate atrophy with chronic caudate nuclei lacunes, bilaterally. CT Cspine: 1. No evidence of fracture. 2. Extensive degenerative changes of the cervical spine with the most profound area of abnormality at C5-C6, where there is moderate canal and moderate foraminal stenosis. 3. Severe panacinar emphysema in the lung apices. 4. Smooth intralobular septal thickening which raises the question of volume overload. Please correlate with clinical exam. 5. 1.3 cm hypodense right thyroid nodule for which ultrasound followup is recommended if not already performed. T/L spine: Superior endplate collapse at L3 of indeterminate age. No specific findings to suggest acute fracture, however correlation with site of pain recommended. [2115-10-9] Echocardiogram: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Increased LVEDP. Moderate pulmonary artery systolic hypertension. Mild-moderate aortic regurgitation. Mild-moderate mitral regurgitation. The constellation of findings of right ventricular enlargement and pulmonary artery hypertension is suggestive of a primary pulmonary process (e.g., pulmonary embolism) ?acute on chronic. [2115-10-10] CT Chest without contrast: 1. Impaction of right lower lobe bronchi with partial right lower lobe collapse. Associated soft tissue density surrounding central bronchovascular structures raises concern for possible neoplastic mass, although inflammatory process surrounding the bronchi is also possible. Consider bronchoscopy for initial further evaluation. Alternatively, if warranted clinically, contrast enhanced CT could be performed to better characterize this region. 2. Incompletely imaged abdominal aortic aneurysm measuring approximately 4 cm with possible chronic dissection. Recommend dedicated CTA examination of the abdominal aorta for more complete assessment. 3. Severe emphysema. 4. Small bilateral pleural effusions. [2115-10-15] CT Chest with contrast: 1. Impaction of right lower lobe bronchi with mild improvement in the degree of right lower lobe aeration. Previously described soft tissue density surrounding the right lower lobe bronchovascular structures is unchanged and concern for possible neoplastic mass is not further evaluated without contrast. 2. Severe emphysema with small bilateral pleural effusions. 3. Incompletely imaged abdominal aortic aneurysm with possible chronic dissection. Day of discharge Labs: WBC 5.6 Hct 37.2 Plt 179 Na 139 K 4.3 Cl 104 bicarb 24 BUN 38 Cr 1.1 glucose 93 Ca 9.0 Phos 3.1 Mg 2.2 PT 16.5* PTT 28.6 INR 1.5* Brief Hospital Course: A/P: 83 y.o. female with PMHx of COPD, CHF, atrial fibrillation, macular degeneration, hyperlipidemia, and DM admitted for syncope work-up s/p fall, transferred to ICU for management of hypoxia likely due to RLL collapse from mucous plugging versus PNA verus mass in patient with severe [Hospital 2182] transferred to ICU for hypoxia. # Shortness of breath secondary to RLL collapse in patient with severe COPD and splinting due to chest wall hematoma. Also with fevers and bandemia initially which resolved. CT on [10-10] showed RLL collapse secondary to possible mucous plug vs neoplastic mass. Initially held off on bronchoscopy given high oxygen requirement. She improved clinically and was on 2L nasal canula prior to discharge breathing comfortably. She was continued on nebulizer treatments and treated with levofloxacin for 7 day course (completed on [10-15]). She underwent repeat CT chest with contrast which showed similar right lower lobe lung finding (results above) again raising question of inflammatory process vs neoplasm. Discussed this finding with patient's daughter. Further work-up including bronchoscopy and washings was discussed and also discussed possibility of lung mass and further work-up with this. The daughter would like to consider whether they would want further work-up. She has an outpatient Pulmonologist who will be notified of this finding prior to patient discharge. Theophylline was discontinued in light of possible episode of syncope (though Theophylline was measured to be slightly sub-therapeutic at 8.3). Continued singulair and fluticasone. Incentive spirometer at bedside to reduce poor inspiration from splinting. Continued pain control for chest contusion to avoid splinting with Lidocaine patch and ATC acetaminophen with PRN oxycodone # SYNCOPE: Etiology of syncope remains unclear, although sounds cardiac (? arrhythmia) in origin. Cardiac enzymes were negative and echo did not reveal a source of syncope: no aortic stenosis although [1-22]+ AR/TR/MR. Carotid ultrasounds were performed, and no significant stenoses bilaterally. Monitored on telemetry without arrythmias. # RENAL FAILURE: Patient's creatine was 1.6 on admission. FeNa of 0.8% upon admission suggested prerenal etiology. Her BUN creatinine trended down to baseline; Based on records from [Location (un) 745] [Hospital 74467] Hospital, patient's baseline creatinine appears to be around 1.3. Maintained adequate urine output. # Pain. Patient has chest wall hematoma due to syncopal event. This is likely contributing to SOB. Continued around the clock tylenol, PRN vicadin, and lidocaine patch which seemed to be controlling her pain. # AAA: Patient incidentally noted to have a 4 cm AAA with possible chronic dissection on her chest CT. She did not have signs/symptoms of acute issue during this hospitalization. Based on her DNR/DNI status it was felt that not sure that patient/family would want this invasive type of surgery. # HTN: Normotensive. Metoprolol started in hospital (switched from home Atenolol at home for HTN/rate controL). Held lisinopril in setting of ARF and controlled blood pressure. # ATRIAL FIBRILLATION: Supratherapeutic on Coumadin on presentation. Currently rate-controlled on Digoxin. Continued Digoxin. INR trended down, coumadin restarted. # ARTHRITIS/GOUT: Held Allopurinol and colchicine given elevated creatinine, consider restarting as outpatient. No acute gout flare during hospitalization. # HYPERCHOLESTEROLEMIA: Continued outpatient statin. # DM: Continued glipizide and sliding scale insulin. # DEPRESSION: Continued outpatient Sertraline. # FEN: Cardiac healthy/diabetic diet. # PPx: SC Heparin/Coumadin in the interim. Bowel regimen. . # CODE STATUS: Per discussion with patient (who was lucid and coherent at the time), she is DNR/DNI. Confirmed with patient's daughter and health care proxy - [Name (NI) ] [Name (NI) ] ([Telephone/Fax (1) 74468]. Medications on Admission: Allopurinol 200mg Atenolol 50mg cochicine 0.6mg digoxin 0.125mg furosemide 80mg qod glipizide 5mg lipitor 10mg lisinopril 2.5mg meloxicam 15mg sertaline 75mg singulair 10mg theophylline 300mg warfarin 2.5mg, except 5mg on Wed. Discharge Medications: 1. Glipizide 5 mg Tablet Sig: One (1) Tablet PO qAM (). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 16. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation . Discharge Disposition: Extended Care Facility: [Last Name (un) 1687] - [Location (un) 745] Discharge Diagnosis: pneumonia syncope acute renal failure secondary diagnoses: COPD Diabetes Mellitus atrial fibrillation on coumadin Discharge Condition: stable, normal oxygen saturations on 2L nasal canula, ambulating with physical therapy Discharge Instructions: You are being discharged to rehab. You were diagnosed and treated for pneumonia. Please call 911 or your primary care physician if you experience worsening shortness of breath, fevers, chest pain, abdominal pain, nausea, vomiting, diarrhea or other concerning symptoms. Followup Instructions: Likely needs: - consider repeat outpatient CT Chest After your discharge from rehab, please schedule follow-up appointments with your primary care physician and your pulmonologist, Dr. [Last Name (STitle) ]. Please discuss with Dr. [Last Name (STitle) ] whether to repeat CT scan of your chest or pursue bronchoscopy. Completed by:[2115-10-17]	[ "42731", "486", "51881", "4280", "4019", "25000" ]
Admission Date: [2173-3-18] Discharge Date: [2173-3-23] Date of Birth: [2108-5-14] Sex: F Service: MEDICINE Allergies: Banana / Melon Flavor / Avocado / IV constrast / Lorazepam Attending:[First Name3 (LF) 11839] Chief Complaint: Fever and right flank pain Major Surgical or Invasive Procedure: none History of Present Illness: 64 yo F with cervical cancer diagnosed 2 months ago, ongoing radiation (last [2173-3-18]), and chemo (last [2173-3-16]). Today she was seen by the Heme/ onc RN service for a lab draw. She complained the the onset of right flank pain (at the site of her nephrostomy tube) which awoke her from sleep Wednesday am. She has had ongoing output from bilateral nephrostomy drains, which is occasionally bloody. Prior to leaving she had a T of 99. After arriving home she developed a fever to 102 at 7pm associated with rigors. She was instructed to go to the emergency apartment. She also has had alternating diarrhea and constipation (most recently diarrhea). No bloody BM. No severe nausea. No cough or SOB. No CP. Poor PO intake x 2 days. In the ED, VS 98.7 100 133/50 20 100%. Got 2L fluid for BP 90s to 110s, HR 80s to 90s. Given Potassium Chloride 20 mEq PO and 40 IV,Acetaminophen 500mg Tablet,CefePIME 1 g, mag 2 gm, calcium gluconate 1gm. She was writtin for vancomycin but it was not recieved. Blood and UCx were obtained. CXR nml Patient was admitted to the [Hospital Unit Name 153] for hypotension. She was maintained on vanco/cefepime and her urine culture from left nephrostomy grew enterococcus and e.coli. She also has GNRs in one set of blood cultures from [3-19]. Repeat blood cx are NGTD. Currently, she is feeling much better. She denies any fevers or chills. She denies any flank pain. She denies any other symptoms at this time. Review of Systems: (+) Per HPI. + 20 lb wt loss. (-) Review of Systems: HEENT: No headache, sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness, palpitations. PULM: No cough, shortness of breath, or wheezing. GI: No vomiting, or abdominal pain. No recent change in bowel habits, no hematochezia or melena. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. DERM: No rashes or skin breakdown. NEURO: No numbness/tingling in extremities. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: Past Oncologic History: # Stage [Doctor First Name ] squamous cell cervical carcinoma: - developed vaginal bleeding around [Holiday 1451] [2172]. Recurred approximately 1-2 weeks later in early [2173-1-13]. - Pap smear showed showed high-grade squamous intraepithelial lesion. - continued to experience vaginal bleeding, and also developed suprapubic abdominal pain, urinary frequency/urgency, and 5-10lb weight loss. - presented to [Hospital1 18] ED [2173-2-9] after noting gross hematuria. A pelvic ultrasound on the day of admission showed a bladder hematoma with no clear visualization of the uterus or ovaries. Abd/pelvic CT the same day showed mild right hydronephrosis and hydroureter with clotted blood in the bladder. - was admitted to the Urology service and on [2173-2-10] had an MR urogram which showed a 5.7 x 3.6 x 1.9 cm cervical mass with bilateral parametrial involvement, mild hydrometria, invasion into the posterior bladder wall over 3.5 cm and right hydronephrosis. A small amount of free fluid was seen in the pelvis. There was also a 1.6-cm gallbladder wall nodule. - Dr. [Last Name (STitle) ] performed a cystoscopy [2173-2-10] which showed the cervical mass to be invading the trigone and posterior wall with a large amount of old clot and oozing. The ureteral orifices were involved. He fulgurated the area of the involved bladder and obtained biopsies of the trigone mass. - Pathology from this biopsy returned positive for invasive squamous cell carcinoma consistent with a cervical origin involving the muscularis propria and the lamina propria without involvement of the bladder mucosa, with lymphovascular invasion. - Examination under anesthesia performed by Dr. [Last Name (STitle) 5797] [2173-2-11] showed a necrotic cervical mass which obliterated the vaginal fornices and infiltrated the anterior upper half of the vagina, with left parametrial involvement to the sidewall and medial right parametrial involvement. Proctoscopy showed no rectal involvement. Biopsies of the cervix again showed squamous cell carcinoma with vascular invasion. She was discharged from the hospital on [2173-2-13]. - Ms. [Known lastname 5936] had a PET-CT scan on [2173-2-16] that showed FDG-avidity in the region of the known cervical mass, with irregularity of the posterior urinary bladder and extension of FDG-avidity through the uterine myometrium to the fundus. No distant metastases were seen, and therefore staging is consistent with T4, FIGO stage [Doctor First Name 690] disease. - She was seen by Dr. [Last Name (STitle) ] of Radiation Oncology on [2173-2-16] and started radiation therapy on [2173-2-19] for planned 37 sessions - saw Dr. [Last Name (STitle) 4149] in Oncology on [2173-2-22], planning to start radiosensitizing weekly cisplatin on [2173-2-25] - admitted [2-25] to [3-4] with ARF relieved with BL nephectomy tubes and developed LGIB [3-17] tumor invading into bowel - started cisplatin weekly [2173-3-4], last dose [2173-3-16] . OTHER MEDICAL HISTORY: # Status post resection of a benign pituitary adenoma at age 21 at [Hospital1 2025] with resultant hypopituitarism; she was previously followed at [Hospital1 2025], last saw Endocrinology at [Hospital1 ]-[Location (un) ] in [Month (only) 547] [2172]. # Osteoporosis # Multiple food allergies # Gynecologic History: Menarche, age 14; menopause, age 22. The patient used hormone replacement therapy from age 22 to her 50s. G2P2, with deliveries at ages 18 and 20. Social History: She grew up in the West End of [Location (un) 86]. She lives in [Location 4628], MA with her husband [Name (NI) ]. They have two daughters. [Name (NI) ] [Name2 (NI) 1685] daughter lives in [Name (NI) 3844]. She describes their family as supportive, close-knit. She has a sister in [Name (NI) 4565] who will be flying here to be with pt. She was employed very briefly in [Location (un) 6692] airport. Her husband is a supervisor of construction for Massport. The patient smoked approximately one-third to [2-14] pack per day for 33 years, recently quitting. She had one alcoholic beverage daily until her illness. Family History: [Name (NI) 1094] brother died of leukemia at age 64 in [2164]. Pt was a match, donated peripheral blood stem cells. Both parents had heart disease. Physical Exam: VS: 96.8 115/59 64 14 100%RA I/O: 3075/3950 GEN: awake, alert. AOx3, NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR, 1/6 SEM at RUSB. R chest por in place Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [Doctor Last Name 515] sign Flank: bilateral nephrostomy tubes present. no CVA tenderness. Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS). gait WNL. Pertinent Results: Labs on admission: [2173-3-18] 04:40PM BLOOD WBC-10.1 RBC-2.81* Hgb-8.9* Hct-25.2* MCV-90 MCH-31.7 MCHC-35.3* RDW-13.7 Plt Ct-118* [2173-3-18] 04:40PM BLOOD Neuts-95* Bands-0 Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2173-3-18] 10:42PM BLOOD PT-15.2* PTT-26.2 INR(PT)-1.3* [2173-3-18] 02:30PM BLOOD UreaN-19 Creat-1.2* Na-128* K-3.0* Cl-91* HCO3-26 AnGap-14 [2173-3-18] 10:42PM BLOOD ALT-20 AST-19 AlkPhos-80 TotBili-0.5 [2173-3-18] 10:42PM BLOOD Calcium-7.1* Phos-1.8* Mg-1.1* [2173-3-18] 10:46PM BLOOD Lactate-1.2 Pertinent lab trends Creatinine [2173-3-18] 02:30PM Creat-1.2* [2173-3-19] 01:50PM Creat-0.9 [2173-3-20] 02:39PM Creat-0.8 Sodium [2173-3-18] 02:30PM Na-128* [2173-3-19] 04:36AM Na-136 [2173-3-20] 05:07AM Na-133 [2173-3-20] 02:39PM Na-134 Hct, Plt [2173-3-18] 04:40PM Hct-25.2* Plt Ct-118* [2173-3-19] 04:36AM Hct-22.5* Plt Ct-84* [2173-3-20] 05:07AM Hct-22.4* Plt Ct-81* [2173-3-20] 02:39PM Hct-23.9* MICRO: Blood culture - GNRs Urine culture - ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. IMAGING: CXR: FINDINGS: There is no pneumonia. There is no pleural effusion or pneumothorax. Hilar, mediastinal, and cardiac silhouette are within normal limits. There is a Port-A-Catheter with tip projecting at the upper right atrium. There are bilateral nephrostomy tubes. Renal U/S: IMPRESSION: 1. Moderate fullness of the right collecting system with nephrostomy tubes visualized within the midline renal pelvis. No evidence of adjacent abscess cavity or focal infection on this ultrasound examination. 2. Normal appearance of the left kidney, nephrostomy tube not visualized. Brief Hospital Course: 64-year-old woman with recently diagnosed stage [Doctor First Name ] cervical cancer, currently on chemo / radiation, presents with fever and right flank pain. # E.coli and Enterococcus UTI with GNR bacteremia: In the setting of chemo and radiation, the fever was felt to represent infection. Patient was symptomatic with right CVA tenderness and U/A from the right nephrostomy tube was suggestive of a UTI with positive nitrites. Renal U/S showed some right collecting system fullness, but was otherwise unremarkable. Urine cultures grew both E. coli and enterococcus and blood cultures also grew out e/coli bacteremia, . Her WBCs trended down and she did not spike any fevers or have any more rigors during her ICU admission. She was covered broadly with cefepime and vanco. Both e.coli and enetrecoccus were pan-sensitive and antibiotic switched to ciporflox and amoxicillin per sensitivities.Pt to compete a two course at home. Surveillance blood cultures were all negative. # Mild hypotension and hypopituitarism: Pt's systolic blood pressure dropped to 90's and responded to IVF in the [Hospital Unit Name 153]. She was continued on prednisone and thryoid replacement therapy. In setting of stress and fever, it was felt that she was relatively [Name2 (NI) 84258] and was given stress dose prednisone at 20mg daily. Prednisone was tapered down as blood pressure remained stable and afebrile.On discharge patinet bck to 5 mg po daily of prednisone. # Electrolyte abnormalities with high urine output: Given her poor PO intake and continued high urine output, she was given IVF boluses for hypovolemia and hyponatremia. She was also hypokalemic,hypo-phosphotemic an dhypomagnesemia. All likely due to the cisplatin she received. Lytes were monitored closely and repleted as needed. Pt d/c with oral replation and close f/u of labs as an outpt. # Thrombocytopenia: New onset thrombocytopenia/ Likely due to the infection in addition te recent chemotherapy. Pt had no evidence of bleed and plts remained in the range of 70-80's. They will need to be monitored as an outpatient as well. # Anemia: Likely due to recent bleeding from tumor ans well as anemia of inflammation. Pt did receive 2 units of PRBCS with appropriate response. # Cervical ca: Pt continued radiation treatment while on the floor. She will contniue radiation adn f/u with her primary oncologist as well.a #Pain: Pt with lower abdominal/pelvic pain due to her cervical cancer. Pain was not well ocntrolled oxycontin 10 mg and recently decreased to 20 mg [Hospital1 ] , which pt reported made her toosleepy throughtout te day. Regimen changed to 10 mg in the morning and afternoon and 20 mg at night. Pt tolerated this regimen well with good pain control. # FEN: regular diet; # PPx: heparin sc colace/senna/miralax # Full code # Dispo: Pt d/c home with VNA services. Medications on Admission: levothyroxine 125mcg daily lidocain-prilociaine crm for accessing port nystatin [Numeric Identifier 4856] u/ml 5ml QID zyprexa 2.5 to 5mg q6h zofran 8mg PO q8h prn oxycontin 10mg q12h prn polyethylene glycol 1 packet daily prn prednisone 5mg PO daily compazine 10mg PO q6h prn acetaminophen 325mg [2-14] Tab q6h prn colace 1 cap [Hospital1 ] Senna 1 cap [Hospital1 ] prn CURRENT MEDICATIONS: 1. Neutra-Phos 2 PKT PO/NG ONCE 2. Olanzapine 2.5 mg PO BID:PRN aggitation 3. Acetaminophen 650 mg PO/NG Q6H:PRN fever 4. Ondansetron 8 mg IV Q8H:PRN nausea 5. CefePIME 1 g IV Q12H day 1 = [3-19] 6. OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain 7. Docusate Sodium 100 mg PO BID 8. Oxycodone SR (OxyconTIN) 20 mg PO Q12H 9. Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation 10. Heparin 5000 UNIT SC TID 11. PredniSONE 20 mg PO/NG DAILY 12. Levothyroxine Sodium 125 mcg PO/NG DAILY 13. Prochlorperazine 10 mg IV Q6H:PRN nausea 14. Lidocaine-Prilocaine 1 Appl TP ASDIR 15. Senna 2 TAB PO/NG [Hospital1 ] 16. Vancomycin 1000 mg IV Q 12H Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for loose stools. 3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 4. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): do not take together with calcium. 5. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for aggitation. 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) Appl Topical ASDIR (AS DIRECTED): for port access. 8. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Insomnia. 9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 10. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO BID (2 times a day): in the morning and afternoon. 11. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO HS (at bedtime). 12. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 11 days. Disp:66 Tablet(s) Refills:0 13. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 6 days. Disp:36 Capsule(s) Refills:0 14. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO BID (2 times a day) for 5 days. 15. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a Disp:30 Tablet(s) Refills:0 17. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days. Disp:14 Tablet Extended Release(s) Refills:0 18. Phospha 250 Neutral 250 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 19. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [2-14] Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Urinary tract infection Gram negative ( e.coli) bacteremia hypomagnesemia hypokalemia hypophosphotemia anemia thrombocytopenia pan-hypopituitarism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms [Known lastname 5936] you were admitted for a urinary tract infection and a bacteria in your blood.You presented with low blood pressure and therefore admitted to the intensive care unit. Blood pressure improved with IV hydration and increase in your prednisone dose as well as IV antibiotics. After final results of the blood and urine cultures and antibiotic sensitivities your antibiotics were switched to oral antibiotics which you will need to continue at home. You did receive 2 units of red blood cells and electrolyte repletion.You will need to have close follow up and blood work to assure that you do not get dehydrated and you may need additional electrolyte supplementation.You also developed diarrhea prior to discharge which is likely due to the antibiotics. A stool was sent for culture and at the time of discharge this result is pending. Change in medications: 1. Ciprofloxacin 750 mg po bid x 11 days. 2. Amoxicillin 500 mg TID x 6 days 3. Oxycontin 10 mg in the morning and afternoon and 20 mg at night. 4. Magnesium oxide daily 5. Potassium chloride 20 [Female First Name (un) ] daily. 6. Neutraphos 1 packet twice a day. Followup Instructions: 1.F/U tomorrow for CBC and chem 10 and possible need for IV fluids and electrolytes. Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2173-3-24] at 9:00 AM With: [First Name4 (NamePattern1) 4617] [Last Name (NamePattern1) 4618], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage 2.Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2173-3-25] at 10:00 AM With: [First Name4 (NamePattern1) 4617] [Last Name (NamePattern1) 4618], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage 3.Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2173-3-29] at 9:00 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage 4. Continue radiation treatment as scheduled.	[ "5990", "2851", "2875", "V1582" ]
Admission Date: [2143-5-7] Discharge Date: Date of Birth: [2071-1-3] Sex: F Service: NEUROSURGE DATE OF DISCHARGE: PENDING, [Hospital 31746] REHABILITATION BED. CHIEF COMPLAINT: Left-sided weakness with a right frontal lobe mass. female who presented with weakness to the left side and veering to the left with slight dizziness. She underwent MRI on [2143-4-20], which showed a mass in the right frontal lobe. She is currently here for excision of the mass. PAST MEDICAL HISTORY: 1. Hypertension. 3. No cardiac history. SOCIAL HISTORY: Tobacco: The patient quit 34 years ago. PAST SURGICAL HISTORY: Previous surgery: Hysterectomy in [2113], hemorrhoidectomy, repair of vaginal prolapse. ALLERGIES: None. MEDICATIONS PRIOR TO ADMISSION: Medications included HZTZ 25 mg q.d. PHYSICAL EXAMINATION: Examination prior to admission: Neurological examination: Gait was normal with smooth swing, unable to lift and hold left leg, but able to support weight on left leg with increased weight on right. Bilateral left patellar reflexes positive. N ankle reflex. Weak left dorsiflexion and plantarflexion. Weak 4- hand grip on the left side. HOSPITAL COURSE: The patient underwent a craniotomy and removal of the frontal lobe mass on [2143-5-7]. She tolerated the procedure well. She was transferred to the PACU in stable condition. In the PACU she had antigravity strength only in the left upper extremity with no strength in the left lower extremity. The right was [3-24]. Sensory system was intact with downgoing toes. She stayed overnight in the PAC and she was transferred to the floor in a stable condition on postoperative day #1. She was continued on steroids postoperatively. Over the course of the hospital stay, the motor examination on the left side has been gradually improving. On [2143-5-10] the neurological examination was on the left side: Deltoid 1+, biceps 3, triceps 3, WA2, SF2, IP3, Q3, hamstring 3, gluteal 2, [Last Name (un) 938] 1. Right side was [3-24]. Sensory was intact. She showed progressive improvement in the strength on the left side. She is now ready for rehabilitation. She has been seen by the Department of Physiotherapy. The Decadron will be weaned slowly to 2 mg b.i.d. until followup. MEDICATIONS ON DISCHARGE: 1. HCTZ 25 mg q.d. 2. Zantac 150 mg b.i.d. 3. Dilantin 100 mg t.i.d. 4. Percocet one to two tablets q.4h. to 6h.p.r.n. 5. Dexamethasone 4 mg q.6h. on [2143-5-10] and [2143-5-11]; 4 mg q.8h. on [5-12] and [5-13]; 2 mg q.6h. on [5-14] to [5-17]; 2 mg q.8h. [5-18] to [5-20]; 2 mg q.12h. until follow up. 6. Bisacodyl 10 mg p.o. pr q.d p.r.n. FOLLOW-UP CARE: The patient is to followup in the Brain [Hospital 341] Clinic with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in ten days. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2143-5-10] 12:42 T: [2143-5-10] 13:29 JOB#: [Job Number 31747]	[ "496", "4019" ]
Admission Date: [2136-8-25] Discharge Date: [2136-8-31] Date of Birth: [2060-1-15] Sex: M Service: MEDICINE Allergies: Protamine Sulfate / Ambien Attending:[First Name3 (LF) 9824] Chief Complaint: Bilateral lower extremity swelling. Major Surgical or Invasive Procedure: [8-26] knee washout, plastic removed but metal left in. History of Present Illness: 76 yo man w/ hx of CKD, DM2, HTN, COPD, who presents to the ED for increasing swelling and redness to b/l LE (L>R) and SOB w/productive cough w/yellowish sputum that has been worsening over the last 1-1.5wks. In ED patient reported weight gain of 15 pounds in last two weeks and bilateral lower extremity swelling. In addition had fever to 101.5 at home, increased sputum, cough, slight hemoptysis and yellow phlegm. Also had worsening DOE to the point that he could not get out of his wheel chair. In ED he was given Vanc and neb X 1. CXR showed CM but no PNA. LENI's unable to r/o DVT, though unlikely. On the floor, patient was given vanc, ctx, azithro to cover CAP and a cellulitis/septic arthritis. Ortho planned to take patient to OR [8-26] for washout and hardware change given may be septic joint. Patient initially had low-grade fever to 99.9 with BPs ranging 140s-170s/70a, HR 90s. Initial O2 sat was 95% on RA. He received amytriptline (150mg), gabapentin (300mg) and a dose of 2 mg Iv morphine at 2200. At ~ 1am NF was called for tachypnea/respiratory distress. Patient was breathing at 30 with new O2 requirement (91% on RA 97% on 2L NC). Felt still SOB as he did when he came in but was not initially altered. Got a neb and labs were sent including ABG which revealed: PH 7.4/ PCO 40/ PO2 62. (abgs from [2132] on with O2 mas as only 70s with pH 7.4 when PCO2 is 40). Patient thought to have acute CHF exacerbation and given 80mg IV lasix with good UOP but no improvement in breathing. Given worry about patients MS (which had waned down over the course of the NF evaluation) and hypoxia he was transferred to the ICU. Past Medical History: Chronic renal failure, Stage IV Hyperlipidemia DM2 HTN CAD Osteoarthritis Peripheral neuropathy [1-31] spinal stenosis AAA MGUS Thrombocytopenia COPD Diastolic CHF w/ LVH Morbid obesity Social History: Former history of tobacco use, [4-2] ppd x 40-50 years, stopped in '[16]. Heavy alcohol use, though decreasing in recent months, last drink was over a week ago. No history of withdrawal. Denies illicit drug use. Family History: Father died at 96. mother died at 93. Diabetes. Physical Exam: Vitals: VS: Tm 98.7 111-132/70s 80-90s 98% RA General: Alert, oriented X 3; appropriate, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: thick neck, supple, JVP difficult to assess given habitus Lungs: short expiratory phase, anterior fields clear b/l, decreased bs at b/l bases CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, GU: foley in place Ext: warm, 2+ chronic venous stasis changes and multiple areas of excoriation and surrounding erythema. Pneumoboots in place. L knee is in immobilizer and is wrapped with Ace wrap. Neuro: A&Ox3; CNII-XII intact; sensation grossly intact Pertinent Results: INITIAL LAB DATA [2136-8-25] 02:45PM BLOOD WBC-15.9# RBC-3.56 Hgb-10.6* Hct-31.9* MCV-90 MCH-29.8 MCHC-33.3 RDW-14.6 Plt Ct-62* [2136-8-27] 03:55AM BLOOD Neuts-93* Bands-1 Lymphs-2* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2136-8-26] 06:08AM BLOOD Fibrino-804* [2136-8-27] 03:55AM BLOOD Glucose-230* UreaN-52* Creat-3.1* Na-138 K-5.0 Cl-103 HCO3-23 AnGap-17 [2136-8-26] 06:08AM BLOOD ALT-10 AST-13 AlkPhos-85 TotBili-0.2 [2136-8-25] 02:45PM BLOOD CK-MB-2 cTropnT-0.03* proBNP-1526* [2136-8-26] 04:00AM BLOOD Type-ART pO2-62* pCO2-41 pH-7.40 calTCO2-26 Base XS-0 [2136-8-26] 06:44PM BLOOD Type-ART pO2-114* pCO2-62* pH-7.24* calTCO2-28 Base XS--2 [2136-8-27] 03:20AM BLOOD Type-ART pO2-117* pCO2-49* pH-7.34* calTCO2-28 Base XS-0 . AT DISCHARGE: CBC ([8-30]) 8.0/9.4/28.2/96 BMP: 137/4.0/99/26/45/2.3/79 . MICRO: [2136-8-25] 2:45 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): BETA STREPTOCOCCUS GROUP B. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. CEFTRIAXONE Susceptibility testing requested by DR. [Last Name (STitle) ] #[Numeric Identifier 78716] [2136-8-28]. CEFTRIAXONE = 0.19 MCG/ML. Cefpodoxime & MINOCYCLINE SENSITIVITY TESTING REQUESTED BY [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] #[Numeric Identifier 14013]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP B \| CEFTRIAXONE----------- S CLINDAMYCIN----------- =>2 R ERYTHROMYCIN---------- =>4 R PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S [2136-8-26] 7:56 am JOINT FLUID Source: Kneeleft. FINAL REPORT [2136-8-29] GRAM STAIN (Final [2136-8-26]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. [2136-8-26] 4:07 pm TISSUE PERI-PORSTHETIC LEFT KNEE. GRAM STAIN (Final [2136-8-26]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2136-8-29]): NO GROWTH. Legionella Urinary Antigen (Final [2136-8-27]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. IMAGING ECHO ([8-27]): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Pulmonary artery systolic hypertension. Mild mitral regurgitation. Dilated ascending aorta. Compared with the prior study (images reviewed) of [2134-4-28], the findings are similar. CXR ([8-28]) IMPRESSION: 1. Small bilateral pleural effusions, unchanged. 2. Mild cardiomegaly and tortuosity of the aorta, stable. 3. Mild pulmonary vascular congestion Brief Hospital Course: # Hypoxia/Shortness of breath: Must likely multifactorial in etiology: with contribution from underlying COPD (wheezing and short expiratory phase on exam), CHF given elevated BNP and fluid on CXR, obesity-hypoventilation syndrome given body habitus, and ?pneumonia though CXR without focal infiltrate. Patient empirically treated for PNA given WBC count with broad spectrum antibiotics:vanc/ctx/azithro. Given IV solumedrol and a prednisone taper for COPD. Home lasix initially held due to acute on chronic kidney failure. In house CXR with mild vascular congestion. As [Last Name (un) ] improved home lasix/metolazone restarted and patient diuresised well. With treatment of COPD, CHF and ?PNA symptoms improved and patient weaned off supplemental oxygen prior to discharge; completed predisone taper. Foley was left in place in our for rehab facility to adequately monitor I/O. # Septic Left knee/right left extremity cellulitis. Patient found to have erythematous and tender left knee as well as possible cellulitis of posterior right calf. Patient taken to OR by ortho for washout of left knee by Dr. [First Name (STitle) ]. PRINCIPAL PROCEDURE:1. Irrigation debridement to bone of left TKR.2. Revision of left TKR exchange of polyethylene liner.3. Biopsy of left knee tissue.4. Total synovectomy left knee. 2 JP drains were placed and removed by ortho on [8-30], Per ortho recs patient without need for further wash-out as they do not believe knee to be primary source of infection; more so that the joint was seeded hematogenously; possible sources include skin flora, or incomplete suppression of previous group B strep infection in [2133].. Fluid cultures andj oint tissue obtained with no growth to date in house. Patient was placed on broad antibiotics and discharge on IV ceftriaxone. Pain controlled in house with Tylenol and oxycodone 5mg PO Q8hrs as needed. Patient maintained on low dose narcotics with attempted to minimize use as patient with sedative side effects as well as mild hallucinations. . # Group B Bacteremia. During infectious work-up blood cultures were obtained that were positive for Grp B Strep susceptible to CTX. Of note, positive history of Grp B Bacteremia in [2133]. Question if this presentation of bacteremia represents new infection or incomplete suppressant of old. Patient initially on vancomycin and CTX. Treatment tailored to IV CTX after susceptibilities obtain. PICC line placed for prolonged course of Abx tx on [8-30]. . # CAD: No complaints of chest pain. EKG with no ischemic changes. Cardiac enzymes negative. Patient continued on ASA, BB, ace-i, statin. . # Thrombocytopenia: Etiology unclear. Chronic issue in patient with known MGUS. Worked up in [2132] by Heme-Onc.Monitored in house. SPEP, UPEP ordered with plan to be followed up as outpatient. At discharge plt count at baseline: 96. . # Chronic Kidney Disease (stage 4) baseline creatinine 2.7. Elevated during admission (peak 3.1) possibly secondary to hypervolemia. Downtrended during admission with re-initiation of diuresis, at discharge creatinine: 2.4. . # Hypertension. Normotensive in house. Continued on amlodipine. Lasix initially held due to [Last Name (un) ]. Home dose restarted in house. . # Peripheral Neuropathy. Gabapentin and Amitriptyline held in house and due to sedative side effects held at time of discharge. . # Depression. Continued on outpatiet Celexa. . # DM. Sugars well controlled on home Lantis and insulin sliding scale. Medications on Admission: ALBUTEROL SULFATE - 0.083 % (0.83 mg/mL) Solution for Nebulization - one ampule inhaled every 6-8 hours as needed for as needed for shortness of breath Use with nebulizer machine - No Substitution ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - [12-31] puffs by mouth every four (4) to six (6) hours as needed for cough/wheezing AMITRIPTYLINE - 150 mg Tablet - 1 (One) Tablet(s) by mouth hs AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day DEPTH SHOES AND INSERTS - - wear daily for patient with diabetes and neuropathy FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs inhales twice a day FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth hs GEMFIBROZIL - 600 mg Tablet - [12-31] Tablet(s) by mouth twice a day INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen - give 4 times a day; give sq as per sliding scale INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin Pen - 76 units sq every morning IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA Aerosol Inhaler - 2 puffs inhaled four times a day LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth twice a day METOLAZONE [ZAROXOLYN] - 2.5 mg Tablet - 1 (One) Tablet(s) by mouth once a day as needed for weight greater than 305 pounds METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth every four (4) - six (6) hours as needed for pain PRAVASTATIN - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day . Medications - OTC ASPIRIN [ENTERIC COATED ASPIRIN] - (Prescribed by Other Provider; OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet by mouth day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 2,000 unit Capsule - 1 Capsule(s) by mouth once a day GERIATRIC MULTIVITAMINS-MIN [MULTI-VIT 55 PLUS] - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth day INSULIN SYRINGE-NEEDLE U-100 - 31 gauge X [5-13]" Syringe - use twice a day as directed Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Five (5) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): This will be continued for minimum 6-week course (start date was [8-26]). Patient will follow-up in infectious diseases clinic on [9-20]. 14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Please continue while patient is relatively immobile. As patient regains ability to ambulate may discontinue at rehab. 16. Insulin Glargine 100 unit/mL Cartridge Sig: Seventy Six (76) Subcutaneous once a day: Once daily in the morning. 17. Insulin Lispro 100 unit/mL Cartridge Sig: ASDIR Subcutaneous three times a day: Per sliding scale, with meals. 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 20. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 21. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating/gas. 22. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for sob/wheezing. 23. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation every six (6) hours. 24. Gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 25. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 26. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for for weight greater than 305lbs. 27. Insulin Aspart 100 unit/mL Insulin Pen Sig: One (1) give 4 times a day Subcutaneous four times a day: give sq as per sliding scale. Discharge Disposition: Extended Care Facility: [Hospital1 700] TCU - [Location (un) 701] Discharge Diagnosis: PRIMARY: Group B Bacteremia Septic Left Knee CHF COPD SECONDARY: Hypertension Chronic Kidney Disease Anemia Thrombocytopenia Discharge Condition: Mental status: clear and coherent Ambulatory status: requires assistance with ambulation, transfer due to knee pain s/p wash-out Discharge Instructions: You presented to [Hospital1 18] with symptoms of shortness of breath and increased pain and swelling of your right leg and left knee. . On admission you had a fever and elevated white blood cell count indicative of infection. Regarding the lower extremity pain you were treated for presumed skin infection of the right leg and left knee. You were started on antibiotics and taken to the OR to have your left knee washed out. During the procedure two drains were placed in the L knee. Orthopedic surgery followed you throughout your stay. They did not feel you needed any additional procedures during the hospitalization. The drains were pulled on [8-30]. You will follow up with Dr. [Last Name (STitle) ] in ortho clinic on [9-14]. . Regarding your shortness of breath with oxygen requirement. It was thought this was due to a constellation of things: underlying COPD, congestive heart failure and possible pneumonia. You were placed on antibiotics to treat pneumonia. You completed treatment prior to discharge. Regarding COPD you were started on a prednisone taper, and given breathing treatments (with nebulizers) as needed. Your initial CXR illustrated mild fluid overload consistent with CHF. You were placed on home dose of Lasix and diuresed well. With these intervention your breathing gradually improved and at time of discharge you no longer required oxygen. . During the infectious work-up, blood cultures were obtained which were positive for Group B Strep. You were placed on IV Ceftriaxone to treat the infection. The infectious disease team also helped work on your case and recommended continued treatment with ceftriaxone for mininum 6weeks. A PICC line was placed prior to discharge to faciliate IV antibiotic treatment. You will follow up with infectious disease clinic as an outpatient. . CHANGES TO MEDICATION: START taking Ceftriaxone IV - 6 week duration Followup Instructions: Department: ORTHOPEDICS When: FRIDAY [2136-9-14] at 4:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: MONDAY [2136-9-17] at 11:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],ANP-BC [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: FRIDAY [2136-9-14] at 4:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: MONDAY [2136-9-17] at 11:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],ANP-BC [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: INFECTIOUS DISEASE When: THURSDAY [2136-9-20] at 8:50 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 456], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: FRIDAY [2136-10-12] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 27625], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2136-8-31]	[ "486", "4280", "40390", "25000", "2875" ]
Admission Date: [2141-12-27] Discharge Date: [2142-1-4] Date of Birth: [2071-3-7] Sex: M Service: MEDICINE Allergies: Percocet / Ciprofloxacin Attending:[First Name3 (LF) 2972] Chief Complaint: chest pain & shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization with Drug eluting stents x2 to ostial and mid RCA. History of Present Illness: Mr. [Known lastname ] is a 70 year old man with a complicated history including CAD s/p CABG in [2130], PVD, systolic CHF (EF 45-50% in [11-15]) w/ diastolic dysfunction, severe COPD, severe AS (0.8cm2) & AI who presents as a transfer from [Hospital6 ] for respiratory failure. Mr. [Known lastname ] has been hospitalized multiple times in the last several months for respiratory failure and has been intubated 3 times over the past 3 months most recently in early [Month (only) 404] at [Hospital1 34]. Following his most recent discharge, he was seen by his PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 216] on [2141-12-13] for persistent upper respiratory symptoms and placed on a Z-pack. His symptoms improved, but the patient's wife called the patient's PCP 3 days prior to this admission stating that the patient had developed worsening cough productive of thick yellow-green sputum and worsening shortness of breath on his home 2L O2, as well as chest tightness that resolved after SL NTG x 2. At that time, his wife reported that he had no chest pain, nausea, sweating, [Date Range ], chills, vomiting or dizziness and he was directed to [Hospital6 33] for further evaluation. . For unclear reasons, he did not seek care until the day prior to admission when his breathing and chest pain symptoms worsened. He was taken to [Hospital6 33] by ambulance and found to be non-verbal in the ED. CXR was negative and pBNP was 3969. He was initially treated for presumed systolic CHF exacerbation and COPD with CPAP, IV Solumedrol, nebulizers, Lasix, and Nitrates. He was also given a dose of IV Levaquin out of concern for infection but his respiratory rate declined and his ABG's demonstrated severe respiratory acidosis so he was intubated in the [Hospital3 ] ED. In the ICU, EKG's demonstrated sinus tachycardia with left anterior fascicular block and ST depressions in II, V3, V4. CE's rose with CK's peaking at 229 and Troponin levels peaking at 0.45. He was placed on a Heparin gtt, ASA, beta-blocker, and a statin. The following morning, his respiratory status improved and he was extubated and placed on BIPAP before being transferred to the [Hospital1 18] at family request. . On arrival to the CCU, the patient was noted to be on BIPAP, but not in respiratory distress. He was able to speak with the health care team, but demonstrated a visible left hand tremor and was relative immobile. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG:CABG '[30] (LIMA -> LAD, SVG -> D2, OM2, RCA; stent to RCA graft '[32]). Has three vessel coronary disease -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PMH: - severe AORTIC STENOSIS (mean gradient 47 mmHg) - h/o [Name (NI) ] [Doctor Last Name 27089] (unclear when) - Hyperlipidemia - Obstructive sleep apnea - GERD - Anxiety - Colon cancer s/p sigmoid colectomy w/ colorectal anastomosis '[37] and adjuvant Xeloda therapy - PVD - B12 deficiency anemia - Ascending aortic aneurysm (4.2x4.2 in [4-13]) - Anterior wall abdominal hernia - COPD - HTN - Asthma Social History: Tobacco: 150 pk-year smoker (currently smokes 1ppd and more in the past), still smoking. EtOH: Greater than 50 years of significant EtOH (previously reported 4 tumblers of vodka/day, recently reporting 2-4 beers per day). Illicits: None Used to work in security and at a mattress factory, has not worked for several years. Walks without assistance at baseline. Family History: Dad died of MI at 57. 2 brother had MI. One brother had emphysema. One other brother with brain tumor. Physical Exam: VS on admission: T 97.3 BP 128/73 HR 89 RR 8 O2 sat 98% on BIPAP at 30% FiO2 GENERAL: Well-developed elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVD not able to be assessed [1-9] soft tissue obscuring anatomy CARDIAC: RRR, normal S1, S2. No murmurs audible. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NT/ND, large ventral hernia with multiple abdominal scars throughout the abdomen. No HSM. Abdominal aorta not enlarged by palpation. No abdominal bruits. Positive bowel sounds. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ Left: DP 1+ NEURO: CNII-CXII intact, able to follow commands, easily conversant, moving all extremities Pertinent Results: 2D-ECHOCARDIOGRAM [2141-11-27]: OSH, EF 45-50%, with aortic valve area of 0.8cm2 and [1-10]+ aortic insufficiency. . [10/2141]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8cm2). An eccentric jet of mild (1+) aortic regurgitation is seen. The mitral valve leaflets and supporting structures are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with mild global hypokinesis. Mild pulmonary artery systolic hypertension. Mild aortic regurgitation. Compared with the report of the prior study (images unavailable for review) of [2136-5-18], the severity of aortic stenosis has progressed, mild aortic regurgitation is now seen, left ventricular systolic function is less vigorous, and the estimated pulmonary artery systolic pressure is higher. . CARDIAC CATH [2139-10-3]: RIGHT ATRIUM {a/v/m} -/[5-12] RIGHT VENTRICLE {s/ed} 33/7 PULMONARY ARTERY {s/d/m} 33/10/20 PULMONARY WEDGE {a/v/m} -/[10-17] LEFT VENTRICLE {s/ed} 143/11 AORTA {s/d/m} 128/53/80 SYSTEMIC VASC. RESISTANCE 1604 PULMONARY VASC. RESISTANCE 214 . PROXIMAL LAD 40% stenosis MID-LAD 100% stenosis DIAGONAL-1 100% stenosis DIAGONAL-2 DIFFUSELY DISEASED OM-2 90% stenosis . Impressions: 1. Three vessel native coronary artery disease. 2. Known occlusion of all SVGs. 3. Patent LIMA-LAD graft. 4. Mild pulmonary arterial hypertension. 5. Severe, but noncritical aortic stenosis. 6. Normal biventricular diastolic function. CT Abd/pelvis Noncon [12-31] CT ABDOMEN WITHOUT IV CONTRAST: Lung bases are clear without consolidation or pleural effusion. The heart size is normal without pericardial effusion. Dense calcification of the coronary arteries is noted. In the abdomen, assessment of solid organs is limited in the absence of IV contrast. However, the liver is grossly unremarkable. A focal hypodensity anteriorly is unchanged and likely represents focal fatty infiltration. A small gallstone is present in a decompressed gallbladder. The pancreas, spleen, adrenal glands and kidneys are grossly unremarkable. There is no hydronephrosis in either kidney. Perinephric stranding size is unchanged. The stomach and duodenum are distended with fluid and small amount of ingested material. The esophagus also contains fluid. There is no free air or free fluid in the abdomen. The abdominal aorta demonstrates atherosclerotic calcification, but is normal in caliber. There is no mesenteric or retroperitoneal lymphadenopathy by size criteria. CT PELVIS WITHOUT IV CONTRAST: Large bowel demonstrates residual oral contrast material, possibly from the CT of [2141-12-13] or from an outside hospital study. Loops of small bowel are distended, extending to the distal small bowel. Both small and large bowel extends into a large, wide-based ventral hernia. A transition in small bowel caliber is noted just adjacent to the ventral hernia, with a small segment of fecalization of contents of the dilated small bowel, measuring up to 4 cm. Distally, there is marked decompression of the distal and terminal ileum. The colon is relatively decompressed, although still retained a small amount of stool and contrast material. There is no extraluminal fluid or air. The sigmoid colon demonstrates scattered diverticulosis without diverticulitis. There is no free fluid layering dependently in the pelvis. The urinary bladder contains excrete contrast material. There is no pelvic or inguinal lymphadenopathy by size criteria. A fem-fem bypass graft is in place. The patient has undergone prior low anterior resection and surgical material is present at the rectosigmoid junction. OSSEOUS STRUCTURES: Degenerative changes are present throughout the lower spine, with no interval change. There is no new fracture. IMPRESSION: 1. High-grade small-bowel obstruction, with dilatation of proximal loops up to 4 cm, and complete decompression of the distal and terminal ileum. Obstruction may be early, as there is residual oral contrast and stool within the colon, which is minimally decompressed. No evidence of perforation. Obstruction occurs adjacent to the mouth of the large ventral hernia. However, both dilated and decompressed loops pass into and out of the hernia sac. Obstruction may be related to adhesions. 2. Cholelithiasis without cholecystitis. 3. Diverticulosis without diverticulitis. 4. No evidence of obstruction at the rectosigmoid anastomosis. 5. Atherosclerotic disease. [1-1] abd x-ray Single supine portable abdomen radiograph was obtained. The radiograph demonstrates focal mild dilatation of small bowel loops in the epigastric region measuring 3.2 cm, consistent with the small bowel loops seen within the ventral hernia on the prior CT scan. Air is seen within the descending colon and the rectum. The relative lack of air in the distal small bowel suggests likely partial or early small bowel obstruction. There is no intraperitoneal free air. The NG tube terminates at the gastroesophageal junction, and the sideholes likely are at the distal esophagus. Recommended advancement of the NG tube. IMPRESSION: 1. Findings suggestive of early/partial small bowel obstruction. 2. Recommended further advancement of the NG tube. Labs at admission: 9>31.8<142 (WBC peaked at 15.3 on [12-31] in the context of steroids) N 90, L7.1, M2.2, E0.6, B0.2 PT 12, PTT 116, INR 1.0 (normalized at discharge) 137/3.8/99/30/25/1.3<171 (Cr peaked at 2.6 on [12-31] and was 1.2 at discharge) ALT 46, AST 45, LD 262, CK 124, Alk Phos 48, TB 0.4 (this was peak CK), other LFTS normalized before discharge Brief Hospital Course: 70 year old man with a complicated history including CAD s/p CABG, PAD, systolic CHF (EF 45-50% in [10-16]) w/ diastolic dysfunction, severe COPD, severe AS (0.8cm2) & AI and a severe ventral hernia who presents as a transfer from [Hospital3 ] for respiratory failure. After rapid stabilization of his respiratory status, he went for a cath with PCI with DESx2 to the RCA on [12-29]. He had intermittent abdominal pain that progressed to an SBO on [12-31]. Patient made progressively less urine and was transferred to MICU through [1-1]. He was sent to the cardiology service on [1-1] and the SBO subsequently resolved. # Small bowel obstruction Patient has history of severe ventral hernia s/p laparotomy for colon resection and intermittent abdominal pain, last on [2141-12-13]. He received a CT ABD with contrast that was negative for SBO at that time. On [12-28] he complained of abdominal pain that passed with ativan and simethicone. On [12-30] he had constipation, [12-31] he had obstipation, bilious emesis and acute renal failure. A NGT was placed. Surgery was consulted. All PO only medications were held except for Plavix which was given down the NGT. Surgery followed and his NGT drainage decreased and he started to have BMs on [1-2]. On [1-2] the NGT was pulled. Mr. [Known lastname 9907] then had intermittent nausea without vomiting which resolved with Ranitidine. He continue to have BMs and flatus. # ARF: On [12-30] he developed ARF in the setting of SBO. Patient made very little urine and was therefore transfered to a MICU for management of fluid status given ARF and Aortic stenosis. IVF were started and a foley catheter was placed which was subsequently removed with voiding prior to discharge. His creatinine at d/c was 1.2, at his baseline. # Respiratory failure/ COPD Patient with known history of COPD, Asthma, and OSA as well as an extensive smoking history. He is on 2L of continuous O2 as well as Albuterol, Advair, and Tiotropium at home and over the past 3 months has required multiple intubations for respiratory distress despite repeated courses of Prednisone & antibiotics, most recently approximately 2 weeks PTA. He was intubated on [12-26] at [Hospital1 34] for an ABG of 7.12/91/62/32 and was extubated on [12-27] AM to CPAP prior to transfer after improved respiratory status. Etiology likely obstructive lung disease with systolic CHF as patient did not demonstrate e/o infection. In the CCU, the patient was placed on BIPAP and eventually weaned to 2L of NC over approximately 24 hours. He received 40 mg of Prednisone daily and a course of levaquin. By [12-31], he was on 2 litres, saturating at 97%. He was able to tolerate room air with good saturations on day of discharge. He was discharged with a slow steroid taper. # Systolic Heart Failure Diasolic Heart Failure Aortic Stenosis, Severe Aortic Insufficiency Patient with known systolic heart failure, last EF in [11-15] demonstrated EF 45-50% with severe AS (mean gradient 47 mm Hg and area 0.8cm^2) and [1-10]+ AR. His EF is unchanged from echocardiograms, but as his AR has progressed significantly since his last echo one month prior, his true forward flow is likely more compromised than his EF would suggest. CXR's from OSH have not demonstrated e/o congestion or effusions and clinical exam does not support fluid overload, but pBNP was elevated at 3969. Patient possibly a candidate for percucanteous valve replacement vs valvuloplasty however this decision will be deferred to the outpatient setting. # CORONARIES: Patient s/p CABG '[30] (LIMA -> LAD, SVG -> D2, OM2, RCA; stent to RCA graft '[32]). His last cardiac catheterization in [2138] demonstrated three vessel coronary disease with a patent LIMA, but occlusion of all vein grafts. Patient with possible old inferior MI based on micro-Q waves in II, III, AvF, but EKG on admission does not demonstrate new ST changes. CE's trended down from OSH levels (peak CK 229) and patient was CP free. Patient initially on Heparin gtt, ASA, statin, beta-blocker. He did not receive Plavix at OSH as he has a history of GI bleed and thrombocytopenia while on Plavix. He was discharged with the addition of Plavix and high-dose statin with high-dose aspirin. # RHYTHM: Patient without known history of arrythmia, but micro-Q waves in II, III, and AvF suggest prior inferior infarct not seen on ECG from 11/[2140]. # Hypertension: Patient takes Imdur SR 120 mg daily & Metoprolol Tartrate 25mg TID at home. Blood pressures at OSH and in CCU were well-controlled. Given h/o AS, patient likely pre-load dependent. Imdur and Metoprolol were restarted before discharge. # Hyperlipidemia: Patient takes Simvastatin 20mg qHS at home. Given question of ACS, high dose statin warranted. Fish oil was also continued. # Alcohol abuse: Patient with extensive EtOH history and an episode of DT in [11/2141] requiring intubation. His EtOH screen on [12-26] at [Hospital1 34] was negative and his wife reported that his last drink was on [12-25]. Patient was maintained on a CIWA scale and continued to get his home q8H prn Ativan for anxiety. # Anxiety: Patient with h/o anxiety, on Celexa 80mg daily, Lorazepam 1mg TID:PRN, and Seroquel 12.5mg [Hospital1 ] at home. Per OMR records, patient preferred not to take Seroquel out of concern for side effects, so it is unlikely to be an active medication. Home medications were continued. # Peripheral vascular disease: Patient with known PAD s/p [Hospital1 ] Fem-[Doctor Last Name ] bypass (unclear when). He also has a known ascending aortic aneurysm last measured at 4.2cm x 4.2cm in 5/[2138]. ASA 325 and Pentoxyfylline SR 400mg TID were continued. # Anemia: Patient with known Vitamin B-12 deficiency anemia for which he receives daily supplementation. Iron studies during this hospitalization were normal and he was continud on his home B-12 1,000 mcg daily. # GERD: Patient was continued on his home Omeprazole 20mg daily and then was switched to an H2B before discharge. Ranitidine worked better than Famotidine. # H/o recurrent C. difficile colitis: Patient has failed multiple Flagyl regimens in the past in the context of EtOH use, and was ultimately successfully treated with an extended course of Vancomycin. He did have an episode of diarrhea and abdominal pain during this hospitalization which resolved. He had multiple bowel movements after resolution of his SBO, likely thought to be due to just improved motility. # H/o Colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis '[37] and adjuvant Xeloda therapy with resulting post-surgical anterior wall abdominal hernia. Patient uses belt for hernia control, but this has exacerbated SOB in the past, so it was not utilized during this hospitalization. # Active smoking habit: Patient smokes ~ 1ppd with >150 pack year history. He was given a Nicotine TD during this hospitalization and provided an Rx and counseling prior to discharge. CODE: FULL CODE (confirmed with patient's wife) COMM: [Name (NI) ] & patient's wife [Doctor First Name ] [Telephone/Fax (1) 106696](h), [Telephone/Fax (1) 106697](c)) Medications on Admission: ALBUTEROL SULFATE 90 mcg HFA Inhaler 1-2 puffs q4-6H:PRN AMITRIPTYLINE 50 mg qHS CITALOPRAM 80mg daily FLUTICASONE-SALMETEROL 500 mcg-50 mcg [Hospital1 ] HYDROCODONE-ACETAMINOPHEN 5 mg-500 mg [Hospital1 ]:PRN IPRATROPIUM-ALBUTEROL 2.5-0.5 mg/3 mL NEB QID ISOSORBIDE MONONITRATE SR 60 mg daily LORAZEPAM 1 mg TID:PRN anxiety METOPROLOL TARTRATE 25mg [Hospital1 ] NITROGLYCERIN 0.4 mg SL PRN:chest pain OMEPRAZOLE EC 20 mg daily PENTOXIFYLLINE SR 400 mg TID PREDNISONE taper (taper unknown) QUETIAPINE 12.5 mg Tablet [Hospital1 ] SIMVASTATIN 20 mg qHS TIOTROPIUM BROMIDE 18 mcg, 1 puff daily ASPIRIN 81 mg Tablet [Hospital1 ] CYANOCOBALAMIN 1,000 mcg daily OMEGA-3 FATTY ACIDS 1,000 mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take every day for one year, do not miss [First Name (Titles) 691] [Last Name (Titles) 4319] or stop taking. . Disp:30 Tablet(s) Refills:11 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:2 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 6. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 7. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO twice a day. 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day. 9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:28 Patch 24 hr(s) Refills:2 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: do not take more than 4 grams in 24 hours. 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [12-9] Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheezing. 14. Citalopram 40 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. 16. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day. 18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 20. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 21. Prednisone 5 mg Tablet Sig: 1-2 Tablets PO once a day: take 2 tablets (with your 20mg tablets to equal 30mg) through [1-6]; on [1-7] start taking one tablet (with your 20mg tablets to equal 25mg). Disp:30 Tablet(s) Refills:2 22. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing: use in place of your nebulizer. Disp:1 INH Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] [Hospital3 269] Discharge Diagnosis: Acute on Chronic Systolic and Diastolic congestive Heart Failure Chronic Kidney Disease, Stage 2 Chronic Obstructive Pulmonary Disease Exacerbation Aortic Valve Stenosis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had trouble breathing and needed to be intubated at [Hospital 7912]. You were extubated and transferred to [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) 4656] your heart. You were treated with antibiotics for COPD (emphysema) and given prednisone and nebulizer treatments to help your oxygen level. A Cardiac catheterization showed blockages in your arteries which may have made your breathing worse. You had 2 stents placed in an artery in your heart. You will need to be on Plavix for one year and possibly longer. It is extremely important that you take Plavix and aspirin every day and not miss [First Name (Titles) 691] [Last Name (Titles) 4319]. Missing [Last Name (Titles) 4319] could cause your stents to clot off and cause a heart attack or death While you were here some of your medications were changed. You should CONTINUE taking: -Imdur 120mg daily -Metoprolol 25mg three times a day -Tylenol 325-650mg every 6 hours as needed for pain -Albuterol nebs four times a day and every 2 hours as needed for shortness of breath or wheezing - Amitriptyline 25mg nightly - Celexa 20 mg twice a dy - Advair 500/50 twice a day - multivitamin daily - trental 400mg three times a day - Seroquel 12.5mg twice a day - Spiriva 18 mcg daily - Fish oil - Vitamin B1 and B12 - Ativan 1mg every 8 hours as needed for anxiety. You should not drive with this medication. You should START taking: - Plavix 75 mg daily - take bactrim for PCP pneumonia prevention because of your steroids until your doctor tells you to stop it - You should stop smoking. Use the nicotine patch once a day to help. DO NOT smoke while using the patch since it can be even more dangerous for your heart. You should CHANGE: - INSTEAD of Aspirin 81 mg daily START spirin 325mg and your cardiologist will let you know when to come down to 81mg - Increase your Simvastatin to 80 mg daily - STOP Prilosec and INSTEAD START Ranitidine for reflux since Prilosec an interfere with your new heart stents. - You should increase your Prednisone to 30mg daily (one 20mg pill plus two 5mg pills) through [1-6]. On [1-7], start taking a total of 25mg daily (one 20mg pill plus one 5mg pill) . 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. Followup Instructions: You have the following appointments: Appointment #1 MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Specialty: Cardiology Date/ Time: [Last Name (NamePattern1) 2974], [1-12], 1:30 Location: [Street Address(2) ], [Location (un) ] Phone number: [0-0-] Special instructions for patient: Appointment #2 MD: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216] Specialty: Internal Medicine/ PCP Date/ Time: Wednesday, [2143-1-10]:10am Location: [Hospital Ward Name 23] building, [Location (un) 453], Atrium Suite Phone number: [Telephone/Fax (1) 250]	[ "41071", "51881", "5849", "41401", "4280", "4241", "40390", "32723", "3051", "4168" ]
Admission Date: [2104-1-7] Discharge Date: [2104-1-18] Date of Birth: [2019-8-14] Sex: M Service: CARDIOTHORACIC Allergies: Tetracycline / Amoxicillin / Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Transfer from OSH, STEMI Major Surgical or Invasive Procedure: [2104-1-11] urgent cabg x3 (LIMA to LAD, SVG to OM, SVG to PDA)/ MV repair (28 mm CE ring)/IABP History of Present Illness: 84 y/o M with a history of diet-controlled diabetes, hypertension presented to [Hospital ] hospital from PCP's office earlier today with cough productive of yellow sputum, sinus congestion, chest pain with coughing, and shortness of breath for the last several days, no fever. PCP subsequently sent patient to the Emergency room on 2L O2. Patient's initial vitals on arrival to ED were HR 102 BP 116/81 RR 20 92% 2L. CXR done showed "diffuse asymmetric interstitial and alveolar process, worse on the right," pulmonary edema vs. pneumonia. Initial ECG showed NSR, LVH, TWI/STD in Leads V4-V6, Q wave III. He received 40 mg IV Lasix. He then desated to 80% when on the commode and was intubated for hypoxic respiratory failure. ECG showed [Street Address(2) 1766] elevation in V3, 1 mm V2, Trop I 10. He was given another 40 mg IV Lasix, started on a heparin gtt, given aspirin 325, plavix 300, and taken urgently to the cath lab. Prior to cath, he was started on a dopamine gtt after SBPs were in the 40s, after recieving multiple doses of propofol/fentanyl during intubation. . Cath showed 90% distal left main disease, 80% mid-LAD, 80% D2, 80% Circumflex, totally occluded distal RCA. Right heart cath was performed (on dopamine and with IABP placed), showing CO 6.38, CI 3.4, SVR 709, PCWP 18, PAP 39/20 (25). Patient was transferred to [Hospital1 18] via [Location (un) 7622] for evaluation for urgent CABG. . On arrival to [Hospital1 18], he had been weaned off dopamine gtt. Initial vitals were HR 69 BP 94/52 RR 24 RR 100% on CMV 500 100% 14 5. IABP was in place. . Remainder of review of systems unobtainable as patient intubated and sedated. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes (diet controlled), Hypertension 2. CARDIAC HISTORY: none 3. OTHER PAST MEDICAL HISTORY: - allergic rhinitis - anxiety - osteoarthritis - olecranon bursitis [2103-12-28] Social History: - Tobacco history: quit [2066-12-21] - ETOH: yes Family History: - Mother: died of cervical cancer at 58 yo - Father: died of "old age" at 88 yo -brother has hypertension Physical Exam: VS: HR 69 BP 94/52 RR 24 RR 100% on CMV 500 100% 14 5 79 kg GENERAL: Intubated, sedated. Unresponsive. HEENT: Sclera anicteric. PERRL. NECK: Supple with JVP of 8 cm at 10 degrees. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,, occassional premature beat. normal S1, S2, left-sided S3. No murmurs. LUNGS: Coarse breath sounds in ant fields bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness EXTREMITIES: 1+ Distal pulses b/l. No edema. Warm. SKIN: + stasis dermatitis Pertinent Results: ADMISSION LABS: . [2104-1-7] 11:55PM BLOOD WBC-12.6* RBC-4.07* Hgb-12.9* Hct-36.6* MCV-90 MCH-31.7 MCHC-35.2* RDW-14.7 Plt Ct-159 [2104-1-7] 11:55PM BLOOD PT-14.0* PTT-105.9* INR(PT)-1.2* [2104-1-7] 11:55PM BLOOD CK-MB-213* MB Indx-13.2* cTropnT-2.43* [2104-1-7] 11:55PM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0 . CARDIAC CATH: 90% distal left main disease, 80% mid-LAD, 80% D2, 80% Circumflex, totally occluded distal RCA. Right heart cath was performed showing CO 6.38, CI 3.4, SVR 709, PCWP 18, PAP 39/20 (25) Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is moderately depressed (LVEF= 25 - 30 %) with preserved basal segments but hypokinetic mid segments and akinesis of the apex. There is moderate global RV hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. There is an IABP 3 cm distal to the left subclavian artery. The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. The jet is central and reflects poor co-aptation of the leaflet tips which is worsened by provocation with Trendelenburg position. There is no pericardial effusion. Post-CPB: The patient is AV-Paced on no inotropes. LV systolic fxn is improved to an EF of 35 - 40%. There is a partial mitral ring prosthesis with no leak, no MR and a residual mean gradient of 4 mmHg. AI remains trace - 1+. IABP in good position. Aorta intact. Brief Hospital Course: CAD/Cardiogenic Shock: Cath showing severe 3-vessel disease amenable to CABG. Echo [1-8] showing hypokinesis distal anterior/septal segments and the apex (mid-LAD distribution). LVEF = 40%. As he was having ongoing ECG changes, he was started on an integrillin gtt. He was diuresed due to pulmonary edema on CXR and high wedge on PA catheter tracings. Patient was plavix loaded at OSH; Plavix was held prior to CABG. Patient remained on IABP on 1:1, as urine output decreased when pump was weaned. He was weaned of a dopamine drip, started on a beta blocker. # Acute on chronic renal failure: Baseline Cr .9. Likely secondary to renal hypoperfusion from cardiogenic shock/hypotension. Cr 1.6 on arrival, trended down to 1.3 prior to CABG. Taken urgently for surgery on [1-11]. Transferred to the CVICU in stable condition. IABP removed on POD #1. PICC placed for access and removed before discharge. Went into A Fib on [1-12] also and was started on amiodarone. Remained in ICU for BP and respiratory mgmt. Extubated on POD #2. Amiodarone stopped per cardiology due to conversion pauses and managed with beta blockade.Evaluated for aspiration risk. Chest tubes and pacing wires removed per protocol. Coumadin started for A Fib. Transferred to the floor on POD #5 to begin increasing his activity level. He was gently diuresed toward his perop weight. Continued to make good progress and was cleared for discharge to [Hospital 19771] Rehab in [Location (un) 2624]. Target INR 2.0-2.5 for A Fib. Medications on Admission: - MVI daily - [Doctor First Name ] 180mg daily Patanol 0.1% Eye drops- 1 gtt both eyes [Hospital1 ] Fluticasone 50mcg nasal spray 2 sprays each nostil daily amlodipine 7.5mg daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day. 3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. warfarin 1 mg Tablet Sig: rehab provider to order daily;target INR 2.0-2.5 for AFib Tablets PO DAILY (Daily) as needed for AF: target INR 2.0-2.5; dose for today [1-18] only 0.5 mg; all further dosing per rehab provider. 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. insulin fixed dose and sliding scale ( see attached) see attached Discharge Disposition: Extended Care Facility: Hellenic - [Location (un) 2624] Discharge Diagnosis: CAD s/p cabg x3/MV repair cardiogenic shock NSTEMI postop A Fib diet-controlled diabetes mellitus hypertension anxiety osteoarthritis olecranon bursitis [2103-12-28] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema - 1+ BLE Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] Thursday [2-7] @ 1:15 pm Cardiologist:Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ( his office will call you with appt) Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 19772] in [3-25] 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 A Fib Goal INR 2.0-2.5 First draw tomorrow [1-19] Please arrange for coumadin/INR f/u prior to discharge from rehab Completed by:[2104-1-18]	[ "41071", "51881", "5849", "9971", "4240", "41401", "25000", "40390", "4280", "5859", "42731" ]
Admission Date: [2151-1-8] Discharge Date: [2151-2-4] Date of Birth: [2073-5-13] Sex: M Service: Neurosurgery ADDENDUM: On [2151-1-29] the patient was awake, alert, and moving his upper extremities spontaneously and withdrawing his lower extremities. The patient was transferred to the regular floor. The patient was evaluated by Physical Therapy and Occupational Therapy and felt to require acute rehabilitation. The patient was also seen by Speech and Swallow who felt the patient was clearly aspirating, and a percutaneous endoscopic gastrostomy tube was placed in Interventional Radiology without complications. Neurologically, the patient remained awake, verbally responding, somewhat inattentive, and followed commands inconsistently. The patient's speech was still somewhat dysarthric. The patient is extremely hard of hearing, so it was difficult to get him to follow commands due to his [Last Name ] problem. The patient remained stable with stable vital signs. A head computed tomography just prior to discharge will be completed. The patient's neurologic status was stable, and he was ready for discharge. MEDICATIONS ON DISCHARGE: (His medications at the time of discharge included) 1. Dilantin 200 mg per nasogastric tube once per day. 2. Dilantin 100 mg per nasogastric tube twice per day. 3. Insulin sliding-scale. 4. Vancomycin 1000 mg intravenously q.24h. 5. Hydralazine 75 mg by mouth q.6h. (hold for a systolic blood pressure of less than 100 or a heart rate of less than 50). 6. Lisinopril 20 mg by mouth once per day (hold for a systolic blood pressure of less than 100 or a heart rate of less than 50). 7. Metoprolol 150 mg by mouth three times per day (hold for a systolic blood pressure of less than 100 or a heart rate of less than 50) 8. Subcutaneous heparin 5000 units subcutaneously q.12h. 9. Famotidine 20 mg by mouth once per day. 10. Ferrous sulfate 325 mg by mouth once per day. 11. Tamsulosin 0.8 mg by mouth at hour of sleep. 12. Gabapentin 600 mg by mouth twice per day. 13. Colace 100 mg by mouth twice per day. 14. Albuterol nebulizers one nebulizer q.6h. as needed. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient's staples and sutures will be removed prior to discharge. 2. The patient was instructed to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in two weeks for a repeat head computed tomography. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2151-2-4] 08:13 T: [2151-2-4] 08:36 JOB#: [Job Number 7247]	[ "5070", "25000", "4019", "2720" ]
Admission Date: [2117-1-27] Discharge Date: [2117-2-2] Date of Birth: [2052-3-25] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[First Name3 (LF) 2195] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: 64M h/o COPD and empyema, tobacco abuse with 40+ pack year smoking history, HLD, HTN, prostate ca s/p cyberknife and radiation p/w gradual onset dyspnea, productive cough and conjunctivitis. Patient started having more difficulty breathing and cough on Friday. Initially got better through saturday, but worsened over the last few days and acutely felt that he was unable to catch his breath last night. Tried using albuterol inhaler at home, does't think it helped. Cough is new and prodcutive of green sputum. Denies myalgias, but does have some nasal congestion and conjunctival discharge (bilateral, not itching) since Friday as well. He had a flu shot this year. Recently visited friends, one of whom had a cold or pneumonia. At home he checked his temperature several times, ranging 99-100.7 since Saturday. Has been admitted in the past for COPD exacerbation, last in [2113], at which time he had PNA and empyema which was drained. Has not been intubated in the past. . In the ED initial VS were 99.9 103 162/58 36 91% RA, temp later checked increased to 100.4. Pt was noted to have increased work of breathing. CXR showed increased vascular markings bibasilar with no obvious consolidation. ABG drawn prior to startig NIPPV showed 7.36/42/71. Becasue of his work of breathing and RR of 30s was put on NIPPV with improvement in O2 sat to high 90s and appeared more comfortable. After 30 minutes, attempted to remove NIPPV and was replaced because appeared very uncomfortable. Given ceftriaxone and azithromycin IV for CAP coverage, solumedrol 125 mg IV and magnesium 2 gm for possible asthma component although has no hx and albuterol and ipratroprium nebs. Blood and sputum cx sent. Labs notable for Na 131, WBC of 13.1 Transferred to ICU for need for NIPPV. . On arrival to the ICU, pt appears comfortable on BiPAP, denies any complaints. Past Medical History: Past Medical History: COPD (empyema s/p drainage in [2113]) HLD HTN Prostate cancer s/p cyberknife and radiation gout L VATS decortication on [2114-4-23] for a strep milleri empyema Social History: Lives wtih wife, has 45+ year packing history and last smoked 6 weeks ago. No EtOH or drugs. Family History: Mother with [Name2 (NI) ], Father deceased with MI Physical Exam: ADISSION EXAM: General: Alert, oriented, no acute distress, comfortable on BiPAP HEENT: Sclera anicteric, yellow-white conjunctival discharge, dry MM, no oropharyngeal lesions, occasional production of yellow-green sputum Neck: supple, JVP difficult to assess due to body habitus, no LAD Lungs: expiratory wheezes throughout, moving air well, no rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: Lungs clear to auscultation, breathing comfortably, >95% on room air with ambulation Pertinent Results: ADMISSION LABS: . [2117-1-27] 07:56AM BLOOD WBC-13.4* RBC-4.46* Hgb-14.6 Hct-41.7 MCV-94 MCH-32.8* MCHC-35.1* RDW-13.3 Plt Ct-246 [2117-1-27] 07:56AM BLOOD Neuts-89.6* Lymphs-5.4* Monos-4.3 Eos-0.2 Baso-0.5 [2117-1-27] 11:59AM BLOOD PT-13.4* PTT-28.8 INR(PT)-1.2* [2117-1-27] 07:56AM BLOOD Glucose-134* UreaN-27* Creat-1.1 Na-131* K-4.3 Cl-94* HCO3-21* AnGap-20 [2117-1-27] 07:56AM BLOOD proBNP-300* [2117-1-27] 07:56AM BLOOD cTropnT-<0.01 [2117-1-27] 11:59AM BLOOD Calcium-8.4 Phos-3.5 Mg-3.0* [2117-1-27] 08:47AM BLOOD Type-ART O2 Flow-4 pO2-71* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2117-1-27] 08:05AM BLOOD Lactate-1.6 DISCHARGE LABS: [2117-2-1] 09:00AM WBC-14.8* RBC-4.52* Hgb-14.6 Hct-42.8 MCV-95 Plt Ct-332 [2117-1-31] 07:08AM Glc-111* BUN-12 Creat-0.8 Na-139 K-3.8 Cl-103 HCO3-28 MICROBIOLOGIC DATA: [2117-1-27] Blood culture (x 2) - pending [2117-1-27] Urine culture - pending [2117-1-27] Legionella urine antigen - negative [2117-1-27] MRSA screen - positive [2117-1-27] Sputum culture - contaminated sample IMAGING STUDIES: [2117-1-27] CHEST (PORTABLE AP) - Single AP erect portable view of the chest was obtained. There is perihilar and bibasilar opacities which could relate to fluid overload, although underlying infectious process could also be present in the appropriate clinical setting. No pleural effusion or pneumothorax is seen. Cardiac and mediastinal silhouettes are stable and unremarkable. PA/LATERAL: Mildly improved, but persistent pulmonary edema or, in the correct clinical context, bibasilar pneumonia (including atypical, viral or PCP [Name Initial (PRE) 105601]). Brief Hospital Course: 64M h/o COPD and empyema, tobacco abuse with 40+ pack year smoking history, HLD, HTN, prostate ca s/p cyberknife and radiation p/w gradual onset dyspnea and productive cough and conjunctivitis, thought to be secondary to a COPD exacerbation and pneumonia. # COPD exacerbation, Pneumonia: Patient was weaned from BiPAP to supplemental oxygen for nasal cannula. Blood, urine and sputum cultures were obtained and are no growth at the time of discharge. Fluticasone and tiotropium treatments were continued. Oral steroids as well as Ceftriaxone and Azithromycin coverage for COPD exacerbation were continued and the patient was transitioned to Levofloxacin at discharge to complete a total of eight days of antibiotics as well as a steroid taper. Overall his clinical exam improved, he was weaned from oxygen, and he had good oxygen saturations on room air with ambulation prior to discharge. # Tobacco abuse: counseled on quitting smoking, currently trying to quit. # Depression: continued buproprion # HTN: continued home dosing of losartan, nifedipine. # Gout: continued allopurinol. # Transitional Issues: -follow up CXR in [5-7] weeks Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs(s) by mouth q 4 hours as needed for cough/wheezing 3 month supply ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth Once a day COLCHICINE [COLCRYS] - 0.6 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for gout FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 Puffs(s) Inhaled Once a day Rinse after use LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth Once a day NIFEDIPINE [NIFEDICAL XL] - 60 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth once a day SILDENAFIL [VIAGRA] - 50 mg Tablet - 1 Tablet(s) by mouth 1 hour pre-sexual activity TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 Puff inhaled Once a day TRIAMTERENE-HYDROCHLOROTHIAZID - - 37.5 mg-25 mg Tablet - 1 Tablet(s) by mouth daily (Just started takign again [1-24]) Buproprion 100 mg [Hospital1 ] ASPIRIN 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth Once a day Discharge Medications: 1. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 5. triamterene 50 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. prednisone 10 mg Tablet Sig: As directed Tablet PO once a day for 6 days: Take 3 Tablets (30mg) [2117-2-3] and [2117-2-4]; take 2 tablets (20mg) [2117-2-5] and [2117-2-6]; take 1 tablet (10mg) [2117-2-7] and [2117-2-8]. Disp:12 Tablet(s) Refills:0 10. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. Disp:1 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Community Acquired Pnuemonia - Acute COPD Excacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 18] with cough and shortness of breath. You have been treated for pneumonia and an exacerbation of COPD. You are being sent home to complete a course of antibiotics and a taper of your steroids. It is important that you follow-up with your primary care doctor to ensure that your breathing continues to improve. Please keep all of your appointments as listed below Followup Instructions: Department: BIDHC [Location (un) ] When: THURSDAY [2117-2-11] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5080], MD [Telephone/Fax (1) 3329] Building: [Location (un) 3966] ([Location (un) 55], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site *The office is working on a sooner appt for you and will call you at home with the appt. If you dont hear from them by Wednesday afternoon, please call them directly to book. Department: PULMONARY FUNCTION LAB When: MONDAY [2117-2-15] at 10:40 AM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: MONDAY [2117-2-15] at 11:00 AM With: [Name6 (MD) 610] [Name8 (MD) ] RN/DR. [Last Name (STitle) 611] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage **This appointment is with a specialist who will focus directly on managing your COPD as you transition from the hospital to home. After this visit you will be scheduled in the department as needed with either your regular pulmonologist or with a new one.	[ "486", "2761", "2724", "311" ]
Admission Date: [2119-3-17] Discharge Date:[2119-3-20] Date of Birth: [2119-3-17] Sex: F Service: NB HISTORY: The patient is a 2295 gram product of a 34 [5-20] week gestation born to a 37 year old G7 P2 woman whose pregnancy was complicated by gestational diabetes. Prenatal screens: A positive, antibody negative, rubella immune, RPR non reactive, hepatitis B surface antigen negative, GBS unknown. The mother was admitted in pre term labor on day of delivery. Delivery by cesarean section for progression of labor. Vigorous at delivery. Given blow-by oxygen and stimulation. Apgars were 8 at one minute and 9 at five minutes. Infant brought to NICU. SUMMARY OF HOSPITAL COURSE BY SYSTEM: Infant has remained on room air throughout this hospitalization. She initially had some intermittent grunting shortly after admission, which resolved. Infant has not had any apnea or bradycardia this hospitalization. Oxygen saturation have been greater than 95 percent. Respiratory rate is 30's - 40's. CARDIOVASCULAR - No murmur. Hemodynamically stable. FLUID, ELECTROLYTES AND NUTRITION - Infant was initially receiving nothing by mouth and 80 cc/kg/day of D10W. Enteral feedings were started in day of life one. The infant is currently taking over 100 cc/kg/day of Similac 20 cal/oz p.o. The most recent electrolytes on day of life one showed a sodium of 141, potassium 5.4, chloride 107, bicarbonate 20. The most recent weight is 2170 grams. GASTROINTESTINAL - Infant has not received phototherapy this hospitalization. The most recent bilirubin level on day of life two was 7.1, indirect 0.2. HEMATOLOGY - CBC on admission: White count 9.9, hematocrit 50.5 percent, platelets 324,000; 32 neutrophils, 0 bands, 61 lymphocytes. INFECTIOUS DISEASE - The infant received 48 hours of ampicillin and gentamicin. Blood cultures were negative at 48 hours and antibiotics were discontinued. Blood cultures remain negative to date. NEUROLOGY - Normal neurologic examination. AUDIOLOGY - Hearing screening is recommended prior to discharge. PSYCHOSOCIAL - Parents involved. CONDITION ON DISCHARGE: Stable on room air. Discharged level I newborn nursery. NAME OF PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 60305] in [Location (un) 1456]. CARE RECOMMENDATIONS: Feedings at discharge: Minimum 80 cc/kg/day p.o. of Similac 20 cal/oz. Medications: None. Car seat position screening recommended prior to discharge home. State newborn screen to be sent on day of life three. Hepatitis B vaccine recommended prior to discharge. IMMUNIZATIONS: Immunizations recommended: Synergist RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks. 2. Born between 32-35 weeks with two of the following: day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings. 3. Chronic lung disease. 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. Followup appointment with primary pediatrician. DISCHARGE DIAGNOSES: 1. Prematurity, triplet number two. 2. Status post transitional respiratory distress. 3. Rule out sepsis, ruled out. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2119-3-20] 13:48:22 T: [2119-3-20] 16:48:41 Job#: [Job Number 60306]	[ "V290", "V053" ]
Admission Date: [2108-9-4] Discharge Date: [2108-9-12] Date of Birth: [2056-11-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1257] Chief Complaint: Hypotension, fever Major Surgical or Invasive Procedure: none History of Present Illness: This is a 51 year-old male with a history of Down's syndrome and chronic hepatitis B, indwelling Foley catheter due to quadraparesis s/p fall in [2108-6-7], s/p cervical laminectomy, recent hospital admission for urosepsis (discharged from [Hospital1 18] on [2108-8-14]) who presents with fevers, malaise. According to records from nursing home, pt was noted to be lethargic and febrile to 104.2 F on the night of admission. Tylenol 1g and Levoquin 250 mg were given. One hour later at the nursing home, pt's vitals were: 100.6 F, HR 76 BP 86/48 O2 sat 92% on RA. Pt was sent to [Hospital1 18] ED for further management. . In the ED, vitals were 101.6 F, HR 88, BP 113/55, RR 18 with O2 sat of 89% on RA (Recovered to 96% on 4 L NC). CXR showed some opacities suggestive of PNA. Pt received Vancomycin 1g, Zosyn 4.5 mg, and Levaquin 750 mg in the ED for presumed HAP. Also given were Toradol 15mg x 1, and 2L of fluid as pt was noted to be hypotensive with SBP in 80s. Pt was admitted to ICU for hypotension and concern for sepsis. Past Medical History: - chronic hep B - on adefovir and lamivudine, no known cirrhosis - Quadraparesis, s/p posterior cervical laminectomy on [2108-7-11] - trisomy 21 - rosacea - Right eye blindness - [3-10] retinal detachment - Right cataract - eczema - Cholelithiasis Social History: Lives at a group home. Sister [Name (NI) 8513] is health care proxy. Family History: non-contributory per medical record Physical Exam: Vitals: T: 98.0 BP: 114/57 HR: 74 RR: 15 O2Sat: 98% on 5L NC GEN: lying in an awkward position in bed, often yelling incomprehensible words. Alert, but ineffective communication. HEENT: EOMI, + hazy opacities over right pupil with purulent discharge, eyes injected bilaterally, left pupil round and reactive to light. sclera anicteric, extremely dry MM NECK: No JVD, no cervical or periclavicular lymphadenopathy, trachea midline COR: RRR, [3-14] holosystolic murmur, normal S1 S2, radial pulses +2 PULM: difficult to assess due to pt's inability to cooperate, however CTAB, no W/R/R ABD: Soft, ND, +BS, Pt affirms presence of diffuse abdominal pain. No guarding, rebound. EXT: No C/C/E. + hyperpigmentation/ thickening of skin in lower extremities associated with early chronic venous stasis Back: Stage 2 decubitus ulcer in sacral area. NEURO: alert, not able to assess orientation. Pertinent Results: [2108-9-4] 08:10PM WBC-8.2 RBC-3.83* HGB-12.0* HCT-36.4* MCV-95 MCH-31.5 MCHC-33.1 RDW-15.5 [2108-9-4] 08:10PM NEUTS-69.1 LYMPHS-25.1 MONOS-4.3 EOS-0.5 BASOS-1.0 [2108-9-4] 08:10PM PLT COUNT-306 [2108-9-4] 08:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-TR [2108-9-4] 08:10PM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.037* [2108-9-4] 08:10PM URINE RBC-21-50* WBC-[12-27]* BACTERIA-MANY YEAST-NONE EPI-0 [2108-9-4] 08:10PM URINE MUCOUS-MANY [2108-9-4] 08:10PM GLUCOSE-105 UREA N-26* CREAT-0.9 SODIUM-140 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16 [2108-9-4] 08:15PM LACTATE-1.2 [2108-9-4] 08:10PM cTropnT-<0.01 [2108-9-4] 08:10PM CK-MB-2 [2108-9-4] 08:10PM CALCIUM-8.5 PHOSPHATE-5.7# MAGNESIUM-2.5 Brief Hospital Course: This is a 51 year-old male with a history of Down's syndrome, history of chronic hepatitis B, chronic indwelling foley catheter with recent admission for urosepsis who presents with hypotension and fevers. The initial suspecion was for urosepsis, however, the urine culture did not reveal any organisms. He then developed hypoxemia with CXR concerning for pneumonia, effusion or atelectasis in right lung lobe, although initial CXR showed left air space disease. After initial IV ABx, he was placed on oral levaquin. The patient had stage 2 ulcers that did not look infected to suggest a source of fever. he was on decubitus ulcer precautions. His hypotension, for the most part, resolved. Baseline SBPs in the 100-110. He had no signs of sepsis. Fludrocort was continued. He needs to continue course of ABx (levofloxacin) for a [11-20] day course, wean off oxygen, if possibe, and repeat CXR in few days to role out progressive pleural effusion in the right side. He may need CT chest if he has progressive effusion, however, the sister may elect against invasive testing. She expressed that she may vote against further hospitalizations or more treatments. he is at risk for recurrent pneumonia/atelectasis because of his severe kyphosis, poor inspiration effort, and atelectasis/lung compromise. He needs insentive spirometry whereever he goes. Again, His sister may decide for comfort treatments only. She is the DPOA. # Chronic hepatitis B, stable: continued home meds # FEN: Regular # Code: Sister [Name (NI) 8513] is HCP. home: [Telephone/Fax (1) 108244], cell: [Telephone/Fax (1) 108245] DNR/DNI order accompanied pt from nursing home. Confirmed with sister. She may go against more invasive tests/treatments. Medications on Admission: Fludrocortisone multivit with minerals cyanocobalamin colace lamivudine adefovir Discharge Medications: Levaquin Fludrocortisone multivit with minerals cyanocobalamin colace lamivudine adefovir Discharge Disposition: Extended Care Facility: [Location (un) ] Manor Discharge Diagnosis: Primary: pneumonia Secondary: cervical stenosis, hepatitis B, Down syndrome, decubitus ulcer Discharge Condition: good Discharge Instructions: You were admitted with hypotension and found to have a pneumonia. You were treated with antibiotics. If you have recurrent shortness of breath, low blood pressure, cloudy urine, change in mental status, or any other concerning symptoms, return to the hospital. Followup Instructions: You will be followed by the physicians at your rehab facility. Please call your primary care physician to set up follow-up 1-2 weeks after you are discharged from rehab. Follow up with Dr. [Last Name (STitle) ] (liver doctor) as scheduled: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2108-10-16*] 9:30	[ "486", "5119" ]
Admission Date: [2103-11-10] Discharge Date: [2103-11-16] Date of Birth: [2103-11-9] Sex: M Service: NB IDENTIFICATION: Baby [Name (NI) ] [Known lastname ] [Known lastname ] is a 10 day old former 36 5/7 weeks gestation infant with prenatal diagnosis of cystic hygroma who is being discharged from the [Hospital1 18] NICU. HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname ] [Known lastname ] delivered at 36 and 5/7 weeks gestation and was admitted to the Neonatal Intensive Care Unit from the newborn nursery on day of life one because of episodes of duskiness with feedings. Birth weight 3530 grams (greater than 90th percentile), length 48.25 cm (75th to 90th percentile). Head circumference 34 cm (75th to 90th percentile). Mother is a 29 year-old, gravida 3, para 0, now 1 mother, with estimated date of delivery [2103-12-2]. The mother's prenatal screens included blood type 0 positive, antibody screen negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune and group B strep unknown. The pregnancy was complicated by the following: 1. The mother has [Name (NI) 13483] disease and was treated with Levothyroxine. 2. A cystic hygroma was noted on an early ultrasound that decreased in size on follow-up ultrasounds. The nuchal thickening persisted but without further cystic component after [2103-10-11]. An amniocentesis at 16 weeks gestation showed a normal karyotype of 46XY. 3. At 19 weeks, an ultrasound showed a left hydrothorax with resolution on the 23 week fetal ultrasound. 4. A fetal echocardiogram was done at 22 weeks gestation, showing normal anatomy but was limited due to the position of the baby. 5. Cervical shortening treated with bed rest. The mother delivered on [2103-11-9] by Cesarean section following a failed Pitocin induction. Apgar scores were 9 and 9 at 1 and 5 minutes respectively. The baby was admitted to the newborn nursery initially. He was noted to have several episodes of duskiness with feedings and to have some dysmorphic features that prompted admission to the NICU for further assessment. PHYSICAL EXAMINATION AT DISCHARGE: Weight 3250 grams, length 50 cm, head circumference 33.5 cm. In general, infant in open crib, comfortable in room air. HEENT: Large anterior fontanel, open and flat. Right ear low set posteriorly rotated with over folded helix and dysplastic lobe. Left ear with over folded helix. Mouth without cleft. Neck: Redundant skin folds. Eyes with positive red reflex bilaterally. Chest: Right breath sounds clear and equal, well aerated, easy work of breathing. Pectus excavatum apparent. Cardiovascular: Regular rate and rhythm without murmur. Normal S1 and S2. Normal pulses and perfusion. Abdomen: Soft, nondistended, no hepatosplenomegaly, no masses. Bowel sounds present. Skeletal: Spine straight, intact, hips stable. Skin: Jaundiced, pink without lesions, mongolian spot on right scapula. Extremities: Moves all extremities equally. Genitourinary: Normal male phallus. Testes descending bilaterally. Neuro: Normal tone and reflexes for gestational age, symmetric, nonfocal. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The baby has always been in room air since admission with comfortable work of breathing. A chest x-ray was done on admission that was normal. The infant continued to desaturate with feedings for the first several days, not requiring intervention after the first day. The last desaturation with feedings was noted on [2103-11-14]. Given the prenatal diagnosis of cystic hygroma, surgery was consulted. A soft tissue ultrasound of the posterior neck was performed. The son[Name (NI) 493] examination of the thickened nuchal tissues showed normal appearing subcutaneous tissue. There were no septations and there was no fluid. The thickened region lies in the subcutaneous layer, deep to the skin and superior to the strap muscles of the neck. No particular follow-up is necessary. Cardiovascular: Infant remained hemodynamically stable throughout hospital stay. He was seen by cardiology due to the possibility of [Doctor Last Name ] syndrome. An echocardiogram was done on [11-12] that showed normal anatomy with a PFO, but mild biventricular dysfunction. A follow-up echocardiogram on [2103-11-15] showed again mild ventricular dysfunction without change. Also noted during admission were frequent premature ventricular beats (PVCs) confirmed by EKG and reviewed by cardiology. Blood chemistries were within normal limits. PVCs have gradually improved over admission. Cardiology will follow the patient as outpatient for both of these issues. Fluids, electrolytes and nutrition: The infant has been ad lib bottle feeding with Enfamil 20 or expressed breast milk. The mother has not established breast feeding while the infant has been in the hospital but plans to breast feed. At discharge, the infant is feeding ad lib, taking about 2 ounces every 2 to 4 hours, voiding and stooling appropriately. Admission weight was 3.530 kg; weight at discharge was 3.250 kg. Gastrointestinal: Phototherapy was started on day of life 3 for a total bilirubin of 16.1, direct of 0.4. Phototherapy was discontinued on day of life 6. The bilirubin done on day of life 8 ([2103-11-17]) was total of 15.7, direct of 0.3. Bilirubin remained overall stable, with values of 14.4/0.3 on [11-18] and 14.7/0.3 on [11-19]. Screen for hemolysis was negative (see below). Hematology: The infant's blood type is 0 positive, direct Coombs is negative. Hematocrit on admission was 51.2%. Repeat Hct on [11-19] was 53 with reticulocyte count of 1%. Infectious disease: Due to desaturations, the infant had a CBC and blood culture drawn on admission. The CBC was normal. The blood culture was negative. He received 48 hours of ampicillin and gentamycin. Sepsis was ruled out. Neurology: Infant has been noted to have a high-pitched cry, but otherwise neurologic exam has been appropriate. Genetics: Infant was seen by genetics from [Hospital3 1810]. Mild dysmorphisms were noted, and [Doctor Last Name ] Syndrome was questioned, although this was considered less likely given normal structure on ECHO. Karyotype was sent; this is pending at time of discharge. Genetics will see infant as outpatient, at which time further genetics testing may be performed. Sensory: Audiology hearing screening was performed with automated auditory brain stem responses. The infant passed in both ears. CONDITION ON DISCHARGE: Stable, 10 day old, now 38 and 1/7 weeks post menstrual age infant. DISCHARGE DISPOSITION: Discharged home with parents. NAME OF PRIMARY PEDIATRICIAN: Parents have identified their pediatric care provider as [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2563],, at [Hospital 1887] Pediatrics, [Location (un) 50340], [Location (un) 1887], [Numeric Identifier 76242]. Telephone number [Telephone/Fax (1) 37518], Fax # [Telephone/Fax (1) 37519]. CARE AND RECOMMENDATIONS: 1. Feeds: Enfamil 20 or breast milk ad lib demand, breast feeding to be established at home. 2. Medications: None. 3. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive Vitamin D supplementation at 200 i.u. (may be provided as a multi-vitamin preparation) daily until 12 months corrected age. 4. Car seat position screening was done for an hour and a half. The infant passed. 5. State newborn screen was sent on day of life 3 and is pending. 6. Immunizations received: Received hepatitis B immunization on [2103-11-15]. 7. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following four criteria: (1) Born at less than 32 weeks; (2) Born between 32 weeks and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; (3) chronic lung disease or (4) hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. This infant has not received Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fewer than 12 weeks of age. FOLLOW-UP: Appointments scheduled/recommended: 1. Follow-up with pediatric care provider [Name Initial (PRE) 176] 2 days following discharge. 2. Cardiology follow-up with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [Location (un) 47], telephone number [Telephone/Fax (1) 76243]. Parents have an appointment for [2103-11-29] at 2 p.m. 3. Follow-up with genetics at [Hospital3 1810] with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6164], [2104-1-23], 1pm. Telephone number [Telephone/Fax (1) 76244]. 4. VNA referral to Centrus Home Care, 1-[Telephone/Fax (1) 45165]. 5. Early intervention referral to Criterion [Location (un) 270] Program in [Location (un) 47], telephone number [Telephone/Fax (1) 43148]. DISCHARGE DIAGNOSES: 1. Late preterm infant at 36 and 5/7 weeks gestation. 2. Large for gestational age. 3. Oxygen desaturations with feedings, resolved. 4. Dysmorphic features with possible [Doctor Last Name ] syndrome. 5. Mild biventricular dysfunction. 6. Neonatal jaundice. 7. Sepsis ruled out. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Name8 (MD) ] MEDQUIST36 D: [2103-11-19] 00:42:25 T: [2103-11-19] 04:49:53 Job#: [Job Number 76245]	[ "7742", "V290" ]
Admission Date: [2181-7-30] Discharge Date: [2181-8-2] Date of Birth: [2128-1-8] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1515] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization with Drug Eluting Stent placement to distal RCA. History of Present Illness: 53yoM with h/o CAD (s/p DES to D1 after anterior MI in '[72]), HTN, [Hospital ] transferred from [Hospital3 ] with inferior STEMI - now s/p DES to distal RCA. The patient reports that he was in his USOH until the last 6-7 days when he began having CP - at first was fleeting and over last 2-3 days only relieved by SL nitro. Today, he reports the onset of [9-19] SSCP at 4PM that radiated to his L neck and down both arms. It was associated with nausea/vomiting. He took ~ 20 SL nitro without relief and then called 911. At [Hospital3 7569], EKG showed large STE inferiorly - BP on arrival was 146/98. He was Plavix loaded with 600 mg, ASA 325 mg, and started on a heparin gtt. He was not CP free until revascularization in the cath lab at [Hospital1 18] despite receiving multiple doses of morphine and dilaudid. CP started ~ 4 PM, stent placed ~ 9 PM. . At [Hospital1 18], the patient went straight to the cath lab, which revealed no flow-limiting disease in LMCA, LAD with diffuse disease, previous diagonal stent with 50-60% ISR, OM1/OM2 with 60-70% stenosis, and total occlusion in the distal RCA. A DES was placed in the RCA. . On arrival to the CCU, the patient reports [2-19] 'twinges' of CP. He denies recent illness. VS 97.9 107 142/88 16 95% on RA. Exam significant for multiple circular excoriated lesions on his arms and legs, CV exam with RR, no murmurs, good distal pulses. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: - PCI w/ stent to first diag in [2172] after anterior MI -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Major depression Hypertension Hyperlipidemia Asthma (not on meds) PUD Obesity Social History: Works in computer repair. Lives alone. Never married, no children. Not close with his family, no official HCP. [Name (NI) ] [Name (NI) 6624] (sister) would be first to contact - unsure of phone #. -Tobacco history: 1 ppd x 40 years (not willing to quit) -ETOH: None -Illicit drugs: remote marijuana Family History: Father died of lung cancer. MaGpa had MI in 60s. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On admission: VS: 97.9 107 142/88 16 95% on RA GENERAL: 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 not elevated CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: CTA anteriorlly ABDOMEN: Obese. Soft, NTND. NABS. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. Numerous circular excoriated lesions w/ scab ~ 5 mm in diameter on bilateral arms PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ . On discharge: AVSS CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: CTA anteriorlly ABDOMEN: Obese. Soft, NTND. NABS. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. Numerous circular excoriated lesions w/ scab ~ 5 mm in diameter on bilateral arms Pertinent Results: [2181-7-30] 09:12PM BLOOD WBC-15.4# RBC-5.01 Hgb-16.2 Hct-45.7 MCV-91 MCH-32.3 MCHC-35.4* RDW-13.8 Plt Ct-247 [2181-7-31] 05:26AM BLOOD PT-11.7 PTT-26.9 INR(PT)-1.0 [2181-7-30] 09:12PM BLOOD Glucose-130* UreaN-19 Creat-0.7 Na-139 K-3.6 Cl-106 HCO3-23 AnGap-14 . [2181-7-30] 09:12PM BLOOD CK(CPK)-661* [2181-7-31] 05:26AM BLOOD CK(CPK)-1850* [2181-7-31] 06:48PM BLOOD CK(CPK)-913* . [2181-7-31] 05:26AM BLOOD CK-MB-223* MB Indx-12.1* [2181-7-31] 10:57AM BLOOD CK-MB-137* MB Indx-10.3* cTropnT-4.39* [2181-7-31] 06:48PM BLOOD CK-MB-68* MB Indx-7.4* cTropnT-3.29* . [2181-7-30] 10:35PM BLOOD %HbA1c-5.2 eAG-103 . [2181-7-31] 05:26AM BLOOD Triglyc-140 HDL-35 CHOL/HD-4.1 LDLcalc-80 . [2181-7-30] Cardiac Cath: COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated three vessel coronary artery disease. The LMCA was without significant disease. The LAD had diffuse non-obstructive disease with distal 50-60% instent restenosis of the diagonal stent. The LCx had 70% stenosis of the origin of OM1 and 70% stenosis of the mid OM2. The RCA had a distal total occlusion. 2. There is moderate systemic arterial hypertension with central aortic pressure 161/100 with a mean of 99 mmHg. 3. Successful aspiration thrombectomy/direct stenting of the distal RCA total occlusion with a Promus Rx 3.0x18 mm [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]-dilated with an NC 3.5 mm balloon. (see PTCA comments) 4. R 6Fr femoral artery Angioseal deployed without complications FINAL DIAGNOSIS: 1. Three vessel CAD with culprit distal RCA total occlusion 2. Successful aspirtation thrombectomy/direct stenting with a Promus Rx 3.0x18 mm [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]-dilated with an NC 3.5 mm balloon (see PTCA comments) 3. ASA 325 mg daily for six months and then can be decreased to 81 mg daily indefinitely; plavix (clopidogrel) 150 mg daily for seven days and then 75 mg daily 4. High dose statin (atorvastatin 80 mg daily) therapy 5. R 6Fr femoral artery Angioseal closure device deployed without complications . TTE: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with inferior, inferolateral and distal anterior hypokinesis (multivessel CAD). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([2-11]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild to moderate regional left ventricular systolic dysfunction, most c/w multivessel CAD. Mild to moderate aortic regurgitation. Moderate mitral regurgitation. Mild pulmonary hypertension. Brief Hospital Course: 53 year old male with CAD (s/p DES to D1 after anterior MI in '[72]), HTN, [Hospital ] transferred from [Hospital3 ] with inferior STEMI - s/p DES to distal RCA. . ACITVE ISSUES: # Inferior STEMI: The patient presented to [Hospital3 7569] with [9-19] CP refractory to ~ 20 SL nitro tablets. EKG there showed inferior STE. He was transferred to [Hospital1 18] for cath, which showed distal RCA occlusion as well as 3VD. A DES was placed to the distal RCA. He was started on ASA 325 mg x 6 months, then 81 mg indefinitely; Plavix 150 mg x 7 days (until [8-7])then followed by 75 mg per day x at least 12 months; atorvastatin 80 mg per day, metoprolol. A1c returned at 5.4. Lipid panel showed LDL of 80. Captopril was started and he was discharged on lisinopril at 5mg. He was counseled about the importance of aspirin after he voiced concern about GI side effects. Ranitidine was started to prevent GI upset. He was also counseled about the importance of tobacco cessation and was discharged on a nicotine patch. . # HTN: He was started on metoprolol 75 mg daily and lisinopril 5 mg daily. BP was at goal of < 130. . # PUMP: TTE showed LVEF of 40%. He was euvolemic on exam. He was discharged on lisinopril and metoprolol. Pt was encouraged to weight himself daily and eat a low Na diet. He was scheduled with cardiology f/u. . # Depression: The patient reported he had stopped taking his medications because of depression. His depression and anxiety has caused severe isolation, inability to work and care for himself. Social work and psychiatry was consulted and concluded that the pt was actively suicidal and needs to be treated as an inpatient. Section 12 paperwork has been started. He was restarted on Celexa while hospitalized and will need outpatient counseling and f/u. . # RHYTHM: NSR. No abnormal rhythm on telemetry. . He remained full code during this admission. Medications on Admission: nifedipine 30 mg qday flaxseed oil - not taking ASA -> reports that it gives him IBS Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for CAD: RCA DES for 7 days. 3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for CAD: RCA DES. 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for indigestion. 11. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis - Acute Myocardial Infarction secondary to instent thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for chest pain and were found to have a heart attack. You underwent a cardiac catheeterization that revealed a clot and a stent was placed. It is extremely important you take your medications as prescribed as this will help prevent another heart attack. . A NUMBER OF MEDICATIONS HAVE BEEN STARTED THAT ARE EXTREMELY IMPORTANT YOUR TAKE FOR YOUR HEART: 1) Aspirin 325mg Daily (as directed) 2) Plavix (Clopidogrel) 150mg Daily for a week then 75mg Daily 3) Atorvastatin 80mg Daily 4) Metoprolol XL 75mg Daily 5) Lisinopril 5mg Daily . We have also prescribed: 1) Ranitidine 150mg Twice Daily for indigestion 2) Calcium Carbonate Three times daily for indigestion as needed Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow-up with your primary care doctor, Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 1159], following discharge from [Hospital1 ] 4. His phone number of [Telephone/Fax (1) 20587].	[ "41401", "311", "412", "2724", "3051" ]
Admission Date: [2147-2-13] Discharge Date: [2147-2-27] Date of Birth: [2075-4-18] Sex: F Service: MEDICINE Allergies: Norvasc / Sulfa (Sulfonamides) / Latex / Codeine / Ace Inhibitors Attending:[First Name3 (LF) 2932] Chief Complaint: Shock Major Surgical or Invasive Procedure: R subclavian central venous line R radial arterial line R femoral arterial line History of Present Illness: 71 year old female with a history of PVD s/p multiple interventions, multiple recent hospitalizations (see summary below) most recently with a liver abscesss presents with hypotension. She had been discharged [2-10] feeling mildly fatigued but able to ambulate around her home. Over the next several days, she became progressively more fatigued with nausea and vomiting. On the morning of admission, she was unable to get up off her chair -> [Hospital1 18] [Location (un) ] and subsequently transferred to [Hospital1 18]. In the ED, her vitals were T 99.3, P 123, BP 86/p. 97 3L. She was started on levophed. Left CVL placed under sterile conditions. She underwent a RUQ US and CT abdomen and received vancomycin and levofloxacin. She was then admitted to the medical ICU for further management. At time of admission, she noted mild shortness of breath. She denied CP, HA, nausea, abdominal pain, or urinary symptoms. Of note, the patient has had several recent hospitalizations, which are sumarized below: [1-11] - [1-19]: Admission at NEBH for pneumonia with pleuritis and severe pleurodynia. She had an abdominal US at that time which showed a normal liver. [2-3] - [2-10]: Admitted to [Hospital1 18] after [Doctor First Name ] outpatient CT scan obtained to evaluate new RUQ pain revealeda 6.3 cm subcapsular liver abscess. IR performed a CT-guided drainage (sterile culture). Urine culture grew VRE (not treated). She was discharged on levofloxacin and metronidazole. [2-10]: CT abdmoen showed decrease of the abscess and pigtail was removed (no longer draining). Past Medical History: HTN Hyperlipidemia Severe PVD: s/p multiple stents to iliac and femoral arteries Renal artery stenosis Rheumatoid Arthritis Asthma Osteoporosis Spinal stenosis, s/p cervical and lumbar laminectomies S/p appendectomy Social History: Smoked 1 ppd x 30 yrs, quit 10 yr prior. No alcohol. Used to work as a LPN in a nursing home. Now retired. Lives with husband in [Name (NI) 620]. Has 3 adult children and 3 grandchildren. Family History: Non-contributory. Physical Exam: Tc 96.9 BP 98/63 on 0.12 levophed. HR 126, RR 20, sats 94% on RA. CVP 16. SvO2: pending I/O: 4 L /80 + unrecorded from the ED. Gen: Pleasant, elderly female in NAD. Appears tachypnic. HEENT: Sclera anicteric, MMdry. CV: tachy, refular rhythm, normal S1 and S2. No m/r/g. L subclavian in place. Lungs: Clear on left, crackles at R and L base ABD: Soft, ND, NT, neg [Doctor Last Name 515] sign. No rebound or guarding. No hepatomegaly. + BS. EXT: No c/c/e. Pulses not palpable bilaterally DP/PT but are dopplerable Pertinent Results: Admission labs: [2147-2-13] GLUCOSE-85 UREA N-41* CREAT-1.2* SODIUM-132* POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-18* ANION GAP-15 ALBUMIN-2.5* CALCIUM-7.3* PHOSPHATE-2.4* MAGNESIUM-1.8 WBC-20.9# RBC-3.11 HGB-9.7* HCT-28.8* MCV-93 MCH-31.1 MCHC-33.6 RDW-16.5* PLT COUNT-208 NEUTS-92.9* BANDS-0 LYMPHS-3.5* MONOS-3.2 EOS-0.2 BASOS-0.1 PT-18.1* PTT-33.0 INR(PT)-1.7* ALT(SGPT)-44* AST(SGOT)-43* CK(CPK)-74 ALK PHOS-95 AMYLASE-17 TOT BILI-0.6 CK-MB-3 cTropnT-0.11* CORTISOL-55.8* LACTATE-1.5 U/A: [Year/Month/Day 3143]-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR RBC-[10-3]* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0-2 Radiology Cxr on admission [2147-2-13]: The newly inserted right subclavian CV line has its tip within the right atrium. The heart is mildly enlarged. Mild pulmonary vascular prominence is noted. Small bilateral pleural effusions are unchanged. No evidence of pneumothorax or consolidation is noted. Dense opacification at the right lung base most likely represents a reactive subpulmonic effusion secondary to hepatic fluid collection. CT Abd/Pelvis [2147-2-14]: Interval removal of pigtail catheter with only small residual rim of fluid noted in the perihepatic space under the diaphragm by the dome of the liver. Findings highly consistent with infarction of the right kidney. The edematous kidney with adjacent perinephric stranding are highly suggestive of relatively acute onset. Diagnostic considerations include arterial dissection/thrombosis versus renal vein thrombosis. No bowel pathology with no free intraperitoneal fluid or air noted. Echo [2147-2-14]: The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (ejection fraction 20 percent). No masses or thrombi are seen in the left ventricle. Right ventricular systolic function appears depressed. Mild (1+) aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Echo [2147-2-16]: Compared with the prior study of [2147-2-14], estimated pulmonary artery sysotlic pressure is now higher and mitral regurgitation is now more prominent. Left ventricular systolic function appears similar. Renal U/S [2147-2-16]: The right kidney measures 10.1 cm. Several attempts at Doppler evaluation of the right kidney demonstrate only venous flow. No arterial waveforms could be obtained. The left kidney measures 11.4 cm. Doppler evaluation of the left kidney was extremely limited as well, due to the patient's inability to hold her breath and difficulty with positioning. Venous flow is noted on the left. Cxr [2147-2-20]: Mild pulmonary edema continues to improve and bilateral pleural effusion, moderate on the right and small on the left are also slightly smaller. New nasogastric feeding tube with a wire stylet in place is looped in the stomach. Tip of the right subclavian line projects over the superior cavoatrial junction. Mild cardiomegaly, decreased since [2-17]. Brief Hospital Course: 71 year old female with recent UTI and liver abscess presents with hypotension. The patient was admitted to the medical ICU on broad-spectrum antibiotics/pressors with a concern for septic shock, given multiple recent infections. The source of infection was unclear ([Name2 (NI) ] cultures negative, urine culture with only 10-100k yeast, chest X-ray without clear infiltrate, nearly completely resolved liver abscess) On [2147-2-14], she developed respiratory distress requiring intubation (attributed to flash pulmonary edema) and SVT requiring cardioversion X 2 (unsuccessful). An echocardiogram was obtained, which revealed EF 20% with global hypokinesis, suggesting that cardiogenic shock may have been contributing to her presenting hypotension, possibly related to known severe acidosis. Given negative CKMB fraction (TnT peak 0.39), ACS was felt to be unlikely. The patient subsequently developed acute renal failure (creatinine rising to 6.4), which was felt to be secondary to ischemic ATN (muddy brown casts on urinary sediment). The renal consult team was consulted, but, given the patient's multiple comorbidities, poor prognosis for renal recovery, and her desire to avoid long-term life support, dialysis was not pursued. The patient's mental status gradually worsened and she became progressively coagulopathic (INR 1.7-1.9), possibly related to shock liver. With diuresis, the patient's pulmonary status improved and she was extubated in the ICU. A family meeting was held, attended by the critical care and renal consult teams. Given the poor prognosis regarding recovery of renal function as outlined by the renal team, the pt's wishes not to be on long term dialysis, her multiple comorbidities, and her rapidly declining clinical status, the patient's husband and daughter decided to pursue comfort-oriented care. She was transferred to the general medical floor on a morphine drip and passed away on [2147-2-27] at 11:10 a.m. Medications on Admission: Medications at last DC [2-11]: --Hydroxychloroquine 200 mg [Hospital1 ] --Simvastatin 20 mg --Lasix 40 mg Tablet PO Q MWF. --Folic Acid 1 mg daily --Docusate Sodium 100 mg [Hospital1 ] --Fluticasone-Salmeterol 250-50 mcg/Dose Disk [Hospital1 ] --Prilosec OTC 20 mg Tablet qday --FOSAMAX 70 mg PO once a week. --Xopenex 0.63 mg/3 mL qday (Also was on ASA 81mg daily and Plavix 75mg daily prior to [Month (only) 958] admission, these meds have been held since IR procedure on [2147-2-7]) PRN: --Loperamide 2 mg QID prn --Acetaminophen prn --Compazine 10 mg prn. --Darvocet-N 50 50-325 mg prn Discharge Disposition: Expired Discharge Diagnosis: Primary: sepsis Secondary: cardiomyopathy, acute renal failure, coagulopathy Discharge Condition: Deceased Discharge Instructions: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2937] Completed by:[2147-2-27]	[ "0389", "78552", "51881", "5849", "2762", "2761", "4280", "99592" ]
Admission Date: [2166-2-11] Discharge Date: [2166-2-17] Date of Birth: [2123-6-21] Sex: M Service: CARDIOTHORACIC Allergies: Codeine / Morphine / Nsaids Attending:[First Name3 (LF) 1283] Chief Complaint: Chest Discomfort Major Surgical or Invasive Procedure: [2166-2-11] - AVR(23mm St. [Male First Name (un) 923] Mechanical Regent Valve) and replacement of Ascending Aorta (28mm gelweave graft) History of Present Illness: 42 year old gentleman with chest discomfort described as pressure. He has also noted increased fatigue. Work-up was significant for a dilated ascending aorta and moderate aortic regurgitation. Past Medical History: Hypercholesterolemia History of alcohol and narcotic abuse S/P Gastric bypass Bilateral knee surgery Bilateral shoulder surgery Social History: Unemployed. Lives with parents. No current alcohol or tobacco. Family History: Noncontributory Physical Exam: 74 pulse 145/80 GEN: A+Ox3, NAD, pleasant HEENT: OP benign HEART: RRR, Nl s1-s2 LUNGS: Clear ABD: Benign EXT: warm, 2+ pulses, no edema Pertinent Results: CHEST (PA & LAT) [2166-2-14] 10:24 AM CHEST (PA & LAT) Reason: assess pneumoperitoneum [Hospital 93] MEDICAL CONDITION: 42 year old man with Aortic replacement s/p CT removal with pneumoperitoneum REASON FOR THIS EXAMINATION: assess pneumoperitoneum 2 VIEW CHEST X-RAY [2166-2-14]: COMPARISON: [2166-2-13]. INDICATION: Pneumoperitoneum. The patient is status post median sternotomy and aortic valve replacement. Again demonstrated is free intraperitoneal air, not significantly changed. There is stable widening of the cardiac and mediastinal contours. Small bilateral pleural effusions and minor atelectatic changes at the left lung base are also without change. Retrosternal air is identified on the lateral view, also present previously, and likely related to recent surgery. IMPRESSION: 1) Persistent free intraperitoneal air, not significantly changed since one day prior. 2) Left basilar atelectasis and small bilateral pleural effusions Sinus rhythm Early repolarization Normal ECG Since previous tracing of [2166-1-10], no significant change Read by: [Last Name (LF) 474],[First Name3 (LF) 475] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 68 182 108 422/438.85 33 -4 15 [2166-2-14] 05:40AM BLOOD WBC-12.0* RBC-3.49* Hgb-10.6* Hct-29.2* MCV-84 MCH-30.3 MCHC-36.2* RDW-13.0 Plt Ct-137* [2166-2-14] 05:40AM BLOOD Glucose-93 UreaN-13 Creat-0.9 Na-138 K-4.0 Cl-101 HCO3-30 AnGap-11 Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2166-2-11] for elective surgical management of his aortic valve and ascending aorta disease. He was taken directly to the operating room where he underwent an aortic valve replacement utilizing a 23mm St. [Male First Name (un) ] mechanical regent valve and replacement of the ascending aorta. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. Within twenty-four hours, Mr. [Known lastname ] [Last Name (Titles) ]e neurologically intact and was extubated. Aspirn, betablockade and coumadin were started. He was then transferred to the cardiac surgical step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He continued to make steady progress in his ambulation and was cleared by physical therapy after he climbed a flight of stairs without difficulty. He was anticoagulated with heparin and coumadin toward a target INR of 2.5-3.0. Outpatient VNA will draw PT/INR on [2166-2-18] and fax PT/INR results to Dr.[Name (NI) 94020] office at [Telephone/Fax (1) 25663]. Office phone # [Numeric Identifier 94021]/12/06. Dr.[Name (NI) 94020] office was contact[Name (NI) ] and agreed to follow the INR and coumadin doses. On POD 5 Mr. [Known lastname ] was at his preop weight with good exercise tolerance, no SOB, or Chest pain. His blood pressure was stable. His sternotomy was clean, dry, and intact without evidence of infection. He was discharged home on POD 5 with services in good condition, cardiac diet, sternal precautions, and instructed to follow up with his PCP and cardiologist in [2-3] weeks. He will follow up with Dr. [Last Name (STitle) 1290] in four weeks. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 7. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 3 days. Disp:3 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Hypercholesterolemia Gastric Bypass History of alcohol and narcotic abuse. S/P Knee and shoulder surgery Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increase pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of greater then 2 pounds in 24 hours, and 5 pounds in 1 week. 4) No lifting greater then 10 pounds in 10 weeks. 5) No driving for 1 month. [Last Name (NamePattern4) 2138]p Instructions: Follow-up with Dr. [Last Name (Prefixes) ] in 4 weeks. Follow-up with Dr. [Last Name (STitle) ] (cardiologist) in [2-3] weeks. Follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Call all providers for appointment.	[ "4241" ]
Admission Date: [2165-8-17] Discharge Date: [2165-8-20] Date of Birth: [2099-10-3] Sex: M Service: HISTORY OF PRESENT ILLNESS: A 65-year-old male with a history of coronary artery disease, hypertension, and hypercholesterolemia admitted for chest pain. The patient had experienced about 45 minutes of chest pain while driving on the day of admission. It was substernal, associated with diaphoresis, and associated as well with nausea and vomiting. The patient presented to an outside hospital where his chest pain continued. He was given heparin, sublingual nitroglycerin, and Integrilin. Also, the patient began to feel a little bit dizzy and become unconscious. He had a ventricular fibrillation arrest. At the outside hospital he was shocked once, and the patient became conscious again after about one minute. The patient was started on a lidocaine drip and amiodarone drip. There was no documentation of the DC cardioversion in the chart from the outside hospital. The patient had described his pain as being about [6-2]. He said that it radiated to his neck. He had no relief with two sublingual nitroglycerin at home. He denies orthopnea and paroxysmal nocturnal dyspnea, and said he has not had any chest pain for the last seven years. He also denied shortness of breath. He said he can walk about two miles without a problem. [Name (NI) ] also can walk about four flights of stairs without a problem. The patient has a history of angina since [2151]. First, he experienced exertional stable angina from [2151] until [2156] which was medically managed until it became unstable in [2157-3-24]. At that time he had negative enzymes. He was taken to the catheterization laboratory on [2157-3-25]; first for a look, and then he was taken back to the catheterization laboratory twice on [3-30] and [4-7] in order to have two percutaneous transluminal coronary angioplasties performed. The first one showed his left main had a 40% lesion, mid right coronary artery had a 40% lesion, and the posterior descending artery had an 80% to 90% lesion which was angioplastied. On the second catheterization, he had a left circumflex lesion of 90% which was angioplastied. At that time, his left ventricular ejection fraction was 79%. He remained chest pain free until [2157-6-23]. He was again ruled out by enzymes. He had a catheterization in [2157-6-23] with a 90% to the obtuse marginal which was angioplastied. An 80% lesion to the posterior descending artery was also angioplastied, and a 90% lesion to the left circumflex was also angioplastied. The patient then remained symptom free until [2157-9-23] when he had chest pain again. At that time he had an exercise tolerance test during which he walked for 11 minutes with 0.5-mm ST depressions and 70% of maximum heart rate achieved. He was again taken to the catheterization laboratory. That showed a 50% mid left circumflex lesion, 50% obtuse marginal lesion, 50% second obtuse marginal lesion. He was treated medically until [2157-11-27], when he again had chest pain. He had an other catheterization with a left main of 30%, left anterior descending artery 90% which was treated with angioplasty. He also had a jailed diagonal which was treated with angioplasty with a 20% residual lesion. He had a left circumflex which was 60% occluded, and a posterior descending artery which was 40% to 50% occluded. In [2158-2-21], again the patient had an exercise stress test with thallium. He was taken to the catheterization laboratory again with a left main of 20%, mid left anterior descending artery 80% which had angioplasty, and a second diagonal lesion of 90% which was also angioplastied. At that time, he had a right heart catheterization which showed right atrial pressure of [12-2], right ventricle 34/10, pulmonary artery 34/15, and a wedge of 13. The patient has had no further catheterizations or chest pain since that time until his catheterization during this admission. PAST MEDICAL HISTORY: (Significant for) 1. Coronary artery disease, status post multiple catheterizations. 2. Hypertension. 3. Hypercholesterolemia. 4. Cholecystectomy. 5. Appendectomy. 6. Obstructive sleep apnea; the patient does not tolerate CPAP. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Outpatient medications included Cardizem 120 mg p.o. q.d., atenolol 75 mg p.o. q.d., Zocor 20 mg p.o. q.d., aspirin 325 mg p.o. q.d., Pepcid 20 mg p.o. b.i.d., and folic acid 1 mg p.o. q.d. MEDICATIONS ON TRANSFER: On transfer, the patient was also on heparin drip, lidocaine drip, and amiodarone drip. SOCIAL HISTORY: The patient has a positive tobacco history. He quit 30 years ago. He occasionally has wine with dinner. He lives with his wife. FAMILY HISTORY: His father died of a myocardial infarction at age 63. His mother died at age 60 from cancer. REVIEW OF SYSTEMS: On review of systems, the patient denied melena, denied hematochezia, hematemesis, and he had a negative colonoscopy earlier this year by report. PHYSICAL EXAMINATION ON ADMISSION: Examination on admission revealed vital signs of temperature 97.5, pulse 75, blood pressure 147/77, respiratory rate 12, satting 95% on 2 liters. Generally, he was a pleasant male in no acute distress. HEENT revealed he was normocephalic and atraumatic with a large neck. The oropharynx was clear. Neck revealed he had no jugular venous distention. His neck was supple. Pulmonary revealed he was clear to auscultation bilaterally/anteriorly. Cardiovascular revealed he had a regular rate and rhythm, S1/S2. No murmurs, rubs or gallops. Abdomen was soft, nontender, and nondistended, with normal active bowel sounds. No hepatosplenomegaly. His groin revealed he had a right introducer in place on the catheterization. Extremities had 2+ distal pulses, warm. No evidence of edema. Neurologically, he was alert and oriented times three. LABORATORY DATA ON ADMISSION: Laboratories on admission included a sodium of 135, potassium 4.6, chloride 102, bicarbonate 20, BUN 19, creatinine 1.4, glucose 153. His initial creatine kinase was 654 with an MB fraction of 39. The patient had a white blood cell count of 14.2, hematocrit of 36.9, and platelets of 209. RADIOLOGY/IMAGING: His electrocardiogram showed sinus rhythm at 75 beats per minute with 1-mm ST depressions in V2 through V5, T wave inversions in aVL, T wave elevation in III which was a change from his last electrocardiogram here in [2158-2-21]. He had a normal axis and early R wave progression. HOSPITAL COURSE: The patient had a catheterization before being brought to the Coronary Intensive Care Unit. His catheterization reported left main which was within normal limits. His proximal left anterior descending artery had diffuse disease. His mid left anterior descending artery and diagonal were normal. He had a mid left circumflex lesion which was a discrete 90% lesion which was stented. He had diffuse disease in his first obtuse marginal, and his right coronary artery had diffuse disease throughout. The mid right coronary artery lesion of about 40% and right posterior descending artery of about 40%. The patient was started on Lopressor 75 mg p.o. b.i.d. in place of his atenolol. The patient was discontinued on his diltiazem and captopril was started and eventually titrated up to 50 mg p.o. t.i.d., and then he was changed to Mavik 3 mg p.o. q.d. The patient was continued on folic acid and aspirin. He was begun on Plavix for his stenting and continued on Zocor 20 mg p.o. q.d. The patient did well without incident throughout the remainder of his hospital course. He had an echocardiogram which showed a normal left systolic function with an ejection fraction of over 50%, and the patient was discharged to home to follow up in cardiac rehabilitation in about three to four weeks. The patient was also seen by Nutrition for a nutritional consultation. The patient continued to do well and was discharged to home. DISCHARGE STATUS: Discharged to home three days after admission. MEDICATIONS ON DISCHARGE: 1. Atenolol 75 mg p.o. q.d. 2. Mavik 3 mg p.o. q.d. 3. Folic acid 1 mg p.o. q.d. 4. Pepcid 20 mg p.o. b.i.d. 5. Plavix 75 mg p.o. q.d. times 30 days. 6. Aspirin 325 mg p.o. q.d. 7. Zocor 20 mg p.o. q.d. CONDITION AT DISCHARGE: The patient's discharge condition was stable. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [Last Name (STitle) 120]. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post stent to the left circumflex artery. 2. Hypertension. 3. Hypercholesterolemia. 4. Obstructive sleep apnea. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 126], M.D. [MD Number(1) 4062] Dictated By:[Last Name (NamePattern1) 1203] MEDQUIST36 D: [2165-8-20] 13:55 T: [2165-8-24] 08:15 JOB#: [Job Number ]	[ "41401", "4019", "2720" ]
Admission Date: [2182-5-4] Discharge Date: [2182-5-28] Date of Birth: [2182-5-4] Sex: M HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname 7741] was born on [2182-5-4] as the 2110 gm product of a 32 [12-31] week gestation to a 30-year-old gravida 1, para 0-2-1 mother. Prenatal [Name2 (NI) ] were notable for blood type AB+, antibody positive for mono rubella immune and group B strep negative. Pregnancy was complicated by recurrent preterm labor and mother was admitted at 27 weeks with the same and treated with betamethasone. She was also treated with magnesium and was subsequently released home. Sequential ultrasounds were reassuring in terms of fetal well being and adequate growth. She was readmitted on [5-3] with preterm labor refractory to antibiotics greater than four hours prior to delivery. Ruptured membranes occurred one hour, 20 minutes prior to delivery. Infant emerged after a vaginal delivery with Apgars of [7-1]. The infant was pale with low tone and exhibited signs of respiratory distress early. Infant was stimulated, dried and resuscitated with free flow oxygen. Infant was then brought to the Neonatal Intensive Care Unit. Of note, close observation of placenta at the time of delivery revealed an approximately 20% abruption. PHYSICAL EXAMINATION: Physical exam on admission, weight 2110 gm, length 45 cm. Infant was a non dysmorphic premature infant, pale with moderately low tone. Intermittent grunting and retracting was noted. Anterior fontanel was soft and flat. Posterior fontanel was soft and flat. Ears, nose, palate and neck were normal. Red reflex was present bilaterally. Heart sounds were normal without murmur. Breath sounds were audible but decreased bilaterally. Abdomen was soft without bowel sounds. Testes were palpable bilaterally in the scrotum. Femoral pulses were 2+ bilaterally. Hands, feet, hips and spine were normal. Tone was noted to improve over the first 22 hours of life. Activity was symmetric. HOSPITAL COURSE: 1. Respiratory: There was increasedwork of breathing and oxygen requirement in day #1 of life, consistent with respiratory distress syndrome. The patient was intubated and treated with two doses of surfactant. The infant responded well and was weaned to continuous positive airway pressure by day #[12-26] of life. The infant was subsequently weaned to nasal cannula by day #4 of life and then to room air by day 6 of life. The patient does have occasional bradycardic episodes, the last being on day #3 of life. The patient did exhibit occasional desaturation episodes subsequently without bradycardia or clear apnea. The patient had been stable on room air with no cardiorespiratory events in the 7 days prior to discharge. 2. Cardiovascular: The patient was hemodynamically stable throughout admission without need for blood pressure support. There was a soft intermittent murmur noted occasionally during the admission. As this appeared to have resolved close to the time of discharge, no further investigations were undertaken. If it is noted again in teh ambulatory setting, cardiology evaluation should be undertaken. 3. Fluids, Electrolytes & Nutrition: The patient was maintained on IV fluids and parenteral nutrition. Feedings were begun on day #[1-27] of life and advanced without difficulty. By day #[4-29] of life the patient was on full feeds and calories were increased to 24 calories per oz. The patient exhibited good weight gain on this regimen. Breast feeding and oral feedings were gradually introduced. As mentioned above, birth weight was 2110 gm. Weight at the time of discharge was 2540 grams. 4. GI: The patient had mild hyperbilirubinemia of prematurity with a peak bilirubin of 10.6/0.4. The patient was treated with phototherapy for approximately 5 days. There was mild persistent jaundice noted at the time of discharge, with a serum bilirubin todya of 8.0/0.3, consistent with some degree of breastmilk jaundice. 5. ID: Initial CBC revealed a white count of 12 with 15% neutrophils and 67% lymphs, 0% bands. The patient received ampicillin and gentamicin for 48 hours with negative cultures and benign clinical course. 6. Heme: Initial hematocrit was 46. Follow-up hematocrit on day #13 of life was 36.2. The patient was treated with iron supplementation. 7. Neuro: Head ultrasound day #9 of life was normal. The patient has maintained a normal neurologic exam throughout admission. Ophthalmologic screening was performed on [5-22] and revealed mature retinas bilaterally; follow-up is recommended at 8 months. Hearing screen was normal on the day of discharge. 8. Other: Newborn screens were sent on [5-10] and [2182-5-21]. Hepatitis B vaccine was given on [2182-5-25]. CONDITION ON DISCHARGE: Patient is stable on room air, feeding well po. The exam revealed a normal, formerly premature infant, well developed, well nourished, in no acute distress. Fontanels were soft and flat. Red reflexes were present bilaterally. Oropharynx was clear. Chest was clear. Cardiac is regular rate and rhythm without murmur. Abdomen was soft, active bowel sounds. Genitalia are normal. Hips are stable bilaterally. Extremities were warm and well perfused. Tone and activity are appropriate. Primary pediatrician is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 24861] of [Location (un) ], [State 350]. DISCHARGE DIAGNOSIS: 1. Prematurity at 32 1/7 weeks. 2. Respiratory distress syndrome, resolved. 3. Hyperbilirubinemia of prematurity, resolved. 4. Sepsis evaluation, resolved. [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36095] Dictated By:[Doctor Last Name 38038] MEDQUIST36 D: [2182-5-21] 18:15 T: [2182-5-21] 18:24 JOB#: [Job Number 41587]	[ "7742", "V290", "V053" ]
Admission Date: [2157-12-15] Discharge Date: [2157-12-23] Date of Birth: [2099-4-13] Sex: M Service: CARDIOTHORACIC Allergies: Ciprofloxacin / Levaquin / Opioid Analgesics Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2157-12-15] Aortic Valve Replacement (21mm CE tissue valve) History of Present Illness: 58 y/o female with known AS. Followeed by serial echo's and cardiac cath which have shown progression of aortic stenosis. Admits to increased chest discomfort, DOE and fatigue over the last several years. Past Medical History: Aortic Stenosis, Hypertension, Hypercholesterolemia, Peripheral [Month/Day/Year ] Disease, Carotid Disease, End-Stage Renal Disease (prev. on HD), Diabetes Mellitus, ?Seizure Disorder, Hepatitis C, Erectile Dysfunction, Cataracts PSH: RLE BPG [2154], Cadaveric Renal Transplant [2155], Parathyroidectomy [2154], Toe amputations [2154]-[2156], Cholecystectomy [2153], L AV fistula Social History: pt denies smoking. rare eoth. h/o IVDA (over 40 yrs ago) Family History: Father, mother and brother have DM. Father died of an MI at 54. Mother died of stomach cancer. Physical Exam: General: Obese male in NAD Skin: Rubor changes distal LE HEENT: EOMI, PERRL NC/AT Neck: Supple, FROM, -bruit (transmitted murmur) Chest: CTAB -w/r/r Heart: RRR w/ SEM Abd: Soft, NT/ND, +BS, obese, +inguinal hernia Ext: Warm, well-perfused, 2+ edema, L arm AV fistula, -varicosities Neuro: MAE, Non-focal, A&O x 3 Discharge General no acute distress Vitals 98.4 F 79 SR, 18 RR, 94% RA sat 132/72 wt 99.4kg Neuro A/O x3 nonfocal Pulm CTA Cardiac RRR Sternal inc no drainage, no erythema sternum stable Ext warm trace edema Pertinent Results: Echo [12-15]: PRE-BYPASS: There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is aortic valve stenosis (area 1.1 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([1-17]+) mitral regurgitation is seen. POST-BYPASS: The aortic valve prosthesis appears to be well seated. No evidence of any perivalvular leak. The peak gradient across the aortic valve is 20 mmHg. Biventricular function appears to be well preserved. The mitral valve has a persitent level of mild regurgitation . Normal aortic contour post decannulation. Head CT [12-16]: Loss of [Doctor Last Name 352]-white matter differentiation and ill-defined hypodensity in anterior left frontal [Last Name (LF) 3630], [First Name3 (LF) ] be secondary to motion artifact, however, cerebral edema in the setting of acute brain ischemia cannot be excluded. Consider performing MR [First Name (Titles) 151] [Last Name (Titles) 3631]-weighted imaging or CT perfusion for further evaluation. EEG [12-16]: This is an abnormal EEG due to the presence of a poorly organized and somewhat slow background with multifocal slow transients. This pattern is consistent with a moderate encephalopathy of toxic, metabolic, and/or anoxic etiology, and can also be seen in patients with significant bilateral or deep midline white matter lesions. No evidence of asymmetries of voltage or frequency were seen to suggest embolic or cortically-based strokes. No epileptiform features were seen. CXR [12-22]: Status post AVR. Right jugular CV line is in upper right atrium as previously noted. No pneumothorax. There are low lung volumes with bibasilar atelectases and a probable small left pleural effusion. [2157-12-15] 10:59AM BLOOD WBC-6.2 RBC-2.90# Hgb-8.8# Hct-26.8# MCV-93 MCH-30.2 MCHC-32.7 RDW-16.3 Plt Ct-76# [2157-12-17] 02:32AM BLOOD WBC-9.7 RBC-3.55 Hgb-10.9* Hct-31.1* MCV-88 MCH-30.6 MCHC-35.0 RDW-16.8* Plt Ct-76* [2157-12-23] 05:56AM BLOOD WBC-6.9 Hct-28.8* [2157-12-15] 10:59AM BLOOD PT-16.8* PTT-35.7* INR(PT)-1.5* [2157-12-23] 05:56AM BLOOD PT-16.3* PTT-31.7 INR(PT)-1.5* [2157-12-15] 12:29PM BLOOD UreaN-27* Creat-1.1 Cl-113* HCO3-23 [2157-12-21] 05:28AM BLOOD Glucose-42* UreaN-29* Creat-1.2 Na-138 K-4.3 Cl-106 HCO3-24 AnGap-12 [2157-12-22] 05:29AM BLOOD UreaN-36* Creat-1.4* K-4.6 Brief Hospital Course: Mr. [Known lastname 3419] was a same day admit following all pre-operative work-up done as an outpatient. On admit day he was brought to the operating room where he underwent an Aortic Valve replacement. Please see operative report for surgical details. He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation and extubated. Initially following commands, but then movements became inappropriate and he was non-conversant. Neurology was consulted and head CT, EEG, and echo were performed. CT was questionable for CVA, but over the next several days his Neuro status improved and by post-op day four he was A&O x 3, following commands with appropriate speech. Neuro felt like episode most likely related to opioid analgesics. During these several days post-op he remained in the CSRU and was started on Beta Blockers, Diuretics, and his pre-op meds. He was gently diuresed towards his pre-op weight. Chest tubes and epicardial pacing wires were removed per protocol. Renal followed pt. during entire post-op course secondary to transplanted kidney and prior HD. On post-op day five he was transferred to the SDU for continued care. He had episode of Atrial fibrillation on this day, beta blockers were increased and Amiodarone was initiated. He continued to have Atrial Fibrillation during rest of hospital course and was started on Coumadin. On post-op day seven there was some sternal drainage and he was started on antibiotics. On post op day 8 he was ready for discharge with VNA services. Plan for INR to be checked [12-25] with results to Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for further dosing, goal INR 2-2.5. Medications on Admission: Humulin N 55 units [Hospital1 ], Humalog, Fosamax 70 qweek, Rapamine 1 qd, Prednisone 5 qd, Pravastatin 40 qd, Epivir 100 qd, Bactrim SS qd, Omeprazole 20 qd, Folate, Lasix 40 [Hospital1 ] (M,W,F,Sat), Lasix qd (T,TH,Sun), Lopressor 100 [Hospital1 ], Cellcept [Pager number ] [Hospital1 ] 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. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:50 Tablet(s) Refills:0 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). Disp:5 Tablet(s) Refills:0 7. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:0 9. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO q pm for 10 days. Disp:10 Tablet(s) Refills:0 14. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Fifty (50) units Subcutaneous twice a day. 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 16. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 12 days. Disp:48 Capsule(s) Refills:0 17. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: please take 2.5mg [12-23] and [12-24] - have INR checked [12-25] with results to Dr [Last Name (STitle) ] for further dosing . Disp:30 Tablet(s) Refills:0 18. Outpatient Lab Work INR/PT as needed - first draw [12-25] Results to Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office # 1-[Telephone/Fax (1) 3632] goal INR 2-2.5 19. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous AC and HS : please continue to follow home sliding scale . 20. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 21. Furosemide 80 mg Tablet Sig: One (1) Tablet PO Q AM for 10 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Post-operative Atrial Fibrillation PMH: Hypertension, Hypercholesterolemia, Peripheral [Name (NI) ] Disease, Carotid Disease, End-Stage Renal Disease (prev. on HD), Diabetes Mellitus, ?Seizure Disorder, Hepatitis C, Erectile Dysfunction, Cataracts PSH: RLE BPG [2154], Cadaveric Renal Transplant [2155], Parathyroidectomy [2154], Toe amputations [2154]-[2156], Cholecystectomy [2153], L AV fistula Discharge Condition: Good Discharge Instructions: [Month (only) 116] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [First Name8 (NamePattern2) 3403] [Last Name (NamePattern1) ] in 1 week ([Telephone/Fax (1) 250]) please call for appointment Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [2-18] weeks ([Telephone/Fax (1) 3632]) please call for appointment Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 1 week ([Telephone/Fax (1) 673]) please call for appointment Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] 2-4 weeks ([Telephone/Fax (1) 2422]) please call for appointment Wound check appointment [Hospital Ward Name 121] 2 on Monday [12-26] ([Telephone/Fax (1) 3633]) Completed by:[2157-12-23]	[ "4241", "9971", "42731", "25000", "4019", "2720" ]
Admission Date: [2105-1-23] Discharge Date: [2105-1-29] Date of Birth: [2038-7-24] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Replacement Asc Aorta, AV resuspension [1-23] History of Present Illness: 66 yo F presented to OSH with CP and palpitations x 1 week. She was given lovenox prior to PE CT which showed Type A dissection. Given protamine. Transferred to [Hospital1 18] for further management. Past Medical History: Gout, Arthritis Social History: deferred Family History: deferred Physical Exam: Admission exam: NAD NCAT CTAB RRR Abdomen benign 2+ DP/PT pulses. Pertinent Results: [2105-1-29] 06:50AM BLOOD WBC-11.6* RBC-4.62 Hgb-13.1 Hct-39.4 MCV-85 MCH-28.3 MCHC-33.2 RDW-13.5 Plt Ct-484* [2105-1-29] 06:50AM BLOOD Plt Ct-484* [2105-1-26] 02:13AM BLOOD PT-13.4 PTT-29.6 INR(PT)-1.1 [2105-1-29] 06:50AM BLOOD Glucose-95 UreaN-11 Creat-0.5 Na-142 K-3.6 Cl-102 HCO3-26 AnGap-18 CHEST (PORTABLE AP) [2105-1-27] 2:26 PM CHEST (PORTABLE AP) Reason: evaluation of effusion [Hospital 93] MEDICAL CONDITION: 66 year old woman with s/p asc aorta replacement REASON FOR THIS EXAMINATION: evaluation of effusion HISTORY: Status post ascending aorta replacement. FINDINGS: In comparison with study of [1-24], there has been removal of all of the tubes and wires. The widening of the mediastinum and opacification at the left base (most likely due to pleural effusion and underlying atelectasis) are again seen. No acute focal pneumonia. MR HEAD W & W/O CONTRAST [2105-1-27] 5:27 PM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: lower extremity weakness [Hospital 93] MEDICAL CONDITION: 66 year old woman with s/p asc aorta replacement REASON FOR THIS EXAMINATION: lower extremity weakness CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 66-year-old female patient, status post proximal aortic clip placement of the ascending aorta, following dissection. The patient having lower extremity weakness, to evaluate for acute infarcts. No prior studies for comparison. TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed without and with IV contrast. 3D TOF MR angiogram of the head and contrast-enhanced MR angiogram of the neck were also performed. PRELIMINARY REPORT: Multiple foci of abnormal restricted diffusion involving the left parietal lobe (302:21, 15), and right posterior temporal lobe (302:13) with associated abnormal FLAIR signal, consistent with acute-to-subacute infarcts. Discussed with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Pager [Numeric Identifier ]-KLAI. FINDINGS: MRI OF THE BRAIN: On the FLAIR sequence, there are multiple areas of increased signal intensity, specifically in the left occipital, right occipital and in the periventricular white matter and in the centrum semiovale on both sides. Some of these have restricted diffusion, in the left parietal and both occipital lobes, consistent with acute infarcts. There is also a small punctate focus in the right cerebellar hemisphere on the gradient echo sequence, a few tiny foci of susceptibility are noted, scattered in the brain parenchyma and the cerebral hemispheres, likely representing micro hemorrhages which is likely calcifications. FINDINGS: There is increased signal within the left sphenoid sinus representing fluid versus mucosal thickening. 3D TOF MR ANGIOGRAM OF THE HEAD: The right posterior inferior cerebellar artery in the left anterior inferior cerebellar arteries are faintly visualized. Otherwise, the distal vertebral, basilar artery and the posterior cerebral arteries or patent. The intracranial internal carotid arteries, including the petrous, the cavernous and the supraclinoid segments are patent. The anterior and middle cerebral arteries_____. There is no flow-limiting stenosis, occlusion or aneurysm more than 3 mm, within the resolution of MR angiogram. There is mild irregularity of the right posterior cerebral artery. However, there is no flow-limiting stenosis. MR ANGIOGRAM OF THE NECK: This study is somewhat limited due to the suboptimal quantity. Artifacts are noted in the lower part of the neck, limiting evaluation of the vessels in this area. Within these limitations, there is no focal flow-limiting stenosis, occlusion in the segments of the arteries, better visualized. IMPRESSION: 1. Multiple foci of restricted diffusion in the brain, in the left occipital, right temporal occipital, left parietal consistent with acute infarcts. 2. MR angiogram of the neck, limited due to poor quality. Within these limitations, no focal flow-limiting stenosis, occlusion or aneurysm more than 3 mm, _____ resolution of MR angiogram noted. 3. The acute infarcts are likely embolic in nature. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 77293], [Known firstname ] [Hospital1 18] [Numeric Identifier 77294] (Complete) Done [2105-1-23] at 6:00:27 AM PRELIMINARY 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: [2038-7-24] Age (years): 66 F Hgt (in): 63 BP (mm Hg): 100/65 Wgt (lb): 143 HR (bpm): 70 BSA (m2): 1.68 m2 Indication: Intraop Type A aortic dissection. Evaluate dissection, ventricular function, valve function. ICD-9 Codes: 440.0, 441.00, 424.1 Test Information Date/Time: [2105-1-23] at 06:00 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Aorta - Annulus: 2.0 cm <= 3.0 cm Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Ascending: 4.5 cm <= 3.4 cm Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV wall thickness. Normal RV systolic function. AORTA: Ascending aortic intimal flap/dissection.. Flow in false lumen. AORTIC VALVE: Three aortic valve leaflets. No AS. Moderate to severe (3+) AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mild to moderate [[12-3]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic 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. Conclusions The left atrium is normal in size. There is mild 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%). with normal free wall contractility. A mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. This flap begins at the distal portion of the sinus of valsalva (near the st junction) above the right and non-coronary cusps and extends through the aortic arch into the descending aorta as far as can be visualized on TEE. There is flow in the false lumen. There are three aortic valve leaflets. There is no aortic valve stenosis. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Post bypass: Biventricular function is preserved. LVEF > 55%. Aortic valve has trace Aortic insufficiency s/p resuspension. Artifact/thickening is seen at the ST junction, possibly from pledgets. Peak gradient on aortic valve is 5 mm Hg (caridac output 4 L/min). Ascending aortic tube graft is seen insitu, but artifact precludes complete evaluation. Dissection flap is still seen in descending aorta and arch, but clot is now forming in the flase lumen. TR is now mild to moderate. Remaing exam is unchanged. All findings discussed with surgeons at the time of the exam. Brief Hospital Course: She was takent emergently to the operating room where she underwent a replacement of ascending aorta dn resuspension of aortic valve. She was transferred to the ICU in stable condition. She awoke and was extubated on POD #1. Her esmolol and nitro drips were weaned to off by POD #3 and she was transferred to the floor. She was started on cipro for a UTI. She was noted to be ataxic by physical therapy and neurology was consulted. MRI/MRA showed bilateral cerebellar, occipital and parietal infarcts. Neurology recommendations included liberalizing blood pressure goals to systolic 120-140, continued PT, aspirin, checking fasting lipid profile after discharge, and following up in [5-10] weeks with Dr. [First Name (STitle) ]. She was ready for discharge to rehab on POD 6. Medications on Admission: Oxaprozin Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 1 days: through [1-/2026]. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks: then reassess need for diuresis. 10. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO DAILY (Daily): while on lasix. Discharge Disposition: Extended Care Facility: Rehab Hospital Of [Doctor Last Name ] Discharge Diagnosis: Type A Dissection now s/p repair Gout, Arthritis Discharge Condition: Stable Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. No lifting more than 10 pounds or driving until follow up with surgeon. Shower, no baths, no lotions, creams or powders to incisions. Followup Instructions: Dr. [First Name (STitle) ] (Neurology) 6 weeks Dr. [Last Name (STitle) ] 4 weeks Primary Care Doctor 2 weeks Completed by:[2105-1-29*]	[ "5990", "4241" ]
Admission Date: [2198-1-6] Discharge Date: [2198-1-16] Service: NSU HOSPITAL COURSE: Ms. [Known firstname ] [Last Name (Titles) ] [Known lastname ] is a [Age over 90 ]-year-old Chinese- speaking woman who had a fall down 4 steps and hit the back of her head. Son was with the patient and started CPR and said he felt no pulse. EMTs arrived and did find patient to have a pulse on the scene. She had a large laceration on the back of her head. On arrival to the ER she was awake but not verbal, was nauseous and vomiting. She was intubated, sedated, and paralyzed and brought to CAT scan. Past medical history is remarkable for osteoporosis, glaucoma, cataracts, and status post cholecystectomy. Meds are ursodiol. Allergies are none known. SOCIAL HISTORY: She is a nonsmoker, drinks no alcohol. PHYSICAL EXAMINATION: Blood pressure was 154/100, heart rate 100, respiratory 16, 100 percent on 2 liters. Head, eyes, ears, nose, and throat showed a large oozing hematoma at the occiput. Lungs were clear bilaterally. Heart showed regular rate and rhythm, normal S1, S2. Abdomen was soft, nontender. Bowel sounds were positive. Neuro: She was off propofol for 15 minutes. She was moving all extremities very strongly, attempting to pull at the endotracheal tube. She is not following commands through the Chinese interpreter. Strength was [4-26] throughout all extremities. Pupils showed a right surgical pupil. Left was 2 mm and nonreactive. Deep tendon reflexes were 2 plus bilaterally in the upper and lower extremities, and toes were upgoing. Her hematocrit was 39, sodium was 141, potassium 4.1, chloride 102, bicarbonate 26. CAT scan showed a thin layer of a right subdural with blood in the sulci and a right temporal subarachnoid bleed. There was no shift, no hydrocephalus. Cervical spine CT showed no acute fracture. Chest x-ray and pelvis x-ray were negative. There was no skull fracture. Patient was admitted with q. 1-hour neuro checks. Blood pressure was recommended to be kept less than 140. She was out of C-spine precautions. She was loaded with a gram of Dilantin. On [1-7] she did spike a temperature to 102.4 and was cultured, and she was requested to get a head CTA to rule out a carotid dissection, and she also had a repeat head CT prior. She was still not following commands. The repeat CT did show a slightly enlarged subdural hematoma and the CTA showed no dissection or vascular abnormality. Repeat CAT scan the next day, on the 17th, was stable. Fever workup did show pneumonia, and she was started on azithromycin for that. She was also started on tube feedings after she was extubated on the 17th. Her neurological exam did slowly improve. Sedation was stopped and she was allowed to wake up. She had an MRA which was stable, and she was then transferred to the floor. She did open her eyes to stimulation but did not follow commands. She would have purposeful movements of all 4 extremities. She did remain in a hard cervical collar. She did slowly become more awake. She was seen by both Physical Therapy and Occupational Therapy and did well. A swallowing evaluation was attempted on [1-12], but she was too sleepy to cooperate but since then has become more awake and purposeful and has been able to take p.o. without difficulties. She did continue to wake up and started to follow visual commands and was nodding "yes" and "no" appropriately and was cooperative with her treatment. She did continue to slowly improve neurologically. She will have a further evaluation by Speech and Swallow. She has been screened for rehab and will be discharged when bed is available. DISCHARGE CONDITION: Neurologically stable. DISCHARGE DIAGNOSES: 1. Subdural hematoma. 2. Pneumonia. 3. Intracranial hemorrhage. Her discharge medications are famotidine 30 mg once daily, subcutaneous heparin 5000 units b.i.d., oxycodone/acetaminophen elixir 5 to 10 mg p.o. q. 4-6 hours p.r.n., Dilantin 150 mg p.o. q. 8, Tylenol p.r.n. She should follow up with Dr. [Last Name (STitle) 739] in 1 month with repeat head CT. [Name6 (MD) ] [Name8 (MD) 739], MD [MD Number(2) 2930] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2198-1-16] 11:21:24 T: [2198-1-16] 11:53:03 Job#: [Job Number 18590]	[ "486" ]
Admission Date: [2120-9-24] Discharge Date: [2120-9-26] Date of Birth: [2068-7-6] Sex: M Service: MEDICINE Allergies: Bactrim Ds Attending:[First Name3 (LF) 2817] Chief Complaint: Black stools Major Surgical or Invasive Procedure: Endoscopy [9-25]: Impression: Varices at the middle third of the esophagus from 28 to 35 no varices 35 to 40 cm Granularity and mosaic appearance in the stomach body and fundus compatible with portal hypertensive gastropathy Erosions in the antrum and pre-pyloric region Otherwise normal EGD to second part of the duodenum Recommendations: Varices essentially eradicated, can discharge from ICU to my service on floor, likely bleeding from antral erosions. Protonix 40 mg twice daily, monitor HCT, restart diurectics. History of Present Illness: 52 y.o. cirrhosis, Hep C, Hep B, EtOH, thrombocytopenia, with esophageal varices recently banded on [2120-8-7], admitted for monitoring for potential worsening GI bleed. He initially presented to Liver clinic today with 3-4 days of melena. In the ED, he received NG lavage and was clear. He was started on somatostatin infusion, IV pantoprazole, and given 2 units FFP and 2 units platelets. Patient remained hemodynamically stable with blood pressure 119/61, and was admitted to MICU. Patient denies any orthostatic symptoms, nausea, vomitting, hematemesis, abdominal pain, fevers, chills, shortness of breath, or chest pain. Past Medical History: 1. EtOH cirrhosis, ascites, EGD with 4 cords grade III varices, gastropathy. Colonoscopy in [2117] with polyps 2. HCV (vl neg), HBV (vl neg), HDV (pos IgG) infection 3. Type 2 Diabetes Mellitus 4. Bipolar Disorder Social History: Past history of EtOH abuse and IVDU, reportedly sober for the last 2+ yrs. Family History: Non-contributory Physical Exam: Vitals: 96.5, 111/49, 62, 17, 100% on RA GEN: NAD HEENT: anicteric, no conjunctival pallor, MMM NECK: Supple, No JVD COR: RRR, no M/G/R, normal S1 S2 PULM: Lungs CTAB, no accessory muscle use ABD: Soft, ND, +BS, no HSM EXT: No oedema, warm and well-perfused NEURO: A&O x 3, CN II-XII grossly intact, gait intact, moves all 4 extremities SKIN: No pallor Pertinent Results: [2120-9-24] 06:00PM PT-17.9* PTT-38.8* INR(PT)-1.7* [2120-9-24] 06:00PM PLT COUNT-31* [2120-9-24] 06:00PM NEUTS-65.7 LYMPHS-25.5 MONOS-4.2 EOS-4.4* BASOS-0.2 [2120-9-24] 06:00PM WBC-4.3 RBC-3.28* HGB-11.4* HCT-30.7* MCV-93 MCH-34.7* MCHC-37.2* RDW-15.4 [2120-9-24] 06:00PM ALBUMIN-2.4* CALCIUM-8.5 PHOSPHATE-3.9 MAGNESIUM-1.9 [2120-9-24] 06:00PM ALT(SGPT)-93* AST(SGOT)-84* ALK PHOS-80 AMYLASE-56 TOT BILI-1.7* [2120-9-24] 06:00PM estGFR-Using this [2120-9-24] 06:00PM GLUCOSE-200* UREA N-31* CREAT-1.3* SODIUM-136 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-25 ANION GAP-7* [2120-9-24] 07:50PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2120-9-24] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-NEG [2120-9-24] 07:50PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.023 [2120-9-24] 07:50PM URINE GR HOLD-HOLD [2120-9-24] 07:50PM URINE HOURS-RANDOM [2120-9-24] 10:07PM PLT COUNT-30* [2120-9-24] 10:07PM HCT-26.9* Brief Hospital Course: 52 y.o. male with cirrhosis, thrombocytopenia, h/o variceal bleed with recent banding, presents with complaint of melena and slightly lower hematocrit. . ## GI bleed - Pt presented to ER from liver clinic with a complaint of melena x 3-4 days. NG lavage in ED clear. He was transferred to the MICU for management of possible UGIB given hx of cirrhosis and varices. Endoscopy performed by GI in MICU on [9-25] showed antral erosions consistent with gastritis, no variceal bleed noted. Given findings, octreotide d/c'ed. HCT (around 30) and BP's have been stable. - Change Pantoprazole 40mg daily to Pantoprazole 40mg PO BID - Home diuretics held during setting of questionable bleed, these meds can be restarted as Cr and BP's are stable. - Change propanolol to home nadolol - f/u with liver as an outpatient. - H. Pylori serology sent. Liver team and PCP to follow up with results. Pt stable, able to dc home per hepatology and MICU team. . ## Cirrhosis - Per records, patient is undergoing transplant work-up as outpatient. MELD score 17. - Continue with lactulose TID per outpatient regimen. . # RENAL - Initially with acute renal failure with Cr of 1.3 on admission, baseline of 0.8-0.9. ARF is most likely pre-renal, secondary to blood loss. It has now resolved, Cr currently at 1.1. Pt seems euvolemic at this time. Will restart home diuretics as he has good UOP and taking adequate PO and electrolytes stable. -- Restart home diuretics . # CARDIOVASCULAR - No current issues . # PULMONARY - No current issues . # HEME - Thrombocytopenia/coagulopathy, secondary to cirrhosis. -- platelets currently 31. Pt should f/u with liver as outpt . # ENDO - Diabetes type 2 -- On home glargine and ISS. . # F/E/N - Full diet. . # Access - Peripheral IV, to be dc'ed at discharge. . # Prophylaxis - Pneumoboots, ad lib activity as an outpatient . # Communication - with patient . # Code - Full code. . # Dispo- dc to home. Medications on Admission: Medications: Humalog sliding scale, 1. Glargine 42 units 2. Pantoprazole 40 mg 3. Buproprion 150 mg b.i.d. 4. Nadolol 20 mg 5. Lactulose 3 x a day 6. Spironolactone 50 mg 7. Furosemide 40 mg 8. Sucralfate 1 gram q.i.d. Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). ML(s) 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Gastritis and esophagitis GI bleed Secondary diagnoses: Cirrhosis Diabetes mellitus Discharge Condition: Stable Discharge Instructions: You were admitted for evaluation of blood in the stool. You received endoscopy and blood transfusions. The endoscopy showed inflammation of the esophagus and stomach. We have increased the dosage interval of your home medication of Pantoprazole 40mg daily to Pantoprazole 40mg TWICE DAILY for treatment of gastritis. Otherwise, You should continue on all of your remaining home medications as prescribed. Please continue with your regular home insulin regimen. Please call your physician or return to the emergency room if you notice bloody or black stools, fevers, chills, abdominal pain, or any other concerning symptoms. Followup Instructions: 1. You are to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] in [4-14] weeks after discharge. Please have him follow up with H. Pylori serology. 2. Please call your PCP within one week after discharge for a f/u appointment. You have an appointment in Liver clinic with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in the liver clinic on [2120-10-29] at 1:30PM. Please call [Telephone/Fax (1) 673] To change your appointment or with any questions.	[ "5849", "2875", "25000" ]
Admission Date: [2119-1-13] Discharge Date: [2119-1-18] Date of Birth: [2055-6-3] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Proton Pump Inhibitors / hayfever Attending:[First Name3 (LF) 1505] Chief Complaint: Intermittent chest pain and SOB that is unpredicable, it occurs with rest and activity Major Surgical or Invasive Procedure: [2119-1-13] - Coronary artery bypass grafting x3: Left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the first diagonal branch and the second diagonal branch. History of Present Illness: Patient is a 62 yo male with history of CAD sp two DES to proximal and mid LAD after positive stress test in [2109], anterior STEMI in [2112] with late in-stent thrombosis s/p DES to LAD and ostium of diagonal. He also has a history of renal calculi and on [2118-5-24], he underwent bilateral lithotripsy and ureteral stents. He had been instructed to hold his Plavix for 5 days leading up to this procedure. He underwent the urological procedure without complication however post procedure while in the PACU, developed chest pain and had anterior ST-elevations. He was brought emergently to the [Hospital1 18] cath lab on [2118-5-24] and was found to have total occlusion of the mid-LAD in the previously placed stent. This was treated with a 5 x 14 mm Integriti stent placed in the mid LAD, a 2.25 x 14 mm Integriti stent was placed in the distal LAD and a 3.0 x 14 mm Integriti stent was placed in the proximal LAD. (bare metal stents) peak CPK increased only slightly to 473. Since [Month (only) ], the patient had been doing well until [Month (only) 359], when he started to notice exertional chest discomfort. He describes a left sided chest discomfort and dyspnea occurring with activity such as walking on the treadmill for 10 minutes. He denies any symptoms at rest, pnd/orthopnea, lightheadedness, lower extremity edema, claudication or weight gain. He was sent for a stress test, which was abnormal and was referred for cardiac catheterization. Todays cath revealed signifiant CAD and reinstent stenosis. He was seen by Dr. [Last Name (STitle) ] and accepted for CABG. Past Medical History: Coronary artery disease s/p anterior Myocardial infarction [2112], [2117] LAD stents [2109], [2112], [2117] Hyperlipidemia Renal calculi s/p lithotripsy, ureteral stents Diabetes type II Hypertension GERD Inguinal hernia- needs to be repaired Social History: Race:Caucasian Last Dental Exam:3 months ago needs tooth removed Lives with:Wife [Name (NI) ] Contact: [Name (NI) ] Phone # 1-[Telephone/Fax (1) 105035] Occupation:Drives School [Doctor Last Name ] Cigarettes: Quit smoking in [2117] prior to that smoked on/off [12-5] PPD x 40 yrs ETOH: None Illicit drug use: Denies Family History: Mother died at 85 of colon cancer, MI in her 70s, DM2 Father with prostate cancer at 60, pacemaker, DM2 Brother with prostate cancer at 51 Brother with prostate cancer Sister with DM2 Physical Exam: Pulse: 65 SR Resp: 16 O2 sat:98% RA B/P Right:Radial cath site Left:117/61 Height: 6ft Weight:210lbs General: Skin: Dry [] intact [x] HEENT: PERRLA xEOMI [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 + [] large right inguinal hernia Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:inguinal hernia Left: +2 DP Right: +2 Left:+2 PT [Name (NI) 167]: +2 Left:+2 Radial Right: cath site Left:+2 Carotid Bruit Right: none Left:None Pertinent Results: [2119-1-13] ECHO Pre Bypass The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) 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. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. Post Bypass: Patient is in sinus rhythm, on nitroglycerine infusion. Preserved biventricular function with normal wall motion. Aortic contours intact. Remaning exam is unchanged. All findings discussed with surgeons at the time of the exam. Admission labs: [2119-1-13] 01:59PM HGB-14.8 calcHCT-44 [2119-1-13] 01:59PM GLUCOSE-173* LACTATE-2.6* NA+-138 K+-3.7 CL--106 [2119-1-13] 04:55PM FIBRINOGE-141* [2119-1-13] 04:55PM PT-14.5* PTT-26.7 INR(PT)-1.4* [2119-1-13] 04:55PM PLT COUNT-154 [2119-1-13] 04:55PM WBC-16.1# RBC-4.14 HGB-12.0# HCT-33.2# MCV-80* MCH-28.9 MCHC-36.0* RDW-13.5 [2119-1-13] 06:50PM UREA N-12 CREAT-0.6 SODIUM-144 POTASSIUM-3.5 CHLORIDE-115* TOTAL CO2-22 ANION GAP-11 Discahrge labs: [2119-1-17] 04:50AM BLOOD WBC-9.2 RBC-3.17* Hgb-9.2* Hct-25.9* MCV-82 MCH-29.1 MCHC-35.6* RDW-14.0 Plt Ct-212 [2119-1-17] 04:50AM BLOOD Plt Ct-212 [2119-1-15] 02:56AM BLOOD PT-14.4* PTT-29.0 INR(PT)-1.3* [2119-1-17] 04:50AM BLOOD Glucose-173* UreaN-17 Creat-0.7 Na-133 K-3.8 Cl-98 HCO3-28 AnGap-11 Radiology Report CHEST (PORTABLE AP) Study Date of [2119-1-15] 9:58 AM Final Report Right internal jugular line is at the level of mid SVC. The patient is extubated with removal of the NG tube and chest tubes. Bilateral pleural effusions are small, associated with atelectasis, unchanged since the prior study. There is no evidence of pneumothorax. DR. [First Name4 (NamePattern1) 2618] [Last Name (NamePattern1) 2619] Brief Hospital Course: Mr. [Known lastname 10840] was admitted to the [Hospital1 18] on [2119-1-13] for further management of his coronary artery disease. He was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. His chest tubes and epicardial pacing wires were removed per protocol. His Foley catheter was reinserted due to failure to void. Flomax was started and he successfully voided after removal of his catheter. He worked with the physical therapy service daily for assistance with his strength and mobility. He had a brief episode of atrial fibrillation which converted back to sinus rhythm with beta-blockers and Amiodarone. [Last Name (un) ] saw patient on post-op day four due to remaining hyperglycemic post-op. Glipizide was added and patient will follow-up with Endocrine as outpatient. He continued to make steady progress and was discharged home with VNA services on post-op day four. He will follow-up with Dr. [Last Name (STitle) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: LIPITOR 80 mg QD CLOPIDOGREL 75 mg daily FLUOXETINE 20 mg daily LISINOPRIL 5 mg Tablet Daily METFORMIN 1,000 mg Tablet [Hospital1 ] METOPROLOL SUCCINATE 25 mg DAILY NTG 0.4 mg SL PRN RANITIDINE 150 mg [Hospital1 ] TADALAFIL 20 mg daily Flomax 0.4mg po bid ASPIRIN 325 DAILY Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(s) Refills:2 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a day). Disp:30 Capsule, Ext Release 24 hr(s) Refills:2 9. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 10. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take two 200mg tablets twice daily for one week. Then take one 200mg tablet twice daily for one week. Finally take one 200mg tablet daily until stopped by cardiologist. Disp:60 Tablet(s) Refills:2 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day for 2 weeks. Disp:28 Tablet, ER Particles/Crystals(s) Refills:0 14. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 932] Area VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: s/p anterior Myocardial infarction [2112], [2117] LAD stents [2109], [2112], [2117] Hyperlipidemia Renal calculi s/p lithotripsy, ureteral stents Diabetes type II Hypertension GERD Inguinal hernia- needs to be repaired Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg- Left - healing well, no erythema or drainage. Edema 1+ bilat Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: WOUND CARE NURSE Phone: [2119-1-26] at 11AM Phone: [Telephone/Fax (1) 170] Surgeon: Dr. [Last Name (STitle) ] on [2119-2-15] at 1:30PM Cardiologist: Dr. [First Name8 (NamePattern2) 10819] [Last Name (NamePattern1) ] on [2119-2-7] at 5PM Phone:[Telephone/Fax (1) 7773] Primary Care: Dr. [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) 2472] on [2119-2-2] at 10AM Phone:[Telephone/Fax (1) 133] Please call for the following appointment Diabetes/Endocrine: Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 65317] in 1 week 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:[2119-1-18]	[ "41401", "25000", "42731", "2724", "4019", "53081", "412", "V4582", "V1582" ]
Admission Date: [2149-8-10] Discharge Date: [2149-8-20] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Acute mental status changes Major Surgical or Invasive Procedure: 1. Intubation 2. Femoral Central Venous Line History of Present Illness: Pt is an 87 yo Cantonese Speaking woman with dementia, h/o CVA, HTN, hyponatremia (thought [3-17] SIADH), who was brought to the ED by her family for lethargy, refusing to eat or get out of bed. She was recently admitted from [8-2] - [8-7] for weakness, poor po intake, fever, and bilateral pleural effusions. She was diagnosed with pneumonia and treated with levofloxacin. Of note, the family was becoming overwhelmed with the required care. Palliative care was consulted, and the family decided not to pursue aggressive treatment, including intubation/CPR, given that the patient has previously refused hospital, aggressive interventions/evaluations. . She has full-time care at home and lives with her daughter & grandson. At baseline, the patient spends most of her day in bed, sleeping. She will wake up to eat. She ambulates with a walker to the bathroom. The extent of her speaking is asking to go bed. She does not respond to questions. . Upon arrival to the [Name (NI) ], pt was noted to have agonal breathing. She was immediately intubated. After intubation, pt was found to be pulseless, received CPR for 20 seconds. A left femoral CVL was placed (semi-sterile). Initial blood pressures were up to 224/150 briefly, then settled in 90s/50s. HR in 70-80s, ?junctional at one point. Temp was 99.8 rectally. Labs were sig. for WBC 6.3, HCT 33.8, Plt 87, PTT 47, INR 1.5, fibrinogen 104, lactate 9.2. ABG was 7.24/61/473 on AC 400 x 14, peep 5, FiO2 100%. CT head showed no acute process. CT torso showed bilateral pleural effusions, R>L, gallstones, heavy atherosclerotic disease of coronaries and aorta, and cardiomegaly with marked right atrial enlargement. Pt received vanc/zosyn and tylenol. With 2.7 L IVFs, lactate improved to 4.1 Past Medical History: - CVA v. Vertebrobasilar insufficiency in [2143] - Hyponatremia thought to be [3-17] SIADH from her CVA + sellar mass - 3.2-cm sellar mass noted on CT, with right parasellar extension; followed by Dr. [Last Name (STitle) ] of Endocrine. - Osteoporosis - Hypertension - Hypercholesterolemia - COPD (per records) - S/P Appendectomy. Social History: Pt lives with her daughter [Name (NI) ] [Known lastname ] and grandson [Name (NI) 3924] [Name (NI) 13260]. Her granddaughter [Name (NI) 3040] [Name (NI) 13260] & grandson help care for her. She stays in bed most of the day. She never smoked cigarettes, drank alcohol, or use illicit drugs. Family History: Noncontributory Physical Exam: (on admission) . General Appearance: No acute distress, Thin, lethargic . Eyes / Conjunctiva: sclerae anicteric, unable to assess MM as pt does not open mouth . Head, Ears, Nose, Throat: unable to assess JVP due to TLC . Cardiovascular: (S1: Normal), (S2: Normal), no m/r/g appreciated . Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) . Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Diminished: at right base ), limited as pt occasionally moaning and not taking deep breaths. no wheezes, rales, rhonchi appreciated . Abdominal: Soft, Non-tender, Bowel sounds present, Distended, mod distention, PEG in place with surrounding denuded area with some maceration. dressing c/d/i . Extremities: Right: Absent, Left: Absent . Musculoskeletal: Muscle wasting . Skin: Warm, no rashes . Neurologic: Responds to: Noxious stimuli, Movement: No spontaneous movement, Tone: Not assessed, RUE tone increased, LUE tone flaccid. lethargic, briefly opens eyes to sternal rub. No spontaneous movement of any 4 extremities. All 4 extremities with contractures. Increased tone of RUE. LUE flaccid. [3-18]+ DTRs b/l. Upgoing toe on left, equivocal on right. Unable to assess remaining neurologic exam due to MS. . Pertinent Results: [8-2]: CXR FINDINGS: No previous images. Severe scoliosis of the thoracic spine. Cardiac silhouette is at the upper limits of normal or slightly enlarged. No acute focal pneumonia. Opacification at the left base could reflect some atelectasis and effusion. . There are several rib fractures in the left mid zone. No evidence of pneumothorax. . [8-2]: Head CT IMPRESSION: Slightly motion limited, without evidence of acute intracranial hemorrhage or fracture. . [8-2]: Abd/pelvis 1. Moderate-to-large bilateral pleural effusions, with associated atelectasis/consolidation of the adjacent lung. 2. Focal outpouching of the aorta at the aortic arch, which demonstrates a rim calcification. This likely reflects a pseudoaneurysm, likely chronic. 3. Diffuse cachexia, with anasarca. 4. Cholelithiasis without evidence of cholecystitis. 5. Multiple old fractures scattered throughout the pelvis, lumbar spine, as well as left ribs. No evidence of acute injury. . [8-2]: Chest CT 1. Moderate-to-large bilateral pleural effusions, with associated atelectasis/consolidation of the adjacent lung. 2. Focal outpouching of the aorta at the aortic arch, which demonstrates a rim calcification. This likely reflects a pseudoaneurysm, likely chronic. 3. Diffuse cachexia, with anasarca. 4. Cholelithiasis without evidence of cholecystitis. 5. Multiple old fractures scattered throughout the pelvis, lumbar spine, as well as left ribs. No evidence of acute injury. . [8-10]: C-spine CT 1. Multilevel degenerative changes, without evidence of fracture. 2. Left pleural effusion partially visualized. 3. Large left thyroid nodule. . [8-10]: Head CT No acute intracranial process. Chronic white matter, involutional parenchymal, and sinus changes, as detailed above. . [8-10]: Abd and pelvis/chest 1. No sign of acute traumatic injury in the chest, abdomen, or pelvis. 2. Moderate bilateral pleural effusions and relaxation atelectasis. 3. Mild periportal edema, mesenteric and small amount of free pelvic fluid, likely related to recent IV hydration. 4. Cardiac enlargement, with marked isolated enlargement of the right atrium, with overall appearance suggestive of Ebstein anomaly. If there has been no prior evaluation, consider echocardiography to evaluate for structural abnormality. 5. Cholelithiasis. 6. Diffuse atherosclerosis and coronary artery calcifications. 7. Likely old and partially-calcified pseudoaneurysm arising off the lateral aspect of the apex of the aortic arch. 8. Heterogeneous, enlarged thyroid gland. Correlate with thyroid function tests and ultrasound, as clinically indicated. 9. Multiple small pulmonary nodules measure up to 3 mm in size in the right lower lobe. Without risk factors such as smoking, or known malignancy, no specific follow-up is necessary. Otherwise, follow-up with chest CT should be performed in 12 months to evaluate for stability. 10. Hyperenhancing adrenal glands of uncertain significance. This finding has been described in the setting of hypoperfusion ("shock") complex, but other findings often seen in this setting such as bowel wall mucosal hyperenhancement and flattening of the inferior vena cava are absent. . [8-11]: Echo The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. 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. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . [8-11] CXR: Little overall change. . Recent labs: [8-19] WBC: 5.3 RBC: 3.36 Hct: 32.9 Plt: 157 PT: 12.8 PTT: 31.4 INR: 1.1 . Na: 139 K: 4.2 Cl: 104 HCO3: 18 BUN: 23 Creat: 0.7 Gluc: 46 . AST: 54 ALT: 144 AP: 51 Amylase: 80 Tbili: 0.9 Alb: 3.0 . Ca:8.4 Phos: 2.5 Mg: 1.9 . [9-11] TSH: 28 Free T4:0.65 . [9-10] HB-negative HAV Ab-positive . [8-18] pO2 55 pCO2 39 pH 7.34 . Lactate 1.1 Free Ca 1.20 . [8-11] urine: unremarkable . Cxs: [8-10] blood cx x1 coag negative staph Brief Hospital Course: # Respiratory distress: Upon arrival to the hospital, the patient was intubated for respiratory distress. Although the patient had bilateral pulmonary edema and was being treated for hospital aquired pneumonia from previous admission, she did not appear to have significant lung parenchymal disease. The patient completed an 8 day course of antibiotics on Vanco and Zosyn and oxygen requirements on the ventilator remained low. She self- extubated on [8-11] but had to be reintubated for hypoventilation likely secondary to sedation and central apnea. Throughout hospitalization, patient repeatedly failed pressure support ventilation and SBT secondary to these episodes of apnea. Repeat conversations with family discussing goals of care (see below) and patient was almost terminally extubated multiple times. Eventually on [8-19] the patient respiratory status and drive to breathe improved enough for an uncomplicated extubation. Upon discharge, the patient was breathing comfortably on room air. . # Unclear goals of care: Although the patient had been seen in palliative care and was made DNR/DNI prior to hospitalization, she was intubated in the ED. At the time, the family decided to make the patient DNR but ok to intubate. Throughout the hospitalization multiple family meetings were held to determine goals of care eventually involving consults with social work and an ethics committee. Eventually the patient was made comfort measures only. As a result, all nonessential medications were held and labortary studies were limited. . # Hypotension: Patient's initial hypotension was felt to be multifactorial, related to hypovolemia in the setting of poor PO intake, sedation and bradycardia. Sepsis was thought to be less likely as patient had no leucocytosis, fever or obvious source of infection (blood cultures, CXR, urine culture showed no abnormalities. Initial elevation of lactate was probably secondary to anaerobic metabolism in context of CPR. Initially a left femoral line was placed to allow adequate fluid resucitation. Antihypertensive home medications were held. Over her hospital course, the patient's hypotension resolved with IVF boluses as needed. At time of discharge the patient was normotensive. . # Coagulopathy: The patient initally presented with elevated PTT, INR, low platelet and low fibrinogen concerning for DIC vs liver disease (see below). On physical exam, the patient had multiple ecchymoses and oozing from femoral line. Coagulopathy was reversed using vitamin K and 2 units FFP. A complete workup of etiology of coagulopathy was deferred as the family wished to limit care. Patient was monitored initally with serial laboratory studies and then via physicqal exam alone in accordance with goals of care. . # Bradycardia: The patient had sinus bradycardia throughout most of her hospital course, HR ranging from 40-60s bpm. Etiology was secondary to cardiac dysfunction and hypothyroidism (initial TSH 28). . # Elevated troponin: The patient presented with elevated troponins without any changes in EKG, thought to be related to cardiac arrest. Troponins trended downward and serially EKGs were stable. The patient was initially started on ASA but this was held after patient became comfort measures only . # ARF: After her cardiac arrest, the patient's creatinine was elevated from baseline of 0.8 in the setting of hypovolemia and having receiving IV contrast. As goals of care were limited, extensive workup was not done. The patient's kidney function returned to baseline over her hospitalization course with IV fluid hydration. . # Transaminitis: The patient's elevated liver function tests were felt to be secondary to shock liver following cardiac arrest vs acute hepatitis. The patient had HAV IgG although a PCR was never done to confirm active infection. Serial LFTs were initially followed and trended downward. The patient had no overt signs of hepatic failure. . # Hypercholesterolemia: stable. The patient's simvistatin was discontinued once she was made comfort measures only . # Osteoporosis: stable. The patient's calcium and vitamin D were discontinued once patient was made comfort measures only . # Communication: With family. Grandson [Doctor Last Name 3924] can be reached by phone: C - [Telephone/Fax (1) 79577]; H - [Telephone/Fax (1) 79578]. - granddaughter [Name (NI) 3040] (HCP) [Telephone/Fax (1) 79578] (h) or [Telephone/Fax (1) 79579] (w) Medications on Admission: Levofloxacin 500 mg PO once a day for 5 days. Aspirin 81 mg PO once a day. Simvastatin 10 mg PO once a day. Calcium 500 with Vitamin D 500 mg(1,250mg) -200 unit PO three times a day. Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: [7-2] mL PO Q1H as needed for Respiratory distress. Disp:20 mL Refills:0 2. Ativan 1 mg Tablet Sig: 1-2 Tablets PO Q2H as needed for Agitation. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] HOSPICE Discharge Diagnosis: 1. Respiratory Failure 2. Cardiac Arrest Discharge Condition: Pt was discharged in stable condition Discharge Instructions: You were admitted becasue you were in respiratory failure. You were intubated during the admission and subsequently extubated. There were numerous family meetings and goals of care were discussed and care was transitioned towards comfort measures only. Followup Instructions: none	[ "2449", "2859", "2875", "51881", "5849", "486", "2761", "5119", "2762", "4019", "496", "42789", "41401", "2720" ]
Admission Date: [2157-1-13] Discharge Date: [2157-2-2] Date of Birth: [2094-5-18] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2157-1-17] Coronary artery bypass graft x 3 [2157-1-18] Mediastinal re-exploration for bleeding History of Present Illness: This 62 year old man presented to the Emergency Room at [Hospital1 5979] complaining of sunsternal pressure for 24 hours prior to presentation. He states that the pain [Last Name (un) ] similar to his previous myocardial infarction and was worse with exertion. He was also complaining of dyspnea with exertion. He stated he had stents about 10 years ago and took medications for about two years after the stents but stopped them himself and has not had follow up for several years. Past Medical History: Coronary artery disease s/p MI/PTCA of LAD and RCA-10yrs ago cardiomyopathy alcohol abuse Social History: Race: caucasian Last Dental Exam: none recently Lives: alone Contact: none/ has ex wife, 2 sons(age 24/25) and sister Occupation: automatic door repair Cigarettes: Smoked yes [x] last cigarette [1-12] Hx:1ppd x 25yrs Other Tobacco use: ETOH: 6 beers/day -last drink [1-11] Illicit drug use: none Family History: No premature coronary artery disease Physical Exam: Pulse: 65 Resp: 18 O2 sat: 97%-RA B/P Right: 124/79 Left: Height: Weight: 55.4kg General: cachetic Skin: Dry [x] intact [x] psoriasis left ear/neck HEENT: PERRLA [x] EOMI [x] 1 loose tooth-only tooth Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] A&Ox3, MAE Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ (cath site) Carotid Bruit none Pertinent Results: Echo [2157-1-17]: PRE-BYPASS: The left atrium is dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. The right atrium is dilated. Mild spontaneous echo contrast is seen in the body of the right atrium. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %) on low dose epinephrine infusion). The apical, inferior, inferoseptal, inferolateral, and lateral segments appear severlely hypokinetic and the anterior segments appear mildly to moderately hypokinetic. The right ventricular cavity is dilated with severe global free wall hypokinesis. There are simple atheroma and focal calcifications in the ascending aorta. There are simple atheroma & calcifications in the aortic arch. There are complex (>4mm) atheroma & focal calcifications in the descending thoracic aorta. Epiaortic scanning was performed prior to aortic pursestring placement & cannulation. 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. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room. POSTBYPASS: The patient was initially AV paced and then was in sinus rhythm. The patient is receiving epinephrine & milrinone infusions. The inferior, inferoseptal, lateral and apical segments remain severely hypokinetic but the function of the anterior, anterolateral, and anteroseptal segments is improved. Overall left ventricular systolic function is improved with an EF of about 25-30%. Right ventricular systolic function is improved and is now mild to moderately globally depressed. Valvular function remains unchanged. The aorta is intact after decannulation. [2157-1-13] 02:42PM BLOOD WBC-11.6* RBC-4.58* Hgb-14.1 Hct-41.5 MCV-91 MCH-30.8 MCHC-34.0 RDW-13.4 Plt Ct-307 [2157-1-20] 06:18PM BLOOD WBC-15.4* RBC-3.74* Hgb-11.6* Hct-32.6* MCV-87 MCH-31.1 MCHC-35.7* RDW-14.2 Plt Ct-116* [2157-1-28] 06:11AM BLOOD WBC-13.2* RBC-3.56* Hgb-10.9* Hct-33.6* MCV-94 MCH-30.6 MCHC-32.4 RDW-13.8 Plt Ct-350 [2157-1-31] 05:20AM BLOOD WBC-12.4* RBC-3.20* Hgb-9.5* Hct-29.4* MCV-92 MCH-29.7 MCHC-32.3 RDW-14.1 Plt Ct-458* [2157-1-13] 02:42PM BLOOD PT-10.6 PTT-29.8 INR(PT)-1.0 [2157-1-19] 02:25AM BLOOD PT-13.6* PTT-34.4 INR(PT)-1.3* [2157-1-29] 04:40AM BLOOD PT-19.1* INR(PT)-1.8* [2157-2-1] 11:15AM BLOOD PT-19.9* INR(PT)-1.9* [2157-2-2] 04:50AM BLOOD PT-22.0* INR(PT)-2.1* [2157-1-13] 02:42PM BLOOD Glucose-89 UreaN-12 Creat-0.8 Na-133 K-5.2* Cl-96 HCO3-27 AnGap-15 [2157-2-2] 04:50AM BLOOD Glucose-81 UreaN-34* Creat-2.0* Na-137 K-4.2 Cl-97 HCO3-29 AnGap-15 [2157-1-26] 02:42AM BLOOD ALT-40 AST-64* AlkPhos-182* TotBili-1.6* [2157-1-31] 05:20AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.4 Brief Hospital Course: Mr. [Known lastname ] was transferred from the outside hospital to [Hospital1 18] for surgical management of his coronary artery disease. Upon transfer he was worked up for surgery. He required a Plavix washout and on [1-17] he was brought to the Operating Room for coronary artery bypass graft x 3. Please see operative report for surgical details. He weaned from bypass on Milrinone, Epinephrine and Neo Synephrine. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Very early on post-op day one he began having increased chest tube output and the chest x-ray was suspicious for hemothorax. He was brought back to the Operating Room for re-exploration and was found to have a branch of the LIMA bleeding. Following this procedure he was brought back to the CVICU for invasive monitoring. He remained stable on a moderate amount of pharmacologic support. He weaned from the ventilator, and pressors over two days. The Milrinone was left for several days and slowly weaned off. After eight or so hours his urine output fell and he was begun again on the inotrope with a good response. The Milrinone was again weaned slowly, and ACE-I was started and he remained stable. Coumadin was given for his paroxysmal atrial and low ejection fraction. The Heart Failure Service was consulted and he will follow up in their clinic. He progressed slowly, was diuresed towards his preoperative weight and his appetite gradually improved. Her had a large fungating mass on the left parietal scalp in the area of a scalp laceration from two years ago. The plastic Surgery and dermatology services were consulted and a biopsy was positive for basal cell cancer. This will be followed at the [Hospital 2652] Clinic and excision will be performed. In the meanwhile, bacitracin ointment and a dry sterile dressing will be used topically. The patient was ready for rehab on [2157-2-2] and discharged with appropriate appointments, medications and instructions. Medications on Admission: Aspirin 325 daily Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 5. 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 6. bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic DAILY (Daily): to scalp lesion. 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: INR 2-2.5 for atrial fibrillation. 12. Outpatient Lab Work INR/PT day after transfer, 48 hours later then prn. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Basal cell carcinoma of scalp Past medical history: s/p percutaneous coronary intervention of LAD and RCA-10yrs ago severe ischemic cardiomyopathy Alcohol 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 2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [3-2] at 1:00pm in the [Hospital ] medical office building [Doctor First Name ] [Hospital Unit Name ] Cardiologist: Dr. [Last Name (STitle) 91773] on [2-24] at 2:45pm Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR 2-2.5 First draw day after admission Results to:Will need Coumadin follow up arranged at discharge Completed by:[2157-2-2]	[ "41401", "5119", "9971", "5849", "2851", "42731", "42789", "3051", "412", "V4582" ]
Admission Date: [2185-10-25] Discharge Date: [2185-11-2] Date of Birth: [2120-2-23] Sex: M Service: CHIEF COMPLAINT: Dyspnea on exertion. HISTORY OF PRESENT ILLNESS: Patient is a 65-year-old man recently evaluated for worsening dyspnea on exertion. The patient was first evaluated for dyspnea on exertion back in [2183-9-28]. At that point, he was found to have mild left coronary artery disease as well as a totally occluded right coronary artery with good collaterals. He was also noted to have a moderate mitral regurgitation. He was managed medically for this condition. During the course of the year [2184], the patient noted progressive decrease in his activity tolerance. After work up, it was determined that the patient was in need of repair of his mitral valve as well as coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Myocardial infarction. 2. Coronary artery disease. 3. Possible chronic obstructive pulmonary disease. 4. Depression. 5. Hypertension. 6. Hyperlipidemia. 7. Valve disease. 8. Remote pleurisy. 9. Arthritis. 10. Possible prior CVA. 11. Recovered alcoholic (has not drank in 16 years). PAST SURGICAL HISTORY: 1. Umbilical hernia repair. 2. Cataract surgery. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Vistaril. 2. Lipitor. 3. Multivitamins. 4. Aspirin. 5. Escitalopram. HOSPITAL COURSE: Patient was admitted to the Medical Center on [2185-10-25] and taken to surgery for coronary artery bypass graft and mitral valve repair. Surgery was performed without complications and patient thereafter was transferred to the CSRU. Later on the day of surgery, the patient received two units of packed red blood cells for a hematocrit of 21.2. Patient required pacing through postoperative day #1 and #2 to maintain an adequate heart rate. He was successfully extubated on postoperative day #1, even though he continued to be wheezy with significant productive cough during his entire stay in the CSRU. The patient as stable enough for transfer to the Cardiothoracic Surgery Floor late on postoperative day #2. Late on postoperative day #5, the patient went into atrial fibrillation. His heart rate was eventually successfully controlled with Metoprolol and Amiodarone. The patient had periods of persistent tachycardia during postoperative day #6. Decision was made to initiate anticoagulation with heparin as well as Coumadin. The patient remained stable and without complaints during postoperative day #7. On postoperative day #8, the patient was deemed stable for discharge to home. The decision was made to discontinue the patient's Amiodarone prior to discharge given decrease in his heart rate to the 50s. He remained in sinus rhythm. Following discharge, it was planned the patient would receive a visit from a visiting nurse two days following discharge for an INR check. The results of the INR check was to be faxed to the patient's cardiologist. The patient was to call his cardiologist on discharge day #2 for instructions on further Coumadin doses. The patient was to take 10 more days of Lasix following discharge since he was still significantly above his admission weight. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Metoprolol 25 mg p.o. b.i.d. 2. Escitalopram 10 mg p.o. q.d. 3. Atorvastatin 200 mg p.o. q.d. 4. Percocet. 5. Enteric coated aspirin 325 mg p.o. q.d. 6. Potassium Chloride 20 mEq p.o. b.i.d. 7. Lasix 40 mg p.o. b.i.d. 8. Coumadin 5 mg p.o. q.d. times two days. FO[Last Name (STitle) 996]P: 1. Patient is to follow up with Dr. [Last Name (Prefixes) ] in clinic four weeks following discharge. 2. Patient was to contact his cardiologist's office two days following discharge for further guidance on his Coumadin dosing as well as to schedule a follow up appointment. 3. The patient was to contact his primary care physician's office for a follow up appointment in approximately three weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 997] MEDQUIST36 D: [2185-11-2] 14:20 T: [2185-11-2] 14:37 JOB#: [Job Number 998]	[ "4240", "42731", "496", "41401", "4019", "53081", "2859" ]
Admission Date: [2117-3-21] Discharge Date: [2117-3-31] Date of Birth: [2044-6-27] Sex: F Service: NEUROLOGY Allergies: Amoxicillin / Detrol Attending:[First Name3 (LF) 5018] Chief Complaint: AMS, Code Stroke Major Surgical or Invasive Procedure: IA tPA and Merci clot retrieval. History of Present Illness: 72 yo woman with metastatic pancreatic CA (to liver, off chemo) s/p palliative Roux en Y and chemotherapy, DM, HTN, multiple TIAs in past - L sided weakness, h/o breast CA s/p lumpectomy and XRT, recent pulmonary embolus in [2-5] and NSTEMI 1.5 weeks ago on lovenox and ASA who presented on [3-21] with R sided back and chest pain and found to have troponin bump. she was otherwise well this AM - last seen well at 7:30 am. when nurse evaluated her at 8:30, she was noted to have unresponsive pupil on R with L sided weakness. As a result, code stroke was called at just before 9am. Upon initial evaluation, pt was arousable to sternal rub and able to maintain arousal initially only with tactile stimulation but after several minutes able to maintain arousal. pt states correct name and age, but thinks it's [Month (only) ] in [2068], follows commands briskly. she is noted to have dilated, nonreactive pupil on R, oculomotor paresis except for ? of R eye abduction, no eyelid opening bilaterally, L sided weakness - antigravity strength but drift to bed in UE and LE. reflexes brisker on R. stroke scale 8 (LOC2, LOC questions 1, commands 1, best gaze 2, facial palsy 2, motor L 1 for both arm and leg. She was taken emergently for CT/CTA where CTA demonstrated top of basilar thrombosis with loss of flow in RPCA. pt also with loss of flow in L vertebral. ? hypodensity noted in midline pons. As a result, pt emergently taken to neurointerventional angiography suite for vascular intervention. Past Medical History: pancreatic CA. mets to liver and lung. palliative chemo and roux en y. has declined chemo since [1-4] PE in [2-5] - on lovenox NSTEMI: presently and 1.5 weeks ago. on ASA. stroke/TIAs: followed previously by neurologist in [Location (un) 3786]. pt with L frontal infarcts in [1-4] (although presented to L sided weakness). h/o previous TIAs with R facial droop/twitching. R frontal meningioma DM2 L total hip replacement GERD migraine - scotoma with throbbing unilateral HA HTN Social History: Lives with her husband in [Name (NI) 3786]. Does not smoke or drink alcohol. Pt. and her husband have 3 sons, one of whom lives in an apt beneath her. Indepedent of ADLs. Walks with cane and walker Family History: Sister with lung cancer- heavy smoker. Stroke and heart attacks run in the family (mother, father, brother). Physical Exam: VS: T 97.1 HR 81-89 BP 156/82 RR18 95-96% RA GENERAL: NAD, pleasant, appropriate and cooperative HEENT: NCAT. Sclera anicteric. CARDIAC: RRR LUNGS: clear bilaterally ABDOMEN: Soft, non-tender, non-distended. Normal bowel sounds. EXTREMITIES: No c/c/e. Neuro: MS: no spont eye opening, arousable initially only with continued sternal rub, but after several minutes able to maintain arousal with continued exam. pt with fluent speech, although trouble with repetition, and following commands without L/R confusion briskly. oriented to name, but thinks she's at home and thinks it's [2068]. CN: able to visualize fingers but without BTT. R pupil 7-8mm, nonreactive. L pupil 1.5 with minimal reactivity. minimal abduction of R eye, but otherwise with oculomotor plegia. L NLF flattening. tongue ml. palate ml. shoulder shrug, head turn full. Motor: nl tone, with full strength on R. on L, delt 3+, bic 5-, tric 5-, WE 1, FE 1, FF 5-. IP 5-, H 4+, DF 3, TE 3 Reflexes: 2+ on R, 1+ on L. toes down coord. does not cooperate. [Last Name (un) ]: withdraws to tickle R>L. Pertinent Results: [2117-3-29] 06:22AM BLOOD WBC-22.7* RBC-2.87* Hgb-8.3* Hct-24.4* MCV-85 MCH-28.8 MCHC-33.8 RDW-18.2* Plt Ct-146* [2117-3-28] 03:20AM BLOOD WBC-20.1* RBC-2.93* Hgb-8.3* Hct-24.9* MCV-85 MCH-28.3 MCHC-33.4 RDW-17.3* Plt Ct-185 [2117-3-27] 11:44AM BLOOD WBC-15.8* RBC-2.87* Hgb-8.0* Hct-24.5* MCV-85 MCH-28.0 MCHC-32.8 RDW-16.8* Plt Ct-221 [2117-3-27] 03:44AM BLOOD WBC-17.6* RBC-2.90* Hgb-8.4* Hct-24.7* MCV-85 MCH-29.0 MCHC-34.0 RDW-17.1* Plt Ct-231 [2117-3-26] 02:45AM BLOOD WBC-16.9* RBC-2.75* Hgb-7.4* Hct-23.5* MCV-86 MCH-27.0 MCHC-31.5 RDW-16.7* Plt Ct-235 [2117-3-25] 03:12AM BLOOD WBC-26.6# RBC-3.13 Hgb-8.6* Hct-26.4* MCV-85 MCH-27.4 MCHC-32.4 RDW-16.7* Plt Ct-286 [2117-3-24] 02:17AM BLOOD WBC-16.3* RBC-3.62* Hgb-10.0* Hct-30.0* MCV-83 MCH-27.7 MCHC-33.4 RDW-16.5* Plt Ct-285 [2117-3-23] 05:07AM BLOOD WBC-11.5* RBC-3.67# Hgb-10.2# Hct-30.2* MCV-82 MCH-27.8 MCHC-33.7 RDW-16.5* Plt Ct-283 [2117-3-22] 06:52AM BLOOD WBC-8.7 RBC-2.85* Hgb-7.5* Hct-23.6* MCV-83 MCH-26.3* MCHC-31.7 RDW-16.4* Plt Ct-302 [2117-3-21] 06:50AM BLOOD WBC-8.7 RBC-3.02* Hgb-7.9* Hct-25.2* MCV-84 MCH-26.2* MCHC-31.3 RDW-15.6* Plt Ct-376 [2117-3-24] 02:17AM BLOOD Neuts-90.4* Lymphs-5.0* Monos-3.8 Eos-0.6 Baso-0.3 [2117-3-21] 06:50AM BLOOD Neuts-87.2* Lymphs-7.9* Monos-3.5 Eos-1.0 Baso-0.3 [2117-3-28] 03:20AM BLOOD PTT-26.0 [2117-3-27] 11:44AM BLOOD PTT-59.9* [2117-3-27] 03:44AM BLOOD PT-13.1 PTT-54.3* INR(PT)-1.1 [2117-3-26] 09:22PM BLOOD PTT-54.4* [2117-3-26] 02:09PM BLOOD PTT-70.5* [2117-3-26] 02:45AM BLOOD PT-14.5* PTT-85.1* INR(PT)-1.3* [2117-3-25] 04:25PM BLOOD PTT-61.2* [2117-3-25] 08:59AM BLOOD PTT-48.5* [2117-3-25] 01:20AM BLOOD PTT-39.8* [2117-3-24] 04:50PM BLOOD PT-14.8* PTT-31.5 INR(PT)-1.3* [2117-3-23] 05:07AM BLOOD PT-14.3* PTT-26.3 INR(PT)-1.2* [2117-3-22] 06:52AM BLOOD PT-13.8* PTT-75.5* INR(PT)-1.2* [2117-3-21] 06:50AM BLOOD PT-13.9* PTT-29.5 INR(PT)-1.2* [2117-3-22] 06:52AM BLOOD Ret Aut-2.3 [2117-3-29] 06:22AM BLOOD Glucose-184* UreaN-15 Creat-0.4 Na-142 K-3.4 Cl-105 HCO3-28 AnGap-12 [2117-3-28] 03:20AM BLOOD Glucose-182* UreaN-18 Creat-0.4 Na-143 K-3.7 Cl-108 HCO3-27 AnGap-12 [2117-3-27] 03:44AM BLOOD Glucose-163* UreaN-19 Creat-0.5 Na-141 K-5.2* Cl-109* HCO3-23 AnGap-14 [2117-3-26] 02:45AM BLOOD Glucose-122* UreaN-22* Creat-0.5 Na-143 K-3.6 Cl-111* HCO3-20* AnGap-16 [2117-3-25] 03:12AM BLOOD Glucose-144* UreaN-19 Creat-0.6 Na-144 K-3.8 Cl-109* HCO3-22 AnGap-17 [2117-3-24] 02:17AM BLOOD Glucose-89 UreaN-9 Creat-0.4 Na-144 K-3.0* Cl-109* HCO3-27 AnGap-11 [2117-3-23] 05:07AM BLOOD Glucose-81 UreaN-9 Creat-0.4 Na-142 K-3.4 Cl-109* HCO3-27 AnGap-9 [2117-3-22] 06:52AM BLOOD Glucose-118* UreaN-13 Creat-0.5 Na-143 K-3.8 Cl-109* HCO3-26 AnGap-12 [2117-3-21] 06:50AM BLOOD Glucose-117* UreaN-13 Creat-0.4 Na-142 K-3.6 Cl-108 HCO3-23 AnGap-15 [2117-3-25] 03:12AM BLOOD CK(CPK)-82 [2117-3-24] 04:50PM BLOOD CK(CPK)-181* [2117-3-24] 11:26AM BLOOD CK(CPK)-216* [2117-3-24] 02:17AM BLOOD CK(CPK)-84 [2117-3-23] 07:23PM BLOOD CK(CPK)-56 [2117-3-23] 05:07AM BLOOD ALT-32 AST-30 LD(LDH)-248 CK(CPK)-36 AlkPhos-195* TotBili-0.7 [2117-3-22] 06:52AM BLOOD ALT-28 AST-29 LD(LDH)-200 CK(CPK)-47 AlkPhos-198* TotBili-0.2 [2117-3-21] 05:00PM BLOOD CK(CPK)-52 [2117-3-21] 06:50AM BLOOD CK(CPK)-30 [2117-3-25] 03:12AM BLOOD CK-MB-14* MB Indx-17.1* cTropnT-0.45* [2117-3-24] 04:50PM BLOOD CK-MB-31* MB Indx-17.1* cTropnT-0.83* [2117-3-24] 11:26AM BLOOD CK-MB-35* MB Indx-16.2* cTropnT-0.68* [2117-3-24] 02:17AM BLOOD CK-MB-NotDone cTropnT-0.28* [2117-3-23] 07:23PM BLOOD CK-MB-NotDone cTropnT-0.22* [2117-3-23] 05:07AM BLOOD CK-MB-NotDone cTropnT-0.14* [2117-3-22] 06:52AM BLOOD CK-MB-5 cTropnT-0.17* [2117-3-21] 05:00PM BLOOD CK-MB-6 cTropnT-0.13* [2117-3-21] 06:50AM BLOOD cTropnT-0.08* [2117-3-29] 06:22AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.0 [2117-3-28] 03:20AM BLOOD Calcium-8.0* Phos-1.7* Mg-1.9 [2117-3-27] 03:44AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.8 [2117-3-26] 02:45AM BLOOD Calcium-8.3* Phos-2.9# Mg-2.0 [2117-3-25] 03:12AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.8 [2117-3-24] 02:17AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.7 Cholest-125 [2117-3-23] 05:07AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.3 Mg-2.0 [2117-3-22] 06:52AM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.5 Mg-2.0 Iron-16* [2117-3-21] 06:50AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9 [2117-3-22] 06:52AM BLOOD calTIBC-220* Ferritn-151* TRF-169* [2117-3-24] 02:17AM BLOOD %HbA1c-6.2* [2117-3-24] 02:17AM BLOOD Triglyc-88 HDL-27 CHOL/HD-4.6 LDLcalc-80 CXR [2117-3-21]: IMPRESSION: No acute cardiopulmonary process identified CTA chest [2117-3-21] IMPRESSION: 1. Interval decrease in the burden of the pulmonary embolus within the right lower lobe pulmonary artery. No other focus of pulmonary embolism is identified. 2. Multiple pulmonary nodules and multiple hypodense liver lesions which appear relatively unchanged compared to the prior study. Findings are compatible with the reported pancreatic metastatic disease CT/CT Perf/CTA head [2117-3-23]: IMPRESSION: 1. Small area of reversible ischemia in the left cerebellar hemisphere in the medial portion. 2. Please note that the accuracy of CTP in the detection of small acute infarcts in the posterior fossa. In addition, acute infarcts in this location are elsewhere in the brain, not imaged, cannot be excluded. MR of the head can be considered, if this information is necessary. 3. Lack of enhancement in the tip of the basilar artery, as well as the posterior cerebral arteries on both sides, P1 and P2 segments on the right side and P1 segment on the left side, consistent with thrombosis. This appearance is new compared to the MR angiogram done on [2116-3-8]. 4. The patient is apparently undergoing conventional angiogram for better assessment and possible intervention; please see the detailed report on the conventional angiogram study. 5. Degenerative changes noted in the cervical spine at C4-5 level, not completely assessed on the present study. MRI/MRA brain [2117-3-24]: IMPRESSION: 1. Multiple acute infarcts, in the bilateral MCA, PCA territories, likely related to embolic etiology. 2. Recanalization of the previously thrombosed tip of the basilar artery and the posterior cerebral arteries on both sides. Evaluation for any acute hemorrhage may be limited. Correlate with follow up CT study. CT Head [2117-3-24]: CONCLUSION: No new intracranial hemorrhage. Beginning visibility of multiple infarcts noted on a prior MR study of [3-23], as described in detail above. CXR [2117-3-24]: IMPRESSION: No acute cardiopulmonary process is identified\ Echo [2117-3-25]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). 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. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2117-3-9], no major change is evident. IMPRESSION: no mass or vegetations seen CXR [2117-3-26]: FINDINGS: As compared to the previous radiograph, a Dobbhoff catheter has been placed. The course of the catheter is unremarkable, the tip of the catheter is not included on the radiograph. Unchanged position of left-sided Port-A-Cath. Mild pre-existing right suprabasilar atelectasis. No new lung opacities. CT Abd/Pelvis [2117-3-27]: IMPRESSION: 1. Right inguinal hematoma, cannot exclude active extravasation. 2. Innumerable liver and pulmonary metastases. Pancreatic head mass. 3. Bilateral small pleural effusions. Femoral U/S [2117-3-27]: IMPRESSION: Large inguinal hematoma, no evidence of pseudoaneurysm CT Head [2117-3-28]: IMPRESSION: 1. Evolving left MCA infarct involving the left frontal and parietal lobes with obliteration of the adjacent sulci and no hemorrhage. This appears larger than on the previous MR examination. 2. Unchanged right thalamic infarction. 3. Right cerebellar and right occipital infarctions, barely detectable on this CT. CXR [2117-3-28]: FINDINGS: As compared to the previous radiograph, there is no relevant change. Right Port-A-Cath and Dobbhoff catheter in place. Unchanged size of the cardiac silhouette, unchanged tortuosity of the thoracic aorta. No signs of overhydration, no pleural effusions, no focal parenchymal opacities suggestive of pneumonia. Brief Hospital Course: This 72 F was admitted for chest pain and was being managed for NSTEMI. She experienced a tip of the basilar stroke as outlined in the HPI. She was taken to the angio suite and received IA tPA and Merci clot retrieval with subsequent recanalization of her PCA's bilaterally. Although post-catheterization she was noted to be speaking, her neuro exam deteriorated overnight and the next morning she was somnolent, nonverbal, but able to move all extermities against gravity. Her brain MRI overnight showed scattered infarcts in the cerebellum, midbrain, right thalamus, and cortex. A repeat head CT showed no evidence of bleeding post-tPA, and she was started on a heparin gtt. Post-catheterization, her troponins began increasing again and peaked at about 0.8. She was started on a beta-blocker and aspirin. Her WBC count increased over days, however an infectious workup returned negative. Over days, her hemoglobin was noted to be trending down, a CT Abd/pelivs was done and confirmed the presence of a femoral hematoma. The heparin gtt was DC'd. Subsequently, her neuro exam deteriorated more to the point where she was not moving her extremities as well as previously. A repeat NCHCT showed evolution of her prior left MCA territory infarct. She was otherwise stable from a caridopulmonary perspective and was transferred out of the ICU to the floor. Given her hx of metastatic pancreatic CA, Trousseau syndrome, and now scattered strokes, her family decided that hospice care would be most appropriate for her. Medications on Admission: -Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig: Two (2) Tablet PO QID. -Atenolol 50 mg Tablet: One (1) Tablet PO DAILY. -Spironolactone 12.5 mg PO DAILY. -Enoxaparin Fifty (50) mg Subcutaneous [Hospital1 ]. -Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr, 1 Tab PO daily. -Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H PRN. -Docusate Sodium 100 mg Capsule Sig: Two (2) PO BID. -Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY. -Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID PRN. Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q1H (every hour) as needed for pain. 2. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed for resp distress, restlessness. 3. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72HR (). 4. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. Discharge Disposition: Extended Care Facility: [Location (un) 582] - [Location (un) 7658] Discharge Diagnosis: End-stage Pancreatic Ca Trouso syndrome Myocardial infarction Cerebral embolism with multiple infarctions Bacteremia Discharge Condition: comfort care Discharge Instructions: You had multiple strokes due to increased clotting caused by pancreatic cancer Followup Instructions: Hospice care [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2117-3-30]	[ "41071", "25000", "4019", "2859" ]
Admission Date: [2120-3-26] Discharge Date: [2120-4-2] Date of Birth: [2051-1-17] Sex: M Service: Neurosrgery HISTORY OF THE PRESENT ILLNESS: The patient is a 69-year-old male with a left middle cerebral artery aneurysm. The symptoms have included dizziness, tingling in his left fingers and difficulty with speech. The patient denied chest pain, shortness of breath, edema, dysuria, fever, chills, cold symptoms. PAST MEDICAL HISTORY: 1. Left transient ischemic attacks. 2. GERD. 3. Hypertension. 4. Emphysema. 6. Six TIAs, the last one six months ago. HOME MEDICATIONS: 1. Atenolol 25 mg q.d. 2. Univasc 7.5 mg q.d. 3. Aggrenox 25 mg b.i.d. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Pulse 55, blood pressure 153/74. General: The patient is a very pleasant male, alert and oriented times three, in no acute distress. HEENT: Normocephalic, atraumatic. Pupils equally round and reactive to light. Extraocular movements intact. Chest: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm, no murmurs. Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly. Extremities: No edema. Neurologic: Cranial nerves II through XII intact. Motor [5-20], bilateral upper and lower extremities. Reflexes 2+ in the bilateral upper and lower extremities. No Romberg sign. No pronator sign. HOSPITAL COURSE: The patient was admitted on [2120-3-26], taken directly to the Operating Room where a craniotomy and clipping of his left MCA aneurysm was performed. The patient was sent to the Intensive Care Unit postoperatively for close observation. As the patient began to wake up it was evident that the patient had developed a postoperative aphasia. The patient was treated with dexamethasone as well as Dilantin postoperatively. The patient did well postoperatively with the exception of his aphasia for which the patient stayed in the ICU for some time in an attempt to discern the cause and be alert for other possible problems. Over the course of the stay, the patient was placed on high-dose intravenous fluids in order to increase his blood pressure which subsequently improved his aphasia. It was, therefore, determined that a higher blood pressure would aid in maintaining better blood flow to his brain speech centers. Once determined the patient was found to be stable and the aphasia improving, the patient was discharged to the regular Neurosurgical Floor where he continued to do well. During the course of his stay, his mental status examination and physical examination continued to be very good. His aphasia continued to improve. The patient was slowly weaned off of his IV fluids which he tolerated well. Periodically, over the course of his weaning, his blood pressure would become slightly lower. For that reason, his blood pressure medication regimen was altered such that he will only be taking only one-quarter of his at-home Atenolol dose on discharge. On [2120-3-28], the patient had an angiogram to ensure appropriate patency of his cranial arteries which was confirmed. The patient did have mild narrowing of his MCA, although patency was evident. It is now [2120-4-2], and the patient is doing quite well. He is being discharged home. He will be sent home with Percocet for pain, Colace for constipation. He will be sent home with Dilantin 100 mg t.i.d. as well as Atenolol 6.25 mg once a day. The patient is not to restart his home medications as they include blood thinners and hypertensive medications. He is to restrict himself to the medications that he is being discharged on. Before discharge, he will have his staples removed. He is to follow-up with Dr. [Last Name (STitle) 1132] in one week. He may observe regular activity, although he should not drive while on pain medication. The patient may start showering tomorrow. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern4) 8358] MEDQUIST36 D: [2120-4-2] 04:52 T: [2120-4-3] 10:08 JOB#: [Job Number 27520]	[ "53081", "4019" ]
Admission Date: [2129-5-25] Discharge Date: [2129-6-1] Date of Birth: [2069-2-22] Sex: M Service: [Last Name (un) 7081] Patient is a 60-year-old gentleman with a history of asthma, who was previously hospitalized for severe respiratory distress requiring intubation. [Hospital ] hospital course was prolonged complicated by congestive heart failure and MRSA pneumonia. Patient had a prolonged wean from the ventilator at the time requiring a tracheostomy. Patient was eventually decannulated and was discharged to home when he represented in [2129-2-20] with respiratory distress again requiring intubation. On bronchoscopy at that time he was found to have significant subglottic stenosis and a trach tube was placed. Again, his hospital course was complicated by MRSA respiratory infection as well as GI bleeding and non-ST- elevation myocardial infarction. At that time he underwent cardiac catheterization revealing nonsignificant coronary artery disease and no lesions requiring intervention. He was subsequently transferred to [Hospital1 188] and evaluated by Dr. [Last Name (STitle) ] for the subglottic stenosis. He is found to have a near complete obstruction of his upper airway at the level of first and second tracheal ring with some degree of involvement of the anterior coracoid on rigid bronchoscopy. On flexible bronchoscopy, he was found to have no disease at the stomal site or distally. At that time, Dr. [Last Name (STitle) 952] was consulted and patient was advised to undergo a surgical resection of the stenosis and reconstruction. Patient after understanding fully the risks and benefits involved to the undergo the elective surgery and presents to the operating room on [5-24]. PAST MEDICAL HISTORY: 1. Coronary artery disease status post non-ST-elevation myocardial infarction. 2. Hypertension. 3. Anemia. 4. Peptic ulcer disease. 5. GI bleeding. 6. Asthma. 7. Hypercholesterolemia. 8. Type 2 diabetes. 9. CHF. MEDICATIONS AT HOME: 1. Clonidine 0.2 mg b.i.d. 2. Hydralazine 10 mg p.o. b.i.d. 3. Lipitor 20 mg p.o. q.d. 4. Zestril 20 mg q.d. 5. Paxil 20 mg q.d. 6. Norvasc 10 mg q.d. 7. Protonix 40 mg p.o. q.d. 8. Lopressor 50 mg p.o. b.i.d. 9. Hydrochlorothiazide 25 mg p.o. q.d. 10. Glyburide 5 mg b.i.d. 11. Glucophage 500 mg b.i.d. ALLERGIES: Patient reports no known drug allergies. SOCIAL HISTORY: Patient has immigrated from [Country ] and is a bus driver in [State 350]. He smoked one pack a day of cigarettes for 16 years and has quit in [2106]. He does not drink a significant amount of alcohol. PHYSICAL EXAMINATION: Patient has stable vital signs. Thin male, who appears quite healthy and not in no apparent distress at the time of examination with trach mask collar with humidified air. He is unable to speak. HEENT exam is within normal limits. Cervical examination reveals no supraclavicular or cervical adenopathy. The ostomy site is well healed around the indwelling trach tube. Lungs are clear to auscultation bilaterally. Heart was regular, rate, and rhythm. S1, S2 without murmurs. Thorax is symmetrical without lesions or masses. Abdomen is soft, nontender, and nondistended. Extremities shows no clubbing or edema. Neurologically the patient is grossly intact. CT scan from [2129-4-21] shows a subglottic stenosis at the level of the anterior coracoid down to approximately [2-22] tracheal rings. Otherwise, the rest of the airway tracheal rings were within normal limits. There was also noted a small ________ nodule, which appears to be benign. LABORATORY STUDIES: Patient's last hematocrit was 30 with a white count of 5, platelets was 165. PT was 13.9, PTT 36, BUN was 20, creatinine 1.2. Patient presented to the OR on [2129-5-25] for elective resection of his subglottic stenosis and reconstruction of airway. Patient underwent this procedure without significant difficulty. Left the OR intubated and was transferred directly to the Surgical ICU. Patient did well there. Patient was weaned to extubate and was extubated on postoperative day two. At the time, patient was also covered with Vancomycin, Kefzol, and Flagyl prophylactically. Postoperatively, patient's hematocrit was down to 22.5. Patient received 2 units of packed red cells with good response. After successful extubation, patient's neck remained flushed. Patient was transferred to the floor, and his course on the floor was uncomplicated. Patient's Vancomycin was D/C'd and patient continued on Kefzol and Flagyl for seven day course. On postoperative day seven, patient underwent a bronchoscopy for evaluation of his surgical site. Patient was found to have a normal anastomosis with granulation tissue, secretions were noted, which were suctioned. Patient's neck was D/C'd from the flexed position. Patient's previously placed PICC was D/C'd, and patient was discharged home without any complications on [2129-6-1]. Patient's hypertension was controlled with his usual regimen while taken at home, and did require a slight adjustment with increase in Lopressor to 50 mg p.o. t.i.d. and hydralazine 20 mg p.o. q.8h. DISCHARGE STATUS: Discharged with home VNA services. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Subglottic tracheal stenosis. 2. T tube prolonged intubation and tracheostomy. 3. Status post resection of the stenosis and airway reconstruction. 4. Hypertension. 5. Coronary artery disease. 6. Diabetes type 2. 7. Asthma. DISCHARGE MEDICATIONS: 1. Clonidine 0.2 mg p.o. b.i.d. 2. Lipitor 20 mg p.o. q.d. 3. Zestril 20 mg p.o. q.d. 4. Lopressor 50 mg p.o. t.i.d. This is increased from his usual home dose. 5. Hydralazine 20 mg p.o. q.8. This is increased from patient's usual home dose. 6. Norvasc 10 mg p.o. q.d. 7. Hydrochlorothiazide 25 mg p.o. q.d. 8. Glyburide 5 mg p.o. b.i.d. 9. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h. 10. Colace 100 mg p.o. b.i.d. while taking Percocet. 11. Protonix 40 mg p.o. q.d. 12. Glucophage 500 mg p.o. b.i.d. FOLLOW UP: Patient is to followup with Dr. [Last Name (STitle) 952] within one week, and is to see his primary care physician regarding his blood pressure control. [First Name11 (Name Pattern1) 951] [Last Name (NamePattern4) ], MD [MD Number(1) 3352] Dictated By:[Last Name (NamePattern1) 12164] MEDQUIST36 D: [2129-6-1] 21:48:52 T: [2129-6-2] 05:18:57 Job#: [Job Number ]	[ "4280", "41401", "412", "49390", "4019", "2859", "25000" ]
Admission Date: [2167-4-27] Discharge Date: [2167-5-2] Date of Birth: [2106-7-14] Sex: M Service: CARDIOTHORACIC Allergies: Latex Gloves Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2167-4-27] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending artery, and saphenous vein grafts to obtuse marginal and posterior descending arteries. History of Present Illness: Mr. [Known lastname 11791] is a 60 year old male with multiple cardiac risk factors. Over the last several months, he admitted to chest pain with minimal exertion. His chest pain did improve with sublingual Nitroglycerin. He underwent elective cardiac catheterization which revealed severe three vessel coronary artery disease. Preoperative echocardiogram showed an ejection fraction of 55%. Given the above results, he was referred for surgical revascularization. Past Medical History: Coronary Artery Disease Hypertension Type II Diabetes Mellitus Dyslipidemia Chronic Renal Insufficiency Gastroesophogeal Reflux Disease Left Shoulder Arthritis/Rotator Cuff Injury History of Detached Retina Social History: Lives with wife. Several children, present at bedside. Smoked a few cigs/day for 2-3 years, stopped in [2117]. Works at [Hospital1 18] in environmental services. He only rarely drinks beer once in a while for holidays. Family History: Parents with CAD in their 70s. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Vitals: bp 145/68 hr 50 General: well appearing male in no acute distress Skin: unremarkable HEENT: oropharynx benign Neck: supple, no jvd Chest: lungs clear bilaterally Heart: regular rate and rhythm, normal s1s2, no murmur or rub Abdomen: benign Ext: warm, no edema Neuro: non-focal Pulses: 1+ distally, no carotid or femoral bruits Pertinent Results: [2167-4-27] Intraop TEE: PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in thedescending thoracic aorta. 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 (1+) mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylehrine at 0.3mcg/kg/min. Thoracic aorta is intact.Mild MR [First Name (Titles) ] [Last Name (Titles) ]. LVEF 55%. Normal RV systolic funciton. [2167-5-1] 05:25AM BLOOD WBC-8.8 RBC-3.08* Hgb-9.1* Hct-27.8* MCV-90 MCH-29.6 MCHC-32.9 RDW-14.3 Plt Ct-219# [2167-5-1] 05:25AM BLOOD Glucose-131* UreaN-19 Creat-1.2 Na-137 K-4.4 Cl-97 HCO3-29 AnGap-15 [2167-5-1] 05:25AM BLOOD Mg-2.3 Brief Hospital Course: Mr. [Known lastname 11791] was admitted and underwent coronary artery bypass grafting surgery by Dr. [Last Name (STitle) 914]. Given he was a same day admit, Cefazolin was used for perioperative antibiotic coverage. For surgical details, please see operative note. Following the procedure, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. His CVICU course was otherwise uneventful and he transferred to the telemetry floor on postoperative day one. Chest tubes and pacing wires were removed without complication. On POD#4 Mr. [Known lastname 11791] developed brief episode of self-limiting Afib. He was staretd on po amiodarone and has maintained NSR. He was discharged in good conditon on POD 5. Medications on Admission: Zestoretic 20/12.5 tabs, 2 daily Metformin 500 daily Toprol XL 100 daily Nambutone 750 daily Protonix 40 daily Nitro prn Aspirin 81 daily Simvastatin 40 daily Tylenol #3 prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 2 weeks. Disp:28 Tablet Sustained Release(s) Refills:0 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. Nabumetone 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): 400mg 3x/day x 7 days, then 400mg 2x/day x 7 days, then 400mg/day x 7 days, then 200mg daily until further instructed . Disp:180 Tablet(s) Refills:2 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease, s/p CABG Hypertension Type II Diabetes Mellitus Dyslipidemia Chronic Renal Insufficiency Discharge Condition: Good Discharge Instructions: - Shower daily, no baths or swimming - No lotions, creams or powders to incisions - No driving for at least 4 weeks and off all narcotics - No lifting more than 10 pounds for 10 weeks - Report any redness or drainage from incisions - Report any fever greater than 100.5 - Report any weight gain greater than 2 pounds a day or 5 pounds a week - Take all medications as directed Followup Instructions: Dr. [Last Name (STitle) 914] in [4-5] weeks, call for appt Dr. [Last Name (STitle) 1789] in [2-3] weeks, call for appt Wound check on [Hospital Ward Name 121] 6 in 2 weeks Completed by:[2167-5-2]	[ "41401", "5859", "42731", "40390", "25000", "2724", "53081" ]
Admission Date: [2194-12-19] Discharge Date: [2194-12-29] Date of Birth: [2124-1-12] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Called by Emergency Department to evaluate Thalamic Hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 23220] is a very [Last Name (un) 1425] 70 year-old right-handed male smoker with a past medical history including HTN, HLD, and afib for which he is on coumadin who presents from [Hospital3 3583] with a left thalamic hemorrhage. The patient is able to confirm the history as shared by the ED team and family; he was in his usual state of health until about 4:30 this morning when he was driving independently. He apparently experienced the sudden onset of numbness on the right aspect of his face, right arm, and right leg. He was first evaluated at [Hospital3 3583], where a non-contrast CT of the head was thought to show a left thalamic hemorrhage measuring approximately 2.9 by 2.2 cm with extension into the left lateral and third ventricles. To reverse an INR of 1.9, the patient was reportedly given 2-4 units of FFP and vitamin k 10 mg IV x 1 before transfer to the [Hospital1 18] for further evaluation and care. Mr. [Known lastname 23220] indicates that he has since developed difficulty expressing himself verbally, although he maintians he can understand what is being said. He denies prior strokes and coagulopathies. He denies current headache. In the ED he was given profilnine and a non-contrast CT of the head was repeated to evaluate for hemorrhagic expansion. NEUROLOGICAL, GENERAL REVIEW OF SYSTEMS - unable to directly assess Past Medical History: - atrial fibrillation - HTN - HLD - presumed COPD - presumed anxiety - erythrocytosis - regular therapeutic phlebotomy (last [2194-12-16]) PAST SURGICAL HISTORY: - bilateral cataract surgery per pt - lap chole [2189-3-24] (acute + chronic cholecystitis, cholangitis, CBD stone) Social History: - married - has four sons - works as a dispathcher for a courier company - was next planning to drive a school bus - Catholic - served in marines Family History: NC Physical Exam: Vitals: T: 100.3 P: 70s-80s R: 20 BP: 163/72 SaO2: 98% on 2L General: Awake, cooperative, NAD but appears frustrated with difficulties communicating HEENT: Normocepahlic, atruamatic, no scleral icterus noted. Mucus membranes moist, no lesions noted in oropharynx. Copious secretions in oropharynx. Neck: Supple. No carotid bruits appreciated. Cardiac: Regular rate, irregularly irregular rhythm. Pulmonary: Coarse breath sounds bilaterally anteriorly. Abdomen: Obese. Normoactive bowel sounds. Soft. Non-tender, non-distended. Extremities: Warm, well-perfused. Skin: no rashes or concerning lesions noted. NEUROLOGIC EXAMINATION: Mental Status: * Degree of Alertness: Alert. Able to nod in agreement and answer "yes" when presented verbally. * Orientation: Oriented to person, place (nods to "hospital"), month ("yes" to [Month (only) 404], "no" to [Month (only) ]), year ("yes" to [2194], "no" to [2193]), situation (indicates "yes" when asked about right-sided numbness, hemiparesis) * Language: Language is non-fluent. Repetition is initially intact (eg "today is a sunny day in [Location (un) 86]"). Comprehension appears intact; pt able to correctly follow midline and appendicular commands, difficulty with cross-body commands. Pt unable to name high (watch) and low frequency objects (knuckles). Cranial Nerves: * I: Olfaction not evaluated. * II: PERRL 3 to 2mm and slightly sluggish. Visual fields difficult to formally test but patient seems to attend to all aspects of visual fields. * III, IV, VI: EOMI with limited upgaze. * V: Difficult to formally assess facial sensation in the V1, V2, V3 distributions (pt says "I don't know" when asked if the right and left sides feel roughly the same). * VII: Flattening of right nasolabial fold. * VIII: Hearing intact to finger-rub bilaterally. * IX, X: Palate elevates symmetrically. * [Doctor First Name 81]: 5/5 strength in trapezii on left. 0/5 on right. * XII: Tongue protrudes in midline. Motor: * Bulk: No evidence of atrophy. * Tone: Flaccid in right extremities. * Drift: No pronator drift on left. * Adventitious Movements: slight postural tremor with left arm outstretched. Strength: * Left Upper Extremity: 5 throughout Delt, Biceps, Triceps, Wrist Ext, Wrist Flex, Finger Ext, Finger Flex * Right Upper Extremity: 0 throughout Delt, Biceps, Triceps, Wrist Ext, Wrist Flex, Finger Ext, Finger Flex * Left Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib Ant, Gastroc, Ext Hollucis Longis * Right Lower Extremity: 0 throughout Iliopsoas, Quad, Ham, Tib Ant, Gastroc, Ext Hollucis Longis Reflexes: * Babinski: flexor left, extensor right - triple flexion with noxious stimulation of right lower extremity Sensation: * Light Touch: intact bilaterally in left lower extremities, upper extremities, trunk, face; difficult to asses right-sided sensation Coordination * Pt seemed to perform activities (eg reaching for the arm of a loved one) with acuity Gait: * not evaluated Pertinent Results: [2194-12-24] 03:56AM BLOOD WBC-16.5* RBC-5.12 Hgb-13.1* Hct-41.4 MCV-81* MCH-25.5* MCHC-31.6 RDW-18.3* Plt Ct-267 [2194-12-25] 02:18AM BLOOD WBC-12.9* RBC-5.16 Hgb-13.4* Hct-41.7 MCV-81* MCH-25.9* MCHC-32.1 RDW-18.2* Plt Ct-260 [2194-12-25] 02:18AM BLOOD PT-13.7* PTT-24.8 INR(PT)-1.2* [2194-12-25] 02:18AM BLOOD Plt Ct-260 [2194-12-25] 02:18AM BLOOD Glucose-135* UreaN-21* Creat-0.9 Na-136 K-3.8 Cl-101 HCO3-26 AnGap-13 [2194-12-24] 03:56AM BLOOD ALT-25 AST-30 AlkPhos-79 TotBili-0.6 [2194-12-20] 01:02AM BLOOD CK-MB-3 cTropnT-<0.01 [2194-12-19] 08:59AM BLOOD cTropnT-0.01 [2194-12-25] 02:18AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1 [2194-12-20] 01:02AM BLOOD %HbA1c-5.7 [2194-12-20] 01:02AM BLOOD Triglyc-104 HDL-25 CHOL/HD-5.4 LDLcalc-90 [2194-12-20] 01:02AM BLOOD Osmolal-292 [2194-12-23] 05:12AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.020 Imaging: CXR [2194-12-24]: Mild edema at the base of the left lung has worsened. More severe consolidation in the right lower lung has also progressed and could be either asymmetric edema or edema and new aspiration or developing pneumonia. Heart size top normal, is unchanged and mediastinal vascular caliber is upper limits of normal. Nasogastric tube passes as far as the distal esophagus but the tip is indistinct. No pneumothorax. CXR [2195-11-22]: Exam is technically limited by respiratory motion artifact. Cardiac silhouette appears enlarged but pulmonary vascularity is within normal limits for technique. The lungs are grossly clear except for an apparent right retrocardiac opacity which could be due to either atelectasis or infectious pneumonia. Standard PA and lateral chest radiograph would be helpful to more fully evaluate this region when the patient's condition allows. Ct head [2194-12-20]: The left thalamic hemorrhage is again noted and allowing for expected evolution, not significantly changed from prior. The hyperdense focus measures 2.7 x 2.3 cm compared to 3.2 x 2.0 cm, previously. There is a similar amount of surrounding vasogenic edema. There is persistent mass effect on the posterior [Doctor Last Name 534] of the left lateral ventricle but no evidence of ventriculomegaly. There is unchanged hyperdense material in the left lateral ventricle. Small amount of hyperdense material in the right ventricle is also unchanged. There is no shift of the normally midline structures. The basilar cisterns are preserved. There is no new hemorrhage or acute major vascular territory infarction. The visualized paranasal sinuses and mastoid air cells are well aerated. No osseous abnormality is identified. IMPRESSION: No significant change in the left thalamic parenchymal hemorrhage with intraventricular extension. No new intracranial hemorrhage or other acute abnormality. CT head [2194-12-19]: 1. 3.2 x 2 cm left thalamic parenchymal hemorrhage with extension into the left lateral ventricle, unchanged from the exam four hours earlier. No herniation or midline shift. 2. No other areas of acute abnormality. EKG: [2194-12-19] Atrial fibrillation with slow ventricular response. Low limb lead voltage. ST segment depressions in leads V2-V3 suggest possible anterior myocardial ischemia. Compared to the previous tracing of [2184-4-14] normal sinus rhythm has been replaced by atrial fibrillation and the anterior ST segment abnormalities are new. Clinical correlation is suggested Brief Hospital Course: 70 year old man with a h/o HTN, AF on Coumadin presents with an acute onset of right sided numbness, weakness and speech difficulty. Initially taken to [Hospital3 ] where a head CT revealed a lateral left thalamic bleed without any ventricular spillage; INR was 1.9. Speech deteriorated since arrival at the [Hospital1 ] ED and had marked difficulty speaking out even simple words and appears frustrated. His speech is dysarthric with severe anomia, and some difficulties with repetition. Follows complex commands. Right facial weakness. Dense right sided HP with hemisensory loss. A Repeat head CT showed increase in size of Hge with lateral extension into the parietal white matter and ventricular cavity. Received FFP, vitamin K and Proplex. He was admitted to the neuro-icu for close monitoring and BP control. As he a reported heavy alcohol user, he was started on a CIWA scale. The patient was initially full code. His language began to improve some the following morning, was slightly more fluent and had some improved naming. His course was complicated by etoh withdrawal, and he would become tachycardic, diaphoretic and very agitated requiring him to receive diazepam according to a withdrawal activity scale. He continue to improve to the point he was able to transfer out of the ICU on [2194-12-22]. He had failed speech and swallow eval and was receiving medications an feeds through [First Name8 (NamePattern2) ] [Last Name (un) ]-gastric tube. On the floor the patient continued to withdraw and there was difficulty controlling his blood pressure. In addition he likely had an aspiration event, and began to have difficulty maintaining his oxygen saturation and became very tachypneic, requiring him to be placed back into the ICU. A follow up xray confirmed a worsening pneumonia. He was started on broad spectrum antibiotics (ciprofloxacin, cefepime, and vancomycin). A family meeting was held about the patient's desires about intubation. We informed the family that he may require intubation, and could be a temporizing measure to help overcome the pneumonia. The family, after much internal discussion, believes that the patient's would not want to be intubated no matter the circumstance. They agreed to continue with current care, i.e. antibiotics and fluids, and to see if the patient's respiratory status improved. Over the course of two days the patient did have a somewhat significant improvement in respiratory status. He was transferred out of the ICU but continued to have difficulty with blood pressure control. He was on clonidine patch, diltiazem, hydralazine, HCTZ, and lisinopril and still required additional PRN medications. Because of his recalcitrant hypertension, he underwent a renal ultrasound to assess for secondary causes of hypertension. Results of this study are currently pending. He also underwent repeat CT head on [2194-12-29] due to worsening dysarthria and inattentiveness which was essentially unchanged from his prior study [2194-12-20]. Another family meeting was held [2194-12-29] and after discussion, the family had wished to stop continued aggressive care including antibiotics and blood pressure control as they believed it would not be consistent with his wishes to continue care given his diagnosis and prognosis. Therefore, he was made comfort-measures only following the meeting and will be discharged on ativan, morphine, tylenol PR, and scopolamine patch PRN for comfort care. Medications on Admission: - warfarin 10 mg po daily - lisinopril 10 mg po daily - diltiazem 240 mg po daily - atenolol 25 mg po bid - simvastatin 40 mg po daily (last filled [2194-6-28]), lovastatin 40 mg po qhs (last filled [2194-10-20]) - spiriva 1 cap inh daily - proair 2 puffs inh qid - diazepam 2 mg po tid - levitra 20 mg po daily prn Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety: sublingual tablets please. PRN for anxiety. Disp:60 Tablet(s) Refills:2 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain. Disp:30 Suppository(s) Refills:0 3. Morphine Concentrate 20 mg/mL Solution Sig: 0.25 mL PO Q4H (every 4 hours) as needed for pain: may titrate upward as needed for comfort. Disp:30 mL Refills:0 4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours as needed for secretions. Disp:10 patches Refills:0 Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: left thalamic hemmorhage aspiration pneumonia alcohol withdrawl Discharge Condition: Awake, alert, follows some basic commands. R facial droop. Dysarthric. RUE plegia, RLE triple flexion. Antigravity in LUE, LLE. Upgoing toe on R. Discharge Instructions: You were found to have a hemorrhage in your brain (left thalamus) at the time of admission. Your hospital course was complicated by alcohol withdrawl, aspiration pneumonia, and persistent hypertension despite multiple antihypertensive agents. After a meeting with your family, it was decided that you would not want to continue aggressive care given your diagnosis and prognosis. It was decided that comfort-measures only care would be most consistent with your wishes. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 162], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2195-1-23] 10:00 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "5070", "51881", "42731", "3051", "4019", "2724", "V5861", "496" ]
Admission Date: [2118-1-19] Discharge Date: [2118-1-29] Date of Birth: [2043-7-18] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[First Name3 (LF) 165] Chief Complaint: increased SOB Major Surgical or Invasive Procedure: [2118-1-21] redo sternotomy AVR ( [Street Address(2) 17009]. [Male First Name (un) 923] mechanical) cardiac cath [2118-1-19] History of Present Illness: 74 year old man with history of CAD status post CABG in [2111] (LIMA to Diagonal, SVG to OM2, SVG to RCA), with a cardiac catheterization in [2115] that revealed three vessel disease, but all grafts were patent. Mild aortic stenosis was noted in [2115] (mean gradient 32 mmHg and valve area 1.1 cm2). Drug eluting stents were placed into the lower pole of OM2 and the proximal LAD. In addition, patient has a history of atrial fibrillation and COPD. On [2118-1-14], he presented to [Hospital1 ] [Location (un) 620] with chest tightness and shortness of breath, with rapid ventricular rate of 126, following several day course of antibiotics prescribed by his PCP. [Name10 (NameIs) ] was converted to normal sinus rate with IV diltiazem and he received IV lasix for diuresis. A TEE was performed on [2118-1-18] that revealed an EF of 65%, worsened AS (0.7cm2), 1+AR, 1-2MR. Patient was transferred for cardiac catheterization on [1-19]. Results demonstrated severe 3 vessel disease, with patent stents to proximal LAD and OM2 and patent graft of SVG to RCA and OM2, and the LIMA to D1 was patent. Severe AS was noted. Patient awaiting AVR. Past Medical History: PMH: 1. CAD, s/p cath and CABG as above, recent TTE showing EF=60-65% 2. AS, AV area 1.1 cm2 3. Carotid stenois, occlusive [Country ], <40% [Doctor First Name 3098] [2111] 4. Gout x 40 yrs 5. Hyperlipidemia 6. HTN 7. COPD, recent flare [10-20] 8. ILD 9. Prostate ca 8 yrs ago, s/p prostatectomy Social History: Lives with wife, quit smoking 25 yrs ago (smoked 1.5 ppd), no Etoh, retired roofer Family History: Mother died age 72 CAD Father died age 63 CAD Physical Exam: T:98.4 BP:150/68 HR:60 RR:18 O2saturation:94% on room air Gen: Pleasant, well appearing. Elderly man laying in bed. HEENT: Slight conjunctival pallor. No icterus. Slightly dry mucous membranes. Oropharynx clear. NECK: Supple. No cervical or supraclavicular lymphadenopathy. No JVD. No thyromegaly. Did not appreciate any carotid bruits. CV: Irregularly irregular rate. Normal S1 and S2. Systolic [4-22] ejection murmur in upper right sternal border. No rubs or [Last Name (un) 549] appreciated. LUNGS: On anterior examination, diffuse inspiratory wheezes noted. Did not auscultate posterior chest. ABD: Infrapubic surgical scar. Distended abdomen. Normal active bowel sounds in all four quadrants. Soft. Nontender and nondistended. No guarding or rebound. Liver edge not palpated. No splenomegaly appreciated. No abdominal aortic bruit. EXT: Warm and well perfused in upper extremities, but feet cool. No clubbing or cyanosis. No lower extremity edema, bilaterally. 2+ radial pulses, bilaterally, but DP 1+ bilaterally. SKIN: No rashes, ulcers, petechiae, or pigmented lesions. No ecchymoses. No xerosis. NEURO: Alert and oriented to person, place, date. Affect appropriate. Cranial nerves II-XII grossly intact. Pertinent Results: [2118-1-29] 05:25AM BLOOD WBC-10.8 RBC-2.72* Hgb-8.6* Hct-25.2* MCV-92 MCH-31.8 MCHC-34.4 RDW-15.3 Plt Ct-186 [2118-1-29] 05:25AM BLOOD PT-21.4* PTT-35.4* INR(PT)-2.1* [2118-1-29] 05:25AM BLOOD Glucose-91 UreaN-36* Creat-1.6* Na-138 K-4.3 Cl-105 HCO3-25 AnGap-12 [2118-1-19] 04:50PM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE [2118-1-19] 04:50PM BLOOD Triglyc-153* HDL-72 CHOL/HD-2.5 LDLcalc-79 [2118-1-19] 04:50PM BLOOD Glucose-144* UreaN-46* Creat-1.6* Na-139 K-5.6* Cl-103 HCO3-28 AnGap-14 [2118-1-19] 04:50PM BLOOD WBC-15.7# RBC-3.90 Hgb-12.2* Hct-36.1* MCV-93# MCH-31.4 MCHC-33.9 RDW-15.0 Plt Ct-177 [2118-1-19] Cardiac Cath: Selective coronary angiography of this right dominant system revealed mult-vessel native disease. The LMCA had no flow limiting lesions. The LAD had a patent stent with competitive flow from the D1. The LCX had a patent stent in the lower pole of OM2. The RCA was distally occluded. Graft angiography revealed patent SVG-OM, SVG-PDA, and SVG-LIMA. The aortic valve had a mean gradient of 55mmHg and a calculated [Location (un) 109] of 0.64 cm2. Mean PCPW was elevated at 20mmHg and cardiac index was low normal at 2.4 l/min/m2. Brief Hospital Course: Preoperatively Mr. [Known lastname ] was seen by pulmonary medicine for his COPD, with recommendations to start standing Atrovent, and continue Prednisone therapy. Preoperative chest CT scan showed severe cystic bronchiectasis involving all lobes of both lungs, with associated air-fluid levels, scattered areas of bronchial mucoid impaction, and minimal peribronchiolar inflammation. There were however no contraindications to surgery. He was taken to the operating room on [2118-1-21] where Dr. [First Name (STitle) ] performed a redo sternotomy, and a mechanical aortic valve replacement. For surgical details, please see seperate dictated operative note. He was transferred to the CSRU in critical but stable condition. Within 24 hours, he awoke neurologiclly intact and was extubated on POD #1 without incident. He was seen by nephrology for oliguria and acute renal insufficiency with likely diagnosis ATN(acute tubular necrosis)secondary to hypotension and bypass, with recomendations for volume and avoiding diuresis. A decrease in platelet count prompted a HIT screen which was positive. He was subsequently started on Argatroban, and eventually Warfarin once his platelet count was > 100. While in the CSRU, he also experienced episodes of paroxsymal atrial fibrillation which was initially treated with Amiodarone and beta blockade. Given his severe COPD, Amiodarone was discontinued while beta blockade was continued for rate control. Despite advancement in beta blockade, he continued to experience PAF. He otherwise remained stable from a cardiac and pulmonary standpoint and transferred to the SDU for further care and recovery. He gradually became therapeutic on Warfarin and Argatroban was eventually discontinued. His renal function continued to improve and returned to baseline prior to discharge. He worked daily with physical therapy and continued to make clinical improvements with gentle diuresis. He was eventually cleared for discharge on POD 8. Prior to discharge, arrangements were made to follow up with primary care physician/cardiologist regarding outpatient Warfarin monitoring. Given his PAF and mechanical AVR, his goal INR should be between 2.5 - 3.0. Medications on Admission: Norvasc 5 Singulair 10 Lasix 20 Crestor 30 Bisoprolol 5 ASA Advair 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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:QS Disk with Device(s) Refills:0 5. Rosuvastatin 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. 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 11. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) Inhalation PRN. Disp:QS 1 month Refills:0 12. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:225 Tablet(s) Refills:0 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks: 40 [Hospital1 ] x 1 week, then 20 daily as prior to surgery. Disp:60 Tablet(s) Refills:0 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 1 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 15. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: s/p redo sternotomy/ AVR [2118-1-21] Heparin induced thrombocytopenia Post op AFib Postop renal insufficiency COPD/interstitial lung dz. HTN prostate CA/[Doctor First Name ]. elev. lipids gout CRI AS s/p cabg [2111] CAD with PCI/DE stent OM2 [11-20] DE stent LAD [2115] Discharge Condition: Good. Discharge Instructions: may shower over incisions and pat dry no lotions, creams or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 101, redness or drainage Followup Instructions: see Dr. [Last Name (STitle) 32208] in [1-18] weeks see Dr. [Last Name (STitle) 121] in [2-19] weeks see Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Provider: [Name10 (NameIs) ],[Name11 (NameIs) 7721] [Name11 (NameIs) ] LMOB (NHB) Date/Time:[2118-11-21] 2:00 Provider: [Name10 (NameIs) 1111],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2118-11-21] 2:30 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2118-2-9]	[ "4280", "4241", "42731", "5845", "40390", "41401", "V4581", "V4582", "V5861" ]
Admission Date: [2190-11-2] Discharge Date: [2190-11-21] Service: MEDICINE Allergies: Iodine-Iodine Containing Attending:[First Name3 (LF) 30] Chief Complaint: Right lower extremity wound dehiscence Major Surgical or Invasive Procedure: [2190-11-4] Right lower extremity gastrocnemius flap reconstruction [2190-11-8] Exploratory laparotomy with left hemicolectomy and splenorrhaphy with transverse end-colostomy and Hartmann's pouch, for ischemic colon History of Present Illness: On admission ([2190-11-2], by Plastic Surgery): Mrs. [Known lastname ] is an 88 year old woman with history of right femur/tibial plateau fracture ([2173]) complicated by multiple revisions/repairs, most recently with right total knee arthroplasty on [9-27], complicated by wound dehiscence, who was now admitted for right knee gastroc muscle flap reconstruction. On transfer to medicine ([2190-11-18]), 88F with HTN, hyperlipidemia, and hypothyroidism, s/p TKR [2190-9-27], who was initially admitted on [2190-11-2] for non-healing right knee wound. She underwent gastrocnemius flap reconstruction, with split-thickness skin graft [2190-11-4]. Her post-operative course was complicated by septic shock (thought initially to be from C.diff given high WBC and daughter with h/o recent c.diff) from necrotic splenic flexure, for which she underwent resection of the splenic flexure with colostomy on [2190-11-8]. This was complicated by splenic laceration which was repaired intraoperatively. Given sepsis, patient was started on flagyl/vanc/cefe/cipro which were peeled off on [11-12] (cefepime d/c'd [11-8]). The patient had return of bowel function on [11-13], at which point her diet was advanced. She had persistent leukocytosis, which was investigated with CT abdomen/pelvis on [11-15]. This showed no evidence of intraabdominal abscess. U/A showed WBC 8, with negative nitrates. Of note, the CT abdomen/pelvis also showed ascites and anasarca. Currently, the patient is tachypneic to about 30 but not dyspneic, O2 sat 95%/RA. Exam notable for bronchial breath sounds at left base and trace bilateral LE edema. CXR shows large left pleural effusion with smaller right pleural effusion and patient is complaining of persistent cough. . Upon transfer, vitals were 97.3, 139/60, 88, 22, 95%RA. Looking comfortable, breathing slightly fast but denies any dyspnea. States knee pain is well controlled. Bothered only by persistent cough. Denies recent fevers, chills, abdominal pain, changes in bowel movements, subjective dyspnea. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Hypertension - Hyperlipidemia - Hypothyroidism - Thyroid nodules - Glaucoma - History of bilateral femur fracture and pelvic fracture after motor vehicle collision ([2173]) Social History: She is a retired secretary and does not currently smoke or drink. Family History: Non-contributory Physical Exam: Discharge Exam: 96.8, 115/47, 82, 18, 98%RA GA: AOx3, elderly woman resting comfortably in bed in NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: bronchial breath sounds bilaterally, worse at left base. No wheezes or rales. somewhat increased rate of breathing, good resp effort Abd: with pink healthy looking ostomy in LLQ, and large linear stapled scar down midline abdomen, soft, NT, ND, +BS. no g/rt. neg HSM. GU: foley in place, minimal dark urine Extremities: wwp, 1+ edema bilaterally. PTs 2+. Neuro/Psych: CNs II-XII grossly intact. sensation intact to LT in toes bilaterally, though decreased on the right Pertinent Results: Admission Labs: [2190-11-2] 04:10PM BLOOD WBC-9.7 RBC-3.71* Hgb-11.0* Hct-33.4* MCV-90 MCH-29.5 MCHC-32.8 RDW-16.2* Plt Ct-395 [2190-11-2] 04:10PM BLOOD PT-10.4 PTT-30.2 INR(PT)-1.0 [2190-11-2] 04:10PM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-131* K-4.6 Cl-95* HCO3-29 AnGap-12 [2190-11-2] 04:10PM BLOOD Albumin-4.1 Calcium-9.1 Phos-4.1 Mg-2.0 Iron-44 [2190-11-2] 04:10PM BLOOD calTIBC-311 Ferritn-452* TRF-239 Labs on [11-8] (day of abdominal surgery): [2190-11-8] 04:23AM BLOOD WBC-19.0* RBC-3.47* Hgb-10.2* Hct-31.0* MCV-89 MCH-29.4 MCHC-32.9 RDW-15.5 Plt Ct-365 [2190-11-8] 04:23AM BLOOD Neuts-77* Bands-3 Lymphs-8* Monos-12* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2190-11-8] 05:12PM BLOOD PT-13.9* PTT-50.2* INR(PT)-1.3* [2190-11-8] 09:46AM BLOOD Glucose-135* UreaN-36* Creat-1.9* Na-130* K-5.8* Cl-98 HCO3-15* AnGap-23* [2190-11-8] 04:23AM BLOOD Calcium-9.9 Phos-6.1* Mg-3.9* [2190-11-8] 01:43PM BLOOD Type-ART pO2-264* pCO2-32* pH-7.42 calTCO2-21 Base XS--2 Intubat-INTUBATED [2190-11-8] 04:39AM BLOOD Lactate-4.0* [2190-11-8] 01:43PM BLOOD Glucose-126* Lactate-3.2* Na-128* K-4.2 Cl-101 [2190-11-8] 03:30PM BLOOD Glucose-109* Lactate-2.5* Na-129* [2190-11-8] 04:37PM BLOOD Glucose-118* Lactate-2.6* Na-129* [2190-11-8] 08:29PM BLOOD Lactate-3.2* [2190-11-8] 01:43PM BLOOD Hgb-8.0* calcHCT-24 [2190-11-8] 03:30PM BLOOD freeCa-1.09* Thoracentesis: [2190-11-18] 10:16PM PLEURAL WBC-3100* RBC-5250* Polys-76* Lymphs-2* Monos-0 Macro-22* [2190-11-18] 10:16PM PLEURAL TotProt-2.0 Glucose-127 LD(LDH)-312 Amylase-60 Cholest-38 Discharge Labs: [2190-11-21] 05:50AM BLOOD WBC-15.3* RBC-3.07* Hgb-8.4* Hct-27.2* MCV-89 MCH-27.5 MCHC-31.1 RDW-15.7* Plt Ct-680* [2190-11-21] 05:50AM BLOOD Glucose-84 UreaN-12 Creat-0.5 Na-130* K-4.5 Cl-95* HCO3-30 AnGap-10 [2190-11-19] 05:03AM BLOOD ALT-7 AST-18 LD(LDH)-189 AlkPhos-45 TotBili-0.3 [2190-11-21] 05:50AM BLOOD Calcium-7.4* Phos-2.7 Mg-2.3 Microbiology: [2190-11-18] blood cultures pending. previous blood, urine, c.diff cultures negative. Imagaing: [2190-11-7] ECG: rate 88, Sinus rhythm. Delayed precordial R wave transition as recorded on [2190-11-12] without diagnostic interim change. [2190-11-7] CXR: Given the decrease in lung volumes, bibasilar opacification is more likely atelectasis than pneumonia. Upper lungs are clear. Pleural effusion is minimal if any. Heart size normal. [2190-11-8] CXR: One supine portable AP view of the chest. Low lung volumes. The left lower lobe opacity likely represents atelectasis. There is a small left pleural effusion, if any. No opacities concerning for pneumonia. Heart size is difficult to evaluate, but likely normal. Mediastinal and hilar contours are normal. No pneumothorax. [2190-11-9] ECHO (prelim): Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). A mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. No mitral regurgitation is seen. No aortic stenosis or regurgitation. IMPRESSION: Suboptimal image quality. Preserved biventricular function. [2190-11-9] CXR: The ET tube sits 5 cm above the carina. The endogastric tube side port tip sits well below the GE junction. A right IJ central line tip sits in the lower SVC. The heart size is within normal limits. The mediastinal contours demonstrate calcified atherosclerotic disease of the aortic knob. There is a small to moderate left pleural effusion with associated atelectasis. There is no pneumothorax. Severe degenerative changes are seen in the left glenohumeral joint. IMPRESSION: 1. Lines and tubes in place. 2. Small to moderate left pleural effusion with associated atelectasis. [2190-11-11] CXR: 1. Left pleural effusion appears unchanged and right pleural effusion is likely increased. Assessment is slightly limited due to different positioning of patient. 2. Mild pulmonary vascular congestion. [2190-11-11] LENI: No evidence for DVT. [2190-11-12] KUB: Air filled dilated loops of large and small bowel are most consistent with an ileus. [2190-11-15] CT abd: 1. Splenorrhaphy, with mild perisplenic hemorrhage and Surgicel packing. 2. Small pleural effusions, mild ascites, and anasarca. No evidence of intra-abdominal abscess, within limitations of a non-contrast study. 3. Left colectomy and transverse colostomy, without complications. [2190-11-16] There has been interval removal of the right IJ central venous catheter tip. The heart size is large. The mediastinal and hilar contours are unchanged. There is a moderate left pleural effusion with underlying atelectasis. Mild right basal atelectasis with a small pleural effusion is also present. IMPRESSION: Bilateral pleural effusions, left greater than right, with associated atelectasis. [2190-11-18] CXR: Assessment of the heart size is limited by the large left and small right pleural effusions with associated atelectasis; an additional component of pneumonia, particularly on the left cannot be excluded. Within that limitation, the heart size likely continues to be enlarged. There is no fluid overload. There is no pneumothorax. [2190-11-18] Comparison is made with prior study performed the same day earlier. Moderate left pleural effusion has markedly decreased. Adjacent atelectases have decreased. There is a new left basal pigtail catheter. There is no evident pneumothorax. mild-to-moderate right pleural effusion with adjacent atelectasis, is unchanged. Cardiomediastinal contours are partially obscured by pleuroparenchymal abnormalities. . Brief Hospital Course: Hopsital course: Patient admitted to plastic surgery service [11-2] in anticipation of gastrocnemius flap to RLE chronic wound dehiscence. Preoperative workup completed 12/6-7 uneventfull and patient taken to OR for flap procedure [11-4]. Tolerated procedure well and was transferred to CC6 for further management. Recovery proceeded uneventfully until [11-7] when patient demonstrated altered mental status, nausea, vomiting and increasing abdominal distention. Transferred to MICU [11-8] for these symptoms and surgery consult obtained for concern of altered mental status and worsening abdominal distention (See ACS Consult note for further details). Patient taken to OR by ACS for colonoscopy with assistance of GI given concern for sigmoid/cecal volvulus. Colonoscopy failed to demonstrate volvulus and exploratory laparotomy was undertaken which revealed necrotic splenic flexure. Left colectomy was performed with mid transverse colon ostomy and long Hartmann's pouch. Patient tolerated procedure well and was brought to TSICU for further management under ACS service. Post-operatively, the patient was brought to the TSICU intubated/sedated. Patient extubated successfully [11-9] and IV pain regimen initiated prn. This was carried out with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. She was then transfered to the floor on [11-11]. She had urinary retention issues and a foley was placed which stayed in throughout hospital course as she failed 2 voiding trials. She was given methylnatrexone x1 and was started on a regular diet. However, she had some emesis and a KUB showed ileus. She began to produce stool in her ostomy on [11-13] and her diet was advanced to regular which she tolerated well. Her WBC began to rise so a CT abd/pelvis was performed to r/o abscess and no intra-abdominal abscesses were identified. She had a chest x-ray on [11-16] which showed bilateral pleural effusions. She continued to have a cough and medicine was consulted to evaluate. Thoracentesis was performed and 1.5 liters of exudative fluid was drained (LDH 312, WBC 3100). Pigtail catheter was placed which drained minimal serosangeous fluid. This was thought to be related to the abdominal surgery and resultant inflammation of the LUQ. Her WBC dropped from 20.8 to 14.5 with the thoracentesis. Patient remains feeling well without and is without fevers off all antibiotics. . Pulmonary: Pulmonary toilet including incentive spirometry and early ambulation were encouraged. The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. CXR on [2190-11-16] showed bilateral pleural effusions L>R. She continued to have a cough and will be transferred to the medicine service for further evaluation and management. Thoracentesis was performed and 1.5L transudative fluid was drained, effectively resolving her cough. WBC dropped from 20.8 to 14.5 with the procedure. Patient remained tachypneic, and given her vascular congestion on xray, she was administered lasix with good urinary output. No antibiotics were administered, as there was no clear infection to be treated (afebrile, feeling well off antibiotics). Pleural fluid studies were consistent with effusion secondary to adrenergic state likley [12-30] splenic flexure infarct and splenic laceration. Rpt chest X-ray showed improving pleural effusion s/p thoracentesis and her lung exam continued to improve until the day of discharge. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced to sips [11-10] and regular diet [11-11]. Patient demonstrated some nausea w emesis 12/15PM and was made NPO. Advanced from sips to clears [11-13] which was tolerated well. Given methylnaltrexone [11-12]. Had gas and stool in ostomy [11-13]. She was also started on a bowel regimen to encourage bowel movement. She was started on a regular diet on [11-13] which she continued to tolerate well. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cephalexin on POD#2. The patient's temperature was closely watched for signs of infection. Her WBC began to slowly uptrend, for which a clear source was not identified. She was given roughly 4 days of cipro/flagyl/vanc/cefepime, all of which were discontinued around [11-12]. U/A blood, urine, and c.diff was negative, her graft site did not appear infected, CT ab/pelvis on [2190-11-15] was negative for any intra-abdominal abscess, and CXR was signficant only for bilateral pleural effusions L>R. No antibiotics were administered as patient did not have a clear source of infection. All culture data was negative, she continued to be afebrile and VS were stable. Her WBC was fluctuating and also with a reactive thrombocytosis. Given no objective signs of infection antibiotics were never started. . # Reactive thrombocytosis: likely in relation to inflammatory state from necrotic bowel, recent operations and pleural effusions irritating the pleural lining. This will need to be trended with repeat CBC within 1 week. . # Hyponatremia: Patient admitted with Na+ 129, corrected to 139, now 129. Thought to be SIADH vs. hypervolemic hyponatremia as patient appears somewhat overloaded on exam (1+edema with ascites and large pleural effusion). Serum osm is low (262), however urine lytes suggested patient was prerenal. Given IV lasix for fluid overload and sodium initially trended up to 130, but then decreased to 126. There was likely a combine picture. Lasix were stopped and the patient equilibrated to 130 at time of discharge. She will need repeat lab work within 1 week to re-evaluate Na levels. . # Urinary Retention: Patient failed trial of voiding twice while inpatient. Urology was consulted and they felt that given recent operations and shock likel state it may take some time for her bladder to regain function. She will be discharged with her Foley in place and follow up with urology within 1-2 weeks for another trial of voiding. . #. [Last Name (un) ]- Patient had transient [Last Name (un) ] to 1.9 on [11-8], when she was septic and necrosing her bowel. Creatinine improved with fluids and was likely prerenal in etiology given her septic physiology. . # Anemia: remained at basline over admission (28-31). No signs of bleeding. Iron borderline low and ferritin high, MCV normal (89). Possibly anemia of chronic disease. Hct trended. . #. HTN: continued HCTZ, lisinopril, diltiazem, ASA . #. HL: continued atorvastatin, ASA . #. Hypothyroidism: continued levothyroxine . #. Glaucoma: continued latanoprost, dorzolamide . Transitional Issues: - At the time of discharge on POD 15, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, with foley in place, and pain well controlled. Patient failed 2 voiding trials, and is being discharged home with foley in place. She will have oruology follow up within 1-2weeks of discharge for voiding trial. - Will also need stitches removed on [2190-11-26] - will need repeat CBC and chem-7 in 1 week to evaluate leukocytosis, reactive thrombocytosis and sodium level Medications on Admission: -alendronate 70 mg by mouth weekly -atorvastatin 10 mg by mouth once a day -cephalexin 500 mg by mouth four times a day take with food -diltiazem HCl 90 mg Extended Release by mouth once a day -hydrocodone-acetaminophen 5 mg-500 mg by mouth at night as needed for pain -latanoprost eye drops -levothyroxine 75 mcg by mouth once a day -aspirin 81 mg by mouth once a day -B complex vitamins daily -calcium/vitamin D3 by mouth twice a day -cholecalciferol 1,000 unit by mouth once a day -hydrochlorothiazide 50 mg by mouth once a day -multivitamin by mouth once a day Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. diltiazem HCl 90 mg Capsule,Extended Release 12 hr Sig: One (1) Capsule,Extended Release 12 hr PO once a day. 3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Vitamin B Complex Tablet Sig: One (1) Tablet PO once a day. 7. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 9. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once a day. 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every four (4) hours as needed for pain: Hold for RR<12, Sedation. 16. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Extended Care Facility: [Hospital1 100] Senior Life [Location (un) 2312] Discharge Diagnosis: Primary Diagnosis: - Right TKR would dehiscence - Infarcted large bowel at splenic flexure - Partially infarcted spleen - Right sympathetic pleural effusion - Urinary retention - Anemia of chronic disease - Reactive leukocytosis - Hyponatremia Surgical Procedures: - Right lower extremity gastrocnemius flap reconstruction - Exploratory laparotomy with left hemicolectomy and splenorrhaphy with transverse end-colostomy and Hartmann's pouch - Right thoracentesis and pig-tail catheter placement Secondary Dignosis: - bilateral femur fracture s/p periprosthetic femur fracture Secondary diagnosis: - Traumatic pelvic and bilateral femur fractures - Osteoporosis - Hypothyroidism - Hyperlipidemia - Hypertension - Hypothyroidism - Glaucoma Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you at [Hospital1 827]. You were initially admitted for a nonhealing wound for which you had a skin flap reconstruction. This healed well, however you developed poor perfusion to your bowel and had to have a colon resection with a colostomy (Hartmann's pouch). Part of your spleen was additionally resected. You remained in the hospital for some time as you had an elevated white blood count (usually a sign of infection) and fluid around your lungs that was making you breathe faster than normal. The fluid was drained from around your left lung and your white blood count began to return to normal and your breathing improved. You are safe for discharge to [Hospital ] rehab for further care.. . The following medications were started: Docusate 100mg by mouth twice a day senna 1 tab by mouth twice a day tylenol 650mg by mouth three times a day tamsulosin 0.4mg by mouth at bedtime trazadone 25mg by mouth as needed for sleep. Followup Instructions: Please call the number below to schedule an appt with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1022] in 2 weeks. [Hospital1 18] Division of Plastic Surgery [Hospital Unit Name 11610] [Location (un) 86], [Numeric Identifier 11611] Phone: [Telephone/Fax (1) 4652] Fax: [Telephone/Fax (1) 11612] . Please call the number below to schedule an appt with Dr. [Last Name (STitle) ] in 2 weeks. [Hospital Unit Name 11613] [Location (un) 86], [Numeric Identifier 718] Phone: [Telephone/Fax (1) 6429] Fax: [Telephone/Fax (1) 11614] . Urology appointment:NEEDED Please arrange new physician appointment with the Urology Department @ [Hospital1 69] within 2 weeks from your discharge from the hospital Phone: [Telephone/Fax (1) 164] . Please call your Primary Care Doctor - Dr. [Last Name (STitle) 5482] at [Telephone/Fax (1) 5483] to schedule an appt when you are discharged from [Hospital 100] Rehab.	[ "0389", "99592", "78552", "5119", "2761", "5849", "2762", "2449", "2724", "4019" ]
Admission Date: [2107-9-23] Discharge Date: [2107-9-24] Date of Birth: [2033-4-27] Sex: F Service: MEDICINE Allergies: Risperdal / Ace Inhibitors Attending:[First Name3 (LF) 2297] Chief Complaint: Urosepsis Major Surgical or Invasive Procedure: none History of Present Illness: 74 y/o female with history of schizophrenia, dementia, HTN, DM, recent T12 fracture in [Month (only) 205] s/p vertebroplasty, recently admitted in [Month (only) 216] for sepsis, source unknown: ? hardware vs. PNA in last discharge summary. Initially thought to be surgically related, CT of the back revealed no evidence for infection (MRI contraindicated given hardware). There was ? of LLL PNA as source although similarly imaging did not really support this. The patient was treated with Vanc and Ceftaz and D/C with the same. (known MRSA). . Patient now presents from NH with temp to 100.8, hypotension, SBP in 80s, WBC 16, Hct 24 from baseline near 29 on [2107-8-29] with +++ UA. Patient has known chronic GI bleeding for which workup has previously been refused, and was only trace guaiac positive here. Benign abdomen on exam. Likely with urosepsis, currently fluid responsive. . Patient was with HR in 80s and then suddenly noted to be with HR 130 without clear precipitant, SBP improved to 120s. Review of last D/C summ reveals patient was noted previously to have intermittent bursts of what appeared to be sinus tach with rates 130s to 150s, although ? raised if this was atrial tach. Patient D/C with lopressor 75mg PO bid. Given improved BP, given 50mg Po x 1 this p.m. . Given persistent tachycardia & tachypnea, admitted to MICU Past Medical History: Dementia, schizophrenia, history of GI bleed for which she declined work-up, gastroesophageal reflux disease, COPD, hypertension, diabetes mellitus, osteoarthritis, neuropathy, urinary incontinence, recent T12 burst fracture complicated by bilateral lower extremity paresis, status post T12 vertebrectomy and T11-L1 fusion by Dr. [Last Name (STitle) 363]. Her OR course at that time was complicated by a lung collapse requiring a chest tube placement, spinal, status post PEG placement in [2107-7-9]. Social History: Longstanding mental illness, presently living in nursing home Family History: Has siblings with schizophrenia, otherwise noncontributory Physical Exam: Temp 98.4 BP 130/45 HR 111 Sat O2: 99% RA Gen: sedate arousable A+O x 2 HEENT: dry MM CV: RRR no m/r/g Lungs: cta bilat no w/r/r/ abd: soft nt nd +gtube extrem: bilat multipodus boots, with ulcers back: pressure ulcer stage 2 at coccyx Pertinent Results: [2107-9-22] 06:00PM BLOOD WBC-16.4# RBC-2.65 Hgb-7.8* Hct-23.7* MCV-90 MCH-29.5 MCHC-33.0 RDW-17.5* Plt Ct-569* [2107-9-23] 04:30AM BLOOD WBC-13.4* RBC-2.65* Hgb-8.1* Hct-23.1* MCV-87 MCH-30.4 MCHC-34.9 RDW-17.1* Plt Ct-432 [2107-9-22] 06:00PM BLOOD Plt Ct-569* [2107-9-23] 04:30AM BLOOD PT-13.1 PTT-23.9 INR(PT)-1.1 [2107-9-23] 04:30AM BLOOD Glucose-106* UreaN-21* Creat-0.5 Na-143 K-4.1 Cl-112* HCO3-22 AnGap-13 [2107-9-22] 06:00PM BLOOD Glucose-118* UreaN-26* Creat-0.6 Na-142 K-4.2 Cl-108 HCO3-27 AnGap-11 [2107-9-23] 04:30AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.3 [2107-9-22] 09:15PM BLOOD Type-[Last Name (un) ] pO2-36* pCO2-41 pH-7.43 calTCO2-28 Base XS-2 [2107-9-22] 10:40PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2107-9-22] 10:40PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [2107-9-22] 10:40PM URINE RBC-21-50* WBC->50 Bacteri-MOD Yeast-OCC Epi-0-2 [2107-9-22] 06:00PM URINE CaOxalX-RARE [2107-9-22] 06:00PM URINE Mucous-MOD [2107-9-22] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING EMERGENCY [Hospital1 ] [2107-9-22] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING EMERGENCY [Hospital1 ] [2107-9-22] URINE URINE CULTURE-PENDING EMERGENCY [Hospital1 ] [2107-9-22] URINE URINE CULTURE-FINAL EMERGENCY [Hospital1 ] RADIOLOGY Final Report CHEST (PORTABLE AP) [2107-9-22] 6:34 PM CHEST (PORTABLE AP) Reason: please eval [Hospital 93] MEDICAL CONDITION: 74 year old woman from NH arrives w/ hypotension, tachynpia. REASON FOR THIS EXAMINATION: please eval 74-year-old female nursing home resident, now with hypertension and tachypnea. COMPARISON: [2107-8-24]. AP PORTABLE CHEST: The heart size and cardiomediastinal contours are within normal limits. The aorta is mildly tortuous and there are calcifications of the arch. The left-sided PICC line has been removed in the interval. The pulmonary vasculature is unremarkable. No focal consolidation, pleural effusion or pneumothorax is identified. There remains linear scar or atelectasis at the left base. The patient is status post thoracolumbar spinal fixation with hardware in similar position. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: A/P: 74 y/o F w/ h/o schizophrenia, dementia, HTN, DM, recent T12 fracture in [Month (only) 205] s/p vertebroplasty, recently admitted for sepsis, now presents with hypotension, leukocytosis, and positive urinalysis, with presumed urosepsis . # Hypotension: Suspected secondary to infection with urosepsis. +U/A, with cultures pending. Started empirically on Vanco/Cefepime, fluid resuscitated, to which she immediately responded with stable BPs. For presumed UTI, she was transitioned to PO levaquin and per PCP recs, started flagyl for C. Diff ppx. . # Tachycardia: Initially felt secondary to volume depletion. However continues to have persistent tachycardia despite volume resucitation. ?rebound tachycardia off b-blocker, vs MAT. Resume outpatient lopressor dose. Monitor HR/BP. . # DMII: Covered with humalog sliding scale. # Schizophremia: cont outpatient regimen # GI Bleed: h/o GI bleed, refuses evaluation. Hct 23 on admission. Typed and crossed, transfused w/pRBC. Now that HD stable, will transfuse for restrictive transfusion strategy, Hct <21 # PPx: pneumoboots, PPI # Access: PIV x 2 # Code: Full Medications on Admission: -Lopressor 50 mg Tablet Sig: 75 mg Tablets PO twice a day. -Combivent 103-18 mcg/Actuation Aerosol Sig: [1-10] Inhalation four times a day. -Ceftazidime 1 g Recon Soln Sig: One (1) Intravenous every eight (8) hours for 3 days: Stop on [8-28]. -Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 3 days: stop on [8-28]. -Nicotine 11 mg/24 hr Patch 24HR Sig: One (1) Transdermal once a day. -Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day -Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day. -Cogentin Sig: 1 mg PO once a day. -Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Inhalation twice a day. -Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1) Subcutaneous four times a day: As per Sliding Scale. -Calcium 500 500 mg Tablet Sig: One (1) Tablet PO three times a day. -Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. -Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. -Lactulose 10 g/15 mL Solution Sig: Three (3) PO twice a day as needed for constipation. -Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. -Remeron 15 mg Tablet Sig: One (1) Tablet PO at bedtime. -Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. -Nystatin 100,000 unit/mL Suspension Sig: One (1) PO three times a day as needed: swish&swallow. -Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal once a day. -Haldol Decanoate 100 mg/mL Solution Sig: 80mg Intramuscular once a month. -Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. -Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO 2x/week for 3 months. -Bactroban 2 % Ointment Sig: One (1) Topical twice a day: To open bullae on right lower extremity Discharge Disposition: Extended Care Facility: [Hospital1 2670] - [Location (un) ] Discharge Diagnosis: Urosepsis _________ Schizophrenia Diabetes Anemia Discharge Condition: good, satting well, baseline non ambulatory, baseline nutritional status Discharge Instructions: please seek medical attention if you remain febrile, or become dizzy, short of breath, or nauseous. If you have chest pain, return to seek medical attention. Please take all medications as prescribed, especially taking note of antibiotics levofloxacin and metronidazole that have been prescribed for a 10 day course Followup Instructions: follow up with PCP in two weeks	[ "0389", "5990", "496", "4019", "25000", "53081" ]
Unit No: [Numeric Identifier 64688] Admission Date: [2192-12-5] Discharge Date: [2193-1-18] Date of Birth: [2192-12-5] Sex: M Service: NB DISCHARGE DIAGNOSES: 1. Premature male infant, twin #1, 32 weeks gestation. 2. Status post respiratory distress syndrome. 3. Status post apnea and bradycardia of prematurity. 4. Status post immature feeding. 5. Status post Serratia marcescens eye infection. HISTORY: [Doctor First Name ] is the former 1575 gram product of a 32 week gestation born to a 35 year-old gravida II, A positive, para 0, now I living II female whose pregnancy was complicated by preterm labor at 27 weeks requiring an initial admission to [Hospital1 69] with treatment with tocolysis and betamethasone and discharged home. She was readmitted on the evening of delivery with spontaneous rupture of membranes. There were no other risk factors for sepsis. Prenatal screens revealed her to be A positive, group B strep status unknown. Remaining screens noncontributory. The infant was delivered by cesarean section. He emerged with Apgars of 7 and 8, given blow-by oxygen and stimulation and brought to the newborn intensive care unit at [Hospital1 346]. On admission his weight was 1575 grams. His height 41 cm and his head circumference 30.5 cm, all appropriate for gestational age. PROBLEMS DURING HOSPITAL COURSE: 1. RESPIRATORY: Infant was initially placed on continuous positive airway pressure on [12-5] and by [12-9] he was off CPAP and went directly to room air. He remained in room air thereafter. He did have episodes of apnea and bradycardia and not significant for initiating caffeine. He was at least 5 days free of any episodes prior to discharge home. 2. CARDIAC: An initial murmur was heard consistent with a closing patent ductus. No murmur has been heard since the early days of his hospital course. His blood pressures were stable. 3. INFECTIOUS DISEASE: The patient had an initial sepsis evaluation for which he was started on Ampicillin and Gentamicin at 48 hours with negative cultures and benign CBC. The antibiotics were discontinued. On [12-20] he was noted to have eye drainage for which he was placed on Erythromycin with inadequate results. Cultures then grew out Serratia marcescens and he was started on Gentamicin eye ointment on [12-21] for which he remained on for 10 days of treatment. 4. FEEDING AND NUTRITION: Patient has had an immature suck- swallow coordination with frequent choking during feeds. This has improved as his gestational age has matured. The use of a Playtex nipple has also improved the situation. At the time of discharge he was feeding good amounts with an occasional choking episode. Parents were comfortable feeding him and weight prior to discharge was 3.020 kilograms. 5. HEMATOLOGIC: Mother was A positive. Baby had a peak bilirubin of 9.1 for which he was started under phototherapy. His rebound bilirubin was 4.8/0.2 and his initial hematocrit was 43.4. He is currently on iron therapy. 6. IMMUNIZATIONS: Hepatitis B #1 vaccine was given on [12-27]/05 7. HEARING SCREENING prior to discharge was normal. 8. CIRCUMCISION Performed on [1-16] with good result. DISCHARGE MEDICATIONS: Fer-In-[Male First Name (un) ] 0.4 cc daily, Vitamins 1 cc daily. DISCHARGE PLANS: 1. Patient is to be followed up at [Hospital1 ] [Hospital1 8] office, Dr. [Last Name (STitle) 41658] within several days of discharge([1-21]) 2. Visiting nurse to come to home the day post discharge. 3. Early intervention referral made. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 37691], [MD Number(1) 55783] Dictated By:[Last Name (NamePattern1) 56049] MEDQUIST36 D: [2193-1-16] 09:41:58 T: [2193-1-16] 10:26:47 Job#: [Job Number 64689]	[ "7742", "V290", "V053" ]
Admission Date: [2200-9-24] Discharge Date: [2200-9-30] Date of Birth: [2119-7-19] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 78] Chief Complaint: Mechanical fall presenting with headache, confusion and progressively worsening conscious level Major Surgical or Invasive Procedure: Endotracheal Intubation [2200-9-24] History of Present Illness: This is an 81 year old woman with complicated PMH who presented following a mechanical fall at her home sustaining a head injury. She was then seen in [Location (un) 620] where a head CT showed a small right frontal ICH with minimal edema and no shift. She also has a comminuted right clavicular fracture. On initial assessment by ED resident finishing at roughly 11:20 she was noted to have a non-focal exam but wsa confused A+Ox3 but was hypertesnsive with SBP 179. INR was noted to be 3.4. By the time of my review perhaps 10 minutes after this she was not verbalising at all, would intermittently obey commands and would intermittently nod or shake head in response to questioning and intermittently open eyes. She seemed to have good limb power and there was pupillary asymmetry R>L. Given her acute mental status changes, she was intubated in the ED and warfarin was reversed with PT concentrate and FFP and repeat CT scan showed considerable worsening in her ICH with midline shift and almost complete obliteration of the right lateral ventricle. She was admitted to the ICU Past Medical History: PAST MEDICAL HISTORY: 1. Atrial fibrillation (diagnosed in [2179], changed from dabigatran to warfarin) 2. Aortic stenosis (s/p bioprosthetic AVR and resection of LAA, [2200-5-28]) 3. Tachy-brady syndrome (s/p ablation of atrial tachycardia and single-chamber pacemaker implant ([Company 1543] Sigma) in [2-/2191]) 4. Hypertension 5. Hyperlipidemia 6. Hypothyroidism 7. Vascular disease including right carotid stenosis and left subclavian stenosis 8. Right cerebellar embolic stroke in [7-/2190] (no residual deficits) 9. Diverticulitis 10. Colon Cancer s/p partial colectomy (roughly 15 yrs ago) 11. Multiple small bowel obstructions . PAST SURGICAL HISTORY: 1. s/p Aortic valve replacement (aortic valve bioprosthesis), removal of left atrial appendage 2. s/p Right shoulder arthroscopic subacromial decompression, debridement ([2199-2-20]) 3. s/p Laparoscopic cholecystectomy ([2192-9-14]) 4. s/p Right shoulder subacromial decompression ([2189-1-14]) 5. s/p Ex-lap, LOA, reanastomosis of proximal sigmoid colostomy to the rectum ([2184-1-6]) 6. Fistulotomy and anal sphincteroplasty ([2182-2-18]) Social History: Lives alone in senior housing, remains active. Denies tobacco or alcohol use; no recreational substance use. Using a walker. Family History: Father died of cancer at 60; Mother died at 83 with diabetes and gangrene. Sisters and brother with emphysema brother died of renal failure Physical Exam: Upon Admission: O: T: 98.1 BP: 179/86 HR: 68 R 18 O2Sats 100% RA Gen: Not opening eyes generally. Resisting eye opening. No verbalising and not making noises. At times appropriately nodding/shaking head to questioning. HEENT: Pupils: R 4->3 mm L 3->2.5mm Neck: Supple. Lungs: CTA bilaterally. Cardiac: AF on monitor irreg irreg. Normal S1/S2 with soft SM in aortic area. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Drowsy, not opening eyes (but resisting eye openning), no verbalising but shaking/nodding head in response to commands. Orientation: Unable to assess Recall: Unable to assess Language: No noises or verbalising Cranial Nerves: I: Not tested II: Anisocoria R larger than L. R 4->3 mm L 3->2.5mm. Both reactive to light but somewhat sluggish. Unable to assess fields. III, IV, VI: Roving eye movements when forecfully open eyes aganst resistance with gaze deviation to left. V, VII: Face symmetric. VIII: Unabel to assess as not responding to commands IX, X: Not lifting palate or vocalising but present gag. [Doctor First Name 81]: Unable to assess XII: Tongue midline but will not protrude to command. Limb exam: Forcefully resisting throughout but ? normal tone. Motor: Forcefully resisting and not obeying commands but seems symmetric with good power ? slightly reduced on left but questionable. Sensation: Localisies to noxious in all 4 limbs. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 3 Technically difficult as forecfully resisting but 4 beats of clonus on left. Plantar reflexes extensor bilaterally Cerebellar: Unable to assess. Roving eye movements and no clear nystagmus. At Discharge: Deceased Time of death 0900 [2200-9-30] Pertinent Results: Laboratory investigations: Admission labs: [2200-9-24] 11:25AM BLOOD WBC-8.3 RBC-4.01* Hgb-10.7* Hct-34.0* MCV-85 MCH-26.6* MCHC-31.5 RDW-15.0 Plt Ct-296 [2200-9-24] 11:25AM BLOOD Neuts-81.5* Lymphs-14.5* Monos-2.8 Eos-0.8 Baso-0.4 [2200-9-24] 11:25AM BLOOD PT-34.0* PTT-32.7 INR(PT)-3.4* [2200-9-24] 11:25AM BLOOD Glucose-115* UreaN-20 Creat-0.7 Na-138 K-3.6 Cl-104 HCO3-21* AnGap-17 [2200-9-25] 01:15AM BLOOD Albumin-4.2 Calcium-9.3 Phos-2.8 Mg-2.0 [2200-9-25] 01:15AM BLOOD ALT-18 AST-32 AlkPhos-75 TotBili-0.9 . INR trend: [2200-9-24] 11:25AM BLOOD PT-34.0* PTT-32.7 INR(PT)-3.4* [2200-9-25] 01:15AM BLOOD PT-13.6* PTT-28.9 INR(PT)-1.2* [2200-9-26] 01:38AM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1 [2200-9-27] 02:04AM BLOOD PT-12.8 PTT-25.6 INR(PT)-1.1 [2200-9-28] 01:52AM BLOOD PT-14.1* PTT-26.2 INR(PT)-1.2* . Final labs: [2200-9-28] 01:52AM BLOOD WBC-4.9 RBC-3.59* Hgb-9.6* Hct-30.2* MCV-84 MCH-26.7* MCHC-31.7 RDW-15.3 Plt Ct-225 [2200-9-28] 01:52AM BLOOD PT-14.1* PTT-26.2 INR(PT)-1.2* [2200-9-28] 01:52AM BLOOD Glucose-146* UreaN-19 Creat-0.5 Na-136 K-4.7 Cl-103 HCO3-27 AnGap-11 [2200-9-28] 01:52AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.0 [2200-9-26] 01:38AM BLOOD Phenyto-16.0 . . Urine: [2200-9-24] 12:45PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.010 [2200-9-24] 12:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD [2200-9-24] 12:45PM URINE RBC-1 WBC-34* Bacteri-NONE Yeast-NONE Epi-1 [2200-9-24] 12:45PM URINE Mucous-RARE . . Microbiology: [2200-9-24] 12:45 pm URINE Site: CLEAN CATCH FINAL REPORT [2200-9-25] URINE CULTURE (Final [2200-9-25]): NO GROWTH. . [2200-9-24] 3:45 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2200-9-27] MRSA SCREEN (Final [2200-9-27]): No MRSA isolated. . . Radiology: CHEST (PORTABLE AP) Study Date of [2200-9-24] 11:59 AM IMPRESSION: No acute intrathoracic process. NG and endotrachial tubes are adequately positioned. . CT HEAD W/O CONTRAST Study Date of [2200-9-24] 12:02 PM FINDINGS: There has been substantial interval increase in the previously seen right frontal lobe intraparenchymal hemorrhage which now extends across midline to the left frontal lobe, with surrounding edema, and with increased mass effect causing a 6 mm right-to-left shift of normally midline structures and subfalcine herniation. No uncal herniation is seen. There is complete effacement of the right ventricular system and extensive effacement of sulci due to mass effect with likely also underlying edema. There is a small hyperdensity in the posterior [Doctor Last Name 534] of the left lateral ventricle which may represent new intraventricular hemorrhage. No hydrocephlus is seen. No acute fracture is seen. IMPRESSION: 1) Substantially increased right frontal intraparenchymal hemorrhage which now extends into the left frontal lobe and with increased surrounding edema and mass effect, as above. 6 mm leftward midline shift. No definite uncal herniation. 2) Small hyperdensity in left posteral [Doctor Last Name 534] raises concern for intraventricular hemorrhage. . CT C-SPINE W/O CONTRAST Study Date of [2200-9-24] 12:07 PM IMPRESSION: Suboptimal exam secondary to motion. Given this, no acute fracture seen. Minimal anterolisthesis of C2 over C3 of indeterminate age. Possible right supraclavicular intramuscular/soft tissue hematoma. . CT HEAD W/O CONTRAST Study Date of [2200-9-25] 5:56 AM FINDINGS: There is the large right frontal lobe intraparenchymal hemorrhage with subfalcine herniation crossing midline to the left frontal lobe. The subfalcine herniation and midline shift to the left may have decreased slightly from the prior exam. The intraventricular hemorrhage layering in the occipital horns has increased. Unchanged mild right cerebral edema. There is no descending transtentorial herniation. IMPRESSION: 1. Possible slight interval decrease of the subfalcine herniation. 2. Interval increase of the intraventricular hemorrhage layering in the occipital horns. No hydrocephalus. . CHEST (PORTABLE AP) Study Date of [2200-9-26] 5:01 AM IMPRESSION: AP chest compared to [9-24]: Bilateral pleural effusions, large on the left, moderate on the right have not improved. Previous mild pulmonary edema has cleared. There is no pulmonary or mediastinal vascular congestion and heart size is top normal. ET tube is in standard placement, nasogastric tube passes below the diaphragm and out of view, and transvenous right atrial and right ventricular pacer leads follow their expected courses. Brief Hospital Course: 81F with a past medical history significant for recent aortic valve surgery in [Month (only) ] with a complicated post operative course, AF for which dabigatran was changed to warfarin, AICD for tachy-brady syndrome, PVD and carotid stenosis, previous bowel cancer and partial colectomy, HTN, HLD presented to the ED as a transfer from [Hospital1 ] [Location (un) 620] following a mechanical fall at home while mobilising to the bathroom. On assessment at [Hospital1 ] [Location (un) 620], she was found to be confused and had a non-focal examination. CT head there revealed a small right frontal ICH and right clavicular fracture. She was transferred to [Hospital1 18] and shortly after admission her conscious level acutely deteriorated such that she was not able to speak and did not follow commands. She was intubated for airway protection in the ED and repeat CT head showed substantially increased right frontal ICH which had extended into the left frontal lobe and with increased surrounding edema and mass effect with 6 mm leftward midline shift. Her INR was 3.4 and this was reversed and the patient was admitted to the ICU under the care of Dr. [First Name (STitle) ]. She was seen by the ACS service. Ortho was consulted to evaluate her clavicle fracture. Surgical decompression was discussed with the family. Her exam continued to remain poor and repeat CT showed subfalcine herniation. After discussions with family on poor prognosis for recovery, she was made comfort measures only on [2200-9-28]. Palliative care were consulted and per their notes, the patient had repeatedly told her family that she would never want prolonged end of life care and a combined medical and family decision was to remove ventilator assistance and make the patient comfort measures only as above. She was pronounced dead at 0900 on [2200-9-30]. Given that her initial injury was a result of trauma, the medical examiner was contact[Name (NI) ] and accepted the case to view and will complete the death certificate. Of note the patient has an AICD. Medications on Admission: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. metoprolol succinate 150mg daily but state 100mg daily on cardilogy letter. 5. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Change dose as directed by coumadin clinic on Friday when you show up. Disp:30 Tablet(s) Refills:0 6. Furosemide 20 mg p.r.n. lower extremity edema Discharge Medications: Patient deceased Discharge Disposition: Expired Discharge Diagnosis: Traumatic large right frontal lobe intraparenchymal hemorrhage with subfalcine herniation crossing midline to the left frontal lobe Supratherapeutic INR Traumatic right clavicle fracture Bilateral pleural effusion Discharge Condition: Patient deceased [2200-9-30] Discharge Instructions: Patient presented on [2200-9-24] with traumatic right sided intracranial hemorrhage in addition to a right clavicular fracture following a fall at home. Patient was on warfarin and admission INR was 3.4. Patient was initially confused with a non-focal examination however shortly after transfer from [Hospital1 ] [Location (un) 620] to [Hospital1 18], the patient rapidly deteriorated and was intubated in the ED. Repeat head CT showed significant progression of her hemorrhage with evidence of subfalcine herniation. Warfarin was reversed in the ED and patient was transferred to the ICU. Patient made poor neurological progress in the ICU and given comorbidities and extent of ICH, the decision was to make the patient CMO and the patient was extubated and died with relatives present at 0900 on [2200-9-30]. Followup Instructions: Patient deceased	[ "5119", "42731", "4019", "2724", "2449" ]
Admission Date: [2102-6-8] Discharge Date: [2102-6-16] Date of Birth: [2040-9-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3266] Chief Complaint: Bloody Paracentesis, Encephalopathy Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 61yo man with h/o etoh cirrhosis, ESLD, ascites s/p frequent taps, FTT, who was admited for w/u of bloody ascites and management of FTT, who developed worsening MS [First Name (Titles) ] [Last Name (Titles) ] compromise, transferred to MICU for further w/u and management. Has had marked weight loss continuing over past 3 months. When healthy his weight was 165-170, currently it is 138 lbs. He was recently ([5-6]) admitted for 4d for this FTT. Pt underwent LVP (7L) on the day of admit [2102-6-8], found to have bloody fluid that was concerning for tuberculous ascites. After his admission and the large volume tap, the patient was feeling "a little better". He had a PPD planted that has since come back negative. His WBC count was slightly elevated, but he had no fevers initially and his ascites were negative for SBP, so no abx were started. A nutrition consult was obtained, he was started on a PO diet in addition to TF supplements. Blood cultures have been neg to date. He had a CXR that showed L>R pleural effusion felt to be from his ascites, as well as a small PTX that was managed conservatively (no chest tube). . In the last several days, the patient developed leukocytosis and ARF. His tube feeds were decreased [2-2] distention, his sodium went down so his lasix/aldactone were held. A repeat CXR showed no enlargement of PTX. His WBC has remained elevated though he has been afebrile, and he was feeling well except for chronic low back pain. He underwent a diagnostic tap given his WBC and bandemia, with no evidence of SBP on gram stain and cell count. He had a repeat u/a, cxr that were unrevealing for infectious etiology. Given his worsening renal function concerning for HRS, the pt was started on midodrine, octreotide, albumin. Because of his worsening LBP, the patient's pain meds were increased this AM to oxycodone 10mg. He had not had a BM since Thursday despite lactulose, but a 90ml dose this AM recently had the effect of a large loose BM. . The team found the pt to be withdrawn and lethargic later on this AM, and called the ICU team for evaluation. He was responding only to pain. His [Month/Day (2) ] rate decreased, and an ABG revealed normal pH but increased pCO2. A repeat CXR is pending. Pt is being transferred to the MICU for further eval and management. Prior to transfer, he received 2 doses of Narcan and a new IV placement, with some mild improvement in his mental status and increase in his resp rate during this period. Past Medical History: EtOH cirrhosis secondary to alcohol use Recurrent ascites, negative cytology Endoscopy [12/2101] with grade 2 varicies Prior h/o HTN Gout History of pancreatitis, presumably [2-2] etoh . s/p appendectomy, distant s/p hernia repair Social History: Patient lives with his wife currently. Significant past ETOH use for 30 years, drinking 4 drinks of hard liquor daily. Per report from last discharge, quit ETOH use 8 weeks ago. Patient is a [Country 3992] Veteran. Family History: No family history of Colon or Pancreatic ca. Father with lung ca Physical Exam: Vitals: Tc 95.4 BP 105/63 HR 76 O2 sat 98% on NC O2 . Gen: Thin, cachetic, weak appearing male in NAD HEENT: Pupils equal and round, anicteric sclera, dry MM, hoarse voice Neck: supple, no LAD CV: soft S1 S2, RRR, with no M/R/G Abd: Abd soft, distended, moderate diffuse tenderness to palpation, + BS Ext: No pedal edema, 2+ DP pulses Neuro: + asterixis Awake, A&O x 3 Pertinent Results: Admission Labs: . [2102-6-8] 02:00PM ASCITES TOT PROT-2.9 LD(LDH)-83 ALBUMIN-1.5 [2102-6-8] 02:00PM ASCITES WBC-139* RBC-[Numeric Identifier 28647]* POLYS-6* LYMPHS-62* MONOS-27* EOS-1* OTHER-4* [2102-6-9] 04:50AM BLOOD WBC-5.9 RBC-3.17* Hgb-10.4* Hct-31.1* MCV-98 MCH-32.8* MCHC-33.4 RDW-16.0* Plt Ct-271 [2102-6-9] 04:50AM BLOOD Neuts-73* Bands-10* Lymphs-10* Monos-6 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2102-6-9] 04:50AM BLOOD PT-15.1* PTT-26.6 INR(PT)-1.4* [2102-6-9] 04:50AM BLOOD Glucose-91 UreaN-66* Creat-1.3* Na-133 K-4.6 Cl-93* HCO3-30 AnGap-15 [2102-6-9] 04:50AM BLOOD ALT-14 AST-27 LD(LDH)-121 AlkPhos-136* Amylase-54 TotBili-0.9 [2102-6-9] 04:50AM BLOOD Lipase-101* [2102-6-9] 04:50AM BLOOD Albumin-3.0* Calcium-8.9 Phos-3.2 Mg-2.1 Pertinent Labs/Studies: . [2102-6-12] 03:57PM BLOOD CEA-28* AFP-3.7 [2102-6-9] 04:50AM BLOOD Lipase-101* [2102-6-11] 07:15AM BLOOD Lipase-63* . [2102-6-11] 11:58AM ASCITES WBC-500* RBC-[Numeric Identifier 17227]* Polys-5* Lymphs-63* Monos-32* [2102-6-8] 02:00PM ASCITES WBC-139* RBC-[Numeric Identifier 28647]* Polys-6* Lymphs-62* Monos-27* Eos-1* Other-4* [2102-6-11] 11:58AM ASCITES TotPro-2.9 Albumin-1.5 [2102-6-8] 02:00PM ASCITES TotPro-2.9 LD(LDH)-83 Albumin-1.5 . . . Microbiology: Blood cultures: [2102-6-11]: NGTD [2102-6-11]: NGTD . Peritoneal Fluid: [2102-6-8]: Gram stain 1+ PMN Culture - no growth, AFB smear negative, no growth Adenosine Deaminase - ADENOSINE DEAMINASE,FLUID <1.0 [2102-6-11]: No growth . . . . Imaging: . Chest Pa/Lat [2102-6-9]: A small right apical pneumothorax has developed. The right-sided pleural effusion has decreased in size. There has also been development of a moderate to large left-sided hydropneumothorax with decrease in the component of left-sided pleural effusion. The feeding tube remains in stable position. The lungs are otherwise clear. IMPRESSION: Development of bilateral pneumothoraces greater on the left side with decrease in bilateral effusions. . Chest Pa/Lat [2102-6-10]: IMPRESSION: Essentially no significant interval change since the previous study in the bilateral hydropneumothoraces. . Chest Pa/Lat [2102-6-11]: There is a feeding tube whose distal portion is not visualized. There is again seen a moderate left-sided hydropneumothorax. There has been no significant interval change in the size of the pneumothorax or the pleural fluid. There is a loculated right-sided pleural effusion, also unchanged. The small right apical pneumothorax seen previously is no longer visualized. Consolidation at the lung bases, particularly at the right side cannot excluded due to the large amount of pleural fluid. IMPRESSION: There has been resolution of the tiny right apical pneumothorax. Otherwise unchanged. . Portable Chest [2102-6-12]: IMPRESSION: 1. Moderate-sized left-sided hydropneumothorax which is not significantly changed from the prior study, with a very tiny apical pneumothorax component. 2. Moderate-sized right pleural effusion, unchanged. . [2102-6-12]: CT CHest w/out contrast - 1. Moderate-sized left-sided hydropneumothorax and moderate-sized right pleural effusion. 2. Rounded opacity seen in the medial aspect of the right lung base, probably representing atelectasis, however, followup imaging is recommended to document resolution and to exclude mass. 3. No pathologically enlarged mediastinal or hilar lymphadenopathy is identified. 4. Large amount of ascites. . [2102-6-14]: Plain films L-Spine - IMPRESSION: Old compression fracture of a low thoracic vertebral body accounting for less than 25% of the normal vertebral body height. Thoracic and lumbar spondylosis without listhesis. . [2102-6-14]: Portable Chest - 1. Moderate sized right pleural effusion, unchanged. 2. Moderate sized left hydropneumothorax is stable with a persistent small apical pneumothorax component. . . . Pathology: [2102-6-8]: Cytology Peritoneal Fluid: Negative for malignant cells. A few mesothelial cells, lymphocytes, and histiocytes. Discharge Labs: . [2102-6-15] 05:35AM BLOOD WBC-9.9 RBC-2.98* Hgb-10.0* Hct-29.5* MCV-99* MCH-33.5* MCHC-33.8 RDW-16.1* Plt Ct-210 [2102-6-15] 05:35AM BLOOD Glucose-110* UreaN-79* Creat-1.7* Na-137 K-4.1 Cl-98 HCO3-26 AnGap-17 [2102-6-15] 05:35AM BLOOD ALT-12 AST-25 AlkPhos-138* TotBili-1.1 [2102-6-15] 05:35AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0 [2102-6-15] 07:17AM BLOOD Type-ART O2 Flow-2 pO2-141* pCO2-41 pH-7.45 calHCO3-29 Base XS-4 Intubat-NOT INTUBA Comment-NC [2102-6-15] 07:17AM BLOOD Lactate-1.2 Brief Hospital Course: A/P: 61 yo man with ESLD, presented with bloody ascites, FTT, encephalopathy. . . #. ESLD: On admission, patient was known to have a history of Alcoholic cirrhosis with need for repeated paracentesis for recurrent ascites. As above, the patient has been noted to have bloody taps concerning for potential underlying malignancy or TB. The patient additionally had developed renal failure with concern for possible hepatorenal syndrome. It was the hope initially that the patient would be eligible for a liver transplant. However, as described in H+P, the patient was noted to have rapid decline in functional status with severe cachexia, concerning for potential secondary process such as malignancy, or possibly TB given bloody taps, although more likely the former. At time of admission, the patient was with such poor functional status that he was not considered eligible for a liver transplant. It was the hope that with improved nutritional status and treatment for encephalopathy patient may improve. Workup was additionally underway for potential underlying condition such as malignancy or infection that was further compromising his health. Unfortunately, the patient continued to decline rapidly clinically throughout the hospital course before further evaluation could be completed and the patient passed (see below). . #. [Month/Day/Year ] depression/Altered Mental Status: The patient was transferred to the MICU because of somnolence thought to be secondary to underlying encephalopathy and med effect from Narcotics with decreased hepatic clearance. The patient had an ABG performed that revealed mild hypoxia, and hypercarbia with normal pH, possibly from increased OxyContin that was initiated for increasing back pain. The patient was observed in the MICU without need for intubation or non-invasive ventilation and was subsequently transferred back to the floor. The patient was noted to have ongoing waxing and [Doctor Last Name 688] mental status with difficulty balancing comfort and pain control with maintaining mental status. The patient was noted again to grow somnolent for which a repeat ABG was performed which revealed no significant acid/base disorder, hypercarbia or hypoxia. The patient's Lactulose was up titrated and rifaximin added to his treatment regimen with hope to reverse potential underlying encephalopathy. Narcotics were held without significant improvement in mental status. Despite these efforts the patient continued to have ongoing worsening mental status with significant somnolence. Code status was discussed with the patient's family where it was clarified that the patient definitely would not want to be aggressively resuscitated. Given the patient's rapidly declining clinical status, it was discussed with the patient's family the treating team's concern that his short term prognosis may not be good. The patient's family understood this and additionally were in agreement that it would be better to treat the patient's pain (which he reported) than to hold pain meds so as to avoid further sedation. Around 1:30 a.m. on [2102-6-16] the patient was noted to be developing increasing tachypnea and course upper airway sounds. For this, he was given a Scopolamine patch and received Ativan for [Date Range ] distress. The patient was noted on telemetry to develop progressive bradycardia until asystolic. Per the patient's and families wishes, no resuscitation efforts were made. The patient was reported to appear comfortable at the time of his passing with his family present. It was discussed with the patient's family the importance of performing a post-mortem exam to evaluate for possible underlying malignancy or infection, which they agreed to. . #. Bloody Paracentesis - The patient has had two paracentesis performed within the last 4 weeks that have bene demonstrated to be bloody by cell count without evidence of SBP. Cytology on two samples did not reveal any malignant cells. Given no evidence for malignancy by cytology, their was additional consideration of possible tuberculosis, particularly given the patient's history of 40 pound weight loss. However, despite the negative cytology, clinical suspicion for underling malignancy remained high. The patient did not have an elevated AFP this admission but did have a mildly elevated CEA of 28. AFB smears from peritoneal fluid were negative for AFB, cultures are all no growth to date, and Adenosine Deaminase levels from peritoneal fluid were < 1. A PPD was planted this admission which was negative. Although suspicion for pulmonary TB was low, the patient was maintained on [Date Range ] precautions as induced sputum was not possible secondary to sedation. The patient's family was instructed that they should be wearing TB barrier aerosol masks on entry to the room but declined to do so. Throughout the patient's clinical course (see below) he continued to decline with depressed mental status, tachypnea, and hypotension. The patient passed away on [2102-6-16] after episode of bradycardia, progressing to asystole. The patient's family was agreeable to autopsy to determine underlying etiology for patient's rapid decline and cachexia, with concern for TB and malignancy as above. . #. ARF: The patient developed acute renal failure during this hospitalization with consideration of pre-renal etiology of possibly hepatorenal syndrome. The patient was given a 1L fluid challenge while in the intensive care unit without any improvement in his renal function. The patient was maintained on octreotide and midodrine for ongoing blood pressure support. Medications on Admission: Folic acid 1 mg po qd CaCO3 0.6 mg po qd Aldactone 25 mg po qd Lasix 40 mg po qd -> recently increased [6-5] to 40 [Hospital1 ]. Lactulose 2 tspns qid MVI qd Tube feeds Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: Primary: End Stage Liver Disease Renal Failure Failure to Thrive Bloody Peritoneal effusion Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None	[ "5849", "51881" ]
Admission Date: [2102-3-28] Discharge Date: [2102-4-5] Date of Birth: [2039-5-18] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1283] Chief Complaint: Coronary artery disease, aortic stenosis, left ventricular outflow obstruction Major Surgical or Invasive Procedure: AVR( )/Septal myomectomy.CABGx1( ) [2102-3-28] History of Present Illness: This is a 62 year old gentleman with a known mumur on auscultation for many years. He was recently found to have significant aortic stenosis on echocardiogram, with a valve area of 0.8 cm^2 and moderate mitral regurgitation, EF of 60%. He is also a 20-year diabetic and on cardiac catheterization in preparation for aortic valve repair he was found to have 40% diseased left main coronary artery. The catheterization also demonstrated peak gradient of 55 mm HG across the aortic valve. He now presents for elective aortic valve repair with repair of left main outflow obstruction and coronary artery bypass grafting x 1. On review of systems he denies significant dyspnea or chest pain, he has no fevers/chills/abdominal pain. Past Medical History: Diabetes Mellitus x 20 years Atrial Fibrillation s/p cardioversion [6-5] Lymph Adenectomy Hypertension Hypercholesterolemia Social History: The patient is retired and worked in marketing and sales. He never smoked tobacco and is married. He occasionally drinks alcohol. He had a recent dental exam with dental clearance. Family History: There is no history of premature coronary artery disease. Physical Exam: On admission: v/s height 6'2, weight 172 lbs, pulse 82, 150/80, RR 18 Gen: no acute distress, pleasant, healthy appearing HEENT: MMM, EOMI, good dentition Neuro: CN 2-12 grossly intact CV: RRR, 2/6 systolic ejection murmur Pulm: CTAB Abd: soft, NT/ND, + BS, no organomegaly Extr: no edema, warm, Vasc: palpable peripheral pulses Pertinent Results: [2102-3-28] 12:48PM BLOOD WBC-9.1 RBC-2.72# Hgb-8.8# Hct-23.8# MCV-88 MCH-32.5 MCHC-37.1* RDW-13.5 Plt Ct-137* [2102-3-28] 02:03PM BLOOD WBC-13.0* RBC-3.45# Hgb-10.9 Hct-30.1# MCV-87 MCH-31.5 MCHC-36.2 RDW-13.4 Plt Ct-182 [2102-3-29] 01:56AM BLOOD WBC-12.0* RBC-3.27* Hgb-10.6* Hct-28.1* MCV-86 MCH-32.5* MCHC-37.7* RDW-13.4 Plt Ct-138* [2102-3-30] 06:35AM BLOOD WBC-9.0 RBC-2.61* Hgb-8.2* Hct-23.6* MCV-90 MCH-31.6 MCHC-35.0 RDW-13.8 Plt Ct-81* [2102-4-1] 04:50AM BLOOD WBC-8.1 RBC-3.02* Hgb-9.7* Hct-26.6* MCV-88 MCH-32.3* MCHC-36.6* RDW-13.9 Plt Ct-150 [2102-4-2] 04:55AM BLOOD WBC-8.2 RBC-2.78* Hgb-9.0* Hct-24.8* MCV-89 MCH-32.6* MCHC-36.5* RDW-14.0 Plt Ct-177 [2102-4-3] 08:30AM BLOOD WBC-9.8 RBC-2.90* Hgb-9.3* Hct-25.8* MCV-89 MCH-32.2* MCHC-36.2* RDW-14.3 Plt Ct-206 [2102-4-4] 05:35AM BLOOD WBC-13.8* RBC-3.27* Hgb-10.4* Hct-29.7* MCV-91 MCH-31.9 MCHC-35.1* RDW-14.4 Plt Ct-323# [2102-3-28] 02:03PM BLOOD PT-14.7* PTT-32.2 INR(PT)-1.3* [2102-3-29] 01:56AM BLOOD PT-15.0* PTT-31.2 INR(PT)-1.3* [2102-3-31] 06:10AM BLOOD PT-12.6 INR(PT)-1.1 [2102-4-1] 04:50AM BLOOD PT-13.2* INR(PT)-1.2* [2102-4-3] 08:30AM BLOOD PT-19.6* PTT-68.1* INR(PT)-1.9* [2102-4-4] 05:35AM BLOOD PT-36.9* PTT-67.3* INR(PT)-4.1* [2102-3-28] 02:03PM BLOOD UreaN-16 Creat-0.7 Cl-115* HCO3-21* [2102-3-29] 01:56AM BLOOD UreaN-13 Creat-0.7 Na-139 Cl-108 HCO3-22 [2102-3-30] 06:35AM BLOOD Glucose-236* UreaN-26* Creat-1.2 Na-137 K-4.6 Cl-103 HCO3-24 AnGap-15 [2102-3-29] 01:56AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.7 [2102-3-30] 06:35AM BLOOD Calcium-7.7* Phos-3.7 Mg-1.9 [2102-3-28] TEE: 1) Overall left ventricular systolic function is normal (LVEF>55%). 2) There is a mild resting left ventricular outflow tract obstruction. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). 3) There are three thickened and calcified aortic valve leaflets and immobile noncoronary cusp and findings c/w2 with probably moderate aortic valve stenosis. [Location (un) 109] was calculated by planimetry and continuity equation was not used in the presence of LVOT gradient. Trace aortic regurgitation is seen. 4) The mitral valve leaflets are mildly thickened with no prolapsing or flail setgments. The mitral annulus is moderately calcified. The mitral regurgitation is mild to moderate, dynamic and exaggerated with ectopic beats and consistent with a contribution by dynamic LVOT obstruction apart from probable intrinsic mitral apparatus issues. Mitral annulus is 30mm. Mildly dilated Left atrium. POSTBYPASS: Preserved biventricular systolic function. EF 60%. The aortic bioprosthesis is in place and and functioning well. The LVOT gradient persists to the prebypass levels and the mitral regurgitation is persistent at mild-moderate levels with LVOT/[Male First Name (un) ]. PATHOLOGY : A. Aortic valve leaflets: Aortic valve tissue with fibrosis and calcification. B. Fragments of myocardium: Myocardial fragments with fibrotic change. [2102-3-28] CXR: 1. No evidence of pneumothorax. 2. Layering left pleural effusion with left basilar atelectasis. 3. Tip of a Swan-Ganz catheter located just barely in the main pulmonary artery. [2102-4-4] CXR: The patient is status post median sternotomy and aortic valve replacement. There is stable widening of the cardiac silhouette. There is upper zone vascular redistribution, but there is no overt pulmonary edema. Bilateral small pleural effusions are present, without significant change allowing for technical differences between the studies. Basilar atelectatic changes are noted in the retrocardiac regions, with slight worsening on the left side. IMPRESSION: Small bilateral pleural effusions. Bibasilar retrocardiac opacities, likely due to atelectasis, with worsening on the left. Pneumonia is not excluded in the appropriate clinical setting. Brief Hospital Course: This is a 62 year old gentleman who was admitted for aortic valve repair and coronary artery bypass grafting on [2102-3-28] (please see the operative report of Dr. [Last Name (STitle) ] for full details). He had an uncomplicated post-operative course. he was extubated on arrival to the cardiac surgery intensive care unite. He was temporarily on neosynephrine for blood pressure control and this was weened off by post-op day 1. he was out of bed on post-op day 1 and his chest tubes were removed; he was then transferred to the step-down unit. His pacing wires were removed on post-op day 2 and his foley was removed. Lasix was started for gentle diuresis. He had elevated blood sugars and [Last Name (un) ] Diabetes was consulted for assistance with blood sugar control. He was transfused 1 u packed red blood cells on post-operative day 3 with an appropriate rise in hematocrit. He had some serosanguinous drainage from his sternal wound and levofloxacin was started empirically, although he did not have a fever or leukocytosis; eventually this was changed to kefzol for coverage of an upper extremity cellulitic phlebitis. He had an episode of rapid atrial fibrillation on post-operative day 4 and amiodarone/diltiazem drips were started. His atrial fibrillation continued for several days and he was changed to oral amiodarone and cardizem; eventually he converted into sinus rhythm. Given the duration of his a-fib, he was started on a heparin drip on post-operative day 5 and coumadin dosing was started. He was discharged on a range of coumadin therapeutic for atrial fibrillation (2.0-3.0) and oral anti-arrythmics. He worked with physical therapy and deemed safe for home discharge with a visiting nurse. He had planned follow-up upon discharge. All questions were answered to his satisfaction upon discharge. Medications on Admission: Atenolol 50 mg po bid Linisopril 10 mg po qdaily Gemfibrozil 600 mg po bid Metformin 1 gm po BID Aspirin 81 mg po qdaily Zetia 10 mg po Qdaily Multivitamins Lipitor 40 mg po qdialy Glucosamine Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:50 Tablet(s) Refills:0 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day: Take two (200mg)tablets three times daily for 1 week, then starting [2102-4-8] take two(200mg) tablet twice daily for one week, then starting [2102-4-15] take two 200mg tablet once daily, then [2102-4-22] take one 200mg tablet once daily until instructed by your cardiologist. . Disp:90 Tablet(s) Refills:2 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 14. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 3 days. Disp:3 Packet(s) Refills:0 15. Lopressor 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 16. Coumadin 1 mg Tablet Sig: As instructed by Dr. [First Name (STitle) ] Tablet PO once a day: Dose will change based on your blood work and as instructed by Dr. [First Name (STitle) ]. Please take 2mg on Thursday [2102-4-6] and then per Dr. [First Name (STitle) ]. Disp:50 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: Americare Discharge Diagnosis: Aortic stenosis IHSS CAD AF NIDDM HTN ^chol. Discharge Condition: Good. Discharge Instructions: 1) Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions until they have healed. 2) Call with fever greater then 100.5, redness or drainage from incision. 3) Call with weight gain more than 2 pounds in one day or five pounds in one week. 4) No lifting more than 10 pounds for 10 weeks. 5) No driving for 1 month. 6) Please have PT/INR blood draw on Friday [2102-4-7] at Dr.[Name (NI) 22054] office. He will dose your coumadin according to your blood work. Please note your dose may change based on your blood levels. Take coumadin only as instructed by Dr. [First Name (STitle) ]. Blood draws are performed by Dr. [First Name (STitle) ] between 9AM-12PM and 1PM-4PM. Goal INR is 2.0-2.5 for atrial fibrillation. 7) Take lasix 20mg once daily with potassium 20mEq once daily for three days and then stop. 8) Amiodarone wean: Take two (200mg)tablets three times daily for 1 week, then starting [2102-4-8] take two(200mg) tablet twice daily for one week, then starting [2102-4-15] take two 200mg tablet once daily, then [2102-4-22] take one 200mg tablet once daily until instructed by your cardiologist. 9) Call with any questions or concerns. Followup Instructions: Make an appointment with Dr. [First Name (STitle) ] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) 1290] for 4 weeks. Fo[Last Name (STitle) ]p with Dr. [Last Name (Prefixes) ] in 1 month. ([Telephone/Fax (1) 11763] Follow-up with Dr. [First Name (STitle) ] on Friday [2102-4-7] for PT/INR blood checjk for coumadin dosing and in [1-2] weeks for postoperative exam. ([Telephone/Fax (1) 65348] Follow-up with Dr. [First Name (STitle) 1075] in [1-2] weeks. Please call all providers for appointments. Completed by:[2102-4-5]	[ "42731", "41401", "25000", "4019", "2720" ]
Admission Date: [2174-4-5] Discharge Date: [2174-4-15] Date of Birth: [2096-4-22] Sex: F Service: MEDICINE Allergies: Demerol / Sulfonamides Attending:[First Name3 (LF) 898] Chief Complaint: on episode of black diarrhea Major Surgical or Invasive Procedure: Colonoscopy EGD Pill endoscopy History of Present Illness: 77-year-old female with a history of a CVA and Afib on coumadin who presented with watery diarrhea for one week that became continuous and dark/tarry leading her to present to the ED. She denied abdominal pain and fevers/chills, but did have some intermittent nausea without vomiting. She had no raw food intake, no alcohol intake, no sick contacts, no unusual or undercooked food intake, no camping, no weightt loss, arthritis, no recent med change/NSAIDuse, or recent antibiotic use. She denies URI symptoms/SOB/CP/GU problems or back pain. She had a virtual colonoscopy that was normal per her report, and had a regular colonoscopy in [2167] showing small polyps (removed), diverticulosis, and hemorrhoids. In the ED, she was hemodynamically stable, found to have a hematocrit drop from 35 to 30 and INR of 5.6. Her coagulopathy was corrected and she had a negative NG lavage. She was admitted to the MICU for close hemodynamic monitoring. Past Medical History: 1. Status post CVA 4 yrs ago, lateral and vertical visual impairment 2. Hypercholesterolemia. 3. Glaucoma. 4. diverticulosis, small polyps, nonbleeding hemorrhoid, (from previous colonoscopy [2167]) 5. Presacral neuropathy for menstrual pain and cramps many years ago. 6. Status post TAH/BSO. 7. L carotid artery stnosis 70% Social History: She was born in [Hospital1 189] and was raised in [State 350]. She completed high school. She was employed as an x-ray technician for many years. She has been married for 46 yrs. She has lived in [Location ] all of her entire life. She no longer has a sexual relationship with her husband as she "has had enough of that." They have 3 children. No STDs. She smoked cigarettes for about 20 yrs., at a pack a day, quitting in l968. She has about 3 glasses of wine in 7 days. Travel to No. Europe recently and they spend each winter in [State 15946]. When asked about hobbies, she reports [State 15946] as one of her hobbies. Family History: Her mother died at 42, she thinks possibly now of a ruptured viscus in her gut, and her father died at 78 of leukemia and Parkinson's disease. Her mother has a sister who died at 80 w/postmenopausal breast cancer. She has 4 siblings, 2 of whom have CAD and l has colitis. She remembers all of the routine childhood diseases. Physical Exam: PE: T98.6 BP 102/44 HR97 RR16 95%@4LNC Gen: Pt lying in bed NAD HEENT: PERRL, EOMI Neck: Supple no LAD, no JVD Lungs: crackles bilaterally CV: [Last Name (un) ]. [Last Name (un) 3526]., no MRG Abd: +BS soft nontender Ext: 1+ edema Neuro: AOX3 Pertinent Results: [2174-4-15] - HCT 29.1 INR 1.8 CREAT 1.0 Stool culture and C.diff assays negative. Normal abdominal ultrasound. CXR - small bilateral pleural effusions EGD: [2174-4-5]: Impression: 1. Circular patches of erythema in the antrum and stomach body compatible with NG tube trauma. 2. Linear streaks of erythema in the antrum compatible with gastritis. 3. These findings do not account for patient's gastrointestinal bleeding. Colonscopy: [4-6] Impression: 1. Very tortuous and redundant colon 2. Diverticulosis of the sigmoid colon. 3. Otherwise normal colonoscopy to cecum. Source of recent gastrointestinal bleeding is not identified by this colonoscopy. Brief Hospital Course: GI bleed: Patient had one episode of dark stool at home with no further episodes while hospitalized. She had a supratherapuetic INR on admission of 5.6 and was reversed with 5mg vit K and 4 units FFP. Her HCT fell from 35 to 23, she recieved two units of packed red blood cells and her hematocrit rose to 30 and remained stable. An NG lavage was negative for blood and an EGD and colonoscopy also were negative. She subsequently underwent a pill endoscopy which showed duodenal AVMs. She then underwent a repeat EGD that showed angioectasias in the antrum and stomach body. Her hematocrit remained stable throughout the remainder of her hospital stay; however, she continued to have persistent diarrhea with 4-8 episodes of small to medium volume, watery stool. Multiple C.diff toxin assays were negative, and her initial stool cultures and O&P studies were negative. She had an unremarkable abdominal ultrasound as well. She was started on Imodium and will have a follow-up EGD and GI appointment within 3-4 weeks. Afib: The patient has a history of Afib and a prior CVA giving her approximately a 12% per year risk of stroke. While in the MICU, she was noted to be going in and out of rapid atrial fibrillation without any symptoms. Her Rhythmol was discontinued and she was started on digoxin and titrated up on her beta-blockers. Her PAF continued despite these medications, and after consultation with the EP cardiology service her digoxin was discontinued (due to her dislike of the fatigue it caused her previously), and her beta-blocker was changed back to atenolol 25 mg daily. She will follow-up with Dr. [Last Name (STitle) ] who will consider an AV nodal ablation and pacemaker placement if her [Doctor Last Name ] of Hearts monitor reveals excessive tachycardia without symptoms. Her INR was 1.8 on the day of discharge and she was discharged on Lovenox for two days and will resume her outpatient coumadin dosing. She will have her INR and HCT checked on Monday, [2174-4-18] and will have her PCP adjust her coumadin dose as needed. Medications on Admission: Coumadin range from 4-6mg/day Atenolol 25mg Univasc 15 Rhythmol 325bid lasix 40 Lipitor 10 KCL 20 macrobid 100 timoptic q am xalatan q pm Calcium MVI folate fish oil . Discharge Medications: 1. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic QAM (once a day (in the morning)). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nitrofurantoin Macrocrystal 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:30 Capsule(s) Refills:0 8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours) for 5 doses: Last dose will be Sunday evening [2174-4-17]. Disp:5 prefilled syringes Refills:0 10. Coumadin 2 mg Tablet Sig: Four (4) Tablet PO at bedtime: Please resume your previous coumadin regimen. Have your INR checked in 3 days and have Dr. [First Name (STitle) ] adjust your coumadin dose. Disp:90 Tablet(s) Refills:0 11. Univasc 15 mg Tablet Sig: One (1) Tablet PO once a day. 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Klor-Con M20 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Discharge Disposition: Home Discharge Diagnosis: Duodenal arteriovenous malformations atrial fibrillation with rapid ventricular response diarrhea hyperlipidemia glaucoma bilateral pleural effusions chronic urinary tract infections h/o a stroke diverticulosis Discharge Condition: stable Discharge Instructions: Please call your PCP or return to the ED if you have any worsening shortness of breath, chest pain, bloody or dark stools, dizziness, high fevers or any other worrisome symptoms. Please have your INR and hematocrit (blood count) checked on Monday, [2174-4-18] and have Dr. [First Name (STitle) ] adjust your coumadin dose as needed. Please follow-up with GI for your repeat endoscopy as scheduled. Please follow-up with Dr. [Last Name (STitle) ] as scheduled. He will review the results from your [Doctor Last Name ] of Hearts monitor. Followup Instructions: Please follow up with your PCP within one week. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 285] Date/Time:[2174-4-19] 12:30 Provider: [Name10 (NameIs) ] WEST,ROOM ONE GI ROOMS Where: GI ROOMS Date/Time:[2174-5-18] 1:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],[First Name3 (LF) ] PROCEDURES ENDOSCOPY SUITES Where: [First Name8 (NamePattern2) ] [Hospital Ward Name ] BUILDING ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX) ENDOSCOPY SUITE Phone:[Telephone/Fax (1) 463] Date/Time:[2174-5-18] 1:30	[ "42731", "2851", "2720" ]
Admission Date: [2202-3-31] Discharge Date: [2202-4-6] Date of Birth: [2168-10-6] Sex: F Service: [Company 191] MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old female, with type 2 diabetes mellitus, poorly controlled diabetes, who was admitted to the Fenard Intensive Care Unit on [2202-3-31] with diabetic ketoacidosis. The patient had been vomiting for several days with chronic diarrhea, and on admission had an initial blood pressure of 70/palp, and in the Emergency Department was found to have a blood glucose level of 1,400, an anion gap of 55, and a serum bicarbonate of 6. She received 7 liters of normal saline, potassium repletion, 55 units of insulin, and then was put on insulin GTT in the ED. The patient had coffee ground emesis, melena on admission. Coffee ground emesis was cleared after a 350 cc NG lavage. Her course was also notable for T wave inversions in the inferolateral leads, and a troponin of 2.5. The patient also grew out Clostridium perfringens, lactobacillus and coag-negative staph aureus from her initial blood cultures. She also was found to have acute on chronic prerenal failure. The patient was initially given 1 gm of vancomycin for her bacteremia before speciation in the [Hospital Unit Name 153], and was later started on clindamycin. Her lytes were repleted and free water was repleted for her hypernatremia on admission in the [Hospital Unit Name 153], and she was then called out to the floor. Upon call-out, the patient was complaining of tender left upper chest pain at her central line site, but no fevers, chills, nausea, vomiting or abdominal pain. PAST MEDICAL HISTORY: 1) Type 1 diabetes since age 6, multiple admissions for DKA, 2) Hypertension, 3) [Doctor First Name ]-[Doctor Last Name ] tears, 4) Gastroparesis, 5) Nephropathy, 6) Asthma, 7) Hypercholesterolemia, 8) Chronic renal insufficiency with a baseline of 1.5. MEDICATIONS AT HOME: 1) reglan, 2) insulin, schedule of Lantus 32 U at night and 18 [Location ] in the morning, and then Humalog sliding scale for lunch and dinner. ALLERGIES: Pork and beef insulin, erythromycin, compazine, codeine, aspirin, barium contrast dye. SOCIAL HISTORY: Married, currently homeless but expecting to move into a new home on the 6. No alcohol or tobacco use. MEDICATIONS ON TRANSFER TO THE FLOOR FROM THE ICU: 1) clindamycin 600 mg IV q 8 h day 1 on [2202-4-3], 2) metoprolol 12.5 tid, 3) Reglan 10 IV qid, 4) famotidine 20 IV qd, 5) Zofran 2 mg q 6 h prn, 6) albuterol/ipratropium nebs, 7) nystatin swish and swallow, 8) viscous lidocaine, 9) subcu heparin, 10) sublingual Nitroglycerin prn, 11) glargine insulin 20 U q hs and regular insulin sliding scale. EXAM ON TRANSFER TO FLOOR: T-max 100.6, T-current 99.1, pulse 97, respirations 12, blood pressure 117/68 with a range of 86-175/32-104, pulse ox 98% on 2 liters. General - the patient was lethargic but awake, alert and oriented. HEENT shows pupils equal, reactive to light and accommodation. Bilateral white plaques in her posterior oropharynx, but mucous membranes moist. Chest clear to auscultation bilaterally. Cardiac - regular rate and rhythm, tachycardic, S1, S2, II/VI systolic ejection murmur in the left upper sternal border. Abdomen nontender, nondistended, normoactive bowel sounds. Musculoskeletal - tender left upper chest to palpation at second rib site. Extremities - no clubbing, cyanosis or edema. Skin - multiple excoriations and foot ulcer without purulent discharge. DATA UPON TRANSFER TO FLOOR: White blood count 14,000, hematocrit 28, platelets 302, MCV 94, sodium 144, potassium 4, chloride 111, bicarb 22, BUN 45, creatinine 3.5, glucose 40, retic count 1.5. Urinalysis - a few bacteria, 15 white blood cells. AST 14, ALT 19, alkaline phosphatase 201, total bilirubin 0.3, calcium 8.7, magnesium 1.8, phosphorus 3.1, amylase 201, lipase 384. CK 165, 207, 210 and 85 on [4-30] and [4-3], respectively. Troponin on [3-31]-0.5, 05/01-2.5, 05/02-1.4, and [4-3]-less than 0.3 with a peak troponin of 2.5 on [4-1]. Iron studies showed iron of 17, TIBC 300, B12 1110, folate 6.8, ferritin 156, UCG negative. Tox screen negative. Throat culture showed 1+ budding yeasts, no group A strep. Feces negative for Clostridium difficile x 1. Blood cultures on [2202-3-31] with lactobacillus, Clostridium perfringens, and coag-negative staph. Urine culture without growth. Chest x-ray unremarkable. On [2202-4-1], abdominal ultrasound normal. Echocardiogram [2202-3-31] with symmetric LVH, hyperdynamic heart. EKG [3-31] shows normal sinus rhythm at 96 with T wave inversions in II, III, AVL and V3 through V6. EKG on [2202-4-3] shows sinus tachycardia at [Street Address(2) 108292] changes, normal appearing EKG. HOSPITAL COURSE: This is a 33-year-old female with type 1 diabetes mellitus admitted with diabetic ketoacidosis, upper GI bleed with coffee ground emesis, increased troponin to 2.5, Clostridium perfringens bacteremia. The patient was initially admitted to the Fenard ICU for care of her severe diabetic ketoacidosis, and when this was under control she was transferred to the floor for further care and dispositioning. 1) DIABETES TYPE 1: DKA was treated in the Intensive Care Unit and resolved at time of call-out to the floor. However, the patient's blood sugars were labile from a low of 38 to a high of 480 while on the floor. Her Lantus dose had been decreased from her outpatient dose of 32 to her inpatient current dose of 20 q hs because of repeatedly low blood sugars in the morning, as low as 38. The patient's blood sugar was controlled with Lantus 20 q hs and qid sliding scale. The patient will be discharged on this dose of Lantus 20 q hs with qid Humalog sliding scale, and she was given this sliding scale on a paper copy. She will follow-up with the [Last Name (un) ] Diabetes Center, Dr. [Last Name (STitle) 3273], in two days after discharge for further diabetic care, as she has not been followed by an endocrinologist in the past according to her. Because of her frequent admissions for diabetic ketoacidosis, it was stressed that it was very important that the patient make this appointment at the [Last Name (un) ]. 2) BACTEREMIA: The patient grew out Clostridium perfringens, lactobacillus and coag-negative staph from her initial blood cultures. An ID consult was obtained. They had thought that the lactobacillus and coag-negative staph were likely contaminants in the setting of a femoral line being placed in the Emergency Room and on an emergent basis. The Clostridium perfringens, because of its potential virulence, was treated with clindamycin. The patient remained afebrile for the remainder of the hospitalization and will be discharged on a total 10-day course of clindamycin. A CT of the abdomen was performed to further evaluate for possible sources of the Clostridium perfringens and this was negative for any source for Clostridium. 3) UPPER GI BLEED: The patient had coffee ground emesis on admission in the setting of refractory vomiting from her diabetic ketoacidosis. The patient does have a history of [Doctor First Name ]-[Doctor Last Name ] tears, and it was likely that this coffee ground emesis was secondary to [Doctor First Name ]-[Doctor Last Name ] tears versus stress gastritis or stress ulcer. A GI consult was obtained that recommended an endoscopy prior to discharge. The patient, however, refused endoscopy this admission and was told risks of not having the endoscopy including rebleeding. She was initially given 2 units of packed red blood on admission for a hematocrit drop to 24 with appropriate increase. She was continued on [Hospital1 ] Protonix for her upper GI bleed. She will likely need an endoscopy as an outpatient. 4) INCREASED PANCREATIC ENZYMES: The patient did have increased lipase and amylase to the 300s on admission. This was not thought to be an acute pancreatitis; the patient did not have any abdominal pain. Rather, it was thought to be secondary to the acute stress, dehydration, electrolytes disturbances of DKA. These were trending down at the time of discharge. 5) CARDIAC - CAD: The patient did have inferolateral T wave inversions on admission with a troponin up to 2.5. A cardiology consult was obtained. They believed that these EKG changes and troponin leak were not acute coronary syndrome, nor signs of an MI, but rather changes in the setting of the severe electrolyte disturbances and hypovolemia associated with her diabetic ketoacidosis. Given her risk factors of hypertension and diabetes, we ordered a stress test for the patient. The patient, however, refused stress test at this time. She was explained the risks, including heart attack, of not having the stress test, and knowing her CAD status, and the patient was aware. She will be continued on her Lopressor 12.5 [Hospital1 ]. The patient has an aspirin allergy and was not continued or started on aspirin. PUMP: The patient had no signs of CHF on admission and no wall motion abnormalities on her echocardiogram with an EF greater than 75% on initial echo. She had no arrhythmias during this hospitalization. 6) BLOOD PRESSURE: The patient's blood pressure was volatile during this hospitalization in the [Hospital Unit Name 153], but was down to 80 initially with her outpatient Lopressor dose. The Lopressor was decreased to 12.5 [Hospital1 ], and the patient's blood pressure remained 100-130 systolic. 7) PHARYNGITIS: The patient did initially complain of throat pain on admission and did have two white erythematous plaques bilaterally on her posterior pharynx that were symmetric. A culture of these was obtained and was negative for group A strep. It was positive for yeast, and she was started on nystatin swish and swallow qid for question of thrush. Her sore throat was relieved. 8) DIARRHEA: The patient has chronic diarrhea that she says she has had since the early [2188]. She takes Imodium at home for this. Her Imodium was held initially because she was on clindamycin, and there was a low suspicion for Clostridium difficile. The patient had negative Clostridium difficile in her stool x 2, and was restarted on her outpatient Imodium to control her diarrhea. 9) FOOT ULCER: These were chronic, likely erythema gangrenosum. She had also been followed by podiatry for these and will follow-up with her podiatrist, Dr. [Last Name (STitle) ], next week. 10) HEME: The patient has a multifactorial anemia. She has blood loss anemia status post her GI bleed and anemia of chronic disease secondary to her chronic renal insufficiency and diabetes. Her initial iron studies were repeated after her acute illness showed an iron of 40, TIBC 239, ferritin 148, transferrin 184, all consistent with anemia of chronic disease. The patient did receive 2 units of blood transfusion initially. Her hematocrit remained stable in 27-26 range status post these blood transfusions. 11) FLUIDS, ELECTROLYTES AND NUTRITION: In the setting of her severe vomiting on admission and diabetic ketoacidosis, the patient was severely dehydrated on admission with large electrolyte losses of hyponatremia, hypophosphatemia, hypocalcemia, and was hypernatremic from her free water deficit. All of these were corrected in the ICU. She was started on a diabetic diet, and her electrolytes remained stable for the remainder of the hospitalization. DISPOSITION AND FOLLOW-UP: 1) The patient will start seeing an endocrinologist, Dr. [Last Name (STitle) 3273], at the [Last Name (un) ], in two days after discharge, [2202-4-8] @ 3:30 pm. 2) She will follow-up with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] who will be her new primary care doctor [First Name (Titles) ] [Hospital3 ], [Hospital Ward Name 23] Bldg, and this will be on Wednesday, [4-14] @ 3:00 pm for a posthospitalization visit, and a full initial visit will be scheduled at that time. 3) She will follow-up with her podiatrist [2202-4-13] @ 3:10 pm, Dr. [Last Name (STitle) ]. 4) The patient also has an appointment with her ophthalmologist in [Month (only) 216]. In terms of her diabetic management, until her appointment with [Last Name (un) ] in two days, the patient was instructed to take Lantus 20 units q hs tonight and given an insulin sliding scale, and was told to call [Company 191] at ([Telephone/Fax (1) 108293] for any blood sugars less than 60 or greater than 400, and then [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] would call her back with further instructions. This will be done until her appointment at [Last Name (un) ] in two days. She was instructed to drink fruit juice if her blood sugar was less than 60. DISCHARGE DIAGNOSES: 1) Diabetic ketoacidosis, type 1 diabetes. 2) Upper gastrointestinal bleed. 3) Bacteremia. 4) Blood loss anemia. 5) Asthma. 6) Diabetic foot ulcer. 7) Chronic diarrhea. 8) Acute on chronic renal insufficiency from prerenal failure. DISCHARGE CONDITION: Good. The patient will be discharged home with VNA for help with her medications and diabetic care as well. [Name6 (MD) ] [Name8 (MD) ], MD [MD Number(1) 34724] Dictated By:[Last Name (NamePattern1) 46676] MEDQUIST36 D: [2202-4-6] 10:27 T: [2202-4-9] 10:44 JOB#: [Job Number ]	[ "2851", "2760" ]
Admission Date: [2158-2-20] Discharge Date: [2158-4-27] Date of Birth: [2084-6-29] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 17683] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: Small bowel resection Small bowel-large bowel bypass History of Present Illness: Mr. [Known lastname ] is a 73 year old man with AIDS (CD4 126 on [12/2157]), type II diabetes mellitus, and an invasive squamous cell carcinoma of the anorectal canal (s/p chemo-radiation therapy and extensive surgery [11-12]) with chief complaint of vomiting over the last month. He says that, for about the last month, he has been vomiting now daily. He denies any blood or coffee grounds in his vomtius. He vomits food or gastric contents. He has stopped eating solid foods due to fear of vomiting. He vomits up any food that he has eaten, even up to 6 hours prior, but has been able to keep liquids and his medications down. His colostomy is working well, although he has noted an increase in bowel movements despite cutting back on his diet. He has no blood in the stools, and no black stools. Stools are liquidy brown and "cocoa -colored." He has had intermittent right lower quadrant "crampy" pain, but is not sure of the association of this with the vomiting or bowel movements. He has had no fevers, and denies night sweats. He says he has been taking all of his medications on time and as directed, and has not been eating outside of his home or had any unusual or poorly cooked meals. His partner notes that he is becoming weaker, and has to rest after walking only a few feet because he's "tired." He denies any shortness of breath. At the time of his prior office visit in [12/2157], he was going for daily walks w/o problems. His partner also thinks that Mr. [Known lastname ] also seems to be confused: Forgetting things/elements of conversations, and not following conversations. Past Medical History: 1. AIDS: He was found to be HIV positive in [2144]; his (only) risk factor is (homo-)sexual exposure(s). He has a multi-resistant virus, due to serial monotherapy in the early [2142]'s and some adherence problems thereafter. [Name2 (NI) ] is currently on a regimen of atazanavir 300 mg/day boosted by ritonavir 100 mg/day, emtrictabine 200 mg/day, tenofovir 300 mg/day, and zidovudine 300 mg po bid. His last CD4 count in [12/2157] was 126, with a corresponding viral load that was undetectable. . 2. Invasive Squamous Cell carcinoma of the Anorectal Canal: In early [4-/2157] had BRBPR. Colonscopy [2157-5-10] showed 8 mm sessile polyp in the sigmoid colon,and a fugating 3.5 cm mass just above the anal verge. The biopsies of both lesions revealed focally invasive squamous cell carcinoma. He had a complicated course since the tumor was necrotic, infected, and obstructing the rectal canal. He needed a diverting colonoscopy to be placed, and had two admissions for fevers due to infection of the tumor. In [6-12], he started radiation therapy with chemotherapy for augmentation (5- fluorouracil and cisplatin).In early [11/2157], he had an antrior/posterior resection of the primary tumor. Pathology of the tissue removed revealed foci of active tumor. . 3. DM2: Diagnosed in [2153]. This was initially treated with dietary intervention. He had been on a regimen of Actos and glyburide, but has had medications withdrawn since marked weight loss during the chemo-radiation therapy. His last glycated hemoglobin in [12-14] was 4.5%. . 4. Remote EtOH abuse:He has a history of ethanol abuse, but this has been inremission for over 10 years. . 5. Lung Nodule: He has a calcified pulmonary nodule on a chest X ray in 11/93.His sister had tuberculosis, but he had minimal exposure to her. . 6. Syphilis: He has a history of syphilis in the late [2132]'s and does not recall what therapy he received. . 7. cystic parotiditis [2152] . 8. Normal ETT MIBI: In [9-/2154], he had a CT Scan of his heart (as part of a study)that revealed extensive calcifications of his coronary arteries.He, therefore, had an exercise thallium study that revealed an EF of 62% and no perfusion defects at a 111% predicted heart rate. . 9. Hyperlipidemia:Was on statins before losing weight. . 10. COPD: "COPD" by CT scan in [2154]. Initial CT scan showed ground glass opacities. Seen by pulmonolgy at [Hospital1 18] and repeat CT scan was normal. . Past Surgical History: 1. He had some cosmetic surgery at the age of 18 to correct a scar on his head sustained in some childhood head trauma. 2. He had an appendectomy at the age of 45. Social History: Social History: He was in the Air Force, and then got a college education.After that, he moved to [State 531] and worked as an interior designer for several decades, and retired to [Location 3615], Mass. He has traveled to Europe, the Middle East, the SW USA, and [State 108]. He lives with his partner. [Name (NI) ] has several dogs at home. Tobacoo: None x 12 years, but previous 40 pack year history; EtOH: Prior alcoholism, but none for 12 years; Illicit Drugs: None. Family History: Family History: Mother who died at the age of 94. His father died at the age of 101. He has 1 sister who had tuberculosis, and 2 sisters died of breast cancer. He has one brother who has had a melanoma, and one brother has arthritis. No other disorders that he is aware of run in his family. Physical Exam: T 97.7 BP 106/60 HR 83 20 97%RA Gen: Chronically ill appearing male in no respiratory distress HEENT: Moderate facial wasting. Anictertic sclera. Conjunctivae not pale.Mucous membranes moist. Poor dentition. O/P clear. Neck: Supple, no lymphadenopathy. Thyroid smooth and not enlarged. JVP at 1cm above angle. Lungs: Clear to auscultation bilateally, no wheezes, rhonchi or rales Cor: Regular rate, nl s1 and s2, II/VI systolic murmur at the LSB. Abd: soft, non-tender (although exam in [Hospital ] clinic notable for RLQ tenderness)hypoactive BS. No masses. Ostomy site without redness. Liquid brown stool in colostomy. Ext: There is no clubbing or edema. Rectal: 2cm opening with white fluid at prximal edge of flap, no tenderness, no surrounding erythema. No drainage. No fluctuance. Otherwise well-healed flap. Neuro:Orientated x 3 to time, place, person. The cranial nerves III to XII are normal. The toes are down-going, and reflexes are equal and intact bilaterally. Strength is [4-13] and symmetric in upper and lower extremities. Brief Hospital Course: A/P 73 yo male with AIDS, DM2, invasive carcinoma of the anorectal canal s/p resection and diverting colostomy [11-12] presented with vomiting and and intermittent RLQ pain. He was diagnosed with a partial small bowel obstruction until [2-27], when his symptoms failed to resolve and a CT scan showed a transition point. He was taken to the operating room and underwent extensive lysis of adhesions and a biopsy of a small bowel mass. The operation was made much more challenging by the existence of radiation changes in his pelvis after treatment for anal cancer. His recovery was arduous, and bowel function was slow to recover. He was started on TPN. On [3-30], he developed gross hematuria, and a Urology consult recommended a cystoscopy. As a follow-up surgery was planned for [4-5], the cystoscopy was done at this time. His surgery on [4-5] consisted of an ex lap and construction of an ileocolic bypass. Cystopscopy revealed only small clot and expected inflammatory changes. Unsurprisingly, his bowel function was again slow to return. He continued TPN, and continued to have high NGT outputs. Although his ostomy output continued to be negligible, the tissue itself was viable, and there was no indication of frank obstruction. A repeat small-bowel follow through on [4-18] was negative for obstruction, and in fact the contrast could be seen freely passing from the ostomy site. On [4-19], his urine again darkened and became quite cloudy. He was fluid resuscitated and his urine color and output improved. Initially the cloudiness was concerning for a colovesical fistula, but a sterile urinalysis and subsequent clearing of the urine argue definitively against this. By [4-19] there was some return of bowel function, with evidence and gas and liquid contents in the ostomy bag, and his NGT was discontinued. The pt experienced no nausea subsequently. He resumed a diet on [4-21] and continued to tolerate this well. Although he was clearly improved, it was felt he would be unable to support himself nutritionally, and a Dobhoff feeding tube was placed on [4-25] and he was placed on Ultracal 1/2strength without fiber at 30cc/h. Unfortunately he vomited this out on [4-26]. However, he was able to increase his oral caloric intake. It is our belief that he can successfully wean off the TPN and onto regular food. At all times he should try to support himself with food intake, unless his abdominal symptoms return. Medications on Admission: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day. 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 7. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:60 9. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 10. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 11. Pioglitazone HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 13. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:qs 1* Refills:2 2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day. Disp:120 Tablet(s) Refills:2 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:qs 1 Refills:2 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:qs 1 Refills:0 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). Disp:qs 1 Refills:2 7. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). Disp:180 Capsule(s) Refills:2 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 9. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 10. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:120 Capsule(s) Refills:2 11. Pioglitazone HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Disp:30 Capsule(s) Refills:2 13. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:qs 1 Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Small Bowel Obstruction Anal Cancer Diabetes Mellitus Type II Hypertension Discharge Condition: stable Discharge Instructions: Routine Ostomy care. Physical therapy. Nutritional [Hospital 22018] Medical Management of HIV Followup Instructions: Please call Dr[Name (NI) 22019] office to schedule your follow up appointment. [Name6 (MD) 843] [Name8 (MD) 844] MD [MD Number(1) 845]	[ "486", "496", "5990" ]
Admission Date: [2119-10-30] Discharge Date: [2119-11-3] Date of Birth: [2050-6-23] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: exertional chest pain Major Surgical or Invasive Procedure: [10-30] Coronary Artery Bypass Graft x3 (Left Internal Mammary Artery > Left Anterior Descending Artery, Saphenous Vein Graft > Obtuse Marginal 1, Saphenous Vein Graft > Obtuse Marginal 2) History of Present Illness: 69 yo M with exertional chest pain that had positive stress test and 3 vessel coronary artery disease per cardiac catherization. Referred for surgical revascularization. Past Medical History: Hypertension Hyperlipidemia Anxiety Kidney stones Coronary Artery Disease Tonsillectomy Social History: retired lives alone denies tobacco denies etoh Family History: NC Physical Exam: NAD 77 16 165/91 Neck supple without carotid bruits Lungs CTAB Heart RRR, No M.R.G Abdomen Soft/NT/ND, +BS Extrem warm, no edema, no varicosities Pertinent Results: [2119-11-3] 07:25AM BLOOD WBC-7.8 RBC-3.47* Hgb-11.0* Hct-32.7* MCV-94 MCH-31.8 MCHC-33.7 RDW-13.3 Plt Ct-198 [2119-10-30] 10:54AM BLOOD WBC-12.6# RBC-3.19# Hgb-10.0# Hct-29.9 MCV-94 MCH-31.3 MCHC-33.3 RDW-13.1 Plt Ct-213 [2119-11-3] 07:25AM BLOOD Plt Ct-198 [2119-10-30] 10:54AM BLOOD Plt Ct-213 [2119-10-30] 12:28PM BLOOD PT-13.6* PTT-45.2* INR(PT)-1.2* [2119-11-3] 07:25AM BLOOD Glucose-108* UreaN-20 Creat-0.9 Na-138 K-4.1 Cl-102 HCO3-29 AnGap-11 [2119-10-31] 02:07AM BLOOD Glucose-134* UreaN-12 Creat-0.8 Na-133 K-5.3* Cl-104 HCO3-25 AnGap-9 [2119-11-2] 07:30AM BLOOD Mg-2.1 [2119-10-31] 02:07AM BLOOD Mg-2.9* RADIOLOGY Final Report CHEST (PORTABLE AP) [2119-11-1] 8:13 AM CHEST (PORTABLE AP) Reason: r/o ptx [Hospital 93] MEDICAL CONDITION: 69 year old man with CABG and ct removal REASON FOR THIS EXAMINATION: r/o ptx HISTORY: CABG with chest tube removal, to assess for pneumothorax. FINDINGS: In comparison with study of [10-30], the left chest tube has been removed. No evidence of pneumothorax. The patient has taken a much poorer inspiration. There are bibasilar atelectatic changes, more marked on the left. DR. [Known firstname 1569] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11006] Approved: WED [2119-11-1] 11:11 AM Cardiology Report ECG Study Date of [2119-10-30] 3:45:12 PM Baseline artifact. Sinus rhythm at a rate of about 60 beats per minute. Borderline low voltage diffusely. Slight ST segment elevations consistent with early repolarization variant. Compared to previous tracing of [2119-10-20] no diagnostic change. Read by: [Last Name (LF) 22387],[First Name3 (LF) ] L. Intervals Axes Rate PR QRS QT/QTc P QRS T 61 152 90 378/379 48 24 32 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 74674], [Known firstname 1569] [Hospital1 18] [Numeric Identifier 74675] (Complete) Done [2119-10-30] at 8:40:05 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: [2050-6-23] Age (years): 69 M Hgt (in): 64 BP (mm Hg): 123/74 Wgt (lb): 148 HR (bpm): 55 BSA (m2): 1.72 m2 Indication: Intra-op TEE for CABG ICD-9 Codes: 745.5, 786.51, 440.0, 424.1 Test Information Date/Time: [2119-10-30] at 08:40 Interpret MD: [Name6 (MD) 928] [Name8 (MD) 929], MD, MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 929], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: 4.0 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.4 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic interatrial septum. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. The left atrium is normal in size. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). 7. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine 1. Biventricular systolic function is preserved 2. Aortic contours are intact post decannulation 3. Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 928] [Name8 (MD) 929], MD, MD, Interpreting physician Brief Hospital Course: Mr. [Known lastname ] was taken to the operating room on [10-30] where he underwent a CABG x 3. He was transferred to the ICU in stable condition. He awoke and was extubated later that same day. He was weaned from his neosynephrine by POD #2, and he was transferred to the floor. On POD 2 he had rapid atrial fibrillation for which he was given IV lopressor and was started on an amiodarone drip. He converted and remained in normal sinus rhythm. Physical followed patient during entire post-op course for strength and mobility. He continued to make steady process without any further post-op complications and was discharged home with VNA services on post-op day four. Medications on Admission: Plavix 75', Simvastatin 20', Atenolol 25', Amlodipine 5', Aspirin 325', Cod liver oil daily, Garlic pills daily, Vitamin E 400 IU daily, MVI daily 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. 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 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): please take 400mg twice a day until [11-8] then decrease to 400mg once a day until [11-15], then decrease to 200mg daily and follow up with cardiologist. Disp:80 Tablet(s) Refills:0 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 5 days. Disp:10 Capsule, Sustained Release(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: caregroup vna Discharge Diagnosis: Coronary Artery Disease s/p CABG Post operative Atrial Fibrillation Hypertension Hyperlipidemia Anxiety Kidney stones Discharge Condition: Good. Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule all appointments Dr. [First Name (STitle) 26317] in 2 weeks [Telephone/Fax (1) 26318] Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) ] 2-3 weeks Wound check appointment [Hospital Ward Name 121] 2 - please schedule with RN [Telephone/Fax (1) 3633] Completed by:[2119-11-3]	[ "41401", "9971", "42731", "4019", "2724" ]
Admission Date: [2107-1-11] Discharge Date: [2107-1-30] Date of Birth: [2060-3-23] Sex: M Service: Medical Intensive Care Unit. CHIEF COMPLAINT: Headache, fever, altered mental status. HISTORY OF PRESENT ILLNESS: 46 year old with ten day history of fevers and emesis times one. His headache initially started on [2107-1-2], when he was evaluated at a [Hospital 11074] clinic without any significant interventions occurring. The headache did not improve over the next few days and he presented to an outside hospital on [2107-1-5]. He was found to be febrile with temperature to 100.1. His course at the outside hospital included a CT of the head and a magnetic resonance scan of the brain and spinal cord, which were both negative, except for nonspecific microangiopathic findings on the magnetic resonance scan. He had two lumbar punctures at the outside hospital which showed between 2 and 16 white blood cells with 90% lymphocytes and a total protein of 196 and glucose of 40. There were 57 red blood cells seen in tube #4 on the initial lumbar puncture. Gram stain and cerebrospinal fluid culture were negative, as well as a negative Acid fast bacilli PCR of the cerebrospinal fluid. He was started on Acyclovir due to concern for HSV encephalitis which was stopped after two days when his HSV cerebrospinal fluid titers came back negative. Acyclovir was then restarted on [2107-1-7] and was continued until date of admission to [Hospital1 69]. An EEG was also performed during his hospitalization at the outside hospital, which showed nonspecific abnormalities but no epileptiform activity. His mental status initially improved during the first few days of admission at the outside hospital, however, this deteriorated over the last four days prior to transfer per family's report. Of note, on the previous admission, he was noted to have an ileus which was thought secondary to abrupt cessation of his SSRI. On [2107-1-10], he had an episode of desaturation to 84%. An arterial blood gases was performed which showed hypercapnia with a PC02 of 70 and he was, therefore, electively intubated for airway protection. Upon presentation to [Hospital1 69], he was intubated and unresponsive, despite being off sedation. His family states that he has no other recent complaints prior to hospitalization at the outside hospital. They have not noticed any focal neurologic deficits, diarrhea, night sweats, rash or weight loss. He had no recent vaccinations or ill contacts. There were no rashes noted. PAST MEDICAL HISTORY: 1.) Pulmonary tuberculosis, diagnosed [2101-8-19], treated with nine months of INH, Rifampin and Pyrazinamide. Sensitive testing revealed no resistance for drug therapy. 2.) Depression. 3.) History of hepatitis B. SOCIAL HISTORY: The patient is originally from [Country 3992]. He moved to the U.S. nine years ago. He has been living with his two brothers since. [Name2 (NI) ] speaks minimal English but understands English when spoken to. He is unemployed but previously worked at [Doctor First Name 11492]. He is a former smoker and quit nine years ago. Family states that the patient does not use alcohol or intravenous drugs. ALLERGIES: No known drug allergies. MEDICATIONS: Zoloft 100 mg q. day. Zyprexa 10 mg q. day. Tylenol. MEDICATIONS ON TRANSFER: Acyclovir 600 mg q. eight hours. Peri-Colace one tablet p.o. twice a day. Calcium carbonate 1,250 mg p.o. three times a day. Pepcid 20 mg q. day. PHYSICAL EXAMINATION: Vital signs on admission to the Intensive Care Unit revealed temperature of 98.8; blood pressure 138/78; heart rate 98; respiratory rate 12. Oxygen saturation 94%. Ventilatory settings SIMV tidal volume 500. Respiratory rate of 12. PEEP of five. FI02 of 40%. In general, the patient is intubated and sedated. He would follow occasional commands. His neck is extremely stiff with decreased range of motion in all directions. His left pupil was constricted but reactive. His left pupil was sluggish and minimally reactive. He had no thyromegaly. His sclera were anicteric. On lung auscultation, breath sounds were decreased throughout but he was otherwise clear to auscultation. Cardiovascular: Regular rate, normal S1 and S2, no mitral regurgitation. Abdominal examination: Soft, mildly distended, decreased bowel sounds but no appreciable hepatosplenomegaly. Extremities: No cyanosis, clubbing or edema. 2+ dorsalis pedis and posterior tibial pulses bilaterally. No apparent rash. Neurologic: He responds to tactile stimuli. He is off sedation but very lethargic. He moved all four extremities. LABORATORY DATA: White blood cells of 8.2; hemoglobin of 15.6; hematocrit of 42.2. Differential revealed 77 neutrophils, 18% bands, 2% lymphocytes. Platelets 279; PT of 12.6; PTT 33.3; INR of 1.1. Sodium of 134; potassium of 4.0; chloride 92; bicarbonate 31; BUN 32; creatinine 0.9; glucose 133. ALT 44; AST 92; LDH 340. CPK was 2265; alkaline phosphatase 61; total bilirubin 1.2; CK MB 23. Index 1.0; calcium 8.2; phosphorus 2.4; magnesium 2.4; albumin 3.4; ammonia level was 36. LABORATORY DATA: RPR nonreactive. Cryptococcal antigen was non detectable. Rubeola IGG was positive. Toxoplasma IGM and IGG was negative. Acid fast bacilli sputum smear was negative times three. Cryptococcal antigen cerebrospinal fluid was negative. Cerebrospinal fluid gram stain was negative. Cerebrospinal fluid fluid culture was negative. Cerebrospinal fluid viral culture negative. CMV IGM antibody negative. CMV IGG positive. HSV serum IGG positive. Tuberculosis, PCR CSF negative. Coccsoidy antibody negative. Urine Histoplasma negative. HIV antibody and HIV viral load both negative. Blood cultures negative times nine sets. Cerebrospinal fluid analysis on [2107-1-12] revealed white blood cell count of 34; red blood cells of 12; 77% polys, protein of 115 and glucose of 41. Cerebrospinal fluid [2106-1-21] revealed white blood cells of 8; red blood cells of 7; 88% lymphs, protein 110; glucose 48; LDH 60. RADIOLOGY DATA: CT of chest on [2107-1-12] revealed multifocal pattern of consolidation, involving upper lobes and superior segments of lower lobes. Reactivation tuberculosis and differential diagnosis as well as aspiration and atypical pneumonia. Small right sided effusion. No cavitary abscesses within the lung. CT head on [2107-1-12]: No hemorrhage, mass or abscess. Magnetic resonance scan of head on [2107-1-18] revealed no abnormal meningeal enhancement, chronic inflammatory pan sinus disease; small tiny foci of G2 hyperintensity within the right basal ganglia which are nonspecific in appearance, possibly related to small vessel changes. Other considerations include demyelinating process and most likely vasculitis or HIV encephalopathy. Chronic deformity of right eye globe, related to either old trauma or prior inflammatory disease. Magnetic resonance scan of the spine on [2107-1-21] revealed no evidence of epidural abscess or spinal cord compression. 2.2 times 8.4 cm enhancing soft tissue fluid collection in the lower neck. CT of the abdomen and pelvis on [2107-1-25] revealed focal fatty infiltration of the liver. No other abdominal or pelvic pathology. IMPRESSION: 46 year old with history of tuberculosis, presenting with headache, fever and altered mental status at outside hospital. Transferred to [Hospital1 190] for further evaluation. HOSPITAL COURSE: 1.) Infectious disease. His constellation of headache, fever, meningismus and altered mental status made leading diagnosis meningeal encephalitis. The differential diagnoses included bacterial meningitis, tuberculosis meningitis, HSV encephalitis, cryptococcus; HIV encephalitis and acute disseminating encephalomyelitis. All of the diagnoses listed above, except for ADM were ruled out with multiple serologic and cerebrospinal fluid testing. His cerebrospinal fluid, acid fast bacilli, PCR, although not completely sensitive test, came back negative on at least two occasions. His sputum was acid fast bacilli negative times three, after concern was raised on chest CT that there were signs of possible reactivation tuberculosis. He was on anti-tuberculosis medications for approximately four days while reactivation tuberculosis was ruled out. Serial lumbar punctures showed improvement in Pleocytosis, however, continued elevated protein and decreased glucose. Gram stains were continued to be negative. He completed a 21 day course of Acyclovir for possible HSV encephalitis. In addition to meningoencephalitis, he was also treated for fourteen days of Ceptaz for hospital acquired ventilator associated pneumonia. He was also treated with Nystatin and Fluconazole for oral thrush. Throughout the hospitalization, he had occasional episodes of hypothermia with p.o. temperatures measuring in the low 90's. Blood cultures taken during these episodes continued to be negative and it was unclear the etiology of the hypothermia. 2.) Pulmonary. The patient was intubated at the outside hospital for airway protection. He has a history of insensitive pulmonary tuberculosis. He completed a nine month course and was ruled out for reactivation during the hospitalization. He was extubated on [2107-1-16] and reintubated the same evening for low tidal volumes and respiratory distress. He continued having difficulty being weaned from the ventilator and was unable to generate large tidal volumes with minimal pressure support, likely secondary to respiratory muscle weakness. Therefore, a tracheostomy was placed on [2107-1-27] and he was weaned to tracheostomy mask ventilation the following day. He has done very well on the tracheostomy and is currently being weaned with poor cough and thick secretions being limiting factors. 3.) Neurology. As stated above, patient with presumptive diagnosis of meningoencephalitis of unclear etiology. A CT scan of the head was performed on [2107-1-13] which was within normal limits. He had no significant elevated opening pressure on lumbar puncture and cerebrospinal fluid studies showed no organism pleocytosis with elevated protein and decreased glucose. EEG was performed on [2107-1-13] and showed no evidence of seizure activity but generalized encephalopathy. His mental status improved significantly in the final two weeks of his hospitalization although he did have occasional episodes of agitation. A Magnetic resonance scan of the brain was performed on [2107-1-8] which showed no meningeal enhancement and possible ischemic disease and dullness basal ganglia. On [2107-1-20], he had an episode of hypotension and hypothermia which raised concern for spinal shock, prompting an magnetic resonance scan of the spine which revealed no evidence of abscess or spinal cord compression. EMG was performed on [2107-1-24], secondary to weakness of the lower extremities. The EMG showed polyneuropathy with axonal distribution and mild asymmetry which raised the concern for mononeuritis multi-plex. Although this was felt likely related to his meningoencephalitis, no unifying diagnosis could be established. His lower extremity weakness improved and it was not felt that further imaging studies were needed. At the time of dictation, he still had some residual lower extremity weakness, with the left mildly weaker than the right. His mental status, however, was markedly improved from admission and per family report was approaching baseline condition. 4.) Cardiovascular. During hospitalization, the patient had occasional episodes of hypotension with systolic blood pressures falling into the low 70's. On most occasions, these responded to intravenous fluid boluses. Dopamine was transiently used for occasions which his blood pressures did not respond to fluid boluses. Given the hypotension and hypothermia, there was concern for adrenal insufficiency and a cortisol stimulation test showed a starting cortisol level which was significantly decreased at 1.3. He was, therefore, started on Hydrocortisone and transitioned to Prednisone for a taper, starting on [2107-1-30]. An echocardiogram was performed on [2107-1-20] which showed an ejection fraction of greater than 55% and no valvular abnormalities. His Dopamine was discontinued completely on [2107-1-28] and he did well with systolic blood pressures in the 100 to 110 range for the remainder of his hospitalization. It was thought that given his size, this was probably his baseline blood pressure. 5.) Renal. The patient had significant urine output in the second half of his hospitalization with, at times, greater than 400 cc an hour of urine output sustained for a number of hours. There was some concern for a neurogenic process such as diabetes insipidus given his overall clinical picture. This, however, was not the case as urinalysis were performed and found to be 400. The renal team was consulted and felt that his urine output was secondary to mobilization of fluid and recommended limiting his intravenous fluids. By the time of dictation, his urine output was appropriate at about 30 to 50 cc an hour and his Foley was discontinued. 6.) Endocrinology. As discussed above, the patient was treated with Hydrocortisone 100 mg q. six hours times seven days for sepsis related adrenal insufficiency. Thyroid function tests were also performed and showed a decreased T3, progressively falling TSH but a normal free T3-4. These findings were likely consistent with sick thyroid and he was not treated. At the time of dictation, the patient had been discontinued from Hydrocortisone and began a Prednisone taper which will last over the next two weeks. He was continued on Reglan sliding scale, secondary to hyperglycemia from steroid use. 7.) FEN/Gastrointestinal. Prior to transfer to the outside hospital, patient with diagnosed ileus. His abdomen was firm with decreased bowel sounds and with comorbid conditions. A CT of the abdomen was performed to rule out abdominal pathology. The CT of the abdomen showed no significant abnormalities aside from fatty infiltrative liver. Rectal examination showed no signs of impaction. Although he did not move his bowels for the first few days of hospitalization, once the tube feedings were initiated, he had adequate stool output. His liver function tests were slightly elevated on admission but his hepatitis panel was negative except for hepatitis B surface antibody and hepatitis A IGG. It was felt that these were both chronic in nature. His nitrogen balance, once at goal tube feeds, was calculated to be -2 grams, which was within normal limits, considering his critical condition. At the time of dictation, he was still continued on Criticare tube feeds, at a goal of 65 cc per hour. A speech and swallow study was pending for possible p.o. intake. Of note, Clostridium difficile and stool viral cultures were all negative on multiple occasions, performed secondary to diarrhea. 8.) Psychiatry. Per family, patient with severe depression on Zoloft and Zyprexa at home. Once he was stabilized, his Zoloft was restarted. After extubation, he was agitated, mostly at night and his Zyprexa was restarted at 5 mg q. hs as well as Haldol 2 mg prn during the day. DISCHARGE DIAGNOSES: Meningioencephalitis, likely viral in etiology. Sepsis. Hospital acquired pneumonia. Status post tracheostomy for respiratory muscle weakness. Polyneuropathy, status post EMG. Sepsis induced adrenal insufficiency. History of hepatitis B. History of tuberculosis. Depression. A subsequent discharge summary will be dictated at the time of discharge with a complete list of medications and discharge instructions. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7585] Dictated By:[Last Name (NamePattern1) 6240] MEDQUIST36 D: [2107-1-30] 11:42 T: [2107-1-31] 05:35 JOB#: [Job Number 31172]	[ "51881", "486", "0389", "311" ]
Admission Date: [2198-5-21] Discharge Date: [2198-6-12] Date of Birth: [2168-1-12] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: headache Major Surgical or Invasive Procedure: Subfrontal craniotomy for resection of tumor History of Present Illness: 30 yo M with a history of a growth hormone secreting pituitary macroadenoma s/p resection in [2195], hypothyroidism, diabetes, and adrenal insufficiency, who presents with intermittent blurry vision and headache since yesterday. Pt notes headache localized to the top of the head and behind the eyes more pronounced on the left. Pain incrased with eye movement particularly with left lateral gaze. Denies loss of vision or visiual deficits however notes general blurriness to vision. He denies any stiff neck, recent trauma,increased weakness of extremitites, new neurologic symptoms including new weakness/numbness, nausea, fevers/chills, cough. Denies any changes to speech, memory, gait. . He presented to OSH, where head CT was consistent with stable 1.7 X1.5 cm hyperdense sellar and suprasellar mass present . He was transferred to [Hospital1 18] for neurosurgery evaluation. . In the ED initial vital signs were 97.7 74 128/86 12 98% 3L. Neurosurgery was consulted who recommended MRI with and without contrast. The patient was given 1mg IV dilaudid. MRI performed and patient transferred to the floor. . Review of Systems: (+) Per HPI (-) Review of Systems: GEN: No fever, chills, night sweats, recent weight loss or gain. HEENT: No headache, sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness, palpitations. PULM: No cough, shortness of breath, or wheezing. GI: No diarrhea, constipation or abdominal pain. No recent change in bowel habits, no hematochezia or melena. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. DERM: No rashes or skin breakdown. NEURO: No numbness/tingling in extremities. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: 1. panhypopituitarism secondary to growth hormone secreting macroadenoma. 2. Diabetes mellitus with hemoglobin A1c of 17. 3. History of sleep apnea, diagnosed recently. 4. History bacteremia with coag-negative staphylococcus, resistant to oxacillin. 5. Adrenal insufficiency. 6. Hypothyroidism. 7. Diabetes insipidus. 8. Growth hormone-secreting pituitary macroadenoma status post resection. 9. Acromegaly. 10. Superficial septic thrombophlebitis with bacteremia. 11. He has had some history of vaccination as in childhood with right arm deformity. 12. CRANIOTOMY with resection of pituitary macroadenoma, [2196-10-28] 13. chronic left MCA territory infarct Social History: He is an illegal immigrant from [Country 6257] who has lived in [Location (un) 29158] for the past eight years. He does not currently work. He does not drink alcohol. He used to smoke one pack per day of cigarettes, but has not smoked since his hospitalization. He drinks mostly decaf coffee, and reports no illicit drug use. Family History: Patient is unaware of any history of diabetes or other endocrinopathies. Physical Exam: On admission: VS: 130/100, 76, 18, 99%3L GEN: AOx3, NAD HEENT: PERRLA. MMM. Macroglossia. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [Doctor Last Name 515] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in L extremities. DTRs 2+ BL in patella/biceps. sensation intact to LT, cerebellar fxn intact to rapid alternating movements. gait WNL. Right arm is held flexed at elbow and wrist.Right UE [4-3] compared to LUE [5-3]. [Month/Day (1) 12588] fields grossly intact. Pain with eye movement to the left lateral side. Pertinent Results: On admission: [2198-5-21] 01:40PM BLOOD WBC-5.2# RBC-4.03* Hgb-10.4* Hct-31.2* MCV-77# MCH-25.9 MCHC-33.4 RDW-16.2* Plt Ct-326 [2198-5-21] 01:40PM BLOOD Neuts-52.1 Lymphs-36.8 Monos-4.8 Eos-5.6* Baso-0.7 [2198-5-21] 01:40PM BLOOD Glucose-265* UreaN-16 Creat-0.5 Na-136 K-4.1 Cl-100 HCO3-24 AnGap-16 [2198-5-23] 07:35AM BLOOD ALT-23 AST-14 AlkPhos-104 TotBili-0.3 [2198-5-22] 06:40AM BLOOD Calcium-9.6 Phos-4.7* Mg-1.6 [2198-5-21] 01:40PM BLOOD calTIBC-662* Ferritn-6.3* TRF-509* [2198-5-22] 06:40AM BLOOD %HbA1c-10.5* eAG-255* [2198-5-23] 07:35AM BLOOD Triglyc-373* HDL-55 CHOL/HD-4.4 LDLcalc-112 LDLmeas-148* [2198-5-23] 07:35AM BLOOD Triglyc-373* HDL-55 CHOL/HD-4.4 LDLcalc-112 LDLmeas-148* [2198-5-22] 06:40AM BLOOD Prolact-5.7 [2198-5-22] 06:40AM BLOOD T4-7.6 T3-120 [2198-5-23] 07:35AM BLOOD Cortsol-18.6 [2198-5-23] 07:35AM BLOOD PSA-0.1 . Imaging: [5-21] MRI: Evaluation of the sella reveals marked interval enlargement of the residual pituitary adenoma centered in the left sella, with suprasellar and left cavernous sinus extension. The sella remains expanded. The pituitary mass measures 2.6 CC x 1.8 AP x 1.7 TRV cm, with extension into the medial aspect of the left cavernous sinus, abutting the medial aspect of the cavernous left carotid, and surrounding approximately 270 degrees of the supraclinoid left carotid after it exits the cavernous sinus. The left optic nerve is difficult to follow, but appears encased by the suprasellar and sellar portions of the mass in the prechiasmatic region. The visualized portions of the optic nerve does have normal signal. The tumor insinuates between the prechiasmatic portions of the optic nerves with mild mass effect upon the right prechiasmatic optic nerve as well. The left A1 segment is at least partially encased by the mass, and the mass displaces the A2 segment anteriorly and abuts these vessels. Chronic post-operative changes are seen in the left subfrontal and pterional region from craniotomy with duraplasty. The floor of the sella remains displaced inferiorly. However, there is no definite evidence of extension into the sphenoidal sinus, nor is there evidence of extension into the left infratemporal fossa. The remainder of the brain is significant for chronic left MCA territory infarct. No other mass is seen. Major intracranial flow voids are preserved, including the left internal carotid where it is partially surrounded by the mass. IMPRESSION: Significant interval enlargement of the residual pituitary macroadenoma centered in the left pituitary with suprasellar and left cavernous sinus extension. CT Head [6-1] Status post left frontal craniotomy with expected post-surgical pneumocephalus. Small amount of residual hyperdense material in the resection bed could represent mass versus hemorrhage. MRI [6-2] At the margin of surgical cavity blood products are seen. There is a residual area of enhancement measuring 10 x 7 mm visualized in the left suprasellar region adjacent to the brain. Blood products and small subdural collection are identified from recent surgery. There remain blood products adjacent to the left optic nerve and optic side of the optic chiasm.Soft tissue changes are seen in the visualized sphenoid sinuses secondary to surgery. Brief Hospital Course: Mr [Known lastname ] is a 30 yo M with a history of a growth hormone secreting pituitary macroadenoma s/p resection in [2195], hypothyroidism, diabetes, and adrenal insufficiency, who presented with intermittent blurry vision and headache of 1 day duration found to have regrowth of pituitary macroadenoma with new [Year (4 digits) ] deficits. . #Pituitary Macroadenoma: MRI head demonstrated significant interval enlargement of the residual pituitary macroadenoma, and [Year (4 digits) ] field testing showed new R eye deficit. Endocrine was consulted and started pt on Somatostatin LAR 10mg IM qmo (first dose 5/24). Neurosurgery was consulted and felt that pt is a surgical candidate given mass effect and new deficits. Pain was controlled with oxycodone prn. No evidence of cosecretion with prolactin. ACTH, IGF-1, HGH pending. On [6-2] he underwent a subfrontal craniotomy for resection of suprasellar mass. Post operatively he was transferred to the ICU for further care including strict blood pressure control and neuro monitoring. He was left intubated in preparation for repair of CSF leak as he had consistent rhinorrhea. On [6-4] a lumbar drain was placed since the amount of rhinorrhea had significantly decreased. After remaining on bedrest for 24hrs with the drain in place, he had no drainage from his nose. On [6-6] he again had no drainage from his nose so he was cleared to advance his diet. On [6-8] his lumbar drain was removed without complication. He was transferred to the floor in stable condition. While on the floor the patient was noted to be draining clear fluid from the nose. On [2198-6-10] he was made NPO in preparation for the O.R on [6-11] for repair of CSF leak. He was found to no longer be leaking CSF so his OR was placed on hold . #Diabetes Mellitus: Unlcear what home meds pt was taking (clearly poorly controlled given HgA1d 10.7%) but these were held and he was started on Insuline therapy with the guidance of the endocrine team. He was on lantus and insulin sliding scale. His lantus dosing was changed to 40 [Hospital1 ]. On the evening of [6-10] his lantus dosing was changed to 26 units [Hospital1 ] as he was NPO. The dosing returned to 40 [Hospital1 ] after he was canceled for the OR. . #Adrenal Insufficiency: Continued hydrocortisone 20 mg in AM, 10 mg in afternoon. On [6-10] he was changed to hydrocortisone 100mg IV q8 hours per endocrinology rec's in preparation for his repeat craniotomy which ltimately did not occur. . #Diabetes Insipidus: Pt was continued on home desmopressin 0.1mg TID however Na decreased from 136 to 131 o/n so desmopressin was held, then restarted at 0.1mg qHS and sodium stabilized. On [6-4] he required additional DDAVP for increased urine output and it responded appropriately. On [6-6] his DDAVP was increased to [Hospital1 ] dosing and on [6-8] back to QHS dosing. . #Hypothyroidism: Continued home synthroid. . #. Microcytic Anemia: Long standing anemia however MCV down to 77. Iron studies showed iron low nl, ferritin low, TIBC high. Should be started on iron as an outpatient. . #Sleep Apnea: Pt has central sleep apnea so needs 4L supplemental oxygen overnight. Previous sleep study showed increased apnea with cpap. Has been using a friend's nasal cpap at home. Needs outpt sleep study after discharge. He remained intubated post op until [6-5] due to extreme difficulty with intubation, and concern for possible need to return to the OR. . #. Blurry vision; likely [1-31] macroadenoma encroaching on the optic chiasm, possibly exacerbated by hyperglycemia. . # FEN: Diabetic diet, replete electrolytes PRN . # PPx: - Pain control: Tylenol, oxycodone Morphine for breakthrough - Bowel regimen: senna and colace - DVT PPx: heparin sc . # Comm: [Name (NI) ] (brother) [Telephone/Fax (1) 84695] [Doctor Last Name ] (Father) [Telephone/Fax (1) 84696] . # Code: FULL On [6-12] he was deemed fit for discharge to home and was given instructions for follow-up Medications on Admission: Metoprolol 100mg [Hospital1 ] Metformin 1000mg qAM, 1500mg qPM Lisinopril 10mg daily Hydrocortisone 20mg qAM, 10mg q4pm Levothyroxine 75mcg 1 tab daily Amlodipine 10mg 1 tab daily Famotidine 20mg [Hospital1 ] Glipizide 10mg [Hospital1 ] Pioglitazone 13mg daily Desmopressin 0.1mg TID Insulin Humulin Sliding scale Omeprazole 20mg daily Insulin NPH (30u qAM, 25u qPM) Discharge Medications: 1. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:90 Tablet(s) Refills:2 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 6. hydrocortisone 20 mg Tablet Sig: see below Tablet PO QPM (once a day (in the evening)): Take 1 tab QAM and 0.5 tabs QPM. Disp:90 Tablet(s) Refills:2 7. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty (40) units Subcutaneous Breakfast and bedtime. Disp:1 pen Refills:2 8. Humalog KwikPen 100 unit/mL Insulin Pen Sig: See Sliding Scale Subcutaneous per sliding scale: per sliding scale given to patient. Disp:1 pen Refills:2 9. lancets Misc Sig: One (1) lancet Miscellaneous when checking blood glucose. Disp:1 box Refills:2 Discharge Disposition: Home Discharge Diagnosis: Pituitary macroadenoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [7-8] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please contact your primary care physician to be seen in 1 week ?????? You will be contact[Name (NI) ] by the endocrinology office to schedule a follow-up appointment ??????You have an appointment in the Brain [Hospital 341] Clinic on [6-18] @ 3pm. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. ??????You will not need a CT scan of the brain without contrast. ??????You will not need an MRI of the brain with/ or without gadolinium contrast. Completed by:[2198-6-12]	[ "2449", "25000", "32723" ]
Admission Date: [2131-1-1] Discharge Date: [2131-1-11] Date of Birth: [2083-8-23] Sex: F Service: CARDIOTHORACIC Allergies: Demerol Attending:[First Name3 (LF) 5790] Chief Complaint: Mucosa defect main carina Major Surgical or Invasive Procedure: [2131-1-1]: Flexible bronchoscopy. [2131-1-3]: Flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy and repair of tracheobronchial laceration with intercostal muscle flap buttress and pericardial fat pad buttress under cardiopulmonary bypass. [2131-1-3]: Institution of femoral vein to femoral artery cardiopulmonary bypass to facilitate radical tracheal and bilateral main stem bronchus reconstruction. [2131-1-3]: Right Bronch 14 mmm stent placed [2131-1-5]: Flexible bronchoscopy. Therapeutic aspiration of secretions. [2131-1-6]: Flexible bronchoscopy. Therapeutic aspiration of secretions. History of Present Illness: Mrs. [Known lastname 17881] is a 47 yoF w/ min smoking hx and severe TBM. Underwent rigid bronch [2130-12-28] with attempted Y stent placement. The stent deployed normally in the RMS, however, it was unable to unfold in the LMS and during manipulation of stent a mucosa defect was noted in the LMS (1-2.5cm) and small defect in the RMS (<5mm). She received IV abx Thurs-Sat and was d/c from hospital saturday afternoon on augmentin and fluconazole. She returned today for f/u bronch before traveling home to [State ]. During flex bronch today, her mucosa defect was noted to have worsened and now involves the main carina. Clinically, she feels better and denies: f/c/ns. She has baseline cough which was productive of yellow sputum yesterday, clear today. Past Medical History: Hiatal hernia GERD s/p lap Nissen fundoplication [11-2] [Hospital1 ] Hashimoto Thyroiditis, Hypothyroidism Mid thoracic vertebral fx @ age 15, s/p TLSO Social History: Married live with family. Director of Ancillary [Hospital 81944] Hospital Tobacco remote history ETOH: occasional Family History: Father - asthma Sister w/ asymptomatic pulm sarcoidosis Grandma w/ late onset leukemia Physical Exam: VS: T: 99.1 HR: 84 SR BP: 100/60 Sats: 97% RA General: 47 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, no lymphadenopathy Card: RRR Resp: decreased breath sounds with [Last Name (un) ] crackles at bases GI: abdomen benign Extr: warm no edema Incision: R. Thoracotomy site clean dry intact. no eythema. Right groin clean dry intact. Neuro: non-focal Pertinent Results: [2131-1-10] Hct-23.3* [2131-1-9] WBC-10.9 RBC-2.37* Hgb-7.0* Hct-20.7* Plt Ct-457* [2131-1-8] WBC-9.8 RBC-2.22* Hgb-6.8* Hct-19.3* Plt Ct-413 [2131-1-7] WBC-10.4 RBC-2.03* Hgb-6.3* Hct-17.7* Plt Ct-265 [2131-1-5] WBC-15.9* RBC-2.33* Hgb-6.9* Plt Ct-204 [2131-1-1] WBC-9.1 RBC-4.54 Hgb-13.5 Hct-38.3 Plt Ct-358 [2131-1-11] Glucose-135* UreaN-9 Creat-0.8 Na-135 K-4.3 Cl-98 HCO3-26 [2131-1-10] Glucose-103 UreaN-6 Creat-0.7 Na-140 K-4.4 Cl-102 HCO3-30 [2131-1-9] Glucose-110* UreaN-5* Creat-0.6 Na-140 K-4.3 Cl-105 HCO3-29 [2131-1-8] Na-139 K-3.7 Cl-103 [2131-1-5] Glucose-138* UreaN-7 Creat-0.6 Na-140 K-4.0 Cl-107 HCO3-30 [2131-1-1] Glucose-101 UreaN-10 Creat-0.8 Na-140 K-3.7 Cl-105 HCO3-23 [2131-1-11] Calcium-8.9 Phos-3.4 Mg-1.9 [2131-1-5] LD(LDH)-571* TotBili-0.4 DirBili-0.1 IndBili-0.3 [2131-1-1] ALT-8 AST-13 LD(LDH)-181 AlkPhos-63 TotBili-0.4 DirBili-0.1 IndBili-0.3 [2131-1-6] calTIBC-174* Ferritn-157* TRF-134* CXR: [2131-1-11]: Right upper lobe aeration has improved. Right mediastinal enlargement is stable. Cardiac size is normal. The left lung is clear. There is no pleural effusion. Right pneumothorax is not identified on today's examination. [2131-1-8]: One of the two right lower chest tubes has been removed in the interim. There is no evidence of pneumothorax. There is no evidence of accumulation of pleural fluid. The cardiomediastinal silhouette is stable and the lung aeration is well preserved [2131-1-7]: IMPRESSION: Increased airspace disease in two distinct locations. Atelectasis versus pneumonia [2131-1-5]: The three right chest tubes are in unchanged positions. There is no evidence of pneumothorax. There is no evidence of pneumomediastinum. Small amount of right chest wall air is noted, unchanged. Left basal opacity is present that may represent atelectasis/aspiration and it is new compared to the prior study. [2131-1-9]: Video-swallow Oropharyngeal swallow was functional, without episode of aspiration. One episode of trace deep penetration occurred with straw sips of thin liquids only. Path: [2131-1-3] SUBMITTED: level 7 lymph nodes. No malignancy identified. Brief Hospital Course: Mrs. [Known lastname 17881] was admitted on [2131-1-1] for a complex carinal (+LMSB/RMSB) laceration. Thoracic surgery was consulted and recommended repair with CPB/ECMO support. Cardiac surgery was then consulted for CPB/ECMO. On [2131-1-3] she underwent successful Flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy and repair of tracheobronchial laceration with intercostal muscle flap buttress and pericardial fat pad buttress under cardiopulmonary bypass. A 14 mm Y stent was cut to the predetermined sizes at roughly 3 cm on the left limb, a beveled 2 cm uptake on the right limb and a 4 cm length in the trachea to cover the initial injury. She tolerated the procedure. She was transferred to the intensive care unit and extubated later without difficulty. She had 2 pleural chest tubes and 1 mediastinal [Doctor Last Name 406] to suction. Her antibiotics were continued. On POD1 she required a right T8 paravertebral catheter with lidocaine with good analgesic effect. Aggressive pulmonary toilet and mucolytic nebs. Cough suppressant were administered. She was started on sips of fluid. On POD2 she was very rhonchus, CXR showed left basilar opacity. Interventional pulmonary performed a flex bronch, therapeutic aspiration of secretions. The Y stent was patent the vocal cords were edema. Her diet was changed to NPO. The chest tubes were placed to water-seal. Her HCT was 20 with no signs of bleeding. Since she remained hemodynamically stable no transfusion was required. On POD3 she had repeat flexible bronchoscopy with therapeutic aspiration of secretions. The paravertebral catheter was removed and a Dilaudid PCA was started. The basilar chest tube was removed. POD4 She was seen by Speech and Swallow who cleared her for a regular diet with thin liquids. She was started on beta-blockers for atrial fibrillation prophylaxis. The electrolytes were replete as needed. On POD5 her respiratory status improved with decreased secretions with good pulmonary toilet. On POD6-7 the anterior chest tube was removed. Follow-up chest film revealed no pneumothorax. She transferred to the floor. Her oxygen saturation was 98% on RA. She still required aggressive pulmonary toilet and mucolytics for Y stent patency. She complained of nausea and responded to bowel regime. On POD8 the mediastinal [Doctor Last Name 406] was removed. She ambulated in the halls. The PCA was converted to PO pain meds with good control. She tolerated a regular diet. She continued to make steady progress and was discharge on a 5 day course of antibiotics and to a hotel with her sister. She will follow-up with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ] as outpatient. Medications on Admission: zantac 150mg [Hospital1 ] synthroid 0.10mg daily advair 250/50 [Hospital1 ] flonase IH [Hospital1 ] augmentin 875 [Hospital1 ] fluconazole 200 qday Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. Disp:5 Tablet(s) Refills:0 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 9. Hydromorphone 4 mg Tablet Sig: 1-1.5 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO every six (6) hours as needed for cough. Disp:30 ML(s) Refills:0 11. 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 12. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea. Disp:15 Tablet(s) Refills:0 13. Ipratropium Bromide 0.02 % Solution Sig: Two (2) ML Inhalation Q6H (every 6 hours) as needed. Disp:30 ML Refills:0 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ML Inhalation Q4H (every 4 hours) as needed. Disp:90 Refills:0 15. Nebulizer Albuterol and Atrovent q6hrs prn Discharge Disposition: Home Discharge Diagnosis: Tracheal tear Trachael bronchomalacia Hiatal Hernia, GERD s/p lap Nissen fundoplication [11-2] at [Hospital1 ] Hashimoto thyroiditis, hypothyroidism Discharge Condition: stable Discharge Instructions: zantac 150mg [Hospital1 ] synthroid 0.10mg daily advair 250/50 [Hospital1 ] flonase IH [Hospital1 ] augmentin 875 [Hospital1 ] fluconazole 200 qday Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] [2131-1-16] for Bronchoscopy. Nothing to eat or drink afer MIDNIGHT [2131-1-16]. They will call you with an appointment Follow-up with Dr. [Last Name (STitle) 1533] Phone:[Telephone/Fax (1) 3020] Date/Time:[2131-1-23] 9:00am in the [Hospital Ward Name 121] Building, [Hospital1 ] I Chest Disease Center. Report to the [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Provider: [Name10 (NameIs) 12554] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[Telephone/Fax (1) 3020] Date/Time:[2131-1-23] 9:30, [Hospital1 ] I Chest Disease Center Provider: [Name10 (NameIs) ] INTAKE,ONE [Name10 (NameIs) ] ROOMS/BAYS Date/Time:[2131-1-23] 12:00 Nothing to Eat or Drink after Midnight [2131-1-23] Completed by:[2131-1-12]	[ "2449", "V1582" ]
Admission Date: [2108-4-1] Discharge Date: [2108-4-11] Date of Birth: [2075-7-3] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1283] Chief Complaint: PFO Major Surgical or Invasive Procedure: s/p Minimal Invasive PFO closure on [2108-4-3] History of Present Illness: 32 y/o female who sustained a Left PCA CVA in [1-21]. Work-up revealed a PFO with left to right shunting. She complains of continued fatigue, mild DOE and some chest pressure which resolves spontaneously. She presents for surgical evaluation of PFO. Past Medical History: Patent Foramen Ovale (PFO) s/p Left Post. Cerebral Artery Cerebral Vascular Aaccident s/p Dilation & Curretage Social History: Married, lives with her husband and three children. Denies tobacco, EtOH, illicits. Family History: Non-contributory Physical Exam: VS 68SR BP 112/60 Ht 65 Wt 160 General: Well-appearing female in NAD Skin: Unremarkable, -lesions or rashes HEENT: EOMI, PERRLA, NC/AT Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r Heart: RRR +S1S2, -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -c/c/e, -varicosities Neuro: Residual R-sided weakness and uncoordination. Blind spot OD. Pertinent Results: [2108-4-1] 06:37PM BLOOD WBC-5.7 RBC-4.00* Hgb-12.2 Hct-35.8* MCV-90 MCH-30.5 MCHC-34.1 RDW-13.1 Plt Ct-171 [2108-4-7] 05:12AM BLOOD WBC-3.8* RBC-2.62* Hgb-8.1* Hct-23.2* MCV-89 MCH-31.0 MCHC-34.9 RDW-13.4 Plt Ct-119* [2108-4-10] 05:30AM BLOOD WBC-8.7# RBC-3.41# Hgb-10.2 Hct-31.1# MCV-91 MCH-29.8 MCHC-32.7 RDW-14.0 Plt Ct-230# [2108-4-1] 06:37PM BLOOD PT-13.3 PTT-28.5 INR(PT)-1.2 [2108-4-10] 05:30AM BLOOD PT-16.0 PTT-63.0* INR(PT)-1.7 [2108-4-1] 06:37PM BLOOD Glucose-143* UreaN-13 Creat-0.8 Na-138 K-4.0 Cl-105 HCO3-25 AnGap-12 [2108-4-7] 05:12AM BLOOD Glucose-124* UreaN-15 Creat-0.6 Na-140 K-3.1* Cl-106 HCO3-25 AnGap-12 [2108-4-1] 06:37PM BLOOD Albumin-4.1 Calcium-8.8 Phos-2.3# Mg-1.9 [2108-4-7] 05:12AM BLOOD Mg-1.7 [2108-4-3] 09:39AM BLOOD freeCa-1.18 [2108-4-5] 04:26AM BLOOD freeCa-1.26 Brief Hospital Course: As mentioned in the HPI, pt. had a CVA in [1-21] and subsequently found to have a PFO. She was started on Coumadin at that time and presents for admission pre-operatively to start heparin (off Coumadin). By HD#2 her INR was 1.2. On HD #3 she was brought to the OR and underwent a Min. Inv. PFO closure. Pt. tolerated the procedure well with a total bypass time of 45 minutes and no cross clamp time. See op note for surgical details. She was transferred to CSRU with a MAP of 79 and HR of 96 SR and being titrated on Neo and Propofol. Later on op day, pt was weaned from mechanical ventilation and propofol and was successfully extubated. She was awake, alert, MAE and following commands. Diuretics and B-blockade were started per protocol on POD #1. Pleural tube was removed and CXR afterwards showed a moderate PTX. On POD #2 Neo was weaned off and repeat CXR showed cont. rt. PTX. She was transfused 1 unit of PRBCs and HCT increased to 26 afterwards. Heparin gtt and Coumadin were started. Patient was appropriately anti-coagulated with an INR of 2 on date of discharge. Medications on Admission: 1. Coumadin 7.5/10 mg am/pm 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. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 4. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 7 days. Disp:30 Tablet(s) Refills:0 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days. Disp:14 Capsule(s) Refills:0 7. Coumadin 5 mg Tablet Sig: 1.5 or 2 Tablets PO at bedtime: 7.5 mg alternating with 10 mg. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 8117] NH VNA Discharge Diagnosis: Patent Foramen Ovale (PFO) s/p Minimal Invasive PFO closure s/p Left Post. Cerebral Artery Cerebral Vascular Aaccident (stroke) s/p Dilation & Curretage Discharge Condition: Good Discharge Instructions: Can take shower. Wash incision with warm water and mild soap. Gently pat dry. Do not bath or swim. Do not apply lotions, creams, or ointments to incisions. Do not drive if taking narcotics/pain meds. Otherwise can drive after 2 weeks. Do not lift anything greater then 10 pounds for 3-4 weeks. Make/Keep all follow-up appointments. [Last Name (NamePattern4) 2138]p Instructions: Follow-up with Dr. [Last Name (Prefixes) ] in 4 weeks. Follow-up with Dr. [First Name (STitle) ] in [12-22] weeks. Follow-up with Dr. [First Name (STitle) 1356] in [11-20] weeks.	[ "V5861" ]
Admission Date: [2127-12-9] Discharge Date: [2128-1-13] Date of Birth: [2127-12-9] Sex: F Service: NEONATOLOGY ADMISSION HISTORY: The 1405 gram product of a 32 and [5-27] week gestation, baby girl [Name (NI) 7518] [Name2 (NI) 37336] number one was born to a 40 year-old G2 P0 now 3 female with prenatal screens of A negative, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, rubella immune and group B strep unknown, conceived by invitro fertilization with an estimated date of confinement of [2128-1-30]. The pregnancy was complicated by cervical shortening for which the mother received a complete course of betamethasone at 26 weeks. With poor growth noted of this [Year (4 digits) 37336], the pregnancy was followed with serial ultrasounds. As oligohydramnios of [Year (4 digits) 37336] number one was noted on the day of delivery, the decision was made to delivery by C section. This [Year (4 digits) 37336] emerged with a spontaneous cry, but heart rate less then 100 and was given PPV with improvement in heart rate and color. Apgars were 4 at one minute and 7 at five minutes. The baby was transferred to the Neonatal Intensive Care Unit for further evaluation and management of prematurity. ADMISSION PHYSICAL EXAMINATION: Weight 1405 grams (20th percentile), length 38.5 cm (less then the 10th percentile), head circumference 29.5 cm (25th percentile). Overall appearance consistent with known gestational age, nondsymorphic, ruddy, anterior fontanel soft, open and flat. Red reflexes were noted bilaterally. The palette is intact. There are mild intercostal retractions with fair air entry. Cardiovascular regular rate and rhythm without murmur. The abdomen is benign without hepatosplenomegaly. A three vessel cord is noted as well as normal female genitalia per gestational age. Back and extremities appear normal with stable hips. The skin is ruddy and has fair perfusion. Tone and responsivity are normal. Initial dextrose stick was 91. HOSPITAL COURSE: 1. Respiratory: Given clinical evidence of surfactant deficiency, the newborn was intubated and received two doses of Surfactant. The neonate briefly made it to CPAP on day of life two and then was reintubated for increased work of breathing. By day of life five the newborn was successfully weaned to CPAP. By the following day the infant was weaned to nasal cannula, but was restarted on CPAP through day of life thirteen given frequent apneic events in spite of being started on caffeine. From day of life fourteen through discharge. The neonate has been stable on room air without significant spells for the past five days. Caffeine was discontinued on day of life fifteen. 2. Cardiovascular: The baby was hemodynamically stable throughout the admission. 3. Fluids, electrolytes and nutrition: The infant was initially started on total parenteral nutrition, the newborn was started on enteral feeds on day of life number two and made it to full volume feeds by day of life nine. The highest caloric density was achieved on day of life fifteen at breast milk 30 with ProMod. The baby has been feeding and growing well more recently on breast milk 24 with the added calories by Enfamil powder. Today's weight is 2305 grams, which is at the 15th percentile, the length is 49.3 cm, which is at the 70th percentile and the head circumference of 33 cm, which is at the 50th percentile. 4. Gastrointestinal: The maximum total bilirubin was 9.3 on day of life three with the direct component of 0.3 for which phototherapy was started through day of life seven. Rebound bilirubin on the following day was acceptable. 5. Hematology: With initial hematocrit of 49.3%, the newborn has been supplemented with oral ferrous sulfate. No transfusions were given. 6. Infectious disease: With an initial white count of [Numeric Identifier ] and 16 polys and 0 bands, the baby was treated for 48 hours with Ampicillin and Gentamycin with cultures negative at that point. 7. Neurological: Given a weight [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 1500 grams and 32 weeks post gestation the baby had a head ultrasound performed on [12-23], which was without evidence of hemorrhage. 8. Sensory: Audiology, hearing screen was performed with automated auditory brain stem responses. The baby passed on [1-7]. Ophthalmology, the eyes were examined most recently on [12-31] revealing mature retinal vessels. A follow up examination is recommended in eight months. 9. Psycho/social: The [Hospital1 69] social work was involved with the family. This service can be reached at [Telephone/Fax (1) 8717]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: The baby is being discharged to home in the care of the parents. The primary pediatrician's name is [Name (NI) ] [Last Name (NamePattern1) ] of Health Care South in [Location (un) 38640] [State 350]. The telephone number is [Telephone/Fax (1) 38641] and the fax number is [Telephone/Fax (1) 47018]. CARE AND RECOMMENDATIONS: Feeds at discharge are breast milk 24 fortified with Enfamil powder. MEDICATIONS: Fer-In-[Male First Name (un) ] (25 mg of elemental iron per ml) 0.3 cc po q day and Poly-Vi-[Male First Name (un) ] 1 cc po q day. Car seat position screening was passed prior to discharge. State newborn screens were sent on [2127-12-12] and [2127-12-23] and had results all within normal limits. Hepatitis B vaccine was given on [2128-1-6]. Immunizations recommended [Year (4 digits) 38801] RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following criteria: 1. Born at less then 32 weeks. 2. Born between 32 and 35 weeks with plans for day care during RSV season, with a smoker in the household or with preschool siblings or with chronic lung disease. By these criteria this baby did not warrant [Name (NI) 38801] RSV prophylaxis. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they meet 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 SCHEDULED AND RECOMMENDED: The parents are to schedule a follow up with the primary pediatrician by the end of the week. Also VNA will be following up three days after discharge. DISCHARGE DIAGNOSES: 1. Preterm appropriate for gestational age newborn female [Name (NI) 37336] number one. 2. Respiratory distress syndrome. 3. Sepsis ruled out. 4. Physiologic hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 35940], M.D. [MD Number(1) 35941] Dictated By:[Last Name (NamePattern4) 47019] MEDQUIST36 D: [2128-1-13] 09:50 T: [2128-1-13] 10:03 JOB#: [Job Number 47020]	[ "7742", "V290" ]
Admission Date: [2166-12-11] Discharge Date: [2166-12-17] Date of Birth: [2096-4-28] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 7227] Chief Complaint: Mental status changes Fever Major Surgical or Invasive Procedure: placement of subclavian line left wrist arthrocentesis arterial line placement History of Present Illness: 70 y.o. female with hx of mult admissions for fever, UTI (mult resitant klebsiella) and hypoglyecemia presents from home with mental status changes and fever. Pt had just finished a 10 day course of Bactrim for UTI. Per daughter, she began to have slurred speech yesterday and had not voided all day. Subjective fevers at home and occ productive cough. Daughter reports that this is the way the pt always gets when she is septic. No N/V. Pt has chronic diarrhea. Pt has R foot pressure ulcer which the daughter says has become slightly worse and she recently restarted using her debriding cream. Pt has hx of MRSA infection in this wound. . On arrival to [Name (NI) ] pt found to be verbal but confused. Fever to 101. Foley placed and thick, purulent urine came out without blood. Found to be febrile to 101, pressure low in 100's but has always been difficult to obtain BP due to habitus. Pt received Vanc and Levaquin in ED. BP improved with IVF. Pt found to have acute on chronic reanl failure and u/a consitent with UTI. Past Medical History: Right Femur Fx S/P ORIF ([10/2165]: Tripped Over Commode), HTN, Hyperlipidemia, DMII, Peripheral Neuropathy, Obesity, IBS (Chronic Constipation, Abdominal Pain and Intermittent Diarrhea), Chronic LBP/Sciatica (Osteoporisis, DJD/OA, Spinal Stenosis), Depression/Anxiety, Panic Disorder, Parotid Gland Tumor S/P Resection, S/P Multiple Falls, H/O Herpes Zoster, S/P CCY, B/L Cataract Removal. Social History: She lives with her daughter, who is very involved with her care. She had 11 children, and one passed away. She was a homemaker. She quit smoking 20 years ago and had between [4-29] py. She uses ETOH rarely (<1x/month). Family History: Her mother had DM. She knows nothing of her father. [Name (NI) ] sister died of [Name (NI) ] at 60. Physical Exam: VS: 101 rectal HR 89 BP 160/119-->106/60 RR 15 O2 100% on 3L NC gen: obese F lying in bed, sleeping. HEENT: PERRL. NO sceral injection. EOMI. MM dry. Neck: Iunable to appreciate JVP 2/2 habitus. CV: RRR. [1-26] blowing systolic murmur. Lungs: decreased BS throughout [1-22] body habitus. no wheezes/ crackles. Abd: obese. large pannus. [Female First Name (un) 564] and minimal skin breakdown beneath pannus. soft. NT. No masses. Back: unable to examine [1-22] size Extr: 1+ edema sl greater on R than L. Dp 1+ B/L. no c/c/e. Neuro: unable to follow commands. Pertinent Results: [2166-12-11] 07:32PM LACTATE-1.7 [2166-12-11] 07:20PM GLUCOSE-208* UREA N-53* CREAT-4.5# SODIUM-132 POTASSIUM-5.8* CHLORIDE-101 TOTAL CO2-16* ANION GAP-21* [2166-12-11] 07:20PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-153* ALK PHOS-179* AMYLASE-38 TOT BILI-0.3 [2166-12-11] 07:20PM LIPASE-17 [2166-12-11] 07:20PM cTropnT-0.04* [2166-12-11] 07:20PM CK-MB-3 [2166-12-11] 07:20PM CALCIUM-8.6 PHOSPHATE-7.4# MAGNESIUM-1.1 [2166-12-11] 07:20PM WBC-18.0# RBC-3.02 HGB-8.9* HCT-27.0* MCV-89 MCH-29.4 MCHC-32.9 RDW-14.4 [2166-12-11] 07:20PM NEUTS-85.1* BANDS-0 LYMPHS-11.9* MONOS-2.7 EOS-0.3 BASOS-0.1 [2166-12-11] 07:20PM PLT COUNT-331# [2166-12-11] 07:20PM PT-15.1* PTT-29.9 INR(PT)-1.5 [2166-12-11] 07:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [2166-12-11] 07:20PM URINE RBC- WBC- BACTERIA-MANY YEAST-NONE EPI- . CXR:CHEST, ONE VIEW: Comparison with [2166-10-17]. The cardiac and mediastinal contours are stable. There are low lung volumes, what appears to be crowded pulmonary vasculature. No upper zone redistribution, pneumothorax, consolidations, or pleural effusion. IMPRESSION: No definite pneumonia or CHF . IMPRESSION: 1. Osteopenia and advanced first CMC degenerative changes. 2. Chondrocalcinosis. This can be seen with CPPD, hyperparathyroidism, or hemachromatosis. Is acute CPPD a clinical consideration? 3. Equivocal superimposed osteopenic foci, which could represent small cysts or erosions. I strongly suspect this is technical, but clinical correlation is requested -- does the patient have focal tenderness along the ulnar border of the fifth carpometacarpal joint?. Brief Hospital Course: A/P: 70 y.o. female with fever, hypotension and mental status change with associated ARF, hyperkalemia, pyuria and leukocytosis. Hx of recurrent UTIs, as well as chronic right foot ulcer. #. Fever/Mental Status Changes - patient presented in urosepsis and was admitted to the MICU. She transiently required pressor support, but was weanted off by day two. Her metabolic acidosis, thought secondary to lactic acidosis resolved. Urine culture grew Klebsiella pneumoniae sensitive to only Zosyn and Meropenem. She was treated with Zosyn, and was discharged with plans to complete a 14day course. Midline placed prior to discharge. CXR showed no pneumonia. Right foot ulcer was not felt to be source of sepsis. Urinary tract infection was most likely source. Patient remained hemodynamically stable from day two onward, and was discharged to rehab for continued iv antibiotics. . #. Acute renal failure: Creatinine 4.5 on admission, elevated from baseline 1.1. Differentinal diagnosis included prerenal vs ATN in setting of septic hypotension. No casts seen, and responded to iv fluids. Creat was trending down daily, and was 1.4 on the day of discharge. She was hyperkalemic on admission, thought secondary to acute renal failure. She recieved kayexelate and iv fluids, and this corrected by day two. . #. Acidosis: Patient had an anion gap metabolic acidosis secondary to renal failure and elevated lactate. This corrected to normal by day two. . #. Pain - Long history of chronic pain on a complicated regimen including high doses of Oxycontin, Zanaflex, Neurontin, Doxepin and oxycodone for breakthrough. Medications were initially held with her relative hypotension. Once transferred to the floor, doses were gradually increased. Patient was tolerating her outpatient regimen by the time of discharge. Although patient does not have any respiratory suppression, she was lethargic and slept frequently during the day on this regimen. . #. Anemia: basline Hct 26-30. stable during hospitalization. . #. TIIDM: Patient's glyburide was held and she was supplemented on slidign scale insulin. Blood sugar well controlled on this regimen with recent A1c in the 5's. Glyburide was resumed prior to discharge. . #. Right heel ulcer: H/o MRSA wound infection, previously treated. Wound care was consulted and daily dressing changes continued. . # Left wrist: patient complained of pain in left wrist, which was noted to be swollen erythematous, and warm. Erythema subsided and swelling decreased. An x-ray showed chronic changes c/w CPPD. Rheumatology was consulted and found findings consistent with pseudogout. Pain control by her chronic pain regimen. . #. Anxiety/ depression/Panic Disorder: Celexa continued. Klonopin initially held due to sepsis. Medications resumed prior to discharge per outpatient regimen. . #. PPX: Patient requires standing bowel regimen given high narcotic dose regimen. . #. Dispo: Patient was discharged to [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] rehab. She will complete 14days iv Zosyn. She will follow-up with Dr. [Last Name (STitle) ] her PCP [2166-1-20]. She will also f/u in rheumatology clinic. She is a full code. Medications on Admission: Lisinopril 5 mg daily Miconazole TP Lidocaine TP Neurontin 300 mg [Hospital1 ] Oxycontin 50 mg [Hospital1 ] MVI Zyprexa 10 mg qhs ASA 325 mg daily Vitamin B12 1000mcg daily Glipizide 5 mg qd Protonix 40 mg daily Prozac 20 mg daily Lipitor 20 mg daily Zanaflex 4 mg qhs Doxepin 50 mg qhs Senna/colace/dulcolax Asacol 800 mg TID Klonopin 2 mg qhs Oxycodone prn Folic Acid 1 mg daily Elidel TP Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 11. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Two (2) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 13. OxyContin 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO twice a day. 14. Doxepin 25 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). 15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 16. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety. 18. Oxycodone 5 mg Tablet Sig: 1-4 Tablets PO Q4-6H (every 4 to 6 hours) as needed for breakthrough pain. 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 20. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 21. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Zosyn 2.25 g Recon Soln Sig: 2.25 g Intravenous four times a day for 10 days. Disp:qs ml Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Primary: Urosepsis Pseudogout Type II diabetes mellitus Chronic pain Depression/Anxiety . Secondary: Hypertension Discharge Condition: Stable Discharge Instructions: 1. Please continue to take all medications as prescribed 2. You will continue on iv antibiotics for another 10days 3. If you develop fever >101.3, chest pain, shortness of breath, decreased urination or any other concnerning symptom, please contact your primary care physician [Name Initial (PRE) ]/or return to the emergency department Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 14865], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2167-1-14] 9:00 -- Rheumatology . Please follow-up with Dr.[Last Name (STitle) ], your primary care physician, [2166-1-20] at 2:10pm Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2167-1-20] 2:10	[ "0389", "5990", "5849", "40391", "5859", "2767", "2762", "99592", "25000", "311" ]
Admission Date: [2146-9-7] Discharge Date: [2146-9-12] Date of Birth: [2060-8-31] Sex: F Service: NEUROLOGY Allergies: Penicillin V Calcium / Allopurinol Attending:[Last Name (NamePattern1) 11784] Chief Complaint: Transferred from OSH for a right temporal IPH (intubated, sedated) Major Surgical or Invasive Procedure: Central line placement History of Present Illness: Ms [Known lastname 15959] ([Last Name (LF) 15960], [First Name3 (LF) 11765]) is an 86 year old right handed woman with a history of HTN, metastatic leiomyosarcoma, diabetes, who was found unresponsive by her daughter around [8-2] am today. No one had spoken to her since the night before when she went to bed. She was taken by EMS to [Location (un) 15961] with a GCS of 9 but became combative and was intubated for med flight and given 200 of Fentanyl. She was started on propofol and remains intubated and was transferred to [Hospital1 18] for further managmeent. Of note, she saw her PCP last month and there was mention of SBP>200At OSH her SBP was 170/87. HR 76. On general review of systems from the son, he denies that she has had any recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: HYPERTENSION METASTATIC LEIOMYOSARCOMA with mets to the lungs (followed at [Company 2860]) HYPERLIPIDEMIA CAD S/P CABG NEUROPATHIC PAIN TONSILLECTOMY APPENDECTOMY [2082] L KNEE ARTHROSCOPY TYPE 2 DIABETES GOUT [2135] COMPLEX R ADNEXAL MASS COLONIC POLYPS LEFT 5TH PHALANX PAIN [First Name8 (NamePattern2) ] [Location (un) ] SYNDROME Social History: She does not smoke and rarelyuses ETOH. She was a banker. Family History: no strokes in family. mother had [Name2 (NI) 499] polyps Physical Exam: Physical Examination on Admission: O: BP: 144/50 HR:64 R 12 O2Sats 100%int Gen: cervical collar. ETT neck: collar HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, Extremities:warm and well perfused Skin: no Neurological Examination: GCS:5 level of arousal - 1 best verbal -1 best motor -4 Mental status: intubated. off sedation grimaces to pain, but does not open eyes or follow any direction Cranial Nerves: -Pupils equally round and reactive to light,2 to 1 mm bilaterally. -no gaze deviation, no bobbing, no nystagmus, no gag, but + cough. Motor: Normal tone bilaterally. withdraws to noxious all 4 extremities. Reflexes: B T Br Pa Ac Right 1 1 1 1 1 Left 1 1 1 1 1 Toes upgoing bilaterally PHYSICAL EXAM ON DISCHARGE: Vital Signs: T 98.8, BP 142/56, HR 56, RR 23, 94% RA GEN: Elderly woman lying in bed in NAD HEENT: OP clear CV: 3/6 systolic murmur heard best at the R 2nd rib space PULM: CTA-B ABD: soft, NT, ND EXT: no peripheral edema . Neurological Exam: . MS: speech fluent, knew which hospital she was at, knew DOW, date and year . CN: PERRL 2.5->1.5mm, pt has difficulty burying her sclerae on lateral gaze bilaterally, tongue midline, face symmetrical, shoulder shrug [4-28] bilaterally. . MOTOR: delt bic tric FExt Grip Quad Ham Gastroc TA R 4+ 5- 5- 5 5 5 5 5 5 L 5- 5 5 5 5 5- 5 5 5 . normal tone, normal bulk . Reflexes: 1's throughout bilaterally, with mute toes bilaterally . Sensory: intact to light touch throughout . Coordination: FNF intact bilaterally . Gait: deferred Pertinent Results: Labs on Admission [2146-9-7] 02:25PM BLOOD WBC-11.0 RBC-3.66* Hgb-10.6* Hct-30.5* MCV-84 MCH-28.9 MCHC-34.7 RDW-14.6 Plt Ct-255 [2146-9-7] 02:25PM BLOOD Plt Ct-255 [2146-9-7] 02:25PM BLOOD PT-12.2 PTT-25.4 INR(PT)-1.0 [2146-9-7] 10:08PM BLOOD Glucose-146* UreaN-40* Creat-1.6* Na-139 K-4.0 Cl-105 HCO3-22 AnGap-16 [2146-9-7] 10:08PM BLOOD ALT-12 AST-27 LD(LDH)-438* CK(CPK)-186 AlkPhos-52 TotBili-0.7 [2146-9-7] 02:25PM BLOOD cTropnT-0.17* [2146-9-7] 02:25PM BLOOD CK-MB-5 [2146-9-7] 10:08PM BLOOD CK-MB-4 cTropnT-0.16* [2146-9-8] 01:53PM BLOOD CK-MB-3 cTropnT-0.10* [2146-9-9] 02:13AM BLOOD CK-MB-3 cTropnT-0.10* [2146-9-7] 10:08PM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.6 Mg-1.6 Cholest-195 [2146-9-7] 10:00PM BLOOD %HbA1c-8.1* eAG-186* [2146-9-7] 10:08PM BLOOD Triglyc-234* HDL-52 CHOL/HD-3.8 LDLcalc-96 [2146-9-7] 10:08PM BLOOD TSH-0.97 [2146-9-7] 02:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2146-9-7] 04:08PM BLOOD Type-ART Rates-[11-29] Tidal V-500 PEEP-5 FiO2-60 pO2-166* pCO2-29* pH-7.48* calTCO2-22 Base XS-0 Intubat-INTUBATED [2146-9-7] 02:31PM BLOOD Glucose-185* Lactate-2.0 Na-139 K-4.4 Cl-104 calHCO3-24 [2146-9-7] 02:38PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2146-9-7] 10:09PM URINE RBC-15* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 RenalEp-<1 [2146-9-7] 05:34PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG LABS ON DISCHARGE: [2146-9-12] 05:40AM BLOOD WBC-7.9 RBC-3.44* Hgb-9.9* Hct-29.0* MCV-84 MCH-28.8 MCHC-34.2 RDW-14.4 Plt Ct-265 [2146-9-12] 05:40AM BLOOD Glucose-173* UreaN-56* Creat-1.6* Na-141 K-5.0 Cl-110* HCO3-21* AnGap-15 [2146-9-12] 05:40AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.4 Imaging/Other data: EKG: Sinus rhythm. Possible old septal myocardial infarction. Left anterior fascicular block. Probable left ventricular hypertrophy. CT Head [2146-9-7]: right temporal intraparenchymal hemorrhage with mild mass effect and leftward shift of midline structures. No new areas of hemorrhage noted. MRI can be obtained for further evaluation. MRI Head [2146-9-7]: Mild-to-moderate-sized area of negative susceptibility in the right capsuloganglionic region, correlating with the previously noted area of hemorrhage, measuring approximately 1.4 x 2.2 cm, with mild-to-moderate amount of surrounding edema. No obvious heterogeneous nodular component of intermediate signal intensity is noted within this location to suggest an obvious tumor. However, assessment is limited due to lack of post-contrast images. These can be considered when appropriate. Diminutive right vertbral artery in the head and c spine- can be congenital; correlate with MRA when appropriate. Diffuse mucosal thickening with fluid in the mastoid air cells, small amount of fluid in the sphenoid sinus and mucosal thickening in the ethmoid air cells as described above. CT Head [2146-9-8]: Unchanged right temporal intraparenchymal hemorrhage adjacent to the capsuloganglionic region. No new areas of hemorrhage or edema. This hemorrhage is most consistent with a hypertensive etiology; however, an underlying mass or vascular malformation cannot be excluded. Please correlate clinically for determining further followup. CT L-Spine: No fracture involving the lumbar spine. Degenerative change in the low lumbar spine worst at L4-5, where chronic grade 1 anterolisthesis, disc bulge, and facet arthropathy cause moderate canal stenosis, though intrathecal detail is poorly assessed by CT. Pl. see subsequent MRI which shows moderate - severe canal stenosis, crowding of the roots of cauda and impingement on L4 and L5 nerves on both sides. Nodule at splenic hilum- likely splenule; left lumbar paraspinal ovoid lesion- pl. see prior MR studies. (Pt. has additional h/o malignant spindle cell neoplasm) CT T Spine: No fracture or traumatic malalignment involving the thoracic spine. Mild multilevel degenerative change, without severe canal narrowing. Numerous pulmonary nodules, the largest being a 3.1 cm mass in the left lower lobe, compatible with patient's known metastatic disease. MRT/L Spine: L4/5: Grade 1 anterolisthesis with pars defects; bil facet joints resulting in moderate-severe canal and foraminal stenosis and crowding of cauda; impingement on L4 and l5 nerves. T spine: no disc herniation or cord compression. Areas of altered signal intensity in the posterior thecal sac- likely pulsation artifacts; however, incompletley assessed MRI C Spine: Multilevel, multifactorial degenerative changes, with broad-based disc osteophyte complexes indenting the ventral thecal sac and the ventral surface of the cord at C5-6 and C6-7 levels, with foraminal narrowing as described above. Subtle linear hyperintense focus, in the C2 body relates to marrow edema. However, the significance of this finding is uncertain as there is no definite fracture on the prior CT C-spine study. Attention on followup can be considered. MRI T and L-spine: IMPRESSION: 1. No obvious focus of marrow edema to suggest injury. 2. Multilevel, multifactorial degenerative changes in the thoracic and the lumbar spine, most prominent at L4-L5 level with mild anterolisthesis, bilateral facet degenerative changes, resulting in moderate-to-severe canal stenosis and moderate-to-severe foraminal narrowing, with impingement on the L4 and L5 nerves. 3. An ovoid lesion noted in the left paraspinous muscles at L2-L3 level measuring approximately 1.2 x 2.3 cm. Please see the details on prior CT studies. 4. Areas of altered signal intensity in the posterior thecal space in the T-spine may relate to pulsation artifacts. However, these are inadequately assessed. 5. A few T2 hyperintense foci in the right side of pelvis on the localizing images can be better assessed with pelvic ultrasound. Brief Hospital Course: Ms. [Known lastname 15959] was admitted to the Intensive Care Unit for close monitoring. She remained afebrile and hemodynamically stable throughout her ICU stay. She was continued on her home medications for her comorbidities (including gout), and her blood pressure was kept below SBP 160 with the help of intravenous agents. All antiplatelet and anticoagulant agents were held. The plan is to restart her aspirin on [9-16] (10 days s/p bleed). In our hands on Day 1, she remained intubated and sedated so as to achieve formal MR imaging of her brain and C-spine so as to rule out soft tissue injury of the cervical spine. A follow up NCHCT showed no evidence of enlarging bleed, and there was no midline shift. With the assistance of the orthopedic spine service and the general surgery team, her spine precautions were officially cleared and she was extubated on [9-10]. Following extubation, she did well. Her physical examination did show some left sided weakness that has remained, but improved throughout her hospitalization. Her renal function remained at baseline, and IV contrast agents were avoided including gadolinium. Her brain MRI showed changes consistent with her known IPH on the right basal ganglia, no obvious evidence of metastatic lesion was noted, although this is difficult to tell in the acute period. She will need to schedule an outpatient repeat MRI with contrast in 6 weeks (phone number in the discharge paperwork). Her PCP and primary oncologist were notified of her admission here. While here, we continued her chronic prednisone therapy. PENDING LABS: Blood Culture x2 [2146-9-8] TRANSITIONAL CARE ISSUES: Patient will need her baby aspirin restarted on [9-16] (10 days s/p bleed). She will need to be monitored for changes in her neurological exam after this is started. Medications on Admission: ASPIRIN - 81MG Tablet - ONE BY MOUTH EVERY DAY ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime FEBUXOSTAT [ULORIC] - (Dose adjustment - no new Rx) - 40 mg Tablet - Half Tablet(s) by mouth daily GABAPENTIN - 300 mg Capsule - 2 Capsule(s) by mouth three times daily ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch, Medicated - [12-26] patches q 12 hrs as needed for prn METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily MOEXIPRIL - 15 mg Tablet - 1 Tablet(s) by mouth once a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sub lingually prn chest pain PREDNISONE - (Dose adjustment - no new Rx) - 10 mg Tablet - 4 Tablet(s) by mouth qd x 2 days then 3 tabs x 2 days then 2 tabs x 2 days then 1 tab daily, for gout attacks. Half a tablet daily ROLLING WALKER - - use as directed diagnosis = leiomyosarcoma left leg, gait instability Medications - OTC BLOOD SUGAR DIAGNOSTIC [SURESTEP TEST] - Strip - use to monitor blood sugar four times a day INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL (70-30) Suspension - Use as directed once a day 44 U pre-breakfast and 24 U pre-dinner Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. febuxostat 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three times a day. 4. moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day as needed for pain: 12hrs on, 12 hrs off in given 24 hr period. 7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain. 9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection TID (3 times a day). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, temp >100.4. Discharge Disposition: Extended Care Facility: [Hospital6 85] TCU - [Location (un) 86] Discharge Diagnosis: Primary: Right basal ganglia cerebral hemorrhage. Secondary: Hypertension, metastatic leiomyosarcoma, diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. NEURO EXAM: weakness in right deltoid, biceps, triceps and left deltoid and quadriceps Discharge Instructions: Dear Ms. [Known lastname 15959], You were seen in the hospital for a bleed in the right side of your brain. While here you were evaluated with an MRI and it was shown that your bleed remained stable. You were able to be sent to a rehabilitation facility to regain as much strength as possible. We made the following changes to your medications: 1) We STOPPED your ASPIRIN. You can restart this medication on [9-16] (10 days after your bleed). 2) We STARTED you on TYLENOL 650mg every 6 hours as needed for pain or fever greater than 100.4 degrees. 3) We STARTED you on SUBCUTANEOUS HEPARIN INJECTIONS. You will only need to take these while you are at your rehab facility. They are to prevent DVTs. If you experience any of the above listed Danger Signs, please contact your PCP or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Please call Phone: ([Telephone/Fax (1) 6713] to set up an appointment to have a brain MRI in 6 weeks (beginning of Novemeber). Department: RHEUMATOLOGY When: MONDAY [2146-10-10] at 9:30 AM With: [First Name8 (NamePattern2) 11595] [Last Name (NamePattern1) 11596], MD [Telephone/Fax (1) 2226] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 861] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: NEUROLOGY When: MONDAY [2146-11-7] at 1:30 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) 162], MD [Telephone/Fax (1) 2574] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2146-11-28] at 10:00 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	[ "5859", "40390", "25000", "2859", "2724", "V4581", "V5867" ]

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.